AB 236: Health care coverage: provider directories.
- Session Year: 2023-2024
- House: Assembly
- Latest Version Date: 2024-06-27
Current Status:
Failed
(2024-08-15: In committee: Held under submission.)
Introduced
In Committee
First Chamber
In Committee
Second Chamber
Enacted
What does this bill do?
The bill requires health plans and insurers to annually verify and remove inaccurate provider listings and meet rising accuracy targets — 60% by July 1, 2025; 80% by 2026; 90% by 2027; and 95% by 2028 — or face administrative fines. If someone reasonably relied on wrong directory information, the plan or insurer must arrange care, cover and pay for covered services as if the provider were in-network, reimburse the provider the contracted in‑network amount, and the person can only be charged the normal in‑network cost sharing. Plans and insurers must also tell callers or online requesters whether a provider is in‑network and accepting new patients within one business day, and regulators may create standard formats and central data tools to improve directory accuracy.
The summary is provided by generative AI which can make mistakes. For original language, please view the details in the table below.
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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires 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 enrollees or insureds, and requires a health care service plan and health insurer to regularly update its printed and online provider directory or directories, as specified. Existing law authorizes the departments to require a plan or insurer to provide coverage for all covered health care services provided to an enrollee or insured who reasonably relied on materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories.
This bill would require a plan or insurer to annually verify and delete inaccurate listings from its provider directories, and would require a provider directory to be 60% accurate on July 1, 2025, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2028. The bill would subject a plan or insurer to administrative penalties for failure to meet the prescribed benchmarks. The bill would require a plan or insurer to arrange care and provide coverage for all covered health care services provided to an enrollee or insured who reasonably relied on inaccurate, incomplete, or misleading information contained in a health plan or policys provider directory or directories and to reimburse the provider the contracted amount for those services. The bill would prohibit a provider from collecting an additional amount from an enrollee or insured other than the applicable in-network cost sharing. The bill would require a plan or insurer to provide information about in-network providers to enrollees and insureds upon request, and would limit the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances.
On or before January 1, 2025, this bill would authorize the Department of Managed Health Care and the Department of Insurance to develop uniform formats for plans and insurers to use to request directory information from providers and to establish a methodology and processes to ensure accuracy of provider directories and consistency with other laws, regulations, or standards. The bill would require the health plan or the insurer, as applicable, to ensure the accuracy of a request to add back a provider who was previously removed from a directory and approve the request within 10 business days of receipt, if accurate.
Because a violation of the bills requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires 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 enrollees or insureds, and requires a health care service plan and health insurer to regularly update its printed and online provider directory or directories, as specified. Existing law authorizes the departments to require a plan or insurer to provide coverage for all covered health care services provided to an enrollee or insured who reasonably relied on materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories.
This bill would require a plan or insurer to annually verify and delete inaccurate listings from its provider directories, and would require a provider directory to be 60% accurate on July 1, 2025, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2028. The bill would subject a plan or insurer to administrative penalties for failure to meet the prescribed benchmarks. If a plan or insurer has not financially compensated a provider in the prior year, the bill would require the plan or insurer to delete the provider from its directory beginning July 1, 2025, unless specified criteria applies. The bill would require a plan or insurer to arrange care and provide coverage for all covered health care services provided to an enrollee or insured who reasonably relied on inaccurate, incomplete, or misleading information contained in a health plan or policys provider directory or directories and to reimburse the provider the contracted amount for those services. The bill would prohibit a provider from collecting an additional amount from an enrollee or insured other than the applicable in-network cost sharing. The bill would require a plan or insurer to provide information about in-network providers to enrollees and insureds upon request, and would limit the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances.
ThisOn or before January 1, 2025, this bill would authorize the Department of Managed Health Care and the Department of Insurance to develop uniform formats for plans and insurers to use to request directory information from providers and would authorize the departments to establish a methodology and processes to ensure accuracy of provider directories. directories and consistency with other laws, regulations, or standards. The bill would require the health plan or the insurer, as applicable, to ensure the accuracy of a request to add back a provider who was previously removed from a directory and approve the request within 10 business days of receipt, if accurate.
Because a violation of the bills requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires 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 enrollees or insureds, and requires a health care service plan and health insurer to regularly update its printed and online provider directory or directories, as specified. Existing law authorizes the departments to require a plan or insurer to provide coverage for all covered health care services provided to an enrollee or insured who reasonably relied on materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories.
This bill would require a plan or insurer to annually audit verify and delete inaccurate listings from its provider directories, and would require a provider directory to be 60% accurate on January 1, 2024, July 1, 2025, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before January 1, 2027. July 1, 2028. The bill would subject a plan or insurer to administrative penalties for failure to meet the prescribed benchmarks and for each inaccurate listing in its directories. benchmarks. If a plan or insurer has not financially compensated a provider in the prior year, the bill would require the plan or insurer to delete the provider from its directory beginning July 1, 2024, 2025, unless specified criteria applies. The bill would require a plan or insurer to arrange care and provide coverage for all covered health care services provided to an enrollee or insured who reasonably relied on inaccurate, incomplete, or misleading information contained in a health plan or policys provider directory or directories and to reimburse the provider the contracted amount for those services. The bill would prohibit a provider from collecting an additional amount from an enrollee or insured other than the applicable in-network cost sharing. The bill would require a plan or insurer to provide information about in-network providers to enrollees and insureds upon request, and would limit the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances. Because a violation of the bills requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
This bill would authorize the Department of Managed Health Care and the Department of Insurance to develop uniform formats for plans and insurers to use to request directory information from providers and would authorize the departments to establish a methodology and processes to ensure accuracy of provider directories. The bill would require the health plan or the insurer, as applicable, to ensure the accuracy of a request to add back a provider who was previously removed from a directory and approve the request within 10 business days of receipt, if accurate.
Because a violation of the bills requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires 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 enrollees or insureds, and requires a health care service plan and health insurer to regularly update its printed and online provider directory or directories, as specified.
This bill would require a plan or insurer to annually audit and delete inaccurate listings from its provider directories, and would require a provider directory to be 60% accurate on January 1, 2024, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before January 1, 2027. The bill would subject a plan or insurer to administrative penalties for failure to meet the prescribed benchmarks and for each inaccurate listing in its directories. If a plan or insurer has not financially compensated a provider in the prior year, the bill would require the plan or insurer to delete the provider from its directory beginning July 1, 2024, unless specified criteria applies. The bill would require a plan or insurer to provide information about in-network providers to enrollees and insureds upon request, and would limit the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances. Because a violation of the bills requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires 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 enrollees or insureds, and requires a health care service plan and health insurer to regularly update its printed and online provider directory or directories, as specified.
This bill would require a plan or insurer to annually audit and delete inaccurate listings from its provider directories, and would require a provider directory to be 60% accurate on January 1, 2024, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before January 1, 2027. The bill would subject a plan or insurer to administrative penalties for failure to meet the prescribed benchmarks and for each inaccurate listing in its directories. If a plan or insurer has not financially compensated a provider in the prior year, the bill would require the plan or insurer to delete the provider from its directory beginning July 1, 2024, unless specified criteria applies. The bill would require a plan or insurer to provide information about in-network providers to enrollees and insureds upon request, and would limit the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances. Because a violation of the bills requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires 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 enrollees or insureds, and requires a health care service plan and health insurer to regularly update its printed and online provider directory or directories, as specified.
This bill would require a plan or insurer to annually audit and delete inaccurate listings from its provider directories, and would require a provider directory to be 60% accurate on January 1, 2024, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before January 1, 2027. The bill would subject a plan or insurer to administrative penalties for failure to meet the prescribed benchmarks and for each inaccurate listing in its directories. If a plan or insurer has not financially compensated a provider in the prior year, the bill would require the plan or insurer to delete the provider from its directory beginning July 1, 2024, unless specified criteria applies. Because a violation of the bills requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
The Legislature finds and declares all of the following:
(a)It has been the responsibility of each health care service plan and health insurer to maintain an accurate provider directory since the enactment of Chapter 649 of the Statutes of 2015. Despite the requirement in existing law that provider directories be accurate, both academic studies and reports of individual consumers indicate that inaccuracies in provider directories are common. Individual consumers and their representatives should be able to obtain care, including an appointment as a new patient, based on accurate information in the provider directory maintained by the health care service plan or health insurer.
(b)Too often consumers find ghost networks in which the provider directories of health care service plans and health insurers include doctors, hospitals, and other providers who are not accepting new patients, not accepting patients for that network of the plan or insurer, have not been compensated by the carrier in the past year, or are inaccessible to consumers because of inaccurate contact information in the provider directory. Some health care service plans and insurers advertise that there are thousands or even tens of thousands of doctors, hospitals, and other providers of care in their network, but when a consumer tries to contact a health care provider, basic information such as name and address are too often inaccurate. Even if the consumer can reach the provider who appears to be in-network for that network of the carrier, too often the consumer discovers either that the provider is not accepting new patients or not accepting patients for that network of the carrier, putting the burden of the inaccurate provider directory on the consumer, not the health care service plan or insurer. These barriers to care are most problematic for those consumers who need care the most, such as persons with disabilities or behavioral health conditions, as well as those with other barriers to seeking care, such as limited English proficiency or lack of health care literacy.
(c)To encourage the development of a provider directory utility that could be used by all health care service plans, in 2015, the Department of Managed Health Care required an undertaking to fund the development of such a provider directory utility as a condition of the departments approval of the acquisition of CareFirst by Blue Shield of California. In the years from 2015 to the introduction of this act, the Integrated Healthcare Association, an association of health care service plans, health insurers, provider groups, and hospitals with no consumer representation, held numerous meetings and workgroups with health care industry entities to develop a provider directory utility. The Integrated Healthcare Association states that as of 2019, the provider directory utility was operational and able to assist health care service plans and health insurers in verifying and crosschecking the accuracy of provider directory information. There are also efforts by the federal Centers for Medicare and Medicaid Services to aid in the accuracy of provider updates to improve provider directories.
(d)Inclusion in a health care service plan or health insurer directory is a form of marketing for health care providers, including hospitals, laboratory services, imaging, provider groups, and individual providers because those directories provide individual consumers information about whether or not the health care provider is available through the network of the plan or insurer. Removal from the provider directory of a health care service plan or health insurer constitutes a financial penalty for a health care provider because a consumer seeking in-network care or to receive referrals from other health care providers for in-network care is less likely to seek care from a provider not included in the provider directory.
(e)It is the intent of the Legislature in enacting this act to ensure that provider directories of health care service plans and health insurers are substantially accurate and that consumers are able to rely on the information provided in those directories, including such basic information as the name of the provider, the telephone number, and the address where care may be sought. It is also the intent of the Legislature to require the improvement of accuracy of provider directories over a number of years. In addition to the financial penalties on providers for failure to provide accurate and timely information for inclusion in the provider directory of a health care service plan or health insurer, it is the intent of the Legislature that the relevant departments have the authority to impose financial penalties on health care service plans and insurers for any failure of a plan or insurer to maintain the accuracy of its own directory.
SEC. 2.Section 1367.27 of the Health and Safety Code is amended to read:1367.27.(a)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 plans 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. Commencing July 1, 2025, a health care service plan shall comply with this section as it read on January 1, 2025.
(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, contracting providers, 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 plans internet website 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 plans public internet website 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 plans public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 plans 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.
(3)A printed provider directory shall be dated with the date of its last update.
(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 providers 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 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 and remove 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)(1)The provider directory or directories shall display the date of the most recent update. The provider directory or directories shall also display a dedicated email address, telephone number, and reporting form hyperlink for members of the public and providers to report possible inaccurate, incomplete, or misleading directory information. The provider directory or directories shall also state that the enrollee may submit a complaint if the enrollee believes they reasonably relied upon materially inaccurate, incomplete, or misleading directory information. This information shall be disclosed prominently in the directory or directories and on the plans internet website.
(2)A health care service plan shall include prominent disclosure on its print and online provider directories of its duty to arrange coverage when behavioral health benefits are not available in-network within applicable geographic and timely access standards. The disclosure shall be included within the Timely Access to Care section of the directory that is required by Section 1367.031 and shall also include the geographic accessibility standards.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
(9)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, dispensing optometrists and opticians, 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, optical dispensaries, and other facilities providing contracted health care services.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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 providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the plans products.
(13)The Whether or not the provider is in the lowest cost-sharing tier, if the product has more than one cost-sharing tier, and 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.
(14)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)Whether or not the provider is in the lowest cost-sharing tier, if the product has more than one cost-sharing tier.(16)(15)Whether or not the provider has seen patients for this product in the last year, based on financial compensation of the provider by the plan, consistent with this section.
(17)(16)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.
(9)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.
(10)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 providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 plans 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 central utility 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.
(4)On or before January 1, 2025, the department may develop a uniform format with standardized naming conventions and other aspects for each plan to use to request directory information from its providers.
(5)(A)On or before January 1, 2025, the department may establish a methodology and processes to ensure accuracy of provider directories and consistency with other state or federal laws, regulations, or standards. The department shall take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity.
(B)The department may require a health care service plan to use a central utility or designate a central utility for those providers included in the directory. In developing the methodology under this section, the department shall seek input from interested parties and may hold one or more public meetings. Standards developed pursuant to paragraph (4) and this paragraph 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, 2028.
(C)If the plan can demonstrate it will meet the benchmarks required in paragraph (2) of subdivision (n) without using the central utility designated in subparagraph (B), the department may allow the plan to not use the central utility. If the plan fails to meet the benchmark in the future, the department may require the plan to use the central utility as a method to achieve higher accuracy of provider directory listings to comply with paragraph (2) of subdivision (n).
(l)(1)A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period.
(5)If a provider that was previously removed from the provider directory or directories requests to be added back to the provider directory or directories, or if a plan requests that a provider that was previously removed from the provider directory or directories be added back to the provider directory or directories, the health plan shall ensure the accuracy of the information required under this section and approve the request within 10 business days of receipt if accurate.
(6)General acute care hospitals shall be exempt from the requirements in paragraphs (3) to (5), inclusive.
(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 this subdivision 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 plans provider directory or directories. This process 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 plans provider directory internet website linking to a form where the information can be reported directly to the plan through its internet website.
(n)A plan shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error that would impact a patients access to care on a listing for a provider, that listing is considered inaccurate.
(A)On July 1, 2025, a plans directories shall be at least 60-percent accurate.
(B)On or before July 1, 2026, a plans directories shall be at least 80-percent accurate.
(C)On or before July 1, 2027, a plans directories shall be at least 90-percent accurate.
(D)On or before July 1, 2028, a plans directories shall be at least 95-percent accurate.
(3)A plan shall annually verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). If the department develops a methodology and standards that permit the use of a central utility, utility or central utilities, and if a health care service plan uses the a central utility for some or all of the plans provider directory, the plan shall ensure that information derived from the central utility is incorporated in the plans provider directory unless the plan can demonstrate that the information is inaccurate. The plan using a central utility shall continue to retain responsibility for ensuring that the requirements of this section are satisfied, including in any contract or other agreement with the central utility. The department shall develop procedures and policies on how a plan shall conduct the verifications. In addition to verifying the information required under subdivisions (h) and (i), the plan shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for enrollees in that product or network.
(B)Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the department to ensure compliance with this section.
(C)Publicly post its accuracy verification reports annually on its internet website.
(D)Verification of the accuracy of the printed directory shall be based on the date of printing, which shall be provided on each page of the printed directory.
(4)Failure by a health care service plan to comply with this section, including failure to meet the required benchmarks for accuracy, shall result in an administrative penalty consistent with this section and this chapter. In determining the appropriate amount of an administrative penalty, a listing inaccuracy that would impact a patients access to care shall be treated as a denial of access to care for covered benefits. For purposes of determining an administrative penalty based on an inaccuracy, required accurate information shall include, but not be limited to, the provider name, address, and telephone number, whether the provider is accepting new patients, whether the provider was financially compensated by the plan consistent with this section, and any other information as determined by the department.
(5)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of not less than five hundred dollars ($500) per 1,000 enrollees and up to five thousand dollars ($5,000) per 1,000 enrollees, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of not less than one thousand dollars ($1,000) per 1,000 enrollees and up to ten thousand dollars ($10,000) per 1,000 enrollees for each year following the first year that the plan failed to meet the benchmark.
(6)When assessing administrative penalties against a health care service plan, the director shall determine the appropriate penalty amount for each violation based on one or more factors as applicable, including the factors outlined in subdivision (d) of Section 1386. The director shall take into consideration evidence provided by the plan of the plans policies and procedures to obtain accurate provider information pursuant to this section and the plans use of a central utility in assessing penalties pursuant to this section.
(7)Beginning January 1, 2028, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(8)Administrative penalties levied by the department on the plan pursuant to this section shall be paid by the plan and shall not be paid by the provider, subscriber, or enrollee. This paragraph does not prevent a plan from including penalties for noncompliance with verification standards in the provider contract.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers 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.
(p)(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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to a plans provider directory or directories are required as a result of the plans 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.
(q)(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 plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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.
(r)(1)In circumstances where the department finds that an enrollee reasonably relied upon inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the health care service plan shall arrange care and provide coverage for all covered health care services provided to the enrollee, 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 enrollees plan contract, and reimburse the provider the amount that they would have been paid if the provider was under contract. The provider shall not collect any additional amount from the enrollee other than the applicable in-network cost sharing. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees 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.
(2)If an enrollee, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the health care service plan shall, if the request is by telephone, tell the enrollee verbally and follow up in writing or electronic format no later than one business day after receiving the request. If the request is by electronic means, the plan shall respond in writing or electronic format no later than one business day after receiving the request. The plan shall also provide information on whether or not the provider is accepting new patients. The plan shall retain a record of the request and the plans response in the enrollees file for at least two years after the date of the request.
(3)For covered benefits, if an enrollee obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the enrollee shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the health care service plan as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise inaccurate, misleading, or incomplete.
(D)The online provider directory of the health care service plan is not accessible to enrollees at the time the enrollee seeks information and the enrollee requests information consistent with paragraph (2).
(4)If the health care service plan contract includes more than one tier of cost sharing, the plan shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the enrollee when the enrollee seeks information about the provider. If the plan provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the enrollee shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the enrollee from the plan.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health care service plan contract includes more than one tier of cost sharing and if the enrollee was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(6)For purposes of this subdivision, information is inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) is inaccurate, incomplete, or misleading.
(s)(1)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.
(2)For a health care service plan issued, amended, or renewed on or after July 1, 2025, if a provider has not been financially compensated consistent with this section or and if the provider has failed to respond timely consistent with this section, and those providers amount to a change of 10 percent or greater in the network for a product in a region, then the plan shall file an amendment to the plan application consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(3)(A)A plan shall not use information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provision of this chapter if the plan cannot demonstrate to the department that one or more of the following applies: the provider is actively contracting with the plan as determined by the department. This paragraph shall apply whether or not the provider has been deleted from the directory.
(i)The provider is contracting with the plan and the provider has been financially compensated by the plan consistent with this section.(ii)The provider has failed to respond timely consistent with this section.(iii)The provider is not in the lowest cost-sharing tier, if the product has more than one cost-sharing tier.(B)This paragraph shall apply whether or not the provider has been deleted from the directory.(4)Consistent with Section 1360, a plan shall not advertise or otherwise represent the extent of its network, including the number or type of contracting providers, unless it is able to demonstrate that each provider is contracting and has been compensated consistent with this section. contracting.
(5)(A)For purposes of this subdivision, financially compensated means having paid one or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network, network in the last five years, unless a special circumstance applies.
(B)A special circumstance requires inclusion of the provider in the directory, consistent with regulations or other guidance by the department. A special circumstance may include a provider in a rural area, a highly specialized specialist who was not used by an enrollee in the prior year, or other circumstances as determined by the department through the regulatory or other rulemaking process. The department may issue guidance to implement, interpret, or make specific the requirements under this subparagraph. The guidance shall 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).
(t)(1)This section applies 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.
(2)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). All other provisions of this section apply to plans with Medi-Cal managed care contracts.
(u)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.
(v)This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.
(w)As part of the departments 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 plans compliance with subdivision (q).
(x)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 of the Insurance Code is amended to read:10133.15.(a)A health insurer that contracts with providers for alternative rates of payment pursuant to Section 10133 shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the insurers 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. Commencing July 1, 2025, a health care service plan shall comply with this section as it read on January 1, 2025.
(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, contracting providers, 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 insurers internet website 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 insurers public internet website 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 insurers public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 insurers 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.
(3)A printed directory shall be dated with the date of its last update.
(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 providers 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 and remove 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)(1)The provider directory or directories shall display the date of the most recent update. The provider directory or directories shall also display a dedicated email address, telephone number, and reporting form hyperlink for members of the public and providers to report possible inaccurate, incomplete, or misleading directory information. The provider directory or directories shall also state that the insured may submit a complaint if the enrollee believes they reasonably relied upon materially inaccurate, incomplete, or misleading directory information. This information shall be disclosed prominently in the directory or directories and on the insurers internet website.
(2)An insurer shall include a prominent disclosure on its print and online provider directories of its duty to arrange coverage when behavioral health benefits are not available in-network within applicable geographic and timely access standards. The disclosure shall be included within the directory and shall also include the geographic accessibility standards.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds.
(9)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, dispensing optometrists and opticians, 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, optical dispensaries, and other facilities providing contracted health care services.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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, if any, on the providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the insurers products.
(13)The Whether or not the provider is in the lowest cost-sharing tier, if the product has more than one cost-sharing tier, and 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.
(14)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)Whether or not the provider is in the lowest cost-sharing tier, if the product has more than one cost-sharing tier.(16)(15)Whether or not the provider has seen patients for this product in the last year, based on financial compensation of the provider by the plan, consistent with this section.
(17)(16)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.
(9)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.
(10)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, if any, on the providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the insurers products.
(12)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 insurers 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 central utility 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.
(4)On or before January 1, 2025, the department may develop a uniform format with standardized naming conventions and other aspects for each insurer to use to request directory information from its providers.
(5)(A)On or before January 1, 2025, the department may establish a methodology and processes to ensure accuracy of provider directories and consistency with other state or federal laws, regulations, or standards. The department shall take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity.
(B)The department may require an insurer to use a central utility or designate a central utility for those providers included in the directory. In developing the methodology under this section, the department shall seek input from interested parties and may hold one or more public meetings. Standards developed pursuant to paragraph (4) and this paragraph 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, 2028.
(C)If the insurer can demonstrate it will meet the benchmarks required in paragraph (2) of subdivision (n) without using the central utility designated in subparagraph (B), the department may allow the insurer to not use the central utility. If the insurer fails to meet the benchmark in the future, the department may require the insurer to use the central utility as a method to achieve higher accuracy of provider directory listings to comply with paragraph (2) of subdivision (n).
(l)(1)An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurers 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period.
(5)If a provider that was previously removed from the provider directory or directories requests to be added back to the provider directory or directories, or if an insurer requests that a provider that was previously removed from the provider directory or directories be added back to the provider directory or directories, the insurer shall ensure the accuracy of the request and approve the request within 10 business days of receipt if accurate.
(6)General acute care hospitals shall be exempt from the requirements in paragraphs (3) to (5), inclusive.
(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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory internet website linking to a form where the information can be reported directly to the insurer through its internet website.
(n)An insurer shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error that would impact a patients access to care on a listing for a provider, that listing is considered inaccurate.
(A)On July 1, 2025, an insurers directories shall be at least 60-percent accurate.
(B)On or before July 1, 2026, an insurers directories shall be at least 80-percent accurate.
(C)On or before July 1, 2027, an insurers directories shall be at least 90-percent accurate.
(D)On or before July 1, 2028, an insurers directories shall be at least 95-percent accurate.
(3)An insurer shall annually verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). If the department develops a methodology and standards that permit the use of a central utility, utility or central utilities, and if an insurer uses the a central utility for some or all of the insurers provider directory, the insurer shall ensure that information derived from the central utility is incorporated in the insurers provider directory unless the insurer can demonstrate that the information is inaccurate. The insurer using a central utility shall continue to retain responsibility for ensuring that the requirements of this section are satisfied, including in any contract or other agreement with the central utility. The department shall develop procedures and policies on how an insurer shall conduct the verifications. In addition to verifying the information required under subdivisions (h) and (i), the insurer shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for insureds in that product or network.
(B)Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the department to ensure compliance with this section.
(C)Publicly post its accuracy verification reports annually on its internet website.
(D)Verification of the accuracy of the printed directory shall be based on the date of printing, which shall be provided on each page of the printed directory.
(4)Failure by an insurer to comply with this section, including failure to meet the required benchmarks for accuracy, shall result in an administrative penalty consistent with this section and this chapter. In determining the appropriate amount of an administrative penalty, a listing inaccuracy that would impact a patients access to care shall be treated as a denial of access to care for covered benefits. For purposes of determining an administrative penalty based on an inaccuracy, required accurate information shall include, but not be limited to, the provider name, address, and telephone number, whether the provider is accepting new patients, whether the provider was financially compensated by the insurer consistent with this section, and any other information as determined by the department.
(5)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of not less than five hundred dollars ($500) per 1,000 insureds and up to five thousand dollars ($5,000) per 1,000 insureds, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of not less than one thousand dollars ($1,000) per 1,000 insureds and up to ten thousand dollars ($10,000) per 1,000 insureds for each year following the first year that the insurer failed to meet the benchmark.
(6)When assessing administrative penalties against a health insurer, the department shall determine the appropriate penalty amount for each violation based on one or more factors as applicable. The department shall take into consideration evidence provided by the insurer of the insurers policies and procedures to obtain accurate provider information pursuant to this section, and the insurers use of a central utility, in assessing penalties pursuant to this section.
(7)Beginning January 1, 2029, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(8)Administrative penalties levied by the department on the insurer pursuant to this section shall be paid by the insurer and shall not be paid by the provider, subscriber, or insured. This paragraph does not prevent an insurer from including penalties for noncompliance with verification standards in the provider contract.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers information.
(C)The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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.
(p)(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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to an insurers provider directory or directories are required as a result of the insurers 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.
(q)(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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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).
(r)(1)In circumstances where the department finds that an insured reasonably relied upon inaccurate, incomplete, or misleading information contained in an insurers provider directory or directories, the insurer shall arrange care and provide coverage for all covered health care services provided to the insured, 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 insureds health insurance policy, and reimburse the provider the amount that they would have been paid if the provider was under contract. The provider shall not collect any additional amount from the insured other than the applicable in-network cost sharing. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the insured were covered services under the insureds 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.
(2)If an insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the insurer shall, if the request is by telephone, tell the insured verbally and follow up in writing or electronic format no later than one business day after receiving the request. If the request is by electronic means, the insurer shall respond in writing or electronic format no later than one business day after receiving the request. The insurer shall also provide information on whether or not the provider is accepting new patients. The insurer shall retain a record of the request and the insurers response in the insureds file for at least two years after the date of the request.
(3)For covered benefits, if an insured obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the group insured shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the insurer as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise inaccurate, misleading, or incomplete.
(D)The online provider directory of the insurer is not accessible to insureds at the time the insured seeks information and the insured requests information consistent with paragraph (2).
(4)If the health insurance policy includes more than one tier of cost sharing, the insurer shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the insured when the insured seeks information about the provider. If the insurer provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the insured shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the insured from the insurer.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health insurance policy includes more than one tier of cost sharing and if the insured was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(6)For purposes of this subdivision, information is inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) is inaccurate, incomplete, or misleading.
(s)(1)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.
(2)For an insurance policy issued, amended, or renewed on or after July 1, 2025, if a provider has not been financially compensated consistent with this section or and if the provider has failed to respond timely consistent with this section, and those providers amount to a change of 10 percent or greater in the network for a product in a region, then the insurer shall file an amendment to the policy application consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(3)(A)An insurer shall not use information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provision of this chapter if the insurer cannot demonstrate to the department that one or more of the following applies: the provider is actively contracting with the insurer as determined by the department. This paragraph shall apply whether or not the provider has been deleted from the directory.
(i)The provider is contracting with the insurer and the provider has been financially compensated by the insurer consistent with this section.(ii)The provider has failed to respond timely consistent with this section.(iii)The provider is not in the lowest cost-sharing tier, if the product has more than one cost-sharing tier.(B)This paragraph shall apply whether or not the provider has been deleted from the directory.(4)Consistent with Section 1360 of the Health and Safety Code, an insurer shall not advertise or otherwise represent the extent of its network, including the number or type of contracting providers, unless it is able to demonstrate that each provider is contracting and has been compensated consistent with this section. contracting.
(5)(A)For purposes of this subdivision, financially compensated means having paid one or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to insureds covered by the relevant network, network in the last five years, unless a special circumstance applies.
(B)A special circumstance requires inclusion of the provider in the directory, consistent with regulations or other guidance by the department. A special circumstance may include a provider in a rural area, a highly specialized specialist who was not used by an insured in the prior year, or other circumstances as determined by the department through the regulatory or other rulemaking process. The department may issue guidance to implement, interpret, or make specific the requirements under this subparagraph. The guidance shall 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).
(t)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.
(u)This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.
(v)As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers compliance with subdivision (q).
(w)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 XIIIB 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 XIIIB of the California Constitution.
The Legislature finds and declares all of the following:
(a)It has been the responsibility of each health care service plan and health insurer to maintain an accurate provider directory since the enactment of Chapter 649 of the Statutes of 2015. Despite the requirement in existing law that provider directories be accurate, both academic studies and reports of individual consumers indicate that inaccuracies in provider directories are common. Individual consumers and their representatives should be able to obtain care, including an appointment as a new patient, based on accurate information in the provider directory maintained by the health care service plan or health insurer.
(b)Too often consumers find ghost networks in which the provider directories of health care service plans and health insurers include doctors, hospitals, and other providers who are not accepting new patients, not accepting patients for that network of the plan or insurer, have not been compensated by the carrier in the past year, or are inaccessible to consumers because of inaccurate contact information in the provider directory. Some health care service plans and insurers advertise that there are thousands or even tens of thousands of doctors, hospitals, and other providers of care in their network, but when a consumer tries to contact a health care provider, basic information such as name and address are too often inaccurate. Even if the consumer can reach the provider who appears to be in-network for that network of the carrier, too often the consumer discovers either that the provider is not accepting new patients or not accepting patients for that network of the carrier, putting the burden of the inaccurate provider directory on the consumer, not the health care service plan or insurer. These barriers to care are most problematic for those consumers who need care the most, such as persons with disabilities or behavioral health conditions, as well as those with other barriers to seeking care, such as limited English proficiency or lack of health care literacy.
(c)To encourage the development of a provider directory utility that could be used by all health care service plans, in 2015, the Department of Managed Health Care required an undertaking to fund the development of such a provider directory utility as a condition of the departments approval of the acquisition of CareFirst by Blue Shield of California. In the years from 2015 to the introduction of this act, the Integrated Healthcare Association, an association of health care service plans, health insurers, provider groups, and hospitals with no consumer representation, held numerous meetings and workgroups with health care industry entities to develop a provider directory utility. The Integrated Healthcare Association states that as of 2019, the provider directory utility was operational and able to assist health care service plans and health insurers in verifying and crosschecking the accuracy of provider directory information. There are also efforts by the federal Centers for Medicare and Medicaid Services to aid in the accuracy of provider updates to improve provider directories.
(d)Inclusion in a health care service plan or health insurer directory is a form of marketing for health care providers, including hospitals, laboratory services, imaging, provider groups, and individual providers because those directories provide individual consumers information about whether or not the health care provider is available through the network of the plan or insurer. Removal from the provider directory of a health care service plan or health insurer constitutes a financial penalty for a health care provider because a consumer seeking in-network care or to receive referrals from other health care providers for in-network care is less likely to seek care from a provider not included in the provider directory.
(e)It is the intent of the Legislature in enacting this act to ensure that provider directories of health care service plans and health insurers are substantially accurate and that consumers are able to rely on the information provided in those directories, including such basic information as the name of the provider, the telephone number, and the address where care may be sought. It is also the intent of the Legislature to require the improvement of accuracy of provider directories over a number of years. In addition to the financial penalties on providers for failure to provide accurate and timely information for inclusion in the provider directory of a health care service plan or health insurer, it is the intent of the Legislature that the relevant departments have the authority to impose financial penalties on health care service plans and insurers for any failure of a plan or insurer to maintain the accuracy of its own directory.
SEC. 2.Section 1367.27 of the Health and Safety Code is amended to read:1367.27.(a)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 plans 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 or that has not been compensated by the plan in the prior year, except as provided in this section. plan. Commencing July 1, 2025, a health care service plan shall comply with this section as it read on January 1, 2025.
(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, contracting providers, 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 plans internet website 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 plans public internet website 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 plans public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 plans 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.
(3)A printed provider directory shall be dated with the date of its last update.
(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 providers 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 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 and remove 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.
(D)Beginning July 1, 2025, for a health care service plan contract issued, renewed, or amended on or after January 1, 2025, the plan cannot confirm that the plan has financially compensated, as defined in this section, the provider for the purpose of providing covered benefits to enrollees for the designated network in the prior year unless one of the following applies:(i)The plan has newly contracted with the provider within the prior six months.(ii)The plan has a newly approved network approved within the prior six months.(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department. A special circumstance may include, but is not limited to, a provider in a rural area or a highly specialized specialist who was not used by an enrollee in the prior year or other circumstances as determined by the department through the regulatory or other rulemaking process. The department may issue guidance to implement, interpret, or make specific the requirements under this clause. The guidance shall 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).(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.(E)For purposes of this subdivision, financially compensated means having paid one or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network.(f)(1)The provider directory or directories shall display the date of the most recent update. The provider directory or directories shall include both an email address and a telephone number also display a dedicated email address, telephone number, and reporting form hyperlink for members of the public and providers to notify the plan if the provider directory information appears to be inaccurate. report possible inaccurate, incomplete, or misleading directory information. The provider directory or directories shall also state that the enrollee may submit a complaint if the enrollee believes they reasonably relied upon materially inaccurate, incomplete, or misleading directory information. This information shall be disclosed prominently in the directory or directories and on the plans internet website.
(2)A health care service plan shall include prominent disclosure on its print and online provider directories of its duty to arrange coverage when behavioral health benefits are not available in-network within applicable geographic and timely access standards. The disclosure shall be included within the Timely Access to Care section of the directory that is required by Section 1367.031 and shall also include the geographic accessibility standards.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
(9)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, dispensing optometrists and opticians, 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, optical dispensaries, and other facilities providing contracted health care services.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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 providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the plans products.
(13)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.
(14)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 1367.28.(15)Whether or not the provider is in the lowest cost-sharing tier, if the product has more than one cost-sharing tier.
(16)Whether or not the provider has seen patients for this product in the last year, based on financial compensation of the provider by the plan, consistent with this section.
(16)(17)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.
(9)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.
(10)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 providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 plans 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 central utility 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.
(4)On or before January 1, 2025, the department may develop a uniform format with standardized naming conventions and other aspects for each plan to use to request directory information from its providers.
(5)(A)On or before January 1, 2026, 2025, the department may establish a methodology and processes to ensure accuracy of provider directories. directories and consistency with other state or federal laws, regulations, or standards. The department shall take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity. The
(B)The department may require a health care service plan to use a central utility or designate a central utility for those providers included in the directory. In developing the methodology under this section, the department shall seek input from interested parties and may hold one or more public meetings. Standards developed pursuant to paragraph (4) and this paragraph 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, 2028.
(C)If the plan can demonstrate it will meet the benchmarks required in paragraph (2) of subdivision (n) without using the central utility designated in subparagraph (B), the department may allow the plan to not use the central utility. If the plan fails to meet the benchmark in the future, the department may require the plan to use the central utility as a method to achieve higher accuracy of provider directory listings to comply with paragraph (2) of subdivision (n).
(l)(1)A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period.
(5)If a provider that was previously removed from the provider directory or directories requests to be added back to the provider directory or directories, or if a plan requests that a provider that was previously removed from the provider directory or directories be added back to the provider directory or directories, the health plan shall ensure the accuracy of the information required under this section and approve the request within 10 business days of receipt if accurate.
(6)General acute care hospitals shall be exempt from the requirements in paragraphs (3) to (5), inclusive.
(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 this subdivision 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 plans provider directory or directories. This process 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 plans provider directory internet website linking to a form where the information can be reported directly to the plan through its internet website.
(n)A plan shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On July 1, 2025, a plans directories shall be at least 60-percent accurate.
(B)On or before July 1, 2026, a plans directories shall be at least 80-percent accurate.
(C)On or before July 1, 2027, a plans directories shall be at least 90-percent accurate.
(D)On or before July 1, 2028, a plans directories shall be at least 95-percent accurate.
(3)A plan shall annually verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). If the department develops a methodology and standards that permit the use of a central utility, and if a health care service plan uses the central utility for some or all of the plans provider directory, the plan shall ensure that information derived from the central utility is incorporated in the plans provider directory unless the plan can demonstrate that the information is inaccurate. The plan using a central utility shall continue to retain responsibility for ensuring that the requirements of this section are satisfied, including in any contract or other agreement with the central utility. The department shall develop procedures and policies on how a plan shall conduct the verifications. In addition to verifying the information required under subdivisions (h) and (i), the plan shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for enrollees in that product or network. If the provider received no compensation in the last year for that product or network, the plan shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the department to ensure compliance with this section.
(C)Publicly post its accuracy verification reports annually on its internet website.
(D)Verification of the accuracy of the printed directory shall be based on the date of printing, which shall be provided on each page of the printed directory.
(4)Failure by a health care service plan to comply with this section, including failure to meet the required benchmarks for accuracy, shall result in an administrative penalty consistent with this section and this chapter. In determining the appropriate amount of an administrative penalty, a listing inaccuracy shall be treated as a denial of access to care for covered benefits. For purposes of determining an administrative penalty based on an inaccuracy, required accurate information shall include, but not be limited to, the provider name, address, and telephone number, whether the provider is accepting new patients, whether the provider was financially compensated by the plan consistent with this section, and any other information as determined by the department.
(5)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of not less than five hundred dollars ($500) per 1,000 enrollees and up to five thousand dollars ($5,000) per 1,000 enrollees, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of not less than one thousand dollars ($1,000) per 1,000 enrollees and up to ten thousand dollars ($10,000) per 1,000 enrollees for each year following the first year that the plan failed to meet the benchmark.
(6)When assessing administrative penalties against a health care service plan, the director shall determine the appropriate penalty amount for each violation based on one or more factors as applicable, including the factors outlined in subdivision (d) of Section 1386.
(7)Beginning January 1, 2028, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(8)Administrative penalties levied by the department on the plan pursuant to this section shall be paid by the plan and shall not be paid by the provider, subscriber, or enrollee.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers 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.
(p)(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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to a plans provider directory or directories are required as a result of the plans 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.
(q)(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 plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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.
(r)(1)In circumstances where the department finds that an enrollee reasonably relied upon inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the health care service plan shall arrange care and provide coverage for all covered health care services provided to the enrollee, 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 enrollees plan contract, and reimburse the provider the contracted amount for those health care services under the contract. amount that they would have been paid if the provider was under contract. The provider shall not collect any additional amount from the enrollee other than the applicable in-network cost sharing. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees 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.
(2)If an enrollee, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the health care service plan shall, if the request is by telephone, tell the enrollee verbally and follow up in writing or electronic format no later than one business day after receiving the request. If the request is by electronic means, the plan shall respond in writing or electronic format no later than one business day after receiving the request. The plan shall also provide information on whether or not the provider is accepting new patients. The plan shall retain a record of the request and the plans response in the enrollees file for at least two years after the date of the request.
(3)For covered benefits, if an enrollee obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the enrollee shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the health care service plan as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise inaccurate, misleading, or incomplete.
(D)The online provider directory of the health care service plan is not accessible to enrollees at the time the enrollee seeks information and the enrollee requests information consistent with paragraph (2).
(4)If the health care service plan contract includes more than one tier of cost sharing, the plan shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the enrollee when the enrollee seeks information about the provider. If the plan provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the enrollee shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the enrollee from the plan.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health care service plan contract includes more than one tier of cost sharing and if the enrollee was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(6)For purposes of this subdivision, information is inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) is inaccurate, incomplete, or misleading.
(s)(1)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.
(2)For a health care service plan issued, amended, or renewed on or after July 1, 2025, if a provider has not been financially compensated consistent with this section or if the provider has failed to respond timely consistent with this section, and those providers amount to a change of 10 percent or greater in the network for a product in a region, then the plan shall file an amendment to the plan application consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(3)(A)A plan shall not use information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provision of this chapter if the plan cannot demonstrate to the department that the one or more of the following applies:
(i)The provider is contracting with the plan and the provider has been financially compensated by the plan consistent with this section or the section.
(ii)The provider has failed to respond timely consistent with this section. This
(iii)The provider is not in the lowest cost-sharing tier, if the product has more than one cost-sharing tier.
(B)This paragraph shall apply whether or not the provider has been deleted from the directory.
(4)Consistent with Section 1360, a plan shall not advertise or otherwise represent the extent of its network, including the number or type of contracting providers, unless it is able to demonstrate that each provider is contracting and has been compensated consistent with this section.
(5)(A)For purposes of this subdivision, financially compensated means having paid one or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network, unless a special circumstance applies.
(B)A special circumstance requires inclusion of the provider in the directory, consistent with regulations or other guidance by the department. A special circumstance may include a provider in a rural area, a highly specialized specialist who was not used by an enrollee in the prior year, or other circumstances as determined by the department through the regulatory or other rulemaking process. The department may issue guidance to implement, interpret, or make specific the requirements under this subparagraph. The guidance shall 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).
(t)(1)This section applies 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.
(2)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). All other provisions of this section apply to plans with Medi-Cal managed care contracts.
(u)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.
(v)This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.
(w)As part of the departments 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 plans compliance with subdivision (q).
(x)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 of the Insurance Code is amended to read:10133.15.(a)A health insurer that contracts with providers for alternative rates of payment pursuant to Section 10133 shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the insurers 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 or that has not been compensated by the insurer in the prior year, except as provided in this section. insurer. Commencing July 1, 2025, a health care service plan shall comply with this section as it read on January 1, 2025.
(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, contracting providers, 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 insurers internet website 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 insurers public internet website 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 insurers public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 insurers 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.
(3)A printed directory shall be dated with the date of its last update.
(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 providers 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 and remove 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.
(D)Beginning July 1, 2025, for a health insurance policy issued, renewed, or amended on or after January 1, 2025, the insurer cannot confirm that the insurer has financially compensated, as defined in this section, the provider for the purpose of providing covered benefits to insureds for the designated network in the prior year unless one of the following applies:(i)The insurer has newly contracted with the provider within the prior six months.(ii)The insurer has a newly approved network approved within the prior six months.(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department. A special circumstance may include, but is not limited to, a provider in a rural area or a highly specialized specialist who was not used by an insured in the prior year or other circumstances as determined by the department through the regulatory or other rulemaking process. The commissioner may issue guidance to implement, interpret, or make specific the requirements under this clause. The guidance shall 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).(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.(E)For purposes of this subdivision, financially compensated means having paid one or more claims to a provider for that network, paid capitation, or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to insureds covered by the relevant network.(f)(1)The provider directory or directories shall display the date of the most recent update. The provider directory or directories shall include both an email address and a telephone number also display a dedicated email address, telephone number, and reporting form hyperlink for members of the public and providers to notify the insurer if the provider directory information appears to be inaccurate. report possible inaccurate, incomplete, or misleading directory information. The provider directory or directories shall also state that the insured may submit a complaint if the enrollee believes they reasonably relied upon materially inaccurate, incomplete, or misleading directory information. This information shall be disclosed prominently in the directory or directories and on the insurers internet website.
(2)An insurer shall include a prominent disclosure on its print and online provider directories of its duty to arrange coverage when behavioral health benefits are not available in-network within applicable geographic and timely access standards. The disclosure shall be included within the directory and shall also include the geographic accessibility standards.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds.
(9)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, dispensing optometrists and opticians, 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, optical dispensaries, and other facilities providing contracted health care services.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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, if any, on the providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the insurers products.
(13)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.
(14)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 10133.14.(15)Whether or not the provider is in the lowest cost-sharing tier, if the product has more than one cost-sharing tier.
(16)Whether or not the provider has seen patients for this product in the last year, based on financial compensation of the provider by the plan, consistent with this section.
(16)(17)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.
(9)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.
(10)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, if any, on the providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the insurers products.
(12)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 insurers 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 central utility 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.
(4)On or before January 1, 2025, the department may develop a uniform format with standardized naming conventions and other aspects for each insurer to use to request directory information from its providers.
(5)(A)On or before January 1, 2026, 2025, the department may establish a methodology and processes to ensure accuracy of provider directories. directories and consistency with other state or federal laws, regulations, or standards. The department shall take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity. The
(B)The department may require an insurer to use a central utility or designate a central utility for those providers included in the directory. In developing the methodology under this section, the department shall seek input from interested parties and may hold one or more public meetings. Standards developed pursuant to paragraph (4) and this paragraph 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, 2028.
(C)If the insurer can demonstrate it will meet the benchmarks required in paragraph (2) of subdivision (n) without using the central utility designated in subparagraph (B), the department may allow the insurer to not use the central utility. If the insurer fails to meet the benchmark in the future, the department may require the insurer to use the central utility as a method to achieve higher accuracy of provider directory listings to comply with paragraph (2) of subdivision (n).
(l)(1)An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurers 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period.
(5)If a provider that was previously removed from the provider directory or directories requests to be added back to the provider directory or directories, or if an insurer requests that a provider that was previously removed from the provider directory or directories be added back to the provider directory or directories, the insurer shall ensure the accuracy of the request and approve the request within 10 business days of receipt if accurate.
(6)General acute care hospitals shall be exempt from the requirements in paragraphs (3) to (5), inclusive.
(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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory internet website linking to a form where the information can be reported directly to the insurer through its internet website.
(n)An insurer shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On July 1, 2025, an insurers directories shall be at least 60-percent accurate.
(B)On or before July 1, 2026, an insurers directories shall be at least 80-percent accurate.
(C)On or before July 1, 2027, an insurers directories shall be at least 90-percent accurate.
(D)On or before July 1, 2028, an insurers directories shall be at least 95-percent accurate.
(3)An insurer shall annually verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). If the department develops a methodology and standards that permit the use of a central utility, and if an insurer uses the central utility for some or all of the insurers provider directory, the insurer shall ensure that information derived from the central utility is incorporated in the insurers provider directory unless the insurer can demonstrate that the information is inaccurate. The insurer using a central utility shall continue to retain responsibility for ensuring that the requirements of this section are satisfied, including in any contract or other agreement with the central utility. The department shall develop procedures and policies on how an insurer shall conduct the verifications. In addition to verifying the information required under subdivisions (h) and (i), the insurer shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for insureds in that product or network. If the provider received no compensation in the last year for that product or network, the insurer shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the department to ensure compliance with this section.
(C)Publicly post its accuracy verification reports annually on its internet website.
(D)Verification of the accuracy of the printed directory shall be based on the date of printing, which shall be provided on each page of the printed directory.
(4)Failure by an insurer to comply with this section, including failure to meet the required benchmarks for accuracy, shall result in an administrative penalty consistent with this section and this chapter. In determining the appropriate amount of an administrative penalty, a listing inaccuracy shall be treated as a denial of access to care for covered benefits. For purposes of determining an administrative penalty based on an inaccuracy, required accurate information shall include, but not be limited to, the provider name, address, and telephone number, whether the provider is accepting new patients, whether the provider was financially compensated by the insurer consistent with this section, and any other information as determined by the department.
(5)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of not less than five hundred dollars ($500) per 1,000 insureds and up to five thousand dollars ($5,000) per 1,000 insureds, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of not less than one thousand dollars ($1,000) per 1,000 insureds and up to ten thousand dollars ($10,000) per 1,000 insureds for each year following the first year that the insurer failed to meet the benchmark.
(6)When assessing administrative penalties against a health insurer, the department shall determine the appropriate penalty amount for each violation based on one or more factors as applicable.
(7)Beginning January 1, 2029, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(8)Administrative penalties levied by the department on the insurer pursuant to this section shall be paid by the insurer and shall not be paid by the provider, subscriber, or insured.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers information.
(C)The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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.
(p)(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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to an insurers provider directory or directories are required as a result of the insurers 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.
(q)(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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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).
(r)(1)In circumstances where the department finds that an insured reasonably relied upon inaccurate, incomplete, or misleading information contained in an insurers provider directory or directories, the insurer shall arrange care and provide coverage for all covered health care services provided to the insured, 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 insureds health insurance policy, and reimburse the provider the contracted amount for those health care services under the policy. amount that they would have been paid if the provider was under contract. The provider shall not collect any additional amount from the insured other than the applicable in-network cost sharing. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the insured were covered services under the insureds 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.
(2)If an insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the insurer shall, if the request is by telephone, tell the insured verbally and follow up in writing or electronic format no later than one business day after receiving the request. If the request is by electronic means, the insurer shall respond in writing or electronic format no later than one business day after receiving the request. The insurer shall also provide information on whether or not the provider is accepting new patients. The insurer shall retain a record of the request and the insurers response in the insureds file for at least two years after the date of the request.
(3)For covered benefits, if an insured obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the group insured shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the insurer as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise inaccurate, misleading, or incomplete.
(D)The online provider directory of the insurer is not accessible to insureds at the time the insured seeks information and the insured requests information consistent with paragraph (2).
(4)If the health insurance policy includes more than one tier of cost sharing, the insurer shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the insured when the insured seeks information about the provider. If the insurer provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the insured shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the insured from the insurer.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health insurance policy includes more than one tier of cost sharing and if the insured was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(6)For purposes of this subdivision, information is inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) is inaccurate, incomplete, or misleading.
(s)(1)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.
(2)For an insurance policy issued, amended, or renewed on or after July 1, 2025, if a provider has not been financially compensated consistent with this section or if the provider has failed to respond timely consistent with this section, and those providers amount to a change of 10 percent or greater in the network for a product in a region, then the insurer shall file an amendment to the policy application consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(3)(A)An insurer shall not use information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provision of this chapter if the insurer cannot demonstrate to the department that the one or more of the following applies:
(i)The provider is contracting with the insurer and the provider has been financially compensated by the insurer consistent with this section or the section.
(ii)The provider has failed to respond timely consistent with this section. This
(iii)The provider is not in the lowest cost-sharing tier, if the product has more than one cost-sharing tier.
(B)This paragraph shall apply whether or not the provider has been deleted from the directory.
(4)Consistent with Section 1360 of the Health and Safety Code, an insurer shall not advertise or otherwise represent the extent of its network, including the number or type of contracting providers, unless it is able to demonstrate that each provider is contracting and has been compensated consistent with this section.
(5)(A)For purposes of this subdivision, financially compensated means having paid one or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to insureds covered by the relevant network, unless a special circumstance applies.
(B)A special circumstance requires inclusion of the provider in the directory, consistent with regulations or other guidance by the department. A special circumstance may include a provider in a rural area, a highly specialized specialist who was not used by an insured in the prior year, or other circumstances as determined by the department through the regulatory or other rulemaking process. The department may issue guidance to implement, interpret, or make specific the requirements under this subparagraph. The guidance shall 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).
(t)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.
(u)This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.
(v)As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers compliance with subdivision (q).
(w)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 XIIIB 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 XIIIB of the California Constitution.
The Legislature finds and declares all of the following:
(a)It has been the responsibility of each health care service plan and health insurer to maintain an accurate provider directory since the enactment of Chapter 649 of the Statutes of 2015. Despite the requirement in existing law that provider directories be accurate, both academic studies and reports of individual consumers indicate that inaccuracies in provider directories are common. Individual consumers and their representatives should be able to obtain care, including an appointment as a new patient, based on accurate information in the provider directory maintained by the health care service plan or health insurer.
(b)Too often consumers find ghost networks in which the provider directories of health care service plans and health insurers include doctors, hospitals, and other providers who are not accepting new patients, not accepting patients for that network of the plan or insurer, have not been compensated by the carrier in the past year, or are inaccessible to consumers because of inaccurate contact information in the provider directory. Some health care service plans and insurers advertise that there are thousands or even tens of thousands of doctors, hospitals, and other providers of care in their network, but when a consumer tries to contact a health care provider, basic information such as name and address are too often inaccurate. Even if the consumer can reach the provider who appears to be in-network for that network of the carrier, too often the consumer discovers either that the provider is not accepting new patients or not accepting patients for that network of the carrier, putting the burden of the inaccurate provider directory on the consumer, not the health care service plan or insurer. These barriers to care are most problematic for those consumers who need care the most, such as persons with disabilities or behavioral health conditions, as well as those with other barriers to seeking care, such as limited English proficiency or lack of health care literacy.
(c)To encourage the development of a provider directory utility that could be used by all health care service plans, in 2015, the Department of Managed Health Care required an undertaking to fund the development of such a provider directory utility as a condition of the departments approval of the acquisition of CareFirst by Blue Shield of California. In the years from 2015 to the introduction of this act, the Integrated Healthcare Association, an association of health care service plans, health insurers, provider groups, and hospitals with no consumer representation, held numerous meetings and workgroups with health care industry entities to develop a provider directory utility. The Integrated Healthcare Association states that as of 2019, the provider directory utility was operational and able to assist health care service plans and health insurers in verifying and crosschecking the accuracy of provider directory information. There are also efforts by the federal Centers for Medicare and Medicaid Services to aid in the accuracy of provider updates to improve provider directories.
(d)Inclusion in a health care service plan or health insurer directory is a form of marketing for health care providers, including hospitals, laboratory services, imaging, provider groups, and individual providers because those directories provide individual consumers information about whether or not the health care provider is available through the network of the plan or insurer. Removal from the provider directory of a health care service plan or health insurer constitutes a financial penalty for a health care provider because a consumer seeking in-network care or to receive referrals from other health care providers for in-network care is less likely to seek care from a provider not included in the provider directory.
(e)It is the intent of the Legislature in enacting this act to ensure that provider directories of health care service plans and health insurers are substantially accurate and that consumers are able to rely on the information provided in those directories, including such basic information as the name of the provider, the telephone number, and the address where care may be sought. It is also the intent of the Legislature to require the improvement of accuracy of provider directories over a number of years. In addition to the financial penalties on providers for failure to provide accurate and timely information for inclusion in the provider directory of a health care service plan or health insurer, it is the intent of the Legislature that the relevant departments have the authority to impose financial penalties on health care service plans and insurers for any failure of a plan or insurer to maintain the accuracy of its own directory.
SEC. 2.Section 1367.27 of the Health and Safety Code is amended to read:1367.27.(a)Commencing July 1, 2016, a 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 plans 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 or that has not been compensated by the plan in the prior year, except as provided in this section. Commencing July 1, 2025, a health care service plan shall comply with this section as it read on January 1, 2025.
(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, contracting providers, 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 plans internet website 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 plans public internet website 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 plans public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 plans 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 providers 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 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 and remove 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.
(D)Beginning July 1, 2024, 2025, for a health care service plan contract issued, renewed, or amended on January 1, 2024, or after January 1, 2025, the plan cannot confirm that the plan has financially compensated compensated, as defined in this section, the provider for the purpose of providing covered benefits to enrollees for the designated network in the prior year unless one of the following applies:
(i)The plan has newly contracted with the provider within the prior six months.
(ii)The plan has a newly approved network approved within the prior six months.
(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department. A special circumstance may include include, but is not limited to, a provider in a rural area or a highly specialized specialist who is was not used by an enrollee in the prior year or other circumstances as determined by the department through the regulatory or other rulemaking process. The department may issue guidance to implement, interpret, or make specific the requirements under this clause. The guidance shall 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).
(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.
(E)If a provider has been deleted from the provider directory, the deleted provider shall not be used for timely access monitoring, determination of network, or compliance with this chapter.(F)(E)For purposes of this subdivision, financially compensated means having paid five one or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network.
(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 plans internet website.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
(9)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, dispensing optometrists and opticians, 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, optical dispensaries, and other facilities providing contracted health care services.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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 providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the plans products.
(13)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.
(14)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 1367.28.
(16)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.
(9)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.
(10)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 providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 plans 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, 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 central utility 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.
(4)On or before January 1, 2025, the department may develop a uniform format with standardized naming conventions and other aspects for each plan to use to request directory information from its providers.
(5)On or before January 1, 2026, the department may establish a methodology and processes to ensure accuracy of provider directories. The department shall take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity. The department may require a health care service plan to use a central utility or designate a central utility for those providers included in the directory. In developing the methodology under this section, the department shall seek input from interested parties and may hold one or more public meetings. Standards developed pursuant to paragraph (4) and this paragraph 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, 2028.
(l)(1)A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period. If the plan cannot verify that the information that is required by subdivisions (h) and (i) in the listing is accurate, the provider shall be deleted and removed from the directory at the next required update. Deleted provider information shall not be used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance with this chapter.
(5)If a provider that was previously removed from the provider directory or directories requests to be added back to the provider directory or directories, or if a plan requests that a provider that was previously removed from the provider directory or directories be added back to the provider directory or directories, the health plan shall ensure the accuracy of the information required under this section and approve the request within 10 business days of receipt if accurate.
(5)(6)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4). to (5), inclusive.
(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 this subdivision 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 plans provider directory or directories. This process 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 plans provider directory internet website linking to a form where the information can be reported directly to the plan through its internet website.
(n)The A plan shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On January 1, 2024, July 1, 2025, a plans directories shall be at least 60-percent accurate.
(B)On or before January 1, 2025, July 1, 2026, a plans directories shall be at least 80-percent accurate.
(C)On or before January 1, 2026, July 1, 2027, a plans directories shall be at least 90-percent accurate.
(D)On or before January 1, 2027, July 1, 2028, a plans directories shall be at least 95-percent accurate.
(3)A plan shall annually audit and verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). If the department develops a methodology and standards that permit the use of a central utility, and if a health care service plan uses the central utility for some or all of the plans provider directory, the plan shall ensure that information derived from the central utility is incorporated in the plans provider directory unless the plan can demonstrate that the information is inaccurate. The plan using a central utility shall continue to retain responsibility for ensuring that the requirements of this section are satisfied, including in any contract or other agreement with the central utility. The department shall develop procedures and policies on how a plan shall conduct the audits. verifications. In addition to verifying the information required under subdivisions (h) and (i), the plan shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for enrollees in that product or network. If the provider received no compensation in the last year for that product or network, the plan shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Submit its accuracy audit reports annually Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the department to ensure compliance with this section.
(C)Publicly post its accuracy audit verification reports annually on its internet website.
(4)Failure by a health care service plan to comply with this section, including failure to meet the required benchmarks for accuracy, shall result in an administrative penalty consistent with this section and this chapter. In determining the appropriate amount of an administrative penalty, a listing inaccuracy shall be treated as a denial of access to care for covered benefits. For purposes of determining an administrative penalty based on an inaccuracy, required accurate information shall include, but not be limited to, the provider name, address, and telephone number, whether the provider is accepting new patients, whether the provider was financially compensated by the plan consistent with this section, and any other information as determined by the department.
(4)(5)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of not less than five hundred dollars ($500) per 1,000 enrollees and up to five thousand dollars ($5,000) per 1,000 enrollees, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of not less than one thousand dollars ($1,000) per 1,000 enrollees and up to ten thousand dollars ($10,000) per 1,000 enrollees for each year following the first year that the plan failed to meet the benchmark.
(5)The plan shall be liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. An inaccurate listing means a listing with at least one error in the information required under subdivision (h) or (i).(6)When assessing administrative penalties against a health care service plan, the director shall determine the appropriate penalty amount for each violation based on one or more factors as applicable, including the factors outlined in subdivision (d) of Section 1386.
(7)Beginning January 1, 2028, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers 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.
(p)(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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to a plans provider directory or directories are required as a result of the plans 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.
(q)(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 plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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.
(r)(1)In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to health care service plan shall arrange care and provide coverage for all covered health care services provided to the enrollee and to enrollee, 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 enrollees plan contract. contract, and reimburse the provider the contracted amount for those health care services under the contract. The provider shall not collect any additional amount from the enrollee other than the applicable in-network cost sharing. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees 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.
(2)If an enrollee, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the health care service plan shall respond shall, if the request is by telephone, tell the enrollee verbally and follow up in writing or electronic format no later than one business day after receiving the request. If the request is by electronic means, the plan shall respond in writing or electronic format no later than one business day after receiving the request. The plan shall also provide information on whether or not the provider is accepting new patients. The plan shall retain a record of the request and the plans response in the enrollees file for at least two years after the date of the request.
(3)For covered benefits, if an enrollee obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the enrollee shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the health care service plan as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise materially inaccurate, misleading, or incomplete.
(D)The online provider directory of the health care service plan is not accessible to enrollees at the time the enrollee seeks information and the enrollee requests information consistent with paragraph (2).
(4)If the health care service plan contract includes more than one tier of cost sharing, the plan shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the enrollee when the enrollee seeks information about the provider. If the plan provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the enrollee shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the enrollee from the plan.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health care service plan contract includes more than one tier of cost sharing and if the enrollee was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(6)For purposes of this subdivision, information is inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) is inaccurate, incomplete, or misleading.
(s)(1)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.
(2)For a health care service plan issued, amended, or renewed on or after July 1, 2025, if a provider has not been financially compensated consistent with this section or if the provider has failed to respond timely consistent with this section, and those providers amount to a change of 10 percent or greater in the network for a product in a region, then the plan shall file an amendment to the plan application consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(3)A plan shall not use information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provision of this chapter if the plan cannot demonstrate to the department that the provider is contracting with the plan and the provider has been financially compensated by the plan consistent with this section or the provider has failed to respond timely consistent with this section. This paragraph shall apply whether or not the provider has been deleted from the directory.
(4)Consistent with Section 1360, a plan shall not advertise or otherwise represent the extent of its network, including the number or type of contracting providers, unless it is able to demonstrate that each provider is contracting and has been compensated consistent with this section.
(t)(1)This section applies 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.
(2)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). All other provisions of this section apply to plans with Medi-Cal managed care contracts.
(u)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.
(v)This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.
(w)As part of the departments 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 plans compliance with subdivision (q).
(x)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 of the Insurance Code is amended to read:10133.15.(a)Commencing July 1, 2016, a A health insurer that contracts with providers for alternative rates of payment pursuant to Section 10133 shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the insurers 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 or that has not been compensated by the insurer in the prior year, except as provided in this section. Commencing July 1, 2025, a health care service plan shall comply with this section as it read on January 1, 2025.
(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, contracting providers, 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 insurers internet website 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 insurers public internet website 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 insurers public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 insurers 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 providers 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 and remove 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.
(D)Beginning July 1, 2024, 2025, for a health insurance policy issued, renewed, or amended on January 1, 2024, or after January 1, 2025, the insurer cannot confirm that the insurer has financially compensated compensated, as defined in this section, the provider for the purpose of providing covered benefits to insureds for the designated network in the prior year unless one of the following applies:
(i)The insurer has newly contracted with the provider within the prior six months.
(ii)The insurer has a newly approved network approved within the prior six months.
(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department. A special circumstance may include include, but is not limited to, a provider in a rural area or a highly specialized specialist who is was not used by an insured in the prior year or other circumstances as determined by the department through the regulatory or other rulemaking process. The commissioner may issue guidance to implement, interpret, or make specific the requirements under this clause. The guidance shall 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).
(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.
(E)If a provider has been deleted from the provider directory, the deleted provider shall not be used for timely access monitoring, determination of network, or compliance with this chapter.(F)(E)For purposes of this subdivision, financially compensated means having paid five one or more claims to a provider for that network, paid capitation, or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees insureds covered by the relevant network.
(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 insurers internet website.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds.
(9)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, dispensing optometrists and opticians, 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, optical dispensaries, and other facilities providing contracted health care services.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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, if any, on the providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the insurers products.
(13)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.
(14)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 10133.14.
(16)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.
(9)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.
(10)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, if any, on the providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the insurers products.
(12)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 insurers 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 central utility 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.
(4)On or before January 1, 2025, the department may develop a uniform format with standardized naming conventions and other aspects for each insurer to use to request directory information from its providers.
(5)On or before January 1, 2026, the department may establish a methodology and processes to ensure accuracy of provider directories. The department shall take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity. The department may require an insurer to use a central utility or designate a central utility for those providers included in the directory. In developing the methodology under this section, the department shall seek input from interested parties and may hold one or more public meetings. Standards developed pursuant to paragraph (4) and this paragraph 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, 2028.
(l)(1)An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurers 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period. If the insurer cannot verify that the information that is required by subdivisions (h) and (i) in the listing is accurate, the provider shall be deleted and removed from the directory at the next required update. Deleted provider information shall not be used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance with this chapter.
(5)If a provider that was previously removed from the provider directory or directories requests to be added back to the provider directory or directories, or if an insurer requests that a provider that was previously removed from the provider directory or directories be added back to the provider directory or directories, the insurer shall ensure the accuracy of the request and approve the request within 10 business days of receipt if accurate.
(5)(6)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4). to (5), inclusive.
(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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory internet website linking to a form where the information can be reported directly to the insurer through its internet website.
(n)An insurer shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On January 1, 2024, July 1, 2025, an insurers directories shall be at least 60-percent accurate.
(B)On or before January 1, 2025, July 1, 2026, an insurers directories shall be at least 80-percent accurate.
(C)On or before January 1, 2026, July 1, 2027, an insurers directories shall be at least 90-percent accurate.
(D)On or before January 1, 2027, July 1, 2028, an insurers directories shall be at least 95-percent accurate.
(3)An insurer shall annually audit and verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). If the department develops a methodology and standards that permit the use of a central utility, and if an insurer uses the central utility for some or all of the insurers provider directory, the insurer shall ensure that information derived from the central utility is incorporated in the insurers provider directory unless the insurer can demonstrate that the information is inaccurate. The insurer using a central utility shall continue to retain responsibility for ensuring that the requirements of this section are satisfied, including in any contract or other agreement with the central utility. The department shall develop procedures and policies on how an insurer shall conduct the audits. verifications. In addition to verifying the information required under subdivisions (h) and (i), the insurer shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for insureds in that product or network. If the provider received no compensation in the last year for that product or network, the insurer shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Submit its accuracy audit reports annually Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the department to ensure compliance with this section.
(C)Publicly post its accuracy audit verification reports annually on its internet website.
(4)Failure by an insurer to comply with this section, including failure to meet the required benchmarks for accuracy, shall result in an administrative penalty consistent with this section and this chapter. In determining the appropriate amount of an administrative penalty, a listing inaccuracy shall be treated as a denial of access to care for covered benefits. For purposes of determining an administrative penalty based on an inaccuracy, required accurate information shall include, but not be limited to, the provider name, address, and telephone number, whether the provider is accepting new patients, whether the provider was financially compensated by the insurer consistent with this section, and any other information as determined by the department.
(4)(5)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of not less than five hundred dollars ($500) per 1,000 insureds and up to five thousand dollars ($5,000) per 1,000 insureds, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of not less than one thousand dollars ($1,000) per 1,000 insureds and up to ten thousand dollars ($10,000) per 1,000 insureds for each year following the first year that the insurer failed to meet the benchmark.
(5)The insurer shall be liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. An inaccurate listing means a listing with at least one error in the information required under subdivision (h) or (i).(6)When assessing administrative penalties against a health insurer, the department shall determine the appropriate penalty amount for each violation based on one or more factors as applicable.
(7)Beginning January 1, 2028, 2029, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers information.
(C)The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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.
(p)(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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to an insurers provider directory or directories are required as a result of the insurers 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.
(q)(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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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).
(r)(1)In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurers provider directory or directories, the department may require the insurer to insurer shall arrange care and provide coverage for all covered health care services provided to the insured and to insured, 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 insureds health insurance policy. policy, and reimburse the provider the contracted amount for those health care services under the policy. The provider shall not collect any additional amount from the insured other than the applicable in-network cost sharing. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the insured were covered services under the insureds 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.
(2)If an insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the insurer shall, if the request is by telephone, tell the insured verbally and follow up in writing or electronic format no later than one business day after receiving the request. If the request is by electronic means, the insurer shall respond in writing or electronic format no later than one business day after receiving the request. The insurer shall also provide information on whether or not the provider is accepting new patients. The insurer shall retain a record of the request and the insurers response in the insureds file for at least two years after the date of the request.
(3)For covered benefits, if an insured obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the group insured shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the insurer as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise materially inaccurate, misleading, or incomplete.
(D)The online provider directory of the insurer is not accessible to insureds at the time the insured seeks information and the insured requests information consistent with paragraph (2).
(4)If the health insurance policy includes more than one tier of cost sharing, the insurer shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the insured when the insured seeks information about the provider. If the insurer provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the insured shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the insured from the insurer.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health insurance policy includes more than one tier of cost sharing and if the insured was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(6)For purposes of this subdivision, information is inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) is inaccurate, incomplete, or misleading.
(s)(1)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.
(2)For an insurance policy issued, amended, or renewed on or after July 1, 2025, if a provider has not been financially compensated consistent with this section or if the provider has failed to respond timely consistent with this section, and those providers amount to a change of 10 percent or greater in the network for a product in a region, then the insurer shall file an amendment to the policy application consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(3)An insurer shall not use information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provision of this chapter if the insurer cannot demonstrate to the department that the provider is contracting with the insurer and the provider has been financially compensated by the insurer consistent with this section or the provider has failed to respond timely consistent with this section. This paragraph shall apply whether or not the provider has been deleted from the directory.
(4)Consistent with Section 1360 of the Health and Safety Code, an insurer shall not advertise or otherwise represent the extent of its network, including the number or type of contracting providers, unless it is able to demonstrate that each provider is contracting and has been compensated consistent with this section.
(t)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.
(u)This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.
(v)As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers compliance with subdivision (q).
(w)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 XIIIB 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 XIIIB of the California Constitution.
The Legislature finds and declares all of the following:
(a)It has been the responsibility of each health care service plan and health insurer to maintain an accurate provider directory since the enactment of Chapter 649 of the Statutes of 2015. Despite the requirement in existing law that provider directories be accurate, both academic studies and reports of individual consumers indicate that inaccuracies in provider directories are common. Individual consumers and their representatives should be able to obtain care, including an appointment as a new patient, based on accurate information in the provider directory maintained by the health care service plan or health insurer.
(b)Too often consumers find ghost networks in which the provider directories of health care service plans and health insurers include doctors, hospitals, and other providers who are not accepting new patients, not accepting patients for that network of the plan or insurer, have not been compensated by the carrier in the past year, or are inaccessible to consumers because of inaccurate contact information in the provider directory. Some health care service plans and insurers advertise that there are thousands or even tens of thousands of doctors, hospitals, and other providers of care in their network, but when a consumer tries to contact a health care provider, basic information such as name and address are too often inaccurate. Even if the consumer can reach the provider who appears to be in-network for that network of the carrier, too often the consumer discovers either that the provider is not accepting new patients or not accepting patients for that network of the carrier, putting the burden of the inaccurate provider directory on the consumer, not the health care service plan or insurer. These barriers to care are most problematic for those consumers who need care the most, such as persons with disabilities or behavioral health conditions, as well as those with other barriers to seeking care, such as limited English proficiency or lack of health care literacy.
(c)To encourage the development of a provider directory utility that could be used by all health care service plans, in 2015, the Department of Managed Health Care required an undertaking to fund the development of such a provider directory utility as a condition of the departments approval of the acquisition of CareFirst by Blue Shield of California. In the years from 2015 to the introduction of this act, the Integrated Healthcare Association, an association of health care service plans, health insurers, provider groups, and hospitals with no consumer representation, held numerous meetings and workgroups with health care industry entities to develop a provider directory utility. The Integrated Healthcare Association states that as of 2019, the provider directory utility was operational and able to assist health care service plans and health insurers in verifying and crosschecking the accuracy of provider directory information. There are also efforts by the federal Centers for Medicare and Medicaid Services to aid in the accuracy of provider updates to improve provider directories.
(d)Inclusion in a health care service plan or health insurer directory is a form of marketing for health care providers, including hospitals, laboratory services, imaging, provider groups, and individual providers because those directories provide individual consumers information about whether or not the health care provider is available through the network of the plan or insurer. Removal from the provider directory of a health care service plan or health insurer constitutes a financial penalty for a health care provider because a consumer seeking in-network care or to receive referrals from other health care providers for in-network care is less likely to seek care from a provider not included in the provider directory.
(e)It is the intent of the Legislature in enacting this act to ensure that provider directories of health care service plans and health insurers are substantially accurate and that consumers are able to rely on the information provided in those directories, including such basic information as the name of the provider, the telephone number, and the address where care may be sought. It is also the intent of the Legislature to require the improvement of accuracy of provider directories over a number of years. In addition to the financial penalties on providers for failure to provide accurate and timely information for inclusion in the provider directory of a health care service plan or health insurer, it is the intent of the Legislature that the relevant departments have the authority to impose financial penalties on health care service plans and insurers for any failure of a plan or insurer to maintain the accuracy of its own directory.
SECTION 1.SEC. 2.Section 1367.27 of the Health and Safety Code is amended 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 plans 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 or that has not been compensated by the plan in the prior year, except as provided in this section.
(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 plans internet website 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 plans public internet website 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 plans public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 plans 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 providers 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 and remove 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.
(D)Beginning July 1, 2024, for a health care service plan contract issued, renewed, or amended on January 1, 2024, the plan cannot confirm that the plan has financially compensated the provider for the purpose of providing covered benefits to enrollees for the designated network in the prior year unless one of the following applies:
(i)The plan has newly contracted with the provider within the prior six months.
(ii)The plan has a newly approved network approved within the prior six months.
(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department. A special circumstance may include a provider in a rural area or a highly specialized specialist who is not used by an enrollee in the prior year or other circumstances as determined by the department through the regulatory or other rulemaking process.
(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.
(E)If a provider has been deleted from the provider directory, the deleted provider shall not be used for timely access monitoring, determination of network, or compliance with this chapter.
(F)For purposes of this subdivision, financially compensated means having paid five or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network.
(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 plans internet website.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
(9)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.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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 providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the plans products.
(13)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.
(14)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 1367.28.
(16)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.
(9)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.
(10)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 providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 plans 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 plans 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period. If the plan cannot verify that the information that is required by subdivisions (h) and (i) in the listing is accurate, the provider shall be deleted and removed from the directory at the next required update. Deleted provider information shall not be used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance with this chapter.
(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 this subdivision 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 plans provider directory or directories. This process 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 plans provider directory internet website linking to a form where the information can be reported directly to the plan through its internet website.
(n)The plan shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On January 1, 2024, a plans directories shall be at least 60-percent accurate.
(B)On or before January 1, 2025, a plans directories shall be at least 80-percent accurate.
(C)On or before January 1, 2026, a plans directories shall be at least 90-percent accurate.
(D)On or before January 1, 2027, a plans directories shall be at least 95-percent accurate.
(3)A plan shall annually audit and verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). The department shall develop procedures and policies on how a plan shall conduct the audits. In addition to verifying the information required under subdivisions (h) and (i), the plan shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for enrollees in that product or network. If the provider received no compensation in the last year for that product or network, the plan shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Submit its accuracy audit reports annually to the department to ensure compliance with this section.
(C)Publicly post its accuracy audit reports annually on its internet website.
(4)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of up to five thousand dollars ($5,000) per 1,000 enrollees, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of up to ten thousand dollars ($10,000) per 1,000 enrollees for each year following the first year that the plan failed to meet the benchmark.
(5)The plan shall be liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. An inaccurate listing means a listing with at least one error in the information required under subdivision (h) or (i).
(6)When assessing administrative penalties against a health care service plan, the director shall determine the appropriate penalty amount for each violation based on one or more factors as applicable, including the factors outlined in subdivision (d) of Section 1386.
(7)Beginning January 1, 2028, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers 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.
(p)(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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to a plans provider directory or directories are required as a result of the plans 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.
(q)(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 plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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.
(r)(1)In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans 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 enrollees 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 enrollees 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.
(2)If an enrollee, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the health care service plan shall respond in writing or electronic format no later than one business day after receiving the request. The plan shall also provide information on whether or not the provider is accepting new patients. The plan shall retain a record of the request and the plans response in the enrollees file for at least two years after the date of the request.
(3)For covered benefits, if an enrollee obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the enrollee shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the health care service plan as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise materially inaccurate, misleading, or incomplete.
(D)The online provider directory of the health care service plan is not accessible to enrollees at the time the enrollee seeks information and the enrollee requests information consistent with paragraph (2).
(4)If the health care service plan contract includes more than one tier of cost sharing, the plan shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the enrollee when the enrollee seeks information about the provider. If the plan provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the enrollee shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the enrollee from the plan.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health care service plan contract includes more than one tier of cost sharing and if the enrollee was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(s)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.
(t)(1)This section applies 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
(2)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). All other provisions of this section apply to plans with Medi-Cal managed care contracts.
(u)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.
(v)This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.
(w)As part of the departments 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 plans compliance with subdivision (q).
(x)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 2.SEC. 3.Section 10133.15 of the Insurance Code is amended 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 insurers 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 or that has not been compensated by the insurer in the prior year, except as provided in this section.
(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 insurers internet website 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 insurers public internet website 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 insurers public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 insurers 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 providers 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 and remove 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.
(D)Beginning July 1, 2024, for a health insurance policy issued, renewed, or amended on January 1, 2024, the insurer cannot confirm that the insurer has financially compensated the provider for the purpose of providing covered benefits to insureds for the designated network in the prior year unless one of the following applies:
(i)The insurer has newly contracted with the provider within the prior six months.
(ii)The insurer has a newly approved network approved within the prior six months.
(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department. A special circumstance may include a provider in a rural area or a highly specialized specialist who is not used by an insured in the prior year or other circumstances as determined by the department through the regulatory or other rulemaking process.
(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.
(E)If a provider has been deleted from the provider directory, the deleted provider shall not be used for timely access monitoring, determination of network, or compliance with this chapter.
(F)For purposes of this subdivision, financially compensated means having paid five or more claims to a provider for that network network, paid capitation, or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network.
(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 insurers internet website.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds.
(9)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.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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, if any, on the providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the insurers products.
(13)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.
(14)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 10133.14.
(16)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.
(9)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.
(10)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, if any, on the providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the insurers products.
(12)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 insurers 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 insurers 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period. If the insurer cannot verify that the information that is required by subdivisions (h) and (i) in the listing is accurate, the provider shall be deleted and removed from the directory at the next required update. Deleted provider information shall not be used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance with this chapter.
(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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory internet website linking to a form where the information can be reported directly to the insurer through its internet website.
(n)An insurer shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On January 1, 2024, an insurers directories shall be at least 60-percent accurate.
(B)On or before January 1, 2025, an insurers directories shall be at least 80-percent accurate.
(C)On or before January 1, 2026, an insurers directories shall be at least 90-percent accurate.
(D)On or before January 1, 2027, an insurers directories shall be at least 95-percent accurate.
(3)An insurer shall annually audit and verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). The department shall develop procedures and policies on how an insurer shall conduct the audits. In addition to verifying the information required under subdivisions (h) and (i), the insurer shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for insureds in that product or network. If the provider received no compensation in the last year for that product or network, the insurer shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Submit its accuracy audit reports annually to the department to ensure compliance with this section.
(C)Publicly post its accuracy audit reports annually on its internet website.
(4)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of up to five thousand dollars ($5,000) per 1,000 insureds, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of up to ten thousand dollars ($10,000) per 1,000 insureds for each year following the first year that the insurer failed to meet the benchmark.
(5)The insurer shall be liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. An inaccurate listing means a listing with at least one error in the information required under subdivision (h) or (i).
(6)When assessing administrative penalties against a health insurer, the department shall determine the appropriate penalty amount for each violation based on one or more factors as applicable.
(7)Beginning January 1, 2028, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers information.
(C)The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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.
(p)(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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to an insurers provider directory or directories are required as a result of the insurers 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.
(q)(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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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).
(r)(1)In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurers 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 insureds 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 insureds 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.
(2)If an insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the insurer shall respond in writing or electronic format no later than one business day after receiving the request. The insurer shall also provide information on whether or not the provider is accepting new patients. The plan insurer shall retain a record of the request and the plans insurers response in the insureds file for at least two years after the date of the request.
(3)For covered benefits, if an insured obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the group insured shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the insurer as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise materially inaccurate, misleading, or incomplete.
(D)The online provider directory of the insurer is not accessible to insureds at the time the insured seeks information and the insured requests information consistent with paragraph (2).
(4)If the health insurance policy includes more than one tier of cost sharing, the insurer shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the insured when the insured seeks information about the provider. If the insurer provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the insured shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the insured from the insurer.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health insurance policy includes more than one tier of cost sharing and if the insured was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(s)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.
(t)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.
(u)This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.
(v)As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers compliance with subdivision (q).
(w)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 3.SEC. 4.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(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 plans 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 or that has not been compensated by the plan in the prior year, except as provided in this section.
(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 plans internet website 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 plans public internet website 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 plans public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 plans 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 providers 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.
(D)Beginning July 1, 2024, for a health care service plan contract issued, renewed, or amended on January 1, 2024, the plan cannot confirm that the plan has financially compensated the provider for the purpose of providing covered benefits to enrollees for the designated network in the prior year unless one of the following applies:
(i)The plan has newly contracted with the provider within the prior six months.
(ii)The plan has a newly approved network approved within the prior six months.
(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department.
(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.
(E)If a provider has been deleted from the provider directory, the deleted provider shall not be used for timely access monitoring, determination of network, or compliance with this chapter.
(F)For purposes of this subdivision, financially compensated means having paid five or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network.
(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 plans internet website.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
(9)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, 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.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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 providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the plans products.
(13)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.
(14)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 1367.28.
(16)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.
(9)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.
(10)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 providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 plans 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 plans 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period. If the plan cannot verify that the information that is required by subdivisions (h) and (i) in the listing is accurate, the provider shall be removed from the directory at the next required update. Deleted provider information shall not be used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance with this chapter.
(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 this subdivision 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 plans provider directory or directories. This process 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 plans provider directory internet website linking to a form where the information can be reported directly to the plan through its internet website.
(n)The plan shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On January 1, 2024, a plans directories shall be at least 60 percent 60-percent accurate.
(B)On or before January 1, 2025, a plans directories shall be at least 80 percent 80-percent accurate.
(C)On or before January 1, 2026, a plans directories shall be at least 90 percent 90-percent accurate.
(D)On or before January 1, 2027, a plans directories shall be at least 95 percent 95-percent accurate.
(3)A plan shall annually audit and verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). The department shall develop procedures and policies on how a plan shall conduct the audits. In addition to verifying the information required under subdivisions (h) and (i), the plan shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for enrollees in that product or network. If the provider received no compensation in the last year for that product or network, the plan shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Submit its accuracy audit reports annually to the department to ensure compliance with this section.
(C)Publicly post its accuracy audit reports annually on its internet website.
(4)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of up to five thousand dollars ($5,000) per 1,000 enrollees, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of up to ten thousand dollars ($10,000) per 1,000 enrollees for each year following the first year that the plan failed to meet the benchmark.
(5)The plan shall be liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. An inaccurate listing means a listing with at least one error in the information required under subdivision (h) or (i).
(6)When assessing administrative penalties against a health care service plan, the director shall determine the appropriate penalty amount for each violation based on one or more factors as applicable, including the factors outlined in subdivision (d) of Section 1386.
(7)Beginning January 1, 2028, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers 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.
(p)(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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to a plans provider directory or directories are required as a result of the plans 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.
(q)(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 plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 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 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.
(r)(1)In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans 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 enrollees 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 enrollees 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.
(2)If an enrollee, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the health care service plan shall respond in writing or electronic format no later than one business day after receiving the request. The plan shall also provide information on whether or not the provider is accepting new patients. The plan shall retain a record of the request and the plans response in the enrollees file for at least two years after the date of the request.
(3)For covered benefits, if an enrollee obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the enrollee shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the health care service plan as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise materially inaccurate, misleading, or incomplete.
(D)The online provider directory of the health care service plan is not accessible to enrollees at the time the enrollee seeks information and the enrollee requests information consistent with paragraph (2).
(4)If the health care service plan contract includes more than one tier of cost sharing, the plan shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the enrollee when the enrollee seeks information about the provider. If the plan provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the enrollee shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the enrollee from the plan.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health care service plan contract includes more than one tier of cost sharing and if the enrollee was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(s)Whenever a plan determines as a result of this section that there has been a 10 percent 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.
(t)This section applies 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).
(u)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.
(v)This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.
(w)As part of the departments 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 plans compliance with subdivision (q).
(x)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 2.Section 10133.15 of the Insurance Code is amended 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 insurers 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 or that has not been compensated by the insurer in the prior year, except as provided in this section.
(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 insurers internet website 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 insurers public internet website 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 insurers public internet website 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, and the information provided shall be verified and accurate, consistent with this section.
(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 insurers 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 providers 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.
(D)Beginning July 1, 2024, for a health insurance policy issued, renewed, or amended on January 1, 2024, the insurer cannot confirm that the insurer has financially compensated the provider for the purpose of providing covered benefits to insureds for the designated network in the prior year unless one of the following applies:
(i)The insurer has newly contracted with the provider within the prior six months.
(ii)The insurer has a newly approved network approved within the prior six months.
(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department.
(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.
(E)If a provider has been deleted from the provider directory, the deleted provider shall not be used for timely access monitoring, determination of network, or compliance with this chapter.
(F)For purposes of this subdivision, financially compensated means having paid five or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network.
(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 insurers internet website.
(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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds.
(9)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, 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.
(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(11)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, if any, on the providers staff.
(12)Identification of providers who no longer accept new patients for some or all of the insurers products.
(13)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.
(14)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 10133.14.
(16)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 providers name, practice location or locations, and contact information, including telephone number.
(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 providers office email address, if available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(8)The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.
(9)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.
(10)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, if any, on the providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the insurers products.
(12)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(13)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 occurs:
(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 insurers 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 insurers 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 providers 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 providers 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 10-business-day notice period. A provider shall not be removed from the provider directory or directories if the provider responds before the end of the 10-business day 10-business-day notice period. If the insurer cannot verify that the information that is required by subdivisions (h) and (i) in the listing is accurate, the provider shall be removed from the directory at the next required update. Deleted provider information shall not be used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance with this chapter.
(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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory internet website linking to a form where the information can be reported directly to the insurer through its internet website.
(n)An insurer shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On January 1, 2024, an insurers directories shall be at least 60 percent 60-percent accurate.
(B)On or before January 1, 2025, an insurers directories shall be at least 80 percent 80-percent accurate.
(C)On or before January 1, 2026, an insurers directories shall be at least 90 percent 90-percent accurate.
(D)On or before January 1, 2027, an insurers directories shall be at least 95 percent 95-percent accurate.
(3)An insurer shall annually audit and verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). The department shall develop procedures and policies on how an insurer shall conduct the audits. In addition to verifying the information required under subdivisions (h) and (i), the insurer shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for insureds in that product or network. If the provider received no compensation in the last year for that product or network, the insurer shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Submit its accuracy audit reports annually to the department to ensure compliance with this section.
(C)Publicly post its accuracy audit reports annually on its internet website.
(4)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of up to five thousand dollars ($5,000) per 1,000 insureds, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of up to ten thousand dollars ($10,000) per 1,000 insureds for each year following the first year that the insurer failed to meet the benchmark.
(5)The insurer shall be liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. An inaccurate listing means a listing with at least one error in the information required under subdivision (h) or (i).
(6)When assessing administrative penalties against a health insurer, the department shall determine the appropriate penalty amount for each violation based on one or more factors as applicable.
(7)Beginning January 1, 2028, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(o)(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 (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers information.
(C)The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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.
(p)(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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to an insurers provider directory or directories are required as a result of the insurers 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.
(q)(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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 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 paragraph (1), 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).
(r)(1)In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurers 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 insureds 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 insureds 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.
(2)If an insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the insurer shall respond in writing or electronic format no later than one business day after receiving the request. The insurer shall also provide information on whether or not the provider is accepting new patients. The plan shall retain a record of the request and the plans response in the insureds file for at least two years after the date of the request.
(3)For covered benefits, if an insured obtained information through the plans online directory or a request consistent with paragraph (2) that a provider was an in-network provider, the insured shall pay no more than in-network cost sharing if any of the following apply:
(A)The provider is not contracting with the insurer as an in-network provider for that product.
(B)The contracting provider is not accepting new patients for that product.
(C)The information provided is otherwise materially inaccurate, misleading, or incomplete.
(D)The online provider directory of the insurer is not accessible to insureds at the time the insured seeks information and the insured requests information consistent with paragraph (2).
(4)If the health insurance policy includes more than one tier of cost sharing, the insurer shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the insured when the insured seeks information about the provider. If the insurer provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the insured shall owe no more than the cost sharing for the cost-sharing tier included in the information received by the insured from the insurer.
(5)For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. If the health insurance policy includes more than one tier of cost sharing and if the insured was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing tier shall apply.
(s)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.
(t)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.
(u)This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.
(v)As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers compliance with subdivision (q).
(w)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
(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 plans 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. plan or that has not been compensated by the plan in the prior year, except as provided in this section.
(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 plans Internet Web site internet website 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 plans public Internet Web site internet website 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 plans public Internet Web site internet website 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. appropriate, and the information provided shall be verified and accurate, consistent with this section.
(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 plans 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 providers 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.
(D)Beginning July 1, 2024, for a health care service plan contract issued, renewed, or amended on January 1, 2024, the plan cannot confirm that the plan has financially compensated the provider for the purpose of providing covered benefits to enrollees for the designated network in the prior year unless one of the following applies:
(i)The plan has newly contracted with the provider within the prior six months.
(ii)The plan has a newly approved network approved within the prior six months.
(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department.
(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.
(E)If a provider has been deleted from the provider directory, the deleted provider shall not be used for timely access monitoring, determination of network, or compliance with this chapter.
(F)For purposes of this subdivision, financially compensated means having paid five or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network.
(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 plans Internet Web site. internet website.
(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 providers name, practice location or locations, and contact information. information, including telephone number.
(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 providers office email address, if available. available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(7)(8)The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
(8)(9)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)(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(10)(11)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 providers staff.
(11)(12)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)(13)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.
(14)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 1367.28.
(13)(16)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 providers name, practice location or locations, and contact information. information, including telephone number.
(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 providers office email address, if available. available to an enrollee or the public.
(7)The population served, meaning adult, pediatric, or both.
(7)(8)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)(9)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)(10)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 providers staff.
(10)(11)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)The providers contract termination date, if any. The plan shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(11)(13)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 occurs:
(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 plans 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 plans 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 providers 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 providers 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 the provider responds before the end of the 10-business-day notice period. If the plan cannot verify that the information that is required by subdivisions (h) and (i) in the listing is accurate, the provider shall be removed from the directory at the next required update. Deleted provider information shall not be used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance with this chapter.
(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 this subdivision 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 plans provider directory or directories. This process 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 plans provider directory Internet Web site internet website linking to a form where the information can be reported directly to the plan through its Internet Web site. internet website.
(n)The plan shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On January 1, 2024, a plans directories shall be at least 60 percent accurate.
(B)On or before January 1, 2025, a plans directories shall be at least 80 percent accurate.
(C)On or before January 1, 2026, a plans directories shall be at least 90 percent accurate.
(D)On or before January 1, 2027, a plans directories shall be at least 95 percent accurate.
(3)A plan shall annually audit and verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). The department shall develop procedures and policies on how a plan shall conduct the audits. In addition to verifying the information required under subdivisions (h) and (i), the plan shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for enrollees in that product or network. If the provider received no compensation in the last year for that product or network, the plan shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Submit its accuracy audit reports annually to the department to ensure compliance with this section.
(C)Publicly post its accuracy audit reports annually on its internet website.
(4)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of up to five thousand dollars ($5,000) per 1,000 enrollees, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of up to ten thousand dollars ($10,000) per 1,000 enrollees for each year following the first year that the plan failed to meet the benchmark.
(5)The plan shall be liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. An inaccurate listing means a listing with at least one error in the information required under subdivision (h) or (i).
(6)When assessing administrative penalties against a health care service plan, the director shall determine the appropriate penalty amount for each violation based on one or more factors as applicable, including the factors outlined in subdivision (d) of Section 1386.
(7)Beginning January 1, 2028, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(n)(o)(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) (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers 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)(p)(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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to a plans provider directory or directories are required as a result of the plans 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)(q)(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 plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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)(r)In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans 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 enrollees 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 enrollees 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)(s)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)(t)This section applies 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)(u)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)(v)This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.
(v)(w)As part of the departments 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 plans compliance with subdivision (p). (q).
(w)(x)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 2.Section 10133.15 of the Insurance Code is amended 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 insurers 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. insurer or that has not been compensated by the insurer in the prior year, except as provided in this section.
(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 insurers Internet Web site internet website 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 insurers public Internet Web site internet website 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 insurers public Internet Web site internet website 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. appropriate, and the information provided shall be verified and accurate, consistent with this section.
(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 insurers 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 providers 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.
(D)Beginning July 1, 2024, for a health insurance policy issued, renewed, or amended on January 1, 2024, the insurer cannot confirm that the insurer has financially compensated the provider for the purpose of providing covered benefits to insureds for the designated network in the prior year unless one of the following applies:
(i)The insurer has newly contracted with the provider within the prior six months.
(ii)The insurer has a newly approved network approved within the prior six months.
(iii)A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by the department.
(iv)A special circumstance occurs particular to a specific provider and subject to prior approval of the department at least 30 days before the inclusion of the provider in the directory.
(E)If a provider has been deleted from the provider directory, the deleted provider shall not be used for timely access monitoring, determination of network, or compliance with this chapter.
(F)For purposes of this subdivision, financially compensated means having paid five or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees covered by the relevant network.
(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 insurers Internet Web site. internet website.
(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 providers name, practice location or locations, and contact information. information, including telephone number.
(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 providers office email address, if available. available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(7)(8)The name of each affiliated provider group currently under contract with the insurer through which the provider sees enrollees. insureds.
(8)(9)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)(10)The provider directory or directories may note that authorization or referral may be required to access some providers.
(10)(11)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, if any, on the providers staff.
(11)(12)Identification of providers who no longer accept new patients for some or all of the insurers products.
(12)(13)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.
(14)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(15)If the provider has affirmed that they offer and have provided gender-affirming services, in accordance with Section 10133.14.
(13)(16)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 providers name, practice location or locations, and contact information. information, including telephone number.
(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 providers office email address, if available. available to an insured or the public.
(7)The population served, meaning adult, pediatric, or both.
(7)(8)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)(9)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)(10)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, if any, on the providers staff.
(10)(11)Identification of providers who no longer accept new patients for some or all of the insurers products.
(12)The providers contract termination date, if any. The insurer shall delete the provider from the directory within five days after the termination date of the providers contract if there is a termination date.
(11)(13)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 occurs:
(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 insurers 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 insurers 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 providers 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 providers 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 the provider responds before the end of the 10-business day notice period. If the insurer cannot verify that the information that is required by subdivisions (h) and (i) in the listing is accurate, the provider shall be removed from the directory at the next required update. Deleted provider information shall not be used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance with this chapter.
(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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory Internet Web site internet website linking to a form where the information can be reported directly to the insurer through its Internet Web site. internet website.
(n)An insurer shall be responsible for maintaining an accurate provider directory.
(1)An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (h) and (i).
(2)The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (h) or (i) is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate.
(A)On January 1, 2024, an insurers directories shall be at least 60 percent accurate.
(B)On or before January 1, 2025, an insurers directories shall be at least 80 percent accurate.
(C)On or before January 1, 2026, an insurers directories shall be at least 90 percent accurate.
(D)On or before January 1, 2027, an insurers directories shall be at least 95 percent accurate.
(3)An insurer shall annually audit and verify its provider directories for accuracy of all of the information required pursuant to subdivisions (h) and (i). The department shall develop procedures and policies on how an insurer shall conduct the audits. In addition to verifying the information required under subdivisions (h) and (i), the insurer shall do all of the following:
(A)In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for insureds in that product or network. If the provider received no compensation in the last year for that product or network, the insurer shall remove that provider from their directory pursuant to subparagraph (D) of paragraph (2) of subdivision (e).
(B)Submit its accuracy audit reports annually to the department to ensure compliance with this section.
(C)Publicly post its accuracy audit reports annually on its internet website.
(4)Failure to meet the required benchmarks in paragraph (2) shall result in an administrative penalty of up to five thousand dollars ($5,000) per 1,000 insureds, and failure to meet the benchmark in the subsequent year shall result in an administrative penalty of up to ten thousand dollars ($10,000) per 1,000 insureds for each year following the first year that the insurer failed to meet the benchmark.
(5)The insurer shall be liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. An inaccurate listing means a listing with at least one error in the information required under subdivision (h) or (i).
(6)When assessing administrative penalties against a health insurer, the department shall determine the appropriate penalty amount for each violation based on one or more factors as applicable.
(7)Beginning January 1, 2028, and every five years thereafter, the penalty amounts specified in this section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment.
(n)(o)(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) (q) if all of the following occurs:
(A)A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.
(B)The provider group documents its efforts to verify the providers information.
(C)The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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)(p)(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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.
(C)If changes to an insurers provider directory or directories are required as a result of the insurers 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)(q)(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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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)(r)In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurers 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 insureds 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 insureds 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)(s)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)(t)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)(u)This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.
(u)(v)As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers compliance with subdivision (p). (q).
(v)(w)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
|
Date
|
Status
|
|---|---|
| Aug 15, 2024 | In committee: Held under submission. |
| Aug 5, 2024 | In committee: Referred to APPR suspense file. |
| Jun 27, 2024 | Read second time and amended. Re-referred to Com. on APPR. |
| Jun 26, 2024 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 9. Noes 1.) (June 26). |
| Jun 18, 2024 | From committee chair, with author's amendments: Amend, and re-refer to committee. Read second time, amended, and re-referred to Com. on HEALTH. |
| Jun 13, 2024 | In committee: Set, first hearing. Hearing canceled at the request of author. |
| May 1, 2024 | Referred to Com. on HEALTH. |
| Jan 30, 2024 | In Senate. Read first time. To Com. on RLS. for assignment. |
| Jan 30, 2024 | Read third time. Passed. Ordered to the Senate. (Ayes 59. Noes 9. Page 3968.) |
| Jan 23, 2024 | Read second time. Ordered to third reading. |
| Jan 22, 2024 | Read second time and amended. Ordered returned to second reading. |
| Jan 18, 2024 | From committee: Amend, and do pass as amended. (Ayes 12. Noes 2.) (January 18). |
| May 18, 2023 | In committee: Hearing postponed by committee. |
| Apr 19, 2023 | In committee: Set, first hearing. Referred to APPR. suspense file. |
| Mar 21, 2023 | Re-referred to Com. on APPR. |
| Mar 20, 2023 | Read second time and amended. |
| Mar 16, 2023 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 10. Noes 1.) (March 14). |
| Feb 15, 2023 | Re-referred to Com. on HEALTH. |
| Feb 14, 2023 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Jan 26, 2023 | Referred to Com. on HEALTH. |
| Jan 14, 2023 | From printer. May be heard in committee February 13. |
| Jan 13, 2023 | Read first time. To print. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Aug 5, 2024 | Placed on suspense file | Senate Standing Committee on Appropriations |
Passed |
|
| Jun 26, 2024 | Do pass as amended, but first amend, and re-refer to the Committee on [Appropriations] | Senate Standing Committee on Health |
Passed |
|
| Jan 30, 2024 | AB 236 Holden Assembly Third Reading | Assembly Floor |
Passed |
|
| Jan 18, 2024 | Do pass as amended. | Assembly Standing Committee on Appropriations |
Passed |
|
| Mar 14, 2023 | Do pass as amended and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| Aetna, Inc. | ** Against | |
| AHIP - America's Health Insurance Plans | * Against | Jun 26, 2024 |
| America'S Physician Groups | ** Support | |
| American Association Of Payers Administrators And Networks | * Against | Jun 26, 2024 |
| American Cancer Society - Cancer Action Network | * Support | Jun 26, 2024 |
| American College of OBGYNs District IX | * Against | Jun 26, 2024 |
| Anthem Blue Cross | ** Against | |
| Association Of California Life And Health Insurance Companies | * Against | Jun 26, 2024 |
| Blue Shield Of California | ** Against | |
| California Alliance Of Child And Family Services | * Support | Jun 26, 2024 |
| California Association Of Dental Plans | * Against | Jun 26, 2024 |
| California Association Of Health Plans | * Against | Jun 26, 2024 |
| California Association Of Orthodontists | * Support | Jun 26, 2024 |
| California Dental Network | ** Against | |
| California LGBTQ Health and Human Services Network | ** Support | |
| California Medical Association | * Against | Jun 26, 2024 |
| California Pan-Ethnic Health Network | * Support | Mar 14, 2023 |
| Children Now | * Support | Jun 26, 2024 |
| Cigna | ** Against | |
| Delta Dental Of California | ** Against | |
| Dental Health Services | ** Against | |
| Guardian Life Insurance Company of America; the | ** Against | |
| Health Access California | * Support | Jun 26, 2024 |
| Health Net | ** Against | |
| Justice in Aging | * Support | Mar 14, 2023 |
| Kennedy Forum | * Support | Jun 26, 2024 |
| Leukemia and Lymphoma Society | * Support | Jun 26, 2024 |
| Liberty Dental Plan | ** Against | |
| Metlife Safeguard Health Plan of Ca. | ** Against | |
| National Association of Vision Care Plans | * Against | Jun 26, 2024 |
| National Council of Negro Women | * Support | Jun 26, 2024 |
| National Multiple Sclerosis Society, Mscan | ** Support | |
| National Union Of Healthcare Workers | * Support | Jun 26, 2024 |
| Principal First Dental Health | ** Against | |
| SCIU California | * Support | Jun 26, 2024 |
| SMILE BRANDS INC | ** Against | |
| Steinberg Institute | * Support | Jun 26, 2024 |
| Sun Life Financial | ** Against | |
| United Concordia | ** Against | |
| United Healthcare Services, Inc. | ** Against | |
| Unum Dental HMO Plan | ** Against | |
| Vsp Vision | * Against Unless Amend | Jun 26, 2024 |
| Western Center On Law & Poverty | * Support | Jun 26, 2024 |
| Western Dental Services, Inc. | ** Against |
SENATE COMMITTEE ON
Senator Anna Caballero, Chair
2023 - 2024 Regular Session
AB 236 (Holden) - Health care coverage: provider directories
Version: | Policy Vote: |
Urgency: | Mandate: |
Hearing Date: | Consultant: |
Bill Summary:
AB 236 would revise and expand existing requirements for health plans and insurers to maintain accurate provider directories.
Fiscal Impact:
- The Department of Managed Health Care (DMHC) estimates costs of approximately $1,977,000 in 2024-25, $3,503,000 in 2025-26, $3,446,000 in 2026-27, $3,491,000 in 2027-28, and $3,538,000 in 2028-29 and annually thereafter for state administration (Managed Care Fund).
- The California Department of Insurance (CDI) estimates costs of $72,000 in the first year and $168,000 ongoing thereafter for state administration (Insurance Fund).
Background:
Current law requires health plans and insurers to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan’s enrollees/insureds, including those that accept new patients. A provider directory may not list or include information on a provider that is not currently under contract with the plan/policy. Among other provisions, existing law requires health plans and insurers to:
- Make available an online provider directory or directories on the Internet Web site to the public, potential enrollees/insureds, enrollees/insureds, and providers without any restrictions or limitations.
- Include both an email address and a telephone number for members of the public and providers to notify the plan/insurer if the provider directory information appears to be inaccurate.
- Take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plan’s/insurer’s provider directory or directories and, at least annually, review and update the entire provider directory or directories for each product offered.
Proposed Law:
Specific provisions of the bill would:
- Require health plans and insurers to maintain accurate provider directories as follows:
- On July 1, 2025, directories must be at least 60-percent accurate.
- On or before July 1, 2026, directories must be at least 80-percent accurate.
- On or before July 1, 2027, directories must be at least 90-percent accurate.
- On or before July 1, 2028, directories must be at least 95-percent accurate.
- Subject the health plan and insurer to administrative penalties for noncompliance, as specified.
- Authorize the DMHC and the CDI to:
- Develop a uniform format with standardized naming conventions and other aspects for each plan/insurer to use to request directory information from its providers.
- Establish a methodology and processes to ensure accuracy of provider directories and consistency with other state or federal laws, regulations, or standards.
- Require a plan/insurer to use a central utility or designate a central utility for those providers included in the directory.
- Require that, for covered benefits, if an enrollee/insured obtained information through the plan/insurer that a provider was an in-network provider, the enrollee/insured must not pay more than in-network cost-sharing if any of the following apply:
- The provider is not contracting with the plan/insurer as an in-network provider for that product.
- The contracting provider is not accepting new patients for that product.
- The information provided is otherwise inaccurate, misleading, or incomplete.
- The online provider directory is not accessible to enrollees/insureds at the time the enrollee/insured seeks information, and the enrollee/insured requests information, as specified.
-- END --
SENATE COMMITTEE ON HEALTH
Senator Richard Roth, Chair
BILL NO: AB 236
AUTHOR: | Holden | ||
VERSION: | June 18, 2024 | ||
HEARING DATE: | June 26, 2024 | ||
CONSULTANT: | Teri Boughton | ||
SUBJECT: Health care coverage: provider directories
SUMMARY:
Phases in provider directory accuracy rates of 60% by July 1, 2025 to at least 95% accurate by July 1, 2028. Imposes fines on plans and insurers that fail to meet the benchmark rates. Makes a listing inaccuracy a denial of access to care. Considers one error an inaccuracy.
Existing law:
- Establishes the Department of Managed Health Care (DMHC) to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); California Department of Insurance (CDI) to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [HSC §1340, et seq., INS §106, et seq., and WIC §14000, et seq.]
- Requires health plans and insurers to publish and maintain a provider directory or directories of contracting providers, including those who are accepting new patients, and prohibits listing or including information on a provider that is not currently under contract. [HSC §1367.27 and INS §10133.15]
- Requires a plan or insurer to provide the directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification methods that ensures the public, enrollees, potential enrollees, regulators, and other state or federal agencies can easily identify which providers participate in which networks for which products. [HSC §1367.27 and INS §10133.15]
- Requires provider directories to be available on the plan’s or insurer’s website and available without any requirement that a member of the public or potential enrollee or insured indicate intent to obtain coverage from the plan or insurer, without demonstrating coverage with the plan or insurer, providing a policy number, providing any other identifying information, or creating or accessing an account, and accessible through a clearly identifiable link or tab. [HSC §1367.27 and INS §10133.15]
- Requires 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. [HSC §1367.27 and INS § 10133.15]
- Requires the plan or insurer to update provider directories, at least weekly, with any change to contracting providers, as specified. Requires a printed directory to be updated quarterly or more frequently if required under federal law, and provided upon request and postmarked within five business days to the requestor. [HSC §1367.27 and INS §10133.15]
- Requires provider directories to 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. Establishes requirements on full service and specialized health plans and insurers for inclusion in directories. [HSC §1367.27 and INS §10133.15]
- Requires DMHC and CDI to develop uniform provider directory standards to permit consistency and the development of multi plan directories to determine the plan or policy a physician or other provider is available through. Requires after the directory standards are developed by DMHC and CDI, a plan or insurer to use the standards for each product offered by the plan or insurer. [HSC §1367.27 and INS §10133.15]
- Requires plans or insurers to ensure processes are in place to allow providers to promptly verify or submit changes to demographic information and participation status that at a minimum, include an online interface for providers to submit verification or changes electronically and to allow providers to receive an acknowledgement of receipt from the plan or insurer. Allows a plan to delay payment or reimbursement owed to a provider or provider group, if the provider fails to respond to the plan’s attempts to verify the provider’s information. [HSC §1367.27 and INS §10133.15]
- Requires in circumstances where the departments find that an enrollee or insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a provider directory or directories, the departments may require the health plan or insurer to provide coverage for all covered health care services and to reimburse the enrollee or insured for any amount beyond what would have been paid, had the services been delivered by an in-network provider under the plan contract or insurance policy. Requires prior to requiring reimbursement in these circumstances, the departments to conclude that the services received were covered services. Prohibits in those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider from being used as a basis to deny reimbursement to the enrollee or insured. [HSC §1367.27 and INS §10133.15]
This bill:
- Requires online provider directories to be verified and accurate. Requires printed directories to be dated based on the last update. Requires directories to state that an enrollee/insured may submit a complaint if they reasonably relied upon materially inaccurate, incomplete, or misleading information.
- Requires a health plan to include prominent disclosure of its duty to arrange coverage when behavioral health benefits are not available in-network within applicable geographic and timely access standards, included within the “Timely Access to Care” section of the directory required under existing law, and also include the geographic accessibility standards.
- Requires provider directories to include the population served, meaning adult, pediatric, or both, contract termination date, if any, whether or not the provider is the lowest cost-sharing tier if the product has more than one cost-sharing tier, and whether or not the provider has seen patients for this product in the last year, based on financial compensation of the provider by the plan or insurer. Requires the provider to be deleted from the directory within five days after the termination date.
- Adds dispensing optometrists, opticians, and optical dispensaries to the list of providers to be listed in a provider directory.
- Permits DMHC and CDI, by January 1, 2025, to develop a uniform format with standardized naming conventions and other aspects for each plan or insurer to use to request directory information from its providers, not subject to the Administrative Procedures Act (APA) until January 1, 2028.
- Permits DMHC and CDI to establish, by January 1, 2025, and not subject to the APA until January 1, 2028, a methodology and processes to ensure accuracy of provider directories and consistency with other state or federal laws, regulations, or standards. Requires the departments to take into account existing methods, including surveys, plan/insurer-reported information, and benchmarks or submission information from a central utility by another entity. Permits the departments to require a plan or insurer to use a central utility or designate a central utility for those providers included in the directory. Permits the departments to allow a plan or insurer that can demonstrate compliance with the benchmarks relief from the requirement to use a central utility.
- Requires the plan or insurer to ensure the accuracy of the information and approve a request within 10 business days of receipt if a provider who was previously removed from the provider directories requests to be added back to the provider directories, or if a plan or insurer requests that a provider that was previously removed from the provider directory be added back to the provider directory.
- Requires a plan or insurer to be responsible for maintaining an accurate provider directory. Specifies that an accurate provider directory maintains accurate information for all information to be included in the directories, as specified.
- Requires the accuracy percentage of a directory to be determined by the percentage of providers for which all required information is accurate. If there is one error on a listing for a provider, that listing is considered inaccurate. Phases in required accuracy rates as follows:
- On July 1, 2025 at least 60% accurate;
- On or before July 1, 2026 at least 80% accurate;
- On or before July 1, 2027 at least 90% accurate; and,
- On or before July 1, 2028 at least 95% accurate.
- Requires a plan or insurer to annually verify its provider directories for accuracy of all of the required information. If the departments develop a methodology and standards that permit the use of a central utility, requires the plan or insurer to continue to retain responsibility for compliance with this bill. Requires the plan or insurer to:
- Determine whether a provider has submitted claims or otherwise been compensated for covered benefits in that provider product or network;
- Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to DMHC and CDI;
- Publicly post its accuracy verification reports annually on its website; and,
- Requires verification of the accuracy of the printed directory to be based on the date of printing as provided on each page of the printed directory.
- Makes a listing inaccuracy a denial of access to care. Imposes for failure to comply with benchmarks an administrative penalty of not less than $500 per 1,000 enrollees/insureds and up to $5,000 per 1,000 enrollees/insureds, and in subsequent years not less than $1,000 per 1,000 enrollees/insureds and up to $10,000 per 1,000 enrollees/insureds for each year following the first year that the plan or insurer failed to meet the benchmark. Adjusts, beginning January 1, 2028, and every five years thereafter, the penalty amounts based on the average rate of change in premium rates for the individual and small group markets, weighted by enrollment, since the previous adjustment. Requires penalties to be paid by the plan or insurer and not the provider, subscriber, or enrollee.
- Requires health plans and insurers to arrange care and provide coverage where DMHC/CDI finds that an enrollee or insured reasonably relied upon inaccurate information and reimburse the provider the contracted amount for those services. Prohibits the provider from collecting any additional amount from the enrollee or insured other than applicable in-network cost-sharing.
- Requires health plans or insurers to inform an enrollee verbally through a telephone call and follow up in writing or electronic format, no later than one business day, on whether or not a provider is contracted as an in-network provider. Requires the plan or insurer to also provide information on whether or not the provider is accepting new patients. Requires the plan or insurer to maintain a record of the request for at least two years.
- Requires an enrollee or insured to pay no more than the in-network cost-sharing, if the provider is not in-network for that product, the provider is not accepting new patients for that product, the information is otherwise inaccurate, misleading, or incomplete, or, the online provider directory is not accessible at the time the enrollee or insured seeks the information. Requires the enrollee or insured to owe the cost-sharing associated with the low cost-sharing tier when the plan or insurer indicates a lower tier than is otherwise indicated, or, if the cost-sharing tier is inaccurate.
- Requires, by July 1, 2025, if a provider has not been financially compensated or if the provider has failed to timely respond consistent with this bill, and those providers amount to a change of 10% or greater of the network in a region, the plan or insurer to file an amendment, as specified. Defines “financially compensated” as having paid one or more claims to a provider for that network or otherwise demonstrably financially compensate that provider for the purposes of providing covered benefits to enrollees or insureds covered by the relevant network.
- Prohibits a plan or insurer from using information for a provider that is not contracting with the plan or insurer and who has not been financially compensated by the plan or insurer or failed to respond timely, consistent with this bill for purposes of compliance with timely access, network adequacy, or compliance with any other provision.
FISCAL EFFECT:
According to the Assembly Appropriations Committee, DMHC estimates ongoing annual costs of up to $12 million for additional staff to do the following: develop a methodology to measure provider directory accuracy and determine "special circumstances" necessitating a provider's continued inclusion in the provider directory; promulgate new regulations and modify existing regulations; develop infrastructure, such as template language for plan responses, spreadsheets, report forms, and instruction manuals; review costs, and review new filings from plans regarding accuracy of provider directories (Managed Care Fund). CDI estimates this bill will require $72,000 in fiscal year (FY) 2023-24, $168,000 FY 2024-25, and $88,000 ongoing for additional staff time (Insurance Fund).
PRIOR VOTES:
Assembly Floor: | 59 - 9 |
Assembly Appropriations Committee: | 12 - 2 |
Assembly Health Committee: | 10 - 1 |
COMMENTS:
- Author’s statement. According to the author, despite California having one of the nation’s strongest laws on health plan provider directories, compliance is at an unbelievable low. Recent studies have found that some health plans have inaccuracy rates as high as 80%, and major plans like Anthem and Kaiser have inaccurate information for 20%-38% of providers. These inaccuracies in provider referral lists are often referred to as ‘ghost networks’ because the referrals simply do not exist. As a result, consumers bear the responsibility of sorting through these grossly inaccurate lists, sifting through directories in an effort to find care, calling provider after provider, only to be told the provider is no longer in-network, no longer accepting new patients, or even no longer in practice. This is especially harmful to those already suffering from health care inequity, such as those with limited English proficiency and persons with disabilities. Ghost networks contribute to inequity in health care by leaving Californians to fend for themselves in their most vulnerable time.
- Studies. Studies referenced by this bill’s sponsor, Health Access California, include one study of Oregon’s Medicaid managed care organizations where the authors compared networks from administrative claims to provider directories between January 1 and December 31, 2018. This study found 58.2% of network listings were “phantom” providers who did not see Medicaid patients, including 67.4% of mental health prescribers, 59% of mental health nonprescribers and 54% of primary care providers. Another 2021 study used California, Louisiana, and Maryland as case studies to demonstrate that existing approaches to directory access fail to protect consumers. As it relates to California, the study used raw data from 2018 provider questionnaires on timely access requirements as a snapshot of directory accuracy for California plans. The data was not actually from provider directories. The study found high error rates across HMOs, Medicaid plans, Affordable Care Act (ACA) plans, and non-ACA plans. All types of plans had higher error rates for psychiatrists than for other types of specialists. The study suggests that SB 137 (Hernandez, Chapter 649, Statutes of 2015), the law that mandates provider directories, described as “on paper, one of the most extensive [accuracy policies] in the country” has had no appreciable effect on accuracy. The paper also suggests lax enforcement by DMHC. The paper references a California State Audit of Medicaid directories that found plans can have high compliance rates, such as Partnership HealthPlan that had only 3% errors in directory entries compared to Anthem, which had an error rate of over 20%. Another California-specific study used a large, random, and representative survey for all DMHC managed care plans for four specialties: primary care providers, cardiologists, endocrinologists, and gastroenterologist for 2018 and 2019. Overall, provider directory entries for the four specialties show inaccuracies ranging from a low of 24% for primary care in commercial plans in 2019 to a high of 41% for endocrinology in Medi-Cal plans in 2018. Results improved between 2018 and 2019 compared to previous findings on primary care. Overall, primary care directory information and cardiology appear to be more accurate. Medi-Cal plans outperformed other markets with regards to timely access, and primary care consistently outperformed all other specialties. Timely access rates were higher for general appointments than for urgent care appointments. The study concludes, despite the fact that California has one of the most active and well-resourced regulators in the nation, authors found concerning results for consumers when it comes to locating in-network providers and gaining timely access. This raises questions about the regulatory regime as well as consumer access and health outcomes.
- Provider experience. In a white paper submitted by America’s Physicians Groups (APG), APG indicates it is typical for a provider group to hold a dozen to two dozen separate plan contracts. A provider group is required to comply with each plan’s distinct procedure for roster verification and updates. Each plan utilizes a different format and exchange procedure. Some require special color codes in the Excel workbook fields. Others require submittal through one and only one email address. Beyond the workload imposed by the varying formatting and protocols for exchange, timing is also an important factor. Health plans use monthly, quarterly, semi‐annual, and annual exchange cycles with their contracted provider groups. The 30‐day review periods triggered by a roster notification could foreseeably overlap between several plans – leading to significant increases in the provider group’s staffing workload to comply with plan directory submittal requirements. The roster verification process utilized by each plan is unique, highly manual in nature, prone to human error and time consuming. Additionally, provider groups often contract with individual providers rather than employ them. These individual providers are not exclusive to one group and are subject to a barrage of phone calls, faxes, and varying submittal procedures from the plans that they contract with. These individual providers will receive dozens of contacts to verify their information. Additionally, it is typical for individual providers to function at several locations. Some locations may be unique to certain provider group network and certain plan contracts. APG raises one example where one preferred provider organization plan selected seven individual providers to serve a particular network who were part of a 1200-doctor Independent Physician Association (IPA). The plan listed the IPA as part of the network, which was inaccurate and raised antitrust exposure for the groups mistakenly listed in the network. The Integrated Healthcare Association (IHA) indicates that a Council for Affordable Quality Healthcare (CAQH) survey of 1,240 physician practices, conducted in September 2019, determined that updating directory information costs each practice $998.84 on average every month, the equivalent of one staff day per week. For independent providers, this can be cost prohibitive to network participation. IHA points out that provider data encompasses hundreds of specific data elements for a single provider or practice location. Some are critical for consumers, such as license verification or accepting new patients. Others may be less critical, but all need to be verified on a very frequent basis, some as frequently as weekly. In addition to providing this data, providers are also required to attest to the accuracy of the information on a very frequent basis.
- Centralized data utility. IHA is a 501(c) (6) non-profit business league whose members are healthcare organizations across California, including hospitals, health systems, health plans, physician organizations, consumer groups, universities, and pharmaceutical and technology companies. One of IHA’s projects is the creation of a centralized cloud-based technology platform, called Symphony, for provider data management, including demographics, services, products and networks. Plans can use this information for their own provider directories and providers can make live updates and validate information through a portal or “File Transfer Protocol,” and are notified when plans accept the information. The initial phase of Symphony’s development is focused on practice location, products accepted, and whether or not a provider is accepting new patients. According to IHA, it recognizes that the core provider data set is consistent across multiple use cases such as provider credentialing but is limiting the initial scope to accurate provider data. Symphony includes 18 health plans and purchasers and more than 100 provider organizations. Using data from 17 health plans, over 80,000 providers and third party reference data, Symphony manages over 500,000 unique records. They process up to 1.7 million data verifications per month and identify approximately 100,000 discrepancies.
- Federal requirements. Under the federal Consolidated Appropriations Act (CAA) of 2021, “No Surprises Act,” providers and health care facilities must generally refund enrollees amounts paid in excess of in-network cost-sharing amounts with interest, if the enrollee has inadvertently received out-of-network care due to inaccurate provider directory information, and if the provider or facility billed the enrollee for an amount in excess of in-network cost-sharing amounts, and the enrollee paid the bill. In addition, providers and health care facilities must maintain business processes to submit provider directory information at specified times to support plan and issuers in maintaining accurate, up to date provider directories. Contract provisions can require a provider to be removed at the time of the contract termination, and the plan to bear financial responsibility for providing inaccurate network status information to an enrollee.
- Related legislation. AB 815 (Wood) Requires the California Health and Human Services Agency to establish a provider credentialing board to establish a standardized credentialing form to be used by every health plan and insurer on or after July 1, 2026 or six months after the form is established, whichever is later, and prohibits a plan or insurer from requesting any additional information from a provider that is not required on the form. AB 815 is set to be heard in the Senate Health Committee on July 3, 2024.
- Prior legislation. SB 923 (Wiener, Chapter 822, Statutes of 2022) requires, within six months after DMHC, CDI, and DHCS issue guidance, and not later than March 1, 2025, a full service health plan to include information within or accessible from the plan’s provider directory and call center that identifies which of the plan’s in-network providers have affirmed that they offer and have provided gender-affirming services, as specified. Requires this information to be updated when an in-network provider requests its inclusion or exclusion as a provider that offers and provides gender-affirming services.
SB 137 (Hernandez, Chapter 649, Statutes of 2015) requires a health plan or insurer to make available a provider directory or directories that provide information on contracting providers, including those that accept new patients. Prohibits a provider directory from including information on a provider that does not have a current contract with the plan or insurer. SB 137 authorizes health plans and insurers to delay payment or reimbursement owed to a provider or provider group after steps have been taken to obtain a response from the provider. SB 137 requires an enrollee or insured to pay no more than the in-network cost-sharing if the provider is not in-network for that product, the provider is not accepting new patients for that product, the information is otherwise inaccurate, misleading, or incomplete, or, the online provider directory is not accessible at the time the enrollee or insured seeks the information.
SB 964 (Hernandez, Chapter 573, Statutes of 2014) increases oversight of health plans with respect to compliance with timely access and provider network adequacy standards.
- Support. Health Access California, this bill’s sponsor, writes error rates vary among health plan directories; inaccuracies are highest for non-physician mental health professionals and psychiatrists and are also high for primary care and specialty care providers. One health plan was found to have an error rate of 80% for non-physician mental health professionals with most having error rates of 20% to 30%. When providers on these lists are unreachable or do not actually provide care to consumers covered by that health plan, this is often referred to as a “ghost network.” Ghost networks lead to confusion among consumers who are trying to do the right thing by using directories to find an in-network provider, but too often have their care denied or delayed. In one case, a consumer seeking help called 73 providers and found that some had retired, others were not accepting their insurance, some had disconnected phone numbers, and a few had passed away; ultimately, they decided to seek care out-of-network and at additional expense to them. These inaccuracies have the greatest impact on consumers who already face the worst access such as those with limited English proficiency, persons with disabilities, and others in marginalized communities, thus worsening health inequities. APG writes over the past several years since SB 137 was enacted, provider directory accuracy has improved marginally. The market place lacks a culture of compliance at both the payer and provider level. It is a harsh assessment, but time has been wasted. This bill addresses some of the problems that have plagued the advancement of provider directory accuracy by requiring a graduated level of thresholds, beginning at 60% accuracy in 2024 and progressing to 95% accuracy by 2027. These thresholds can drive adoption of better systems for the development of timely and accurate directories. Accurate provider directories can and must be developed in order to support compliance with statutory network adequacy requirements and patient access to care. The California Association of Orthodontists writes that this is a crucial piece of legislation aimed at eliminating “ghost networks” and rampant provider inaccuracies. This bill will strengthen current policies by introducing accuracy guidelines, benchmark goals, and effective enforcement methods. The Steinburg Institute writes accurate provider directories are an essential component of realizing land mark mental health and substance use parity, as inaccurate directories place unnecessary burdens on those seeking care which, in turn, serves as a barrier to receiving treatment. The National Multiple Sclerosis Society writes given the high inaccuracy rates today of directories and the damaging impact it can have on patients’ health if they cannot find a medical provider, it is critical that provider directories have correct information.
- Opposition. The California Association of Dental Plans writes in opposition that there are many terms in this bill without clear definitions or which need additional language to understand the full impact. Additionally, one error would make the entire provider listing inaccurate, including an erroneous suite number or a misspelling. These items are not detrimental to the consumer receiving dental services. Fines are disproportionate to dental plans with low monthly premiums vs. medical plans. There are many instances where a provider may not submit a claim or the claim may not be adjudicated but would require a provider to be removed or deleted from the directory. Disallowing suppressed providers for timely access and networks goes against all efforts to build dental networks which is what affords the significant costs savings for dental care for consumers. Provisions from the No Surprises Act related to network status responses and holding consumers harmless do not apply to stand-alone dental plans. America’s Health Insurance Plans, the Association of California Life and Health Insurance Companies, and the California Association of Health Plans writes this bill does nothing to address the root cause of the issue, and instead simply places the full responsibility of the database accuracy on health plans and insurers, without fully appreciating that this endeavor was always intended to be a shared responsibility between contracted providers and health plans/insurers. This proposal does not appear to take into consideration that the accuracy of each individual provider directory is solely reliant upon practitioners and medical groups maintaining their own accurate records, providing that information to plans and insurers in a timely manner and informing plans and insurers in real time of any relevant changes when they are made. Without that consideration being included in this bill, plans and insurers will continue to struggle to meet the expectations set forth by the legislature. Additionally, this bill does not recognize the existing work being done by both the DMHC and IHA around provider directory accuracy. The DMHC is still in the process of official rulemaking for SB 137, demonstrating how difficult it is to obtain the accuracy we all seek. Our collective member plans have dedicated substantial time and resources toward implementing SB 137 and the federal CAA of 2021, with the intent to address issues of inaccuracy, including adopting new and easier ways for contracted providers to report accurate and timely information to health plans and insurers. Lastly, this bill attaches enormous financial penalties solely on health plans and insurers if the directories are inaccurate, even when a provider fails to disclose updated or accurate information to the plan or insurer. These opponents believe that this enforcement mechanism is unnecessarily punitive, fundamentally unfair, and will not address the issue that this bill is seeking to fix.
- Oppose unless amended. The California State Association of Psychiatrists (CSAP) would like the bill language to clarify that the burden to maintain accurate provider directories is the responsibility of the health plan and that any burden on a physician should be minimized.
CSAP also wants to make sure that when a patient sees an out-of-network physician and only pays in-network cost-sharing amounts, the physician is made whole or compensated at a fair rate. Other suggestions are to include on every provider directory information about an enrollee's right to timely access to care and who they can contact if the health plan is not meeting that requirement. Lastly, CSAP wants to ensure that there is due process for a provider if they are mistakenly removed from a plan's provider directory or if the health plan wrongly concludes the information provided to them is inaccurate. VSP Vision has concerns about the methodology and verification of the accuracy benchmarks and believes it needs clarification, penalties on plans do not include accountability for providers, payment of a provider when an enrollee or insured reasonably relied on inaccurate information doesn’t include accountability on provider that failed to inform the plan of changes, and, adding a removed provider back within 10 days of request regardless of reason for removal conflicts with National Committee for Quality Assurance Standards. These deficiencies should be addressed.
- Policy comment. All stakeholders seem to agree that accurate provider directories are essential to enrollees and insureds accessing in-network providers, which should be the primary purpose of a provider directory. The current regulatory structure appears not to sufficiently ensure that the parties with the accurate information are submitting and/or updating the information in a timely fashion. Both plans and providers have important roles to play in this process. A solution is necessary to make it easier on providers to maintain accurate information with their contracted plans in the least burdensome manner and at the same time hold all parties accountable for provider director accuracy, particularly as it relates to information that is necessary for enrollees and insureds to access covered services.
SUPPORT AND OPPOSITION:
Support: Health Access California (sponsor)
America’s Physician Groups
American Cancer Society Cancer Actin Network
Asian Resources, Inc.
California Alliance of Child and Family Services
California Association of Orthodontists
California Association of Local Behavioral Health Boards and Commissions
California Black Health Network
California LGBTQ Health and Human Services Network
California Optometric Association
California Pan-Ethnic Health Network
California State Council of Service Employees International Union
California Teachers Association
Children Now
Courage California
Depression and Bipolar Support Alliance California
DIRFloortime Coalition of California
Greenhouse Therapy Center
Hillsides Pasadena
Justice in Aging
National Health Law Program
National Multiple Sclerosis Society
National Union of Healthcare Workers
Purchaser Business Group on Health
Steinberg Institute
The Kennedy Forum
Western Center on Law & Poverty
Oppose: America’s Health Insurance Plans
American Association of Payers Administrators and Networks
Association of California Life & Health Insurance Companies
California Association of Dental Plans
California Association of Health Plans
California Medical Association
California State Association of Psychiatrists (unless amended)
Local Health Plans of California
Los Angeles County Business Federation
National Association of Vision Care Plans
VSP Vision (unless amended)
-- END --
ASSEMBLY THIRD READING
ATR Bill Id:AB 236
Author:(Holden)
As Amended Ver:January 22, 2024
Majority vote
SUMMARY
Requires a health care service plan (health plan) or insurer to annually verify and delete inaccurate listings from its provider directories, and requires a provider directory to be 60% accurate on July 1, 2025 and 95% accurate on or before July 1, 2028. Subjects a health plan or insurer to administrative penalties for failure to meet the prescribed benchmarks. Requires the health plan or insurer to delete the provider from its directory beginning July 1, 2025, if a plan or insurer has not financially compensated a provider in the prior year unless specified criteria applies. Requires a health plan or insurer to provide information about in-network providers to enrollees and insureds upon request, and limits the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances. Authorizes the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI), on or before January 1, 2025, to develop uniform formats for health plans and insurers to use when requesting directory information from providers. Authorizes the DMHC and CDI, on or before January 1, 2026, to establish a methodology and processes to ensure accuracy of provider directories, including requiring a health plan or insurer, to use a central utility or designate a central utility for those providers included in the directory.
Major Provisions
COMMENTS
- California's Provider Directory. Provider directories help patients identify clinicians based on specialty, location, and hours. California was one of the first states to enact laws related to provider directories, in SB 137 (Hernandez), Chapter 649, Statutes of 2015, which requires health plans and insurers to maintain accurate online and paper directories as of July 1, 2016. SB 137 also requires some of the following:
- The DMHC and CDI to develop uniform provider directory standards and to take appropriate steps to ensure the accuracy of the information contained in the plan or health insurer's directory or directories, and requires the plan or insurer, at least annually, to review and update the entire provider directory or directories for each product offered;
- A plan or insurer, at least weekly, to update its online provider directory or directories, and requires a plan or insurer, at least quarterly, to update its printed provider directory or directories; and,
- A plan or 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 and authorizes 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.
- Federal Provider Directory Requirements. In a secret shopper Health Affairs study of California qualified health plans (QHPs) (offered on Covered California – California's state based exchange) in 2015, 73% of calls to providers listed in network directories were unable to secure appointments. Failures generally related to inaccurate phone numbers or addresses for listed providers, inaccurate specialty listings, or listed providers who were not actually in the network. As part of its annual compliance review, the Centers for Medicare & Medicaid Services selects a small sample of issuers and reviews the machine-readable provider directory to verify accuracy. The 2020 Plan Year Federally-Facilitated Exchange Issuer Compliance Review Summary Report found inaccuracies in all directories examined in 2020, with similar compliance problems observed in prior years.
Beginning in 2022, the federal No Surprises Act requires all private health plans, including QHPs, to maintain accurate provider directories and requires providers to regularly update plans about any changes in their information. Plans must verify and update directories at least every 90 days and, on an ongoing basis, post any changes within two business days. Plans are also required to apply in-network cost sharing for covered services provided by facilities or providers mistakenly listed as in-network.
- Enforcement. The Yale Law & Policy Review (Yale Review) entitled, "Laying ghost networks to rest: Combatting deceptive health plan provider directories," also revealed high error rates. Even the lowest error rate, 21%, means that one out of five provider listings will lead enrollees seeking care to a dead end. At the high end, more than half of all provider listings lead to a dead end. While consumers can theoretically seek out correct addresses and phone numbers, search engines are at best a partial replacement for accurate directories. Furthermore, the provider directories examined had higher error rates for psychiatrists than for other types of specialists, underlining the particular burden placed on people who need behavioral care. According to the Yale Review, when states do carry out enforcement actions, they tend to result in minimal or no fines, removing any incentive for insurers to increase the accuracy of their plans. Despite SB 137's broad scope and detailed requirements, the Yale Review indicated that California continues to have high levels of directory errors. California does not directly collect data about directory errors. However, to comply with California's timely access standards, health plans regulated by the DMHC must submit yearly surveys of all providers that take appointments from enrollees to assess how soon an appointment can be scheduled. According to the Yale Review, DMHC only uses this data to compile timely access reports, but this survey also functions as a directory accuracy survey: the raw data notes when providers could not complete the timely access questionnaire because their address was incorrect, their phone number was incorrect, their specialty was incorrect, they do not take appointments at that location, they are not actually in-network, or they are no longer practicing. This bill builds upon California's provider directory by requiring plans and insurers to annually audit, delete inaccurate listings, and requires a 95% accuracy by July 1, 2028. Failure to meet these required benchmarks will result increased administrative penalties.
According to the Author
Despite California having one of the nation's strongest laws on health plan provider directories, compliance is at an unbelievable low. Recent studies have found that some health plans have inaccuracy rates as high as 80%, and major plans like Anthem and Kaiser have inaccurate information for 20%-38% of providers. According to the author, these inaccuracies in provider referral lists are often referred to as 'ghost networks' because the referrals simply do not exist. As a result, consumers bear the responsibility of sorting through these grossly inaccurate lists, sifting through directories in an effort to find care, calling provider after provider, only to be told the provider is no longer in-network, no longer accepting new patients, or even no longer in practice. This is especially harmful to those already suffering from health care inequity, such as those with limited English proficiency and persons with disabilities. The author concludes that ghost networks contribute to inequity in health care by leaving Californians to fend for themselves in their most vulnerable time.
Arguments in Support
Health Access California (HAC), sponsors of this bill, references the same Yale Review study cited above that found the following: Kaiser was 12-38% inaccurate; Molina was 54-80% inaccurate; Blue Cross 20-25% inaccurate; and, CenCal Health Plan was 39-62% inaccurate. According to HAC, consumers depend on a provider directory to find an in-network provider whether it be a doctor, specialist, dentist, hospital, laboratory, imaging center, or another provider. A consumer's right to timely access to care is affected by a provider directory; if a consumer is unable to find a provider, they waste necessary time simply searching for one. According to HAC, timely access to care monitoring by DMHC routinely finds that 20%-30% of providers are unreachable by the health plan, often because of inaccuracies in the health plan's own provider directory. If a provider directory is replete with doctors and other professionals who are not actually seeing patients covered by that health plan, it raises serious questions about the plan's assertions about an adequate network of doctors and other providers that are available to provide timely access to care.
Arguments in Opposition
The California Association of Health Plans (CAHP), the Association of California Life and Health Insurance Companies (ACLHIC), and America's Health Insurance Plans (AHIP) state that provider directories act as an essential guide that health plans and insurers rely upon to help our enrollees and insureds access timely and appropriate care but state that this bill does nothing to address the root cause of the issue, and instead simply places the full responsibility of the database accuracy on health plans and insurers, without fully appreciating that this endeavor was always intended to be a shared responsibility between contracted providers and health plans/insurers. Without that consideration being included in this bill, plans and insurers will continue to struggle to meet the expectations set forth by the Legislature. Additionally, this bill does not recognize the existing work being done by both the DMHC and the Integrated Health Association around provider directory accuracy. The DMHC is still in the process of official rulemaking for SB 137, demonstrating how difficult it is to obtain accuracy. According to CAHP, ACLHIC, and AHIP, currently, commercial health plans and insurers spend over 2.1 billion dollars annually to maintain provider databases, clearly demonstrating the commitment health plans and insurers have to supporting accurate provider directories. Lastly, this bill attaches enormous financial penalties solely on health plans and insurers if the directories are inaccurate, even when a provider fails to disclose updated or accurate information to the plan or insurer.
The California State Association of Psychiatrists (CSAP), in oppose unless amended, would like this bill language to clarify that the burden to maintain accurate provider directories is the responsibility of the health plan and that any burden on a physician should be minimized. CSAP also wants to make sure that when a patient sees an out-of-network physician and only pays in-network cost-sharing amounts, the physician is made whole or compensated at a fair rate. Other suggestions are to include on every provider directory information about an enrollee's right to timely access to care and who they can contact if the health plan is not meeting that requirement, and to clarify that a physician is not obligated to disclose whether they provide gender-affirming care due to safety, security and privacy concerns. Lastly, CSAP wants to ensure that there is due process for a provider if they are mistakenly removed from a plan's provider directory or if the health plan wrongly concludes the information provided to them is inaccurate.
FISCAL COMMENTS
According to the Assembly Appropriations Committee, DMHC estimates ongoing annual costs of up to $12 million for additional staff to do the following: develop a methodology to measure provider directory accuracy and determine "special circumstances" necessitating a provider's continued inclusion in the provider directory; promulgate new regulations and modify existing regulations; develop infrastructure, such as template language for plan responses, spreadsheets, report forms, and instruction manuals; review costs, and review new filings from plans regarding accuracy of provider directories (Managed Care Fund).
CDI estimates this bill will require $72,000 in fiscal year (FY) 2023-24, $168,000 FY 2024-25, and $88,000 ongoing for additional staff time (Insurance Fund).
VOTES
ASM HEALTH: 10-1-4
YES: Wood, Aguiar-Curry, Arambula, Boerner Horvath, Maienschein, McCarty, Rodriguez, Santiago, Villapudua, Weber
NO: Waldron
ABS, ABST OR NV: Wendy Carrillo, Flora, Lackey, Joe Patterson
ASM APPROPRIATIONS: 12-2-2
YES: Holden, Arambula, Wood, Calderon, Connolly, Mike Fong, Grayson, Haney, Hart, Lowenthal, Pellerin, Villapudua
NO: Sanchez, Dixon
ABS, ABST OR NV: Megan Dahle, Ta
UPDATED
VERSION: January 22, 2024
CONSULTANT: Kristene Mapile / HEALTH / (916) 319-2097 FN: 0002600
Date of Hearing: April 19, 2023
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Chris Holden, Chair
ABPCA Bill Id:AB 236
Author:(Holden) – As Amended Ver:March 20, 2023
Policy Committee: | Health | Vote: | 10 - 1 |
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Urgency: No State Mandated Local Program: Yes Reimbursable: Yes
SUMMARY:
This bill requires a health care service plan (health plan) or insurer to annually audit and delete inaccurate provider listings, and subjects a health plan or insurer to administrative penalties if it fails to meet prescribed benchmarks for accuracy, as specified. This bill also requires a health plan or insurer to delete a provider from its directory if the health plan or insurer has not financially compensated a provider in the prior year unless specified criteria apply. The bill further requires a health plan or insurer to provide information about in-network providers to enrollees and insureds upon request, and limits the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances.
FISCAL EFFECT:
According to the Department of Managed Health Care (DMHC), this bill will require complicated regulations and determinations, as well as expanded compliance monitoring and enforcement. DMHC has not yet determined how it will implement this bill, but states this bill will result in a significant workload increase in most, if not all, of DMHC’s program areas, and will have a correspondingly large, but indeterminate, fiscal impact (Managed Care Fund).
The California Department of Insurance (CDI) estimates this bill will require $72,000 in fiscal year (FY) 2023-24, $168,000 FY 2024-25, and $88,000 ongoing for additional staff time (Insurance Fund).
COMMENTS:
- Purpose. According to the author:
Despite California having one of the nation’s strongest laws on health plan provider directories, compliance is at an unbelievable low. Recent studies have found that some health plans have inaccuracy rates as high as 80%, and major plans like Anthem and Kaiser have inaccurate information for 20%-38% of providers. These inaccuracies in provider referral lists are often referred to as ‘ghost networks’ because the referrals simply do not exist. As a result, consumers bear the responsibility of sorting through these grossly inaccurate lists, sifting through directories in an effort to find care, calling provider after provider, only to be told the provider is no longer in-network, no longer accepting new patients, or even no longer in practice. This is especially harmful to those already suffering from health care inequity, such as those with limited English proficiency and persons with disabilities. Ghost networks contribute to inequity in health care by leaving Californians to fend for themselves in their most vulnerable time.
- Background. In a Health Affairs study of California qualified health plans (QHPs; these are plans offered through Covered California, California’s state-based exchange), in 2015, 73% of calls to providers listed in network directories were unable to secure appointments. Failures generally related to inaccurate phone numbers or addresses for listed providers, inaccurate specialty listings, or listed providers who were not actually in the network.
- Federal Law. Beginning in 2022, the federal No Surprises Act (NSA) requires every private health plan, including every QHP, to maintain accurate provider directories and requires providers to regularly update plans about any changes in their information. The NSA requires plans to verify and update directories at least every 90 days and, on an ongoing basis, post any changes within 2 business days. Plans are also required to apply in-network cost sharing for covered services provided by facilities or providers mistakenly listed as in-network. However, enforcement of the NSA will be delayed because implementing regulations have not yet been published.
- Role of Providers. Health plans argue that the reliability of the provider directory depends on providers updating their information to the plan in a timely manner, and this bill does not adequately incentivize providers to do so.
- Related Legislation. AB 815 (Wood) extends the period within which a health plan or disability insurer is required to assess and verify the qualifications of a health care provider, from 60 days after receiving a completed provider credentialing application to 90 days. AB 815 is pending in the Assembly Committee on Health.
Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081
Date of Hearing: March 14, 2023
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
ABPCA Bill Id:AB 236
Author:(Holden) – As Amended Ver:February 14, 2023
SUBJECT: Health care coverage: provider directories.
SUMMARY: Requires a health care service plan (health plan) or insurer to annually audit and delete inaccurate listings from its provider directories, and requires a provider directory to be 60% accurate on January 1, 2024 and 95% accurate on or before January 1, 2027. Subjects a health plan or insurer to administrative penalties for failure to meet the prescribed benchmarks and for each inaccurate listing in its directories. Requires the health plan or insurer to delete the provider from its directory beginning July 1, 2024, if a plan or insurer has not financially compensated a provider in the prior year unless specified criteria applies. Requires a health plan or insurer to provide information about in-network providers to enrollees and insureds upon request, and limits the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances. Specifically, this bill:
- Requires the online provider directory to be verified and accurate, as specified.
- Specifies that beginning July 1, 2024, for a health plan contract or insurance policy issued, renewed, or amended on January 1, 2024, the plan or insurer cannot confirm that the plan or insurer has financially compensated the provider for the purpose of providing covered benefits to enrollees or insureds for the designated network in the prior year unless one of the following applies:
- The plan or insurer has newly contracted with the provider within the prior six months;
- The plan or insurer has a newly approved network approved within the prior six months;
- A special circumstance requires inclusion of the provider in the directory consistent with regulations or other guidance by Department of Managed Health Care (DMHC) or California Department of Insurance (CDI); or,
- A special circumstance occurs particular to a specific provider and subject to prior approval of the DMHC or CDI at least 30 days before the inclusion of the provider in the directory.
- Defines financially compensated in 2) above as having paid five or more claims to a provider for that network or otherwise demonstrably financially compensated that provider for the purposes of providing covered benefits to enrollees or insureds covered by the relevant network.
- Makes clarifications to provider directory information, including provider’s telephone number and the population served, meaning adult, pediatric, or both. Adds to the provider directory, the provider’s contract termination date, if any. Requires the plan or insurer to delete the provider from the directory within five days after the termination date of the provider’s contract if there is a termination date. Adds to the provider directory if the provider has affirmed that they offer and have provided gender-affirming services.
- Requires the provider to be removed from the directory at the next required update if the plan cannot verify that the required information in the listing is accurate. Prohibits deleted provider information from being used for timely access monitoring, solicitation, network adequacy reporting, including time and distance standards, or compliance.
- Requires the plan or insurer to be responsible for maintaining an accurate provider directory, and that the accuracy percentage of a directory to be determined by the percentage of providers for which all information as required is accurate. Specifies that if there is one error on a listing for a provider, that listing is considered inaccurate.
- Requires the following accuracy on a plan or insurer’s directories:
- On January 1, 2024, a plan or insurer’s directories to be at least 60% accurate;
- On or before January 1, 2025, a plan or insurer’s directories to be at least 80% accurate;
- On or before January 1, 2026, a plan or insurer’s directories to be at least 90% accurate; and,
- On or before January 1, 2027, a plan or insurer’s directories to be at least 95% accurate.
- Requires a plan or insurer to annually audit and verify its provider directories for accuracy of all of the required information. Requires the DMHC and CDI to develop procedures and policies on the audits. Requires the plan and insurer, in addition to verifying the information required, to do all of the following:
- In verifying the accuracy of information in the provider directory or directories, determine whether a provider has submitted claims or otherwise been compensated for covered benefits for enrollees in that product or network. Requires the plan or insurer to remove that provider from their directory pursuant to 2) above if the provider received no compensation in the last year for that product or network;
- Submit its accuracy audit reports annually to the DMHC or CDI to ensure compliance with this bill; and,
- Publicly post its accuracy audit reports annually on its internet website.
- Specifies that failure to meet the required benchmarks in 7) above to result in an administrative penalty of up to five thousand dollars ($5,000) per 1,000 enrollees, and failure to meet the benchmark in the subsequent year to result in an administrative penalty of up to ten thousand dollars ($10,000) per 1,000 enrollees or insured for each year following the first year that the plan or insurer failed to meet the benchmark.
- Makes the plan or insurer liable for an administrative penalty of up to one thousand dollars ($1,000) for each inaccurate listing in its directory. Defines an inaccurate listing to be a listing with at least one error in the required information.
- Requires the DMHC Director or CDI, when assessing administrative penalties against a health plan or insurer, to determine the appropriate penalty amount for each violation based on one or more factors as applicable, as specified.
- Specifies that the penalty amounts to be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment beginning January 1, 2028, and every five years thereafter.
- Requires the health plan or insurer to respond in writing or electronic format no later than one business day after receiving the request if an enrollee or insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits. Requires the plan or insurer to also provide information on whether or not the provider is accepting new patients. Requires the plan or insurer to retain a record of the request and the plan or insurer’s response in the enrollee or insured’s file for at least two years after the date of the request.
- Requires the enrollee or insured to pay no more than in-network cost sharing, for covered benefits, if an enrollee or insurer obtained information through the plan or insurer’s online directory or a request consistent with 13) above that a provider was an in-network provider, if any of the following apply:
- The provider is not contracting with the health plan or insurer as an in-network provider for that product;
- The contracting provider is not accepting new patients for that product;
- The information provided is otherwise materially inaccurate, misleading, or incomplete; or,
- The online provider directory is not accessible to enrollees or insureds at the time the enrollee or insured seeks information and the enrollee or insured requests information consistent with 13) above.
- Requires the plan or insurer to document the cost-sharing tier that the provider is contracted to accept and to provide that information to the enrollee or insured when the enrollee or insured seeks information about the provider if the health plan contract or insurance policy includes more than one tier of cost sharing. Prohibits the enrollee or insured from owing more than the cost sharing for the cost-sharing tier included in the information received by the enrollee or insured from the plan or insurer of the plan or insurer provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate.
- Specifies the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing. Requires the lowest cost-sharing tier to apply if the health plan contract or insurance policy includes more than one tier of cost sharing and if the enrollee or insured was not informed accurately of the applicable cost-sharing tier.
EXISTING LAW:
- Establishes the DMHC to regulate health plans and CDI to regulate health insurance. [Health and Safety Code (HSC) §1340, et seq.; Insurance Code (INS) §106, et seq.]
- Requires the DMHC and CDI to develop uniform provider directory standards, as well as requires health plans to perform regular updates and an annual review of their directories. Requires a health plan or insurer to provide coverage for health care services in the event an enrollee or insured reasonably relied upon inaccurate information within the health plan’s directory. [HSC §1367.27 and INS §10133.15]
- Requires health plans to ensure that all services be readily available at reasonable times to each enrollee consistent with good professional practice, and to the extent feasible, a health plan to make all services readily accessible to all enrollees consistent with existing law on timely access to health care services. [HSC §1367]
- Requires DMHC to develop and adopt regulations to ensure that enrollees have access to health care services in a timely manner, regarding:
- Waiting times for appointments, including primary and specialty care physicians;
- Care in an episode of illness, including timeliness of referrals and obtaining other services, as needed; and,
- Waiting time to speak to a physician, registered nurse, or other qualified health professional trained to screen or triage. [HSC §1367.03]
- Requires, in developing these standards, DMHC to consider the clinical appropriateness, the nature of the specialty, the urgency or care, and the requirements of law governing utilization review. [HSC §1367.03]
- Requires CDI to promulgate regulations applicable to health insurers to ensure access to health care in a timely manner, and designed to ensure adequacy of the number of locations of institutional facilities and professional providers, adequacy of number of professional providers, and license classifications, consistent with standards of good health care and clinically appropriate care, and that contracts are fair and reasonable. [INS §10133.5]
- Requires, in designing the regulations, CDI to consider regulations promulgated by DMHC and all other relevant guidelines in an effort to accomplish maximum accessibility within a cost efficient system of indemnification. [INS §10133.5]
FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.
COMMENTS:
- PURPOSE OF THIS BILL. According to the author, despite California having one of the nation’s strongest laws on health plan provider directories, compliance is at an unbelievable low. Recent studies have found that some health plans have inaccuracy rates as high as 80%, and major plans like Anthem and Kaiser have inaccurate information for 20%-38% of providers. According to the author, these inaccuracies in provider referral lists are often referred to as ‘ghost networks’ because the referrals simply do not exist. As a result, consumers bear the responsibility of sorting through these grossly inaccurate lists, sifting through directories in an effort to find care, calling provider after provider, only to be told the provider is no longer in-network, no longer accepting new patients, or even no longer in practice. This is especially harmful to those already suffering from health care inequity, such as those with limited English proficiency and persons with disabilities. The author concludes that ghost networks contribute to inequity in health care by leaving Californians to fend for themselves in their most vulnerable time.
- BACKGROUND.
- Existing Network Adequacy Requirements. California law sets forth various network adequacy requirements on health plans and insurers. For example, health plans are subject to the following:
- Timely Access. Timely Access Laws and Regulations require that health plans meet a set of standards which include specific time frames under which enrollees must be able to access care. These requirements generally include the following standards for appointment availability:
- Urgent care without prior authorization: within 48 hours;
- Urgent care with prior authorization: within 96 hours;
- Non-urgent primary care appointments: within 10 business days;
- Non-urgent specialist appointments: within 15 business days;
- Non-Urgent mental health (MH) appointments: within 15 business days for psychiatrist, within 10 business days for non-physician MH provider; and,
- Non-urgent appointment for ancillary services for the diagnosis or treatment of injury, illness or other health condition: within 15 business days.
- Timely Access. Timely Access Laws and Regulations require that health plans meet a set of standards which include specific time frames under which enrollees must be able to access care. These requirements generally include the following standards for appointment availability:
- Geographic Access. Health plans are also generally required to ensure geographic access such that there are a sufficient number of providers located within a reasonable distance from where each enrollee lives or works. For example, primary care physicians (PCPs) and hospitals should be located within 15 miles or 30 minutes from work or home.
- Existing Network Adequacy Requirements. California law sets forth various network adequacy requirements on health plans and insurers. For example, health plans are subject to the following:
Health plans must also ensure provider capacity such that health plan networks have enough of each of the right types of providers to deliver the volume of services needed. For example, plan networks should include one PCP for every 2,000 beneficiaries.
- Timely Access Report. DMHC recently published its Timely Access Report for Measurement Year 2021 and include the following:
- Key Survey Findings for Full Service Health Plans: For non-urgent and urgent appointments combined, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 94% to a low of 47%. For non-urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 96% to a low of 56%. For urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 92% to a low of 37%.
- Key Survey Findings for Behavioral Health Plans: For non-urgent and urgent appointments combined, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 76% to a low of 65%. For non-urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 83% to a low of 73%. For urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 70% to a low of 56%.
- California’s Provider Directory. Provider directories help patients identify clinicians based on specialty, location, and hours. California was one of the first states to enact laws related to provider directories, in SB 137 (Hernandez), Chapter, Statutes of 2015, which requires health plans and insurers to maintain accurate online and paper directories as of July 1, 2016. SB 137 also requires some of the following:
- DMHC and CDI to develop uniform provider directory standards and to take appropriate steps to ensure the accuracy of the information contained in the plan or health insurer’s directory or directories, and requires the plan or insurer, at least annually, to review and update the entire provider directory or directories for each product offered;
- A plan or insurer, at least weekly, to update its online provider directory or directories, and requires a plan or insurer, at least quarterly, to update its printed provider directory or directories; and,
- A plan or 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 and authorizes 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.
- Federal Provider Directory Requirements. According to the Kaiser Family Foundation, regulators evaluate plans against quantitative network adequacy standards using network directory data, which often contain errors. Plans offered on HealthCare.gov (federal exchange marketplace) are required to include directory links showing providers’ location, contact information, specialty, and whether they are accepting new patients. Issuers are required to update directories at least monthly. Oversight of appointment wait-time standards also rely on directory data. In a secret shopper Health Affairs study of California qualified health plans (QHPs) (offered on Covered California – California’s state based exchange) in 2015, 73% of calls to providers listed in network directories were unable to secure appointments. Failures generally related to inaccurate phone numbers or addresses for listed providers, inaccurate specialty listings, or listed providers who were not actually in the network. As part of its annual compliance review, the Centers for Medicare & Medicaid Services (CMS) selects a small sample of issuers and reviews the machine-readable provider directory to verify accuracy. The 2020 Plan Year Federally-Facilitated Exchange Issuer Compliance Review Summary Report found inaccuracies in all directories examined in 2020, with similar compliance problems observed in prior years.
- Timely Access Report. DMHC recently published its Timely Access Report for Measurement Year 2021 and include the following:
Beginning in 2022, the federal No Surprises Act (NSA) requires all private health plans, including QHPs, to maintain accurate provider directories and requires providers to regularly update plans about any changes in their information. Plans must verify and update directories at least every 90 days and, on an ongoing basis, post any changes within 2 business days. Plans are also required to apply in-network cost sharing for covered services provided by facilities or providers mistakenly listed as in-network. However, enforcement will be delayed because implementing regulations have not yet been published. CMS expects plans to make good faith efforts to comply with new requirements beginning in 2022. It should be noted, that according to the California Association of Dental Plans (CADP), the NSA does not apply to dental with respect to the provision requiring plans to respond in one business day to a provider network status request and the plan is responsible for cost-sharing above the in-network costs if the consumer relies on this information and the provider is later determined to be out-of-network.
Provider directories are commonly posted online as PDFs or other “flat file” formats. Most QHPs require that they be available in machine-readable formats, which can be easily downloaded and read by computers to identify information that is likely incorrect. A 2019 Commonwealth Fund–supported study compared the accuracy of four sources of provider information from five U.S. counties: i) machine-readable directories from QHPs; ii) Medicare Advantage (MA) plan directories with traditional flat-file directories; iii) online information from Google Places, which is self-reported by physicians; and, iv) files from CMS’s National Plan and Provider Enumeration System, a national Medicare file for nearly all U.S. providers. The study found the following:
- Extensive inaccuracies were found across all four sources of information. The inaccuracy rate for phone numbers, meanwhile, ranged from 25 % to 48 %;
- Insurance carriers offering both MA and exchanges did not report the same addresses 31 % of the time;
- Google was the most accurate source for a provider’s name, address, and phone number;
- Directories for marketplace plans, which are machine readable, were slightly less accurate than traditional, flat-file MA directories;
- Machine-readable directories can be downloaded and used for analysis vastly more cheaply compared to flat-file conventional directories; and,
- Interviews with stakeholders identified reasons other than directory file type for inaccuracies. These included the low priority some providers place on maintaining correct information; a lack of consistent definitions and standards; and lack of a coordinated national approach for resolving the accuracy issue.
- Enforcement. The Yale Law & Policy Review (Yale Review) entitled, “Laying ghost networks to rest: Combatting deceptive health plan provider directories,” also revealed high error rates. Even the lowest error rate, 21%, means that one out of five provider listings will lead enrollees seeking care to a dead end. At the high end, more than half of all provider listings lead to a dead end. While consumers can theoretically seek out correct addresses and phone numbers, search engines are at best a partial replacement for accurate directories. Furthermore, the provider directories examined had higher error rates for psychiatrists than for other types of specialists, underlining the particular burden placed on people who need behavioral care. According to the Yale Review, when states do carry out enforcement actions, they tend to result in minimal or no fines, removing any incentive for insurers to increase the accuracy of their plans. Despite SB 137’s broad scope and detailed requirements, the Yale Review indicated that California continues to have high levels of directory errors. California does not directly collect data about directory errors. However, to comply with California’s timely access standards, health plans regulated by the DMHC must submit yearly surveys of all providers that take appointments from enrollees to assess how soon an appointment can be scheduled. According to the Yale Review, DMHC only uses this data to compile timely access reports, but this survey also functions as a directory accuracy survey: the raw data notes when providers could not complete the timely access questionnaire because their address was incorrect, their phone number was incorrect, their specialty was incorrect, they do not take appointments at that location, they are not actually in-network, or they are no longer practicing. This bill builds upon California’s provider directory by requiring plans and insurers to annually audit, delete inaccurate listings, and requires a 95% accuracy by January 1, 2027. Failure to meet these required benchmarks will result increased administrative penalties.
- SUPPORT. Health Access California (HAC), sponsors of this bill, references the same Yale Review study cited above that found the following: Kaiser was 12-38% inaccurate; Molina was 54-80% inaccurate; Blue Cross 20-25% inaccurate; and, CenCal Health Plan was 39-62% inaccurate. According to HAC, consumers depend on a provider directory to find an in-network provider whether it be a doctor, specialist, dentist, hospital, laboratory, imaging center, or another provider. A consumer’s right to timely access to care is affected by a provider directory; if a consumer is unable to find a provider, they waste necessary time simply searching for one. According to HAC, timely access to care monitoring by DMHC routinely finds that 20%-30% of providers are unreachable by the health plan, often because of inaccuracies in the health plan’s own provider directory. If a provider directory is replete with doctors and other professionals who are not actually seeing patients covered by that health plan, it raises serious questions about the plan’s assertions about an adequate network of doctors and other providers that are available to provide timely access to care. In addition, to assess network adequacy, provider surveys are required and such surveys need accuracy. According to HAC, existing law has failed to fully ensure the accuracy of these directories. Audits by the Department of Health Care Services in 2019 have shown that Kaiser and CenCal Health Plan failed to even include mental health (MH) providers in their provider directories. HAC concludes that California’s laws and regulations on provider directories and network adequacy are, on paper, some of the strongest in the country, yet they are falling short and this bill would address ghost networks and provider inaccuracies.
America’s Physician Groups (APG) states that SB 137 was enacted due to rampant inaccuracies in the Covered California exchange online provider directory, which made it frustratingly difficult for prospective enrollees to find network providers with open practices accepting new patients. DMHC conducted an investigation of plan directories and found as much as 40% inaccuracies. The DMHC levied significant fines against the plans. Over the past several years since SB 137 was enacted, provider directory accuracy has improved marginally. According to APG, the market place lacks a culture of compliance at both the payor and provider level. It is a harsh assessment, but time has been wasted. This bill addresses some of the problems that have plagued the advancement of provider directory accuracy by requiring a graduated level of thresholds, beginning at 60% accuracy in 2024 and progressing to 95% accuracy by 2027. These thresholds can drive adoption of better systems for the development of timely and accurate directories. APG concludes that accurate provider directories can and must be developed in order to support compliance with statutory network adequacy requirements and patient access to care.
- OPPOSITION. CADP contends that due to undefined or unclear terms used in this bill, the new provisions in this bill and the current regulatory requirements, consumers would lose access to dental providers as dental plans would be unable to meet access requirements and could be forced to withdraw from service areas including vulnerable rural areas. Additionally, this bill states any “one error” in a directory makes the entire provider listing inaccurate and requires removal or deletion from the provider directory. According to CADP, this “one error” could include an erroneous suite number, zip code, or simple misspelling, i.e., items that would not be detrimental to the consumer obtaining needed dental services from a provider. These non-detrimental errors have no bearing on the providers’ willingness to provide dental services to consumers and availability to a consumer on the dental plans’ network. Errors not detrimental to the consumer receiving dental services would impact the overall accuracy of the directory and make dental plans subject to significant fines. Additionally, there are many instances where a specialty dental provider, especially in rural areas, may be available to a consumer but might not submit a certain number of claims in a 12-month period. Furthermore, the potential suppression that leads to a plan being forced to withdraw from a service area impacts smaller dental plans much more than larger dental plans. The larger plans have significantly larger networks that can absorb the changes while leaving smaller regional plans at a disadvantage with regards to their networks. CADP concludes that with significant numbers of providers not responding to the required provider directory outreach, the additional requirement of this bill will significantly increase the percentage of providers who would be removed/deleted from provider directories leading to loss of access in service areas for consumers.
The California Association of Health Plans (CAHP), the Association of California Life and Health Insurance Companies (ACLHIC), and America’s Health Insurance Plans (AHIP) state that provider directories act as an essential guide that health plans and insurers rely upon to help our enrollees and insureds access timely and appropriate care but state that this bill does nothing to address the root cause of the issue, and instead simply places the full responsibility of the database accuracy on health plans and insurers, without fully appreciating that this endeavor was always intended to be a shared responsibility between contracted providers and health plans/insurers. Without that consideration being included in this bill, plans and insurers will continue to struggle to meet the expectations set forth by the Legislature. Additionally, this bill does not recognize the existing work being done by both the DMHC and the Integrated Health Association around provider directory accuracy. The DMHC is still in the process of official rulemaking for SB 137, demonstrating how difficult it is to obtain accuracy. According to CAHP, ACLHIC, and AHIP, currently, commercial health plans and insurers spend over 2.1 billion dollars annually to maintain provider databases, clearly demonstrating the commitment health plans and insurers have to supporting accurate provider directories. Lastly, this bill attaches enormous financial penalties solely on health plans and insurers if the directories are inaccurate, even when a provider fails to disclose updated or accurate information to the plan or insurer.
- RELATED LEGISLATION.
- AB 1331 (Wood) establishes the Data Exchange Framework governing board and require the board to approve any modifications to that data sharing agreement and its policies and procedures. AB 1331 is pending in Assembly Health Committee.
- AB 815 (Wood) extends the period within which a health plan or disability insurer is required to assess and verify the qualifications of a health care provider from 60 days to 90 days after receiving a completed provider credentialing application. AB 815 is currently pending in Assembly Health Committee.
- SB 598 (Skinner) prohibits a health plan or insurer from requiring a contracted health professional to complete or obtain a prior authorization for any health care services if the plan or insurer approved or would have approved not less than 90% of the prior authorization requests they submitted in the most recent one-year contracted period. Sets standards for this exemption and its denial, rescission, and appeal. Authorizes a plan or insurer to evaluate the continuation of an exemption not more than once every 12 months, and authorizes a plan or insurer to rescind an exemption only at the end of the 12-month period and only if specified criteria are met. SB 598 is currently pending in Senate Health Committee.
- PREVIOUS LEGISLATION.
- SB 858 (Wiener), Chapter 985, Statutes of 2022, increases the base amount of the civil penalty from $2,500 per violation to not more than $25,000 per violation, and authorizes a lower, proportionate penalty for specialized dental and vision health care service plans. Adjusts the civil penalty base amount annually commencing January 1, 2028, and every five years thereafter, as specified. Doubles the minimum and maximum amounts of the civil and administrative penalties described above, and, commencing January 1, 2028, and every five years thereafter, adjusts these civil and administrative penalties, as specified. Authorizes the DMHC Director to impose a corrective action plan to require future compliance with the act, under certain circumstances.
- SB 221 (Wiener), Chapter 724, Statutes of 2021, codifies existing timely access to care standards for health plans and insurers, applies these requirements to Medi0Cal Managed Care plans, and adds a standard for non-urgent follow-up appointments for nonphysician MH care or substance use disorder (SUD) providers that is within 10 business days of the prior appointment.
- AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, requires the California Health and Human Services Agency, and in consultation with stakeholders and local partners through an established Stakeholder Advisory Group, to establish a Data Exchange Framework by July 1, 2022.
- AB 1131 (Wood) of 2021 would have established the statewide health information network governing board, an independent public entity not affiliated with an agency or department with specified membership, to provide the data infrastructure needed to meet California’s health care access, equity, affordability, public health, and quality goals, as specified. AB 1131 was held in the Assembly Suspense Committee.
- SB 855 (Wiener), Chapter 151, Statutes of 2020, revises and recasts California’s Mental Health Parity provisions, and requires a health plan contract or disability insurance policy issued, amended, or renewed on or after January 1, 2021, to provide coverage for medically necessary treatment of MH and SUD, as defined, under the same terms and conditions applied to other medical conditions and prohibits a health plan or disability insurer from limiting benefits or coverage for MH and SUD to short-term or acute treatment. Specifies that if services for the medically necessary treatment of a MH and SUD are not available in network within the geographic and timely access standards in existing law, the health plan or insurer is required to arrange coverage to ensure the delivery of medically necessary out of network services and any medically necessary follow up services, as specified.
- SB 137 (Hernandez), Chapter 649, Statutes of 2015, requires a health plan or insurer to make available a provider directory or directories that provide information on contracting providers, including those that accept new patients and prohibits a provider directory from including information on a provider that does not have a current contract with the plan or insurer.
- SB 964 (Hernandez), Chapter 573, Statutes of 2014, requires a health plan to annually report specified network adequacy data to DMHC as a part of its annual timely access compliance report, and requires DMHC to review the network adequacy data for compliance.
- AB 2179 (Cohn), Chapter 797, Statutes of 2002, requires DMHC and CDI to develop and adopted regulations to ensure that enrollees have access to needed health care services.
- AUTHOR AMENDMENTS. To address concerns related to unclear terms, the author is proposing to amend this bill as follows:
- Require the plan or insurer to delete and remove a provider from the directories upon specified circumstances;
- Specify that special circumstances include but are not limited to providers in rural areas or high specialized specialists; and,
- Include paid capitation to the definition of financially compensated.
- COMMENTS.
- Improving provider directory data quality to lessen consumer and administrative burden. Provider directories poses many administrative challenges, similar to prior authorization and provider credentialing, as providers and plans share different information depending upon the different contractual relationships. According to CMS and after it completed its third round of MA online provider directory reviews between November 2017 and July 2018, CMS noted that it has become clear that a centralized repository for provider data is a key component missing from the accurate provider directory equation. CMS is currently looking at the provider data CMS collects to determine how it may be used to foster a collaborative industry approach to achieving a centralized location for provider data. According to CMS, this approach would make data collection and verification more efficient and less burdensome for MA plans and providers, and result in more accurate and timely data sharing. Moreover, a centralized database could allow the current inward facing MA plan efforts to have a broader impact. For example, when an MA plan identifies a directory error, it is fixed only for their own directory, whereas a corrected error in a centralized database would improve directory accuracy for all MA plans using that system. As this bill moves forward, the author may wish to consider a similar approach to review opportunities for interoperability and data standards that can be leveraged, to streamline the flow of accurate provider directory data between health plans and practices and within each organization.
- Provider responsibility and information verification. Existing law allows the health plan to delay payment or reimbursement owed to a provider if the provider fails to respond to the plan’s attempts to verity information. This bill deletes a provider from the network if the plan has not paid claims five or more claims to a provider and allows the plan to delete the provider if the plan can not verify information. Concerns have been raised that provisions in this bill do not adequately incentivize providers to provide updates in a timely manner. It is unclear to what extent providers have been engaged in provider directory discussions but the reliability of the provider directory involves providers updating their information to the plan in a timely manner. As such, the author may wish to address these concerns, such as reviewing incentives and penalties for providers to ensure accurate and timely data sharing.
REGISTERED SUPPORT / OPPOSITION:
Support
Health Access California (sponsor)
American Cancer Society Cancer Action Network
America's Physician Groups
California LGBTQ Health and Human Services Network
California Pan - Ethnic Health Network
California State Council of Service Employees International Union (SEIU California)
Justice in Aging
National Multiple Sclerosis Society, MS-CAN
National Union of Healthcare Workers (NUHW)
Steinberg Institute
Western Center on Law & Poverty, INC.
Opposition
Aetna, INC.
America's Health Insurance Plans (AHIP)
Anthem Bluecross
Association of California Life & Health Insurance Companies
Blue Shield of California
California Association of Dental Plans (CADP)
California Association of Health Plans
California Dental Network
Cigna
Delta Dental of California
Dental Health Services
Guardian Life Insurance Company of America; the
Health Net
Liberty Dental Plan
Metlife Safeguard Health Plan of Ca.
Principal First Dental Health
Smile Brands INC.
Sun Life Financial (UDC of California)
United Concordia
United Healthcare Services, INC.
Unum Dental HMO Plan
Western Dental Services, INC.
Analysis Prepared by: Kristene Mapile / HEALTH / (916) 319-2097
Discussed in Hearing
1MIN
Senate Standing Committee on Appropriations
46MIN
Senate Standing Committee on Health
2MIN
Assembly Floor
53MIN
Assembly Standing Committee on Health
Bill Author
