Senate Bill No. 1135

Introduced by Senator Monning

February 18, 2016

An act to amend Section 1368.02 of, and to add Section 1367.031 to, the Health and Safety Code, and to add Sections 10133.53 and 10133.662 to the Insurance Code, relating to health care coverage.

LEGISLATIVE COUNSEL’S DIGEST

SB 1135, as introduced, Monning. Health care coverage: notice of timely access to care.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires each department to develop and adopt regulations to ensure that enrollees have access to needed health care services in a timely manner.

This bill would require a health care service plan contract or a health insurance policy that is issued, renewed, or amended on or after January 1, 2017, and that provides coverage for hospital, physician, or dental services, to require the plan or insurer to provide information to enrollees and insureds regarding access to health care services, including appointment wait times, the availability of triage or screening services by telephone, the availability of interpreter services at the time of an appointment, and information regarding consumer assistance provided by the licensing agencies, as specified. The bill would also require a health care service plan or a health insurer to provide a contracting health care provider with specified information relating to the provision of referrals or health care services in a timely manner.

Because a willful violation of the bill’s provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

The people of the State of California do enact as follows:

SECTION 1.  

Section 1367.031 is added to the Health and
Safety Code, to read:

1367.031.  

(a) A health care service plan contract that is issued,
renewed, or amended on or after January 1, 2017, shall provide
that the health care service plan shall provide information to an
enrollee regarding the standards for timely access to care adopted
pursuant to Section 1367.03 and the information required by this
section, including information related to receipt of interpreter
services in a timely manner, no less than annually.

(b) A health care service plan that provides or arranges for
hospital or physician services shall at a minimum provide the
following information regarding timely access to care to enrollees
and contracting providers:

(1) An urgent care appointment shall be offered to the enrollee
within 48 hours of a request for an appointment, unless prior
authorization is required.

(2) A nonurgent primary care appointment shall be offered to
the enrollee within 10 business days of a request for an
appointment.

(3) A nonurgent appointment with a specialist shall be offered
to the enrollee within 15 business days of a request for an
appointment.

(4) Triage or screening services are available by telephone to
the enrollee 24 hours per day, 7 days per week, from a designated
telephone number. A call made to that number shall be returned
by a qualified health professional within 30 minutes.

(5) Interpreter services shall be available at the time of the
appointment, if needed.

(c) A health care service plan that provides coverage for dental
services, either directly or through a contract with another entity,
shall at a minimum provide the following information regarding
timely access to care to enrollees and providers:

(1) Urgent care shall be offered to an enrollee within 72 hours
of a request for an appointment.

(2) Nonurgent care shall be offered to an enrollee within 36
days of a request for an appointment.

(3) Preventive care shall be offered to an enrollee within 40
days of a request for an appointment.

(4) Interpreter services shall be available at the time of the
appointment, if needed.

(d) The information required to be provided pursuant to this
section shall be provided to an enrollee with individual coverage
upon initial enrollment and annually thereafter upon renewal, and
to enrollees and subscribers with group coverage upon initial
enrollment and annually thereafter upon renewal. The information
shall be provided in the following manner:

(1) In a separate section of the evidence of coverage titled
“Timely Access to Care.”

(2) In the same manner and place that notice of language
assistance programs is provided pursuant to Section 1367.04 and
the regulations adopted thereunder.

(3) In a separate section of the provider directory published and
maintained by the health care service plan pursuant to Section
1367.27. The separate section shall be titled “Timely Access to
Care.”

(4) On the Internet Web site published and maintained by the
health care service plan, in a manner that allows enrollees and
prospective enrollees to easily locate the information.

(e) A health care service plan shall also provide the information
required by this section to contracting providers on no less than
an annual basis, and shall additionally provide a contracting
provider with the following information:

“If one of your patients is unable to obtain a timely referral,
either you or your patient may call the health care service plan or
the Department of Managed Health Care Help Center at
1-888-HMO-2219 to obtain help.

“California law requires a health care service plan to provide or
arrange for the provision of covered health care services in a timely
manner appropriate for the nature of the enrollee’s condition,
consistent with good professional practice. If an appointment is
delayed or extended, the referring or treating health care
professional shall note in the relevant record that a longer waiting
time will not have a detrimental effect on the health of the enrollee.

“It is the obligation of the health care service plan to have
sufficient numbers of contracted providers to maintain compliance
with timely access to care for enrollees. If a contracting provider
is unable to provide care in a timely manner consistent with the
requirements for timely access to care, the health care service plan
shall have in place policies and procedures to ensure that the
enrollee shall receive timely access to care.”

SEC. 2.  

Section 1368.02 of the Health and Safety Code is
amended to read:

1368.02.  

(a) The director shall establish and maintain a toll-free
telephone number for the purpose of receiving complaints regarding
health care service plans regulated by the director.

(b)  begin insert (1) end insert begin insert   end insert begin insert Every health care service plan shall include the
department’s toll-free telephone number and Internet Web site
address on the card presented by enrollees to providers as proof
of coverage. The department’s toll-free telephone number and
Internet Web site address shall be displayed immediately below
the toll-free telephone number for the health care service plan.
The health care service plan may include the following statement
on the card: end insert
begin insert end insert

begin insert

“Please contact us first regarding any complaint. If you wish to
complain directly to the government agency that licenses this health
plan, please call 1-888-HMO-2219.”

end insert
begin insert end insert

begin insert (2) end insert begin insert   end insert Every health care service plan shall publish the department’s
toll-free telephone number, the department’s TDD line for the
hearing and speech impaired, the plan’s telephone number, and
the department’s Internet Web site address, on every plan contract,
on every evidence of coverage, on copies of plan grievance
procedures, on plan complaint forms, and on all written notices to
enrollees required under the grievance process of the plan,
including any written communications to an enrollee that offer the
enrollee the opportunity to participate in the grievance process of
the plan and on all written responses to grievances. The
department’s telephone number, the department’s TDD line, the
plan’s telephone number, and the department’s Internet Web site
address shall be displayed by the plan in each of these documents
in 12-point boldface type in the following regular type statement:

“The California Department of Managed Health Care is
responsible for regulating health care service plans. If you have a
grievance against your health plan, you should first telephone your
health plan at (insert health plan’s telephone number) and use your
health plan’s grievance process before contacting the department.
Utilizing this grievance procedure does not prohibit any potential
legal rights or remedies that may be available to you. If you need
help with a grievance involving an emergency, a grievance that
has not been satisfactorily resolved by your health plan, or a
grievance that has remained unresolved for more than 30 days,
you may call the department for assistance. You may also be
eligible for an Independent Medical Review (IMR). If you are
eligible for IMR, the IMR process will provide an impartial review
of medical decisions made by a health plan related to the medical
necessity of a proposed service or treatment, coverage decisions
for treatments that are experimental or investigational in nature
and payment disputes for emergency or urgent medical services.
The department also has a toll-free telephone number
(1-888-HMO-2219) and a TDD line (1-877-688-9891) for the
hearing and speech impaired. The department’s Internet Web site
http://www.hmohelp.ca.gov has complaint forms, IMR application
forms and instructions online.”

SEC. 3.  

Section 10133.53 is added to the Insurance Code, to
read:

10133.53.  

(a) A policy of health insurance that is issued,
renewed, or amended on or after January 1, 2017, shall provide
that the insurer shall provide information to an insured regarding
the standards for timely access to care adopted pursuant to Section
10133.5 and the information required by this section, including
information related to receipt of interpreter services in a timely
manner, no less than annually.

(b) A health insurer for a policy of health insurance, as defined
in subdivision (b) of Section 106, that provides or arranges for
hospital or physician services shall at a minimum provide the
following information regarding timely access to care to insureds
and contracting providers:

(1) An urgent care appointment shall be offered to the insured
within 48 hours of a request for an appointment, unless prior
authorization is required.

(2) A nonurgent primary care appointment shall be offered to
the insured within 10 business days of a request for an appointment.

(3) A nonurgent appointment with a specialist shall be offered
to the insured within 15 business days of a request for an
appointment.

(4) Triage or screening services are available by telephone to
the insured 24 hours per day, 7 days per week, from a designated
telephone number. A call made to that number shall be returned
by a qualified health professional within 30 minutes.

(5) Interpreter services shall be available at the time of the
appointment, if needed.

(c) A policy of health insurance that provides coverage for dental
services, either directly or through a contract with another entity,
shall at a minimum provide the following information regarding
timely access to care to insureds and providers:

(1) Urgent care shall be offered to the insured within 72 hours
of a request for an appointment.

(2) Nonurgent care shall be offered to the insured within 36
days of a request for an appointment.

(3) Preventive care shall be offered to the insured within 40
days of a request for an appointment.

(4) Interpreter services shall be available at the time of the
appointment, if needed.

(d) The information required to be provided pursuant to this
section shall be provided to an insured with individual coverage
upon initial enrollment and annually thereafter upon renewal, and
to insureds and group policy holders with group coverage upon
initial enrollment and annually thereafter upon renewal. The
information shall be provided in the following manner:

(1) In a separate section of the evidence of coverage titled
“Timely Access to Care.”

(2) In the same manner and place that notice of language
assistance programs is provided pursuant to Section 10133.8 and
the regulations adopted thereunder.

(3) In a separate section of the provider directory published and
maintained by the insurer pursuant to Section 10133.15. The
separate section shall be titled “Timely Access to Care.”

(4) On the Internet Web site published and maintained by the
insurer, in a manner that allows insureds and prospective insureds
to easily locate the information.

(e) A health insurer shall also provide the information required
by this section to contracting providers on no less than an annual
basis, and shall additionally provide a contracting provider with
the following information:

“If one of your patients is unable to obtain a timely referral,
either you or your patient may call the health insurer or the
Department of Insurance at 1-800-927-4357 to obtain help.

“California law requires a health insurer to provide or arrange
for the provision of covered health care services in a timely manner
appropriate for the nature of the insured’s condition, consistent
with good professional practice. If an appointment is delayed or
extended, the referring or treating health care professional shall
note in the relevant record that a longer waiting time will not have
a detrimental effect on the health of the insured.

“It is the obligation of the health insurer to have sufficient
numbers of contracted providers to maintain compliance with
timely access to care for insureds. If a contracting provider is
unable to provide care in a timely manner consistent with the
requirements for timely access to care, the health insurer shall have
in place policies and procedures to ensure that the insured shall
receive timely access to care.”

SEC. 4.  

Section 10133.662 is added to the Insurance Code, to
read:

10133.662.  

Every health insurer shall include the department’s
toll-free telephone number and Internet Web site address on the
card presented by insureds to providers as proof of coverage. The
department’s toll-free telephone number and Internet Web site
address shall be displayed immediately below the toll-free
telephone number for the insurer. The insurer may include the
following statement on the card:

“Please contact us first regarding any complaint. If you wish to
complain directly to the government agency that licenses this
insurer, please call 1-800-927-4357.”

SEC. 5.  

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.