AB 280: Health care coverage: provider directories.
- Session Year: 2025-2026
- House: Assembly
- Latest Version Date: 2026-09-27
Current Status:
Passed
(2026-09-27: Chaptered by Secretary of State - Chapter 499, Statutes of 2026.)
Introduced
In Committee
Awaiting First Chamber Vote
Passed First Chamber
In Committee
Awaiting Second Chamber Vote
Passed Second Chamber
Enacted
What does this bill do?
The bill requires the Department of Managed Health Care to choose a central provider directory utility and set uniform standards so health plans and insurers must use it to collect, verify, and submit provider listings for consistency reports. If a patient reasonably relied on inaccurate or misleading directory information, the plan or insurer must cover the services and pay the provider the agreed or a reasonable amount, and the patient may only owe in‑network cost sharing. It sets deadlines for providers to update listings, lets plans delay payments to nonresponsive providers, and requires regular online and printed updates.
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 plans or insurers provider directory or directories.
This bill would require the Department of Managed Health Care to select a central utility and develop uniform provider directory standards requiring a health care service plan to use the designated central utility to collect, manage, and verify the consistency and completeness of their provider directories. The bill would also require health insurers to use the designated central utility and follow the uniform provider directory standards. The bill would require plans and health insurers to submit their provider directories to the central utility for analysis, and would require the central utility to create a consistency report for each directory.
This bill would require a plan or insurer to provide coverage for all covered benefits provided to an enrollee or insured who reasonably relied on inaccurate, incomplete, or misleading information contained in the plans or insurers provider directory or directories and to reimburse the provider the agreed upon amount, or, if none, a reasonable and customary amount, as specified, 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, which would count toward the in-network deductible and out-of-pocket maximum. The bill would require the health care service 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. The bill would authorize a health care service plan or insurer to include a specified statement in the provider listing before removing the provider from the directory if the provider does not respond within 5 calendar days of the plans or insurers annual notification. The bill would require a plan or insurer to comply with its provisions on and after July 1, 2027. 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 plans or insurers provider directory or directories.
This bill would require the Department of Managed Health Care to select a central utility and develop uniform provider directory standards requiring a health care service plan to use the designated central utility to collect, manage, and verify the consistency and completeness of their provider directories. The bill would also require health insurers to use the designated central utility and follow the uniform provider directory standards. The bill would require plans and health insurers to submit their provider directories to the central utility for analysis, and would require the central utility to create a consistency report for each directory.
This bill would require a plan or insurer to provide coverage for all covered benefits provided to an enrollee or insured who reasonably relied on inaccurate, incomplete, or misleading information contained in the plans or insurers provider directory or directories and to reimburse the provider the agreed upon amount, or, if none, a reasonable and customary amount, as specified, 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, which would count toward the in-network deductible and out-of-pocket maximum. The bill would require the health care service 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. The bill would authorize a health care service plan or insurer to include a specified statement in the provider listing before removing the provider from the directory if the provider does not respond within 5 calendar days of the plans or insurers annual notification. The bill would require a plan or insurer to comply with its provisions on and after July 1, 2027. 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 plans or insurers 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, 2026, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2029. The bill would subject a plan or insurer to administrative penalties for failure to meet the prescribed benchmarks. TheThis bill would require the Department of Managed Health Care to select a central utility and develop uniform provider directory standards requiring a health care service plan to use the designated central utility to collect, manage, and verify the consistency and completeness of their provider directories. The bill would also require health insurers to use the designated central utility and follow the uniform provider directory standards. The bill would require plans and health insurers to submit their provider directories to the central utility for analysis, and would require the central utility to create a consistency report for each directory.
This bill would require a plan or insurer to provide coverage for all covered health care services benefits provided to an enrollee or insured who reasonably relied on inaccurate, incomplete, or misleading information contained in a health plan or policys the plans or insurers provider directory or directories and to reimburse the provider the out-of-network amount agreed upon amount, or, if none, a reasonable and customary amount, as specified, 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, which would count toward the in-network deductible and out-of-pocket maximum. The bill would require a plan or insurer to provide information about in-network providers to enrollees and insureds upon request, including whether the provider is accepting new patients at the time, and would limit the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances. The bill would require the health care service 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. The bill would authorize a health care service plan or insurer to include a specified statement in the provider listing before removing the provider from the directory if the provider does not respond within 5 calendar days of the plan plans or insurers annual notification. The bill would require a plan or insurer to comply with its provisions on and after July 1, 2027. 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.
On or before January 1, 2026, this bill would authorize the Department of Managed Health Care and the Department of Insurance to update 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 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 plans or insurers 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, 2026, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2029. 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 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 out-of-network 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, which would count toward the in-network deductible and out-of-pocket maximum. The bill would require a plan or insurer to provide information about in-network providers to enrollees and insureds upon request, including whether the provider is accepting new patients at the time, and would limit the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances. The bill would require the health care service 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. The bill would authorize a health care service plan or insurer to include a specified statement in the provider listing before removing the provider from the directory if the provider does not respond within 5 calendar days of the plan or insurers annual notification. 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.
On or before January 1, 2026, this bill would authorize the Department of Managed Health Care and the Department of Insurance to develop update 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 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 plans or insurers 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, 2026, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2029. 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 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 out-of-network 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. sharing, which would count toward the in-network deductible and out-of-pocket maximum. 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. The bill would require the health care service 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.
On or before January 1, 2026, 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 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 plans or insurers 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, 2026, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2029. 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 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 out-of-network 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. The bill would require the health care service 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.
On or before January 1, 2026, 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 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 plans or insurers 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, 2026, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2029. 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 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 out-of-network 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. The bill would require the health care service 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.
On or before January 1, 2026, 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 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 network 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 in-network with the plan. Commencing July 1, 2027, a health care service plan shall comply with this section as it read on January 1, 2027.
(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, network 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 network 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 in-network 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 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 to the health care service plan or to the department if the enrollee believes they reasonably relied upon 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 covered health care services 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 a summary of 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 in-network with the plan through which the provider sees enrollees.
(9)A listing for each of the following providers that are in-network with the plan:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals in-network 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 a 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 in-network 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)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 cost-sharing tier, as applicable. This section does not require the use of network tiers other than contract and noncontracting tiers.
(14)All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c).
(15)Any other necessary information, as specified by the department.
(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 in-network 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)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(13)Any other necessary information, as specified by the department.
(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.
(4)The contract between the health care service plan and the provider shall require the provider to submit and update their information through the central utility designated by the department pursuant to this section. The contract between the health care service plan and provider shall also require the plan to provide all information to the provider that is necessary to enable the provider to complete all information fields required by the central utility, including identifying the name of each health care service plan product line for which the provider is in-network.
(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.
(4)(A)The department shall select a central utility and develop uniform provider directory standards requiring a health care service plan to use the designated central utility to collect, manage, and verify the consistency and completeness of the information required for provider directories pursuant to subdivisions (h) and (i).
(B)The department shall establish a process to designate a central utility that has demonstrated the ability to meet requirements of this section.
(C)The department shall develop a methodology, including a uniform format with standardized naming conventions, that a health care service plan shall use to request providers submit their information to the central utility. In developing the methodology for requesting provider information, the department shall consider ways to minimize the burden on responding providers.
(D)The department shall develop a methodology for a health care service plan to annually verify the consistency and completeness of its provider directories against information in the central utility using a consistency report created by the central utility. The departments methodology governing the consistency reports and corresponding plan verifications shall include all of the following requirements:
(i)Health care service plans shall submit all provider directories to be analyzed by the central utility to the central utility.
(ii)The central utility shall create a consistency report for each plan directory that identifies each inconsistency between the plans provider directory and the information in the central utility, each incomplete provider directory entry, and any other information specified by the department.
(iii)The central utility shall annually inform the plan and the department of its methodology for updating provider information and resolving data inconsistencies.
(iv)The central utility shall send the consistency reports to both the health care service plan and the department.
(v)A health care service plan shall submit an attestation to the department that does both of the following:
(I)Affirms the plan has reviewed the consistency report.
(II)Describes how it will remedy each inconsistency identified in the report.
(E)The department shall annually publish the results of the provider directory consistency reports on its internet website.
(F)If the department determines that a central utility designated pursuant to this paragraph is frequently failing to provide accurate information to health care service plans, the department may consider no longer requiring or designating that central utility for use and may do either of the following:
(i)No longer require a central utility while still requiring health care service plans to meet the requirements of this section.
(ii)Designate the use of another central utility.
(G)Nonprofit health care service plans with at least 3,500,000 enrollees that provide health care services to enrollees in a specific geographic area through a mutually exclusive contract with a single medical group shall not be required to utilize the central utility for a provider that exclusively provides services to, or is employed by, that health care service plan, medical group, health facility, or health system. The requirement to use the central utility shall apply to a plan described in this subparagraph for any network provider that is contracted to provide services to more than one health care service plan.
(l)(1)A health care service plan shall be responsible for maintaining a complete and accurate provider directory that is consistent with the information in the central utility designated by the department, unless the plan verifies that the information from the central utility is inaccurate based on an investigation by the plan pursuant to subdivision (o).
(2)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 network 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 network providers to ensure that all of the providers are contacted by the plan at least once annually.
(3)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).
(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is actively in-network with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(4)The plan shall require an affirmative response from the provider or provider group acknowledging that the notification was received. Within 30 calendar days of receiving the notification, 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.
(5)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.
(6)If a health care service plan receives a request to reinstate a provider that was previously removed from the provider directory or directories, the health care service plan shall ensure the accuracy of the information required under this section and approve the request within 10 business days of receipt, if accurate.
(7)If a provider does not respond within five calendar days, a health care service plan may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is in-network with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(8)General acute care hospitals shall be exempt from the requirements in paragraphs (4) to (6), 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. A provider shall submit changes to the information required to be in the directory within 30 calendar days of a change.
(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)A 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. This process shall include how a provider would notify the plan if they find an inaccuracy in their listing before the quarterly verification. If the provider notifies the plan of an inaccuracy, the plan shall notify the central utility to correct the information.
(4)Within 12 months of the department designating a central utility, a health care service plan shall update the policies and procedures as required by this subdivision to require providers to submit their verifications and changes to the central utility.
(n)(1)This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan.
(2)If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan shall continue to retain responsibility for ensuring that the requirements of this section are satisfied.
(3)A provider group may terminate a contract with a provider for a pattern or repeated failure of the provider to update the information required to be in the directory or directories pursuant to this section.
(4)A provider group is not subject to the payment delay described in subdivision (p) if all of the following occurs:
(A)A provider does not respond to the provider 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)(1)Whenever a health care service plan receives a report, or otherwise becomes aware, 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.
(D)If changes to a health care service plans provider directory or directories are required as a result of the plans investigation, the plan shall notify the central utility. The plan, as part of its contract with the central utility, shall require the central utility to update the providers information accordingly within five business days.
(p)(1)Notwithstanding Sections 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the 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 (5) 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 Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.
(q)(1)If the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health care service plans provider directory or directories, the department shall require the health care service plan to provide coverage for all covered benefits provided to the enrollee, hold the enrollee harmless 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 agreed upon amount, or, if there is no agreed upon amount, the reasonable and customary amount for the same or similar services in the general geographic region in which the services were rendered, less the enrollees in-network cost share. The provider shall not bill or collect any additional amount from the enrollee other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 an out-of-network provider shall not be used as a basis to deny reimbursement to the enrollee.
(2)If the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health care service plans provider directory or directories in order to select a health coverage product, the plan may be subject to an administrative penalty.
(3)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 two business days 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 check if the provider is accepting new patients at the time, confirm if the provider is accepting new patients at the location of practice, and inform the enrollee. If the provider indicates that they are not accepting new patients, the plan shall update the provider directory to reflect that the provider is no longer 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.
(4)If the health care service plan contract uses a tiered network with two or more in-network tiers with differential 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, the enrollee shall owe no more than the cost sharing for the lower cost-sharing tier.
(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.
(6)For purposes of this subdivision, information is materially inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) regarding the providers network status is inaccurate, incomplete, or misleading, regardless of whether or not the information is consistent with the information in the central utility.
(r)Whenever a plan determines as a result of this section that there has been a 10-percent change in the network for a product in a region, the plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(s)(1)This section does not apply to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code to the extent that this section is inconsistent with, prohibited by, or otherwise contrary to federal or state law, regulations, rules, or guidance. Provisions of this section that were added or amended by Assembly Bill 280 of the 202526 Regular Session do not apply to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code.
(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).
(t)A health care service 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)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)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).
(w)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
(x)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-plan letters, methodologies, rules, definitions, policies, forms, information or data requests, or similar instructions, without taking regulatory action, until January 1, 2032. In developing guidance pursuant to this subdivision, the department shall consult with interested stakeholders.
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 participating 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 in-network with the insurer. Commencing July 1, 2027, a health insurer shall comply with this section as it read on January 1, 2027.
(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, participating 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 participating 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 in-network 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 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 to the insurer or to the department if the insured believes they reasonably relied upon 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 covered health care services are not available in-network within applicable geographic and timely access standards. The disclosure shall be included within the directory and shall also include a summary of 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 in-network with the insurer through which the provider sees insureds.
(9)A listing for each of the following providers that are in-network with the insurer:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals in-network 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 a 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 in-network 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)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 cost-sharing tier, as applicable. This section does not require the use of network tiers other than contract and noncontracting tiers.
(14)All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c).
(15)Any other necessary information, as specified by the department.
(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 in-network 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)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(13)Any other necessary information, as specified by the department.
(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.
(4)The contract between the health insurer and the provider shall require the provider to submit and update their information through the central utility designated pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code. The contract between the health insurer and provider shall also require the health insurer to provide all information to the provider that is necessary to enable the provider to complete all information fields required by the central utility, including identifying the name of each health insurer product line for which the provider is in-network.
(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.
(4)(A)An insurer subject to this section shall use the central utility designated, and the uniform provider directory standards developed, pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code. When designating the central utility and developing standards, the Department of Managed Health Care shall seek input from interested stakeholders, including the Department of Insurance.
(B)An insurer subject to this section shall use the methodology, including a uniform format with standardized naming conventions, developed pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code when requesting providers to submit their information to the central utility. The Department of Managed Health Care shall seek input from interested stakeholders, including the Department of Insurance, when developing methodologies. The Department of Insurance may add to the methodology used by insurers to conform to the Insurance Code and regulations. The methodology shall require the central utility to notify responding providers if the providers submission is incomplete or inconsistent with other data the central utility has on file.
(C)An insurer subject to this section shall use the methodology developed pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code when annually verifying consistency and completeness of its provider directories against information in the central utility using a consistency report created by the central utility. The methodology governing the consistency reports and corresponding insurer verifications shall include all of the following requirements:
(i)An insurer shall submit all provider directories to be analyzed by the central utility to the central utility.
(ii)The central utility shall create a consistency report for each insurer directory that identifies each inconsistency between the insurers provider directory and the information in the central utility, each incomplete provider directory entry, and any other information specified by the department.
(iii)The central utility shall send the consistency reports to both the insurer and the department.
(iv)An insurer shall submit an attestation to the department that does both of the following:
(I)Affirms the insurer has reviewed the consistency report.
(II)Describes how it will remedy each inconsistency identified in the report.
(v)The central utility shall annually inform insurers of its methodology for updating provider information and resolving data inconsistencies.
(D)The Department of Managed Health Care shall annually share the methodology from the central utility required pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code with the Department of Insurance. The Department of Insurance shall post the methodology on its internet website.
(E)A nonprofit health insurer that has at least 3,500,000 insureds or enrollees in a health insurance policy or a health care service plan product in a specific geographic area through a mutually exclusive contract with a single medical group shall not be required to utilize the central utility for any provider that exclusively provides services to, or is employed by, that health care service plan, health insurer, medical group, health facility, or health system. The requirement to use the central utility shall apply to an insurer described in this subparagraph for any network provider that is contracted to provide services to more than one insurer or health care service plan.
(l)(1)An insurer shall be responsible for maintaining a complete and accurate provider directory that is consistent with the information in the central utility designated pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code, unless the insurer verifies that the information from the central utility is inaccurate based on an investigation by the insurer pursuant to subdivision (o).
(2)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 participating 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 participating providers to ensure that all of the providers are contacted by the insurer at least once annually.
(3)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).
(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is in-network with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(4)The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. Within 30 calendar days of receiving the notification, 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.
(5)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.
(6)If a health insurer receives a request to reinstate a provider that was previously removed from the provider directory or directories, the health insurer shall ensure the accuracy of the information required under this section and approve the request within 10 business days of receipt if accurate.
(7)If a provider does not respond within five calendar days, a health insurer may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is in-network with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(8)General acute care hospitals shall be exempt from the requirements in paragraphs (4) to (6), 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. A provider shall submit changes to the information required to be in the directory within 30 calendar days of a change.
(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. This process shall include how a provider would notify the insurer if they find an inaccuracy in their listing before the quarterly verification. If the provider notifies the insurer of an inaccuracy, the insurer shall notify the central utility to correct the information.
(4)Within 12 months of the Department of Managed Health Care designating a central utility pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code, a health insurer shall update the policies and procedures as required by this subdivision to require providers to submit their verifications and changes to the central utility.
(n)(1)This section does not prohibit an insurer from requiring its provider groups or contracting specialized health insurers to provide information to the insurer that is required by the insurer to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health insurer. This responsibility shall be specifically documented in a written contract between the insurer and the provider group or contracting specialized health insurer.
(2)If an insurer requires its contracting provider groups or contracting specialized health insurers to provide the insurer with information described in paragraph (1), the insurer shall continue to retain responsibility for ensuring that the requirements of this section are satisfied.
(3)A provider group may terminate a contract with a provider for a pattern or repeated failure of the provider to update the information required to be in the directory or directories pursuant to this section.
(4)A provider group is not subject to the payment delay described in subdivision (p) if all of the following occurs:
(A)A provider does not respond to the provider 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)(1)Whenever an insurer receives a report, or otherwise becomes aware, 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.
(D)If changes to a health insurers provider directory or directories are required as a result of the insurers investigation, the insurer shall notify the central utility. The insurer, as part of its contract with the central utility, shall require the central utility to update the providers information accordingly within five business days.
(p)(1)Notwithstanding Sections 10123.13 and 10123.147, an insurer may delay payment or reimbursement owed to a provider or provider group for any claims payment made to a provider or provider group for up to one calendar month beginning on the first day of the following month, if the provider or provider group fails to respond to the 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 (5) 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)(1)If 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 shall require the insurer to provide coverage for all covered benefits provided to the insured, hold the insured harmless for any amount beyond what the insured would have paid, had the services been delivered by a participating provider under the insureds health insurance policy, and reimburse the provider the agreed upon amount, or if there is no agreed upon amount, the reasonable and customary amount for the same or similar services in the general geographic region in which the services were rendered, less the insureds in-network cost share. The provider shall not bill or collect any additional amount from the insured other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 an out-of-network provider shall not be used as a basis to deny reimbursement to the insured.
(2)If the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health insurers provider directory or directories in order to select a health coverage product, the insurer may be subject to an administrative penalty.
(3)If an insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as a participating 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 two business days after receiving the request. The insurer shall also check if the provider is accepting new patients at the time, confirm if the provider is accepting new patients at the location of practice, and inform the insured. 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.
(4)If the health insurance policy uses a tiered network with two or more in-network tiers with differential 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, the insured shall owe no more than the cost sharing for the lower cost-sharing tier.
(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.
(6)For purposes of this subdivision, information is materially inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) regarding the providers network status is inaccurate, incomplete, or misleading, regardless of whether or not the information is consistent with the information in the central utility.
(r)Whenever an insurer determines as a result of this section that there has been a 10-percent change in the network for a product in a region, the insurer shall file a statement with the commissioner.
(s)An insurer that contracts with multiple employer welfare agreements regulated pursuant to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall meet the requirements of this section.
(t)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)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).
(v)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
(w)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of letters, methodologies, rules, definitions, policies, forms, information or data requests, or similar instructions, without taking regulatory action, until January 1, 2032. In developing guidance pursuant to this subdivision, the department shall consult with interested stakeholders.
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 network 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 in-network with the plan. Commencing July 1, 2027, a health care service plan shall comply with this section as it read on January 1, 2027.
(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, network 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 network 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 in-network 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 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 to the health care service plan or to the department if the enrollee believes they reasonably relied upon 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 covered health care services 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 a summary of 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 in-network with the plan through which the provider sees enrollees.
(9)A listing for each of the following providers that are in-network with the plan:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals in-network 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 a 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 in-network 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)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 cost-sharing tier, as applicable. This section does not require the use of network tiers other than contract and noncontracting tiers.
(14)All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c).
(15)Any other necessary information, as specified by the department.
(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 in-network 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)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(13)Any other necessary information, as specified by the department.
(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.
(4)The contract between the health care service plan and the provider shall require the provider to submit and update their information through the central utility designated by the department pursuant to this section. The contract between the health care service plan and provider shall also require the plan to provide all information to the provider that is necessary to enable the provider to complete all information fields required by the central utility, including identifying the name of each health care service plan product line for which the provider is in-network.
(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.
(4)(A)The department shall select a central utility and develop uniform provider directory standards requiring a health care service plan to use the designated central utility to collect, manage, and verify the consistency and completeness of the information required for provider directories pursuant to subdivisions (h) and (i).
(B)The department shall establish a process to designate a central utility that has demonstrated the ability to meet requirements of this section.
(C)The department shall develop a methodology, including a uniform format with standardized naming conventions, that a health care service plan shall use to request providers submit their information to the central utility. In developing the methodology for requesting provider information, the department shall consider ways to minimize the burden on responding providers.
(D)The department shall develop a methodology for a health care service plan to annually verify the consistency and completeness of its provider directories against information in the central utility using a consistency report created by the central utility. The departments methodology governing the consistency reports and corresponding plan verifications shall include all of the following requirements:
(i)Health care service plans shall submit all provider directories to be analyzed by the central utility to the central utility.
(ii)The central utility shall create a consistency report for each plan directory that identifies each inconsistency between the plans provider directory and the information in the central utility, each incomplete provider directory entry, and any other information specified by the department.
(iii)The central utility shall annually inform the plan and the department of its methodology for updating provider information and resolving data inconsistencies.
(iv)The central utility shall send the consistency reports to both the health care service plan and the department.
(v)A health care service plan shall submit an attestation to the department that does both of the following:
(I)Affirms the plan has reviewed the consistency report.
(II)Describes how it will remedy each inconsistency identified in the report.
(E)The department shall annually publish the results of the provider directory consistency reports on its internet website.
(F)If the department determines that a central utility designated pursuant to this paragraph is frequently failing to provide accurate information to health care service plans, the department may consider no longer requiring or designating that central utility for use and may do either of the following:
(i)No longer require a central utility while still requiring health care service plans to meet the requirements of this section.
(ii)Designate the use of another central utility.
(G)Nonprofit health care service plans with at least 3,500,000 enrollees that provide health care services to enrollees in a specific geographic area through a mutually exclusive contract with a single medical group shall not be required to utilize the central utility for a provider that exclusively provides services to, or is employed by, that health care service plan, medical group, health facility, or health system. The requirement to use the central utility shall apply to a plan described in this subparagraph for any network provider that is contracted to provide services to more than one health care service plan.
(l)(1)A health care service plan shall be responsible for maintaining a complete and accurate provider directory that is consistent with the information in the central utility designated by the department, unless the plan verifies that the information from the central utility is inaccurate based on an investigation by the plan pursuant to subdivision (o).
(2)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 network 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 network providers to ensure that all of the providers are contacted by the plan at least once annually.
(3)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).
(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is actively in-network with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(4)The plan shall require an affirmative response from the provider or provider group acknowledging that the notification was received. Within 30 calendar days of receiving the notification, 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.
(5)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.
(6)If a health care service plan receives a request to reinstate a provider that was previously removed from the provider directory or directories, the health care service plan shall ensure the accuracy of the information required under this section and approve the request within 10 business days of receipt, if accurate.
(7)If a provider does not respond within five calendar days, a health care service plan may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is in-network with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(8)General acute care hospitals shall be exempt from the requirements in paragraphs (4) to (6), 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. A provider shall submit changes to the information required to be in the directory within 30 calendar days of a change.
(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)A 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. This process shall include how a provider would notify the plan if they find an inaccuracy in their listing before the quarterly verification. If the provider notifies the plan of an inaccuracy, the plan shall notify the central utility to correct the information.
(4)Within 12 months of the department designating a central utility, a health care service plan shall update the policies and procedures as required by this subdivision to require providers to submit their verifications and changes to the central utility.
(n)(1)This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan.
(2)If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan shall continue to retain responsibility for ensuring that the requirements of this section are satisfied.
(3)A provider group may terminate a contract with a provider for a pattern or repeated failure of the provider to update the information required to be in the directory or directories pursuant to this section.
(4)A provider group is not subject to the payment delay described in subdivision (p) if all of the following occurs:
(A)A provider does not respond to the provider 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)(1)Whenever a health care service plan receives a report, or otherwise becomes aware, 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.
(D)If changes to a health care service plans provider directory or directories are required as a result of the plans investigation, the plan shall notify the central utility. The plan, as part of its contract with the central utility, shall require the central utility to update the providers information accordingly within five business days.
(p)(1)Notwithstanding Sections 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the 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 (5) 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 Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.
(q)(1)If the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health care service plans provider directory or directories, the department shall require the health care service plan to provide coverage for all covered benefits provided to the enrollee, hold the enrollee harmless 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 agreed upon amount, or, if there is no agreed upon amount, the reasonable and customary amount for the same or similar services in the general geographic region in which the services were rendered, less the enrollees in-network cost share. The provider shall not bill or collect any additional amount from the enrollee other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 an out-of-network provider shall not be used as a basis to deny reimbursement to the enrollee.
(2)If the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health care service plans provider directory or directories in order to select a health coverage product, the plan may be subject to an administrative penalty.
(3)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 two business days 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 check if the provider is accepting new patients at the time, confirm if the provider is accepting new patients at the location of practice, and inform the enrollee. If the provider indicates that they are not accepting new patients, the plan shall update the provider directory to reflect that the provider is no longer 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.
(4)If the health care service plan contract uses a tiered network with two or more in-network tiers with differential 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, the enrollee shall owe no more than the cost sharing for the lower cost-sharing tier.
(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.
(6)For purposes of this subdivision, information is materially inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) regarding the providers network status is inaccurate, incomplete, or misleading, regardless of whether or not the information is consistent with the information in the central utility.
(r)Whenever a plan determines as a result of this section that there has been a 10-percent change in the network for a product in a region, the plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(s)(1)This section does not apply to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code to the extent that this section is inconsistent with, prohibited by, or otherwise contrary to federal or state law, regulations, rules, or guidance. Provisions of this section that were added or amended by Assembly Bill 280 of the 202526 Regular Session do not apply to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code.
(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).
(t)A health care service 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)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)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).
(w)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
(x)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-plan letters, methodologies, rules, definitions, policies, forms, information or data requests, or similar instructions, without taking regulatory action, until January 1, 2032. In developing guidance pursuant to this subdivision, the department shall consult with interested stakeholders.
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 participating 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 in-network with the insurer. Commencing July 1, 2027, a health insurer shall comply with this section as it read on January 1, 2027.
(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, participating 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 participating 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 in-network 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 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 to the insurer or to the department if the insured believes they reasonably relied upon 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 covered health care services are not available in-network within applicable geographic and timely access standards. The disclosure shall be included within the directory and shall also include a summary of 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 in-network with the insurer through which the provider sees insureds.
(9)A listing for each of the following providers that are in-network with the insurer:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals in-network 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 a 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 in-network 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)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 cost-sharing tier, as applicable. This section does not require the use of network tiers other than contract and noncontracting tiers.
(14)All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c).
(15)Any other necessary information, as specified by the department.
(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 in-network 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)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(13)Any other necessary information, as specified by the department.
(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.
(4)The contract between the health insurer and the provider shall require the provider to submit and update their information through the central utility designated pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code. The contract between the health insurer and provider shall also require the health insurer to provide all information to the provider that is necessary to enable the provider to complete all information fields required by the central utility, including identifying the name of each health insurer product line for which the provider is in-network.
(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.
(4)(A)An insurer subject to this section shall use the central utility designated, and the uniform provider directory standards developed, pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code. When designating the central utility and developing standards, the Department of Managed Health Care shall seek input from interested stakeholders, including the Department of Insurance.
(B)An insurer subject to this section shall use the methodology, including a uniform format with standardized naming conventions, developed pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code when requesting providers to submit their information to the central utility. The Department of Managed Health Care shall seek input from interested stakeholders, including the Department of Insurance, when developing methodologies. The Department of Insurance may add to the methodology used by insurers to conform to the Insurance Code and regulations. The methodology shall require the central utility to notify responding providers if the providers submission is incomplete or inconsistent with other data the central utility has on file.
(C)An insurer subject to this section shall use the methodology developed pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code when annually verifying consistency and completeness of its provider directories against information in the central utility using a consistency report created by the central utility. The methodology governing the consistency reports and corresponding insurer verifications shall include all of the following requirements:
(i)An insurer shall submit all provider directories to be analyzed by the central utility to the central utility.
(ii)The central utility shall create a consistency report for each insurer directory that identifies each inconsistency between the insurers provider directory and the information in the central utility, each incomplete provider directory entry, and any other information specified by the department.
(iii)The central utility shall send the consistency reports to both the insurer and the department.
(iv)An insurer shall submit an attestation to the department that does both of the following:
(I)Affirms the insurer has reviewed the consistency report.
(II)Describes how it will remedy each inconsistency identified in the report.
(v)The central utility shall annually inform insurers of its methodology for updating provider information and resolving data inconsistencies.
(D)The Department of Managed Health Care shall annually share the methodology from the central utility required pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code with the Department of Insurance. The Department of Insurance shall post the methodology on its internet website.
(E)A nonprofit health insurer that has at least 3,500,000 insureds or enrollees in a health insurance policy or a health care service plan product in a specific geographic area through a mutually exclusive contract with a single medical group shall not be required to utilize the central utility for any provider that exclusively provides services to, or is employed by, that health care service plan, health insurer, medical group, health facility, or health system. The requirement to use the central utility shall apply to an insurer described in this subparagraph for any network provider that is contracted to provide services to more than one insurer or health care service plan.
(l)(1)An insurer shall be responsible for maintaining a complete and accurate provider directory that is consistent with the information in the central utility designated pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code, unless the insurer verifies that the information from the central utility is inaccurate based on an investigation by the insurer pursuant to subdivision (o).
(2)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 participating 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 participating providers to ensure that all of the providers are contacted by the insurer at least once annually.
(3)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).
(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is in-network with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(4)The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. Within 30 calendar days of receiving the notification, 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.
(5)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.
(6)If a health insurer receives a request to reinstate a provider that was previously removed from the provider directory or directories, the health insurer shall ensure the accuracy of the information required under this section and approve the request within 10 business days of receipt if accurate.
(7)If a provider does not respond within five calendar days, a health insurer may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is in-network with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(8)General acute care hospitals shall be exempt from the requirements in paragraphs (4) to (6), 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. A provider shall submit changes to the information required to be in the directory within 30 calendar days of a change.
(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. This process shall include how a provider would notify the insurer if they find an inaccuracy in their listing before the quarterly verification. If the provider notifies the insurer of an inaccuracy, the insurer shall notify the central utility to correct the information.
(4)Within 12 months of the Department of Managed Health Care designating a central utility pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code, a health insurer shall update the policies and procedures as required by this subdivision to require providers to submit their verifications and changes to the central utility.
(n)(1)This section does not prohibit an insurer from requiring its provider groups or contracting specialized health insurers to provide information to the insurer that is required by the insurer to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health insurer. This responsibility shall be specifically documented in a written contract between the insurer and the provider group or contracting specialized health insurer.
(2)If an insurer requires its contracting provider groups or contracting specialized health insurers to provide the insurer with information described in paragraph (1), the insurer shall continue to retain responsibility for ensuring that the requirements of this section are satisfied.
(3)A provider group may terminate a contract with a provider for a pattern or repeated failure of the provider to update the information required to be in the directory or directories pursuant to this section.
(4)A provider group is not subject to the payment delay described in subdivision (p) if all of the following occurs:
(A)A provider does not respond to the provider 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)(1)Whenever an insurer receives a report, or otherwise becomes aware, 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.
(D)If changes to a health insurers provider directory or directories are required as a result of the insurers investigation, the insurer shall notify the central utility. The insurer, as part of its contract with the central utility, shall require the central utility to update the providers information accordingly within five business days.
(p)(1)Notwithstanding Sections 10123.13 and 10123.147, an insurer may delay payment or reimbursement owed to a provider or provider group for any claims payment made to a provider or provider group for up to one calendar month beginning on the first day of the following month, if the provider or provider group fails to respond to the 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 (5) 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)(1)If 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 shall require the insurer to provide coverage for all covered benefits provided to the insured, hold the insured harmless for any amount beyond what the insured would have paid, had the services been delivered by a participating provider under the insureds health insurance policy, and reimburse the provider the agreed upon amount, or if there is no agreed upon amount, the reasonable and customary amount for the same or similar services in the general geographic region in which the services were rendered, less the insureds in-network cost share. The provider shall not bill or collect any additional amount from the insured other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 an out-of-network provider shall not be used as a basis to deny reimbursement to the insured.
(2)If the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health insurers provider directory or directories in order to select a health coverage product, the insurer may be subject to an administrative penalty.
(3)If an insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as a participating 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 two business days after receiving the request. The insurer shall also check if the provider is accepting new patients at the time, confirm if the provider is accepting new patients at the location of practice, and inform the insured. 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.
(4)If the health insurance policy uses a tiered network with two or more in-network tiers with differential 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, the insured shall owe no more than the cost sharing for the lower cost-sharing tier.
(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.
(6)For purposes of this subdivision, information is materially inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) regarding the providers network status is inaccurate, incomplete, or misleading, regardless of whether or not the information is consistent with the information in the central utility.
(r)Whenever an insurer determines as a result of this section that there has been a 10-percent change in the network for a product in a region, the insurer shall file a statement with the commissioner.
(s)An insurer that contracts with multiple employer welfare agreements regulated pursuant to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall meet the requirements of this section.
(t)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)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).
(v)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
(w)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of letters, methodologies, rules, definitions, policies, forms, information or data requests, or similar instructions, without taking regulatory action, until January 1, 2032. In developing guidance pursuant to this subdivision, the department shall consult with interested stakeholders.
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. Commencing July 1, 2026, a health care service plan shall comply with this section as it read on January 1, 2026.(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 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 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)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. This section does not require the use of network tiers other than contract and noncontracting tiers.(14)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)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, 2026, the department may update a uniform format with standardized naming conventions and other aspects for each plan to use to request directory information from its providers, consistent with current law.(5)(A)On or before January 1, 2026, 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 or designate a central utility or central utilities for those providers included in the directory and may take into consideration impact on provider financial interests, enrollee access to providers, and health care service plans. If the department requires or designates a central utility or central utilities, in developing the methodology under this section, the department shall seek input from interested parties, including providers, health care service plans, consumers, and consumer advocates, 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, 2029.(i)If the department designates or requires a health care service plan to use a central utility or central utilities, the health care service plans contract with the utility shall require that incomplete or incorrect information submitted to the central utility shall not be conveyed to the health care service plan. The contract shall also require that the central utility notify the submitter of incomplete or inaccurate information.(ii)If the department determines that a central utility designated or required pursuant to this subparagraph is frequently failing to provide accurate information to health care service plans, the department may consider no longer requiring or designating that central utility for use.(iii)A health care service plan may require providers to update their information through the central utility to update the health care service plans provider directory. However, if the department requires a health care service plan to use or designate a central utility or central utilities, the health care service plan shall require providers to update their information through the central utility to update the health care service plans provider directory.(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 (q).(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).(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is actively contracting with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.(3)The plan shall require an affirmative response from the provider or provider group acknowledging that the notification was received. Within 30 calendar days of receiving the notification, 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 care service 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)If a provider does not respond within five calendar days, a health care service plan may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is actively contracting with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date. (7)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. Providers shall submit any changes to the information required to be in the directory within 30 calendar days of any change.(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, 2026, a plans directories shall be at least 60 percent accurate.(B)On or before July 1, 2027, a plans directories shall be at least 80 percent accurate.(C)On or before July 1, 2028, a plans directories shall be at least 90 percent accurate.(D)On or before July 1, 2029, 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 or central utilities, and if a health care service plan uses 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 from the central utility 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 if a provider is actively contracting, as defined by the department pursuant to subdivision (s).(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. (5)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.(6)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.(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 care service 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, hold the enrollee harmless 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 out-of-network amount. The provider shall not collect any additional amount from the enrollee other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 two business days 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 check if the provider is accepting new patients at the time and inform the enrollee. 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)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, subsequently receives covered benefits from that provider, and the enrollee receives a bill for an amount exceeding in-network cost sharing, 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 at the time the enrollee receives otherwise covered benefits from that provider. (B)The information provided regarding the providers network status is otherwise inaccurate, misleading, or incomplete.(C)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 uses a tiered network with two or more in-network tiers with differential 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 lower cost-sharing tier.(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.(6)For purposes of this subdivision, information is inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) regarding the providers network status 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, 2026, if the number of providers who are not actively contracting pursuant to this section and have not responded to a plans notifications pursuant to subdivision (l) for at least 18 months amounts to 10 percent or greater of the providers 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 actively contracting as determined by the department.(4)(A)The department shall determine the definition of actively contracting, and consider the degree of utilization for that provider by considering if the provider has one or more claims or encounters for covered benefits to enrollees in the relevant network, unless a special circumstance applies. In determining the utilization threshold for these purposes, the department shall not set a threshold greater than at least one claim or encounter for covered benefits for an enrollee every three calendar years.(B)A special circumstance may include a provider in a rural area, a highly specialized specialist who did not provide covered benefits for an enrollee in the prior three calendar years, 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).(5)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.(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, rules, guidance, and regulations and state law and guidance issued after January 1, 2016, and not prohibited or otherwise contrary to federal law, rules, guidance, and regulations.(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 care service 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.(y)Paragraphs (2), (4), (5), (6), (7), and (8) of subdivision (n) of this section do not apply to a Medi-Cal managed care plan that contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.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, 2026, a health insurer shall comply with this section as it read on January 1, 2026.(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 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 insured believes they reasonably relied upon 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)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)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)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, 2026, the department may update a uniform format with standardized naming conventions and other aspects for each insurer to use to request directory information from its providers, consistent with current law.(5)(A)On or before January 1, 2026, 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, insurer-reported information, and benchmarks or submission information from a central utility by another entity.(B)The department may require an insurer to use or designate a central utility or central utilities for those providers included in the directory and may take into consideration impact on provider financial interests, insured access to providers, and health insurers. If the department requires or designates a central utility or central utilities, in developing the methodology under this section, the department shall seek input from interested parties, including providers, health insurers, consumers, and consumer advocates, 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, 2029.(i)If the department designates or requires an insurer to use a central utility or central utilities, the insurers contract with the utility shall require that incomplete or incorrect information submitted to the central utility shall not be conveyed to the insurer. The contract shall also require that the central utility notify the submitter of incomplete or inaccurate information.(ii)If the department determines that a central utility designated or required pursuant to this subparagraph is frequently failing to provide accurate information to insurers, the department may consider no longer requiring or designating that central utility for use.(iii)A health insurer may require providers to update their information through the central utility to update the health insurers provider directory. However, if the department requires a health insurer to use or designated a central utility or central utilities, the health insurer shall require providers to update their information through the central utility to update the health insurers provider directory.(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 (q).(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).(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is actively participating with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.(3)The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. Within 30 calendar days of receiving the notification, 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)If a provider does not respond within five calendar days, a health insurer may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is actively participating with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.(7)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. Providers shall submit any changes to the information required to be in the directory within 30 calendar days of any change.(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, 2026, an insurers directories shall be at least 60 percent accurate.(B)On or before July 1, 2027, an insurers directories shall be at least 80 percent accurate.(C)On or before July 1, 2028, an insurers directories shall be at least 90 percent accurate.(D)On or before July 1, 2029, 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 or central utilities, and if an insurer uses 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 from the central utility 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 if a provider is actively participating, as defined by the department pursuant to subdivision (s).(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. (5)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.(6)Beginning January 1, 2030, 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 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, hold the insured harmless 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 out-of-network amount. The provider shall not collect any additional amount from the insured other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 two business days after receiving the request. The insurer shall also check if the provider is accepting new patients at the time and inform the insured. 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)If an insured obtained information through the insurers online directory or a request consistent with paragraph (2) that a provider was an in-network provider, subsequently receives covered benefits from that provider, and the insured receives a bill for an amount exceeding in-network cost sharing, 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 at the time the insured receives otherwise covered benefits from that provider. (B)The information provided regarding the providers network status is otherwise inaccurate, misleading, or incomplete.(C)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 uses a tiered network with two or more in-network tiers with differential 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 lower cost-sharing tier.(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.(6)For purposes of this subdivision, information is inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) regarding the providers network status 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, 2026, if the number of providers who are not actively participating pursuant to this section and have not responded to an insurers notifications pursuant to subdivision (l) for at least 18 months amount to 10 percent or greater of the providers in the network for a product in a region, which is considered material consistent with subdivision (f) of Section 2240.5 of Title 10 of the California Code of Regulations, then the insurer shall file a corrective action plan consistent with that regulation.(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 actively participating as determined by the department.(4)(A)The department shall determine the definition of actively participating, and consider the degree of utilization for that provider by considering if the provider has one or more claims or encounters for covered benefits to insureds in the relevant network, unless a special circumstance applies. In determining the utilization threshold for these purposes, the department shall not set a threshold greater than at least one claim or encounter for covered benefits for an insured every three calendar years.(B)A special circumstance may include a provider in a rural area, a highly specialized specialist who did not provide covered benefits for an insured in the prior three calendar years, 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).(5)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.(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. 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 network 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 in-network with the plan. Commencing July 1, 2027, a health care service plan shall comply with this section as it read on January 1, 2027.
(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, network 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. 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 network 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 in-network 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 include both an email address and a telephone number display the date of the most recent update. The provider directory or directories shall also display a dedicated email address, telephone number, and reporting 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 to the health care service plan or to the department if the enrollee believes they reasonably relied upon 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 covered health care services 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 a summary of 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. 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 in-network with the plan through which the provider sees enrollees.
(8)(9)A listing for each of the following providers that are under contract in-network with the plan:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted in-network 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 4999.200 of the Business and Professions Code, nurse midwives, 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 a 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 in-network 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)The(13)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 cost-sharing tier, as applicable. Nothing in this section shall be construed to This section does not require the use of network tiers other than contract and noncontracting tiers.
(13)(14)All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c).
(15)Any other necessary information, as specified by the department.
(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 in-network 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)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(13)Any other necessary information, as specified by the department.
(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.
(4)The contract between the health care service plan and the provider shall require the provider to submit and update their information through the central utility designated by the department pursuant to this section. The contract between the health care service plan and provider shall also require the plan to provide all information to the provider that is necessary to enable the provider to complete all information fields required by the central utility, including identifying the name of each health care service plan product line for which the provider is in-network.
(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.
(4)(A)The department shall select a central utility and develop uniform provider directory standards requiring a health care service plan to use the designated central utility to collect, manage, and verify the consistency and completeness of the information required for provider directories pursuant to subdivisions (h) and (i).
(B)The department shall establish a process to designate a central utility that has demonstrated the ability to meet requirements of this section.
(C)The department shall develop a methodology, including a uniform format with standardized naming conventions, that a health care service plan shall use to request providers submit their information to the central utility. In developing the methodology for requesting provider information, the department shall consider ways to minimize the burden on responding providers.
(D)The department shall develop a methodology for a health care service plan to annually verify the consistency and completeness of its provider directories against information in the central utility using a consistency report created by the central utility. The departments methodology governing the consistency reports and corresponding plan verifications shall include all of the following requirements:
(i)Health care service plans shall submit all provider directories to be analyzed by the central utility to the central utility.
(ii)The central utility shall create a consistency report for each plan directory that identifies each inconsistency between the plans provider directory and the information in the central utility, each incomplete provider directory entry, and any other information specified by the department.
(iii)The central utility shall annually inform the plan and the department of its methodology for updating provider information and resolving data inconsistencies.
(iv)The central utility shall send the consistency reports to both the health care service plan and the department.
(v)A health care service plan shall submit an attestation to the department that does both of the following:
(I)Affirms the plan has reviewed the consistency report.
(II)Describes how it will remedy each inconsistency identified in the report.
(E)The department shall annually publish the results of the provider directory consistency reports on its internet website.
(F)If the department determines that a central utility designated pursuant to this paragraph is frequently failing to provide accurate information to health care service plans, the department may consider no longer requiring or designating that central utility for use and may do either of the following:
(i)No longer require a central utility while still requiring health care service plans to meet the requirements of this section.
(ii)Designate the use of another central utility.
(G)Nonprofit health care service plans with at least 3,500,000 enrollees that provide health care services to enrollees in a specific geographic area through a mutually exclusive contract with a single medical group shall not be required to utilize the central utility for a provider that exclusively provides services to, or is employed by, that health care service plan, medical group, health facility, or health system. The requirement to use the central utility shall apply to a plan described in this subparagraph for any network provider that is contracted to provide services to more than one health care service plan.
(l)(1)A health care service plan shall be responsible for maintaining a complete and accurate provider directory that is consistent with the information in the central utility designated by the department, unless the plan verifies that the information from the central utility is inaccurate based on an investigation by the plan pursuant to subdivision (o).
(l)(1)(2)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 network 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 network providers to ensure that all of the providers are contacted by the plan at least once annually.
(2)(3)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).
(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is actively in-network with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(3)(4)The plan shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The Within 30 calendar days of receiving the notification, 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)(5)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 they respond the provider responds before the end of the 10-business-day notice period.
(6)If a health care service plan receives a request to reinstate a provider that was previously removed from the provider directory or directories, the health care service plan shall ensure the accuracy of the information required under this section and approve the request within 10 business days of receipt, if accurate.
(7)If a provider does not respond within five calendar days, a health care service plan may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is in-network with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(5)(8)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4). (4) to (6), 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. A provider shall submit changes to the information required to be in the directory within 30 calendar days of a change.
(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 A 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. This process shall include how a provider would notify the plan if they find an inaccuracy in their listing before the quarterly verification. If the provider notifies the plan of an inaccuracy, the plan shall notify the central utility to correct the information.
(4)Within 12 months of the department designating a central utility, a health care service plan shall update the policies and procedures as required by this subdivision to require providers to submit their verifications and changes to the central utility.
(n)(1)This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan.
(2)If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan shall continue to retain responsibility for ensuring that the requirements of this section are satisfied.
(3)A provider group may terminate a contract with a provider for a pattern or repeated failure of the provider to update the information required to be in the directory or directories pursuant to this section.
(4)A provider group is not subject to the payment delay described in subdivision (p) if all of the following occurs:
(A)A provider does not respond to the provider 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)(1)Whenever a health care service plan receives a report indicating report, or otherwise becomes aware, 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.
(D)If changes to a health care service plans provider directory or directories are required as a result of the plans investigation, the plan shall notify the central utility. The plan, as part of its contract with the central utility, shall require the central utility to update the providers information accordingly within five business days.
(p)(1)Notwithstanding Sections 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the 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) (5) 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 Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.
(q)In circumstances where(q)(1)If the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health care service plans provider directory or directories, the department may shall require the health care service plan to provide coverage for all covered health care services benefits provided to the enrollee and to reimburse enrollee, hold the enrollee harmless 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 contract, and reimburse the agreed upon amount, or, if there is no agreed upon amount, the reasonable and customary amount for the same or similar services in the general geographic region in which the services were rendered, less the enrollees in-network cost share. The provider shall not bill or collect any additional amount from the enrollee other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 an out-of-network provider shall not be used as a basis to deny reimbursement to the enrollee.
(2)If the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health care service plans provider directory or directories in order to select a health coverage product, the plan may be subject to an administrative penalty.
(3)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 two business days 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 check if the provider is accepting new patients at the time, confirm if the provider is accepting new patients at the location of practice, and inform the enrollee. If the provider indicates that they are not accepting new patients, the plan shall update the provider directory to reflect that the provider is no longer 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.
(4)If the health care service plan contract uses a tiered network with two or more in-network tiers with differential 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, the enrollee shall owe no more than the cost sharing for the lower cost-sharing tier.
(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.
(6)For purposes of this subdivision, information is materially inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) regarding the providers network status is inaccurate, incomplete, or misleading, regardless of whether or not the information is consistent with the information in the central utility.
(r)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.
(s)(1)This section applies does not apply to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 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 that this section is inconsistent with, prohibited by, or otherwise contrary to federal or state law, regulations, rules, or guidance. Provisions of this section that were added or amended by Assembly Bill 280 of the 202526 Regular Session do not apply to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code.
(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).
(t)A health care service 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)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)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).
(w)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
(x)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of all-plan letters, methodologies, rules, definitions, policies, forms, information or data requests, or similar instructions, without taking regulatory action, until January 1, 2032. In developing guidance pursuant to this subdivision, the department shall consult with interested stakeholders.
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 participating 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 in-network with the insurer. Commencing July 1, 2027, a health insurer shall comply with this section as it read on January 1, 2027.
(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, participating 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. 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 participating 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 in-network 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 include both an email address and a telephone number display the date of the most recent update. The provider directory or directories shall also display a dedicated email address, telephone number, and reporting 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 to the insurer or to the department if the insured believes they reasonably relied upon 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 covered health care services are not available in-network within applicable geographic and timely access standards. The disclosure shall be included within the directory and shall also include a summary of 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. 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 in-network with the insurer through which the provider sees insureds.
(8)(9)A listing for each of the following providers that are under contract in-network with the insurer:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted in-network 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 4999.200 of the Business and Professions Code, nurse midwives, 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 a 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 in-network 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)The(13)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 cost-sharing tier, as applicable. Nothing in this section shall be construed to This section does not require the use of network tiers other than contract and noncontracting tiers.
(13)(14)All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c).
(15)Any other necessary information, as specified by the department.
(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 in-network 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.
(11)(12)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(13)Any other necessary information, as specified by the department.
(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.
(4)The contract between the health insurer and the provider shall require the provider to submit and update their information through the central utility designated pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code. The contract between the health insurer and provider shall also require the health insurer to provide all information to the provider that is necessary to enable the provider to complete all information fields required by the central utility, including identifying the name of each health insurer product line for which the provider is in-network.
(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.
(4)(A)An insurer subject to this section shall use the central utility designated, and the uniform provider directory standards developed, pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code. When designating the central utility and developing standards, the Department of Managed Health Care shall seek input from interested stakeholders, including the Department of Insurance.
(B)An insurer subject to this section shall use the methodology, including a uniform format with standardized naming conventions, developed pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code when requesting providers to submit their information to the central utility. The Department of Managed Health Care shall seek input from interested stakeholders, including the Department of Insurance, when developing methodologies. The Department of Insurance may add to the methodology used by insurers to conform to the Insurance Code and regulations. The methodology shall require the central utility to notify responding providers if the providers submission is incomplete or inconsistent with other data the central utility has on file.
(C)An insurer subject to this section shall use the methodology developed pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code when annually verifying consistency and completeness of its provider directories against information in the central utility using a consistency report created by the central utility. The methodology governing the consistency reports and corresponding insurer verifications shall include all of the following requirements:
(i)An insurer shall submit all provider directories to be analyzed by the central utility to the central utility.
(ii)The central utility shall create a consistency report for each insurer directory that identifies each inconsistency between the insurers provider directory and the information in the central utility, each incomplete provider directory entry, and any other information specified by the department.
(iii)The central utility shall send the consistency reports to both the insurer and the department.
(iv)An insurer shall submit an attestation to the department that does both of the following:
(I)Affirms the insurer has reviewed the consistency report.
(II)Describes how it will remedy each inconsistency identified in the report.
(v)The central utility shall annually inform insurers of its methodology for updating provider information and resolving data inconsistencies.
(D)The Department of Managed Health Care shall annually share the methodology from the central utility required pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code with the Department of Insurance. The Department of Insurance shall post the methodology on its internet website.
(E)A nonprofit health insurer that has at least 3,500,000 insureds or enrollees in a health insurance policy or a health care service plan product in a specific geographic area through a mutually exclusive contract with a single medical group shall not be required to utilize the central utility for any provider that exclusively provides services to, or is employed by, that health care service plan, health insurer, medical group, health facility, or health system. The requirement to use the central utility shall apply to an insurer described in this subparagraph for any network provider that is contracted to provide services to more than one insurer or health care service plan.
(l)(1)An insurer shall be responsible for maintaining a complete and accurate provider directory that is consistent with the information in the central utility designated pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code, unless the insurer verifies that the information from the central utility is inaccurate based on an investigation by the insurer pursuant to subdivision (o).
(l)(1)(2)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 participating 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 participating providers to ensure that all of the providers are contacted by the insurer at least once annually.
(2)(3)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).
(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is in-network with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(3)(4)The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The Within 30 calendar days of receiving the notification, 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)(5)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 they respond the provider responds before the end of the 10-business day 10-business-day notice period.
(6)If a health insurer receives a request to reinstate a provider that was previously removed from the provider directory or directories, the health insurer shall ensure the accuracy of the information required under this section and approve the request within 10 business days of receipt if accurate.
(7)If a provider does not respond within five calendar days, a health insurer may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is in-network with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(5)(8)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4). (4) to (6), 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. A provider shall submit changes to the information required to be in the directory within 30 calendar days of a change.
(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. This process shall include how a provider would notify the insurer if they find an inaccuracy in their listing before the quarterly verification. If the provider notifies the insurer of an inaccuracy, the insurer shall notify the central utility to correct the information.
(4)Within 12 months of the Department of Managed Health Care designating a central utility pursuant to paragraph (4) of subdivision (k) of Section 1367.27 of the Health and Safety Code, a health insurer shall update the policies and procedures as required by this subdivision to require providers to submit their verifications and changes to the central utility.
(n)(1)This section does not prohibit an insurer from requiring its provider groups or contracting specialized health insurers to provide information to the insurer that is required by the insurer to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health insurer. This responsibility shall be specifically documented in a written contract between the insurer and the provider group or contracting specialized health insurer.
(2)If an insurer requires its contracting provider groups or contracting specialized health insurers to provide the insurer with information described in paragraph (1), the insurer shall continue to retain responsibility for ensuring that the requirements of this section are satisfied.
(3)A provider group may terminate a contract with a provider for a pattern or repeated failure of the provider to update the information required to be in the directory or directories pursuant to this section.
(4)A provider group is not subject to the payment delay described in subdivision (p) if all of the following occurs:
(A)A provider does not respond to the provider 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)(1)Whenever an insurer receives a report indicating report, or otherwise becomes aware, 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.
(D)If changes to a health insurers provider directory or directories are required as a result of the insurers investigation, the insurer shall notify the central utility. The insurer, as part of its contract with the central utility, shall require the central utility to update the providers information accordingly within five business days.
(p)(1)Notwithstanding Sections 10123.13 and 10123.147, an insurer may delay payment or reimbursement owed to a provider or provider group for any claims payment made to a provider or provider group for up to one calendar month beginning on the first day of the following month, if the provider or provider group fails to respond to the 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) (5) 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)In circumstances where(q)(1)If 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 shall require the insurer to provide coverage for all covered health care services benefits provided to the insured and to reimburse insured, hold the insured harmless for any amount beyond what the insured would have paid, had the services been delivered by an in-network a participating provider under the insureds health insurance policy. Prior to policy, and reimburse the provider the agreed upon amount, or if there is no agreed upon amount, the reasonable and customary amount for the same or similar services in the general geographic region in which the services were rendered, less the insureds in-network cost share. The provider shall not bill or collect any additional amount from the insured other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 an out-of-network provider shall not be used as a basis to deny reimbursement to the insured.
(2)If the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health insurers provider directory or directories in order to select a health coverage product, the insurer may be subject to an administrative penalty.
(3)If an insured, by telephone call or electronic means, requests information on whether or not a provider is contracted as a participating 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 two business days after receiving the request. The insurer shall also check if the provider is accepting new patients at the time, confirm if the provider is accepting new patients at the location of practice, and inform the insured. 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.
(4)If the health insurance policy uses a tiered network with two or more in-network tiers with differential 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, the insured shall owe no more than the cost sharing for the lower cost-sharing tier.
(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.
(6)For purposes of this subdivision, information is materially inaccurate, incomplete, or misleading if any information in subdivision (h) or (i) regarding the providers network status is inaccurate, incomplete, or misleading, regardless of whether or not the information is consistent with the information in the central utility.
(r)Whenever an insurer determines as a result of this section that there has been a 10-percent change in the network for a product in a region, the insurer shall file a statement with the commissioner.
(s)An insurer that contracts with multiple employer welfare agreements regulated pursuant to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 shall meet the requirements of this section.
(t)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)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).
(v)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
(w)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this section by means of letters, methodologies, rules, definitions, policies, forms, information or data requests, or similar instructions, without taking regulatory action, until January 1, 2032. In developing guidance pursuant to this subdivision, the department shall consult with interested stakeholders.
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. Commencing July 1, 2026, a health care service plan shall comply with this section as it read on January 1, 2026.
(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 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 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)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. This section does not require the use of network tiers other than contract and noncontracting tiers.
(14)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)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, 2026, the department may develop update a uniform format with standardized naming conventions and other aspects for each plan to use to request directory information from its providers. providers, consistent with current law.
(5)(A)On or before January 1, 2026, 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 central utilities or designate a central utility or central utilities for those providers included in the directory. directory and may take into consideration impact on provider financial interests, enrollee access to providers, and health care service plans. If the department requires or designates a central utility or central utilities, in developing the methodology under this section, the department shall seek input from interested parties parties, including providers, health care service plans, consumers, and consumer advocates, 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, 2029.
(i)If the department designates or requires a health care service plan to use a central utility or central utilities, the health care service plans contract with the utility shall require that incomplete or incorrect information submitted to the central utility shall not be conveyed to the health care service plan. The contract shall also require that the central utility notify the submitter of incomplete or inaccurate information.
(ii)If the department determines that a central utility designated or required pursuant to this subparagraph is frequently failing to provide accurate information to health care service plans, the department may consider no longer requiring or designating that central utility for use.
(iii)A health care service plan may require providers to update their information through the central utility to update the health care service plans provider directory. However, if the department requires a health care service plan to use or designate a central utility or central utilities, the health care service plan shall require providers to update their information through the central utility to update the health care service plans provider directory.
(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). (q).
(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).
(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is actively contracting with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(3)The plan shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The Within 30 calendar days of receiving the notification, 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 care service 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)If a provider does not respond within five calendar days, a health care service plan may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is actively contracting with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(6)(7)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. Providers shall submit any changes to the information required to be in the directory within 30 calendar days of any change.
(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, 2026, a plans directories shall be at least 60 percent accurate.
(B)On or before July 1, 2027, a plans directories shall be at least 80 percent accurate.
(C)On or before July 1, 2028, a plans directories shall be at least 90 percent accurate.
(D)On or before July 1, 2029, 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 or central utilities, and if a health care service plan uses 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 from the central utility 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 if a provider has submitted claims or otherwise been compensated for covered benefits for enrollees in that product or network. is actively contracting, as defined by the department pursuant to subdivision (s).
(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.
(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)(5)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)(6)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 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 care service 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 hold the enrollee harmless 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 out-of-network amount. The provider shall not collect any additional amount from the enrollee other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 two business days 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. check if the provider is accepting new patients at the time and inform the enrollee. 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 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, subsequently receives covered benefits from that provider, and the enrollee receives a bill for an amount exceeding in-network cost sharing, 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. product at the time the enrollee receives otherwise covered benefits from that provider.
(B)The contracting provider is not accepting new patients for that product. (C)(B)The information provided regarding the providers network status is otherwise inaccurate, misleading, or incomplete.
(D)(C)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 uses a tiered network with two or more in-network tiers with differential 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 lower cost-sharing tier.
(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) regarding the providers network status 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, 2026, if a provider has not been actively contracting consistent with this section 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 the number of providers who are not actively contracting pursuant to this section and have not responded to a plans notifications pursuant to subdivision (l) for at least 18 months amounts to 10 percent or greater of the providers 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 actively contracting as determined by the department.
(4)(A)The department shall determine the definition of actively contracting, and consider the degree of utilization for that provider by considering if the provider has filed one or more claims or encounters for covered services benefits to enrollees by in the relevant network, unless a special circumstance applies. In determining the utilization threshold for these purposes, the department shall not set a threshold greater than at least one claim or encounter for covered benefits for an enrollee every three calendar years.
(B)A special circumstance may include a provider in a rural area, a highly specialized specialist who was not used by did not provide covered benefits for an enrollee in the prior year, three calendar years, 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).
(5)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.
(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, rules, guidance, and regulations and state law and guidance issued after January 1, 2016, and not prohibited or otherwise contrary to federal law, rules, guidance, and regulations.
(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 care service 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.
(y)Paragraphs (2), (4), (5), (6), (7), and (8) of subdivision (n) of this section do not apply to a Medi-Cal managed care plan that contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.
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, 2026, a health insurer shall comply with this section as it read on January 1, 2026.
(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 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 insured believes they reasonably relied upon 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)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)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)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, 2026, the department may develop update a uniform format with standardized naming conventions and other aspects for each insurer to use to request directory information from its providers. providers, consistent with current law.
(5)(A)On or before January 1, 2026, 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, insurer-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 central utilities or designate a central utility or central utilities for those providers included in the directory. In directory and may take into consideration impact on provider financial interests, insured access to providers, and health insurers. If the department requires or designates a central utility or central utilities, in developing the methodology under this section, the department shall seek input from interested parties parties, including providers, health insurers, consumers, and consumer advocates, 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, 2029.
(i)If the department designates or requires an insurer to use a central utility or central utilities, the insurers contract with the utility shall require that incomplete or incorrect information submitted to the central utility shall not be conveyed to the insurer. The contract shall also require that the central utility notify the submitter of incomplete or inaccurate information.
(ii)If the department determines that a central utility designated or required pursuant to this subparagraph is frequently failing to provide accurate information to insurers, the department may consider no longer requiring or designating that central utility for use.
(iii)A health insurer may require providers to update their information through the central utility to update the health insurers provider directory. However, if the department requires a health insurer to use or designated a central utility or central utilities, the health insurer shall require providers to update their information through the central utility to update the health insurers provider directory.
(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). (q).
(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).
(D)A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: As of the last directory update, this provider is actively participating with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(3)The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The Within 30 calendar days of receiving the notification, 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)If a provider does not respond within five calendar days, a health insurer may include the following statement in the provider listing before removing the provider from the directory: As of the last directory update, this provider is actively participating with the insurer. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.
(6)(7)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. Providers shall submit any changes to the information required to be in the directory within 30 calendar days of any change.
(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, 2026, an insurers directories shall be at least 60 percent accurate.
(B)On or before July 1, 2027, an insurers directories shall be at least 80 percent accurate.
(C)On or before July 1, 2028, an insurers directories shall be at least 90 percent accurate.
(D)On or before July 1, 2029, 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 or central utilities, and if an insurer uses 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 from the central utility 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 if a provider has submitted claims or otherwise been compensated for covered benefits for insureds in that product or network. is actively participating, as defined by the department pursuant to subdivision (s).
(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.
(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)(5)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)(6)Beginning January 1, 2030, 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 hold the insured harmless 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 out-of-network amount. The provider shall not collect any additional amount from the insured other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 two business days after receiving the request. The insurer shall also provide information on whether or not the provider is accepting new patients. check if the provider is accepting new patients at the time and inform the insured. 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 If an insured obtained information through the insurers online directory or a request consistent with paragraph (2) that a provider was an in-network provider, subsequently receives covered benefits from that provider, and the insured receives a bill for an amount exceeding in-network cost sharing, 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. product at the time the insured receives otherwise covered benefits from that provider.
(B)The contracting provider is not accepting new patients for that product. (C)(B)The information provided regarding the providers network status is otherwise inaccurate, misleading, or incomplete.
(D)(C)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 uses a tiered network with two or more in-network tiers with differential 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 lower cost-sharing tier.
(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) regarding the providers network status 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, 2026, if a provider has not been actively participating consistent with this section 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 the number of providers who are not actively participating pursuant to this section and have not responded to an insurers notifications pursuant to subdivision (l) for at least 18 months amount to 10 percent or greater of the providers in the network for a product in a region, which is considered material consistent with subdivision (f) of Section 2240.5 of Title 10 of the California Code of Regulations, then the insurer shall file a corrective action plan consistent with that regulation.
(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 actively participating as determined by the department.
(4)(A)The department shall determine the definition of actively participating, and consider the degree of utilization for that provider by considering if the provider has filed one or more claims or encounters for covered services benefits to insureds by in the relevant network, unless a special circumstance applies. In determining the utilization threshold for these purposes, the department shall not set a threshold greater than at least one claim or encounter for covered benefits for an insured every three calendar years.
(B)A special circumstance may include a provider in a rural area, a highly specialized specialist who was not used by did not provide covered benefits for an insured in the prior year, three calendar years, 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).
(5)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.
(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. Commencing July 1, 2026, a health care service plan shall comply with this section as it read on January 1, 2026.
(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 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 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)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. This section does not 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)(14)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)(12)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, 2026, 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, 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 central utilities or designate a central utility or central utilities for those providers included in the directory. In If the department requires or designates a central utility or central utilities, 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, 2029.
(i)If the department designates or requires a health care service plan to use a central utility or central utilities, the health care service plans contract with the utility shall require that incomplete or incorrect information submitted to the central utility shall not be conveyed to the health care service plan. The contract shall also require that the central utility notify the submitter of incomplete or inaccurate information.
(ii)If the department determines that a central utility designated or required pursuant to this subparagraph is frequently failing to provide accurate information to health care service plans, the department may consider no longer requiring or designating that central utility for use.
(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 care service 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, 2026, a plans directories shall be at least 60 percent accurate.
(B)On or before July 1, 2027, a plans directories shall be at least 80 percent accurate.
(C)On or before July 1, 2028, a plans directories shall be at least 90 percent accurate.
(D)On or before July 1, 2029, 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 or central utilities, and if a health care service plan uses 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 from the central utility 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 if 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.
(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, 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 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 care service 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 out-of-network amount. The provider shall not collect any additional amount from the enrollee other than the applicable in-network cost sharing. sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 lower cost-sharing tier included in the information received by the enrollee from the plan. tier.
(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, 2026, if a provider has not been actively contracting consistent with this section 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 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 actively contracting as determined by the department.
(4)(A)The department shall determine the definition of actively contracting, and consider the degree of utilization for that provider by considering if the provider has filed one or more claims for covered services to enrollees by the relevant network, unless a special circumstance applies.
(B)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).
(5)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.
(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, rules, guidance, and regulations and state law guidance issued after January 1, 2016, and not prohibited or otherwise contrary to federal law, rules, guidance, and regulations.
(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 care service 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.
(y)Paragraphs (2), (4), (5), (6), (7), and (8) of subdivision (n) of this section do not apply to a Medi-Cal managed care plan that contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.
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, 2026, a health insurer shall comply with this section as it read on January 1, 2026.
(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 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 insured believes they reasonably relied upon 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)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)(14)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)(12)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, 2026, 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, 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, insurer-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 central utilities or designate a central utility or central utilities 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, 2029.
(i)If the department designates or requires an insurer to use a central utility or central utilities, the insurers contract with the utility shall require that incomplete or incorrect information submitted to the central utility shall not be conveyed to the insurer. The contract shall also require that the central utility notify the submitter of incomplete or inaccurate information.
(ii)If the department determines that a central utility designated or required pursuant to this subparagraph is frequently failing to provide accurate information to insurers, the department may consider no longer requiring or designating that central utility for use.
(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, 2026, an insurers directories shall be at least 60 percent accurate.
(B)On or before July 1, 2027, an insurers directories shall be at least 80 percent accurate.
(C)On or before July 1, 2028, an insurers directories shall be at least 90 percent accurate.
(D)On or before July 1, 2029, 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 or central utilities, and if an insurer uses 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 from the central utility 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 if 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.
(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, 2030, 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 out-of-network amount. The provider shall not collect any additional amount from the insured other than the applicable in-network cost-sharing. cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before 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 insurers 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 lower cost-sharing tier included in the information received by the insured from the insurer. tier.
(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, 2026, if a provider has not been actively participating consistent with this section 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, which is considered material consistent with subdivision (f) of Section 2240.5 of Title 10 of the California Code of Regulations, then the insurer shall file an amendment to the policy application a corrective action plan consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations. that regulation.
(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 actively participating as determined by the department.
(4)(A)The department shall determine the definition of actively participating, and consider the degree of utilization for that provider by considering if the provider has filed one or more claims for covered services to insureds by the relevant network, unless a special circumstance applies.
(B)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).
(5)Consistent with Section 1360 of the Health and Safety Code, an 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.
(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. Commencing July 1, 2026, a health care service plan shall comply with this section as it read on January 1, 2026.
(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 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 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)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. This section does not 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)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, 2026, 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, 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 central utilities or designate a central utility or central utilities 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, 2029.
(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 care service 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, 2026, a plans directories shall be at least 60 percent accurate.
(B)On or before July 1, 2027, a plans directories shall be at least 80 percent accurate.
(C)On or before July 1, 2028, a plans directories shall be at least 90 percent accurate.
(D)On or before July 1, 2029, 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 or central utilities, and if a health care service plan uses 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 from the central utility 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 if 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.
(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, 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 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 care service 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 out-of-network amount. The provider shall not collect any additional amount from the enrollee other than the applicable in-network cost sharing. Before 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, 2026, if a provider has not been actively contracting consistent with this section 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 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 actively contracting as determined by the department.
(4)(A)The department shall determine the definition of actively contracting, and consider the degree of utilization for that provider by considering if the provider has filed one or more claims for covered services to enrollees by the relevant network, unless a special circumstance applies.
(B)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).
(5)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.
(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, rules, guidance, and regulations and state law guidance issued after January 1, 2016, and not prohibited or otherwise contrary to federal law, rules, guidance, and regulations.
(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 care service 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.
(y)Paragraphs (2), (4), (5), (6), (7), and (8) of subdivision (n) of this section do not apply to a Medi-Cal managed care plan that contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.
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, 2026, a health insurer shall comply with this section as it read on January 1, 2026.
(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 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 insured believes they reasonably relied upon 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)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)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, 2026, 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, 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, insurer-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 central utilities or designate a central utility or central utilities 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, 2029.
(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, 2026, an insurers directories shall be at least 60 percent accurate.
(B)On or before July 1, 2027, an insurers directories shall be at least 80 percent accurate.
(C)On or before July 1, 2028, an insurers directories shall be at least 90 percent accurate.
(D)On or before July 1, 2029, 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 or central utilities, and if an insurer uses 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 from the central utility 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 if 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.
(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, 2030, 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 out-of-network amount. The provider shall not collect any additional amount from the insured other than the applicable in-network cost-sharing. Before 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 insurers 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, 2026, if a provider has not been actively participating consistent with this section 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)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 actively participating as determined by the department.
(4)(A)The department shall determine the definition of actively participating, and consider the degree of utilization for that provider by considering if the provider has filed one or more claims for covered services to insureds by the relevant network, unless a special circumstance applies.
(B)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).
(5)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.
(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. Commencing July 1, 2026, a health care service plan shall comply with this section as it read on January 1, 2026.
(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 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.
(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 include both an email address and a telephone number display the date of the most recent update. The provider directory or directories shall also display a dedicated email address, telephone number, and reporting 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 inaccurate, incomplete, or misleading directory information. This information shall be disclosed prominently in the directory or directories and on the plans Internet Web site. 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. 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, 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, 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.
(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)The(13)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 This section does not 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.
(13)(15)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, 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, 2026, 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, 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 central utilities or designate a central utility or central utilities 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, 2029.
(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 he or she 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 care service 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 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)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, 2026, a plans directories shall be at least 60 percent accurate.
(B)On or before July 1, 2027, a plans directories shall be at least 80 percent accurate.
(C)On or before July 1, 2028, a plans directories shall be at least 90 percent accurate.
(D)On or before July 1, 2029, 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 or central utilities, and if a health care service plan uses 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 from the central utility 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 if 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.
(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, 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 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.
(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 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.
(q)(r)(1)In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health care service 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. Prior to contract, and reimburse the provider the out-of-network amount. The provider shall not collect any additional amount from the enrollee other than the applicable in-network cost sharing. Before 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.
(r)(s)(1)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.
(2)For a health care service plan issued, amended, or renewed on or after July 1, 2026, if a provider has not been actively contracting consistent with this section 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 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 actively contracting as determined by the department.
(4)(A)The department shall determine the definition of actively contracting, and consider the degree of utilization for that provider by considering if the provider has filed one or more claims for covered services to enrollees by the relevant network, unless a special circumstance applies.
(B)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).
(5)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.
(s)(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 law, rules, guidance, and regulations and state law guidance issued after January 1, 2016. Notwithstanding 2016, and not prohibited or otherwise contrary to federal law, rules, guidance, and regulations.
(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.
(t)(u)A health care service 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. 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. Commencing July 1, 2026, a health insurer shall comply with this section as it read on January 1, 2026.
(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 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.
(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 include both an email address and a telephone number display the date of the most recent update. The provider directory or directories shall also display a dedicated email address, telephone number, and reporting 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 insured believes they reasonably relied upon inaccurate, incomplete, or misleading directory information. This information shall be disclosed prominently in the directory or directories and on the insurers Internet Web site. 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. 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, 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, 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.
(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)The(13)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.
(13)(15)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 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, 2026, 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, 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, insurer-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 central utilities or designate a central utility or central utilities 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, 2029.
(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 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 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.
(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 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 that would impact a patients access to care on a listing for a provider, that listing is considered inaccurate.
(A)On July 1, 2026, an insurers directories shall be at least 60 percent accurate.
(B)On or before July 1, 2027, an insurers directories shall be at least 80 percent accurate.
(C)On or before July 1, 2028, an insurers directories shall be at least 90 percent accurate.
(D)On or before July 1, 2029, 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 or central utilities, and if an insurer uses 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 from the central utility 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 if 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.
(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, 2030, 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.
(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 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)(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. Prior to policy, and reimburse the provider the out-of-network amount. The provider shall not collect any additional amount from the insured other than the applicable in-network cost-sharing. Before 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 insurers 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.
(r)(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, 2026, if a provider has not been actively participating consistent with this section 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)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 actively participating as determined by the department.
(4)(A)The department shall determine the definition of actively participating, and consider the degree of utilization for that provider by considering if the provider has filed one or more claims for covered services to insureds by the relevant network, unless a special circumstance applies.
(B)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).
(5)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.
(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. 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.
|
Date
|
Status
|
|---|---|
| Sep 27, 2026 | Chaptered by Secretary of State - Chapter 499, Statutes of 2026. |
| Sep 27, 2026 | Approved by the Governor. |
| Sep 4, 2026 | Enrolled and presented to the Governor at 4 p.m. |
| Aug 27, 2026 | Senate amendments concurred in. To Engrossing and Enrolling. (Ayes 64. Noes 2.). |
| Aug 27, 2026 | Senate amendments concurred in. To Engrossing and Enrolling. (Ayes 64. Noes 2. Page 6696.). |
| Aug 27, 2026 | In Assembly. Concurrence in Senate amendments pending. |
| Aug 26, 2026 | Read third time. Passed. Ordered to the Assembly. (Ayes 31. Noes 3.). |
| Aug 24, 2026 | Read second time. Ordered to third reading. |
| Aug 21, 2026 | Read second time and amended. Ordered returned to second reading. |
| Aug 21, 2026 | Ordered to second reading. |
| Aug 21, 2026 | From inactive file. |
| Sep 8, 2025 | Ordered to inactive file at the request of Senator Durazo. |
| Aug 29, 2025 | Read second time. Ordered to third reading. |
| Aug 29, 2025 | From committee: Do pass. (Ayes 5. Noes 0.) (August 29). |
| Aug 18, 2025 | In committee: Referred to suspense file. |
| Jul 15, 2025 | Read second time and amended. Re-referred to Com. on APPR. |
| Jul 14, 2025 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 8. Noes 0.) (July 9). |
| Jun 30, 2025 | 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 11, 2025 | Referred to Com. on HEALTH. |
| Jun 3, 2025 | In Senate. Read first time. To Com. on RLS. for assignment. |
| Jun 2, 2025 | Read third time. Passed. Ordered to the Senate. (Ayes 61. Noes 7. Page 1926.) |
| May 27, 2025 | Read second time. Ordered to third reading. |
| May 23, 2025 | Read second time and amended. Ordered returned to second reading. |
| May 23, 2025 | From committee: Amend, and do pass as amended. (Ayes 11. Noes 1.) (May 23). |
| May 23, 2025 | Assembly Rule 63 suspended. (Ayes 51. Noes 16. Page 1644.) |
| Apr 23, 2025 | In committee: Set, first hearing. Referred to suspense file. |
| Apr 2, 2025 | From committee: Do pass and re-refer to Com. on APPR. (Ayes 11. Noes 0.) (April 1). Re-referred to Com. on APPR. |
| Feb 10, 2025 | Referred to Com. on HEALTH. |
| Jan 22, 2025 | From printer. May be heard in committee February 21. |
| Jan 21, 2025 | Read first time. To print. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Aug 27, 2026 | AB 280 Aguiar-Curry Concurrence in Senate Amendments | Assembly Floor |
Passed |
|
| Aug 26, 2026 | Assembly 3rd Reading AB280 Aguiar-Curry et al. By Padilla | Senate Floor |
Passed |
|
| Aug 29, 2025 | Do pass | Senate Standing Committee on Appropriations |
Passed |
|
| Aug 18, 2025 | Placed on suspense file | Senate Standing Committee on Appropriations |
Passed |
|
| Jul 9, 2025 | Do pass as amended, but first amend, and re-refer to the Committee on [Appropriations] | Senate Standing Committee on Health |
Passed |
|
| Jun 2, 2025 | AB 280 Aguiar-Curry Assembly Third Reading | Assembly Floor |
Passed |
|
| May 23, 2025 | Do pass as amended. | Assembly Standing Committee on Appropriations |
Passed |
|
| Apr 1, 2025 | Do pass 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
|
|---|---|---|
| AARP | ** Support | |
| America'S Physician Groups | ** Against | |
| American College Of Obstetricians And Gynecologists, District Ix | ** Against | |
| American Federation of State, County, and Municipal Employees | ** Support | |
| Asian Americans Advancing Justice Southern California | ** Support | |
| Asian Americans Advancing Justice – Southern California | ** Support | |
| Association Of California Life & Health Insurance Companies | ** Against | |
| Association Of California State Supervisors | ** Support | |
| Autism Speaks | ** Support | |
| California Alliance Of Child And Family Services | ** Support | |
| California Association Of Health Plans | ** Against | |
| California Association Of Orthodontists | ** Against | |
| California Coalition on Family Caregiving | ** Support | |
| California Dental Association | ** Against | |
| California Medical Association | ** Against | |
| California Orthopaedic Association | ** Against | |
| California Pan-Ethnic Health Network | ** Support | |
| California Pharmacists Association | ** Support | |
| California Physicians Alliance | ** Support | |
| California Podiatric Medical Association | ** Against | |
| California Public Employees Retirement System | ** Support | |
| California Public Employees’ Retirement System | ** Support | |
| California Retired Teachers Association | ** Support | |
| California Senior Legislature | ** Support | |
| California State Council of Service Employees International Union | ** Support | |
| California State Retirees | ** Support | |
| California Teachers Association | ** Support | |
| Children Now | ** Support | |
| Community Clinic Association of Los Angeles County | ** Support | |
| Courage California | ** Support | |
| Family Caregiver Alliance | ** Support | |
| Health Access | ** Support | |
| Indivisible Ca: Statestrong | ** Support | |
| Latino Coalition for a Healthy California | ** Support | |
| Local Health Plans Of California | ** Against | |
| Mental Health America of California | ** Support | |
| National Health Law Program | ** Support | |
| National Union Of Healthcare Workers | ** Support | |
| Osteopathic Physicians & Surgeons Of California | ** Against | |
| Retired Public Employees Association | ** Support | |
| Small Business Majority | ** Support | |
| Steinberg Institute | ** Support | |
| The American College of Obstetricians and Gynecologists, District IX | ** Against | |
| The Childrens Partnership | ** Support | |
| The Children’s Partnership | ** Support | |
| The Kennedy Forum | ** Support | |
| The Leukemia & Lymphoma Society | ** Support | |
| Western Center on Law & Poverty, INC. | ** Support |
CONCURRENCE IN SENATE AMENDMENTS
CSA1 Bill Id:AB 280
Author:(Aguiar-Curry and Papan)
As Amended Ver:August 21, 2026
Majority vote
SUMMARY
Requires the Department of Managed Health Care (DMHC) to select a central utility and develop uniform standards for provider directories. Requires health plans and insurers to use the designated central utility to collect, manage, and verify the consistency and completeness of their provider directories. Requires health plans and insurers to require their in-network or participating providers to use the central utility to update and verify information for provider directories. Authorizes DMHC and the California Department of Insurance (CDI) to issue guidance to implement this bill until January 1, 2032.
Senate Amendments
- Strike provider directory accuracy benchmark requirements for plans and insurers.
- Require DMHC to select a central utility and develop standards requiring plans and insurers to use the designated central utility to collect, manage, and verify consistency and completeness of the information required for provider directories. Require DMHC to establish a process to designate a central utility that has demonstrated the ability to meet the requirements of this bill. Require DMHC to seek input from stakeholders, including CDI. Permit CDI to add to the methodology to conform to Insurance Code and regulations.
- Require contracts between health plans and insurers and providers to require the provider to submit and update their information through the central utility designated by DMHC. Require the contracts to also require the health plan or insurer to provide all information to the provider that is necessary to enable the provider to complete all information fields required by the central utility, including identifying the name of each product line for which the provider is in-network or participating. Require DMHC to develop a methodology, including a uniform format with standardized naming conventions, that a plan or insurer must use to request providers submit their information to the central utility. In developing the methodology for requesting provider information, require DMHC to consider ways to minimize burden on responding providers.
- Permit DMHC and CDI to implement by guidance or all-plan letters without regulatory action until January 1, 2032, and require DMHC and CDI to consult with interested stakeholders in developing guidance.
- Permit administrative penalty if an enrollee or insured reasonably relied upon materially inaccurate, incomplete, or misleading information when selecting a plan or policy.
- Delete requirements on the departments to update standardized formats, establish a methodology and process for provider directory accuracy, authorization to require plans to use central utility, and authorization for plans to require providers to use a central utility.
- Delete terminology in disclosure that provider is ″actively contracting″ in-network with a plan or insurer.
- Delete requirements associated with ″actively contracting″ providers, including that DMHC and CDI develop definition and exclusions from provider directory for non-actively contracting providers.
- Strike requirements about assessing administrative penalties in specified amounts, with adjustments every five years.
- Exempt nonprofit health plans or insurers with at least 3.5 million enrollees or insureds that provide health care services to enrollees or insureds in a specific geographic area through a mutually exclusive contract with a single medical group from being required to utilize the central utility for a provider that exclusively provides services to or is employed by that health plan, medical group, health facility, or health system. Require the plan or insurer to use the central utility for any network provider that is contracted to provide services to more than one health care service plan or insurer shall be required to use the central utility pursuant to this bill.
- Exempt Medi-Cal managed care plans from the provisions of this bill.
- Make technical and conforming changes, add a coauthor, and update the commencement date of the requirements in this bill to July 1, 2027.
COMMENTS
Network Adequacy Requirements. Network adequacy standards are utilized to ensure that health plans contain and maintain a network of health care providers adequate for enrollees to access medically necessary in a timely manner. In California state and federal law sets forth various network adequacy requirements on health plans and insurers, including the following:
- Timely Access to Care. State law requires 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 provide health plan members the right to appointments within the following time frames:
- 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 to Care. State law requires 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 provide health plan members the right to appointments within the following time frames:
The Department of Managed Health Care (DMHC) publishes a Timely Access Report, with the most recent publication covering data from measurement year 2022. This report highlighted 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 87% to a low of 56%. For non-urgent appointments, 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 66%. For urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 84% to a low of 46%.
- 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 83% to a low of 66%. For non-urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 89% to a low of 77%. For urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 77% to a low of 46%.
- Geographic Access. Health plans are also generally required to ensure geographic access, meaning 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.
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.
- Provider Directories. Provider directories help patients identify clinicians based on specialty, location, and hours. Provider directories can also act as a tool to inform a patient′s choice in health plan, allowing them to search if a particular provider is in-network or assess how many provider choices they will have near them.
- California Law. California was one of the first states to enact provider directory standards. SB 137 (Hernandez), Chapter 649, Statutes of 2015, requires health plans and insurers to maintain accurate online and paper directories as of July 1, 2016. SB 137 also requires the following:
- Provider Directories. Provider directories help patients identify clinicians based on specialty, location, and hours. Provider directories can also act as a tool to inform a patient′s choice in health plan, allowing them to search if a particular provider is in-network or assess how many provider choices they will have near them.
- DMHC and California Department of Insurance (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 Law. Plans offered on HealthCare.gov (the 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.
Beginning in 2022, the federal No Surprises Act (NSA) requires all private health plans 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.
- Persistent Inaccuracies. Despite state and federal laws, a Yale Law & Policy Review (Yale Review) article titled, ″Laying Ghost Networks to Rest: Combatting Deceptive Health Plan Provider Directories,″ revealed high error rates across provider directories in California, Louisiana, and Maryland. In California, even the lowest error rate the Yale Review identified, 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 led to a dead end in California.
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. A recent secret shopper survey in Los Angeles revealed that only 15% of phone calls seeking psychiatric appointments for Medi-Cal patients led to a scheduled appointment - the lowest success across the four states surveyed. 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. In 2024, CMS reported inaccuracies in all directories examined in 2022, with similar compliance problems observed in prior years.
- Enforcement, or lack thereof. 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. The Yale Review urges states, like California, to adopt frameworks to prevent directory errors. The Yale Review contends that such frameworks should be focused on regular enforcement, consistent fines for noncompliance, and engaging as many actors as possible in the enforcement scheme.
- DMHC draft provider directory regulations. In December 2024, DMHC proposed regulations on provider directories. According to DMHC, these proposed regulations ″will provide clarity regarding the scope of provider directory standards and will allow DMHC to effectively enforce current law.″ DMHC continues that these proposed regulations will make clear the obligations for both health plans and the DMHC. The first public comment period on these proposed regulations recently closed in February 2025 and the regulatory process is still underway. According to DMHC, it is anticipated to be completed by this summer.
The author and sponsor have argued that these proposed regulations do not include a defined penalty or enforcement mechanism, whereas this bill would outline a clear penalty structure, as recommended by the Yale Review, to ensure health plan compliance.
According to the Author
Every health plan in California is required to maintain an accurate list of in-network health care providers for enrollees, which they must update and have reviewed by the regulating department. The author continues that providers on these lists are often unreachable, not accepting new patients, or not part of the health plan′s network. When people sign up for a health plan, they should be able to reasonably expect that most of the health professionals on the list are available to provide care. The author argues that this bill will improve access to care by establishing accuracy benchmarks and authorizing the use of a third-party central utility to improve the accuracy of provider directories. The author concludes that this legislation provides a roadmap to improve transparency and accountability, making our healthcare system work better for everyone.
Arguments in Support
Health Access (HA), sponsor of this bill, states that 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. HA continues that 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. HA states that DMHC′s monitoring of timely access to care routinely finds that 20% to 30% of providers are unreachable by the health plan, often because of inaccuracies in the health plan′s provider directory. HA argues that inaccuracies have the greatest impact on consumers who already face the worst access such as individuals with limited English proficiency, persons with disabilities, and marginalized communities, thus worsening health inequities. HA contends that existing law puts the burden on individual consumers to complain about provider directory inaccuracies rather than requiring the health plan that created the provider directory to demonstrate its accuracy to the regulator. HA further argues that while our laws and regulations on provider directories and network adequacy are, on paper, some of the strongest in the country, they are falling short for consumers and delaying the access to care they desperately need. HA states that this bill addresses the problem of provider directory inaccuracies through consumer protections, more efficient processes, and effective enforcement.
Arguments in Opposition
America′s Physician Groups (APG) is opposed to this bill unless it′s amended to address their concerns. APG′s central concern is that this bill does not adequately recognize the role of medical groups and independent practice associations as authoritative managers of their provider rosters. APG notes that in a delegated arrangement, the physician organization often has the most current information concerning provider affiliation, practice location, availability, and acceptance of new patients. Requiring individual physicians to submit the same information separately to a central utility may create conflicting records rather than improve accuracy. APG requests that the bill expressly permit a medical group or Independent Physician Association to submit and attest to provider information on behalf of its affiliated physicians. APG further requests that the central utility should be required to accept batch files, application programming interfaces, and other interoperable submissions from physician organizations. APG is also concerned about the provision allowing a health plan to withhold as much as 50% of a provider group′s capitation payment for up to one month. APG argues that neither the mock-up nor the information supporting it establishes that physician organizations are a source of systematic provider-directory reporting failures. APG believes the inclusion of this provision, in the absence of any history that would warrant it, is troubling. APG further argues that plans and physician organizations should not face enforcement consequences for errors originating with a state-designated central utility when they have reasonably relied on the utility and acted promptly after discovering the error. APG requests that the bill provide a safe harbor or rebuttable presumption of compliance under those circumstances. APG requests that the bill also establish a clear process for resolving conflicts between verified plan or physician-organization data and information maintained by the utility before disputed information is published or used for enforcement.
FISCAL COMMENTS
According to the Senate Appropriations Committee:
Unknown ongoing costs, potentially low millions, for DMHC for state administration (Managed Care Fund).
Unknown ongoing costs, potentially low hundreds of thousands, for CDI for state administration (Insurance Fund).
VOTES:
ASM HEALTH: 11-0-4
YES: Bonta, Addis, Aguiar-Curry, Arambula, Carrillo, Mark González, Krell, Patel, Celeste Rodriguez, Schiavo, Stefani
ABS, ABST OR NV: Chen, Flora, Sanchez, Sharp-Collins
ASM APPROPRIATIONS: 11-1-3
YES: Wicks, Arambula, Calderon, Caloza, Elhawary, Fong, Mark González, Hart, Pacheco, Pellerin, Solache
NO: Dixon
ABS, ABST OR NV: Sanchez, Ta, Tangipa
ASSEMBLY FLOOR: 61-7-11
YES: Addis, Aguiar-Curry, Ahrens, Alvarez, Arambula, Ávila Farías, Bains, Bauer-Kahan, Berman, Boerner, Bonta, Bryan, Calderon, Caloza, Carrillo, Chen, Connolly, Elhawary, Fong, Gabriel, Gallagher, Garcia, Gipson, Mark González, Haney, Harabedian, Hart, Irwin, Jackson, Kalra, Krell, Lee, Lowenthal, McKinnor, Muratsuchi, Nguyen, Ortega, Pacheco, Papan, Patel, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Ransom, Celeste Rodriguez, Michelle Rodriguez, Rogers, Blanca Rubio, Schiavo, Schultz, Sharp-Collins, Solache, Soria, Stefani, Valencia, Ward, Wicks, Wilson, Zbur, Rivas
NO: Alanis, Davies, DeMaio, Dixon, Hoover, Tangipa, Wallis
ABS, ABST OR NV: Bennett, Castillo, Ellis, Flora, Jeff Gonzalez, Hadwick, Lackey, Macedo, Patterson, Sanchez, Ta
UPDATED
VERSION: August 21, 2026
CONSULTANT: Riana King / HEALTH / (916) 319-2097 FN: 0004192
SENATE RULES COMMITTEE Office of Senate Floor Analyses (916) 651-4171 | AB 280 |
THIRD READING
Bill No: AB 280
Author: Aguiar-Curry (D)
Amended: 8/21/26 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 7/9/25
AYES: Menjivar, Durazo, Gonzalez, Limón, Padilla, Richardson, Rubio, Wiener
NO VOTE RECORDED: Valladares, Grove, Weber Pierson
SENATE APPROPRIATIONS COMMITTEE: 5-0, 8/29/25
AYES: Caballero, Cabaldon, Grayson, Richardson, Wahab
NO VOTE RECORDED: Seyarto, Dahle
ASSEMBLY FLOOR: 61-7, 6/2/25 - See last page for vote
SUBJECT: Health care coverage: provider directories
SOURCE: Health Access California
DIGEST:
This bill requires the Department of Managed Health Care (DMHC) to designate a central utility for health plan and insurer provider directories and requires health plans and insurers to require their in-network or participating providers to use the central utility to update and verify information for health plan and insurer directories. Exempts a specified health plan and insurer with mutually exclusive medical group contracts, as specified. Authorizes DMHC and the California Department of Insurance (CDI) to issue guidance to implement this bill until January 1, 2032. Exempts Medi-Cal managed care plans from this bill.
Senate Floor Amendments of 8/21/2026 require DMHC to select a central utility and develop standards requiring plans and insurers to use the designated central utility to collect, manage, and verify consistency and completeness of the information required for provider directories. Require DMHC to establish a process to designate a central utility that has demonstrated the ability to meet the requirements of this bill. Require DMHC to seek input from stakeholders, including CDI. Permit CDI to add to the methodology to conform to Insurance Code and regulations. Require contracts between health plans and insurers and providers to require the provider to submit and update their information through the central utility designated by DMHC. Require the contracts to also require the health plan or insurer to provide all information to the provider that is necessary to enable the provider to complete all information fields required by the central utility, including identifying the name of each product line for which the provider is in-network or participating. Require DMHC to develop a methodology, including a uniform format with standardized naming conventions, that a plan or insurer must use to request providers submit their information to the central utility. In developing the methodology for requesting provider information, DMHC to consider ways to minimize burden on responding providers.
Exempt nonprofit health plans or insurers with at least 3.5 million enrollees or insureds that provide health care services to enrollees or insureds in a specific geographic area through a mutually exclusive contract with a single medical group from being required to utilize the central utility for a provider that exclusively provides services to or is employed by that health plan, medical group, health facility, or health system. Require the plan or insurer to use the central utility for any network provider that is contracted to provide services to more than one health care service plan or insurer shall be required to use the central utility pursuant to this bill.
The amendments make conforming changes, add a coauthor and update the commencement date of the requirements in this bill to July 1, 2027.
Exempt Medi-Cal managed care plans from this bill.
Permit DMHC and CDI to implement by guidance or all-plan letters without regulatory action until January 1, 2032, and require DMHC and CDI to consult with interested stakeholders in developing guidance.
Permit administrative penalty if an enrollee or insured reasonably relied upon materially inaccurate, incomplete, or misleading information when selecting a plan or policy.
Delete requirements on the departments to update standardized formats, establish a methodology and process for provider directory accuracy, authorization to require plans to use central utility, and authorization for plans to require providers to use a central utility.
Delete terminology in disclosure that provider is “actively contracting” in-network with a plan or insurer.
Delete accuracy benchmark requirements for plans and insurers.
Delete requirements about assessing administrative penalties in specified amounts, with adjustments every five years.
Delete requirements associated with “actively contracting” providers, including that DMHC and CDI develop definition and exclusions from provider directory for non-actively contracting providers.
ANALYSIS:
Existing law:
- Establishes DMHC to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); CDI to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [Health and Safety Code (HSC) §1340, et seq., Insurance (INS) §106, et seq. and Welfare and Institutions Code (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. Requires the plan or insurer to update provider directories, at least weekly, with any change to contracting providers, as specified. 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]
- Authorizes DMHC or CDI to require the health plan or insurer to be responsible for covered health care services provided that provider 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. Prohibits the fact that services were rendered or delivered by a noncontracting or out-of-network provider from being used as a basis to deny reimbursement. [HSC §1367.27 and INS §10133.15]
This bill:
- Requires a plan or insurer to arrange care and cover health care services provided by an out-of-network provider when an enrollee or insured relied upon inaccurate, incomplete or misleading information. Requires the enrollee or insured to pay in-network cost-sharing only (prohibits the provider from collecting more) that counts toward an in-network deductible and out-of-pocket maximum, and the provider to be paid the out-of-network amount.
- Requires out-of-network providers when a plan or insurer is required to cover services because of inaccurate directory to be paid an agreed upon amount or reasonable and customary for the same or similar services in the geographic region in which the services were rendered, less in-network cost sharing.
- Requires the provider directory to state the enrollee/insured may submit a complaint if the enrollee/insured believes they reasonably relied upon inaccurate, incomplete, or misleading directory information.
- Requires a plan or insurer to include prominent disclosure on its print and online provider directories of its duty to arrange coverage when health benefits are not available in-network within applicable geographic and timely access standards. Requires the disclosure to be included within the “Timely Access to Care” section of the directory and include the geographic accessibility standards.
- Permits administrative penalties if an enrollee or insured reasonably relied upon materially inaccurate, incomplete, or misleading information when selecting a plan or insurer.
- Requires a plan or insurer to notify providers that failure to respond to verification notification within five calendar days may result in a notice in the provider listing that states: “As of the last directory update, this provider is actively contracting with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.” Requires a provider to respond within 30 calendar days of receiving a verification notification.
- Requires DMHC to select a central utility and develop standards requiring plans and insurers to use the designated central utility to collect, manage, and verify consistency and completeness of the information required for provider directories. Requires DMHC to establish a process to designate a central utility that has demonstrated the ability to meet the requirements of this bill. Requires DMHC to seek input from stakeholders, including CDI. Permits CDI to add to the methodology to conform to Insurance Code and regulations.
- Requires DMHC to develop a methodology, including a uniform format with standardized naming conventions, that a plan or insurer must use to request providers submit their information to the central utility. In developing the methodology for requesting provider information, requires DMHC to consider ways to minimize burden on responding providers.
- Requires DMHC to develop a methodology for a plan or insurer to annually verify the consistency and completeness of their provider directories against information in the central utility using a consistency report created by the central utility. Requires the methodology to include all of the following requirements:
- The plan or insurer to submit all provider directories to the central utility to be analyzed.
- The central utility to create a consistency report for each directory that identifies each inconsistency between each provider directory and the central utility.
- The central utility to annually inform the plan or insurer and DMHC and CDI of its methodology for updating information and resolving data inconsistencies.
- The central utility to send consistency reports to plans and DMHC, insurers and CDI.
- The plans and insurers to submit attestations that affirm review of consistency report and describe how they will remedy each inconsistency.
- Requires DMHC to annually share the methodology from the central utility with CDI. Requires DMHC and CDI to publish on their websites.
- Requires DMHC to annually publish the results of consistency reports on its website.
- Permits DMHC to consider terminating the contract with the central utility if accuracy issues persist and not require plans to use the central utility or to designate another central utility, as specified.
- Exempts nonprofit health plans or insurers with at least 3.5 million enrollees or insureds that provide health care services to enrollees or insureds in a specific geographic area through a mutually exclusive contract with a single medical group from being required to utilize the central utility for a provider that exclusively provides services to or is employed by that health plan, medical group, health facility, or health system. Requires those plans and insurers to use the central utility for any network provider that is contracted to provide services to more than one health care service plan or insurer pursuant to this bill.
- Requires a plan or insurer to be responsible for maintaining a complete and accurate provider directory that is consistent with the information in the central utility, unless the plan or insurer verifies that the information from the central utility is inaccurate based on the plan’s or insurer’s investigation.
- Requires plans and insurers to notify central utility of inaccuracies and require central utility to update accordingly within five business days.
- Requires within 12 months of DMHC designating a central utility, a plan or insurer to update the policies and procedures to require providers to submit verifications and changes to the central utility.
Comments
According to the author of this bill:
Every health plan in California is required to maintain an accurate list of in-network health care providers for enrollees, which they must update and have reviewed by the regulating department. However, providers on these lists are often unreachable, not accepting new patients, or not part of the health plan’s network. When people sign up for a health plan, they should be able to reasonably expect that most of the health professionals on the list are available to provide care. This bill will improve access to care by establishing accuracy benchmarks and authorizing the use of a third-party central utility to improve the accuracy of provider directories. This legislation provides a roadmap to improve transparency and accountability, making our healthcare system work better for everyone.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes
According to the Senate Appropriations Committee:
- Unknown ongoing costs, potentially low millions, for the DMHC for state administration (Managed Care Fund).
- Unknown ongoing costs, potentially low hundreds of thousands, for the CDI for state administration (Insurance Fund).
SUPPORT: (Verified 8/25/26)
Health Access California (source)
AARP
American Federation of State, County, and Municipal Employees
Asian Americans Advancing Justice – Southern California
Association of California State Supervisors
Autism Speaks
California Alliance of Child and Family Services
California Coalition on Family Caregiving
California Pan-Ethnic Health Network
California Pharmacists Association
California Physicians Alliance
California Public Employees’ Retirement System
California Retired Teachers Association
California Senior Legislature
California State Council of Service Employees International Union
California State Retirees
California Teachers Association
Children Now
Community Clinic Association of Los Angeles County
Courage California
Family Caregiver Alliance
Health Access California
Indivisible CA: StateStrong
Latino Coalition for a Healthy California
Mental Health America of California
National Health Law Program
National Union of Healthcare Workers
Retired Public Employees Association
Small Business Majority
Steinberg Institute
The Children’s Partnership
The Kennedy Forum
The Leukemia & Lymphoma Society
Western Center on Law & Poverty, Inc.
OPPOSITION: (Verified 8/25/26)
Association of California Life & Health Insurance Companies
California Association of Health Plans
California Association of Orthodontists
California Dental Association
California Orthopaedic Association
California Podiatric Medical Association
Local Health Plans of California
Osteopathic Physicians & Surgeons of California
The American College of Obstetricians and Gynecologists, District IX
ARGUMENTS IN SUPPORT: Health Access California (HAC) is the sponsor of this bill. HAC writes, “A 2018 study investigated the error rates of four health plans in California and found inaccuracy rates up to 80% with a 25% inaccuracy rate for even the best-scoring plan. These inaccuracies are the worst for behavioral health providers. A recent secret shopper survey in Los Angeles revealed that only 15% of those phone calls seeking psychiatric appointments for Medi-Cal patients led to a scheduled appointment - the lowest success across the four states surveyed.” HAC states that existing law puts the burden on individual consumers to complain about provider directory inaccuracies rather than requiring the health plan that created the provider directory to demonstrate its accuracy to the regulator, and, that this bill addresses the problem of provider directory inaccuracies through consumer protections, more efficient processes, and effective enforcement. The California Public Employees’ Retirement System believes this bill will increase the accuracy of provider directories for the benefit of their members, and will enable them to find providers more efficiently, make better informed decisions when choosing plans and providers and reduces barriers to accessing health care.
ARGUMENTS IN OPPOSITION: The California Association of Health Plans and the Association of California Life and Health Insurance Companies does not believe this bill addresses 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. The opposition writes, “Currently, commercial health plans and insurers spend over $2.1 billion annually to maintain provider databases, clearly demonstrating the commitment health plans and insurers have to supporting accurate provider directories. We certainly appreciate that the bill acknowledges the need for a ‘central utility’ to collect the necessary information for accurate provider directories. However, without provider buy-in and participation, we will ultimately be in the same situation where health plans and insurers are struggling to collect the necessary information to update the provider directories.” Organizations representing health and dental providers write that they have serious concerns that this bill will create an unnecessarily complex and confusing framework with the burden falling on medical groups. They raise concerns with the accuracy benchmarks and that Medi-Cal managed care plans are exempted from those requirements.
ASSEMBLY FLOOR: 61-7, 6/2/25
AYES: Addis, Aguiar-Curry, Ahrens, Alvarez, Arambula, Ávila Farías, Bains, Bauer-Kahan, Berman, Boerner, Bonta, Bryan, Calderon, Caloza, Carrillo, Chen, Connolly, Elhawary, Fong, Gabriel, Gallagher, Garcia, Gipson, Mark González, Haney, Harabedian, Hart, Irwin, Jackson, Kalra, Krell, Lee, Lowenthal, McKinnor, Muratsuchi, Nguyen, Ortega, Pacheco, Papan, Patel, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Ransom, Celeste Rodriguez, Michelle Rodriguez, Rogers, Blanca Rubio, Schiavo, Schultz, Sharp-Collins, Solache, Soria, Stefani, Valencia, Ward, Wicks, Wilson, Zbur, Rivas
NOES: Alanis, Davies, DeMaio, Dixon, Hoover, Tangipa, Wallis
NO VOTE RECORDED: Bennett, Castillo, Ellis, Flora, Jeff Gonzalez, Hadwick, Lackey, Macedo, Patterson, Sanchez, Ta
Prepared by: Teri Boughton / HEALTH / (916) 651-4111
8/25/26 10:53:53
**** END ****
SENATE RULES COMMITTEE Office of Senate Floor Analyses (916) 651-4171 | AB 280 |
THIRD READING
Bill No: AB 280
Author: Aguiar-Curry (D)
Amended: 8/21/26 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 7/9/25
AYES: Menjivar, Durazo, Gonzalez, Limón, Padilla, Richardson, Rubio, Wiener
NO VOTE RECORDED: Valladares, Grove, Weber Pierson
SENATE APPROPRIATIONS COMMITTEE: 5-0, 8/29/25
AYES: Caballero, Cabaldon, Grayson, Richardson, Wahab
NO VOTE RECORDED: Seyarto, Dahle
ASSEMBLY FLOOR: 61-7, 6/2/25 - See last page for vote
SUBJECT: Health care coverage: provider directories
SOURCE: Health Access California
DIGEST:
This bill requires the Department of Managed Health Care (DMHC) to designate a central utility for health plan and insurer provider directories and requires health plans and insurers to require their in-network or participating providers to use the central utility to update and verify information for health plan and insurer directories. Exempts a specified health plan and insurer with mutually exclusive medical group contracts, as specified. Authorizes DMHC and the California Department of Insurance (CDI) to issue guidance to implement this bill until January 1, 2032. Exempts Medi-Cal managed care plans from this bill.
Senate Floor Amendments of 8/21/2026 require DMHC to select a central utility and develop standards requiring plans and insurers to use the designated central utility to collect, manage, and verify consistency and completeness of the information required for provider directories. Require DMHC to establish a process to designate a central utility that has demonstrated the ability to meet the requirements of this bill. Require DMHC to seek input from stakeholders, including CDI. Permit CDI to add to the methodology to conform to Insurance Code and regulations. Require contracts between health plans and insurers and providers to require the provider to submit and update their information through the central utility designated by DMHC. Require the contracts to also require the health plan or insurer to provide all information to the provider that is necessary to enable the provider to complete all information fields required by the central utility, including identifying the name of each product line for which the provider is in-network or participating. Require DMHC to develop a methodology, including a uniform format with standardized naming conventions, that a plan or insurer must use to request providers submit their information to the central utility. In developing the methodology for requesting provider information, DMHC to consider ways to minimize burden on responding providers.
Exempt nonprofit health plans or insurers with at least 3.5 million enrollees or insureds that provide health care services to enrollees or insureds in a specific geographic area through a mutually exclusive contract with a single medical group from being required to utilize the central utility for a provider that exclusively provides services to or is employed by that health plan, medical group, health facility, or health system. Require the plan or insurer to use the central utility for any network provider that is contracted to provide services to more than one health care service plan or insurer shall be required to use the central utility pursuant to this bill.
The amendments make conforming changes, add a coauthor and update the commencement date of the requirements in this bill to July 1, 2027.
Exempt Medi-Cal managed care plans from this bill.
Permit DMHC and CDI to implement by guidance or all-plan letters without regulatory action until January 1, 2032, and require DMHC and CDI to consult with interested stakeholders in developing guidance.
Permit administrative penalty if an enrollee or insured reasonably relied upon materially inaccurate, incomplete, or misleading information when selecting a plan or policy.
Delete requirements on the departments to update standardized formats, establish a methodology and process for provider directory accuracy, authorization to require plans to use central utility, and authorization for plans to require providers to use a central utility.
Delete terminology in disclosure that provider is “actively contracting” in-network with a plan or insurer.
Delete accuracy benchmark requirements for plans and insurers.
Delete requirements about assessing administrative penalties in specified amounts, with adjustments every five years.
Delete requirements associated with “actively contracting” providers, including that DMHC and CDI develop definition and exclusions from provider directory for non-actively contracting providers.
ANALYSIS:
Existing law:
- Establishes DMHC to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); CDI to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [Health and Safety Code (HSC) §1340, et seq., Insurance (INS) §106, et seq. and Welfare and Institutions Code (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. Requires the plan or insurer to update provider directories, at least weekly, with any change to contracting providers, as specified. 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]
- Authorizes DMHC or CDI to require the health plan or insurer to be responsible for covered health care services provided that provider 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. Prohibits the fact that services were rendered or delivered by a noncontracting or out-of-network provider from being used as a basis to deny reimbursement. [HSC §1367.27 and INS §10133.15]
This bill:
- Requires a plan or insurer to arrange care and cover health care services provided by an out-of-network provider when an enrollee or insured relied upon inaccurate, incomplete or misleading information. Requires the enrollee or insured to pay in-network cost-sharing only (prohibits the provider from collecting more) that counts toward an in-network deductible and out-of-pocket maximum, and the provider to be paid the out-of-network amount.
- Requires out-of-network providers when a plan or insurer is required to cover services because of inaccurate directory to be paid an agreed upon amount or reasonable and customary for the same or similar services in the geographic region in which the services were rendered, less in-network cost sharing.
- Requires the provider directory to state the enrollee/insured may submit a complaint if the enrollee/insured believes they reasonably relied upon inaccurate, incomplete, or misleading directory information.
- Requires a plan or insurer to include prominent disclosure on its print and online provider directories of its duty to arrange coverage when health benefits are not available in-network within applicable geographic and timely access standards. Requires the disclosure to be included within the “Timely Access to Care” section of the directory and include the geographic accessibility standards.
- Permits administrative penalties if an enrollee or insured reasonably relied upon materially inaccurate, incomplete, or misleading information when selecting a plan or insurer.
- Requires a plan or insurer to notify providers that failure to respond to verification notification within five calendar days may result in a notice in the provider listing that states: “As of the last directory update, this provider is actively contracting with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.” Requires a provider to respond within 30 calendar days of receiving a verification notification.
- Requires DMHC to select a central utility and develop standards requiring plans and insurers to use the designated central utility to collect, manage, and verify consistency and completeness of the information required for provider directories. Requires DMHC to establish a process to designate a central utility that has demonstrated the ability to meet the requirements of this bill. Requires DMHC to seek input from stakeholders, including CDI. Permits CDI to add to the methodology to conform to Insurance Code and regulations.
- Requires DMHC to develop a methodology, including a uniform format with standardized naming conventions, that a plan or insurer must use to request providers submit their information to the central utility. In developing the methodology for requesting provider information, requires DMHC to consider ways to minimize burden on responding providers.
- Requires DMHC to develop a methodology for a plan or insurer to annually verify the consistency and completeness of their provider directories against information in the central utility using a consistency report created by the central utility. Requires the methodology to include all of the following requirements:
- The plan or insurer to submit all provider directories to the central utility to be analyzed.
- The central utility to create a consistency report for each directory that identifies each inconsistency between each provider directory and the central utility.
- The central utility to annually inform the plan or insurer and DMHC and CDI of its methodology for updating information and resolving data inconsistencies.
- The central utility to send consistency reports to plans and DMHC, insurers and CDI.
- The plans and insurers to submit attestations that affirm review of consistency report and describe how they will remedy each inconsistency.
- Requires DMHC to annually share the methodology from the central utility with CDI. Requires DMHC and CDI to publish on their websites.
- Requires DMHC to annually publish the results of consistency reports on its website.
- Permits DMHC to consider terminating the contract with the central utility if accuracy issues persist and not require plans to use the central utility or to designate another central utility, as specified.
- Exempts nonprofit health plans or insurers with at least 3.5 million enrollees or insureds that provide health care services to enrollees or insureds in a specific geographic area through a mutually exclusive contract with a single medical group from being required to utilize the central utility for a provider that exclusively provides services to or is employed by that health plan, medical group, health facility, or health system. Requires those plans and insurers to use the central utility for any network provider that is contracted to provide services to more than one health care service plan or insurer pursuant to this bill.
- Requires a plan or insurer to be responsible for maintaining a complete and accurate provider directory that is consistent with the information in the central utility, unless the plan or insurer verifies that the information from the central utility is inaccurate based on the plan’s or insurer’s investigation.
- Requires plans and insurers to notify central utility of inaccuracies and require central utility to update accordingly within five business days.
- Requires within 12 months of DMHC designating a central utility, a plan or insurer to update the policies and procedures to require providers to submit verifications and changes to the central utility.
Comments
According to the author of this bill:
Every health plan in California is required to maintain an accurate list of in-network health care providers for enrollees, which they must update and have reviewed by the regulating department. However, providers on these lists are often unreachable, not accepting new patients, or not part of the health plan’s network. When people sign up for a health plan, they should be able to reasonably expect that most of the health professionals on the list are available to provide care. This bill will improve access to care by establishing accuracy benchmarks and authorizing the use of a third-party central utility to improve the accuracy of provider directories. This legislation provides a roadmap to improve transparency and accountability, making our healthcare system work better for everyone.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes
According to the Senate Appropriations Committee:
- Unknown ongoing costs, potentially low millions, for the DMHC for state administration (Managed Care Fund).
- Unknown ongoing costs, potentially low hundreds of thousands, for the CDI for state administration (Insurance Fund).
SUPPORT: (Verified 8/21/26)
Health Access California (source)
AARP
American Federation of State, County, and Municipal Employees
Asian Americans Advancing Justice – Southern California
Association of California State Supervisors
Autism Speaks
California Alliance of Child and Family Services
California Coalition on Family Caregiving
California Pan-Ethnic Health Network
California Pharmacists Association
California Physicians Alliance
California Public Employees’ Retirement System
California Retired Teachers Association
California Senior Legislature
California State Council of Service Employees International Union
California State Retirees
California Teachers Association
Children Now
Community Clinic Association of Los Angeles County
Courage California
Family Caregiver Alliance
Health Access California
Indivisible CA: StateStrong
Latino Coalition for a Healthy California
Mental Health America of California
National Health Law Program
National Union of Healthcare Workers
Retired Public Employees Association
Small Business Majority
Steinberg Institute
The Children’s Partnership
The Kennedy Forum
The Leukemia & Lymphoma Society
Western Center on Law & Poverty, Inc.
OPPOSITION: (Verified 8/21/26)
Association of California Life & Health Insurance Companies
California Association of Health Plans
California Association of Orthodontists
California Dental Association
California Medical Association
California Orthopaedic Association
California Podiatric Medical Association
Local Health Plans of California
Osteopathic Physicians & Surgeons of California
The American College of Obstetricians and Gynecologists, District IX
ARGUMENTS IN SUPPORT: Health Access California (HAC) is the sponsor of this bill. HAC writes, “A 2018 study investigated the error rates of four health plans in California and found inaccuracy rates up to 80% with a 25% inaccuracy rate for even the best-scoring plan. These inaccuracies are the worst for behavioral health providers. A recent secret shopper survey in Los Angeles revealed that only 15% of those phone calls seeking psychiatric appointments for Medi-Cal patients led to a scheduled appointment - the lowest success across the four states surveyed.” HAC states that existing law puts the burden on individual consumers to complain about provider directory inaccuracies rather than requiring the health plan that created the provider directory to demonstrate its accuracy to the regulator, and, that this bill addresses the problem of provider directory inaccuracies through consumer protections, more efficient processes, and effective enforcement. The California Public Employees’ Retirement System believes this bill will increase the accuracy of provider directories for the benefit of their members, and will enable them to find providers more efficiently, make better informed decisions when choosing plans and providers and reduces barriers to accessing health care.
ARGUMENTS IN OPPOSITION: The California Association of Health Plans and the Association of California Life and Health Insurance Companies does not believe this bill addresses 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. The opposition writes, “Currently, commercial health plans and insurers spend over $2.1 billion annually to maintain provider databases, clearly demonstrating the commitment health plans and insurers have to supporting accurate provider directories. We certainly appreciate that the bill acknowledges the need for a ‘central utility’ to collect the necessary information for accurate provider directories. However, without provider buy-in and participation, we will ultimately be in the same situation where health plans and insurers are struggling to collect the necessary information to update the provider directories.” Organizations representing health and dental providers write that they have serious concerns that this bill will create an unnecessarily complex and confusing framework with the burden falling on medical groups. They raise concerns with the accuracy benchmarks and that Medi-Cal managed care plans are exempted from those requirements.
ASSEMBLY FLOOR: 61-7, 6/2/25
AYES: Addis, Aguiar-Curry, Ahrens, Alvarez, Arambula, Ávila Farías, Bains, Bauer-Kahan, Berman, Boerner, Bonta, Bryan, Calderon, Caloza, Carrillo, Chen, Connolly, Elhawary, Fong, Gabriel, Gallagher, Garcia, Gipson, Mark González, Haney, Harabedian, Hart, Irwin, Jackson, Kalra, Krell, Lee, Lowenthal, McKinnor, Muratsuchi, Nguyen, Ortega, Pacheco, Papan, Patel, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Ransom, Celeste Rodriguez, Michelle Rodriguez, Rogers, Blanca Rubio, Schiavo, Schultz, Sharp-Collins, Solache, Soria, Stefani, Valencia, Ward, Wicks, Wilson, Zbur, Rivas
NOES: Alanis, Davies, DeMaio, Dixon, Hoover, Tangipa, Wallis
NO VOTE RECORDED: Bennett, Castillo, Ellis, Flora, Jeff Gonzalez, Hadwick, Lackey, Macedo, Patterson, Sanchez, Ta
Prepared by: Teri Boughton / HEALTH / (916) 651-4111
8/24/26 11:16:38
**** END ****
SENATE RULES COMMITTEE Office of Senate Floor Analyses (916) 651-1520 Fax: (916) 327-4478 | AB 280 |
THIRD READING
Bill No: AB 280
Author: Aguiar-Curry (D)
Amended: 7/15/25 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 7/9/25
AYES: Menjivar, Durazo, Gonzalez, Limón, Padilla, Richardson, Rubio, Wiener
NO VOTE RECORDED: Valladares, Grove, Weber Pierson
SENATE APPROPRIATIONS COMMITTEE: 5-0, 8/29/25
AYES: Caballero, Cabaldon, Grayson, Richardson, Wahab
NO VOTE RECORDED: Seyarto, Dahle
ASSEMBLY FLOOR: 61-7, 6/2/25 - See last page for vote
SUBJECT: Health care coverage: provider directories
SOURCE: Health Access California
DIGEST:
This bill establishes health plan and insurer accuracy benchmarks for their provider directories, which require a plan or insurer’s directories to be 60% accurate by July 2026 and 95% percent accurate by July 2029. Authorizes the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) to require the use of a central utility or utilities for providers included in their directories. Requires a plan or insurer, when verifying the accuracy of provider information, to determine if the provider is actively contracting, as defined by DMHC or CDI. Exempts Medi-Cal managed care plans from the accuracy benchmarks and provisions related to administrative penalties.
ANALYSIS:
Existing law:
- Establishes DMHC to regulate health plans under the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act); CDI to regulate health and other insurance; and, the Department of Health Care Services (DHCS) to administer the Medi-Cal program. [Health and Safety Code (HSC) §1340, et seq., Insurance (INS) §106, et seq. and Welfare and Institutions Code (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 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 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]
- Authorizes DMHC or CDI to require the health plan or insurer to be responsible for covered health care services provided that provider 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, DMHC and CDI 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-network 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 specified provider information such as location, contact information, type of provider, area of specialty and other information in the provider directory to be verified and accurate. Requires a plan or insurer to annually verify its provider directories for accuracy of all of the specified information. Requires a printed provider directory to be dated with the date of its last update displayed.
- Requires a provider to be removed from a directory under specified circumstances, such as the provider is no longer under contract. Requires the health plan or insurer, if a provider that was previously removed from a provider directory requests to be added back to ensure the accuracy of the information and approve the request within 10 business days of receipt if accurate.
- Requires a plan or insurer to be responsible for maintaining an accurate provider directory. Requires the accuracy percentage of a directory to be determined by the percentage of providers for which all information required is accurate. If there is one error that would impact a patient’s access to care on a listing for a provider, that listing is considered inaccurate. Requires:
- On July 1, 2026, a plan’s directories to be at least 60% accurate.
- On or before July 1, 2027, a plan’s directories to be at least 80% accurate.
- On or before July 1, 2028, a plan’s directories to be at least 90% accurate.
- On or before July 1, 2029, a plan’s directories to be at least 95% accurate.
- Requires DMHC or CDI to develop procedures and policies on how a plan or insurer is to conduct the verifications. Requires a plan or insurer to respond no later than one business day after receiving a request by an enrollee or insured to a request for information about whether or not a provider is contacted as an in-network provider, as specified.
- Requires a plan or insurer to arrange care and cover health care services provided by an out-of-network provider when an enrollee or insured relied upon inaccurate, incomplete or misleading information. Requires the enrollee or insured to pay in-network cost-sharing only (prohibits the provider from collecting more) that counts toward an in-network deductible and out-of-pocket maximum, and the provider to be paid the out-of-network amount. Adds, to the circumstances under which an enrollee or insured pays no more than in-network cost-sharing, items such as if the online directory is not accessible at the time the enrollee or insured seeks information.
- Requires the provider directory to state the enrollee/insured may submit a complaint if the enrollee/insured believes they reasonably relied upon inaccurate, incomplete, or misleading directory information.
- Requires a plan or insurer to 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. Requires the disclosure to be included within the “Timely Access to Care” section of the directory and include the geographic accessibility standards.
- Requires a plan or insurer to notify providers that failure to respond to verification notification within five calendar days may result in a notice in the provider listing that states: “As of the last directory update, this provider is actively contracting with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.” Requires a provider to respond within 30 calendar days of receiving a verification notification.
- Requires the plan or insurer, if DMHC and CDI develops a methodology and standards that permit the use of a central utility or central utilities, and if a health plan or insurer uses a central utility for some or all of the plan’s provider directory, to ensure that information derived from the central utility is incorporated in the plan’s or insurer’s provider directory unless the plan or insurer can demonstrate that the information from the central utility is inaccurate. Exempts these standards from the Administrative Procedure Act until January 1, 2029.
- Permits DMHC and CDI to require a health plan or insurer to use or designate a central utility or central utilities for providers included in the directory. Permits a health plan or insurer to require providers to update their information through the central utility to update the health plan’s or insurer’s provider directory. Requires a plan or insurer to require providers to use the central utility or utilities if the plan or insurer is required to use one.
- Requires the contract with the utility, if DMHC or CDI designates or requires a health plan or insurer to use a central utility or central utilities, to require that incomplete or incorrect information submitted to the central utility not be conveyed to the health plan or insurer. Requires the contract to also require that the central utility notify the submitter of incomplete or inaccurate information.
- Permits DMHC or CDI to allow a plan or insurer not to use the central utility if the plan or insurer can demonstrate it will meet the required benchmarks without using it. Permits DMHC or CDI, if the plan fails to meet the benchmark in the future, to require the plan or insurer to use the central utility as a method to achieve higher accuracy of provider directory listings to comply with the benchmarks in this bill.
- Requires failure by a health plan or insurer to comply with this bill and the law it amends, including failure to meet the required benchmarks for accuracy, to result in an administrative penalty in an amount consistent with a denial of access to care for covered benefits.
- Requires DMHC or CDI to determine the appropriate penalty amount for each violation based on one or more factors as applicable, including the factors outlined in existing law. Requires DMHC or CDI to take into consideration evidence provided by the plan or insurer of policies and procedures to obtain accurate provider information and the use of a central utility.
- Requires penalty amounts, beginning January 1, 2029, and every five years thereafter, 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.
- Exempts Medi-Cal managed care plans from 3), 13), 14), and 15) above.
Comments
According to the author of this bill:
Every health plan in California is required to maintain an accurate list of in-network health care providers for enrollees, which they must update and have reviewed by the regulating department. However, providers on these lists are often unreachable, not accepting new patients, or not part of the health plan’s network. When people sign up for a health plan, they should be able to reasonably expect that most of the health professionals on the list are available to provide care. This bill will improve access to care by establishing accuracy benchmarks and authorizing the use of a third-party central utility to improve the accuracy of provider directories. This legislation provides a roadmap to improve transparency and accountability, making our healthcare system work better for everyone.
Background
Studies. Health Access California, this bill’s sponsor, references a 2021 study that 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.
FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes
According to the Senate Appropriations Committee:
- Unknown ongoing costs, potentially low millions, for the DMHC for state administration (Managed Care Fund).
- Unknown ongoing costs, potentially low hundreds of thousands, for the CDI for state administration (Insurance Fund).
- Unknown potential cost pressures to capitation payments for Medi-Cal plans for administration (General Fund and federal funds).
SUPPORT: (Verified 8/29/25)
Health Access California (sponsor)
AARP
American Federation of State, County, and Municipal Employees
Asian Americans Advancing Justice – Southern California
Association of California State Supervisors
Autism Speaks
California Alliance of Child and Family Services
California Coalition on Family Caregiving
California Pan-Ethnic Health Network
California Pharmacists Association
California Physicians Alliance
California Public Employees’ Retirement System
California Retired Teachers Association
California Senior Legislature
California State Council of Service Employees International Union
California State Retirees
California Teachers Association
Children Now
Community Clinic Association of Los Angeles County
Courage California
Family Caregiver Alliance
Health Access California
Indivisible CA: StateStrong
Latino Coalition for a Healthy California
Mental Health America of California
National Health Law Program
National Union of Healthcare Workers
Retired Public Employees Association
Small Business Majority
Steinberg Institute
The Children’s Partnership
The Kennedy Forum
The Leukemia & Lymphoma Society
Western Center on Law & Poverty, Inc.
OPPOSITION: (Verified 8/29/25)
Association of California Life & Health Insurance Companies
California Association of Health Plans
California Association of Orthodontists
California Dental Association
California Medical Association
California Orthopaedic Association
California Podiatric Medical Association
Local Health Plans of California
Osteopathic Physicians & Surgeons of California
The American College of Obstetricians and Gynecologists, District IX
ARGUMENTS IN SUPPORT: Health Access California (HAC) is the sponsor of this bill. HAC writes, “A 2018 study investigated the error rates of four health plans in California and found inaccuracy rates up to 80% with a 25% inaccuracy rate for even the best-scoring plan. These inaccuracies are the worst for behavioral health providers. A recent secret shopper survey in Los Angeles revealed that only 15% of those phone calls seeking psychiatric appointments for Medi-Cal patients led to a scheduled appointment - the lowest success across the four states surveyed.” HAC states that existing law puts the burden on individual consumers to complain about provider directory inaccuracies rather than requiring the health plan that created the provider directory to demonstrate its accuracy to the regulator, and, that this bill addresses the problem of provider directory inaccuracies through consumer protections, more efficient processes, and effective enforcement. The California Public Employees’ Retirement System believes this bill will increase the accuracy of provider directories for the benefit of their members, and will enable them to find providers more efficiently, make better informed decisions when choosing plans and providers and reduces barriers to accessing health care.
ARGUMENTS IN OPPOSITION: The California Association of Health Plans and the Association of California Life and Health Insurance Companies does not believe this bill addresses 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. The opposition writes, “Currently, commercial health plans and insurers spend over $2.1 billion annually to maintain provider databases, clearly demonstrating the commitment health plans and insurers have to supporting accurate provider directories. We certainly appreciate that the bill acknowledges the need for a ‘central utility’ to collect the necessary information for accurate provider directories. However, without provider buy-in and participation, we will ultimately be in the same situation where health plans and insurers are struggling to collect the necessary information to update the provider directories.” Organizations representing health and dental providers write that they have serious concerns that this bill will create an unnecessarily complex and confusing framework with the burden falling on medical groups. They raise concerns with the accuracy benchmarks and that Medi-Cal managed care plans are exempted from those requirements.
ASSEMBLY FLOOR: 61-7, 6/2/25
AYES: Addis, Aguiar-Curry, Ahrens, Alvarez, Arambula, Ávila Farías, Bains, Bauer-Kahan, Berman, Boerner, Bonta, Bryan, Calderon, Caloza, Carrillo, Chen, Connolly, Elhawary, Fong, Gabriel, Gallagher, Garcia, Gipson, Mark González, Haney, Harabedian, Hart, Irwin, Jackson, Kalra, Krell, Lee, Lowenthal, McKinnor, Muratsuchi, Nguyen, Ortega, Pacheco, Papan, Patel, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Ransom, Celeste Rodriguez, Michelle Rodriguez, Rogers, Blanca Rubio, Schiavo, Schultz, Sharp-Collins, Solache, Soria, Stefani, Valencia, Ward, Wicks, Wilson, Zbur, Rivas
NOES: Alanis, Davies, DeMaio, Dixon, Hoover, Tangipa, Wallis
NO VOTE RECORDED: Bennett, Castillo, Ellis, Flora, Jeff Gonzalez, Hadwick, Lackey, Macedo, Patterson, Sanchez, Ta
Prepared by: Teri Boughton / HEALTH / (916) 651-4111
8/30/25 11:03:06
**** END ****
SENATE COMMITTEE ON
Senator Anna Caballero, Chair
2025 - 2026 Regular Session
AB 280 (Aguiar-Curry) - Health care coverage: provider directories
Version: | Policy Vote: |
Urgency: | Mandate: |
Hearing Date: | Consultant: |
Bill Summary:
AB 280 would revise and expand existing requirements for health plans and insurers to maintain accurate provider directories.
Fiscal Impact:
- Unknown ongoing costs, potentially low millions, for the Department of Managed Health Care (DMHC) for state administration (Managed Care Fund).
- Unknown ongoing costs, potentially low hundreds of thousands, for the California Department of Insurance (CDI) for state administration (Insurance Fund).
- Unknown potential cost pressures to capitation payments for Medi-Cal plans for administration (General Fund and federal funds).
Background:
The DMHC regulates health plans under the Knox-Keene Act and the CDI regulates health and other insurers. 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 their enrollees/insureds, including those that accept new patients. These requirements also apply to DMHC-regulated health plans that have Medi-Cal managed care contracts with the DHCS. 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.
- 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/insurer of any of the following:
- 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.
- A provider is no longer under contract for a particular product.
- A provider’s practice location or other information required, as specified, has changed.
- Upon completion of an investigation, a change is necessary based on an enrollee/insured complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly.
- Any other information that affects the content or accuracy of the provider directory or directories.
- 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.
Current law authorizes DMHC and CDI, in circumstances where the department finds that an enrollee/insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plan’s/insurer’s provider directory or directories, to require the health plan/insurer to provide coverage for all covered health care services provided to the enrollee/insured and to reimburse the enrollee/insured for any amount beyond what the enrollee/insured would have paid, had the services been delivered by an in-network provider.
Proposed Law:
Specific provisions of the bill would:
- Authorize DMHC and CDI to establish a methodology and processes to ensure accuracy of provider directories and consistency with other state or federal laws, regulations, or standards; and require the departments to take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity.
- Authorize DMHC and CDI to require a health plan/insurer to use or designate a central utility or central utilities for those providers included in the directory, as specified.
- Require that for health plans (except Medi-Cal managed care plans) and insurers:
- On July 1, 2026, directories must be at least 60 percent accurate.
- On or before July 1, 2027, directories must be at least 80 percent accurate.
- On or before July 1, 2028, directories must be at least 90 percent accurate.
- On or before July 1, 2029, directories must be at least 95 percent accurate.
- Require that failure by a health plan (except a Medi-Cal managed care plan) or insurer to comply with specified provisions, including failure to meet the required benchmarks for accuracy, would result in an administrative penalty, as specified.
- Require, rather than authorize DMHC and CDI to require, health plans and insurers to provide coverage and limit enrollee/insured cost-sharing, as specified, in circumstances when an enrollee/insured relied upon inaccurate provider directories.
Related Legislation:
AB 787 (Papan) would require health plans and insurers to provide assistance to enrollees and insureds in finding an in-network provider, as specified. The bill is currently on the suspense file in this committee.
AB 236 (Holden, 2023) would have revised and expanded existing requirements for health plans and insurers to maintain accurate provider directories. The bill was held on the suspense file in this committee.
-- END --
SENATE COMMITTEE ON HEALTH
Senator Caroline Menjivar, Chair
BILL NO: AB 280
AUTHOR: | Aguiar-Curry | ||
VERSION: | June 30, 2025 | ||
HEARING DATE: | July 9, 2025 | ||
CONSULTANT: | Teri Boughton | ||
SUBJECT: Health care coverage: provider directories
SUMMARY:
Establishes health plan and insurer accuracy benchmarks for their provider directories, which require a plan or insurer’s directories to be 60% accurate by July 2026 and 95% percent accurate by July 2029. Authorizes the Department of Managed Health Care and the Department of Insurance to require the use of a central utility or utilities for providers included in their directories. Requires a plan or insurer, when verifying the accuracy of provider information, to determine if the provider has submitted claims or has been compensated. Authorizes administrative penalties that range from $500 per 1,000 enrollees/insureds to $10,000 per 1,000 enrollees/insureds for each year a plan or insurer fails to meet their benchmark. Adjusts the penalty amount every five years after January 1, 2029. Exempts Medi-Cal managed care plans from specified provisions.
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 without any requirement that a member of the public or potential enrollee/insured indicate intent to obtain coverage from the plan/insurer, without demonstrating coverage with the plan/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. [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 provider is available through. Requires a plan or insurer, after the directory standards are developed, to use the standards for each product it offers. [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]
- Authorizes, if there is a finding by DMHC or CDI that an enrollee or insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a provider directory or directories leading to treatment by an out-of-network provider, DMHC or CDI to require the health plan or insurer to be responsible for covered health care services provided that provider 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, DMHC and CDI 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-network provider from being used as a basis to deny reimbursement to the enrollee or insured. [HSC §1367.27 and INS §10133.15]
This bill:
Accuracy requirements
- Requires specified provider information such as location, contact information, type of provider, area of specialty and other information in the provider directory to be verified and accurate. Requires a plan or insurer to annually verify its provider directories for accuracy of all of the specified information.
- Requires a printed provider directory to be dated with the date of its last update displayed.
- Requires a provider to be removed from a directory under specified circumstances, such as the provider is no longer under contract (existing law requires the provider to be deleted).
- Requires the directory to also display a dedicated email address telephone number, and hyperlink for the public and providers to report possible inaccurate, incomplete, or misleading directory information.
- Requires the directory to indicate the population served; meaning adult, pediatric, or both.
- Adds dispensing optometrist, opticians, and optical dispensaries to the providers that must be listed in the directory.
- Permits DMHC and CDI, by January 1, 2026, to establish a methodology and processes to ensure accuracy of provider directories and consistency with other state or federal laws, regulations, or standards. Requires DMHC and CDI to take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity.
- Permits DMHC or CDI, by January 1, 2026, to develop a uniform format with standardized naming conventions and other aspects for each plan to use to request directory information from its providers.
- Requires the health plan or insurer, if a provider that was previously removed from a provider directory requests to be added back to ensure the accuracy of the information and approve the request within 10 business days of receipt if accurate.
- Requires a plan or insurer to be responsible for maintaining an accurate provider directory. Requires the accuracy percentage of a directory to be determined by the percentage of providers for which all information required is accurate. If there is one error that would impact a patient’s access to care on a listing for a provider, that listing is considered inaccurate. Requires:
- On July 1, 2026, a plan’s directories to be at least 60% accurate.
- On or before July 1, 2027, a plan’s directories to be at least 80% accurate.
- On or before July 1, 2028, a plan’s directories to be at least 90% accurate.
- On or before July 1, 2029, a plan’s directories to be at least 95% accurate.
- Requires DMHC or CDI to develop procedures and policies on how a plan or insurer is to conduct the verifications. In addition to verifying the information, requires the plan or insurer to:
- In verifying the accuracy of information in the provider directory or directories, determine if a provider has submitted claims or otherwise been compensated for covered benefits in that product or network;
- Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to DMHC or CDI to ensure compliance with this bill;
- Publicly post its accuracy verification reports annually on its website; and,
- Verify the accuracy of the printed directory based on the date of printing, as indicated on each page of the printed directory.
- Requires a plan or insurer to respond no later than one business day after receiving a request by an enrollee or insured to a request for information about whether or not a provider is contacted as an in-network provider, as specified.
Disclosures
- Requires the provider directory to also state the enrollee/insured may submit a complaint if the enrollee/insured believes they reasonably relied upon inaccurate, incomplete, or misleading directory information.
- Requires a plan or insurer to 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. Requires the disclosure to be included within the “Timely Access to Care” section of the directory and include the geographic accessibility standards.
Central utility
- Requires the plan or insurer, if DMHC and CDI develops a methodology and standards that permit the use of a central utility or central utilities, and if a health plan or insurer uses a central utility for some or all of the plan’s provider directory, the plan or insurer to ensure that information derived from the central utility is incorporated in the plan’s or insurer’s provider directory unless the plan or insurer can demonstrate that the information from the central utility is inaccurate.
- Permits DMHC and CDI to require a health plan or insurer to use a central utility or central utilities or designate a central utility or central utilities for providers included in the directory. In developing the methodology, requires DMHC and CDI to seek input from interested parties and permits DMHC and CDI to hold one or more public meetings. Exempts these standards from the Administrative Procedure Act until January 1, 2029.
- Requires the contract with the utility, if DMHC or CDI designates or requires a health plan or insurer to use a central utility or central utilities, to require that incomplete or incorrect information submitted to the central utility not be conveyed to the health plan or insurer. Requires the contract to also require that the central utility notify the submitter of incomplete or inaccurate information.
- Permits DMHC or CDI to allow a plan or insurer not to use the central utility if the plan or insurer can demonstrate it will meet the required benchmarks without using it. Permits DMHC or CDI, if the plan fails to meet the benchmark in the future, to require the plan or insurer to use the central utility as a method to achieve higher accuracy of provider directory listings to comply with the benchmarks in this bill.
- Permits, DMHC or CDI, if they determine that a central utility is frequently failing to provide accurate information to health plans or insurers, to consider no longer requiring or designating that central utility for use.
- Requires a plan or insurer using a central utility to continue to retain responsibility for ensuring that the requirements of this bill are satisfied, including in any contract or other agreement with the central utility.
Penalties
- Requires failure by a health plan or insurer to comply with this bill and the law it amends, including failure to meet the required benchmarks for accuracy, to result in an administrative penalty in an amount consistent with a denial of access to care for covered benefits.
- Makes failure to meet the required benchmarks result in an administrative penalty of not less than $500 per 1,000 enrollees or insureds and up to $5,000 per 1,000 enrollees or insureds, and in the subsequent year shall result in an administrative penalty of not less than one $1,000 per 1,000 enrollees or insureds and up to $10,000 per 1,000 enrollees or insureds for each year following the first year that the plan or insurer failed to meet the benchmark.
- Requires DMHC or CDI to determine the appropriate penalty amount for each violation based on one or more factors as applicable, including the factors outlined in existing law. Requires DMHC or CDI to take into consideration evidence provided by the plan or insurer of policies and procedures to obtain accurate provider information and the use of a central utility.
- Requires penalty amounts, beginning January 1, 2029, and every five years thereafter, 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.
- Requires a plan or insurer to pay any administrative penalties levied on it, and not the provider, subscriber, or enrollee. This does not prevent a plan or insurer from including penalties for noncompliance with verification standards in the provider contract.
- Requires a plan or insurer to arrange care and cover health care services provided by an out-of-network provider when an enrollee or insured relied upon inaccurate, incomplete or misleading information (existing law applies a higher standard of “materially” inaccurate, incomplete, or misleading information). Requires the enrollee or insured to pay in-network cost-sharing only (prohibits the provider from collecting more) that counts toward an in-network deductible and out-of-pocket maximum, and the provider to be paid the out-of-network amount. Adds, to the circumstances under which an enrollee or insured pays no more than in-network cost-sharing, items such as if the online directory is not accessible at the time the enrollee or insured seeks information.
- Specifies that “in-network cost-sharing 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 enrollee or insured is misinformed about the cost-sharing tier of the provider.
- Requires a plan or insurer to file an amendment to their application, or a corrective action, for providers who are not actively participating and have failed to respond timely, if those providers amount to a change of 10% or greater in the network for a product in a region.
- Prohibits a plan or insurer, in any timely access, network adequacy, or other compliance requirements, from using information about a provider not actively participating. Requires DMHC or CDI to define what is “actively participating,” and include consideration of the amount of claims filed by the provider unless a special circumstance (rural area, specialist). Authorizes the departments to issue guidance.
FISCAL EFFECT:
According to the Assembly Committee on Appropriations:
- DMHC estimates costs of approximately $2 million in fiscal year (FY) 2025-26 and $3.5 million annually thereafter for state administration (Managed Care Fund).
- CDI estimates costs of $86,000 in FY 2025-26, $350,000 in FY 2026-27, and $199,000 for FY 2027-28 ongoing (Insurance Fund).
- Both DMHC and CDI will incur costs for staff to inform health plans and insurers of new requirements, review health plans and insurers' provider directory accuracy verification reports, investigate complaints from enrollees and providers, take enforcement actions such as assessing penalties, develop a uniform format for submission of provider directory information from providers, investigate the use of a central utility for provider information, and promulgate regulations.
PRIOR VOTES:
Assembly Floor: | 61 - 7 |
Assembly Appropriations Committee: | 11 - 1 |
Assembly Health Committee: | 11 - 0 |
COMMENTS:
- Author’s statement. According to the author, every health plan in California is required to maintain an accurate list of in-network health care providers for enrollees, which they must update and have reviewed by the regulating department. However, providers on these lists are often unreachable, not accepting new patients, or not part of the health plan’s network. When people sign up for a health plan, they should be able to reasonably expect that most of the health professionals on the list are available to provide care. This bill will improve access to care by establishing accuracy benchmarks and authorizing the use of a third-party central utility to improve the accuracy of provider directories. This legislation provides a roadmap to improve transparency and accountability, making our healthcare system work better for everyone.
- Studies. Health Access California, this bill’s sponsor, references a 2021 study that 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.
- 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.
- DMHC regulations. Since 2015, DMHC has been collaborating closely with stakeholders to develop uniform standards for provider directories for use by health plans. In conjunction with input from stakeholders, DMHC issued the Uniform Provider Directory Standards in December of 2016, requiring health plan compliance by January 2018. In new proposed regulations, DMHC proposes to interpret, implement, and make specific the requirements of the law by updating and promulgating the requirements of the Uniform Provider Directory Standards and by enumerating and defining the scope of requirements for a provider directory or directories and plan obligations. The DMHC comment period closed on May 28, 2025. The proposed regulations clarify ambiguities in key terms and phrases in existing Uniform Provider Directory Standards. These regulations clarify definitions, such as a definition that “accepting new patients” means the network provider is open to enrollees in the network and new patients without limitations such as waitlist, and the process for health plans to update their directories, to include the date of the update, including the date of verification for each provider, and obligations for reporting and investigating inaccurate data as well as other requirements.
- Provider Directory Accuracy Report. RTI International prepared a report for the Office of the Assistance Secretary for Planning and Evaluation (ASPE) at the U.S. Department of Health and Human Services, which was published in December 2023. The report provides case studies of the use of a centralized provider directory in California and other states. California’s “Symphony” is described as the only operational centralized provider directory. Symphony is a statewide, cloud-based technology platform administered by the Integrated Healthcare Association (IHA). Efforts in other states have been explored and planned, but not implemented. Some states have developed centralized databases for other information such as collecting provider credentialing information. The ASPE report indicates that there is no evidence to assess if Symphony leads to fewer inaccuracies. One study referenced in the report indicates even with a central utility, few providers completed the validation process, whether contacted by phone, email, fax, or online portal. A lesson learned included in the ASPE report is that regulatory mandates and accuracy standards may be useful in motivating participation but not sufficient to attain high levels of participation. Additionally, the report indicates that providers need incentives to improve the accuracy of health plan directories. The ASPE report also suggests that data analytics due to machine-readable formats may be one promising method for provider directory accuracy and actively practicing behavioral health providers can be identified through claims data.
According to IHA, currently Symphony has data from 17 health plans and purchasers and 80,000 providers. Plans can access all provider data in one place and providers can update and validate information to all Symphony participating plans simultaneously, reducing administrative budget and ensuring contracted plans have up to date information.
- IHA Testimony. At a Congressional hearing in May of 2023, IHA’s CEO testified that identifying inaccuracies and correcting them is necessary and feasible. In the 30 days before the hearing, a review of provider data from three plans representing 169,731 unique providers, with up to 300 data attributes each (which translates to over 50 million data elements), Symphony’s data mastering identified 138,124 inconsistent data elements (“updates” or “corrections”) that required health plan and provider changes based on validation and survivorship rules adopted by all parties. Of these, over 5,000 were errors in the physical office address, while nearly 2,127 were related to license issues. The CEO also states, a Council for Affordable Quality Healthcare 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—of which mental health providers are more likely to be—this can be cost prohibitive to network participation.
- Related legislation. AB 787 (Papan) requires a plan or insurer to provide a list of providers covered by an enrollee’s health plan contract or insured’s health insurance policy who are accepting patients within two business days upon an urgent request or five business days upon a nonurgent request for assistance from an enrollee or insured, and, requires a health plan’s and health insurer’s provider directories to include information advising an enrollee or insured to contact their health plan or health insurer for assistance finding an in-network provider, their rights for seeing an out-of-network provider, and the specified response times. AB 787 is set to be heard in the Senate Appropriations Committee on July 7, 2025.
- Prior legislation. AB 236 (Holden of 2024) would have phased-in provider directory accuracy rates of 60% by July 1, 2025 to at least 95% accurate by July 1, 2028, and would have imposed fines on plans and insurers that fail to meet the benchmark rates. AB 236 would have made a listing inaccuracy that would impact a patient’s access to care a denial of access to care. AB 236 was held on the Senate Appropriations Committee suspense file.
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 (HAC) is the sponsor of this bill. HAC writes, “A 2018 study investigated the error rates of four health plans in California and found inaccuracy rates up to 80% with a 25% inaccuracy rate for even the best-scoring plan. These inaccuracies are the worst for behavioral health providers. A recent secret shopper survey in Los Angeles revealed that only 15% of those phone calls seeking psychiatric appointments for Medi-Cal patients led to a scheduled appointment - the lowest success across the four states surveyed.” HAC states that existing law puts the burden on individual consumers to complain about provider directory inaccuracies rather than requiring the health plan that created the provider directory to demonstrate its accuracy to the regulator, and, that this bill addresses the problem of provider directory inaccuracies through consumer protections, more efficient processes, and effective enforcement. AARP writes, “When Californians of all ages rely on these inaccurate directories, they may find themselves unable to locate appropriate healthcare, especially in the field of behavioral health, which can result in higher costs to the state in the long-term when Californians cannot find appropriate care. They may also end up having to pay unexpected, large sums out of their own pocket for so-called “out of network” providers. Clearly, these inaccuracies can have truly detrimental impacts on individuals trying to find care that meets their needs in a timely and affordable manner. This danger is especially acute for older Californians and individuals with disabilities.” The California Physicians Alliance writes that they support this bill “because it directly impacts both doctors and patients by reducing administrative burdens and improving access to care. Inaccurate provider directories create frustration for patients who struggle to find available doctors, delaying necessary medical treatment and exacerbating health disparities. For physicians, these inaccuracies result in an influx of patients mistakenly directed to their offices, increasing their workload and straining already limited resources.” The California Public Employees’ Retirement System believes this bill will increase the accuracy of provider directories for the benefit of their members, and will enable them to find providers more efficiently, make better informed decisions when choosing plans and providers and reduces barriers to accessing health care.
- Opposition. The California Association of Health Plans and the Association of California Life and Health Insurance Companies does not believe this bill addresses 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. The opposition writes, “Currently, commercial health plans and insurers spend over $2.1 billion annually to maintain provider databases, clearly demonstrating the commitment health plans and insurers have to supporting accurate provider directories. We certainly appreciate that the bill acknowledges the need for a ‘central utility’ to collect the necessary information for accurate provider directories. However, without provider buy-in and participation, we will ultimately be in the same situation where health plans and insurers are struggling to collect the necessary information to update the provider directories.” The Local Health Plans of California (LHPC) writes, “Plans are already beholden to a myriad of provider directory requirements, including ensuring accuracy. SB 137 (Hernandez) is still in the process of official rulemaking with DMHC, but local plans have implemented the sub- regulatory guidance related to this bill, including annual filings with DMHC. As part of this process, plans annually submit their policies and procedures that outline how provider information is displayed, the schedule for regular updates, how receipt and verification of information works, and process for receiving and investigating reports of inaccurate information. Implementing all the additional administrative requirements of this bill would require plans to dedicate additional resources, including staffing, to comply with monitoring and reporting requirements imposed by DMHC and DHCS.” LHPC also indicates that this bill will subject plans to large penalties disproportionate to member impact, and, the high accuracy benchmarks will propose a challenge that plans will struggle to reach.
- Policy comment. Health plans and insurers should be held accountable for the accuracy of their provider directories but the important role of health care providers in updating their information is a critical component. This bill proposes more requirements and penalties on plans and insurers but does not identify policies to motivate providers to do their part. While the use of a central utility or utilities may help streamline the process it still relies on provider verification. It may be difficult to achieve the accuracy patients’ need without a more balanced approach.
SUPPORT AND OPPOSITION:
Support: Health Access California (sponsor)
AARP
American Federation of State, County, and Municipal Employees
Asian Americans Advancing Justice – Southern California
Association of California State Supervisors
Autism Speaks
California Alliance of Child and Family Services
California Association of Orthodontists
California Coalition on Family Caregiving
California Orthopedic Association
California Pan-Ethnic Health Network
California Pharmacists Association
California Physicians Alliance
California Public Employees’ Retirement System
California Retired Teachers Association
California Senior Legislature
California State Council of Service Employees International Union
California State Retirees
California Teachers Association
Children Now
Community Clinic Association of Los Angeles County
Courage California
Family Caregiver Alliance
Indivisible CA: StateStrong
Latino Coalition for a Healthy California
Mental Health America of California
National Health Law Program
National Union of Healthcare Workers
Retired Public Employees Association
Small Business Majority
Steinberg Institute
The Children’s Partnership
The Kennedy Forum
The Leukemia & Lymphoma Society
Western Center on Law & Poverty, Inc.
Oppose: Association of California Life & Health Insurance Companies
California Association of Health Plans
Local Health Plans of California
-- END --
ASSEMBLY THIRD READING
ATR Bill Id:AB 280
Author:(Aguiar-Curry)
As Amended Ver:May 23, 2025
Majority vote
SUMMARY
Requires a health care service plan (health plan) or health insurer to be responsible for maintaining an accurate provider directory and annually verify and delete inaccurate listings from its provider directories. Requires a provider directory to be 60% accurate on July 1, 2026, with increasing accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2029. Imposes administrative penalties (fines) on health plans and insurers that fail to meet the benchmark rates. Exempts Medi-Cal managed care plans from the accuracy benchmarks and the administrative penalty provisions contained in this bill.
Major Provisions
COMMENTS
Network Adequacy Requirements. Network adequacy standards are utilized to ensure that health plans contain and maintain a network of health care providers adequate for enrollees to access medically necessary in a timely manner. In California state and federal law sets forth various network adequacy requirements on health plans and insurers, including the following:
- Timely Access to Care. State law requires 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 provide health plan members the right to appointments within the following time frames:
- 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 to Care. State law requires 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 provide health plan members the right to appointments within the following time frames:
The Department of Managed Health Care (DMHC) publishes a Timely Access Report, with the most recent publication covering data from measurement year 2022. This report highlighted 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 87% to a low of 56%. For non-urgent appointments, 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 66%. For urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 84% to a low of 46%.
- 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 83% to a low of 66%. For non-urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 89% to a low of 77%. For urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 77% to a low of 46%.
- Geographic Access. Health plans are also generally required to ensure geographic access, meaning 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.
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.
- Provider Directories. Provider directories help patients identify clinicians based on specialty, location, and hours. Provider directories can also act as a tool to inform a patient's choice in health plan, allowing them to search if a particular provider is in-network or assess how many provider choices they will have near them.
- California Law. California was one of the first states to enact provider directory standards. SB 137 (Hernandez), Chapter 649, Statutes of 2015, requires health plans and insurers to maintain accurate online and paper directories as of July 1, 2016. SB 137 also requires the following:
- Provider Directories. Provider directories help patients identify clinicians based on specialty, location, and hours. Provider directories can also act as a tool to inform a patient's choice in health plan, allowing them to search if a particular provider is in-network or assess how many provider choices they will have near them.
- DMHC and California Department of Insurance (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 Law. Plans offered on HealthCare.gov (the 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.
Beginning in 2022, the federal No Surprises Act (NSA) requires all private health plans 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.
- Persistent Inaccuracies. Despite state and federal laws, a Yale Law & Policy Review (Yale Review) article titled, "Laying Ghost Networks to Rest: Combatting Deceptive Health Plan Provider Directories," revealed high error rates across provider directories in California, Louisiana, and Maryland. In California, even the lowest error rate the Yale Review identified, 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 led to a dead end in California.
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. A recent secret shopper survey in Los Angeles revealed that only 15% of phone calls seeking psychiatric appointments for Medi-Cal patients led to a scheduled appointment - the lowest success across the four states surveyed. 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. In 2024, CMS reported inaccuracies in all directories examined in 2022, with similar compliance problems observed in prior years.
- Enforcement, or lack thereof. 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. The Yale Review urges states, like California, to adopt frameworks to prevent directory errors. The Yale Review contends that such frameworks should be focused on regular enforcement, consistent fines for noncompliance, and engaging as many actors as possible in the enforcement scheme.
- DMHC draft provider directory regulations. In December 2024, DMHC proposed regulations on provider directories. According to DMHC, these proposed regulations "will provide clarity regarding the scope of provider directory standards and will allow DMHC to effectively enforce current law." DMHC continues that these proposed regulations will make clear the obligations for both health plans and the DMHC. The first public comment period on these proposed regulations recently closed in February 2025 and the regulatory process is still underway. According to DMHC, it is anticipated to be completed by this summer.
The author and sponsor have argued that these proposed regulations do not include a defined penalty or enforcement mechanism, whereas this bill would outline a clear penalty structure, as recommended by the Yale Review, to ensure health plan compliance.
According to the Author
Every health plan in California is required to maintain an accurate list of in-network health care providers for enrollees, which they must update and have reviewed by the regulating department. The author continues that providers on these lists are often unreachable, not accepting new patients, or not part of the health plan's network. When people sign up for a health plan, they should be able to reasonably expect that most of the health professionals on the list are available to provide care. The author argues that this bill will improve access to care by establishing accuracy benchmarks and authorizing the use of a third-party central utility to improve the accuracy of provider directories. The author concludes that this legislation provides a roadmap to improve transparency and accountability, making our healthcare system work better for everyone.
Arguments in Support
Health Access (HA), sponsor of this bill, states that 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. HA continues that 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. HA states that DMHC's monitoring of timely access to care routinely finds that 20% to 30% of providers are unreachable by the health plan, often because of inaccuracies in the health plan's provider directory. HA argues that inaccuracies have the greatest impact on consumers who already face the worst access such as individuals with limited English proficiency, persons with disabilities, and marginalized communities, thus worsening health inequities. HA contends that existing law puts the burden on individual consumers to complain about provider directory inaccuracies rather than requiring the health plan that created the provider directory to demonstrate its accuracy to the regulator. HA further argues that while our laws and regulations on provider directories and network adequacy are, on paper, some of the strongest in the country, they are falling short for consumers and delaying the access to care they desperately need. HA states that this bill addresses the problem of provider directory inaccuracies through consumer protections, more efficient processes, and effective enforcement.
Arguments in Opposition
The California Association of Health Plans (CAHP) and Association of California Life and Health Insurance Companies (ACLHIC) oppose this bill. CAHP and ACLHIC do not believe that this bill addresses the root cause of the issue of provider directory inaccuracies, 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. According to CAHP and ACLHIC 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. CAHP and ACLHIC further contend that this bill does not recognize the existing work being done by both DMHC and the Integrated Health Care Association around provider directory accuracy. CAHP and ACLHIC agree it is essential to reduce the burden of collecting and maintaining directory information to ensure it is comprehensive and up to date, however in their experience burden reduction alone is not a significant enough incentive to ensure providers consistently update their information in a timely and accurate way.
FISCAL COMMENTS
According to the Assembly Committee on Appropriations:
- DMHC estimates costs of approximately $2 million in fiscal year (FY) 2025-26 and $3.5 million annually thereafter for state administration (Managed Care Fund).
- CDI estimates costs of $86,000 in FY 2025-26, $350,000 in FY 2026-27, and $199,000 for FY 2027-28 ongoing (Insurance Fund).
- Both DMHC and CDI will incur costs for staff to inform health plans and insurers of new requirements, review health plans and insurers' provider directory accuracy verification reports, investigate complaints from enrollees and providers, take enforcement actions such as assessing penalties, develop a uniform format for submission of provider directory information from providers, investigate the use of a central utility for provider information, and promulgate regulations.
VOTES
ASM HEALTH: 11-0-4
YES: Bonta, Addis, Aguiar-Curry, Arambula, Carrillo, Mark González, Krell, Patel, Celeste Rodriguez, Schiavo, Stefani
ABS, ABST OR NV: Chen, Flora, Sanchez, Sharp-Collins
ASM APPROPRIATIONS: 11-1-3
YES: Wicks, Arambula, Calderon, Caloza, Elhawary, Fong, Mark González, Hart, Pacheco, Pellerin, Solache
NO: Dixon
ABS, ABST OR NV: Sanchez, Ta, Tangipa
UPDATED
VERSION: May 23, 2025
CONSULTANT: Riana King / HEALTH / (916) 319-2097 FN: 0000920
Date of Hearing: April 23, 2025
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Buffy Wicks, Chair
ABPCA Bill Id:AB 280
Author:(Aguiar-Curry) – As Introduced Ver:January 21, 2025
Policy Committee: | Health | Vote: | 11 - 0 |
|
| ||
|
|
Urgency: No State Mandated Local Program: Yes Reimbursable: No
SUMMARY:
This bill requires a health care service plan (health plan) or health insurer to maintain an accurate provider directory and annually verify and delete inaccurate listings from its provider directory. The bill requires a provider directory to be 60% accurate on July 1, 2026, with increasing accuracy benchmarks each year, reaching 95% accuracy on or before July 1, 2029, and imposes fines on a health plan or insurer that fails to meet the benchmark rates.
Specifically, this bill:
- Requires a health plan or health insurer to meet the following minimum accuracy benchmarks:
- 60% on or before July 1, 2026.
- 80% on or before July 1, 2027.
- 90% on or before July 1, 2028.
- 95% on or before July 1, 2029.
- Sets an administrative penalty at no less than $500 per 1,000 enrollees and up to $5,000 per 1,000 enrollees if a health plan or insurer fails to meet the required benchmarks above, and specifies increased penalties if a health plan or health insurer fails to meet the benchmark in the subsequent year.
- Establishes numerous other requirements for provider directories, including calculation of accuracy, annual verification of accuracy, provision of health plan or insurer contact information, disclosures of a health plan or insurer’s duties to arrange coverage when behavioral health benefits are not available in-network within applicable access standards, provider cost-sharing tier, if applicable,
- Requires a health plan or health insurer to annually submit its accuracy verification reports to the Department of Managed Health Care (DMHC) or California Department of Insurance (CDI) to ensure compliance with this section and publicly post its accuracy verification reports annually on its internet website.
- Requires DMHC and CDI, when assessing administrative penalties against a health plan or health insurer, to determine the appropriate penalty amount for each violation based on specified factors. Provides for adjustments to penalties every five years.
- Authorizes, on or before January 1, 2026, DMHC and CDI to develop a uniform format with standardized naming conventions and other aspects for each plan to use to request directory information from its providers.
- Authorizes, on or before January 1, 2026, DMHC and CDI to establish a methodology and processes to ensure accuracy of provider directories and consistency with other state or federal laws, regulations, or standards, as specified.
- Authorizes DMHC and CDI to require a health plan or health insurer to use a central utility or central utilities, or designate a central utility or central utilities for those providers included in the directory.
- Specifies that this bill and existing law applies to plans with Medi-Cal managed care contracts.
FISCAL EFFECT:
DMHC estimates costs of approximately $2 million in fiscal year (FY) 2025-26 and $3.5 million annually thereafter for state administration (Managed Care Fund).
CDI estimates costs of $86,000 in FY 2025-26, $350,000 in FY 2026-27, and $199,000 for FY 2027-28 ongoing (Insurance Fund).
Both DMHC and CDI will incur costs for staff to inform health plans and insurers of new requirements, review health plans and insurers’ provider directory accuracy verification reports, investigate complaints from enrollees and providers, take enforcement actions such as assessing penalties, develop a uniform format for submission of provider directory information from providers, investigate the use of a central utility for provider information, and promulgate regulations.
COMMENTS:
- Purpose. This bill is sponsored by Health Access. According to the author:
Every health plan in California is required to maintain an accurate list of in-network health care providers for enrollees…However, providers on these lists are often unreachable, not accepting new patients, or not part of the health plan’s network. When people sign up for a health plan, they should be able to reasonably expect that most of the health professionals on the list are available to provide care. AB 280 will improve access to care by establishing accuracy benchmarks and authorizing the use of a third-party central utility to improve the accuracy of provider directories. This legislation provides a roadmap to improve transparency and accountability, making our healthcare system work better for everyone.
- 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.
In December 2024, DMHC proposed regulations on provider directories. According to DMHC, these proposed regulations “will provide clarity regarding the scope of provider directory standards and will allow DMHC to effectively enforce current law.” DMHC states these proposed regulations will make clear the obligations to both health plans and the DMHC. The regulatory process is still underway; DMHC anticipates it to be completed by this summer.
- Related Legislation. AB 787 (Papan) requires a health plan and insurer to include a statement at the top of the provider directory advising an enrollee or insured to contact the health plan or insurer for assistance in finding an in-network provider, and requires the plan or insurer to respond within one business day if contacted for assistance, and to provide within two business days a list of in-network providers confirmed to be accepting new patients. AB 787 is pending in this committee.
- Prior Legislation.
SB 137 (Hernandez), Chapter 649, Statutes of 2015, established the requirements that provider name, address, telephone number, languages spoken, and email contacts be listed accurately in provider directories; that directories be regularly updated by plans and insurers; and that the directories be reviewed annually by CDI and DMHC to verify the directories have been updated accurately.
AB 236 (Holden), of the 2023-24 Legislative Session, was substantially similar to this bill. AB 236 was held in the Senate Appropriations Committee.
Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081
Date of Hearing: April 1, 2025
ASSEMBLY COMMITTEE ON HEALTH
Mia Bonta, Chair
ABPCA Bill Id:AB 280
Author:(Aguiar-Curry) – As Introduced Ver:January 21, 2025
SUBJECT: Health care coverage: provider directories.
SUMMARY: Requires a health care service plan (health plan) or health insurer to be responsible for maintaining an accurate provider directory and annually verify and delete inaccurate listings from its provider directories. Requires a provider directory to be 60% accurate on July 1, 2026, with increasing accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2029. Imposes fines on health plans and insurers that fail to meet the benchmark rates. Specifically, this bill:
- Requires a health plan or health insurer to be responsible for maintaining an accurate provider directory.
- Requires the following accuracy benchmarks to be met by a health plan or health insurer:
- On July 1, 2026, directories to be at least 60% accurate;
- On or before July 1, 2027, directories to be at least 80% accurate;
- On or before July 1, 2028, directories to be at least 90% accurate; and,
- On or before July 1, 2029, directories to be at least 95% accurate.
- Requires the accuracy percentage of a directory to be determined by the percentage of providers for which all information required in this bill and existing statute is accurate. Specifies that if there is one error that would impact a patient’s access to care on a listing for a provider, that listing is considered inaccurate.
- Requires a health plan or health insurer to annually verify its provider directories for accuracy.
- Requires, in addition to verifying the information required under this bill and existing statute, a health plan or health insurer to do all of the following:
- Determine, in verifying the accuracy of information in the provider directory or directories, if a provider has submitted claims or otherwise been compensated for covered benefits for enrollees in that product or network;
- Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the Department of Managed Health Care (DMHC) or California Department of Insurance (CDI) to ensure compliance with this section;
- Publicly post its accuracy verification reports annually on its internet website; and,
- Base verification of the accuracy of the printed directory on the date of printing and provide the accuracy on each page of the printed directory.
- Requires a provider directory to display the date of the most recent update, including a printed provider directory. Requires the provider directory to 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. Requires the provider directory to state that the enrollee may submit a complaint if the enrollee believes they reasonably relied upon materially inaccurate, incomplete, or misleading directory information.
- Requires a health plan or health insurer 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 on its print and online provider directories.
- Requires a provider directory to also include:
- The provider’s telephone number;
- The population served by the provider, meaning adult, pediatric, or both;
- A listing for dispensing optometrists and opticians and optical dispensaries;
- Whether or not the provider is in the lowest cost-sharing tier, if there is more than one cost-sharing tier; and,
- The provider’s contract termination date, if any. Requires the health plan or health 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.
- Authorizes administrative penalties for a health plan or health insurer who fails to comply with the requirements of this bill and existing law. Specifies that in determining the appropriate amount of an administrative penalty, a listing inaccuracy that would impact a patient’s access to care shall be treated as a denial of access to care for covered benefits.
- Requires that if a health plan or health insurer fails to meet the required benchmarks in 2) above, an administrative penalty will be no less than $500 per 1,000 enrollees and up to $5,000 per 1,000 enrollees. Specifies that if a health plan or health insurer fails to meet the benchmark in the subsequent year, an administrative penalty will be no less than $1,000 per 1,000 enrollees and up to $10,000 per 1,000 enrollees for each year following the first year that the health plan or health insurer failed to meet the benchmark.
- Requires DMHC and CDI, when assessing administrative penalties against a health plan or health insurer, to determine the appropriate penalty amount for each violation based on one more factors, as specified.
- Requires, beginning January 1, 2029, and every subsequent five years, the penalty amounts specified in 10) above 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.
- Requires administrative penalties to be paid by the health plan or health insurer. Prohibits payment of the administrative penalties by the provider, subscriber, or enrollee. Clarifies that a plan is not prevented from including penalties for noncompliance with verification standards in a provider contract.
- Requires the health plan or health insurer, in circumstances where the DMHC or CDI find that an enrollee reasonably relied on inaccurate, incomplete, or misleading information in the provider directory, to 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 in-network under the enrollee’s plan, and reimburse the provider the out-of-network amount. Prohibits the provider from collecting any additional amount from the enrollee other than the applicable in-network cost sharing.
- Requires, within one business day, the health plan or health insurer to follow up with an enrollee who by telephone or electronic means requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits. Requires the health plan or health insurer to retain a record of the request and the plan or insurers response in the enrollee’s file for at least two years.
- Prohibits an enrollee from paying more than in-network cost sharing for covered benefits, if the enrollee obtained information that a provider was in-network through the health plan or health insurer’s online directory or through a request consistent with 15) above, in any of the following situations:
- The provider is not contracting with the health plan or health 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; or,
- The online provider directory is not accessible to enrollees at the time the enrollee seeks information and the enrollee requests information consistent with 15) above.
- Requires, if the health plan or health insurer contract includes more than one tier of cost sharing, the plan or insurer to document the cost-sharing tier that the provider is contracted to accept and provide that information to the enrollee when the enrollee seeks information about the provider. Prohibits an enrollee from owing more than the cost sharing for the cost-sharing tier included in the information provided by the plan or insurer.
- Defines in-network cost sharing amount for a contracted provider to include copayments, deductibles, coinsurance, and any other form of cost sharing. Specifies that if an enrollee was not informed accurately of the applicable cost-sharing tier, then the lowest cost-sharing will apply.
- Prohibits a health plan or health insurer from using information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provisions of existing law if the plan or insurer cannot demonstrate that the provider is actively contracting with the plan, as specified.
- Requires DMHC and CDI to determine the definition of “actively contracting” and consider the degree of utilization for that provider by considering if the provider has filed one or more claims for covered services to enrollees by the relevant network, unless special circumstances apply.
- Specifies that for 20) above, 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 through regulatory or other rulemaking processes.
- Prohibits a plan from advertising or otherwise representing the extent of its network, including the number or type of contracting providers, unless it is able to demonstrate that each provider is contracting.
- Permits, on or before January 1, 2026, DMHC and CDI to develop a uniform format with standardized naming conventions and other aspects for each plan to use to request directory information from its providers.
- Permits, on or before January 1, 2026, DMHC and CDI to establish a methodology and processes to ensure accuracy of provider directories and consistency with other state or federal laws, regulations, or standards. Requires DMHC and CDI to take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity.
- Permits DMHC and CDI to require a health plan or health insurer to use a central utility or central utilities, or designate a central utility or central utilities for those providers included in the directory. Requires DMHC and CDI to seek input from interested parties and permits them to hold one or more public meetings.
- Permits DMHC and CDI to allow a plan to not use the central utility, if the plan can demonstrate that it will meet the benchmarks required in 2) above without it.
- Clarifies that if DMHC or CDI permit the use of a central utility or central utilities, and the health plan or health insurer use the central utility for some or all of the plan’s provider directory, the plan must ensure that the information derived from the central utility is incorporated in the plan’s provider directory unless the health plan or health insurer can demonstrate that the information from the central utility is inaccurate.
- Specifies that this bill and existing law applies to plans with Medi-Cal managed care contracts with the Department of Health Care Services (DHCS).
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 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, every health plan in California is required to maintain an accurate list of in-network health care providers for enrollees, which they must update and have reviewed by the regulating department. The author continues that providers on these lists are often unreachable, not accepting new patients, or not part of the health plan’s network. When people sign up for a health plan, they should be able to reasonably expect that most of the health professionals on the list are available to provide care. The author argues that this bill will improve access to care by establishing accuracy benchmarks and authorizing the use of a third-party central utility to improve the accuracy of provider directories. The author concludes that this legislation provides a roadmap to improve transparency and accountability, making our healthcare system work better for everyone.
- BACKGROUND.
- Network Adequacy Requirements. Network adequacy standards are utilized to ensure that health plans contain and maintain a network of health care providers adequate for enrollees to access medically necessary in a timely manner. In California state and federal law sets forth various network adequacy requirements on health plans and insurers, including the following:
- Timely Access to Care. State law requires 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 provide health plan members the right to appointments within the following time frames:
- 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 to Care. State law requires 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 provide health plan members the right to appointments within the following time frames:
- Network Adequacy Requirements. Network adequacy standards are utilized to ensure that health plans contain and maintain a network of health care providers adequate for enrollees to access medically necessary in a timely manner. In California state and federal law sets forth various network adequacy requirements on health plans and insurers, including the following:
DMHC publishes a Timely Access Report, with the most recent publication covering data from measurement year 2022. This report highlighted 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 87% to a low of 56%. For non-urgent appointments, 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 66%. For urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 84% to a low of 46%.
- 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 83% to a low of 66%. For non-urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 89% to a low of 77%. For urgent appointments, the percentage of all surveyed providers who had appointments available within the wait time standards ranged from a high of 77% to a low of 46%.
In this report, DMHC noted that they will begin holding health plans accountable to meet the minimum urgent and non-urgent rates of compliance set forth in regulations. This means that DMHC will require health plans that don’t meet a 70% rate in measurement year 2023, for urgent or non-urgent appointments, to submit a corrective action plan to DMHC. For behavioral health follow-up appointments, health plans who do not meet the 10 business day standard at an 80% rate in measurement year 2023 will need to submit a corrective action plan.
- Geographic Access. Health plans are also generally required to ensure geographic access, meaning 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.
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.
- Provider Directories. Provider directories help patients identify clinicians based on specialty, location, and hours. Provider directories can also act as a tool to inform a patient’s choice in health plan, allowing them to search if a particular provider is in-network or assess how many provider choices they will have near them.
- California Law. California was one of the first states to enact provider directory standards. SB 137 (Hernandez), Chapter 649, Statutes of 2015, requires health plans and insurers to maintain accurate online and paper directories as of July 1, 2016. SB 137 also requires 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 Law. Plans offered on HealthCare.gov (the 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.
- California Law. California was one of the first states to enact provider directory standards. SB 137 (Hernandez), Chapter 649, Statutes of 2015, requires health plans and insurers to maintain accurate online and paper directories as of July 1, 2016. SB 137 also requires the following:
- Provider Directories. Provider directories help patients identify clinicians based on specialty, location, and hours. Provider directories can also act as a tool to inform a patient’s choice in health plan, allowing them to search if a particular provider is in-network or assess how many provider choices they will have near them.
Beginning in 2022, the federal No Surprises Act (NSA) requires all private health plans 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.
- Persistent Inaccuracies. Despite state and federal laws, a Yale Law & Policy Review (Yale Review) article titled, “Laying Ghost Networks to Rest: Combatting Deceptive Health Plan Provider Directories,” revealed high error rates across provider directories in California, Louisiana, and Maryland. In California, even the lowest error rate the Yale Review identified, 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 led to a dead end in California.
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. A recent secret shopper survey in Los Angeles revealed that only 15% of phone calls seeking psychiatric appointments for Medi-Cal patients led to a scheduled appointment - the lowest success across the four states surveyed. 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. In 2024, CMS reported inaccuracies in all directories examined in 2022, with similar compliance problems observed in prior years.
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. Some of the findings included:
- Extensive inaccuracies were found across all four sources of information. The inaccuracy rate for phone numbers ranged from 25% to 48%;
- Google was the most accurate source for a provider’s name, address, and phone number; 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.
While consumers can theoretically seek out correct addresses and phone numbers on their own, search engines are at best a partial replacement for accurate directories. Furthermore, inaccurate provider directories can cause a wide range of consumer harms. According to the Yale Review, directory errors misrepresent the breadth, and thus the value, of a plan’s coverage. Individuals may also receive large, surprise bills if they see a provider that is inaccurately listed as in-network. Some individuals get worn down by hours of calling providers who are incorrectly listed and give up on finding an in-network provider, leading them to either pay a higher fee to see an out-of-network provider or delay or skip care altogether.
- Enforcement, or lack thereof. 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.
The Yale Review urges states, like California, to adopt frameworks to prevent directory errors. The Yale Review contends that such frameworks should be focused on regular enforcement, consistent fines for noncompliance, and engaging as many actors as possible in the enforcement scheme.
- DMHC draft provider directory regulations. In December 2024, DMHC proposed regulations on provider directories. According to DMHC, these proposed regulations “will provide clarity regarding the scope of provider directory standards and will allow DMHC to effectively enforce current law.” DMHC continues that these proposed regulations will make clear the obligations for both health plans and the DMHC. The first public comment period on these proposed regulations recently closed in February 2025 and the regulatory process is still underway. According to DMHC, it is anticipated to be completed by this summer.
The author and sponsor have argued that these proposed regulations do not include a defined penalty or enforcement mechanism, whereas this bill would outline a clear penalty structure, as recommended by the Yale Review, to ensure health plan compliance.
- Central Utility. This bill permits DMHC and CDI to require health plans or insurers to use a central utility or designate a central utility for providers included in the directory. There is an existing centralized platform for provider directory data in California, Symphony, run by the Integrated Health Care Association. Symphony is a cloud-based platform that partners with health plans and providers to streamline the burdensome work associated with provider data exchange and validation. According to Symphony’s website, they have collected data directly from 17 health plans and 80,000 providers. Health plans utilizing Symphony can access all provider information in one place to update their member directories. These 80,000 providers can then update and validate their information to all health plans utilizing Symphony simultaneously. It should be noted that this bill is not specific to a vendor, so state regulators could designate one or more central utilities for the purposes of this bill.
- SUPPORT. Health Access (HA), sponsor of this bill, states that 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. HA continues that 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. HA states that DMHC’s monitoring of timely access to care routinely finds that 20% to 30% of providers are unreachable by the health plan, often because of inaccuracies in the health plan’s provider directory. HA argues that inaccuracies have the greatest impact on consumers who already face the worst access such as individuals with limited English proficiency, persons with disabilities, and marginalized communities, thus worsening health inequities. HA contends that existing law puts the burden on individual consumers to complain about provider directory inaccuracies rather than requiring the health plan that created the provider directory to demonstrate its accuracy to the regulator. HA further argues that while our laws and regulations on provider directories and network adequacy are, on paper, some of the strongest in the country, they are falling short for consumers and delaying the access to care they desperately need. HA states that this bill addresses the problem of provider directory inaccuracies through consumer protections, more efficient processes, and effective enforcement.
- OPPOSITION. The California Association of Health Plans (CAHP) and Association of California Life and Health Insurance Companies (ACLHIC) oppose this bill. CAHP and ACLHIC do not believe that this bill addresses the root cause of the issue of provider directory inaccuracies, 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. According to CAHP and ACLHIC 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. CAHP and ACLHIC further contend that this bill does not recognize the existing work being done by both DMHC and the Integrated Health Care Association around provider directory accuracy. CAHP and ACLHIC agree it is essential to reduce the burden of collecting and maintaining directory information to ensure it is comprehensive and up to date, however in their experience burden reduction alone is not a significant enough incentive to ensure providers consistently update their information in a timely and accurate way.
- RELATED LEGISLATION. AB 787 (Papan) would require health plans and insurers to include in its provider directory a statement at the top of the directory advising an enrollee or insured to contact the health plan or insurer for assistance in finding an in-network provider. AB 787 would require the plan or insurer to respond within 24 hours if contacted for assistance, and to provide a list of in-network providers confirmed to be accepting new patients within 2 business days. AB 787 is pending in the Assembly Health Committee.
- PREVIOUS LEGISLATION.
- AB 236 (Holden) of 2023, would have phased in provider directory accuracy rates of 60% by July 1, 2025 to at least 95% accurate by July 1, 2028. Would have imposed fines on plans and insurers that fail to meet the benchmark rates. AB 236 was held in the Senate Appropriations Committee.
- AB 815 (Wood) of 2023, would have extended 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 was held in the Senate Appropriations Committee.
- 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 Medi-Cal 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.
- 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 adopt regulations to ensure that enrollees have access to needed health care services.
REGISTERED SUPPORT / OPPOSITION:
Support
Health Access California (sponsor)
American Federation of State, County and Municipal Employees, AFL-CIO
Asian Americans Advancing Justice – Southern California
California Alliance of Child and Family Services
California Association of Orthodontists
California Coalition on Family Caregiving
California Orthopedic Association
California Pan-Ethnic Health Network
California Pharmacists Association
California Physicians Alliance
Children Now
Courage California
Family Caregiver Alliance
Indivisible CA: Statestrong
Mental Health America of California
National Union of Healthcare Workers (NUHW)
Steinberg Institute
The Children’s Partnership
Western Center on Law & Poverty, INC.
Opposition
California Association of Health Plans
Association of California Life & Health Insurance Companies
Local Health Plans of California
Analysis Prepared by: Riana King / HEALTH / (916) 319-2097
Discussed in Hearing
1MIN
Assembly Floor
2MIN
Senate Floor
32SEC
Senate Standing Committee on Appropriations
22MIN
Senate Standing Committee on Health
1MIN
Assembly Floor
20MIN
Assembly Standing Committee on Health
Bill Co-Author(s):