BILL NUMBER: SB 1135 AMENDED
BILL TEXT
AMENDED IN SENATE JUNE 1, 2016
AMENDED IN SENATE MARCH 30, 2016
INTRODUCED BY Senator Monning
FEBRUARY 18, 2016
An act to amend Section 1368.02 of, and to add
Section 1367.031 to, to the Health and
Safety Code, to add Sections 10133.53 and 10133.662 to the
Insurance Code, and to add Section 14450.1 to the Welfare and
Institutions Code, and to add Section 10133.53 to the
Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
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.
Existing 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.
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, to provide information to enrollees and
insureds regarding the standards for timely access to health care
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. 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
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 at a minimum shall provide
information regarding appointment wait times for urgent care,
nonurgent primary care, nonurgent specialty care, and telephone
screening established pursuant to Section 1367.03 to enrollees and
contracting providers. The information shall also include notice of
the availability of interpreter services at the time of the
appointment pursuant to Section 1367.04. A health care service plan
may indicate that exceptions to appointment wait times may apply if
the department has found exceptions to be permissible.
(c) 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.
(d) 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."
(e) This section shall apply to plans with Medi-Cal managed care
plan contracts with the State Department of Health Care Services
pursuant to Chapter 7 (commencing with Section 14000) and Chapter 8
(commencing with Section 14200) of Part 3 of Division 9 of the
Welfare and Institutions Code.
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) (1) 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:
"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."
(2) 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. SEC. 2. 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
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 at a minimum shall provide information
regarding appointment wait times for urgent care, nonurgent primary
care, nonurgent specialty care, and telephone screening established
pursuant to Section 10133.5 to insureds and contracting providers.
The information shall also include notice of the availability of
interpreter services at the time of the appointment pursuant to
Section 10133.8. A health insurer for a policy of health insurance
may indicate that exceptions to appointment wait times may apply if
the department has found exceptions to be permissible.
(c) 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
policyholders 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.
(d) 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. Section 14450.1 is added to the Welfare
and Institutions Code, to read:
14450.1. Medi-Cal managed care plans shall include on the card
presented by enrollees to providers as proof of coverage the
toll-free telephone number for the department's Medi-Cal Managed Care
Office of the Ombudsman. A plan may omit this information if it
complies with paragraph (1) of subdivision (b) of Section 1368.02 of
the Health and Safety Code.
SEC. 6. SEC. 3. 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.