BILL ANALYSIS Ó
SENATE COMMITTEE ON APPROPRIATIONS
Senator Ricardo Lara, Chair
2015 - 2016 Regular Session
SB 1135 (Monning) - Health care coverage: notice of timely
access to care
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|Version: March 30, 2016 |Policy Vote: HEALTH 8 - 1 |
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|Urgency: No |Mandate: Yes |
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|Hearing Date: April 25, 2016 |Consultant: Brendan McCarthy |
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This bill meets the criteria for referral to the Suspense File.
Bill
Summary: SB 1135 would require health plans and health insurers
(including Medi-Cal managed care plans) to notify enrollees and
contracted providers about existing requirements to provide
timely access to covered health care services. The bill would
require health plans and health insurers (including Medi-Cal
managed care plans) to include the appropriate regulatory
agency's phone number on an enrollee's proof of coverage card.
Fiscal
Impact:
Likely costs in the tens of millions per year for the
Department of Managed Health Care to respond to questions and
complaints from health plan enrollees and take enforcement
action against health plans, when appropriate (Managed Care
Fund). See staff comments below.
Likely costs in the low millions for the Department of
Insurance to respond to questions and complaints from Health
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insurance enrollees and take enforcement action against health
insurers, when appropriate (Insurance Fund). See staff
comments below.
Likely costs in the millions for the Medi-Cal Managed Care
Office of the Ombudsman to respond to questions and complaints
from enrollees in Medi-Cal managed care plans not regulated by
the Department of Managed Health Care (General Fund and
federal funds). See staff comments below.
No significant increase in Medi-Cal utilization or costs are
anticipated under the bill. Medi-Cal managed care plans are
required to comply with existing timely access requirements
and are already required to notify enrollees of those
requirements. It is not anticipated that providing the
additional information under the bill will significantly
increase enrollee utilization of services.
Background: Under current law, health plans and health insurers are
required to meet timely access standards - under which they are
required to ensure that enrollees have access to covered
benefits in specified timeframes. Health plans and health
insurers are not required to provide specific notice of those
timely access rights to their enrollees, although some health
plans or health insurers may do so as part of the information
they provide to enrollees on covered benefits and health care
networks. Medi-Cal managed care plans are required to provide
such information to enrollees upon enrollment and ever year,
under the plans' contracts with the Department of Health Care
Services.
Proposed Law:
SB 1135 would require health plans and health insurers
(including Medi-Cal managed care plans) to notify enrollees and
contracted providers about existing requirements to provide
timely access to covered health care services. The bill would
require health plans and health insurers (including Medi-Cal
managed care plans) to include the appropriate regulatory
agency's phone number on an enrollee's proof of coverage card.
Specific provisions of the bill would:
Require health plan contracts or health insurance contracts to
provide information on requirements for timely access to care
SB 1135 (Monning) Page 2 of
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for enrollees and enrollee rights to interpretation services;
Require such disclosures to include specific information on
timely access requirements in law and regulation;
Require the information to be provided upon enrollment and
annually thereafter;
Require the information to be provided in specified ways,
including in the enrollee's evidence of coverage, in provider
directories, and on the health plan or health insurer's
website;
Require the same information to be provided annually to
providers that contract with a health plan or health insurer;
Apply these requirements to Medi-Cal managed care plans;
Require health plans and health insurers to provide the
toll-free number and website for either the Department of
Managed Health Care or the Department of Insurance on the
enrollee's proof of coverage card;
Require Medi-Cal managed care plans not regulated by the
Department of Managed Health Care to provide the toll-free
number for the Medi-Cal Managed Care Office of the Ombudsman
on the enrollee's proof of coverage card.
Staff
Comments: Under current law and practice, enrollees in health
plans and health insurance have proof of coverage cards which
include the health plan or health insurer's toll-free number for
enrollee questions or complaints about covered benefits, access
to services, and other issues. According to data collected by
the Department of Managed Health Care, about 7% of the state's
25 million health plan enrollees contact their health plan each
month. On the other hand, the Department gets about 100,000
calls per year from health plan enrollees. This indicates that a
relatively small number of enrollees either need to contact the
Department or are aware that they can contact the Department if
they are unhappy with their health plan's response.
By putting the Department of Managed Health Care's toll-free
line on the enrollee's proof of coverage card, enrollee
awareness of the option to contact the Department will increase
dramatically. It is likely that the number of enrollees who
contact the Department (either instead of calling their health
plan or if they are not satisfied with the health plan's
response) will rise dramatically. According to calculations by
the Department, if even 3% of the enrollees who contact their
plan each year call the Department for assistance, it will
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result in over 500,000 additional calls per year. At that call
volume, the cost to the Department to respond to calls and take
enforcement action when appropriate will be about $50 million
per year.
Health insurance companies would also be required to provide the
toll-free number for the Department of Insurance. Medi-Cal
managed care plans not regulated by the Department of Managed
Health Care would be required to provide the toll-free number
for the Medi-Cal Office of the Ombudsman. It is likely that both
of those departments would receive a similar call volume in
proportion to their enrollments. The cost estimates above assume
that a similar proportion of their enrollees contact those
departments each year, at a similar cost per call to operate
their call centers.
The only costs that may be incurred by a local agency relate to
crimes and infractions. Under the California Constitution, such
costs are not reimbursable by the state.
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