BILL ANALYSIS Ó SB 137 Page 1 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. SB 137 Page 2 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; SB 137 Page 3 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. SB 137 Page 4 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: SB 137 Page 5 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. SB 137 Page 6 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 SB 137 Page 7 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; SB 137 Page 8 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 SB 137 Page 9 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 SB 137 Page 10 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 SB 137 Page 11 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 SB 137 Page 12 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. SB 137 Page 13 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 SB 137 Page 14 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 SB 137 Page 15 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. SB 137 Page 16 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; SB 137 Page 17 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 SB 137 Page 18 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 SB 137 Page 19 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 SB 137 Page 20 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. SB 137 Page 21 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 SB 137 Page 22 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. SB 137 Page 23 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. SB 137 Page 24 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 SB 137 Page 25 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) SB 137 Page 32 319-2097