BILL NUMBER: SB 137 CHAPTERED
BILL TEXT
CHAPTER 649
FILED WITH SECRETARY OF STATE OCTOBER 8, 2015
APPROVED BY GOVERNOR OCTOBER 8, 2015
PASSED THE SENATE SEPTEMBER 11, 2015
PASSED THE ASSEMBLY SEPTEMBER 10, 2015
AMENDED IN ASSEMBLY SEPTEMBER 4, 2015
AMENDED IN ASSEMBLY AUGUST 31, 2015
AMENDED IN ASSEMBLY JULY 16, 2015
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 1367.27 to, and to repeal Section 1367.26
of, 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, 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 health 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.
This bill, commencing July 1, 2016, would require a health care
service plan, and a health insurer that contracts with providers for
alternative rates of payment, to publish and maintain a provider
directory or directories with information on contracting providers
that deliver health care services to the plan's enrollees or the
health insurer's insureds, and would require the plan or health
insurer to make an online provider directory or directories available
on the plan or health insurer's Internet Web site, as specified.
This bill would require the Department of Managed Health Care and
the Department of Insurance to develop uniform provider directory
standards. The bill would require a health care service plan or
health insurer to take appropriate steps to ensure the accuracy of
the information contained in the plan or health insurer's directory
or directories, and would require the plan or health insurer, at
least annually, to review and update the entire provider directory or
directories for each product offered, as specified. The bill would
require a plan or insurer, at least weekly, to update its online
provider directory or directories, and would require a plan or
insurer, at least quarterly, to update its printed provider directory
or directories. The bill would require a health care service plan or
health insurer to reimburse an enrollee or insured for any amount
beyond what the enrollee or insured would have paid for in-network
services, if the enrollee or insured reasonably relied on the
provider directory, as specified. The bill would authorize a plan or
health insurer to delay payment or reimbursement owed to a provider
or provider group, as specified, if the provider or provider group
fails to respond to the plan's or health insurer's attempts to verify
the provider's or provider group's information. 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.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1367.26 of the Health and Safety Code is
repealed.
SEC. 2. Section 1367.27 is added to the Health and Safety Code, to
read:
1367.27. (a) Commencing July 1, 2016, a health care service plan
shall publish and maintain a provider directory or directories with
information on contracting providers that deliver health care
services to the plan's enrollees, including those that accept new
patients. A provider directory shall not list or include information
on a provider that is not currently under contract with the plan.
(b) A health care service 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 the networks and plan products in which a provider
participates. By July 31, 2017, or 12 months after the date provider
directory standards are developed under subdivision (k), whichever
occurs later, a health care service plan shall use the naming,
numbering, or classification method developed by the department
pursuant to subdivision (k).
(c) (1) An online provider directory or directories shall be
available on the plan's Internet Web site to the public, potential
enrollees, enrollees, and providers without any restrictions or
limitations. The directory or directories shall be accessible without
any requirement that an individual seeking the directory information
demonstrate coverage with the plan, indicate interest in obtaining
coverage with the plan, provide a member identification or policy
number, provide any other identifying information, or create or
access an account.
(2) The online provider directory or directories shall be
accessible on the plan's public Internet Web site through an
identifiable link or tab and in a manner that is accessible and
searchable by enrollees, potential enrollees, the public, and
providers. By July 31, 2017, or 12 months after the date provider
directory standards are developed under subdivision (k), whichever
occurs later, the plan's public Internet Web site shall allow
provider searches by, at a minimum, name, practice address, city, ZIP
Code, California license number, National Provider Identifier
number, admitting privileges to an identified hospital, product,
tier, provider language or languages, provider group, hospital name,
facility name, or clinic name, as appropriate.
(d) (1) A health care service plan shall allow enrollees,
potential enrollees, providers, and members of the public to request
a printed copy of the provider directory or directories by contacting
the plan through the plan's toll-free telephone number,
electronically, or in writing. A printed copy of the provider
directory or directories shall include the information required in
subdivisions (h) and (i). The printed copy of the provider directory
or directories shall be provided to the requester by mail postmarked
no later than five business days following the date of the request
and may be limited to the geographic region in which the requester
resides or works or intends to reside or work.
(2) A health care service plan shall update its printed provider
directory or directories at least quarterly, or more frequently, if
required by federal law.
(e) (1) The plan shall update the online provider directory or
directories, at least weekly, or more frequently, if required by
federal law, when informed of and upon confirmation by the plan of
any of the following:
(A) A contracting provider is no longer accepting new patients for
that product, or an individual provider within a provider group is
no longer accepting new patients.
(B) A provider is no longer under contract for a particular plan
product.
(C) A provider's practice location or other information required
under subdivision (h) or (i) has changed.
(D) Upon completion of the investigation described in subdivision
(o), a change is necessary based on an enrollee complaint that a
provider was not accepting new patients, was otherwise not available,
or whose contact information was listed incorrectly.
(E) Any other information that affects the content or accuracy of
the provider directory or directories.
(2) Upon confirmation of any of the following, the plan shall
delete a provider from the directory or directories when:
(A) A provider has retired or otherwise has ceased to practice.
(B) A provider or provider group is no longer under contract with
the plan for any reason.
(C) The contracting provider group has informed the plan that the
provider is no longer associated with the provider group and is no
longer under contract with the plan.
(f) 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. This information shall be disclosed
prominently in the directory or directories and on the plan's
Internet Web site.
(g) The provider directory or directories 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 in accordance with
Section 1367.04.
(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.
(h) A full service health care service plan and a specialized
mental health 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) The provider's office email address, if available.
(7) The name of each affiliated provider group currently under
contract with the plan through which the provider sees enrollees.
(8) A listing for each of the following providers that are under
contract with the plan:
(A) For physicians and surgeons, the provider group, and admitting
privileges, if any, at hospitals contracted with the plan.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, qualified autism service providers, as defined
in Section 1374.73, nurse midwives, and dentists.
(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) Facilities, including, but not limited to, general acute care
hospitals, skilled nursing facilities, urgent care clinics,
ambulatory surgery centers, inpatient hospice, residential care
facilities, and inpatient rehabilitation facilities.
(F) Pharmacies, clinical laboratories, imaging centers, and other
facilities providing contracted health care services.
(9) The provider directory or directories may note that
authorization or referral may be required to access some providers.
(10) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 1367.04, if any, on the provider's staff.
(11) Identification of providers who no longer accept new patients
for some or all of the plan's products.
(12) The network tier to which the provider is assigned, if the
provider is not in the lowest tier, as applicable. Nothing in this
section shall be construed to require the use of network tiers other
than contract and noncontracting tiers.
(13) All other information necessary to conduct a search pursuant
to paragraph (2) of subdivision (c).
(i) A vision, dental, or other specialized health care service
plan, except for a specialized mental health plan, shall include all
of the following information for each provider directory or
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, if applicable.
(5) The area of specialty, including board certification, or other
accreditation, if any.
(6) The provider's office email address, if available.
(7) The name of each affiliated provider group or specialty plan
practice group currently under contract with the plan through which
the provider sees enrollees.
(8) The names of each allied health care professional to the
extent there is a direct contract for those services covered through
a contract with the plan.
(9) The non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 1367.04, if any, on the provider's staff.
(10) Identification of providers who no longer accept new patients
for some or all of the plan's products.
(11) All other applicable information necessary to conduct a
provider search pursuant to paragraph (2) of subdivision (c).
(j) (1) The contract between the plan and a provider shall include
a requirement that the provider inform the plan within five business
days when either of the following occur:
(A) The provider is not accepting new patients.
(B) If the provider had previously not accepted new patients, the
provider is currently accepting new patients.
(2) If a provider who is not accepting new patients is contacted
by an enrollee or potential enrollee seeking to become a new patient,
the provider shall direct the enrollee or potential enrollee to both
the plan for additional assistance in finding a provider and to the
department to report any inaccuracy with the plan's directory or
directories.
(3) If an enrollee or potential enrollee informs a plan of a
possible inaccuracy in the provider directory or directories, the
plan shall promptly investigate, and, if necessary, undertake
corrective action within 30 business days to ensure the accuracy of
the directory or directories.
(k) (1) On or before December 31, 2016, the department shall
develop uniform provider directory standards to permit consistency in
accordance with subdivision (b) and paragraph (2) of subdivision (c)
and development of a multiplan directory by another entity. Those
standards shall not be subject to the Administrative Procedure Act
(Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code), until January 1, 2021. No more
than two revisions of those standards shall be exempt from the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code)
pursuant to this subdivision.
(2) In developing the standards under this subdivision, the
department shall seek input from interested parties throughout the
process of developing the standards and shall hold at least one
public meeting. The department shall take into consideration any
requirements for provider directories established by the federal
Centers for Medicare and Medicaid Services and the State Department
of Health Care Services.
(3) By July 31, 2017, or 12 months after the date provider
directory standards are developed under this subdivision, whichever
occurs later, a plan shall use the standards developed by the
department for each product offered by the plan.
(l) (1) A plan shall take appropriate steps to ensure the accuracy
of the information concerning each provider listed in the plan's
provider directory or directories in accordance with this section,
and shall, at least annually, review and update the entire provider
directory or directories for each product offered. Each calendar year
the plan shall notify all contracted providers described in
subdivisions (h) and (i) as follows:
(A) For individual providers who are not affiliated with a
provider group described in subparagraph (A) or (B) of paragraph (8)
of subdivision (h) and providers described in subdivision (i), the
plan shall notify each provider at least once every six months.
(B) For all other providers described in subdivision (h) who are
not subject to the requirements of subparagraph (A), the plan shall
notify its contracted providers to ensure that all of the providers
are contacted by the plan at least once annually.
(2) The notification shall include all of the following:
(A) The information the plan has in its directory or directories
regarding the provider or provider group, including a list of
networks and plan products that include the contracted provider or
provider group.
(B) A statement that the failure to respond to the notification
may result in a delay of payment or reimbursement of a claim pursuant
to subdivision (p).
(C) Instructions on how the provider or provider group can update
the information in the provider directory or directories using the
online interface developed pursuant to subdivision (m).
(3) The plan shall require an affirmative response from the
provider or provider group acknowledging that the notification was
received. The provider or provider group shall confirm that the
information in the provider directory or directories is current and
accurate or update the information required to be in the directory or
directories pursuant to this section, including whether or not the
provider or provider group is accepting new patients for each plan
product.
(4) If the plan does not receive an affirmative response and
confirmation from the provider that the information is current and
accurate or, as an alternative, updates any information required to
be in the directory or directories pursuant to this section, within
30 business days, the plan shall take no more than 15 business days
to verify whether the provider's information is correct or requires
updates. The plan shall document the receipt and outcome of each
attempt to verify the information. If the plan is unable to verify
whether the provider's information is correct or requires updates,
the plan shall notify the provider 10 business days in advance of
removal that the provider will be removed from the provider directory
or directories. The provider shall be removed from the provider
directory or directories at the next required update of the provider
directory or directories after the 10-business day notice period. A
provider shall not be removed from the provider directory or
directories if he or she responds before the end of the 10-business
day notice period.
(5) General acute care hospitals shall be exempt from the
requirements in paragraphs (3) and (4).
(m) A plan shall establish policies and procedures with regard to
the regular updating of its provider directory or directories,
including the weekly, quarterly, and annual updates required pursuant
to this section, or more frequently, if required by federal law or
guidance.
(1) The policies and procedures described under subdivision (l)
shall be submitted by a plan annually to the department for approval
and in a format described by the department pursuant to Section
1367.035.
(2) 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 or directories pursuant
to this section. Those processes shall, at a minimum, include an
online interface for providers to submit verification or changes
electronically and shall generate an acknowledgment of receipt from
the health care service plan. Providers shall verify or submit
changes to information required to be in the directory or directories
pursuant to this section using the process required by the health
care service plan.
(3) The plan shall establish and maintain a process for enrollees,
potential enrollees, other providers, and the public to identify and
report possible inaccurate, incomplete, or misleading information
currently listed in the plan's provider directory or directories.
These processes shall, at a minimum, include a telephone number and a
dedicated email address at which the plan will accept these reports,
as well as a hyperlink on the plan's provider directory Internet Web
site linking to a form where the information can be reported
directly to the plan through its Internet Web site.
(n) (1) This section does not prohibit a plan from requiring its
provider groups or contracting specialized health care service plans
to provide information to the plan that is required by the plan to
satisfy the requirements of this section for each of the providers
that contract with the provider group or contracting specialized
health care service plan. This responsibility shall be specifically
documented in a written contract between the plan and the provider
group or contracting specialized health care service plan.
(2) If a plan requires its contracting provider groups or
contracting specialized health care service plans to provide the plan
with information described in paragraph (1), the plan shall continue
to retain responsibility for ensuring that the requirements of this
section are satisfied.
(3) A provider group may terminate a contract with a provider for
a pattern or repeated failure of the provider to update the
information required to be in the directory or directories pursuant
to this section.
(4) A provider group is not subject to the payment delay described
in subdivision (p) if all of the following occurs:
(A) A provider does not respond to the provider group's attempt to
verify the provider's information. As used in this paragraph,
"verify" means to contact the provider in writing, electronically,
and by telephone to confirm whether the provider's information is
correct or requires updates.
(B) The provider group documents its efforts to verify the
provider's information.
(C) The provider group reports to the plan that the provider
should be deleted from the provider group in the plan directory or
directories.
(5) Section 1375.7, known as the Health Care Providers' Bill of
Rights, applies to any material change to a provider contract
pursuant to this section.
(o) (1) Whenever a health care service plan receives a report
indicating that information listed in its provider directory or
directories is inaccurate, the plan shall promptly investigate the
reported inaccuracy and, no later than 30 business days following
receipt of the report, either verify the accuracy of the information
or update the information in its provider directory or directories,
as applicable.
(2) When investigating a report regarding its provider directory
or directories, the plan shall, at a minimum, do the following:
(A) Contact the affected provider no later than five business days
following receipt of the report.
(B) Document the receipt and outcome of each report. The
documentation shall include the provider's name, location, and a
description of the plan's investigation, the outcome of the
investigation, and any changes or updates made to its provider
directory or directories.
(C) If changes to a plan's provider directory or directories are
required as a result of the plan's investigation, the changes to the
online provider directory or directories shall be made no later than
the next scheduled weekly update, or the update immediately following
that update, or sooner if required by federal law or regulations.
For printed provider directories, the change shall be made no later
than the next required update, or sooner if required by federal law
or regulations.
(p) (1) Notwithstanding Sections 1371 and 1371.35, a plan may
delay payment or reimbursement owed to a provider or provider group
as specified in subparagraph (A) or (B), if the provider or provider
group fails to respond to the plan's attempts to verify the provider'
s or provider group's information as required under subdivision (l).
The plan shall not delay payment unless it has attempted to verify
the provider's or provider group's information. As used in this
subdivision, "verify" means to contact the provider or provider group
in writing, electronically, and by telephone to confirm whether the
provider's or provider group's information is correct or requires
updates. A plan may seek to delay payment or reimbursement owed to a
provider or provider group only after the 10-business day notice
period described in paragraph (4) of subdivision (l) has lapsed.
(A) For a provider or provider group that receives compensation
on a capitated or prepaid basis, the plan may delay no more than 50
percent of the next scheduled capitation payment for up to one
calendar month.
(B) For any claims payment made to a provider or provider group,
the plan may delay the claims payment for up to one calendar month
beginning on the first day of the following month.
(2) A plan shall notify the provider or provider group 10 business
days before it seeks to delay payment or reimbursement to a provider
or provider group pursuant to this subdivision. If the plan delays a
payment or reimbursement pursuant to this subdivision, the plan
shall reimburse the full amount of any payment or reimbursement
subject to delay to the provider or provider group according to
either of the following timelines, as applicable:
(A) No later than three business days following the date on which
the plan receives the information required to be submitted by the
provider or provider group pursuant to subdivision (l).
(B) At the end of the one-calendar month delay described in
subparagraph (A) or (B) of paragraph (1), as applicable, if the
provider or provider group fails to provide the information required
to be submitted to the plan pursuant to subdivision (l).
(3) 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 or
directories pursuant to this section.
(4) A plan that delays payment or reimbursement under this
subdivision shall document each instance a payment or reimbursement
was delayed and report this information to the department in a format
described by the department pursuant to Section 1367.035. This
information shall be submitted along with the policies and procedures
required to be submitted annually to the department pursuant to
paragraph (1) of subdivision (m).
(5) With respect to plans with Medi-Cal managed care contracts
with the State Department of Health Care Services pursuant to Chapter
7 (commencing with Section 14000), Chapter 8 (commencing with
Section 14200), or Chapter 8.75 (commencing with Section 14591) of
the Welfare and Institutions Code, this subdivision shall be
implemented only to the extent consistent with federal law and
guidance.
(q) In circumstances where the department finds that an enrollee
reasonably relied upon materially inaccurate, incomplete, or
misleading information contained in a health plan's provider
directory or directories, the department may require the health plan
to provide coverage for all covered health care services provided to
the enrollee and to reimburse the enrollee for any amount beyond what
the enrollee would have paid, had the services been delivered by an
in-network provider under the enrollee's plan contract. Prior to
requiring reimbursement in these circumstances, the department shall
conclude that the services received by the enrollee were covered
services under the enrollee's plan contract. In those circumstances,
the fact that the services were rendered or delivered by a
noncontracting or out-of-plan provider shall not be used as a basis
to deny reimbursement to the enrollee.
(r) Whenever a plan determines as a result of this section that
there has been a 10-percent change in the network for a product in a
region, the plan shall file an amendment to the plan application with
the department consistent with subdivision (f) of Section 1300.52 of
Title 28 of the California Code of Regulations.
(s) 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), Chapter 8 (commencing
with Section 14200), or Chapter 8.75 (commencing with Section 14591)
of the Welfare and Institutions Code to the extent consistent with
federal law and guidance and state law guidance issued after January
1, 2016. Notwithstanding any other provision to the contrary in a
plan contract with the State Department of Health Care Services, and
to the extent consistent with federal law and guidance and state
guidance issued after January 1, 2016, a Medi-Cal managed care plan
that complies with the requirements of this section shall not be
required to distribute a printed provider directory or directories,
except as required by paragraph (1) of subdivision (d).
(t) 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.
(u) Nothing in this section shall be construed to alter a provider'
s obligation to provide health care services to an enrollee pursuant
to the provider's contract with the plan.
(v) As part of the department's routine examination of the fiscal
and administrative affairs of a health care service plan pursuant to
Section 1382, the department shall include a review of the health
care service plan's compliance with subdivision (p).
(w) For purposes of this section, "provider group" means a medical
group, independent practice association, or other similar group of
providers.
SEC. 3. Section 10133.15 is added to the Insurance Code, to read:
10133.15. (a) Commencing July 1, 2016, a health insurer that
contracts with providers for alternative rates of payment pursuant to
Section 10133 shall publish and maintain
provider directory or directories with information on
contracting providers that deliver health care services to the
insurer's insureds, including those that accept new patients. A
provider directory shall not list or include information on a
provider that is not currently under contract with the insurer.
(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 the networks and insurer products in which a provider
participates. By July 31, 2017, or 12 months after the date provider
directory standards are developed under subdivision (k), whichever
occurs later, an insurer shall use the naming, numbering, or
classification method developed by the department pursuant to
subdivision (k).
(c) (1) An online provider directory or directories shall be
available on the insurer's Internet Web site to the public, potential
insureds, insureds, and providers without any restrictions or
limitations. The directory or directories shall be accessible without
any requirement that an individual seeking the directory information
demonstrate coverage with the insurer, indicate interest in
obtaining coverage with the insurer, provide a member identification
or policy number, provide any other identifying information, or
create or access an account.
(2) The online provider directory or directories shall be
accessible on the insurer's public Internet Web site through an
identifiable link or tab and in a manner that is accessible and
searchable by insureds, potential insureds, the public, and
providers. By July 1, 2017, or 12 months after the date provider
directory standards are developed under subdivision (k), whichever
occurs later, the insurer's public Internet Web site shall allow
provider searches by, at a minimum, name, practice address, city, ZIP
Code, California license number, National Provider Identifier
number, admitting privileges to an identified hospital, product,
tier, provider language or languages, provider group, hospital name,
facility name, or clinic name, as appropriate.
(d) (1) An insurer shall allow insureds, potential insureds,
providers, and members of the public to request a printed copy of the
provider directory or directories by contacting the insurer through
the insurer's toll-free telephone number, electronically, or in
writing. A printed copy of the provider directory or directories
shall include the information required in subdivisions (h) and (i).
The printed copy of the provider directory or directories shall be
provided to the requester by mail postmarked no later than five
business days following the date of the request and may be limited to
the geographic region in which the requester resides or works or
intends to reside or work.
(2) An insurer shall update its printed provider directory or
directories at least quarterly, or more frequently, if required by
federal law.
(e) (1) The insurer shall update the online provider directory or
directories, at least weekly, or more frequently, if required by
federal law, when informed of and upon confirmation by the insurer of
any of the following:
(A) A contracting provider is no longer accepting new patients for
that product, or an individual provider within a provider group is
no longer accepting new patients.
(B) A contracted provider is no longer under contract for a
particular product.
(C) A provider's practice location or other information required
under subdivision (h) or (i) has changed.
(D) Upon the completion of the investigation described in
subdivision (o), a change is necessary based on an insured complaint
that a provider was not accepting new patients, was otherwise not
available, or whose contact information was listed incorrectly.
(E) Any other information that affects the content or accuracy of
the provider directory or directories.
(2) Upon confirmation of any of the following, the insurer shall
delete a provider from the directory or directories when:
(A) A provider has retired or otherwise has ceased to practice.
(B) A provider or provider group is no longer under contract with
the insurer for any reason.
(C) The contracting provider group has informed the insurer that
the provider is no longer associated with the provider group and is
no longer under contract with the insurer.
(f) 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. This information shall be disclosed
prominently in the directory or directories and on the insurer's
Internet Web site.
(g) The provider directory or directories 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 in accordance with
Section 10133.8.
(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.
(h) The insurer and a specialized mental health 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) The provider's office email address, if available.
(7) The name of each affiliated provider group currently under
contract with the insurer through which the provider sees enrollees.
(8) A listing for each of the following providers that are under
contract with the insurer:
(A) For physicians and surgeons, the provider group, and admitting
privileges, if any, at hospitals contracted with the insurer.
(B) Nurse practitioners, physician assistants, psychologists,
acupuncturists, optometrists, podiatrists, chiropractors, licensed
clinical social workers, marriage and family therapists, professional
clinical counselors, qualified autism service providers, as defined
in Section 10144.51, nurse midwives, and dentists.
(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) Facilities, including but not limited to, general acute care
hospitals, skilled nursing facilities, urgent care clinics,
ambulatory surgery centers, inpatient hospice, residential care
facilities, and inpatient rehabilitation facilities.
(F) Pharmacies, clinical laboratories, imaging centers, and other
facilities providing contracted health care services.
(9) The provider directory or directories may note that
authorization or referral may be required to access some providers.
(10) Non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 10133.8 of the Insurance Code, if any, on the provider's
staff.
(11) Identification of providers who no longer accept new patients
for some or all of the insurer's products.
(12) The network tier to which the provider is assigned, if the
provider is not in the lowest tier, as applicable. Nothing in this
section shall be construed to require the use of network tiers other
than contract and noncontracting tiers.
(13) All other information necessary to conduct a search pursuant
to paragraph (2) of subdivision (c).
(i) A vision, dental, or other specialized insurer, except for a
specialized mental health insurer, shall include all of the following
information for each provider directory or 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, if applicable.
(5) The area of specialty, including board certification, or other
accreditation, if any.
(6) The provider's office email address, if available.
(7) The name of each affiliated provider group or specialty
insurer practice group currently under contract with the insurer
through which the provider sees insureds.
(8) The names of each allied health care professional to the
extent there is a direct contract for those services covered through
a contract with the insurer.
(9) The non-English language, if any, spoken by a health care
provider or other medical professional as well as non-English
language spoken by a qualified medical interpreter, in accordance
with Section 10133.8 of the Insurance Code, if any, on the provider's
staff.
(10) Identification of providers who no longer accept new patients
for some or all of the insurer's products.
(11) All other applicable information necessary to conduct a
provider search pursuant to paragraph (2) of subdivision (c).
(j) (1) The contract between the insurer and a provider shall
include a requirement that the provider inform the insurer within
five business days when either of the following occur:
(A) The provider is not accepting new patients.
(B) If the provider had previously not accepted new patients, the
provider is currently accepting new patients.
(2) If a provider who is not accepting new patients is contacted
by an insured or potential insured seeking to become a new patient,
the provider shall direct the insurer or potential insured to both
the insurer for additional assistance in finding a provider and to
the department to report any inaccuracy with the insurer's directory
or directories.
(3) If an insured or potential insured informs an insurer of a
possible inaccuracy in the provider directory or directories, the
insurer shall promptly investigate and, if necessary, undertake
corrective action within 30 business days to ensure the accuracy of
the directory or directories.
(k) (1) On or before December 31, 2016, the department shall
develop uniform provider directory standards to permit consistency in
accordance with subdivision (b) and paragraph (2) of subdivision (c)
and development of a multiplan directory by another entity. Those
standards shall not be subject to the Administrative Procedure Act
(Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3
of Title 2 of the Government Code), until January 1, 2021. No more
than two revisions of those standards shall be exempt from the
Administrative Procedure Act (Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code)
pursuant to this subdivision.
(2) In developing the standards under this subdivision, the
department shall seek input from interested parties throughout the
process of developing the standards and shall hold at least one
public meeting. The department shall take into consideration any
requirements for provider directories established by the federal
Centers for Medicare and Medicaid Services and the State Department
of Health Care Services.
(3) By July 31, 2017, or 12 months after the date provider
directory standards are developed under this subdivision, whichever
occurs later, an insurer shall use the standards developed by the
department for each product offered by the insurer.
(l) (1) An insurer shall take appropriate steps to ensure the
accuracy of the information concerning each provider listed in the
insurer's provider directory or directories in accordance with this
section, and shall, at least annually, review and update the entire
provider directory or directories for each product offered. Each
calendar year the insurer shall notify all contracted providers
described in subdivisions (h) and (i) as follows:
(A) For individual providers who are not affiliated with a
provider group described in subparagraph (A) or (B) of paragraph (8)
of subdivision (h) and providers described in subdivision (i), the
insurer shall notify each provider at least once every six months.
(B) For all other providers described in subdivision (h) who are
not subject to the requirements of subparagraph (A), the insurer
shall notify its contracted providers to ensure that all of the
providers are contacted by the insurer at least once annually.
(2) The notification shall include all of the following:
(A) The information the insurer has in its directory or
directories regarding the provider or provider group, including a
list of networks and products that include the contracted provider or
provider group.
(B) A statement that the failure to respond to the notification
may result in a delay of payment or reimbursement of a claim pursuant
to subdivision (p).
(C) Instructions on how the provider or provider group can update
the information in the provider directory or directories using the
online interface developed pursuant to subdivision (m).
(3) The insurer shall require an affirmative response from the
provider or provider group acknowledging that the notification was
received. The provider or provider group shall confirm that the
information in the provider directory or directories is current and
accurate or update the information required to be in the directory or
directories pursuant to this section, including whether or not the
provider group is accepting new patients for each product.
(4) If the insurer does not receive an affirmative response and
confirmation from the provider that the information is current and
accurate or, as an alternative, updates any information required to
be in the directory or directories pursuant to this section, within
30 business days, the insurer shall take no more than 15 business
days to verify whether the provider's information is correct or
requires updates. The insurer shall document the receipt and outcome
of each attempt to verify the information. If the insurer is unable
to verify whether the provider's information is correct or requires
updates, the insurer shall notify the provider 10 business days in
advance of removal that the provider will be removed from the
directory or directories. The provider shall be removed from the
directory or directories at the next required update of the provider
directory or directories after the 10-business day notice period. A
provider shall not be removed from the provider directory or
directories if he or she responds before the end of the 10-business
day notice period.
(5) General acute care hospitals shall be exempt from the
requirements in paragraphs (3) and (4).
(m) An insurer shall establish policies and procedures with regard
to the regular updating of its provider directory or directories,
including the weekly, quarterly, and annual updates required pursuant
to this section, or more frequently, if required by federal law or
guidance.
(1) The policies and procedures described under subdivision (l)
shall be submitted by an insurer annually to the department for
approval and in a format described by the department.
(2) 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 or directories pursuant to this
section. Those processes shall, at a minimum, include an online
interface for providers to submit verification or changes
electronically and shall generate an acknowledgment of receipt from
the insurer. Providers shall verify or submit changes to information
required to be in the directory or directories pursuant to this
section using the process required by the insurer.
(3) The insurer shall establish and maintain a process for
insureds, potential insureds, other providers, and the public to
identify and report possible inaccurate, incomplete, or misleading
information currently listed in the insurer's provider directory or
directories. These processes shall, at a minimum, include a telephone
number and a dedicated email address at which the insurer will
accept these reports, as well as a hyperlink on the insurer's
provider directory Internet Web site linking to a form where the
information can be reported directly to the insurer through its
Internet Web site.
(n) (1) This section does not prohibit an insurer from requiring
its provider groups or contracting specialized health insurers to
provide information to the insurer that is required by the insurer to
satisfy the requirements of this section for each of the providers
that contract with the provider group or contracting specialized
health insurer. This responsibility shall be specifically documented
in a written contract between the insurer and the provider group or
contracting specialized health insurer.
(2) If an insurer requires its contracting provider groups or
contracting specialized health insurers to provide the insurer with
information described in paragraph (1), the insurer shall continue to
retain responsibility for ensuring that the requirements of this
section are satisfied.
(3) A provider group may terminate a contract with a provider for
a pattern or repeated failure of the provider to update the
information required to be in the directory or directories pursuant
to this section.
(4) A provider group is not subject to the payment delay described
in subdivision (p) if all of the following occurs:
(A) A provider does not respond to the provider group's attempt to
verify the provider's information. As used in this paragraph,
"verify" means to contact the provider in writing, electronically,
and by telephone to confirm whether the provider's information is
correct or requires updates.
(B) The provider group documents its efforts to verify the
provider's information.
(C) The provider group reports to the insurer that the provider
should be deleted from the provider group in the insurer's provider
directory or directories.
(5) Section 10133.65, known as the Health Care Providers' Bill of
Rights, applies to any material change to a provider contract
pursuant to this section.
(o) (1) Whenever an insurer receives a report indicating that
information listed in its provider directory or directories is
inaccurate, the insurer shall promptly investigate the reported
inaccuracy and, no later than 30 business days following receipt of
the report, either verify the accuracy of the information or update
the information in its provider directory or directories, as
applicable.
(2) When investigating a report regarding its provider directory
or directories, the insurer shall, at a minimum, do the following:
(A) Contact the affected provider no later than five business days
following receipt of the report.
(B) Document the receipt and outcome of each report. The
documentation shall include the provider's name, location, and a
description of the insurer's investigation, the outcome of the
investigation, and any changes or updates made to its provider
directory or directories.
(C) If changes to an insurer's provider directory or directories
are required as a result of the insurer's investigation, the changes
to the online provider directory or directories shall be made no
later than the next scheduled weekly update, or the update
immediately following that update, or sooner if required by federal
law or regulations. For printed provider directories, the change
shall be made no later than the next required update, or sooner if
required by federal law or regulations.
(p) (1) Notwithstanding Sections 10123.13 and 10123.147, an
insurer may delay payment or reimbursement owed to a provider or
provider group for any claims payment made to a provider or provider
group for up to one calendar month beginning on the first day of the
following month, if the provider or provider group fails to respond
to the insurer's attempts to verify the provider's information as
required under subdivision (l). The insurer shall not delay payment
unless it has attempted to verify the provider's or provider group's
information. As used in this subdivision, "verify" means to contact
the provider or provider group in writing, electronically, and by
telephone to confirm whether the provider's or provider group's
information is correct or requires updates. An insurer may seek to
delay payment or reimbursement owed to a provider or provider group
only after the 10-business day notice period described in paragraph
(4) of subdivision (l) has lapsed.
(2) An insurer shall notify the provider or provider group 10 days
before it seeks to delay payment or reimbursement to a provider or
provider group pursuant to this subdivision. If the insurer delays a
payment or reimbursement pursuant to this subdivision, the insurer
shall reimburse the full amount of any payment or reimbursement
subject to delay to the provider or provider group according to
either of the following timelines, as applicable:
(A) No later than three business days following the date on which
the insurer receives the information required to be submitted by the
provider or provider group pursuant to subdivision (l).
(B) At the end of the one-calendar month delay described in
subparagraph (A) or (B) of paragraph (1), as applicable, if the
provider or provider group fails to provide the information required
to be submitted to the insurer pursuant to subdivision (l).
(3) 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 or
directories pursuant to this section.
(4) An insurer that delays payment or reimbursement under this
subdivision shall document each instance a payment or reimbursement
was delayed and report this information to the department in a format
described by the department. This information shall be submitted
along with the policies and procedures required to be submitted
annually to the department pursuant to paragraph (1) of subdivision
(m).
(q) In circumstances where the department finds that an insured
reasonably relied upon materially inaccurate, incomplete, or
misleading information contained in an insurer's provider directory
or directories, the department may require the insurer to provide
coverage for all covered health care services provided to the insured
and to reimburse the insured for any amount beyond what the insured
would have paid, had the services been delivered by an in-network
provider under the insured's health insurance policy. Prior to
requiring reimbursement in these circumstances, the department shall
conclude that the services received by the insured were covered
services under the insured's health insurance policy. In those
circumstances, the fact that the services were rendered or delivered
by a noncontracting or out-of-network provider shall not be used as a
basis to deny reimbursement to the insured.
(r) Whenever an insurer determines as a result of this section
that there has been a 10-percent change in the network for a product
in a region, the insurer shall file a statement with the
commissioner.
(s) 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.
(t) Nothing in this section shall be construed to alter a provider'
s obligation to provide health care services to an insured pursuant
to the provider's contract with the insurer.
(u) As part of the department's routine examination of a health
insurer pursuant to Section 730, the department shall include a
review of the health insurer's compliance with subdivision (p).
(v) For purposes of this section, "provider group" means a medical
group, independent practice association, or other similar group of
providers.
SEC. 4. 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.