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 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, shall provide
5information to an enrollee regarding the standards for timely access
6to care adopted pursuant to Section 1367.03 and the information
7required by this section, including information related to receipt
8of interpreter services in a timely manner, no less than annually.
9(b) A health care service plan at a minimum shall provide
10information regarding appointment wait times for urgent care,
11nonurgent primary care, nonurgent specialty care, and telephone
12screening established pursuant to Section 1367.03 to enrollees and
13contracting providers. The information shall
also include notice
14of the availability of interpreter services at the time of the
15appointment pursuant to Section 1367.04. A health care service
P3 1plan may indicate that exceptions to appointment wait times may
2apply if the department has found exceptions to be permissible.
3(c) The information required to be provided pursuant to this
4section shall be provided to an enrollee with individual coverage
5upon initial enrollment and annually thereafter upon renewal, and
6to enrollees and subscribers with group coverage upon initial
7enrollment and annually thereafter upon renewal. The information
8shallbegin insert alsoend insert be provided in the following manner:
9(1) In a separate section of the evidence of coverage
titled
10“Timely Access to Care.”
11(2) In the same manner and place that notice of language
12assistance programs is provided pursuant to Section 1367.04 and
13the regulations adopted thereunder.
14(3) In a separate section of the provider directory published and
15maintained by the health care service plan pursuant to Section
161367.27. The separate section shall be titled “Timely Access to
17Care.”
18(4) On the Internet Web site published and maintained by the
19health care service plan, in a manner that allows enrollees and
20prospective enrollees to easily locate the information.
21(d) begin insert(1)end insertbegin insert end insert A health care service plan shall also provide the
22information required by this section to contracting providers on
23no less than an annual basis, and shall additionally provide a
24contracting provider with the following information:
26“If one of your patients is unable to obtain a timely referral,
27either you or your patient may call the health care service plan or
28the Department of Managed Health Care Help Center at
291-888-HMO-2219 to obtain help.
30California law requires a health care service plan to provide or
31arrange for the provision of covered health care services in a timely
32manner appropriate for the nature of the enrollee’s condition,
33consistent with good professional practice. If an appointment is
34delayed or extended, the referring or treating
health care
35professional shall note in the relevant record that a longer waiting
36time will not have a detrimental effect on the health of the enrollee.
37It is the obligation of the health care service plan to have
38sufficient numbers of contracted providers to maintain compliance
39with timely access to care for enrollees. If a contracting provider
40is unable to provide care in a timely manner consistent with the
P4 1requirements for timely access to care, the health care service plan
2shall have in place policies and procedures to ensure that the
3enrollee shall receive timely access to care.”
4
(2) A health care service plan may comply with this subdivision
5by including the information with an existing communication with
6a contracting provider.
8(e) This section shall apply tobegin delete plans withend delete Medi-Cal managed
9care plan contractsbegin insert entered intoend insert with the State Department of Health
10Care Services pursuant to Chapter 7 (commencing with Section
1114000)begin delete andend deletebegin insert orend insert Chapter 8 (commencing with Section 14200) of
12Part 3 of Division 9 of the Welfare and Institutions Code.
Section 10133.53 is added to the Insurance Code, to
14read:
(a) Abegin delete policy ofend delete health insurancebegin insert policyend insert that is issued,
16renewed, or amended on or after January 1, 2017, shall provide
17information to an insured regarding the standards for timely access
18to care adopted pursuant to Section 10133.5 and the information
19required by this section, including information related to receipt
20of interpreter services in a timely manner, no less than annually.
21(b) A health insurer for abegin delete policy of health insurance,end deletebegin insert
health
22insurance policy,end insert as defined in subdivision (b) of Section 106, that
23provides or arranges for hospital or physician services at a
24minimum shall provide information regarding appointment wait
25times for urgent care, nonurgent primary care, nonurgent specialty
26care, and telephone screening established pursuant to Section
2710133.5 to insureds and contracting providers. The information
28shall also include notice of the availability of interpreter services
29at the time of the appointment pursuant to Section 10133.8. A
30health insurer for a policy of health insurance may indicate that
31exceptions to appointment wait times may apply if the department
32has found exceptions to be permissible.
33(c) 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 policyholders with group coverage upon
37initial enrollment and annually thereafter upon renewal. The
38information shallbegin insert alsoend insert
be provided in the following manner:
39(1) In a separate section of the evidence of coverage titled
40“Timely Access to Care.”
P5 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(d) begin insert(1)end insertbegin insert end insert A health insurer shall also provide the information
11required by this section to contracting providers on no less than
12an annual basis, and shall additionally provide a contracting
13provider with the following information:
15“If one of your patients is unable to obtain a timely referral,
16either you or your patient may call the health insurer or the
17Department of Insurance at 1-800-927-4357 to obtain help.
18California law requires a health insurer to provide or arrange for
19the provision of covered health care
services in a timely manner
20appropriate for the nature of the insured’s condition, consistent
21with good professional practice. If an appointment is delayed or
22extended, the referring or treating health care professional shall
23note in the relevant record that a longer waiting time will not have
24a detrimental effect on the health of the insured.
25It is the obligation of the health insurer to have sufficient
26numbers of contracted providers to maintain compliance with
27timely access to care for insureds. If a contracting provider is
28unable to provide care in a timely manner consistent with the
29requirements for timely access to care, the health insurer shall have
30in place policies and procedures to ensure that the insured shall
31receive timely access to care.”
32
(2) A health insurer may comply with this subdivision by
33including the information with an existing communication with a
34contracting provider.
No reimbursement is required by this act pursuant to
37Section 6 of Article XIII B of the California Constitution because
38the only costs that may be incurred by a local agency or school
39district will be incurred because this act creates a new crime or
40infraction, eliminates a crime or infraction, or changes the penalty
P6 1for a crime or infraction, within the meaning of Section 17556 of
2the Government Code, or changes the definition of a crime within
3the meaning of Section 6 of Article XIII B of the California
4Constitution.
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