SB 1135, as amended, 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.
begin insertExisting law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law requires each prepaid health plan to establish a grievance procedure under which enrollees may submit their grievances.
end insertThis 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,begin delete and that provides coverage for hospital, physician, or dental services, to require the plan or insurerend delete to provide information to enrollees and insureds regardingbegin insert the standards for timelyend insert access to health carebegin delete 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.end deletebegin insert services and other specified health care access information, including information related to receipt of interpreter services in a timely manner, no less than annually, and would make these provisions applicable to Medi-Cal managed care plans. The bill would require a health care service plan, including a Medi-Cal managed care plan, or health insurer to provide an enrollee or an insured with information regarding consumer assistance provided by the licensing agency, as specified.end insert 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 1367.031 is added to the Health and
2Safety Code, to read:
(a) A health care service plan contract that is issued,
4renewed, or amended on or after January 1, 2017,begin delete shall provide shall provide information to an
5that the health care service planend delete
6enrollee regarding the standards for timely access to care adopted
7pursuant to Section 1367.03 and the information required by this
8section, including information related to receipt of interpreter
9services in a timely manner, no less than annually.
10(b) A health care service planbegin delete that provides or arranges for begin insert
at a minimum shall provide information
11hospital or physician services shall at a minimum provide the
P3 1following information regarding timely access to care to enrollees
2and contracting providers:end delete
3regarding appointment wait times for urgent care, nonurgent
4primary care, nonurgent specialty care, and telephone screening
5established pursuant to Section 1367.03 to enrollees and
6contracting providers. The information shall also include notice
7of the availability of interpreter services at the time of the
8appointment pursuant to Section 1367.04. A health care service
9plan may indicate that exceptions to appointment wait times may
10apply if the department has found exceptions to be permissible.end insert
11(1) An urgent care appointment shall
be offered to the enrollee
12within 48 hours of a request for an appointment, unless prior
13authorization is required.
14(2) A nonurgent primary care appointment shall be offered to
15the enrollee within 10 business days of a request for an
16appointment.
17(3) A nonurgent appointment with a specialist shall be offered
18to the enrollee within 15 business days of a request for an
19appointment.
20(4) Triage or screening services are available by telephone to
21the enrollee 24 hours per day, 7 days per week, from a designated
22telephone number. A call made to that number shall be returned
23by a qualified health professional within 30 minutes.
24(5) Interpreter services shall be available at the time of the
25appointment, if needed.
26(c) A health care service plan that provides coverage for dental
27services, either directly or through a contract with another entity,
28shall at a minimum provide the following information regarding
29timely access to care to enrollees and providers:
30(1) Urgent care shall be offered to an enrollee within 72 hours
31of a request for an appointment.
32(2) Nonurgent care shall be offered to an enrollee within 36
33days of a request for an appointment.
34(3) Preventive care shall be offered to an enrollee within 40
35days of a request for an appointment.
36(4) Interpreter services shall be available at the time of the
37appointment, if needed.
38(d)
end delete
39begin insert(c)end insert The information required to be provided pursuant to this
40section shall be provided to an enrollee with individual coverage
P4 1upon initial enrollment and annually thereafter upon renewal, and
2to enrollees and subscribers with group coverage upon initial
3enrollment and annually thereafter upon renewal. The information
4shall be provided in the following manner:
5(1) In a separate section of the evidence of coverage titled
6“Timely Access to Care.”
7(2) In the same manner and place that notice of language
8assistance programs is provided pursuant to Section 1367.04 and
9the regulations adopted thereunder.
10(3) In a separate section of the provider directory published and
11maintained by the health care service plan pursuant to Section
121367.27. The separate section shall be titled “Timely Access to
13Care.”
14(4) On the Internet Web site published and maintained by the
15health care service plan, in a manner that allows enrollees and
16prospective enrollees to easily locate the information.
17(e)
end delete
18begin insert(d)end insert A health care service plan shall also provide the information
19required by this section to
contracting providers on no less than
20an annual basis, and shall additionally provide a contracting
21provider with the following information:
23“If one of your patients is unable to obtain a timely referral,
24either you or your patient may call the health care service plan or
25the Department of Managed Health Care Help Center at
261-888-HMO-2219 to obtain help.
27begin delete“California end deletebegin insertCalifornia end insertlaw requires a health care service plan to
28provide or arrange for the provision of covered health care services
29in a timely manner appropriate for the nature of the enrollee’s
30condition, consistent with good professional practice. If an
31
appointment is delayed or extended, the referring or treating health
32care professional shall note in the relevant record that a longer
33waiting time will not have a detrimental effect on the health of the
34enrollee.
35begin delete“It end deletebegin insertIt end insertis the obligation of the health care service plan to have
36sufficient numbers of contracted providers to maintain compliance
37with timely access to care for enrollees. If a contracting provider
38is unable to provide care in a timely manner consistent with the
39requirements for timely access to care, the health care service plan
P5 1shall have in place policies and procedures to ensure that the
2enrollee shall receive timely access to care.”
4
(e) This section shall apply to plans with Medi-Cal managed
5care plan contracts with the State Department of Health Care
6Services pursuant to Chapter 7 (commencing with Section 14000)
7and Chapter 8 (commencing with Section 14200) of Part 3 of
8Division 9 of the Welfare and Institutions Code.
Section 1368.02 of the Health and Safety Code is
10amended to read:
(a) The director shall establish and maintain a toll-free
12telephone number for the purpose of receiving complaints regarding
13health care service plans regulated by the director.
14(b) (1) Every health care service plan shall include the
15department’s toll-free telephone number and Internet Web site
16address on the card presented by enrollees to providers as proof
17of coverage. The department’s toll-free telephone number and
18Internet Web site address shall be displayed immediately below
19the toll-free telephone number for the health care service plan. The
20health care service plan may include the following statement on
21the card:
22“Please contact us first regarding any complaint. If you wish to
23complain directly to the government agency that licenses this health
24plan, please call 1-888-HMO-2219.”
26(2) Every health care service plan shall publish the department’s
27toll-free telephone number, the department’s TDD line for the
28hearing and speech impaired, the plan’s telephone number, and
29the department’s Internet Web site address, on every plan contract,
30on every evidence of coverage, on copies of plan grievance
31procedures, on plan complaint forms, and on all written notices to
32enrollees required under the grievance process of the plan,
33including any written communications to an enrollee that offer the
34enrollee the opportunity to participate in the grievance process of
35the plan and on all
written responses to grievances. The
36department’s telephone number, the department’s TDD line, the
37plan’s telephone number, and the department’s Internet Web site
38address shall be displayed by the plan in each of these documents
39in 12-point boldface type in the following regular type statement:
P6 1“The California Department of Managed Health Care is
2responsible for regulating health care service plans. If you have a
3grievance against your health plan, you should first telephone your
4health plan at (insert health plan’s telephone number) and use your
5health plan’s grievance process before contacting the department.
6Utilizing this grievance procedure does not prohibit any potential
7legal rights or remedies that may be available to you. If you need
8help with a grievance involving an emergency, a grievance that
9has not been satisfactorily resolved by your health plan,
or a
10grievance that has remained unresolved for more than 30 days,
11you may call the department for assistance. You may also be
12eligible for an Independent Medical Review (IMR). If you are
13eligible for IMR, the IMR process will provide an impartial review
14of medical decisions made by a health plan related to the medical
15necessity of a proposed service or treatment, coverage decisions
16for treatments that are experimental or investigational in nature
17and payment disputes for emergency or urgent medical services.
18The department also has a toll-free telephone number
19(1-888-HMO-2219) and a TDD line (1-877-688-9891) for the
20hearing and speech impaired. The department’s Internet Web site
21http://www.hmohelp.ca.gov has complaint forms, IMR application
22forms and instructions online.”
Section 10133.53 is added to the Insurance Code, to
24read:
(a) A policy of health insurance that is issued,
26renewed, or amended on or after January 1, 2017,begin delete shall provide shall provide information to an insured regarding
27that the insurerend delete
28the standards for timely access to care adopted pursuant to Section
2910133.5 and the information required by this section, including
30information related to receipt of interpreter services in a timely
31manner, no less than annually.
32(b) A health insurer for a policy of health insurance, as defined
33in subdivision (b) of Section 106, that provides or arranges for
34hospital or physician servicesbegin delete shall at a minimum provide the begin insert
at a minimum shall provide information
35following information regarding timely access to care to insureds
36and contracting providers:end delete
37regarding appointment wait times for urgent care, nonend insertbegin inserturgent
38primary care, nonend insertbegin inserturgent specialty care, and telephone screening
39established pursuant to Section 10133.5 to insureds and
40contracting providers. The information shall also include notice
P7 1of the availability of interpreter services at the time of the
2appointment pursuant to Section 10133.8. A health insurer for a
3policy of health insurance may indicate that exceptions to
4appointment wait times may apply if the department has found
5exceptions to be permissible.end insert
6(1) An urgent care appointment shall be offered to the insured
7within 48 hours of a request for an appointment, unless prior
8authorization is required.
9(2) A nonurgent primary care appointment shall be offered to
10the insured within 10 business days of a request for an appointment.
11(3) A nonurgent appointment with a specialist shall be offered
12to the insured within 15 business days of a request for an
13appointment.
14(4) Triage or screening services are available by telephone to
15the insured 24 hours per day, 7 days per week, from a designated
16telephone number. A call made to that number shall be returned
17by a qualified health professional within 30 minutes.
18(5) Interpreter services shall be available at the time of the
19appointment, if
needed.
20(c) A policy of health insurance that provides coverage for dental
21services, either directly or through a contract with another entity,
22shall at a minimum provide the following information regarding
23timely access to care to insureds and providers:
24(1) Urgent care shall be offered to the insured within 72 hours
25of a request for an appointment.
26(2) Nonurgent care shall be offered to the insured within 36
27days of a request for an appointment.
28(3) Preventive care shall be offered to the insured within 40
29days of a request for an appointment.
30(4) Interpreter services shall be available at the time of the
31appointment, if needed.
32(d)
end delete
33begin insert(c)end insert The information required to be provided pursuant to this
34section shall be provided to an insured with individual coverage
35upon initial enrollment and annually thereafter upon renewal, and
36to insureds and group policy holders with group coverage upon
37initial enrollment and annually thereafter upon renewal. The
38information shall be provided in the following manner:
39(1) In a separate section of the evidence of coverage titled
40“Timely Access to Care.”
P8 1(2) In the same manner and place that notice of language
2assistance programs is provided pursuant to Section 10133.8 and
3the regulations adopted thereunder.
4(3) In a separate section of the provider directory published and
5maintained by the insurer pursuant to Section 10133.15. The
6separate section shall be titled “Timely Access to Care.”
7(4) On the Internet Web site published and maintained by the
8insurer, in a manner that allows insureds and prospective insureds
9to easily locate the information.
10(e)
end delete
11begin insert(d)end insert A health insurer shall also provide the information required
12by this section to contracting providers on no less than an annual
13basis,
and shall additionally provide a contracting provider with
14the following information:
16“If one of your patients is unable to obtain a timely referral,
17either you or your patient may call the health insurer or the
18Department of Insurance at 1-800-927-4357 to obtain help.
19begin delete“California end deletebegin insertCalifornia end insertlaw requires a health insurer to provide
20or arrange for the provision of covered health care services in a
21timely manner appropriate for the nature of the insured’s condition,
22consistent with good professional practice. If an appointment is
23delayed or extended, the referring or treating health care
24professional shall note in the
relevant record that a longer waiting
25time will not have a detrimental effect on the health of the insured.
26begin delete“It end deletebegin insertIt end insertis the obligation of the health insurer to have sufficient
27numbers of contracted providers to maintain compliance with
28timely access to care for insureds. If a contracting provider is
29unable to provide care in a timely manner consistent with the
30requirements for timely access to care, the health insurer shall have
31in place policies and procedures to ensure that the insured shall
32receive timely access to care.”
Section 10133.662 is added to the Insurance Code, to
35read:
Every health insurer shall include the department’s
37toll-free telephone number and Internet Web site address on the
38card presented by insureds to providers as proof of coverage. The
39department’s toll-free telephone number and Internet Web site
40address shall be displayed immediately below the toll-free
P9 1telephone number for the insurer. The insurer may include the
2following statement on the card:
4“Please contact us first regarding any complaint. If you wish to
5complain directly to the government agency that licenses this
6insurer, please call 1-800-927-4357.”
begin insertend insert
7
begin insertSection 14450.1 is added to the end insertbegin insertWelfare and Institutions
9Codeend insertbegin insert, to read:end insert
Medi-Cal managed care plans shall include on the
11card presented by enrollees to providers as proof of coverage the
12toll-free telephone number for the department’s Medi-Cal Managed
13Care Office of the Ombudsman. A plan may omit this information
14if it complies with paragraph (1) of subdivision (b) of Section
151368.02 of the Health and Safety Code.
No reimbursement is required by this act pursuant to
18Section 6 of Article XIII B of the California Constitution because
19the only costs that may be incurred by a local agency or school
20district will be incurred because this act creates a new crime or
21infraction, eliminates a crime or infraction, or changes the penalty
22for a crime or infraction, within the meaning of Section 17556 of
23the Government Code, or changes the definition of a crime within
24the meaning of Section 6 of Article XIII B of the California
25Constitution.
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