BILL NUMBER: SB 296 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JULY 14, 2009
AMENDED IN ASSEMBLY JUNE 30, 2009
AMENDED IN SENATE APRIL 13, 2009
INTRODUCED BY Senator Lowenthal
FEBRUARY 25, 2009
An act to amend Section 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 the licensing and regulation
of health care service plans by the Department of Managed Health
Care. Existing law provides for the 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, on and after July 1, 2011, require every health
care service plan, including a specialized health care service plan,
and health insurer that provides professional mental health services
to issue an identification card , as specified, to each
enrollee in order to assist the enrollee with accessing health
benefits coverage information and other 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 coverage for 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 , and when
assessment services are provided by the health care service
plan, access to assessment services for the purpose of
referral to an appropriate level of care or an appropriate health
care provider.
(5)
(4) 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 (WEDI) or other national uniform standards
with respect to identification cards, and a health care service
plan shall be deemed compliant with this section if the plan conforms
with these standards, as long as the minimum requirements
described in subdivision (a) have been met.
(f) For the purposes of this section, "identification card"
includes other technology that performs substantially the same
function as an identification card.
(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 care service plans, except
behavioral health-only plans.
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 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 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 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 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 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) "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 Internet 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 or instructions
on how to obtain the formulary, 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 or instructions on how to obtain the
provider list, 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 Any
modified 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).
(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 care service plans, except
behavioral health-only plans.
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
coverage for 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 , and when
assessment services are provided by the health insurer, access to
assessment services for the purpose of referral to an
appropriate level of care or an appropriate health care provider.
(5)
(4) 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 (WEDI) or other national
uniform standards with respect to identification cards, and a
health insurer shall be deemed compliant with this section if the
insurer conforms with these standards, as long as the minimum
requirements described in subdivision (a) have been met.
(f) For the purposes of this section, "identification card"
includes other technology that performs substantially the same
function as an identification card.
(f)
(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. 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 or instructions
on how to obtain formulary information .
(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 or instructions on how to obtain a
provider list 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.