BILL ANALYSIS Ó
SB 137
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Date of Hearing: July 14, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
137 (Ed Hernandez) - As Amended July 2, 2015
AS PROPOSED TO BE AMENDED
SENATE VOTE: 35-0
SUBJECT: Health care coverage: provider directories.
SUMMARY: Requires health care service plans (plans) and health
insurers (insurers), collectively referred to as carriers, to
publish and maintain printed and online provider directories,
and requires the provider directories to be updated within
specified timeframes; requires the Department of Managed Health
Care (DMHC) and the California Department of Insurance (CDI) to
establish provider directory standards. Specifically, this
bill:
1)Requires carriers to publish and maintain provider directories
with information on contracting providers that deliver health
care services to enrollees, including those that accept new
patients, and prohibits provider directories from listing or
including information on providers not currently under
contract.
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2)Requires carriers to provide the directories for the network
offered for each product, using a consistent method of network
and product naming, numbering, or classification method that
ensures the public, enrollees, potential enrollees, DMHC, CDI,
and other state and federal agencies can identify the networks
and plan products in which a provider participates.
3)Requires an online provider directory to be available on the
carrier's Website, and accessible to the public, potential
enrollees, enrollees, and providers without any restrictions
or limitations, and without any requirements that an
individual demonstrate coverage, indicate interest in
obtaining coverage, provide a member identification or policy
number, provide any other identifying information, or create
or access an account.
4)Requires an online provider directory to be accessible through
a clearly identifiable link or tab and in a manner that is
searchable by name, practice address, distance from a
specified address, California license number, National
Provider Identifier (NPI) number, admitting privileges to an
identified hospital, product, tier, provider language, medical
group, independent practice association, hospital name,
facility name, or clinic name, as appropriate.
5)Requires carriers to update online provider directories at
least weekly, or more frequently if required by federal law.
Requires any of the following changes in information
concerning a listed contracting provider to be included in the
weekly update:
a) Whether a contracting provider is no longer accepting
new patients, or is no longer under contract, for a
specific product;
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b) Whether the provider relocated from the contracted
service area, retired, ceased to practice, or no longer
contracts with the plan. In any of these cases the
provider shall be deleted from the directory;
c) Whether the contracting medical group, independent
practice association, or other provider group informs a
plan that the provider group is no longer under contract
with the plan, in which case any provider of the group who
does not maintain an independent contract with the plan
shall be deleted from the directory;
d) Whether the provider's practice location or other
information, as specified, has changed;
e) When the carrier identified a change is necessary based
on an enrollee complaint that a provider was not accepting
new patients, was otherwise not available, or whose contact
information was listed incorrectly; or,
f) Any other relevant information that has come to the
attention of the plan affecting the content and accuracy of
the provider directory.
6)Requires carriers to update printed provider directories at
least quarterly, or more frequently if required by federal
law.
7)Requires carriers to provide a printed directory upon request
by mail no later than 15 business days following the date of
the request, as specified.
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8)Requires provider directories to include an email address and
a phone number for members of the public and providers to
notify the carrier if the directory information appears to be
inaccurate, and to include specified disclosures informing
enrollees that they are entitled to language interpreter
services at no cost, and full and equal access to covered
services, including enrollees with disabilities, as specified.
9)Requires carriers, and specialized mental health carriers to
include all of the following information in the provider
directories:
a) Provider's name, practice location(s), and contact
information, including office email address, if available;
b) Type of practitioner;
c) NPI number, California license number, and type of
license;
d) Area of specialty, including board certification, if
any;
e) Names of all affiliated medical groups currently under a
contract with the plan through which the provider sees
enrollees;
f) Listing for each of the following providers, facilities,
and services under contract with the plan:
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i) For physicians, the medical group and affiliation or
admitting privileges, if any, at hospitals contracted
with the plan;
ii) Nurse practitioners, physician assistants,
psychologists, optometrists, substance abuse counselors,
qualified autism providers, and other practitioners
types;
iii) Federally qualified health centers or primary care
clinics, and the names of providers employed, as
specified;
iv) Facilities, including hospitals, skilled nursing
facilities, urgent care clinics, ambulatory surgery
centers, inpatient hospice, residential care facilities,
and inpatient rehabilitation facilities; and,
v) Pharmacies, clinical laboratories, imaging centers,
and other facilities contracted to provide services.
g) Non-English language spoken by a health care provider or
qualified medical interpreter on the provider's staff;
h) Identification of providers no longer accepting new
patients for one or more of the plan's products or for all
of the plan's products; and,
i) Network tier to which the provider is assigned, if the
provider is not in the lowest tier.
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10)Requires vision, dental, and other specialized carriers to
identify providers no longer accepting new patients, and to
include the same information listed in a) to e), g) and h) of
12) above, as well as information regarding affiliated medical
groups, independent practice associations, specialty plan
practice groups, and contracted allied health professionals,
as specified.
11)Requires, if a contracting provider informs an enrollee or
potential enrollee that the provider is not accepting new
patients, providers to:
a) Inform the carrier that the provider is not accepting
new patients;
b) Direct the enrollee or potential enrollee to the carrier
for additional assistance in finding a provider; and,
c) Direct the enrollee or potential enrollee to DMHC or CDI
to inform the department of a possible inaccuracy in the
provider directory.
12)Requires DMHC and CDI, by December 31, 2016, to develop
uniform provider directory standards, and, in doing so,
requires DMHC and CDI to seek input from interested parties,
hold at least one public meeting, and consider requirements
for provider directories established by the federal Centers
for Medicare and Medicaid Services (CMS). Exempts the DMHC
and CDI from the Administrative Procedures Act until January
1, 2021 for guidance issued to implement these standards.
13)Requires carriers to use the standards developed by DMHC and
CDI by July 31, 2017, or six months after the date the
standards are developed.
14)Requires carriers to establish policies and procedures to
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update its provider directories, and to submit those policies
and procedures annually to DMHC or CDI, as specified.
15)Requires carriers to, at least annually, update the entire
provider directory for each product.
16)Requires carriers to, at least quarterly, notify contracted
providers of the information in the directory and instruct the
providers how to access and update the information. Requires
an affirmative response from the provider acknowledging
receipt of the notice. Requires the provider to attest that
the information in the provider directory is accurate or
update the information as necessary.
17)Requires carriers to remove providers that do not
affirmatively respond within 30 business days to the
notification in from the directory. Requires carriers to
notify the provider 10 days in advance that the provider will
be removed from the provider directory.
18)Requires carriers to ensure processes are in place to allow
providers to promptly verify or submit changes to provider
directory information, as specified.
19)Requires plans to establish a process for enrollees,
prospective enrollees, other providers, and the public to
identify and report possible inaccurate, incomplete,
confusing, or misleading information listed in the provider
directory, as specified.
20)Requires a plan receiving a report above to investigate the
report and, no later than 30 days following receipt of the
report, to either verify the accuracy of the information in
the provider directory, or update the information in its
provider directory or directories, as applicable. Requires
plans, when investigating, to:
a) Contact the affected provider no later than five
business days following receipt of the report;
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b) Document the receipt and outcome of each communication,
including the outcome of the investigation, and any changes
or updates made to its provider directory; and,
c) Make changes to the directory based on the investigation
outcomes no later than the next scheduled weekly update, or
the update immediately following, as specified. Requires,
for printed directories, the change to be made no later
than the next quarterly update, or the quarterly update
immediately following that update.
21)Authorizes a carrier to delay payment or reimbursement to a
provider who has not responded to the carrier's attempts to
verify the provider's information, up to 45 business days.
Specifies the 45 business-day delay is in addition to the
timeframes set forth in existing law for claims reimbursement.
As noted, carriers have 30 days to reimburse a claim, or 45
days if the claim is paid by a health maintenance organization
(HMO). Thus, under this provision of the bill, a carrier
could delay payment or reimbursement for a total of 75 days,
or 90 days if the carrier is an HMO.
22)Authorizes a carrier to terminate a contract for a pattern or
repeated failure of the provider to alert the carrier to a
change in the information required to be in the directory.
23)Authorizes DMHC and CDI to require a carrier to provide
coverage for all health care services provided to an enrollee,
and to reimburse an enrollee for any amount beyond what the
enrollee would have paid for services provided by a
contracting provider, if DMHC or CDI find that the enrollee
reasonably relied upon inaccurate, incomplete, confusing, or
misleading information contained in a provider directory and,
as a result, obtained services from a non-contracting
provider. Requires DMHC and CDI, prior to requiring
reimbursement in these circumstances, to conclude that the
services received by the enrollee were covered services.
Specifies that, in these circumstances, the fact that the
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services were rendered or delivered by a non-contracting or
out-of-network provider may not be used as a basis to deny
reimbursement to the enrollee.
24)Requires carriers to inform enrollees of a special enrollment
period, as specified, in circumstances where an enrollee in
the individual market reasonably relied upon inaccurate,
incomplete, confusing, or misleading information contained in
a health plan's provider directory.
25)Provides that carriers are not prohibited from delegating the
responsibility of meeting the requirements in this bill to
risk-bearing organizations (RBO) or contracting specialized
plans or insurers. Specifies that carriers retain
responsibility to ensure the requirements of this bill are
met, unless the delegated responsibility has been separately
negotiated and documented in written contracts between the
plan and the RBO or contracting specialized carrier.
26)Specifies that the provider directory standards apply to
Medi-Cal managed (MCMC) care plans to the extent consistent
with federal law and guidance, and to carriers that contract
with multiple employer welfare agreements (MEWAs).
27)Repeals existing law requiring plans to provide provider
lists, as, specified, upon request.
EXISTING LAW:
1)Establishes the Knox-Keene Health Care Service Plan Act of
1975, the body of law governing plans in the state, and
provides for the licensure and regulation of plans by DMHC.
2)Provides for the regulation of insurers by CDI.
3)Establishes the Medi-Cal program, administered by the
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Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
4)Requires plans to provide, upon request, a list of specified
contracting providers, including primary care providers,
medical groups, independent practice associations, hospitals,
and all other contracting health care professionals to the
extent their services may be accessed and are covered through
the contract with the plan.
5)Requires the list of contracting providers to indicate which
providers have closed their practices or are otherwise not
accepting new patients; that the list is subject to change
without notice; and, include a telephone number for enrollees
to obtain information regarding a particular provider.
6)Requires plans to, upon request, provide this information in
written form to enrollees or prospective enrollees. Permits a
plan, with permission from the enrollee, to direct the
enrollee or prospective enrollee to the plan's provider
listings on its Website.
7)Requires plans to ensure that the information on contracting
providers is updated at least quarterly, as specified.
8)Requires plans, upon request, to make information available
concerning a contracting provider's professional degree, board
certifications, and any specialist's subspecialty
qualifications.
9)Requires insurers to provide group policyholders with a
current roster of institutional and professional providers
under contract to provide services at alternative rates under
their group policy, and make such lists available for public
inspection, as specified.
10)Requires carriers to submit to DMHC and CDI product-line data
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regarding network adequacy, including provider office
location; providers with open practices; the number of
assigned patients to primary care providers and information
that demonstrates the capacity of the accessibility of primary
care providers; and, grievances received regarding network
adequacy and timely access.
11)Requires carriers to reimburse uncontested claims as soon as
practicable, but no later than 30 working days after receipt
of the claim, or, if the plan is an HMO, 45 working days after
receipt of the claim, as specified.
12)Establishes and defines MEWAs as an employee welfare benefit
plan, or any other arrangement, which is established or
maintained for the purpose of offering or providing medical,
surgical, or hospital benefits to the employees of two or more
employers who are not parties to a bona fide collective
bargaining agreement.
FISCAL EFFECT: According to the Senate Appropriations
Committee, this bill, as amended April 21, 2015, would result
in:
1)One-time costs of about $160,000 in 2015-16 and $200,000 in
2016-17 to work with stakeholders, develop standards, and
issue regulations by CDI (Insurance Fund).
2)One-time costs, likely between $150,000 and $300,000 to work
with stakeholders, develop standards, and issue regulations by
DMHC (Managed Care Fund).
3)No significant costs to the Medi-Cal program are anticipated.
DHCS indicates that any additional costs to Medi-Cal managed
care plans would not likely lead to increased rates paid to
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those plans by the state.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, Californians
shopping for health insurance must have confidence in the
provider directory information upon which they are basing
their decisions, especially when health insurance coverage is
required by government for most of the population. For too
long, Californians have been unable to rely on information
provided by carriers and even their own health care providers
about which carriers their existing health care providers are
contracted with and if a provider is taking new patients.
California's provider directory law needs to be updated to
reflect technological advancements away from paper-based
directories. Federal and state health insurance regulations
have established requirements on different segments of health
insurance carriers but uniform standards are necessary to
ensure consistency among carriers and markets. The author
states that this bill would establish provider directory
standards and require weekly updates of online directories.
2)BACKGROUND. The reliability of provider directories has
recently become a source of policy concern, particularly
following the implementation of the Patient Protection and
Affordable Care Act (ACA) establishes an individual mandate to
maintain coverage, and which expands Medicaid to new eligible
populations. As such, many consumers are making health
coverage decisions for themselves and their families for the
first time. Provider directories serve as a resource for
consumers to evaluate coverage options; determine whether a
provider, including primary care physicians, specialists, or
hospitals they would like to see are contracted in a carrier's
network; and, to identify and locate providers and services
when seeking care.
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a) Federal Qualified Health Plan (QHP) regulations.
Carriers participating in health benefit exchanges
established under the ACA are referred to as QHPs. Under
federal regulations, QHPs are required to meet specified
standards regarding provider networks, including
requirements that a QHP provider directory must be
available to an exchange for publication online, and to
potential enrollees in hard copy upon request. QHPs must
identify providers that are not accepting new patients,
and, for plan years beginning on or after January 1, 2016,
a QHP must publish an up-to-date, accurate, and complete
provider directory, including which providers are accepting
new patients, the provider's location, contact information,
specialty, medical group, and any institutional
affiliations, in a manner that is easily accessible to plan
enrollees, prospective enrollees, the state, the exchange,
the federal Department of Health and Human Services (HHS),
and the United States Office of Personnel Management.
Under the federal regulations, a provider directory is
considered easily accessible when the public is able to view all
of the current providers in the provider directory on the plan's
Website through a clearly identifiable link or tab without
having to create or access an account or enter a policy number.
Additionally, a provider directory is easily accessible when a
carrier that maintains multiple provider directories, the public
is able to easily discern which provides participate in which
plans and which provider networks.
b) Covered California. Covered California is California's
state health benefit exchange. In the fall of 2013,
Covered California established an online aggregated
provider directory which would allow consumers to see which
providers belonged to which QHP networks. However, due to
inaccurate information regarding the providers, the Website
was discontinued in February 2014. According to Covered
California, while the combined provider directory was a
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useful service for consumers, some enrollees who located
physicians thought to be in their plan, subsequently
discovered they were not.
State regulations governing QHPs establish special enrollment
periods during which a qualified individual may enroll in a QHP,
or change from one QHP to another, outside of open enrollment.
To qualify for special enrollment, an individual must meet one
of a number of specified qualifying events. Under the
regulations, an individual qualifies for special enrollment when
that individual's enrollment in a QHP is "unintentional,
inadvertent, or erroneous and is the result of the error,
misrepresentation, misconduct, or inaction of an officer,
employee, or agent of the Exchange or HHS, its
instrumentalities, or a non-Exchange entity providing enrollment
assistance or conducting enrollment activities. According to
Covered California, it interprets a qualifying life event to
include misrepresentation or error regarding the provider
directory on its Website.
c) Medi-Cal requirements. MCMC plans enter into contracts
with DHCS in order to provide or arrange services for
Medi-Cal beneficiaries. Federal and state laws establish
the rules that govern MCMC plans, and many significant
requirements are established and enforced by DHCS through
contracts, including provisions relating to provider
networks and provider directories. Specifically, the
contracts require MCMC pans to provide to DHCS a list of
network providers, and linguistic capabilities of the
providers. MCMC plans are required to submit the provider
directory to DHCS every six months.
MCMC plans are also required to comply with provider listing
requirements applicable to DMHC-regulated plans, and to report,
on a quarterly basis, and upon significant changes to the
network, specified information, including the number of primary
care providers; provider deletions and additions and the impact
to geographic access; cultural and linguistic services; the
percentage of traditional safety net provides; the percentage of
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members assigned to each primary care physician; the percentage
of member assigned to traditional and safety net providers; and,
network providers who are not accepting new patients.
d) Federal MCMC regulations. On May 26, 2015, CMS released
proposed regulations regarding MCMC. According to CMS,
provider directories are foundational tools to help
enrollees utilize the benefits and services available to
them from their managed care plan. Since the majority of
Medicaid beneficiaries use Medicaid managed care plans to
access covered benefits, CMS believes it is critical for
enrollees to have information necessary to understand their
rights, and maximize their benefits.
The proposed regulations require Medicaid (Medi-Cal in
California) managed care plan provide directories to include
information on specified providers, including physicians,
hospitals, pharmacies, behavioral health, and long-term services
and supports providers. The proposed regulations describe the
minimum content standards for provider directories, including a
provider's group affiliation; the provider's Website; the
provider's cultural and linguistic capabilities, including
languages spoken by the provider or skilled medical interpreters
at the provider's office; and, whether the provider's office or
facility is accessible for people with disabilities.
Medicaid managed care plans would be required to update paper
provider directories at least monthly and electronic provider
directories within three days of learning of changes from
providers. MCMC plans would be required to post provider
directories on their Websites in a machine-readable file and
format, as specified. The purpose of establishing
machine-readable files with provider directories is to provide
the opportunity for third parties to create resources that
aggregate information from different plans. CMS asserts that
posting machine readable formats of directories will increase
transparency by allowing software developers to access provider
directory information and create tools to help enrollees better
understand the availability of providers in a specific plan.
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CMS also states it is considering requiring provide directories
to meet specified standards that would allow CMS, state Medicaid
agencies, or private third parties to plug into provider
directories to perform automated accuracy checks, by comparing
the directories against other data sources such as death
registries, and licensure registries.
e) CDI Regulations. Emergency regulations issued by CDI
became effective in February 2015, and require insurers to
post provider directories on their Websites, to be
available to both covered persons and consumers shopping
for coverage without requirements to create an access
account, or enter a password or policy number. Insurers
are required to maintain accurate provider directories for
their networks, and demonstrate the accuracy of its
directories to CDI. The regulations require, if an insurer
has more than one provider network, that it be reasonably
clear to a covered person which network applies to each
insurance product. Further, the provider directories must
be updated weekly and offered in a way to accommodate
individuals with limited-English proficiency or
disabilities. Covered persons must be informed of the
availability of translations and interpreter services in
languages other than English.
The regulations require the following for each provider
listed in the provider directory:
i) Name and gender of the provider;
ii) Specialty areas;
iii) Whether the provider is a primary care
physician;
iv) Whether the provider is accepting new patients;
v) Whether the provider may be accessed without a
referral;
vi) The location(s), including address and contact
information;
vii) Languages spoken by the provider and office
staff;
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viii) Network facilities where the provider has
admitting privileges; and,
ix) Whether the office is accessible under the
Americans with Disabilities Act.
Under the regulations, the provider directories, both
printed and online, are required to inform consumers of the
insurer's obligation to offer consumers primary and
specialty care within the specified time frames, and must
identify contracting providers who themselves are
multilingual or who employ other multilingual providers or
staff.
The regulations require insurers to notify patients seen by
a provider within the past year when the provider leaves
the insurer's network for any reason.
f) DMHC enforcement and State Auditor report. In 2014,
following numerous complaints regarding inaccurate provider
list information, DMHC performed non-routine surveys of two
plans selling commercial insurance on the state's health
benefits exchange. DMHC found that more than 25% of the
providers listed in the provider directories offered by the
two plans were not accepting patients with Covered
California plans or were no longer at the location listed
in the directory. Specifically, among one plan, 12.8% did
not accept Covered California plans, and 12.5% had changed
locations. For the other plan, 8.8% did not accept
patients with exchange plans, and 18.2% had changed
locations.
Additionally, the accuracy of provider directories in MCMC fell
into scrutiny after media reports indicated that Medi-Cal
beneficiaries encountered serious difficulties finding a
Medi-Cal provider, and that MCMC provider directories contained
many inaccuracies. In the summer of 2014, the Joint Legislative
Audit Committee approved a request by Senator Ricardo Lara for
the State Auditor to examine California's MCMC provider
directories, provider networks, and the current regulatory
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framework to ensure the accuracy of provider directories.
According to the request, there were several alarming reports
about the difficulty some Medi-Cal beneficiaries have in finding
Medi-Cal providers who will accept new patients.
The State Auditor completed and released its report in June
2015. Based on its audit findings, the State Auditor concluded
that DHCS did not verify provider network data it received from
MCMC plans was accurate. Therefore, DHCS cannot ensure that the
health plans it contracts with had adequate networks of
providers to serve Medi-Cal beneficiaries. The State Auditor
determined that flaws in DHCS' process for reviewing provider
directories have resulted in it approving provider directories
with inaccurate information. Specifically, the State Auditor's
reviewed provider directories from three MCMC plans, and found
many errors, including incorrect provider telephone numbers and
addresses, incorrect information about whether providers were
accepting new patients, and listings of providers that were no
longer participating with the plan. DHCS had not identified
these inaccuracies before approving the directories for
publication.
The State Auditor also found that those health plans that
regularly reach out to providers that update their information
had fewer errors in their provider directories. Additionally,
the State Auditor states that DHCS must improve its own process
for reviewing provider directories. While DHCS requires health
plans to submit updated versions of their printed directories
every six months for review and approval, but its directory
review tool is inadequate.
g) Provider directory policies in other states. Recent
regulatory actions in the state of New York have resulted
in carriers taking action to better to monitor and update
provider directories. For example, the New York State
Attorney General entered into settlement agreements with
some carriers requiring the carriers to ensuring accuracy
of provider directories, implement business practices to
update provider directors in a timely manner, and pay
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restitution to enrollees who paid more than they should
have because they saw providers erroneously listed as
in-network providers in the provider directory. New York's
Legislature mandated that online directories be updated
within 15 days of the addition or termination of a provider
from the network or a change in a physician's hospital
affiliation.
According to a May 2015 report issued by The Commonwealth
Fund entitled, "Implementing the Affordable Care Act: State
Regulation of Marketplace Plan Provider Networks," health
plans with relatively narrow networks have generated
widespread debate mainly concerning the level of regulatory
oversight necessary to ensure plans provide consumers
meaningful access to care. In 2014, policymakers in many
states considered whether and how to adjust their
regulatory approach to network adequacy, some of which set
rules intended to increase transparency of plan networks.
Six states strengthened requirements for plans to update
provider directories. For example, Washington and Rhode
Island now require plans to update their directories on a
monthly basis. Connecticut requires provider directories
to be updated no less than quarterly, and Nevada requires
directories to be updated no less than every 60 days.
Illinois and Maine passed legislation promoting timely
disclosures of directory information.
3)SUPPORT. Consumers Union (CU), California Pan-Ethnic Health
Network (CPEHN) and Health Access California (HAC) are the
sponsors of this bill, and argue that this bill provides
critical improvements to provider directories which are a
crucial tool for consumers choosing and using a health plan.
CU states that consumers need to know which doctors,
hospitals, and other providers are covered by each products
network, and only by having access to this information can
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consumers compare the relative value of plans and products.
HAC states that accurate provider directories are important
when consumers try to use their coverage, and by knowing which
providers are in their networks, they can avoid exposure to
unexpected medical bills by inadvertently obtaining care from
out-of-network providers. CPEHN and other supporters state
that errors and misleading information in provider directories
can exacerbate obstacles that communities of color and limited
English-proficient consumers encounter when attempting to
access care, and that these consumers are less likely to be
able to navigate around incorrect provider information and
find the support they need to make informed plan choices.
This bill will allow consumers from diverse backgrounds to
identify health plans and providers that can best meet their
needs by identifying what languages providers speak.
The Western Center on Law and Poverty (WCLP) supports this
bill as currently in print, stating that one of the
significant challenges with health reform implementation has
been a lack of accurate information for consumers about what
providers are in a health plan's network. WCLP states that
many consumers picked plans within Covered California and in
the general individual market based on the understanding from
provider directories that they could continue seeing their
doctor in a given plan only to find out that the provider was
actually not a part of the network.
The California Labor Federation (CLF) supports this bill as
currently in print, citing a case in which union members from
two school districts signed up for a specific plan after
noting that a specific hospital was in the plan's provider
directory. CLF states that after signing up with the plan,
the union members were informed that the hospital was not, and
had never been, in the plan's network. CLF states that DMHC
found that the plan was not out of compliance with existing
law in this case, which speaks to the need for stronger laws
governing provider directories.
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The California Association of Health Underwriters, supports
this bill as currently in print, stating that accurate
provider directories will permit agents help their clients
more effectively, and being able to access accurate provider
information in a timely manner will help agents select plans
for their clients that include their preferred providers,
hospitals, or clinics.
4)OPPOSITION. The California Association of Physician Groups
(CAPG) opposes the bill as currently in print, unless amended
to ensure that carriers retain financial responsibility for
implementation of provider directory requirements unless
financial responsibility is delegated to physician groups
through separately negotiated contracts. CAPG also suggests
that time be taken to implement a single electronic portal
through which physician groups can report their updated
information and from which carriers can draw down the
information. CAPG asserts that this will help avoid
situations where delegated provider groups will have to
constantly log onto each plan's electronic portal and update
individual provider information.
Delta Dental opposes this bill as currently in print, unless
amended to address concerns regarding the bill's provisions
requiring plans to use claims as a means to determine whether
a provider should be listed in a provider directory, and to
remove providers who do not respond to plan outreach from
provider directories. Additionally, Delta Dental states that
plans should have 30 days to update online provider
directories, which is consistent with recent federal
guidance.
California Advocates for Nursing Home Reform opposes this
bill as currently in print, stating concerns that excluding
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skilled nursing facilities from provider directories will put
vulnerable elderly and disabled at a disadvantage when
choosing a plan.
5)CONCERNS. The California Association of Health Plans (CAHP)
maintains concerns with this bill as currently in print,
specifically regarding the timeframes set forth in the bill,
requirements to use claims data to monitor the participation
of network providers, as well as the frequency of provider
directory updates required. CAHP states that it appreciates
the inclusion of mechanisms for plans to use to ensure
provider information is accurate. CAHP remains concerned with
the bill's requirements to maintain a 95% accuracy rate in the
directory, and prefers monthly directory updates, rather than
weekly, so that the ongoing maintenance of the directories is
timed with other aspects of managed care, such as contracting,
and would mirror federal requirements. CAHP notes that some
plans, including smaller regional or MCMC plans, may have
issues implementing the new requirements of the bill within
prescribed timeframes, as plans will be required to make
significant information technology investments and possibly
new network management staff.
6)RELATED LEGISLATION. AB 533 (Bonta) requires a health plan
contract or health insurance policy issued, amended, or
renewed on or after January 1, 2016, to provide that if an
enrollee or insured obtains care from a participating
facility, as defined, at which, or as a result of which, the
enrollee or insured receives covered services provided by a
nonparticipating provider, as defined, the enrollee or insured
is required to pay the nonparticipating provider only the same
cost sharing required if the services were provided by a
participating provider. AB 533 is set for hearing on July
15, 2015 in the Senate Health Committee.
7)PREVIOUS LEGISLATION.
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a) SB 964 (Ed Hernandez), Chapter 573, Statutes of 2014,
increases the oversight of health plans and compliance with
timely access to care requirements by requiring health
plans to annually report specified network adequacy data,
authorizing health plans to include provisions requiring
compliance with timely access in its provider contracts,
and requiring DHCS to publicly report its findings of
finalized medical audits as soon as possible, as specified,
and to share those findings and other information with
respect to health plans regulated by DMHC.
b) AB 2179 (Cohn), Chapter 797, Statutes of 2002, requires
DMHC and CDI to develop and adopted regulations to ensure
that enrollees have access to needed health care services.
8)POLICY COMMENT. By removing providers from the provider
directory for failing to confirm or update their information,
does the bill inadvertently reduce access to providers by
consumers? This bill, as proposed to be amended, requires
carriers, on a quarterly basis, to notify providers of the
information they have for them in their provider directories.
Providers are required to, within 30 business days, attest
that the information is correct or update the information as
necessary. If the provider does not respond within that
required timeframe, the carrier, with additional notice, is
required to remove the provider from the directory.
This requirement may inadvertently reduce access to
contracting providers by consumers. Provider directories
should be an accurate reflection of the carrier's provider
network. However, if a provider is removed from the
directory, it does not mean that the provider is removed from
the network. If a provider is removed from the directory, a
consumer may reasonably, but falsely, assume that the
provider is not in the carrier's network. As such, consumers
relying on the provider directory to select a plan or to
change providers may assume they have fewer provider options
than they actually do.
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The author and sponsor assert that a lack of response from
providers may be an indication that the providers are not
seeing patients assigned to the plan, and that carrier should
not be able to market those providers in the directory if
they are not a real option for patients. This is a
reasonable concern. However, a lack of response by a
provider to a carrier may not necessarily be a true
indication that the provider is not seeing patients of the
plan. There may be a variety of reasons a provider does not
respond within the required timeframe, including
administrative oversight. By comparison, if a carrier
receives an actual indication, through an actual report from
an individual, that information in the provider directory may
be inaccurate, the bill requires the carrier to take
investigatory action, including contacting the affected
provider, to determine what changes need to be made to the
provider directory.
The author and sponsor also assert that the removal
requirement serves as an incentive for providers to engage
and keep their information current with the carrier. To the
extent that the provider does not respond, the provider will
be removed from the directory thereby potentially losing new
patients, and thus new business. While this may reasonably
provide such an incentive, the committee should also bear in
mind that the bill contains provisions that allow carriers to
delay payment or reimbursement to providers that do not
respond to the quarterly notices. This may be a more direct
and effective tool for carriers to use to incentivize
provider engagement, and one that may not have the unintended
consequence of eliminating information about potentially
available providers to consumers. This bill also allows
carriers to terminate a contract with a provider that
repeatedly fails to engage. Assuming carriers will not wish
to exercise this option unless absolutely necessary so as to
preserve their networks, this provision also serves as
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another incentive for providers to engage with the carriers.
The Committee may wish to consider aligning the actions
carriers are required to take against providers that don't
respond to the quarterly update notices, with the
investigative actions they take when receiving a report of an
inaccuracy. For example, rather than automatically removing
a provider for not responding, carriers could be required to
investigate and take actions, including contacting the
provider, to try and verify the providers' information. If,
after taking those additional actions, the carrier still
cannot verify the provider's information, then the carrier
shall remove the provider from the directory.
REGISTERED SUPPORT / OPPOSITION:
Support
California Pan-Ethnic Health Network (sponsor)
Consumers Union (sponsor)
Health Access California (sponsor)
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AARP
Activ3p Inc.
AIDS Project Los Angeles
ALS Association Golden West Chapter
American Cancer Society Cancer Action Network
American Federation of State, County, and
Municipal Employees, AFL-CIO
Asian Law Alliance
California Academy of Family Physicians
California Academy of Physician Assistants
California Affiliates of Susan G. Komen
California Association of Health Underwriters
California Black Health Network
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California Chapter of the American College of
Emergency Physicians
California Chronic Care Coalition
California Council of Community Mental Health
Agencies
California Coverage and Health Initiatives
California Dental Association
California Immigrant Policy Center
California Labor Federation
California Life Sciences Association
California Optometric Association
California Pharmacists Association
California Primary Care Association
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California School Boards Association
California School Employees Association
California Teachers Association
CALPIRG
Children's Defense Fund - California
Children NOW
Community Clinic Association of Los Angeles
County
Community Health Partnership
El Rancho Unified School District
Having Our Say Coalition
Latino Coalition for a Healthy California
Leukemia and Lymphoma Society
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Mental Health America of California
Montebello Unified School District
National Association of Social Workers -
California Chapter
National Health Law Program
National Multiple Sclerosis Society - CA
Action Network
Occupational Therapy Association of
California
Osteopathic Physicians and Surgeons of
California
Planned Parenthood Affiliates of
California
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SEIU California
Southeast Asian Resource Action Center
Susan G. Komen, Central Valley Affiliate
Susan G. Komen, Inland Empire Affiliate
Susan G. Komen, Los Angeles County
Affiliate
Susan G. Komen, Orange County Affiliate
Susan G. Komen, Sacramento Valley
Affiliate
Susan G. Komen, San Diego Affiliate
Susan G. Komen, San Francisco Bay Area
Affiliate
The Children's Partnership
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Ukiah Unified School District
United Ways of California
Western Center on Law and Poverty
One individual
Opposition
California Advocates for Nursing Home Reform
California Association of Physician Groups (unless amended)
Delta Dental (unless amended)
Analysis Prepared by:Kelly Green / HEALTH / (916)
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319-2097