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


                                   ****  END  ****








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