Amended in Assembly August 15, 2016

Amended in Assembly June 30, 2016

Amended in Senate June 1, 2016

Amended in Senate March 30, 2016

Senate Bill No. 1135

Introduced by Senator Monning

February 18, 2016

An act to add Section 1367.031 to the Health and Safety 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 begin insert that provides benefits through contracts with providers for alternative rates end insert that is issued, renewed, or amended on or after begin delete January end delete begin insert July end insert 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 begin insert that contracts with providers for alternative rates of payment end insert 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 begin delete January end delete begin insert July end insert 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. begin insert A health care
service plan may include this information with other materials
sent to the enrollee. end insert The information shall also be provided in the
following manner:

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

begin delete

(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.

end delete begin insert

(2) At least annually, in or with newsletters, outreach, or other
materials that are routinely disseminated to the plan’s enrollees.

end insert

(3)  begin delete In end delete begin insert Commencing January 1, 2018, in end insert 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.

begin delete

(d) (1) 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.”

end delete begin insert

(d) (1) A health care service plan shall provide the information
required by this section to contracting providers on no less than
an annual basis.

end insert begin insert

(2) A health care service plan shall also inform a contracting
provider of all of the following:

end insert begin insert

(A) Information about a health care service plan’s obligation
under California law to provide or arrange for timely access to
care.

end insert begin insert

(B) How a contracting provider or enrollee can contact the
health care service plan to obtain assistance if a patient is unable
to obtain a timely referral to an appropriate provider.

end insert begin insert

(C) The toll-free telephone number for the Department of
Managed Health Care where providers and enrollees can file a
complaint if they are unable to obtain a timely referral to an
appropriate provider.

end insert begin delete

(2)

end delete

begin insert (3) end insert  A health care service plan may comply with this subdivision
by including the information with an existing communication with
a contracting provider.

begin delete end delete

(e) This section shall apply to Medi-Cal managed care plan
contracts entered into with the State Department of Health Care
Services pursuant to Chapter 7 (commencing with Section 14000)
or Chapter 8 (commencing with Section 14200) of Part 3 of
Division 9 of the Welfare and Institutions Code.

SEC. 2.  

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

10133.53.  

(a) A health insurance policy that is issued, renewed,
or amended on or after begin delete January end delete begin insert July end insert 1, 2017, begin insert that provides benefits
through contracts with providers for alternative rates pursuant to
Section 10133 end insert 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 begin delete for a health insurance policy, as defined in
subdivision (b) of Section 106, that provides or arranges for
hospital or physician services at a minimum shall end delete begin insert that contracts
with providers for alternative rates of payment pursuant to Section
10133 shall, at a minimum, end insert 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 begin delete for a policy of health insurance end delete
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 policyholders with group coverage upon
initial enrollment and annually thereafter upon renewal. begin insert An insurer
may include this information with other materials sent to the
insured. end insert The information shall also be provided in the following
manner:

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

begin delete

(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.

end delete begin insert

(2) At least annually, in or with newsletters, outreach, or other
materials that are routinely disseminated to the policy’s insureds.

end insert

(3)  begin delete In end delete begin insert Commencing January 1, 2018, in end insert 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.

begin delete

(d) (1) 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.”

end delete begin insert

(d) (1) A health insurer shall provide the information required
by this section to contracting providers on no less than an annual
basis.

end insert begin insert

(2) A health insurer shall also inform a contracting provider of
all of the following:

end insert begin insert

(A) Information about a health insurer’s obligation under
California law to provide or arrange for timely access to care.

end insert begin insert

(B) How a contracting provider or insured can contact the
health insurer to obtain assistance if a patient is unable to obtain
a timely referral to an appropriate provider.

end insert begin insert

(C) The toll-free telephone number for the Department of
Insurance where providers and insureds can file a complaint if
they are unable to obtain a timely referral to an appropriate
provider.

end insert begin delete

(2)

end delete

begin insert (3) end insert   A health insurer may comply with this subdivision by
including the information with an existing communication with a
contracting provider.

begin delete end delete

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.