Bill Text: CA SB137 | 2015-2016 | Regular Session | Amended
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Health care coverage: provider directories.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2015-10-08 - Chaptered by Secretary of State. Chapter 649, Statutes of 2015. [SB137 Detail]
Download: California-2015-SB137-Amended.html
Bill Title: Health care coverage: provider directories.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2015-10-08 - Chaptered by Secretary of State. Chapter 649, Statutes of 2015. [SB137 Detail]
Download: California-2015-SB137-Amended.html
BILL NUMBER: SB 137 AMENDED
BILL TEXT
AMENDED IN SENATE APRIL 21, 2015
AMENDED IN SENATE MARCH 26, 2015
INTRODUCED BY Senator Hernandez
JANUARY 26, 2015
An act to add Section 1367.27 to the Health and Safety Code, and
to add Section 10133.15 to the Insurance Code, relating to health
care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 137, as amended, Hernandez. Health care coverage: provider
directories.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care. A willful violation
of the act is a crime. Existing law requires a health care service
plan to provide a list of contracting providers within a requesting
enrollee's or prospective enrollee's general geographic area.
Existing law also provides for the regulation of health insurers
by the Insurance Commissioner. Existing law requires insurers subject
to regulation by the commissioner to provide group policyholders
with a current roster of institutional and professional providers
under contract to provide services at alternative rates.
This bill would require health care service plans and insurers
subject to regulation by the commissioner for services at alternative
rates to make a provider directory available on its Internet Web
site and to update the directory weekly. The bill would require the
Department of Managed Health Care and the Department of Insurance to
develop provider directory standards. By placing additional
requirements on health care service plans, the violation of which is
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 1367.27 is added to the Health and Safety Code,
to read:
1367.27. (a) (1) A health care service plan shall make available
a provider directory or directories that shall provide information on
contracting providers, including those that accept new patients,
pursuant to the requirements of this section and Section 1367.26. A
provider directory shall not include information on a provider that
does not have a current contract with the plan.
(2) A plan shall provide the directory or directories for the
specific network offered for each product using a consistent method
of network and product naming, numbering, or other classification
method that ensures the public, enrollees, potential enrollees, the
department, and other state or federal agencies can easily identify
which providers participate in which networks for which products. A
health plan shall use the same consistent classification method in
provider contracts and communications to ensure that providers can
identify the products and networks that they are legally contracted
to provide services in. The classification shall be consistent across
plans in order to permit the department and other state or federal
agencies to construct multiplan directories.
(3) The provider directory or directories shall be available on
the plan's Internet Web site to the public and potential enrollees
without any requirement that a member of the public or potential
enrollee indicate intent to obtain coverage from the plan. The
directory or directories shall be available to the public without
requiring that an individual seeking the directory information
demonstrate coverage with the plan, provide a policy number, provide
any other identifying information, or create or access an account.
(b) (1) The provider directory or directories shall be accessible
on the plan's public Internet Web site through a clearly identifiable
link or tab and in a manner that is accessible and searchable by the
public, potential enrollees, enrollees, and providers. The plan's
public Internet Web site shall allow for provider searches by name,
practice address, National Provider Identification number, California
license, facility or identification number, product, tier, provider
language, medical group, or independent practice association,
hospital, or clinic, as appropriate. If another technology emerges
that takes the place of Internet Web sites, the department shall
direct the plan to make the information required under this section
available on the subsequent technology in a timeframe that allows for
implementation of the technology, not to exceed six months. The plan
shall also make a paper copy of the directory or directories
available upon request.
(2) The plan shall update the provider directory or directories,
at least weekly, pursuant to paragraph (1) with any change to
contracting providers, including all of the following:
(A) Instances where Whether a
contracting provider is no longer accepting new patients, or that the
provider moved or relocated from the contracted service area of the
plan, or has retired or has otherwise ceased to practice.
(B) Instances where Whether the
contracting provider group, if any, has identified that the provider
is no longer associated with the group or is no longer accepting new
patients.
(C) Instances where Whether the plan
identified a change based on an enrollee complaint that a provider
was not accepting new patients or was otherwise not available.
(D) Any other relevant information that has come to the attention
of the plan affecting the content of the provider directory.
(3) The provider directory or directories shall include both an
email address and a telephone number for members of the public and
providers to notify the plan if the provider directory information
appears to be inaccurate.
(4) By September 15, 2016, or no later than six months after the
date that provider directory standards are developed under
subdivision (d), a plan shall use the developed standards pursuant to
subdivision (d) for each product offered by the plan.
(c) A full service health care service plan shall include all of
the following information in the provider directory or directories:
(1) The provider's name, location(s)
practice location or locations , and contact information.
(2) Type of practitioner.
(3) National Provider Identification number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) (A) For physicians, the medical group, if any.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, and nurse midwives to the extent their services
may be accessed and are covered through the contract with the plan.
(C) For federally qualified health centers or primary care
clinics, the name of the federally qualified health center or clinic.
(D) For any provider described in subparagraph (A) or (B) who is
employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the plan, the name of the provider,
and the name of the federally qualified health center or clinic.
(7) Hospital admitting privileges, if any, for physicians and
other health professionals contracted with the plan whose scope of
services for the plan include admitting patients and who have
admitting privileges at a hospital.
(8) Non-English language, if any, spoken by a health professional
as well as non-English language, if any, spoken by staff to
the provider. the provider's staff.
(9) Whether a provider is accepting new patients with the product
selected by the enrollee or potential enrollee.
(10) Network tier to which the provider is assigned, if
applicable. "Tiered provider network" means a network of
participating providers that has been divided into subgroupings
differentiated by the health plan according to enrollee cost-sharing
levels or quality scores. Nothing in this section shall be construed
to require the use of network tiers other than contract and
noncontracting tiers.
(11) A disclosure that enrolles enrollees
are entitled to full and equal access to covered services,
including enrollees with disabilities as required under the Americans
with Disabilities Act and Section 504 of the Rehabilitation Act.
(12) All other information necessary to conduct a search pursuant
to subdivision (b).
(d) A specialized health care service plan shall include all of
the following information for each of the provider directories used
by the plan for its networks:
(1) The provider's name, location,
practice location or locations, and contact information.
(2) Type of Practitioner practitioner
.
(3) National Provider Identification number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) If participating in a group practice, the name of the group
practice.
(7) The names of any allied health care professionals to the
extent their services are covered through the contract with the plan.
(8) Non-English language, if any, spoken by a health provider as
well as non-English language, if any, spoken by the provider's
staff.
(9) Whether a provider is accepting new patients enrolled in the
product that the directory applies to.
(10) A disclosure that enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities as
required under the Americans with Disabilities Act and Section 504 of
the Rehabilitation Act.
(e) (1) By March 15, 2016, the department and the Department of
Insurance shall develop provider directory standards for purposes of
paragraph (3) of subdivision (b).
(2) The standards shall be sufficient to permit a single uniform
electronic directory that would allow a member of the public to
determine whether a physician or other provider is available to an
enrollee of the California Health Benefit Exchange as well
as Exchange, a beneficiary of the Medi-Cal
program enrolled in a Medi-Cal managed care plan. The
standards shall be sufficient to permit a single uniform directory
that would allow a member of the public to determine whether a
physician or other provider is available to an enrollee with group
coverage as well as to a beneficiary of the Medi-Cal program enrolled
in a Medi-Cal managed care plan or to an enrollee of the California
Health Benefit Exchange. plan, as well as to an
enrollee with group coverage.
(3) The department and the Department of Insurance shall seek
input from interested parties, including holding at least one public
meeting. In developing the directory template,
standards, the department shall take into consideration
any requirements for provider directories established by the federal
Centers for Medicare and Medicaid Services.
(f) (1) The plan shall provide the directory or directories to the
department in a format and manner to be specified by the department.
(2) The plan shall demonstrate no less than quarterly to the
department that the information provided in the provider directory or
directories is consistent with the information required under
Sections 1367.03 and 1367.035, and other provisions of this chapter.
The plan shall assure that other information reported to the
department is consistent with the information provided to enrollees,
potential enrollees, and the department pursuant to this section.
(3) The plan shall demonstrate to the department that enrollees or
potential enrollees seeking a provider that is contracted with the
network for a particular product can identify these providers and
that the provider is accepting new patients. The plan shall ensure
that the accuracy of the provider directory meets or exceeds 97
percent.
(4) The plan shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past three months for primary care providers, or six months for
specialty care providers, to determine whether the provider is
accepting patients or referrals from the plan, if claims are paid by
the plan. If claims are not paid by the plan, the plan shall contact
any provider that is listed in the provider directory who has not
submitted encounter data within the past three months for primary
care providers, or six months without encounter data for a specialty
care provider. If the provider does not respond within 30 days, the
plan shall remove the provider from the provider directory. This
requirement does not apply to claims or encounter data from new
primary care providers in the first three months, or new specialty
care providers in the first six months, of the contract.
(g) The plan shall make available an electronic copy of, or upon
request, one physical copy of the provider directory or directories
to the following:
(1) To the State Department of Health Care Services for Medi-Cal
managed care plans.
(2) To the California Health Benefit Exchange for the networks of
the products offered through the California Health Benefit Exchange,
as required by contract.
(3) On request by the Public Employees' Retirement System, to the
Public Employees' Retirement System.
(4) The department and the Department of Insurance.
(5) On request by a group purchaser, provider directory or
directories for the products available in the market segment of the
group.
(h) If a contracting provider, or the representative of a
contracting provider, informs an enrollee or potential enrollee that
the provider is not accepting new patients, the contract between the
plan and the provider shall require the provider to inform the
plan that the provider is not accepting new patients and direct
the enrollee or potential enrollee to the plan for additional
assistance in finding a provider and also to the department to inform
it of the possible inaccuracy in the provider directory. If an
enrollee or potential enrollee informs a plan of a possible
inaccuracy in the provider directory or directories, the plan shall
undertake immediate corrective action to ensure the accuracy of the
directory or directories.
(i) This section does not prohibit a plan from requiring its
contracting providers, contracting provider groups, or contracting
specialized health care plans to satisfy the requirements of this
section. If a plan delegates the responsibility of complying with
this section to its contracting providers, contracting provider
groups, or contracting specialized health care plans, the plan shall
ensure that the requirements of this section are met.
(j) Every health care service plan shall ensure processes are in
place to allow providers to promptly verify or submit changes to
demographic information and participation status. Those processes
shall, at a minimum, include an online interface for providers to
submit verification or changes electronically and shall allow
providers to receive an acknowledgment of receipt from the health
care service plan. Providers shall verify or submit changes to
demographic information and participation status using this process
according to the terms of their contract with the contracted health
plan. Providers shall verify or submit changes to demographic
information and participation status using this process according to
the terms of their contract with the contracted health plan.
(k) Every health care service plan shall allow enrollees to
request the information required by this section through their
toll-free telephone number, electronically, or in writing. On request
of an enrollee or potential enrollee, the plan shall provide the
information required under subdivisions (a), (b), (c), and (g) in
written form. The information provided in written form may be limited
to the geographic region in which the enrollee or potential enrollee
resides or intends to reside.
SEC. 2. Section 10133.15 is added to the Insurance Code, to read:
10133.15. (a) (1) A health insurer that contracts with providers
for alternative rates of payment pursuant to Section 10133 shall make
available a provider directory or directories that shall provide
information on contracting providers, including those that accept new
patients pursuant to the requirements of this section and Section
10133.1. A provider directory shall not include information on a
provider that does not have a current contract with the insurer.
(2) An insurer shall provide the directory or directories for the
specific network offered for each product using a consistent method
of network and product naming, numbering, or other classification
method that ensures the public, enrollees,
insureds, potential enrollees,
insureds, the department, and other state or federal agencies
can easily identify which providers participate in which networks for
which products. An insurer shall use the same consistent
classification method in provider contracts and communications to
ensure that providers can identify the products and networks that
they are legally contracted to provide services in. The
classification shall be consistent across plans
products in order to permit the department and other state
or federal agencies to construct multiplan directories.
(3) The provider directory or directories shall be available on
the insurer's Internet Web site to the public and potential
enrollees insureds without any requirement that
a member of the public or potential enrollee
insureds indicate intent to obtain coverage from the insurer.
The directory or directories shall be available to the public without
requiring that an individual seeking the directory information
demonstrate coverage with insurer, provide a policy number, provide
any other identifying information, or create or access an account.
(b) (1) The provider directory or directories shall be accessible
on the insurer's public Internet Web site through a clearly
identifiable link or tab and in a manner that is accessible and
searchable by the public, potential enrollees, enrollees,
insureds, insureds, and providers. The insurer's
public Internet Web site shall allow for provider searches by name,
practice address, National Provider Index number, California license
number, facility or identification number, product, tier, provider
language, medical group, or independent practice association,
hospital, or clinic, as appropriate. If another technology emerges
that takes the place of Internet Web sites, the department shall
direct the insurer to make the information required under this
section available on the subsequent technology in a timeframe that
allows for implementation of the technology, not to exceed six
months. The insurer shall also make a paper copy of the directory or
directories available upon request.
(2) The insurer shall update the provider directory directories,
at least weekly, posted pursuant to paragraph (1) with any change to
contracting providers, including all of the following:
(A) Instances where Whether a
contracting provider has notified the insurer that the provider no
longer intents intends to participate
as a contracting provider, is no longer accepting new patients, that
the provider moved or relocated from the contracted service area of
the plan, product, or has retired or
otherwise ceased to practice.
(B) Instances where Whether the
contracting provider group, if any, has identified that the provider
is no longer associated with the group or is no longer accepting new
patients.
(C) Instances where Whether the
plan insurer identified a change based
on an enrollee an insured complaint
that a provider was not accepting new patients or was otherwise not
available.
(D) Any other relevant information that has come to the attention
of the plan product affecting the
content of the provider directory.
(3) The provider directory or directories shall include both an
email address and a telephone number for members of the public and
providers to notify the insurer if the provider directory information
appears to be inaccurate.
(4) By September 15, 2016, or no later than six months after the
date that provider directory standards are developed under
subdivision (d), an insurer shall use the developed standards
pursuant to subdivision (d) for each product offered by the insurer.
(c) The insurer shall include all of the following information in
the provider directory or directories:
(1) The provider's name, location,
practice location or locations, and contact information.
(2) Type of practitioner.
(3) National Provider Identification number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) (A) For physicians, the medical group, if any.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, and nurse midwives to the extent their services
may be accessed and are covered through the contract with the
insurer.
(C) For federally qualified health centers or primary care
clinics, the name of the federally qualified health center or clinic.
(D) For any provider described in subparagraph (A) or (B) who is
employed by a federally qualified health center or primary care
clinic, and to the extent their services may be accessed and are
covered through the contract with the plan,
insurer, the name of the provider, and the name of the
federally qualified health center or clinic.
(7) Hospital admitting privileges, if any, for physicians and
other health professionals contracted with the insurer whose scope of
services for the plan product include
admitting patients and who have admitting privileges at a hospital.
(8) Non-English language, if any, spoken by a health professional
as well as non-English language, if any, spoken by staff to
the provider. the provider's staff.
(9) Whether a provider is accepting new patients with the product
selected by the enrollee insured or
potential enrollee. insured.
(10) Network tier that the provider is assigned to, if applicable.
"Tiered provider network" means a network of participating providers
that has been divided into subgroupings differentiated by the
insurer according to enrollee insured
cost-sharing levels or quality scores. Nothing in this section shall
be construed to require the use of network tiers other than
contracting and noncontracting tiers.
(11) A disclosure that insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the Americans with Disabilities Act and Section 504 of
the Rehabilitation Act.
(12) All other information necessary to conduct a search pursuant
to subdivision (b).
(d) A specialized insurer shall include all of the following
information for each of the provider directories used by the insurer
for its networks:
(1) The provider's name, location(s)
practice location or locations , and contact information.
(2) Type of practitioner.
(3) National Provider Identification number.
(4) California license number and type of license.
(5) The area of specialty, including board certification, if any.
(6) If participating in a group practice, the name of the group
practice.
(7) The names of any allied health care professionals to the
extent their services are covered through the contract with the
plan. insurer.
(8) Non-English language, if any, spoken by a health professional
as well as non-English language, if any, spoken by staff.
the provider's staff.
(9) Whether a provider is accepting new patients enrolled in the
product that the directory applies to.
(10) A disclosure that insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the Americans with Disabilities Act and Section 504 of
the Rehabilitation Act.
(e) (1) By March 15, 2016, the Department of Managed Health Care
and the department shall develop a provider directory standards for
purposes of paragraph (3) of subdivision (b).
(2) The standards shall be sufficient to permit a single uniform
electronic directory that would allow a member of the public to
determine whether a physician or other provider is available to an
enrollee insured of the California
Health Benefit Exchange as well as Exchange,
a beneficiary of the Medi-Cal program enrolled in a Medi-Cal
managed care plan. The standards shall be sufficient to
permit a single uniform directory that would allow a member of the
public to determine whether a physician or other provider is
available to an enrollee with group coverage as well as to a
beneficiary of the Medi-Cal program enrolled in a Medi-Cal managed
care plan or to an enrollee of the California Health Benefit
Exchange. plan, as well a s to an insured
with group coverage.
(3) The department and the Department of Managed Health Care shall
seek input from interested parties, including holding at least one
public meeting. In developing the directory template,
standards, the department and the
Department of Managed Health Care shall take into consideration any
requirements for provider directories established by the federal
Centers for Medicare and Medicaid Services.
(f) (1) The insurer shall provide the directory or directories to
the department in a format and manner to be specified by the
department.
(2) The insurer shall demonstrate no less than quarterly to the
department that the information provided in the provider directory or
directories is consistent with the information required under
Section 10133.5 and other provisions of this part. The insurer shall
assure that other information reported to the department is
consistent with the information provided to enrollees,
insureds, potential enrollees,
insureds, and the department pursuant to this
section.
(3) The insurer shall demonstrate to the department that
enrollees insureds or potential
enrollees insureds seeking a provider that is
contracted with the network for a particular product can identify
these providers and that the provider is accepting new patients. The
insurer shall ensure that the accuracy of the provider directory
meets or exceeds 97 percent.
(4) The insurer shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past three months for primary care providers, or six months for
specialty care providers, to determine whether the provider is
accepting patients or referrals from the plan,
insurer, if claims are paid by the insurer. If the
provider does not respond within 30 days, the insurer shall remove
the provider from the provider directory. This requirement does not
apply to claims or claim data from new primary care providers in the
first three months, or new specialty care providers in the first six
months, of the contract.
(g) The insurer shall make available an electronic copy of, or
upon request, one physical copy of the provider directory or
directories to the following:
(1) To the State Department of Health Care Services for Medi-Cal
managed care plans.
(2) To the California Health Benefit Exchange for the networks of
the products offered through the California Health Benefit Exchange,
as required by contract.
(3) On request by the Public Employees' Retirement System, to the
Public Employees' Retirement System.
(4) The department and the Department of Managed Health Care.
(5) On request by a group purchaser, provider directory or
directories for the products available in the market segment of the
group.
(h) If a contracting provider, or the representative of a
contracting provider, informs an enrollee
insured or potential enrollee insured
that the provider is not accepting new patients, the contract
between the insurer and the provider shall require the provider to
inform the insurer that the provider is not accepting new
patients and direct the enrollee
insured or potential
enrollee insured to the insurer for
additional assistance in finding a provider and also to the
department to inform it of the possible inaccuracy in the provider
directory. If an enrollee insured or
potential enrollee insured informs an
insurer of a possible inaccuracy in the provider directory or
directories, the insurer shall undertake immediate corrective action
to ensure the accuracy of the directory or directories.
(i) This section does not prohibit an insurer from requiring its
contracting providers, contracting provider groups, or contracting
specialized health care plans to satisfy the requirements of this
section. If an insurer delegates the responsibility of complying with
this section to its contracting providers, contracting provider
groups, or contracting specialized health care plans, the insurer
shall ensure that the requirements of this section are met.
(j) Every insurer shall ensure processes are in place to allow
providers to promptly verify or submit changes to demographic
information and participation status. Those processes shall, at a
minimum, include an online interface for providers to submit
verification or changes electronically and shall allow providers to
receive an acknowledgment of receipt from the health insurer.
Providers shall verify or submit changes to demographic information
and participation status using this process according to the terms of
their contract with the insurer.
(k) Every health insurer shall allow enrollees
insureds to request the information required by this
section through their toll-free telephone number, electronically, or
in writing. On request of an enrollee insured
or potential enrollee, insured,
the insurer shall provide the information required under subdivisions
(a), (b), (c), and (g) in written form. The information provided in
written form may be limited to the geographic region in which the
enrollee insured or potential
enrollee insured resides or intends to reside.
SEC. 3. 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.
