BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1135
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|AUTHOR: |Monning |
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|VERSION: |March 30, 2016 |
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|HEARING DATE: |April 6, 2016 | | |
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|CONSULTANT: |Teri Boughton |
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SUBJECT : Health care coverage: notice of timely access to care
SUMMARY : Requires health plans, health insurers and Medi-Cal managed
care plans to notify enrollees and contracted providers about
information on timely access to care standards and information
about interpreter services, at least annually, and requires the
toll-free telephone number of the Department of Managed Health
Care, California Department of Insurance, or the Medi-Cal
Managed Care Office of the Ombudsman to be provided on the
enrollee or insureds proof of coverage card.
Existing law:
1)Establishes the Department of Managed Health Care (DMHC) to
regulate health plans, the California Department of Insurance
(CDI) to regulate insurers, including health insurers, and the
Department of Health Care Services (DHCS) to administer the
Medi-Cal program.
2)Requires DMHC to develop and adopt regulations to ensure that
enrollees have access to needed health care services in a
timely manner and consider the following as indicators of
timeliness of access to care:
a) Waiting times for appointments with physicians,
including primary care and specialty physicians;
Timeliness of care in an episode of illness, including the
timeliness of referrals and obtaining other services, if
needed; and,
b) Waiting time to speak to a physician, registered nurse,
or other qualified health professional acting within his or
her scope of practice who is trained to screen or triage an
enrollee who may need care.
SB 1135 (Monning) Page 2 of ?
3)Requires DMHC in developing these standards for timeliness of
access to consider clinical appropriateness, the nature of the
specialty, the urgency of care, and the requirements of other
provisions of law, including provisions governing utilization
review that may affect timeliness of access.
4)Requires DMHC to develop and adopt regulations establishing
standards and requirements to provide health plan enrollees
with appropriate access to language assistance in obtaining
health care services, including that plans have notices
advising limited-English-proficient persons of the
availability of free language assistance and other outreach
materials that are provided to enrollees. Pursuant to
regulations, requires the plan to describe processes for
including the notice with all vital documents, all enrollment
materials and all correspondence, if any, from the plan
confirming a new or renewed enrollment, and processes for
including statements, in English and in threshold languages,
about the availability of free language assistance services
and how to access them, in or with brochures, newsletters,
outreach and marketing materials and other materials that are
routinely disseminated to the plan's enrollees.
5)Requires CDI to promulgate regulations to ensure that insureds
have the opportunity to access needed health care service in a
timely manner and ensure adequacy of number and locations of
facilities and providers and consider the regulations adopted
by DMHC in an effort to accomplish maximum accessibility
within a cost efficient system of indemnification.
6)Requires, pursuant to CDI regulations, insurers to disclose
annually, in insurer newsletters or comparable communications
to covered persons, CDI's standards for timely access, the
insurer's process for ensuring timely access, and what steps a
covered person should take when experiencing access problems
inconsistent with timely access standards, including when and
how to access applicable CDI and insurer helplines.
7)Requires CDI to promulgate regulations applicable to all
individual and group policies of health insurance establishing
standards and requirements to provide insureds with
appropriate access to translated materials and language
assistance in obtaining covered benefits, including notices
advising limited-English-proficient persons of the
availability of free language assistance and other outreach
SB 1135 (Monning) Page 3 of ?
materials that are provided to insureds. Pursuant to CDI
regulations, this notice must be included in all welcome and
renewal packets, letters, correspondence, brochures,
newsletters, outreach and marketing materials, and any other
materials sent to insureds.
This bill:
1)Requires a health plan contract or health insurance policy
issued, renewed, or amended on or after January 1, 2017 to
provide information to an enrollee or insured regarding the
standards for timely access to care, as specified, including
information related to receipt of interpreter services in a
timely manner, no less than annually.
2)Requires, at a minimum, a health plan or health insurer to
provide information regarding appointment wait times for
urgent care, non-urgent primary care, non-urgent specialty
care, and telephone screening, as specified, to enrollees,
insureds and contracting providers. Authorizes a health plan
or insurer to indicate that exceptions to appointment wait
times may apply if DMHC or CDI has found exceptions
permissible.
3)Requires the information to be provided upon initial
enrollment and annually upon renewal, and in the following
manner:
a) In a separate section of the evidence of coverage titled
"Timely Access to Care;"
b) In the same manner and place that notice of language
assistance programs is provided, as specified;
c) In a separate section of the provider directory
published and maintained by the health plan or insurer and
titled "Timely Access to Care;" and,
d) On the Internet Web site published and maintained by the
health plan or insurer, in a manner that allows enrollees
or insureds, and prospective enrollees or insureds to
easily locate the information.
4)Requires the information to be provided to contracting
providers on no less than an annual basis, and to additionally
provide the following statement:
If one of your patients is unable to obtain a timely referral,
either you or your patient may call the health plan/health
SB 1135 (Monning) Page 4 of ?
insurer or the DMHC Help Center at 1-888-HMO-2219 or the CDI
at 1-800-927-4357 to obtain help.
California law requires a health plan or health insurer 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 or insured.
It is the obligation of the health plan or health insurer to
have sufficient numbers of contracted providers to maintain
compliance with timely access to care for enrollees or
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 plan or health insurer shall have
in place policies and procedures to ensure that the enrollee
or insured shall receive timely access to care.
5)Applies the provisions of this bill as described above, to
plans with Medi-Cal managed care plan contracts with DHCS, as
specified.
6)Requires every health plan or health insurer to include the
DMHC's or CDI's toll-free telephone number and Internet Web
site address on the card presented by enrollees or insureds to
providers as proof of coverage, displayed immediately below
the health plan's or health insurer's toll-free number.
7)Requires Medi-Cal managed care plans to include on the card
presented by enrollees to providers as proof of coverage the
toll-free telephone number for DHCS' Medi-Cal Managed Care
Office of the Ombudsman. Authorizes a plan to omit this
information if it complies with 6) above.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, very few
California consumers know that they are entitled to timely
access to care and in their preferred language. In addition, a
recent survey found that an overwhelming majority do not even
SB 1135 (Monning) Page 5 of ?
know which state regulator oversees their health plan or how
to file a complaint with the appropriate regulator should an
issue arise. The goal of SB 1135 is to help inform consumers
about their timely access rights and who to call when they are
having health issues. Better consumer knowledge on their
rights and how to file a complaint could lead to better
adherence to timely access requirements and provide more
accurate consumer complaint data for state regulators and
policymakers.
2)Timely access requirements. Both the DMHC and CDI have
similar timely access regulations which require each health
plan or health insurer to contract with adequate numbers of
physicians and other health care providers in each geographic
area to meet clinical and time elapsed standards. The DMHC
standards include:
a) Enrollees must be offered appointments for covered
health care services within a time period appropriate for
their condition(s);
b) Enrollees must be offered appointments within the
following timeframes:
i. Within 48 hours of a request for an
urgent care appointment for services that do not
require prior authorization.
ii. Within 96 hours of a request for an
urgent appointment for services that do require
prior authorization.
iii. Within 10 business days of a request for
non-urgent primary care appointments.
iv. Within 15 business days of a request for
an appointment with a specialist.
v. Within 10 business days of a request for
an appointment with non-physician mental health care
providers.
vi. Within 15 business days of a request for
a non-urgent appointment for ancillary services for
the diagnosis or treatment of injury, illness or
other health condition.
c) The applicable waiting time for an appointment may
be shorter or longer as clinically appropriate based on
the opinion of a qualified health care professional
acting within the scope of his or her practice consistent
SB 1135 (Monning) Page 6 of ?
with professionally recognized standards of practice. If
the waiting time is extended, it must be noted in the
relevant record that a longer waiting time will not have
a detrimental impact on the health of the enrollee;
d) In areas with provider shortages, plans must still
meet their obligation to arrange for enrollees to receive
timely care as necessary for their health condition. If
timely
appointments are not available in a particular area, a plan
must refer enrollees to or assist enrollees in locating
available and accessible contracted providers in
neighboring service areas; and,
e) Health plans and insurers also are required to:
i. Provide or make available telephone
triage or screening services 24 hours a day, 7 days
a week to determine the urgency of an enrollee's
condition.
ii. Triage must be performed by qualified
health care professionals, and, if needed, a call
back must be made to an enrollee within 30 minutes.
iii. Ensure that during normal business hours,
the telephone waiting time for an enrollee to speak
with a knowledgeable and competent plan customer
service representative does not exceed 10 minutes.
3)Medi-Cal timely access requirements. According to Medi-Cal
managed care contract provisions, Medi-Cal managed care plans
are required to meet the same timely access standards as
established by DMHC. Excerpts from those contracts include
the following: Contractor shall establish acceptable
accessibility standards in accordance with Title 28 CCR
Section 1300.67.2 (DMHC's timely access regulations) and as
specified below. DHCS will review and approve standards for
reasonableness. Contractor shall ensure that Contracting
Providers offer hours of operation similar to commercial
Members or comparable to Medi-Cal fee-for-service, if the
provider serves only Medi-Cal Members. Contractor shall
communicate, enforce, and monitor providers' compliance with
these standards. The contract goes on to list the same
standards as in 2) directly above.
4)Consumer complaints. In the spring of 2015, the Consumer
Reports National Research Center conducted a survey of 825
privately-insured English speaking Californians to learn more
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about their experience with surprise medical bills. One of the
most striking findings of the survey was that most California
consumers do not understand that they can complain to a state
agency about health insurance. Specifically, the results
indicate that 85% of privately insured Californians do not
know which state agency is tasked with handling complaints
about health insurance. And only a small percentage (11%)
surveyed believe that a state agency is responsible for
resolving health insurance billing issues. More than
two-thirds of Californians (71%) are unaware of their right to
appeal to the state or an independent medical expert if a
health plan refuses coverage for medical services they think
they need.
The Consumer Reports survey indicates that even when consumers
are aware of the complaint system it does not always work as
effectively as it should. For example, DHCS' Medi-Cal Managed
Care Office of the Ombudsman has the authority to investigate
and resolve complaints by Medi-Cal beneficiaries about health
plans. Yet, a report by the State Auditor, commissioned in
2015 at the request of the Joint Legislative Audit Committee,
found substantial shortcomings in the Office's handling of
such complaints, with its telephone system unable to respond
to 7,000 to 45,000 calls from consumers per month. During the
audit period, the Ombudsman Office chief stated that due to
staffing limitations at that time it could not handle 50-70%
of the calls it received and that the Office was losing data
due to hardware inadequacies. Funding was approved in the
2015-16 Budget to provide more staffing for DHCS for this
phone line. In addition, DHCS is implementing an updated
telephone system that is expected to increase response times,
increase queue capacity from 30 callers to more than 500
callers, provide the ability to collect data regarding wait
times, call times, abandonment rates, and other full call
center monitoring functions and provides supervisors the
ability to adjust resources.
5)Consumer complaint oversight. SB 857 (Committee on Budget and
Fiscal Review, Chapter 31, Statues of 2014), revised the
responsibilities of the Office of Patient Advocate (OPA) to:
(1) clarify that OPA is not the primary source of direct
assistance to consumers; (2) clarify OPA's responsibilities to
track, analyze, and produce reports with data collected from
calls, about problems and complaints by, and questions from,
consumers about health care coverage received by health
SB 1135 (Monning) Page 8 of ?
consumer call centers and helplines operated by other
departments, regulators or governmental entities; (3) require
OPA to make recommendations for the standardization of
reporting on complaints, grievances, questions, and requests
for assistance; and (4) require OPA to develop model
protocols, in consultation with each call center, consumer
advocates and other stakeholders that may be used by call
centers for responding to and referring calls that are outside
the jurisdiction of the call center or regulator. According
to the Senate Budget Subcommittee #3 on Health and Human
Services, March 3, 2015 agenda, at the request of the Brown
Administration, the requirement that OPA be a single point of
entry for consumer assistance and inquiries with its own 1-800
number for all health care consumer entries was repealed. This
was based on the assertion that existing consumer assistance
help lines such as the DMHC and the DHCS' Managed Care
Ombudsman Program were more than adequate and another line
would be redundant. In exchange, the OPA responsibilities as
an oversight agency were expanded. As part of this agreement,
OPA was required to conduct complaint data report as a
baseline in order to make recommendations for improvements and
uniformity among systems; and for the Legislature, the public,
and advocates to have a more robust picture of the adequacy of
existing help lines.
The first complaint data report was due to the Legislature on
July 1, 2015. This report has not yet been finalized or made
public.
6)Prior legislation. SB 137 (Hernandez, Chapter 649, Statutes of
2015), requires a health plan or insurer to make available a
provider directory or directories that provide information on
contracting providers, including those that accept new
patients and prohibits a provider directory from including
information on a provider that does not have a current
contract with the plan or insurer.
SB 857 (Committee on Budget and Fiscal Review, Chapter 31,
Statues of 2014), revises the responsibilities of the OPA.
SB 964 (Hernandez, Chapter 573, Statutes of 2014), requires a
health plan to annually report specified network adequacy
data, including separate Medi-Cal managed care and individual
market product line data, as specified, to DMHC as a part of
its annual timely access compliance report, and requires DMHC
to review the network adequacy data for compliance with
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Knox-Keene Health plan Act of 1975 requirements.
SB 853 (Escutia, Chapter 713, Statutes of 2003), requires
DMHC and CDI to adopt regulations by January 1, 2006 to
ensure enrollees and insureds have access to language
assistance in obtaining health care services.
AB 2179 (Cohn, Chapter 797, Statutes of 2002), requires DMHC
and CDI to develop and adopt regulations to ensure that
enrollees have access to needed health care services.
7)Support. Health Access California, the sponsor of this bill,
writes that very few consumers know these timely access
consumer protections exist or where to complain to state
regulators if they do not get timely access to care or care in
the language they speak. Consumers Union writes that
California stands out among the states for its strong,
quantified standards for how quickly enrollees are entitled to
get care, from primary care check-ups to urgent care. Yet,
many consumers do not realize they have these important rights
to prompt care, as well as to interpreter services to ensure
clear communication with their health care provider. This
bill would ensure that enrollees get this important
information. The Los Angeles Professional Peace Officers
Association states that existing law already requires the
health plan's toll-free number to be included on the insurance
card but not the toll-free number for DMHC or CDI. Consumers
do not know where to complain when they need help getting the
care they need when they need it. Western Center on Law and
Poverty writes that over 10 million Californians are enrolled
in Medi-Cal managed care plans but these individuals make up a
small fraction of individuals who file complaints with DMHC
despite representing a third of lives in health plans DMHC
regulates. Western Center adds that there are over two
million Medi-Cal beneficiaries in County Organized Health
Systems that are not licensed by either DMHC or CDI, and the
Medi-Cal Managed Care Office of the Ombudsman is available to
assist these beneficiaries. The National Union of Healthcare
Workers (NUHW) writes that in recent years they have filed a
successful complaint with DMHC regarding a plan's failure to
provide timely access to thousands of California consumers
seeking mental health services. As a result of NUHW's work
with consumers, they learned that many consumers are unaware
of their right to receive timely care. The California Chapter
of the American College of Emergency Physicians writes that
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emergency physicians see the effects of inadequate access to
care on the patients they treat. Many patients present to the
emergency department seeking care for health conditions that
have significantly deteriorated because care was delayed due
to inability to access primary and specialty providers.
Similarly, emergency physician routinely treat an emergency
condition that requires follow up care, but even with the help
of emergency department staff, the patient is unable to book
the needed follow-up appointment because of inadequate
networks.
8)Opposition. The Association of California Life and Health
Insurance Companies (ACLHIC) writes that it is unclear what
problem the bill is trying to solve. Currently, CDI requires
insurers to adhere to exceptionally rigorous network adequacy
standards and insurers are already required to provide much of
the same information that would be required under this bill.
Furthermore, with respect to providing additional information
on an insurance identification card, ACLHIC believes that
adding additional text to an already overly crowded space may
unduly lead to confusion rather than provide the useful
benefit intended under this bill.
SUPPORT AND OPPOSITION :
Support: Health Access California (sponsor)
ALS Association Golden West Chapter
Asian Law Alliance
Autism Speaks
California Chapter of the American College of
Emergency Physicians
California Catholic Conference
California Pan-Ethnic Health Network
California State Council of the Service Employees
International Union
CALPIRG
Center for Autism and Related Disorders
Coalition of California Welfare Rights Organizations,
Inc.
Congress of California Seniors
Consumers Union
Los Angeles Professional Peace Officers Association
Mexican American Legal Defense and Education Fund
National Alliance of Mental Illness
National Multiple Sclerosis Society - CA Action
Network
SB 1135 (Monning) Page 11 of ?
National Union of Healthcare Workers
Planned Parenthood Affiliates of California
San Francisco Bay Area Physicians for Social
Responsibility
SEIU California
Western Center on Law and Poverty
Oppose: Association of California Life & Health Insurance
Companies
California Association of Health Plans
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