BILL ANALYSIS Ó
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Date of Hearing: June 28, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
SB
1135 (Monning) - As Amended June 1, 2016
SENATE VOTE: 29-10
SUBJECT: Health care coverage: notice of timely access to
care.
SUMMARY: Requires a health care service plan (health plan) or
health insurer to provide enrollees or insureds with information
regarding standards for timely access to care (timely access
standards) and interpreter services pursuant to existing law.
Specifically, this bill:
1)Requires a health plan contract or health insurance policy
that is issued, renewed, or amended on or after January 1,
2017, to provide information, no less than annually, to an
enrollee or insured regarding the timely access standards
pursuant to existing law, including information related to the
provision of interpreter services in a timely manner.
2)Requires a health plan or health insurer to provide
information regarding appointment wait times for urgent care,
nonurgent primary care, nonurgent specialty care, and
telephone screening established in existing law. Requires
information to also include notice of the availability of
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interpreter services at the time of the appointment consistent
with existing law. Allows a health plan or health insurer to
indicate that exceptions to appointment wait times may apply
if the Department of Managed Health Care (DMHC) or California
Department of Insurance (CDI) has found exceptions to be
permissible.
3)Requires information to be provided to an enrollee or insured
with individual coverage and to enrollees and subscribers or
policyholders with group coverage upon initial enrollment and
annually thereafter upon renewal. Requires information to be
provided as follows:
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 are provided pursuant to existing law;
c) In a separate section, titled "Timely Access of Care,"
of the provider directory published and maintained by the
health plan and health insurer pursuant to existing law;
and,
d) On the Internet Website published and maintained by the
health plan or health insurer, in a manner that allows
current and prospective enrollees or insureds to easily
locate the information.
4)Requires health plans to provide the following information to
contracting providers no less than annually, and include the
following:
"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
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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."
5)Requires health insurers to provide the information to
contracting providers on a no less than annual basis, and
include the following:
"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
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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."
6)Applies similar notice requirements to Medi-Cal managed care
plan contracts with the Department of Health Care Services
(DHCS).
EXISTING LAW:
1)Establishes the DMHC to regulate health plans, the CDI to
regulate health insurers, and the 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;
b) Timeliness of care in an episode of illness, including
the timeliness of referrals and obtaining other services,
if needed; and,
c) 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.
3)Requires DMHC, in developing these timely access standards, 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.
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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 health plans have notices
advising limited-English-proficient (LEP) persons of the
availability of free language assistance and other outreach
materials that are provided to enrollees. Pursuant to
regulations, requires the health plan to describe the process
of 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 the process
of 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 services in
a timely manner and ensure adequacy of the 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 the 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
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advising LEP persons of the availability of free language
assistance and other outreach 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.
8)Requires a health plan, and a health insurer that contracts
with providers for alternative rates of payment, to publish
and maintain a provider directory or directories with
information on contracting providers that deliver health care
services to the health plan's enrollees or the health
insurer's insureds, and requires the health plan or health
insurer to make an online provider directory or directories
available on the health plan or health insurer's Internet
Website, as specified.
FISCAL EFFECT: According to the Senate Appropriations
Committee:
1)Minor costs are anticipated for enforcement of this bill's
requirements by the DMHC (Managed Care Fund).
2)Minor costs are anticipated for enforcement of this bill's
requirements by the CDI (Insurance Fund).
3)No significant increase in Medi-Cal utilization or costs is
anticipated under this 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 this bill will significantly
increase enrollee utilization of services.
COMMENTS:
1)PURPOSE OF THIS BILL. 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,
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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 this bill is to help inform
consumers about their timely access rights so consumers are
better able to insure health plan accountability in meeting
timely access standards. In addition, by informing consumers
about their timely access rights, more accurate data can be
compiled for policymakers and regulators and assist in
determining network adequacy.
2)BACKGROUND.
a) 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. For example, the DMHC includes the following
appointment wait times on its Website:
---------------------------------------------------------------
|Urgent Appointments: |Wait Time |
| | |
|--------------------------------------------------+------------|
|for services that don't need prior approval |48 hours |
| | |
|--------------------------------------------------+------------|
|for services that do need prior approval |96 hours |
| | |
|--------------------------------------------------+------------|
|Non-Urgent Appointments |Wait Time |
| | |
|--------------------------------------------------+------------|
|Primary care appointment |10 business |
| | |
| |days |
| | |
|--------------------------------------------------+------------|
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|Specialist appointment |15 business |
| | |
| |days |
| | |
|--------------------------------------------------+------------|
|Appointment with a mental health care provider |10 business |
| | |
|(who is not a physician) |days |
| | |
|--------------------------------------------------+------------|
|Appointment for other services to diagnose or |15 business |
| | |
|treat a health condition |days |
| | |
---------------------------------------------------------------
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. In areas
with provider shortages, health 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
health plan must refer enrollees to, or assist enrollees in
locating, available and accessible contracted providers in
neighboring service areas. Health plans are also required
to 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. Health plans must also
provide triage that is performed by qualified health care
professionals, and, if needed, a call back must be made to
an enrollee within 30 minutes. Additionally, health plans
must ensure that during normal business hours, the
telephone waiting time for an enrollee to speak with a
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knowledgeable and competent plan customer service
representative does not exceed 10 minutes.
b) 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 a)
directly above.
c) Consumer complaints. In the Fall of 2014, Consumer
Representatives to the National Association of Insurance
Commissioners (NAIC) fielded a survey of all 50 state
insurance commissioners to assess their work on network
adequacy and the commissioners reported that consumer
complaints are one of the strongest resources state
agencies have for monitoring network adequacy issues. 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
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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.
d) Office of the Patient Advocate (OPA). SB 857 (Committee
on Budget and Fiscal Review), revises the responsibilities
of the OPA to: i) clarify that the OPA is not the primary
source of direct assistance to consumers; ii) 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; iii) require OPA to make
recommendations for the standardization of reporting on
complaints, grievances, questions, and requests for
assistance; and, iv) requires OPA to develop model
protocols, in consultation with each call center, consumer
advocate, 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.
OPA is required to conduct a 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 having 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 and OPA
published its first report in May of this year. OPA notes
this is the first report and is considered a baseline
review of California's health care complaint data. The
report also identified gaps in data due in part to the
reporting entities not having previously collected some of
the requested data elements. Since the reporting entities
did not use common complaint codes, OPA will continue to
work with each reporting entity to standardize data
collection and enable additional analysis in subsequent
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reports.
3)SUPPORT. Health Access California, sponsor of this bill,
states that this bill will provide consumers with information
about their existing rights so that they can get the care they
need, when they need it, in a language they can understand.
The Western Center of Law and Poverty states that very few
people know about the consumer protection in existing law.
The California Pan-Ethnic Health Network writes that providing
notice of timely access and language assistance services will
help to ensure all Californians can access culturally and
linguistically appropriate care when they need it. The
California Labor Federation, AFL-CIO, states that educating
consumers is one of the most effective strategies to enforce
existing laws on timely care and language access.
4)PREVIOUS LEGISLATION.
a) SB 137 (Hernandez), Chapter 649, Statutes of 2015,
requires a health plan or health 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.
b) 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 part of its annual timely access compliance report, and
requires DMHC to review the network adequacy data for
compliance with existing requirements.
c) 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.
d) AB 2179 (Cohn), Chapter 797, Statutes of 2002, requires
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DMHC and CDI to develop and adopt regulations to ensure
that enrollees have access to needed health care services.
5)TECHNICAL AMENDMENTS. The author is proposing to clarify that
a health plan or health insurer may comply with this bill's
requirement through existing communication with a contracting
provider.
REGISTERED SUPPORT / OPPOSITION:
Support
Health Access California (sponsor)
AARP
Amyotrophic Lateral Sclerosis Association Golden West Chapter
Asian Law Alliance
Autism Speaks
California Academy of Family Physicians
California Chapter of the American College of Emergency
Physicians
California Congress of Seniors
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California Immigrant Policy Center
California Labor Federation, AFL-CIO
California Pan-Ethnic Health Network
California School Employees Association, AFL-CIO
California State Council of the Service Employees International
Union
California Teachers Association
CaliforniaHealth+ Advocates
CALPIRG
Center for Autism and Related Disorders
Coalition of California Welfare Rights Organizations
Congress of California Seniors
Consumers Union
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Doctors for America
Los Angeles Professional Peace Officers Association
Mental Health America of California
Mexican American Legal Defense and Education Fund
National Alliance on Mental Illness
National Association of Social Workers - California Chapter
National Health Law Program
National Multiple Sclerosis Society
National Union of Healthcare Workers
Organization of SMUD Employees
Physicians for Social Responsibility San Francisco Bay Area
Chapter
Planned Parenthood Affiliates of California
San Luis Obispo County Employees Association
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Union of Healthcare Workers
Western Center on Law and Poverty
Opposition
Association of California Life and Health Insurance Companies
California Association of Health Plans (prior version)
Analysis Prepared by:Kristene Mapile / HEALTH / (916)
319-2097