BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 1135|
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THIRD READING
Bill No: SB 1135
Author: Monning (D)
Amended: 6/1/16
Vote: 21
SENATE HEALTH COMMITTEE: 8-1, 4/6/16
AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Pan, Roth,
Wolk
NOES: Nielsen
SENATE APPROPRIATIONS COMMITTEE: 5-2, 5/27/16
AYES: Lara, Beall, Hill, McGuire, Mendoza
NOES: Bates, Nielsen
SUBJECT: Health care coverage: notice of timely access to
care
SOURCE: Health Access California
DIGEST: This bill 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.
ANALYSIS:
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.
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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 specified indicators of timeliness
of access to care, such as waiting times for appointments and
referrals.
3)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.
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 the information to be provided to consumers upon
initial enrollment, annually upon renewal, and to contracting
providers no less than on an annual basis. Specifies the
requirements of the notices to consumers and providers.
3)Applies the provisions of this bill as described above, to
plans with Medi-Cal managed care plan contracts with DHCS, as
specified.
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
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
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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
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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 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, seven 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
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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 California
Code of Regulations Section 1300.67.2 (DMHC's timely access
regulations. 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
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,
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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:
(a) clarify that OPA is not the primary source of direct
assistance to consumers; (b) 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
consumer call centers and helplines operated by other
departments, regulators or governmental entities; (c) require
OPA to make recommendations for the standardization of
reporting on complaints, grievances, questions, and requests
for assistance; and (d) 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
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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. The report was released in May of 2016.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: Yes
According to the Senate Appropriations Committee:
1)Minor costs are anticipated for enforcement of the bill's
requirements by the DMHC (Managed Care Fund).
2)Minor costs are anticipated for enforcement of the bill's
requirements by the CDI (Insurance Fund).
3)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.
SUPPORT: (Verified 5/27/16)
Health Access California (source)
AARP
ALS Association Golden West Chapter
Asian Law Alliance
Autism Speaks
California Academy of Family Physicians
California Chapter of the American College of Emergency
Physicians
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California Catholic Conference
CaliforniaHealth+ Advocates
California Labor Federation
California Pan-Ethnic Health Network
California School Employees Association
California State Council of the Service Employees International
Union
California Teachers Association
CALPIRG
Center for Autism and Related Disorders
Coalition of California Welfare Rights Organizations, Inc.
Congress of California Seniors
Consumers Union
Doctors for America, California
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
National Union of Healthcare Workers
Organization of SMUD Employees
Planned Parenthood Affiliates of California
San Diego County Court Employees Association
San Francisco Bay Area Physicians for Social Responsibility
San Luis Obispo County Employees Association
Western Center on Law and Poverty
OPPOSITION:(Verified 5/27/16)
America's Health Insurance Plans
Association of California Life and Health Insurance Companies
California Association of Health Plans
ARGUMENTS IN 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
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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 ensures that enrollees
get this important information. The Los Angeles Professional
Peace Officers Association states that 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.
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 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.
ARGUMENTS IN OPPOSITION: The Association of California Life and
Health Insurance Companies 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.
Prepared by:Teri Boughton / HEALTH / (916) 651-4111
6/1/16 18:41:34
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