BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 137|
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UNFINISHED BUSINESS
Bill No: SB 137
Author: Hernandez (D)
Amended: 9/4/15
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 4/15/15
AYES: Hernandez, Hall, Mitchell, Monning, Nielsen, Pan, Roth,
Wolk
NO VOTE RECORDED: Nguyen
SENATE APPROPRIATIONS COMMITTEE: 6-0, 5/28/15
AYES: Lara, Beall, Hill, Leyva, Mendoza, Nielsen
NO VOTE RECORDED: Bates
SENATE FLOOR: 35-0, 6/3/15
AYES: Allen, Anderson, Beall, Berryhill, Block, Cannella, De
León, Gaines, Galgiani, Glazer, Hall, Hancock, Hernandez,
Hertzberg, Hill, Hueso, Huff, Jackson, Lara, Leno, Leyva, Liu,
McGuire, Mendoza, Mitchell, Monning, Moorlach, Morrell, Pan,
Pavley, Roth, Stone, Vidak, Wieckowski, Wolk
NO VOTE RECORDED: Bates, Fuller, Nguyen, Nielsen, Runner
ASSEMBLY FLOOR: 69-9, 9/10/15 - See last page for vote
SUBJECT: Health care coverage: provider directories
SOURCE: California Pan-Ethnic Health Network
Consumers Union
Health Access California
DIGEST: This bill requires a health plan or insurer to make
available a provider directory or directories that provide
information on contracting providers, including those that
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accept new patients. This bill prohibits a provider directory
from including information on a provider that does not have a
current contract with the plan or insurer.
Assembly Amendments (1) repeal existing health plan provider
list requirements; (2) delay implementation of the provider
directory requirements to July 1, 2016; (3) provide the
California Department of Insurance (CDI) and the Department of
Managed Health Care (DMHC) more time to develop uniform
directory standards (from March 15, to, December 31, 2016) and
exempt the departments from the Administrative Procedures Act
for five years; (4) delete a requirement that plans make the
information available on another technology if one emerges that
takes the place of the Internet in a timeframe that allows for
implementation not to exceed six months; (5) give health
insurance carriers 12 months to implement standards after DMHC
and CDI develop those standards; (6) delete a requirement that
that electronic directories be sent to specified purchasers; (7)
delete the requirement that the directories be 97% accurate; (8)
clarify the type of updated information which requires weekly
updates of the directory; (9) require health plans and insurers
to at least annually, review and update the entire provider
directory for each product offered and notify each contracted
provider annually or semiannually , depending on the provider
type, with the information the plan has in its directory
including a list of networks and plan products that include the
contracted provider or provider group. This replaces the
requirement that the plan or insurer contact providers if claims
or encounter data is not submitted to the plan within six months
(10) require affirmative response from the providers and
provider groups and include a process for the plan verification
if the provider does not respond; (11) exempt hospitals from the
requirements related to affirmative response to plan
notification; (12) authorize health plans and insurers to delay
payment or reimbursement owed to a provider or provider group
after steps have been taken to obtain a response from the
provider; (13) require plans and insurers to document and report
annually to CDI and DMHC instances when a plan imposes a payment
delay for failure of a provider to respond to a plan's or
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insurer's request for verification of information; (14) require
an audit of payment delay as part of existing department audit
requirements; (15) allow a provider group to terminate a
provider that does not respond to attempts to verify or update
information; (16) protect a provider group from payment delay if
the group documents attempts to verify the information, makes
multiple efforts to verify the information, and reports to a
plan or insurer that the provider should not be listed as part
of the provider group; (17) make clear that the Provider Bill of
Rights applies; (18) require the plan and insurers to file an
amendment with its regulator whenever there is a 10% change in
the network for a product in a region; (19) relieve Medi-Cal
managed care plans in compliance with this bill of a Medi-Cal
requirement to distribute provider directories annually; and,
(20) make other clarifying and reorganizing changes.
ANALYSIS:
Existing law requires a health plan to provide, upon request, a
list of specified contracting providers, within the enrollee's
or prospective enrollee's general geographic area, indicate
which providers have notified the plan that they have closed
practices or are otherwise not accepting new patients at that
time, and that the list is subject to change without notice.
This bill:
1) Requires a health plan or insurer to make available a
provider directory or directories that provide information
on contracting providers, including those that accept new
patients, as specified. Prohibits a provider directory
from including information on a provider that does not have
a current contract with the plan or insurer.
2) Requires a plan or insurer to provide the directory or
directories for the specific network offered for each
product using a consistent method of network and product
naming, numbering, or other classification method that
ensures the public, enrollees, potential enrollees, the
regulators, and other state or federal agencies can easily
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identify which providers participate in which networks for
which products.
3) Requires the provider directory or directories to be
available on the plan's or insurer's Internet Web site and
available without any requirement that a member of the
public or potential enrollee indicate intent to obtain
coverage from the plan or insurer, without demonstrating
coverage with the plan or insurer, providing a policy
number, providing any other identifying information, or
creating or accessing an account, and accessible through a
clearly identifiable link or tab.
4) Requires searches by name, practice address, National
Provider Identifier number, California license, facility or
identification number, product, tier, provider language,
medical group or independent practice association, hospital
or clinic, as appropriate.
5) Requires the plan or insurer to update the provider
directory or directories, at least weekly, with any change
to contracting providers, as specified.
6) Requires the provider directory or directories to
include both an email address and a telephone number for
members of the public and providers to notify the plan if
the provider directory information appears to be
inaccurate.
7) Establishes requirements on full service and specialized
health plans and insurers for inclusion in the directory or
directories.
8) Requires by December 31, 2016, DMHC and CDI to develop
uniform provider directory standards to permit consistency
and the development of multi plan directories to determine
the plan a physician or other provider is available
through. Requires by July 31, 2016, or no later than 12
months after the date that provider directory standards are
developed by DMHC and CDI, a plan or insurer to use the
standards for each product offered by the plan or insurer.
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9) Requires plans or insurers to ensure processes are in
place to allow providers to promptly verify or submit
changes to demographic information and participation status
that at a minimum, include an online interface for
providers to submit verification or changes electronically
and to allow providers to receive an acknowledgement of
receipt from the plan or insurer.
10) Requires providers to verify or submit changes to
demographic information and participation status using the
process required by the plan or insurer.
Comments
1)Author's statement. According to the author, Californians
shopping for health insurance must have confidence in provider
directory information in order to make coverage 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 health insurance carriers and 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 also 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, markets and programs. This
bill would establish uniform provider directory standards and
require weekly updates of online directories.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: Yes
According to the Assembly Appropriations Committee:
1)One-time costs to DMHC in the hundreds of thousands (Managed
Care Fund), and in the range of $100,000 for CDI (Insurance
Fund) for development of complex regulations related to
standard provider directories.
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2)Enforcement costs are unknown but likely significant for both
DMHC and CDI. Most costs would fall on DMHC, as they now
regulate the vast majority of the marketplace. Enforcement
and complaint resolution costs would depend on compliance and
level of consumer complaints.
3)Although not a direct state cost, health plans indicate the
complex and prescriptive nature of the requirements translate
into several million dollars of one-time infrastructure costs
per plan, and significant costs ongoing. Increased
administrative costs can be passed on to consumers and
purchasers, including the state, as higher premiums and
cost-sharing and lower benefits.
SUPPORT: (Verified9/10/15)
California Pan-Ethnic Health Network (co-source)
Consumers Union (co-source)
Health Access California (co-source)
AARP
AIDS Project Los Angeles
ALS Association Golden West Chapter
American Cancer Society Cancer Action Network
American Federation of State, County, and Municipal Employees
Asian Law Alliance
California Academy of Physician Assistants
California Advocates for Nursing Home Reform
California Association of Health Underwriters
California Black Health Network
California Chapter American College of Emergency Physicians
California Chapter National Association of Social Workers
California Chronic Care Coalition
California Council of Community Mental Health Agencies
California Coverage and Health Initiatives
California Dental Association
California Labor Federation
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California Optometric Association
California Pharmacists Association
California Primary Care Association
California School Boards Association
California School Employees Association
California State Council of the Service Employees International
Union
California Teachers Association
CALPIRG
Children Now
Children's Defense Fund California
Having Our Say Coalition
Leukemia and Lymphoma Society
Local Health Plans of California
Mental Health America of California
Montebello Unified School District
National Health Law Program
National Multiple Sclerosis Society California Action Network
Osteopathic Physicians and Surgeons of California
Southeast Asia 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
The Leukemia and Lymphoma Society
Ukiah Unified School District
United Ways of California
Western Center on Law and Poverty
OPPOSITION: (Verified9/10/15)
California Association of Physician Groups
Greater Newport Physicians
Memorial Care Medical Group
Pioneer Medical Group
Riverside Medical Clinic
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Scripps Health Plan Services Inc.
Sharp Community Medical Group
SynerMed Innovating Healthcare
ARGUMENTS IN SUPPORT: The California Pan Ethnic Health
Network (CPEHN), cosponsor of this bill writes, health care
coverage alone does not ensure consumers can access care.
Consumers rely on information supplied by health plan provider
directories to make decisions about which plans best meet their
needs. Errors and misleading information in provider directories
can become a huge obstacle for individuals in accessing care.
These obstacles are exacerbated in communities of color who
often face an insufficient distribution of providers,
transportation barriers, language barriers, and lack of flexible
hours. Incorrect or out-of-date provider directories further
limit the number of available providers, may delay timely access
to care, require excessive amount of travel or prevent a
consumer from receiving culturally and linguistically
appropriate care. Consumers Union and Health Access California,
also cosponsors of this bill, writes without knowing which
providers are in the network, consumers cannot keep medical
costs under control and avoid the surprise medical bills that
can come with getting care from out-of-network providers.
California recognized the importance of provider directories by
enacting a law on access to them a decade ago. Since that time,
technology has transformed, making information once available
only in telephone book-sized tomes now more readily accessible
online. The statutes have not been updated to reflect both
advances in technology and the transformation of the health
insurance landscape of active consumers shopping for coverage.
The first ACA open enrollment period drew significant attention
to the issue of inaccurate and insufficiently accessible
provider directories. Some consumers faced difficulty getting
accurate provider information prior to enrolling; others once
enrolled found that the directories they relied upon were not up
to date. These issues prompted DMHC to audit two of
California's largest insurers last summer and fall, revealing
deficiencies in their provider directories. Health Access
California believes this bill is the next logical step now that
timely access and network adequacy requirements are in place.
The Montebello Unified School District supports this bill
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indicating that many of their employees selected a certain
CalPERS plan based on misinformation by the plan that a
community hospital was in the network. This hospital continues
to be listed in the network three months later despite CalPERS
responding to the district that it was working with the plan "to
ensure their website is clear and understandable to our
members."
ARGUMENTS IN OPPOSITION: The California Association of
Physician Groups and individual medical groups have raised
concerns about provisions of this bill which would allow
payments to be delayed to providers who do not respond to plan
attempts to update directory information. Concerns have also
been raised about implementation timelines and the burdens this
creates for provider groups.
ASSEMBLY FLOOR: 69-9, 9/10/15
AYES: Achadjian, Alejo, Baker, Bigelow, Bloom, Bonilla, Bonta,
Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu,
Chu, Cooley, Cooper, Dababneh, Daly, Dodd, Eggman, Frazier,
Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson,
Gomez, Gonzalez, Gordon, Gray, Hadley, Roger Hernández,
Holden, Irwin, Jones, Jones-Sawyer, Lackey, Levine, Linder,
Lopez, Low, Maienschein, Mayes, McCarty, Medina, Mullin,
Nazarian, Obernolte, O'Donnell, Perea, Quirk, Rendon,
Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark
Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams,
Wood, Atkins
NOES: Travis Allen, Brough, Dahle, Beth Gaines, Grove, Harper,
Mathis, Melendez, Patterson
NO VOTE RECORDED: Kim, Olsen
Prepared by:Teri Boughton / HEALTH /
9/10/15 23:22:47
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