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)









                                                                     SB 137


                                                                    Page  26






          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









                                                                     SB 137


                                                                    Page  27






          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









                                                                     SB 137


                                                                    Page  28






          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









                                                                     SB 137


                                                                    Page  29






          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









                                                                     SB 137


                                                                    Page  30






          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









                                                                     SB 137


                                                                    Page  31






          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