BILL NUMBER: SB 296 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 30, 2009
AMENDED IN SENATE APRIL 13, 2009
INTRODUCED BY Senator Lowenthal
FEBRUARY 25, 2009
An act to add Sections 1367.27, 1367.28, and 1367.29 to
the Health and Safety Code, and to add Sections 10123.197, 10123.198,
and An act to amend Se ction 1368.015 of,
and to add Sections 1367.29 and 1368.016 to, the Health and Safety
Code, and to add Sections 10123.198 and 10123.199 to the
Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 296, as amended, Lowenthal. Mental health services.
Existing law provides for licensing and regulation of health care
service plans by the Department of Managed Health Care. Existing law
provides for licensing and regulation of health
insurers by the Department of Insurance. A willful violation of
provisions governing health care service plans is a crime. Existing
law imposes certain requirements on health care service plans,
specialized health care service plans, and health insurers that
provide coverage for professional mental health services.
Existing law also requires every health care service plan, other than
a plan that primarily serves Med-Cal or Healthy Family Program
enrollees, to maintain an Internet Web site.
This bill would require every health care service plan,
including a specialized health care service plan, and every health
insurer that offers professional mental health services to direct
those services to be provided in a manner that ensures coordination
of benefits between all mental health care providers and general
physical health care providers. The bill would require these plans
and insurers to establish an Internet Web site and to issue a
benefits card to enrollees or insureds with specified information.
, on and after July 1, 2011, require every
health care service plan, including a specialized health care service
plan, and health insurer th at provides professional
mental health services to issue an identification card to each
enrollee in order to assist the enrollee with accessing health
benefits coverage information. The bill would require the
identification card to be issued upon enrollment or commencement of
coverage or upon any change in the enrollee's coverage that impacts
the data content or format of the card. The bill would also require
those plans and insurers to provide, on or before January 1, 2012,
specified information on their Internet Web sites, to be updated as
specified, and would require those insurers to establish Internet Web
sites for that purpose. The bill would also require the departments
to include on their Internet Web sites a link to the Internet Web
site of each of those plans or insurers. The bill would also make
changes to related provisions.
By imposing new requirements on certain health care service plans,
the willful violation of which 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 1367.29 is added to the
Health and Safety Code , to read:
1367.29. (a) On and after July 1, 2011, in accordance with the
requirements of subdivision (b), every health care service plan that
provides professional mental health services, including a specialized
health care service plan that provides coverage for professional
mental health services, shall issue an identification card to each
enrollee in order to assist the enrollee with accessing health
benefits coverage information, including, but not limited to,
in-network provider access information, and claims processing
purposes. The identification card, at a minimum, shall include all of
the following information:
(1) The name of the health care service plan issuing the
identification card.
(2) The enrollee's identification number.
(3) A telephone number that enrollees or providers may call for
assistance with health benefits coverage information, in-network
provider access information, and claims processing information.
(4) A telephone number that enrollees may call to access
assessment services for the purpose of referral to an appropriate
level of care or an appropriate health care provider.
(5) The health care service plan's Internet Web site address.
(b) The identification card required by this section shall be
issued by a health care service plan or a specialized health care
service plan to an enrollee upon enrollment or upon any change in the
enrollee's coverage that impacts the data content or format of the
card.
(c) Nothing in this section requires a health care service plan to
issue a separate identification card for professional mental health
services coverage if the plan issues a card for health care coverage
in general and the card provides the information required by this
section.
(d) If a health care service plan or a specialized health care
service plan, as described in subdivision (a), delegates
responsibility for issuing the identification card to a contractor or
an agent, the contractor or agent shall be required to comply with
this section.
(e) Nothing in this section shall be construed to prohibit a
health care service plan or a specialized health care service plan
from meeting the standards of the Workgroup for Electronic Data
Interchange or other national uniform standards with respect to
identification cards, as long as the minimum requirements described
in subdivision (a) have been met.
SEC. 2. Section 1368.015 of the Health
and Safety Code is amended to read:
1368.015. (a) Effective July 1, 2003, every plan with a
an Internet Web site shall provide an online
form through its Internet Web site that subscribers or
enrollees can use to file with the plan a grievance, as described in
Section 1368, online.
(b) The Internet Web site shall have an easily
accessible online grievance submission procedure that shall be
accessible through a hyperlink on the Internet
Web site's home page or member services portal clearly identified as
"GRIEVANCE FORM." All information submitted through this process
shall be processed through a secure server.
(c) The online grievance submission process shall be approved by
the Department of Managed Health Care and shall meet the following
requirements:
(1) It shall utilize an online grievance form in HTML format that
allows the user to enter required information directly into the form.
(2) It shall allow the subscriber or enrollee to preview the
grievance that will be submitted, including the opportunity to edit
the form prior to submittal.
(3) It shall include a current hyperlink to the California
Department of Managed Health Care Internet Web site, and
shall include a statement in a legible font that is clearly
distinguishable from other content on the page and is in a legible
size and type, containing the following language:
"The California Department of Managed Health Care is responsible
for regulating health care service plans. If you have a grievance
against your health plan, you should first telephone your health plan
at (insert health plan's telephone number) and use your health plan'
s grievance process before contacting the department. Utilizing this
grievance procedure does not prohibit any potential legal rights or
remedies that may be available to you. If you need help with a
grievance involving an emergency, a grievance that has not been
satisfactorily resolved by your health plan, or a grievance that has
remained unresolved for more than 30 days, you may call the
department for assistance. You may also be eligible for an
Independent Medical Review (IMR). If you are eligible for IMR, the
IMR process will provide an impartial review of medical decisions
made by a health plan related to the medical necessity of a proposed
service or treatment, coverage decisions for treatments that are
experimental or investigational in nature and payment disputes for
emergency or urgent medical services. The department also has a
toll-free telephone number (1-888-HMO-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The department'
s Internet Web site http://www.hmohelp.ca.gov has complaint forms,
IMR application forms and instructions online."
The plan shall update the URL, hyperlink, and telephone numbers in
this statement as necessary.
(d) A plan that utilizes a hardware system that does not have the
minimum system requirements to support the software necessary to meet
the requirements of this section is exempt from these requirements
until January 1, 2006.
(e) For purposes of this section, the following terms shall have
the following meanings:
(1) "Homepage" means the first page or welcome page of a
an Internet Web site that serves as a starting
point for navigation of the Internet Web site.
(2) "HTML" means Hypertext Markup Language, the authoring language
used to create documents on the World Wide Web, which defines the
structure and layout of a Web document.
(3) "Hyperlink" means a special HTML code that allows text or
graphics to serve as a link that, when clicked on, takes a user to
another place in the same document, to another document, or to
another Internet Web site or Web page.
(4) "Member services portal" means the first page or welcome page
of a an Internet Web site that can be
reached directly by the Internet Web site's homepage and
that serves as a starting point for a navigation of member services
available on the Internet Web site.
(5) "Secure server" means an Internet connection to a
an Internet Web site that encrypts and decrypts
transmissions, protecting them against third-party tampering and
allowing for the secure transfer of data.
(6) "URL" or "Uniform Resource Locator" means the address of
a an Internet Web site or the location
of a resource on the World Wide Web that allows a browser to locate
and retrieve the Internet Web site or the resource.
(7) "Web "Internet Web site" means a
site or location on the World Wide Web.
(f) Every health care service plan, except a plan that primarily
serves Medi-Cal or Healthy Families Program enrollees, shall maintain
a Internet Web site. For a health care service plan that
provides coverage for professional mental health services, the
Inter net Web site shall include, but not be limited
to, providing information to subscribers, enrollees, and providers
that will assist subscribers and enrollees in accessing mental health
services as well as the information described in Section
1368.016 .
SEC. 3. Section 1368.016 is added to the
Health and Safety Code , to read:
1368.016. (a) On or before January 1, 2012, every health care
service plan that provides coverage for professional mental health
services, including a specialized health care service plan that
provides coverage for professional mental health services, shall,
pursuant to subdivision (f) of Section 1368.015, include on its
Internet Web site, or provide a link to, the following information:
(1) A telephone number that the enrollee or provider can call,
during normal business hours, for assistance obtaining mental health
benefits coverage information, including the extent to which benefits
have been exhausted, in-network provider access information, and
claims processing information.
(2) A link to prescription drug formularies as described in
Section 1367.20.
(3) A detailed summary that describes the process by which the
plan reviews and authorizes or approves, modifies, or denies requests
for health care services as described in Sections 1363.5 and
1367.01.
(4) Lists of providers as required by Section 1367.26.
(5) A detailed summary of the enrollee grievance process as
described in Sections 1368 and 1368.015.
(6) A detailed description of how an enrollee may request
continuity of care pursuant to subdivisions (a) and (b) of Section
1373.95.
(7) Information concerning the right, and applicable procedure, of
an enrollee to request an independent medical review pursuant to
Section 1374.30.
(8) A link to the department's final report of the plan's periodic
review as described in subdivision (h) of Section 1380.
(9) Provider manual templates containing nonproprietary
information provided to individual, group, and institutional
providers who contract with the plan. The material described in this
paragraph shall be updated within 30 days of any material change. An
electronic notification of material changes shall be communicated to
applicable contract providers immediately.
(b) Except as otherwise specified, the material described in
subdivision (a) shall be updated at least quarterly.
(c) The information described in subdivision (a) may be made
available through a secured Internet Web site that is only accessible
to enrollees.
(d) The material described in subdivision (a) shall also be made
available to enrollees in hard copy upon request.
(e) Nothing in this article shall preclude a health care service
plan from including additional information on its Internet Web site
for applicants, enrollees or subscribers, or providers, including,
but not limited to, the cost of procedures or services by health care
providers in a plan's network.
(f) The department shall include on the department's Internet Web
site a link to the Internet Web site of each health care service plan
and specialized health care service plan described in subdivision
(a).
SEC. 4. Section 10123.198 is added to the
Insurance Code , to read:
10123.198. (a) On and after July 1, 2011, in accordance with the
requirements of subdivision (b), every health insurer that provides
professional mental health services shall issue an identification
card to each insured in order to assist the insured with accessing
health benefits coverage information, including, but not limited to,
in-network provider access information, and claims processing
purposes. The identification card, at a minimum, shall include all of
the following information:
(1) The name of the health insurer issuing the identification
card.
(2) The insured's identification number.
(3) A telephone number that insureds or providers may call for
assistance with health benefits coverage information, in-network
provider access information, and claims processing information.
(4) A telephone number that insureds may call to access assessment
services for the purpose of referral to an appropriate level of care
or an appropriate health care provider.
(5) The health insurer's Internet Web site address.
(b) The identification card required by this section shall be
issued by a health insurer to an insured upon commencement of
coverage or upon any change in the insured's coverage that impacts
the data content or format of the card.
(c) Nothing in this section requires a health insurer to issue a
separate identification card for professional mental health coverage
if the insurer issues a card for health care coverage in general and
the card provides the information required by this section.
(d) If a health insurer, as described in subdivision (a),
delegates responsibility for issuing the card to a contractor or
agent, the contractor or agent shall be required to comply with this
section.
(e) Nothing in this section shall be construed to prohibit a
health insurer from meeting the standards of the Workgroup for
Electronic Data Interchange or other national uniform standards with
respect to identification cards, as long as the minimum requirements
described in subdivision (a) have been met.
(f) This section shall not apply to Medicare supplement,
short-term limited duration health insurance, Champus-supplement
insurance, TRI-CARE supplement, or to hospital indemnity,
accident-only, and specified disease insurance. This section shall
also not apply to specialized health insurance policies, except
behavioral health-only policies.
SEC. 5. Section 10123.199 is added to the
Insurance Code , to read:
10123.199. (a) On or before January 1, 2012, every health insurer
that provides coverage for professional mental health services shall
establish an Internet Web site. Each Internet Web site shall
include, or provide a link to, the following information:
(1) A telephone number that the insured or provider can call,
during normal business hours, for assistance obtaining mental health
benefits coverage information, including the extent to which benefits
have been exhausted, in-network provider access information, and
claims processing information.
(2) A link to prescription drug formularies.
(3) A detailed summary description of the process by which the
insurer reviews and approves, modifies, or denies requests for health
care services as described in Section 10123.135.
(4) Lists of providers as required by Section 10133.1.
(5) A detailed summary of the health insurer's grievance process.
(6) A detailed description of how the insured may request
continuity of care as described in Section 10133.55.
(7) Information concerning the right, and applicable procedure, of
the insured to request an independent medical review pursuant to
subdivision (i) of Section 10169.
(8) A link to the results of any market conduct examinations of
the insurer as required by Section 12938.
(9) Provider manual templates containing nonproprietary
information provided to individual, group, and institutional
providers who contract with the insurer. The material described in
this paragraph shall be updated within 30 days of any material
change. An electronic notification of material changes shall be
communicated to applicable contract providers immediately.
(b) Except as otherwise specified, the material described in
subdivision (a) shall be updated at least quarterly.
(c) The information described in subdivision (a) may be made
available through a secured Internet Web site that is only accessible
to the insured.
(d) The material described in subdivision (a) shall also be made
available to insureds in hard copy upon request.
(e) Nothing in this article shall preclude an insurer from
including additional information on its Internet Web site for
applicants or insureds, including, but not limited to, the cost of
procedures or services by health care providers in an insurer's
network.
(f) The department shall include on the department's Internet Web
site, a link to the Internet Web site of each health insurer
described in subdivision (a).
(g) This section shall not apply to Medicare supplement,
short-term limited duration health insurance, Champus-supplement
insurance, TRI-CARE supplement, or to hospital indemnity,
accident-only, and specified disease insurance. This section shall
also not apply to specialized health insurance policies, except
behavioral health-only policies.
SEC. 6. 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.
SECTION 1. Section 1367.27 is added to the
Health and Safety Code, to read:
1367.27. (a) The Legislature finds and declares that coordination
of care between mental health care providers and general physical
health care providers is necessary to optimize the overall health of
a patient.
(b) Every health care service plan that offers professional mental
health services, including a specialized health care service plan
that offers those services, shall direct those services to be
provided in a manner that ensures coordination of benefits between
mental health care providers and general physical health care
providers.
SEC. 2. Section 1367.28 is added to the Health
and Safety Code, to read:
1367.28. (a) The Legislature finds and declares that health care
consumers should be provided important information regarding health
care services in an easily accessible manner. While most health care
service plans are required to maintain Internet Web sites pursuant to
subdivision (f) of Section 1368.015, it is the intent of this
section to improve online access to all policies, guidelines,
disclosure forms, and other materials that health care service plans
are required by law to provide to the department or consumers.
(b) On or before January 1, 2012, every health care service plan
that offers professional mental health services, including a
specialized health care service plan that offers only those services,
shall establish an Internet Web site. Each Web site shall include,
or provide a link to, information relative to all of the following:
(1) Plan policies and procedures related to:
(A) Modified contracts or coverage as required by Section 1352.1.
(B) Enrollee contract benefits and terms as required by
subdivisions (a) and (b) of Section 1363.
(C) Economic profiling as required by Section 1367.02.
(D) Utilization review and modified coverage as required by
Sections 1363.5 and 1367.01.
(E) Cancellation of contracts as required by Section 1367.23.
(F) Lists of providers as required by Section 1367.26.
(G) Enrollee and subscriber grievances as required by Sections
1368 and 1368.015.
(H) Continuity of care as required by subdivisions (a) and (b) of
Section 1373.95.
(I) Independent medical review as required by subdivision (i) of
Section 1374.30.
(2) The department's final report of the plan's periodic review as
required by subdivision (h) of Section 1380.
(3) All provider manuals, policies, and procedures related to the
terms and conditions of provider contracts, including any material
changes to those manuals, policies, and procedures.
(c) The material described in subdivision (b) shall be updated at
least every month.
(d) The department shall include on the department's Internet Web
site a link to each plan Internet Web site.
SEC. 3. Section 1367.29 is added to the Health
and Safety Code, to read:
1367.29. (a) Every health care service plan that offers
professional mental health services, including a specialized health
care service plan that offers those services, shall issue a benefits
card to each enrollee for assistance with mental health benefits
coverage information, in-network provider access information, and
claims processing purposes. The benefits card, at a minimum, shall
include all of the following information:
(1) The name of the benefit administrator or health care service
plan issuing the card, which shall be displayed on the front side of
the card.
(2) The enrollee's identification number, or the subscriber's
identification number when the enrollee is a dependent who accesses
services using the subscriber's identification number. The number
shall be displayed on the front side of the card.
(3) A telephone number that enrollees may call 24 hours a day,
seven days a week, for assistance regarding health benefits coverage
information, in-network provider access information, and claims
processing.
(4) A brief statement indicating that enrollees may call the
telephone number for assistance regarding mental health services and
coverage.
(5) The plan's Internet Web site address.
(b) A health care service plan shall not print any of the
following information on the benefits card:
(1) Any information that may result in fraudulent use of the card.
(2) Any information that is otherwise prohibited from being
included on the card.
(c) On and after July 1, 2011, the benefits card required by this
section shall be issued by a health care service plan or a
specialized health care service plan to an enrollee upon enrollment
or upon any change in the enrollee's coverage that impacts the data
content or format of the card.
(d) Nothing in this section requires a health care service plan to
issue a separate benefits card for mental health coverage if the
plan issues a card for health care coverage in general and the card
provides the information required by this section.
(e) If a specialized health care service plan delegates
responsibility for issuing the benefits card to a contractor or
agent, then the contract between the plan and its contractor or agent
shall require compliance with this section.
SEC. 4. Section 10123.197 is added to the
Insurance Code, to read:
10123.197. (a) The Legislature finds and declares that
coordination of care between mental health care providers and general
physical health care providers is necessary to optimize the overall
health of a patient.
(b) Every health insurer that offers professional mental health
services shall direct those services to be provided in a manner that
ensures coordination of benefits between mental health care providers
and general physical health care providers.
SEC. 5. Section 10123.198 is added to the
Insurance Code, to read:
10123.198. (a) The Legislature finds and declares that health
care consumers should be provided important information regarding
health care services in an easily accessible manner. The intent of
this section is to improve online access to all policies, guidelines,
disclosure forms, and other materials that health insurers are
required by law to provide to the commissioner or consumers.
(b) On or before January 1, 2012, every health insurer that offers
professional mental health services shall establish an Internet Web
site. Each Web site shall include, or provide a link to, information
relative to all of the following:
(1) Insurer policies and procedures related to:
(A) Modified contracts or coverage.
(B) Policyholder contract benefits and terms.
(C) Economic profiling as required by Section 10123.36.
(D) Utilization review and modified coverage as required by
Section 10123.135.
(E) Cancellation of contracts as required by Section 10199.44.
(F) Lists of providers as required by Section 10133.1.
(G) Policyholder and insured grievances.
(H) Continuity of care as required by Section 10133.55.
(I) Independent medical review as required by subdivision (i) of
Section 10169.
(2) The results of any market conduct examinations of the insurer
as required by Section 12938.
(3) All provider manuals, policies, and procedures related to the
terms and conditions of provider contracts, including any material
changes to those manuals, policies, and procedures.
(c) The material described in subdivision (b) shall be updated at
least every month.
(d) The commissioner shall include on the department's Internet
Web site, a link to each health insurer's Internet Web site.
SEC. 6.
Section 10123.199 is added to the Insurance Code,
to read:
10123.199. (a) Every health insurer that offers professional
mental health services shall issue a benefits card to each insured
for assistance with mental health benefits coverage information,
in-network provider access information, and claims processing
purposes. The benefits card, at a minimum, shall include all of the
following information:
(1) The name of the benefit administrator or health insurer
issuing the card, which shall be displayed on the front side of the
card.
(2) The insured's identification number, or the policyholder's
identification number when the insured is a dependent who accesses
services using the policyholder's identification number. The number
shall be displayed on the front side of the card.
(3) A telephone number that insureds may call 24 hours a day,
seven days a week, for assistance regarding health benefits coverage
information, in-network provider access information, and claims
processing.
(4) A brief statement indicating that insureds may call the
telephone number for assistance regarding mental health services and
coverage.
(5) The health insurer's Internet Web site address.
(b) A health insurer shall not print any of the following
information on the benefits card:
(1) Any information that may result in fraudulent use of the card.
(2) Any information that is otherwise prohibited from being
included on the card.
(c) On and after July 1, 2011, the benefits card required by this
section shall be issued by a health insurer to an insured upon
commencement of coverage or upon any change in the insured's coverage
that impacts the data content or format of the card.
(d) Nothing in this section requires a health insurer to issue a
separate benefits card for mental health coverage if the plan issues
a card for health care coverage in general and the card provides the
information required by this section.
SEC. 7. 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.