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 ASSEMBLY JULY 2, 2015
AMENDED IN SENATE JUNE 1, 2015
AMENDED IN SENATE APRIL 21, 2015
AMENDED IN SENATE MARCH 26, 2015
INTRODUCED BY Senator Hernandez
JANUARY 26, 2015
An act to add Section Sections
1367.27 and 1367.28 to the Health and Safety Code, and to
add Section Sections 10133.15 and
10133.16 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.
Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive health care services.
One of the methods by which Medi-Cal services are provided is
pursuant to contracts with various types of managed health care
plans.
Commencing February 1, 2016, this bill would require health care
service plans, and insurers subject to regulation by the commissioner
for services at alternative rates, to make an online provider
directory available on its Internet Web site, as specified.
This
Commencing, March 15, 2016, the bill would require the
Department of Managed Health Care and the Department of Insurance to
jointly develop uniform provider directory standards. Commencing
September 15, 2016, or no later than 6 months after the provider
directory standards are developed, this bill would require
health care service plans plans, plans with
Medi-Cal managed care contracts, and insurers subject to
regulation by the commissioner for services at alternative rates to
make a an online 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
Commencing February 1, 2016, a health care
service plan shall make available a an online
provider directory or directories that shall
provide information on contracting providers,
providers that provide health care services to plan
enrollees, 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)
(b) A plan shall provide the online
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 naming, numbering, or 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 naming, numbering, or
classification shall be consistent across plans in order to permit
the department and other state or federal agencies to
construct multiplan directories.
(3)
(c) The online provider directory or
directories shall be available on the plan's Internet Web site to the
public and potential enrollees public,
potential enrollees, enrollees, and providers through a clearly
identifiable link or tab and in a manner that is accessible and
searchable 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 Identifier 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)
(d) The plan shall update the online
provider directory or directories, at least weekly, pursuant
to paragraph (1) with any change to contracting providers,
including all of the following:
(A)
(1) 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. patients
for that product, or whether the contracting provider group has
identified that a provider of the group is n o longer
accepting new patients.
(2) Whether the provider moved or relocated from the contracted
service area of the plan, has retired, or has otherwise ceased to
practice, in which case the provider shall be deleted from the
directory.
(B)
(3) Whether the contracting provider group, if any, has
identified informed the plan that the
provider is no longer associated with the group or is no
longer accepting new patients. and is no longer under
contract with the plan, in which case the provider shall be deleted
from the directory.
(C) Whether the plan identified
(4) When the plan identified a
change is necessary based on an enrollee complaint that a
provider was not accepting new patients or
patients, was otherwise not available.
available, or whose contact information was listed incorrectly.
(D)
(5) Any other relevant information that has come to the
attention of the plan affecting the content and accuracy
of the provider directory.
(3)
(e) The online 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, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier 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 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 enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(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, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier 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 federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(e) (1) By March 15, 2016, the department and the Department of
Insurance shall develop uniform provider directory standards for
purposes of subdivision (b) which would allow directories to be
aggregated and searchable to determine the plan a physician or other
provider is available through.
(2) The department and the Department of Insurance shall seek
input from interested parties, including holding at least one public
meeting. In developing the directory 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 ensure 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.
(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.
(f) The online provider directory shall include the following
disclosures informing enrollees that they are entitled to both of the
following:
(1) Language interpreter services, at no cost to the enrollee,
including how to obtain interpretation services.
(2) Full and equal access to covered services, including enrollees
with disabilities as required under the federal Americans with
Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of
1973.
SEC. 2. Section 1367.28 is added to the
Health and Safety Code , to read:
1367.28. (a) (1) By March 15, 2016, the department and the
Department of Insurance shall jointly develop uniform provider
directory standards consistent with this section. These standards
shall also require directories to be aggregated and searchable to
determine the plan with which a physician or other provider is
contracted.
(2) The department and the Department of Insurance shall seek
input from interested parties, including holding at least one public
meeting. In developing the directory standards, the department shall
take into consideration any requirements for provider directories
established by the federal Centers for Medicare and Medicaid
Services.
(3) By September 15, 2016, or no later than six months after the
date that provider directory standards are developed a plan shall use
the developed standards for each product offered by the plan.
(4) The uniform provider directory standards shall require the
plan's public Internet Web site to allow for provider searches by
name, practice address, National Provider Identifier number,
California license, facility or identification number, product, tier,
provider language, medical group, or independent practice
association, hospital, or clinic, as appropriate.
(b) A full service health care service plan and a specialized
mental health plan shall include all of the following information in
the online provider directory or directories:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier 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, nurse midwives, and dentists to the extent
their services may be accessed and are covered through the contract
with the plan. The plan may specify in the online provider directory
or directories that authorization or referral may be required to
access some providers.
(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.
(E) Pharmacies.
(F) Skilled nursing facilities.
(G) Urgent care clinics.
(7) Hospital affiliation or 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 contracted hospital.
(8) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a skilled medical interpreter, if any, on 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 the
participating provider has been divided into subgroupings
differentiated by the health plan according to enrollee cost-sharing
levels. Nothing in this section shall be construed to require the use
of network tiers other than contract and noncontracting tiers.
(11) A disclosure that enrollees are entitled to full and equal
access to covered services, including enrollees with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(12) A disclosure that enrollees are entitled to language
interpreter services at no cost to the enrollee, including how to
obtain interpretation services.
(13) All other information necessary to conduct a search pursuant
to subparagraph (A) of paragraph (4) of subdivision (a).
(c) A vision, dental and other specialized health care service
plan, except for a specialized mental health plan, shall include all
of the following information for each of the online provider
directories used by the plan for its networks:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier 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 there is a direct contract for those services covered through
the contract with the plan.
(8) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a skilled medical interpreter, if any, on 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 federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(11) A disclosure that enrollees are entitled to language
interpreter services at no cost to the enrollee, including how to
obtain interpretation services.
(d) (1) The plan shall provide the online 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 ensure 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 95
percent with regard to the participation of providers in the network,
the extent to which the provider is accepting new patients, and if
any non-English language is spoken by the provider or other medical
professionals, as well as non-English language spoken by a skilled
medical interpreter, if any, on the provider's staff.
(4) The plan shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past six months for primary care providers, or twelve 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 six months for primary care
providers, or 12 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. A plan is not
required to terminate a provider who is removed from the directory
according to this paragraph. This requirement does not apply to
claims or encounter data from new primary care providers in the first
six months, or new specialty care providers in the first 12 months,
of the contract. This paragraph shall not apply if a provider has
affirmatively responded under the requirements of subdivision (h)
that the provider information is accurate and the provider is
continuing to participate in the network.
(e) 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 immediately investigate and undertake
corrective action within 30 business days to ensure the accuracy of
the directory or directories.
(f) 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.
(g) Every health care service plan shall ensure processes are in
place to allow providers to promptly verify or submit changes to the
information required to be in the directory pursuant to this section.
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
information required to be in the directory pursuant to this section
using the process required by the health plan.
(h) (1) At least every six months the plan shall notify the
contracted provider or provider group of the information on the
provider or provider group contained in the directory including a
list of each product marketed by the plan for the network. The plan
shall include with this notification instructions as to how to access
and update the information using the online interface in subdivision
(g).
(2) The plan shall require an affirmative response from the
provider or provider group acknowledging that the notification was
received and attesting that the information in the provider directory
is current and accurate. The provider shall update the information
required to be in the directory pursuant to this section, including
whether or not the provider or provider group is accepting new
patients for each product.
(3) If the plan does not receive an affirmative response and
attestation from the provider within 30 business days, the provider
shall be removed from the directory.
(i) 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
provider directory in printed form. The information provided in
printed form may be limited to the geographic region in which the
enrollee or potential enrollee resides or intends to reside.
(j) Notwithstanding the provisions of Section 1371, a plan may use
reasonable compliance methods, such as delaying payment or
reimbursement to a provider who has not responded or removal of the
provider from other directories only until the plan receives an
affirmative response and attestation from the provider. A plan may
terminate a contract for a pattern or repeated failure of the
provider or provider group to alert the plan to a change in the
information required to be in the directory pursuant to this section.
A plan may not impose any compliance method pursuant to this
subdivision without first providing written notice to the provider.
(k) This section shall apply to plans with Medi-Cal managed care
contracts with the State Department of Health Care Services pursuant
to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing
with Section 14200) of the Welfare and Institutions Code to the
extent consistent with federal law and guidance.
(l) A health plan that contracts with multiple employer welfare
agreements regulated pursuant to Article 4.7 (commencing with Section
742.20) of Chapter 1 of Part 2 of Division 1 of the Insurance Code
shall meet the requirements of this section.
SEC. 2. SEC. 3. Section 10133.15 is
added to the Insurance Code, to read:
10133.15. (a) (1)
A Commencing February 1, 2016, a health insurer
that contracts with providers for alternative rates of payment
pursuant to Section 10133 shall make available a
an online provider directory or directories that
shall provide information on contracting
providers, providers that provide health care services
to insureds, 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)
(b) An insurer shall provide the online
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,
insureds, potential 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 naming, numbering, or 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 naming, numbering, or
classification shall be consistent across products in order to permit
the department and other state or federal agencies to
construct multiplan directories.
(3)
(c) The online provider directory or
directories shall be available on the insurer's Internet Web site to
the public and potential insureds public,
potential insureds, insureds, and providers through a clearly
identifiable link or tab and in a manner that is accessible and
searchable without any requirement that a member of the public
or potential 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 the 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 insureds, insureds, and
providers. The insurer's public Internet Web site shall allow for
provider searches by name, practice address, National Provider
Identifier 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)
(d) The insurer shall update the online
provider directory or directories, at least weekly, posted
pursuant to paragraph (1) with any change to contracting
providers, including all of the following:
(A)
(1) Whether a contracting provider has
notified the insurer that the provider no longer 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 product, or has retired or
otherwise ceased to practice. patients for that
product, or whether the contracting provider group has identified
that a provider of the group is no longer accepting new patients.
(2) Whether the provider moved or relocated from the contracted
service area of the insurer, or has retired or has otherwise ceased
to practice, in which case the provider shall be deleted from the
directory.
(B)
(3) Whether the contracting provider group, if any, has
identified informed the insurer that
the provider is no longer associated with the group or is no
longer accepting new patients. and is no longer under
contract with the plan, in which case the provider shall be deleted
from the directory.
(C) Whether the insurer identified
(4) When the plan identified a
change is necessary based on an insured complaint that a
provider was not accepting new patients or
patients, was otherwise not available.
available, or whose contact information was listed incorrectly.
(D)
(5) Any other relevant information that has come to the
attention of the product affecting the content and accuracy
of the provider directory.
(3)
(e) The online 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, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier 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 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 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 the provider's
staff.
(9) Whether a provider is accepting new patients with the product
selected by the insured or potential 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 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 federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(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, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier 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
insurer.
(8) Non-English language, if any, spoken by a health professional
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 insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(e) (1) By March 15, 2016, the Department of Managed Health Care
and the department shall develop uniform provider directory standards
for purposes of subdivision (b) which would allow directories to be
aggregated and searchable to determine the plan a physician or other
provider is available through.
(2) 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 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
ensure that other information reported to the department is
consistent with the information provided to insureds, potential
insureds, and the department pursuant to this section.
(3) The insurer shall demonstrate to the department that insureds
or potential 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 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 insured or potential 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 insured or potential 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
insured or potential 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 insureds to request the
information required by this section through their toll-free
telephone number, electronically, or in writing. On request of an
insured or potential 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 insured or potential insured
resides or intends to reside.
(f) The online provider directory shall include the following
disclosures informing insureds that they are entitled to both of the
following:
(1) Language interpreter services, at no cost to the insured,
including how to obtain interpretation services.
(2) Full and equal access to covered services, including insureds
with disabilities as required under the federal Americans with
Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of
1973.
SEC. 4. Section 10133.16 is added to the
Insurance Code , to read:
10133.16. (a) (1) By March 15, 2016, the department and the
Department of Managed Health Care shall jointly develop uniform
provider directory standards consistent with this section. These
standards shall also require directories to be aggregated and
searchable to determine the insurer with which a physician or other
provider is contracted.
(2) 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 standards, the department
shall take into consideration any requirements for provider
directories established by the federal Centers for Medicare and
Medicaid Services.
(3) By September 15, 2016, or no later than six months after the
date that provider directory standards are developed, an insurer
shall use the developed standards for each product offered by the
insurer.
(4) The uniform provider directory standards shall require the
insurer's public Internet Web site to allow for provider searches by
name, practice address, National Provider Identifier number,
California license number, facility or identification number,
product, tier, provider language, medical group, or independent
practice association, hospital, or clinic, as appropriate.
(b) The insurer and a specialized mental health insurer shall
include all of the following information in the online provider
directory or directories:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier 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, nurse midwives, and dentists to the extent
their services may be accessed and are covered through the contract
with the insurer. The insurer may specify in the provider directory
or directories that authorization or referral may be required to
access some providers.
(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 insurer, the name of the
provider, and the name of the federally qualified health center or
clinic.
(E) Pharmacies.
(F) Skilled nursing facilities.
(G) Urgent care clinics.
(7) Hospital affiliation or admitting privileges, if any, for
physicians and other health professionals contracted with the insurer
whose scope of services for the product include admitting patients
and who have admitting privileges at a contracted hospital.
(8) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a skilled medical interpreter, if any, on the provider's staff.
(9) Whether a provider is accepting new patients with the product
selected by the insured or potential insured.
(10) Network tier that the provider is assigned if the
participating provider has been divided into subgroupings
differentiated by the insurer according to insured 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 insureds are entitled to full and equal
access to covered services, including insureds with disabilities as
required under the federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(12) A disclosure that insureds are entitled to language
interpreter services at no cost to the insured, including how to
obtain interpretation services.
(13) All other information necessary to conduct a search pursuant
to subparagraph (A) of paragraph (4) of subdivision (a).
(c) A vision, dental, and other specialized insurer, except for a
specialized mental health insurer, shall include all of the following
information for each of the online provider directories used by the
insurer for its networks:
(1) The provider's name, practice location or locations, and
contact information.
(2) Type of practitioner.
(3) National Provider Identifier 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 there is a direct contract for those services covered through
the contract with the insurer.
(8) Non-English language, if any, spoken by a health care provider
or other medical professional as well as non-English language spoken
by a skilled medical interpreter, if any, on 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 federal Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973.
(11) A disclosure that insureds are entitled to language
interpreter services at no cost to the insured, including how to
obtain interpretation services.
(d) (1) The insurer shall provide the online 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
ensure that other information reported to the department is
consistent with the information provided to insureds, potential
insureds, and the department pursuant to this section.
(3) The insurer shall demonstrate to the department that insureds
or potential 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 95
percent with regard to the participation of providers in the network,
the extent to which the provider is accepting new patients, as well
as non-English language spoken by a skilled medical interpreter, if
any, on the provider's staff.
(4) The insurer shall contact any provider which is listed in the
provider directory and which has not submitted a claim within the
past six months for primary care providers, or 12 months for
specialty care providers, to determine whether the provider is
accepting patients or referrals from the 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. An
insurer is not required to terminate a provider who is removed from
the directory according to this paragraph. This requirement does not
apply to claims or claim data from new primary care providers in the
first six months, or new specialty care providers in the first 12
months, of the contract. This paragraph shall not apply if a provider
has affirmatively responded under the requirements of subdivision
(h) that the provider information is accurate and the provider is
continuing to participate in the network.
(e) If a contracting provider, or the representative of a
contracting provider, informs an insured or potential 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 insured or potential 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
insured or potential insured informs an insurer of a possible
inaccuracy in the provider directory or directories, the insurer
shall immediately investigate and undertake corrective action within
30 business days to ensure the accuracy of the directory or
directories.
(f) 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.
(g) Every insurer shall ensure processes are in place to allow
providers to promptly verify or submit changes to the information
required to be in the directory pursuant to this section. 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
information required to be in the directory pursuant to this section
using the process required by the insurer.
(h) (1) At least once every six months the insurer shall notify
the contracted provider or provider group of the information on the
provider or provider group contained in the directory including a
list of each product marketed by the insurer for the network. The
insurer shall include with this notification, instructions as to how
to access and update the information using the online interface in
subdivision (g).
(2) The insurer shall require an affirmative response from the
provider or provider group acknowledging that the notification was
received and attesting that the information in the provider directory
is current and accurate. The provider shall update the information
required to be in the directory pursuant to this section, including
whether or not the provider or provider group is accepting new
patients for each product.
(3) If the insurer does not receive an affirmative response and
attestation from the provider within 30 business days, the provider
shall be removed from the directory.
(i) Every health insurer shall allow insureds to request the
information required by this section through their toll-free
telephone number, electronically, or in writing. On request of an
insured or potential insured, the insurer shall provide the provider
directory in printed form. The information provided in printed form
may be limited to the geographic region in which the insured or
potential insured resides or intends to reside.
(j) Notwithstanding the provisions of Section 10123.13, an insurer
may use reasonable compliance methods, such as delaying payment or
reimbursement to a provider who has not responded or removal of the
provider from other directories only until the plan receives an
affirmative response and attestation from the provider. An insurer
may terminate a contract for a pattern or repeated failure of the
provider or provider group to alert the insurer to a change in the
information required to be in the directory pursuant to this section.
An insurer may not impose any compliance method pursuant to this
subdivision without first providing written notice to the provider.
(k) An insurer that contracts with multiple employer welfare
agreements regulated pursuant to Article 4.7 (commencing with Section
742.20) of Chapter 1 of Part 2 of Division 1 shall meet the
requirements of this section.
SEC. 3. SEC. 5. 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.
