BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 137| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- 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 SB 137 Page 2 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 SB 137 Page 3 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 SB 137 Page 4 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. SB 137 Page 5 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. SB 137 Page 6 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 SB 137 Page 7 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 SB 137 Page 8 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 SB 137 Page 9 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 **** SB 137 Page 10