AB 787: Provider directory disclosures.
- Session Year: 2025-2026
- House: Assembly
- Latest Version Date: 2025-06-23
Current Status:
In Progress
(2025-08-29: In committee: Held under submission.)
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?
Health plans and health insurers, including specialized mental health and dental plans, must add a clear statement in their provider directories telling members to contact the plan or insurer for help finding an in‑network provider and to explain their rights about out‑of‑network coverage. When a member asks for help the plan or insurer must acknowledge the request within one business day and provide a confirmed list of in‑network providers accepting new patients within two business days for requests the member marks urgent and within five business days for nonurgent requests; the list must show when each provider was confirmed and note that availability can change.
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 specified health care service plans and health insurers to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to enrollees or insureds, and requires a health care service plan or health insurer to regularly update its printed and online provider directory or directories, as specified. Existing law requires provider directories to include specified information and disclosures.
This bill would require a full service health care service plan, specialized mental health or dental plan, health insurer, or specialized mental health or dental insurer to include in its provider directory or directories a statement at the top of the directory advising an enrollee or insured to contact the plan or insurer for assistance in finding an in-network provider. provider and for an explanation of their rights regarding out-of-network coverage, and would specify the format of the statement. The bill would require the plan or insurer to respond acknowledge the request within one business day if contacted for that assistance, and to provide a list of in-network providers confirmed to be accepting new patients within 2 business days. days for a request deemed urgent by the enrollee or insured and 5 business days for a request deemed nonurgent by an enrollee or insured. Because a violation of these provisions 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 specified health care service plans and health insurers to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to enrollees or insureds, and requires a health care service plan or health insurer to regularly update its printed and online provider directory or directories, as specified. Existing law requires provider directories to include specified information and disclosures.
This bill would require a full service health care service plan, specialized mental health plan, health insurer, or specialized mental health insurer to include in its provider directory or directories a statement at the top of the directory advising an enrollee or insured to contact the plan or insurer for assistance in finding an in-network provider. The bill would require the plan or insurer to respond within 24 hours one business day if contacted for that assistance, and to provide a list of in-network providers confirmed to be accepting new patients within 2 business days. Because a violation of these provisions 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 specified health care service plans and health insurers to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to enrollees or insureds, and requires a health care service plan or health insurer to regularly update its printed and online provider directory or directories, as specified. Existing law requires provider directories to include specified information and disclosures.
This bill would require a full service health care service plan, specialized mental health plan, health insurer, or specialized mental health insurer to include in its provider directory or directories a statement at the top of the directory advising an enrollee or insured to contact the plan or insurer for assistance in finding an in-network provider. The bill would require the plan or insurer to respond within 24 hours if contacted for that assistance, and to provide a list of in-network providers confirmed to be accepting new patients within 2 business days. Because a violation of these provisions 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 requires a private not-for-profit acute hospital to annually adopt and update a community benefits plan that describes the activities that the hospital has undertaken to address identified community needs within its mission and financial capacity. Under existing law, community benefit includes, among other things, health care services rendered to vulnerable populations, including, but not limited to, charity care and the unreimbursed cost of providing services to the uninsured, underinsured, and persons eligible for specified public health care programs. Existing law requires the hospital to annually submit its community benefits plan to the Department of Health Care Access and Information.This bill would make technical, nonsubstantive changes to certain definitions for purposes of the above-described provisions.Existing law requires a private not-for-profit acute hospital to annually adopt and update a community benefits plan that describes the activities that the hospital has undertaken to address identified community needs within its mission and financial capacity. Under existing law, community benefit includes, among other things, health care services rendered to vulnerable populations, including, but not limited to, charity care and the unreimbursed cost of providing services to the uninsured, underinsured, and persons eligible for specified public health care programs. Existing law requires the hospital to annually submit its community benefits plan to the Department of Health Care Access and Information.
This bill would make technical, nonsubstantive changes to certain definitions for purposes of the above-described provisions.
(a)Commencing July 1, 2016, a health care service plan shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plans enrollees, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the plan.
(b)A health care service plan shall provide the directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, enrollees, potential enrollees, the department, and other state or federal agencies can easily identify the networks and plan products in which a provider participates. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), (l), whichever occurs later, a health care service plan shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k). (l).
(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), (l), 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.
(d)(1)A health care service plan shall allow enrollees, potential enrollees, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the plan through the plans toll-free telephone number, electronically, or in writing. A printed copy of the provider directory or directories shall include the information required in subdivisions (h) and (i). The printed copy of the provider directory or directories shall be provided to the requester by mail postmarked no later than five business days following the date of the request and may be limited to the geographic region in which the requester resides or works or intends to reside or work.
(2)A health care service plan shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law.
(e)(1)The plan shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the plan of any of the following:
(A)A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients.
(B)A provider is no longer under contract for a particular plan product.
(C)A providers practice location or other information required under subdivision (h) or (i) has changed.
(D)Upon completion of the investigation described in subdivision (o), (p), a change is necessary based on an enrollee complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly.
(E)Any other information that affects the content or accuracy of the provider directory or directories.
(2)Upon confirmation of any of the following, the plan shall delete a provider from the directory or directories when:
(A)A provider has retired or otherwise has ceased to practice.
(B)A provider or provider group is no longer under contract with the plan for any reason.
(C)The contracting provider group has informed the plan that the provider is no longer associated with the provider group and is no longer under contract with the plan.
(f)The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the plan if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the plans internet website.
(g)The provider directory or directories shall include the following disclosures informing enrollees that they are entitled to both of the following:
(1)Language interpreter services, at no cost to the enrollee, including how to obtain interpretation services in accordance with Section 1367.04.
(2)Full and equal access to covered services, including enrollees with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.
(h)A full service health care service plan and a specialized mental health plan shall include all of the following information in the provider directory or directories:
(1)The providers name, practice location or locations, and contact information.
(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.
(7)The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
(8)A listing for each of the following providers that are under contract with the plan:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the plan.
(B)Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in Section 1374.73, nurse-midwives, and dentists.
(C)For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic.
(D)For any provider described in subparagraph (A) or (B) who is employed by a federally qualified health center or primary care clinic, and to the extent their services may be accessed and are covered through the contract with the plan, the name of the provider, and the name of the federally qualified health center or clinic.
(E)Facilities, including, but not limited to, general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities.
(F)Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services.
(9)The provider directory or directories may note that authorization or referral may be required to access some providers.
(10)Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 1367.04, if any, on the providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)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.
(13)A statement at the top of the directory advising an enrollee to contact the health care service plan for assistance in finding an in-network provider. provider and for an explanation of their rights regarding out-of-network coverage. The statement shall be drafted pursuant to both of the following:
(A)The statement shall appear as follows:
(i)For a printed directory, the statement shall appear either at the top of each page or on the front cover of the directory in 16-point type.
(ii)For a PDF directory, the statement shall appear at the top of each page.
(iii)For a navigable or searchable directory on an internet web page, the statement shall appear in a fixed banner visible at the top of each page.
(B)The statement shall include a notice advising the enrollee that they may designate the request as either urgent or nonurgent. The statement shall contain language that advises the enrollee that urgent requests shall be responded to within two business days and nonurgent requests shall be responded to within five business days.
(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.
(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.
(7)The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.
(8)The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the plan.
(9)The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 1367.04, if any, on the providers staff.
(10)Identification of providers who no longer accept new patients for some or all of the plans products.
(11)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(j)A specialized dental plan shall include a statement in each provider directory or directories used by the plan for its networks advising an enrollee to contact the plan for assistance finding an in-network provider and for an explanation of their rights regarding out-of-network coverage, which shall meet the requirements of paragraph (13) of subdivision (h).
(j)(k)(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)(l)(1)On or before December 31, 2016, the department shall develop uniform provider directory standards to permit consistency in accordance with subdivision (b) and paragraph (2) of subdivision (c) and development of a multiplan directory by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2021. No more than two revisions of those standards shall be exempt from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) pursuant to this subdivision.
(2)In developing the standards under this subdivision, the department shall seek input from interested parties throughout the process of developing the standards and shall hold at least one public meeting. The department shall take into consideration any requirements for provider directories established by the federal Centers for Medicare and Medicaid Services and the State Department of Health Care Services.
(3)By July 31, 2017, or 12 months after the date provider directory standards are developed under this subdivision, whichever occurs later, a plan shall use the standards developed by the department for each product offered by the plan.
(l)(m)(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). (n).
(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)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4).
(m)(n)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)(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). (m). 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) (m) 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). (m).
(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). (m).
(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). (n).
(5)With respect to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.
(q)(r)In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee.
(r)(s)Whenever a plan determines as a result of this section that there has been a 10-percent change in the network for a product in a region, the plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.
(s)(t)If an enrollee contacts a health care service plan for assistance in finding an in-network provider, provider and for an explanation of their rights regarding out-of-network coverage, the plan shall respond acknowledge the request to the enrollee within one business day and shall provide search results within two business days. days for a request deemed urgent by the enrollee and five business days for a request deemed nonurgent by an enrollee. For purposes of this subdivision, search results means a list of providers covered by the enrollees contract that are accepting patients, which shall be confirmed by the health care service plan at the time of the enrollees request. Search results shall only include providers that have responded to requests to verify their listing information in the health care service plans last annual verification pursuant to subdivision (l). (m). A plan shall include with the search results the date that the plan confirmed the providers on the list are accepting new patients and a statement indicating that a provider may close to new patients at the providers discretion, so this information may change in the future.
(t)(u)This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d).
(u)(v)A health plan that contracts with multiple employer welfare agreements regulated pursuant to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 of the Insurance Code shall meet the requirements of this section.
(v)(w)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)(x)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).
(x)(y)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 2.Section 10133.15 of the Insurance Code is amended to read:10133.15.(a)Commencing July 1, 2016, a health insurer that contracts with providers for alternative rates of payment pursuant to Section 10133 shall publish and maintain provider directory or directories with information on contracting providers that deliver health care services to the insurers insureds, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the insurer.
(b)An insurer shall provide the online directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, insureds, potential insureds, the department, and other state or federal agencies can easily identify the networks and insurer products in which a provider participates. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), (l), whichever occurs later, an insurer shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k). (l).
(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), (l), 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.
(d)(1)An insurer shall allow insureds, potential insureds, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the insurer through the insurers toll-free telephone number, electronically, or in writing. A printed copy of the provider directory or directories shall include the information required in subdivisions (h) and (i). The printed copy of the provider directory or directories shall be provided to the requester by mail postmarked no later than five business days following the date of the request and may be limited to the geographic region in which the requester resides or works or intends to reside or work.
(2)An insurer shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law.
(e)(1)The insurer shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the insurer of any of the following:
(A)A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients.
(B)A contracted provider is no longer under contract for a particular product.
(C)A providers practice location or other information required under subdivision (h) or (i) has changed.
(D)Upon the completion of the investigation described in subdivision (o), (p), a change is necessary based on an insured complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly.
(E)Any other information that affects the content or accuracy of the provider directory or directories.
(2)Upon confirmation of any of the following, the insurer shall delete a provider from the directory or directories when:
(A)A provider has retired or otherwise has ceased to practice.
(B)A provider or provider group is no longer under contract with the insurer for any reason.
(C)The contracting provider group has informed the insurer that the provider is no longer associated with the provider group and is no longer under contract with the insurer.
(f)The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the insurer if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the insurers internet website.
(g)The provider directory or directories shall include the following disclosures informing insureds that they are entitled to both of the following:
(1)Language interpreter services, at no cost to the insured, including how to obtain interpretation services in accordance with Section 10133.8.
(2)Full and equal access to covered services, including insureds with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.
(h)The insurer and a specialized mental health insurer shall include all of the following information in the provider directory or directories:
(1)The providers name, practice location or locations, and contact information.
(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.
(7)The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds.
(8)A listing for each of the following providers that are under contract with the insurer:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the insurer.
(B)Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in Section 10144.51, nurse-midwives, and dentists.
(C)For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic.
(D)For any provider described in subparagraph (A) or (B) who is employed by a federally qualified health center or primary care clinic, and to the extent their services may be accessed and are covered through the contract with the insurer, the name of the provider, and the name of the federally qualified health center or clinic.
(E)Facilities, including, but not limited to, general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities.
(F)Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services.
(9)The provider directory or directories may note that authorization or referral may be required to access some providers.
(10)Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, 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 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.
(13)A statement at the top of the directory advising an insured to contact the insurer for assistance in finding an in-network provider. provider and for an explanation of their rights regarding out-of-network coverage. The statement shall be drafted pursuant to both of the following:
(A)The statement shall appear as follows:
(i)For a printed directory, the statement shall appear either at the top of each page or on the front cover of the directory in 16-point type.
(ii)For a PDF directory, the statement shall appear at the top of each page.
(iii)For a navigable or searchable directory on an internet web page, the statement shall appear in a fixed banner visible at the top of each page.
(B)The statement shall include a notice advising the insured that they may designate the request as either urgent or nonurgent. The statement shall contain language that advises the insured that urgent requests shall be responded to within two business days and nonurgent requests shall be responded to within five business days.
(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.
(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.
(7)The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.
(8)The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the insurer.
(9)The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, if any, on the providers staff.
(10)Identification of providers who no longer accept new patients for some or all of the insurers products.
(11)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(j)A specialized dental insurer shall include a statement in each provider directory or directories used by the insurer for its networks advising an insured to contact the insurer for assistance finding an in-network provider and for an explanation of their rights regarding out-of-network coverage, which shall meet the requirements of paragraph (13) of subdivision (h).
(j)(k)(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)(l)(1)On or before December 31, 2016, the department shall develop uniform provider directory standards to permit consistency in accordance with subdivision (b) and paragraph (2) of subdivision (c) and development of a multiplan directory by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2021. No more than two revisions of those standards shall be exempt from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) pursuant to this subdivision.
(2)In developing the standards under this subdivision, the department shall seek input from interested parties throughout the process of developing the standards and shall hold at least one public meeting. The department shall take into consideration any requirements for provider directories established by the federal Centers for Medicare and Medicaid Services and the State Department of Health Care Services.
(3)By July 31, 2017, or 12 months after the date provider directory standards are developed under this subdivision, whichever occurs later, an insurer shall use the standards developed by the department for each product offered by the insurer.
(l)(m)(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). (n).
(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)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4).
(m)(n)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)(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). (m). 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) (m) 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). (m).
(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). (m).
(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). (n).
(q)(r)In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurers provider directory or directories, the department may require the insurer to provide coverage for all covered health care services provided to the insured and to reimburse the insured for any amount beyond what the insured would have paid, had the services been delivered by an in-network provider under the insureds health insurance policy. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the insured were covered services under the insureds health insurance policy. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-network provider shall not be used as a basis to deny reimbursement to the insured.
(r)(s)Whenever an insurer determines as a result of this section that there has been a 10-percent change in the network for a product in a region, the insurer shall file a statement with the commissioner.
(s)(t)If an insured contacts an insurer for assistance in finding an in-network provider, provider and for an explanation of their rights regarding out-of-network coverage, the insurer shall respond acknowledge the request to the insured within one business day and shall provide search results within two business days. days for a request deemed urgent by the insured and five business days for a request deemed nonurgent by an insured. For purposes of this subdivision, search results means a list of providers covered by the insureds policy that are accepting patients, which shall be confirmed by the insurer at the time of the insureds request. Search results shall only include providers that have responded to requests to verify their listing information in the insurers last annual verification pursuant to subdivision (l). (m). An insurer shall include with the search results the date that the insurer confirmed the providers on the list are accepting new patients and a statement indicating that a provider may close to new patients at the providers discretion, so this information may change in the future.
(t)(u)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)(v)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)(w)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).
(w)(x)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
(a)Commencing July 1, 2016, a health care service plan shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plans enrollees, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the plan.
(b)A health care service plan shall provide the directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, enrollees, potential enrollees, the department, and other state or federal agencies can easily identify the networks and plan products in which a provider participates. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, a health care service plan shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k).
(c)(1)An online provider directory or directories shall be available on the plans internet website to the public, potential enrollees, enrollees, and providers without any restrictions or limitations. The directory or directories shall be accessible without any requirement that an individual seeking the directory information demonstrate coverage with the plan, indicate interest in obtaining coverage with the plan, provide a member identification or policy number, provide any other identifying information, or create or access an account.
(2)The online provider directory or directories shall be accessible on the plans public internet website through an identifiable link or tab and in a manner that is accessible and searchable by enrollees, potential enrollees, the public, and providers. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, the plans public internet website shall allow provider searches by, at a minimum, name, practice address, city, ZIP Code, California license number, National Provider Identifier number, admitting privileges to an identified hospital, product, tier, provider language or languages, provider group, hospital name, facility name, or clinic name, as appropriate.
(d)(1)A health care service plan shall allow enrollees, potential enrollees, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the plan through the plans toll-free telephone number, electronically, or in writing. A printed copy of the provider directory or directories shall include the information required in subdivisions (h) and (i). The printed copy of the provider directory or directories shall be provided to the requester by mail postmarked no later than five business days following the date of the request and may be limited to the geographic region in which the requester resides or works or intends to reside or work.
(2)A health care service plan shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law.
(e)(1)The plan shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the plan of any of the following:
(A)A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients.
(B)A provider is no longer under contract for a particular plan product.
(C)A providers practice location or other information required under subdivision (h) or (i) has changed.
(D)Upon completion of the investigation described in subdivision (o), a change is necessary based on an enrollee complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly.
(E)Any other information that affects the content or accuracy of the provider directory or directories.
(2)Upon confirmation of any of the following, the plan shall delete a provider from the directory or directories when:
(A)A provider has retired or otherwise has ceased to practice.
(B)A provider or provider group is no longer under contract with the plan for any reason.
(C)The contracting provider group has informed the plan that the provider is no longer associated with the provider group and is no longer under contract with the plan.
(f)The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the plan if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the plans internet website.
(g)The provider directory or directories shall include the following disclosures informing enrollees that they are entitled to both of the following:
(1)Language interpreter services, at no cost to the enrollee, including how to obtain interpretation services in accordance with Section 1367.04.
(2)Full and equal access to covered services, including enrollees with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.
(h)A full service health care service plan and a specialized mental health plan shall include all of the following information in the provider directory or directories:
(1)The providers name, practice location or locations, and contact information.
(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.
(7)The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
(8)A listing for each of the following providers that are under contract with the plan:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the plan.
(B)Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in Section 1374.73, nurse-midwives, and dentists.
(C)For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic.
(D)For any provider described in subparagraph (A) or (B) who is employed by a federally qualified health center or primary care clinic, and to the extent their services may be accessed and are covered through the contract with the plan, the name of the provider, and the name of the federally qualified health center or clinic.
(E)Facilities, including, but not limited to, general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities.
(F)Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services.
(9)The provider directory or directories may note that authorization or referral may be required to access some providers.
(10)Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 1367.04, if any, on the providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)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.
(13)A statement at the top of the directory advising an enrollee to contact the health care service plan for assistance in finding an in-network provider.
(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.
(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.
(7)The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.
(8)The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the plan.
(9)The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 1367.04, if any, on the providers staff.
(10)Identification of providers who no longer accept new patients for some or all of the plans products.
(11)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(j)(1)The contract between the plan and a provider shall include a requirement that the provider inform the plan within five business days when either of the following occurs:
(A)The provider is not accepting new patients.
(B)If the provider had previously not accepted new patients, the provider is currently accepting new patients.
(2)If a provider who is not accepting new patients is contacted by an enrollee or potential enrollee seeking to become a new patient, the provider shall direct the enrollee or potential enrollee to both the plan for additional assistance in finding a provider and to the department to report any inaccuracy with the plans directory or directories.
(3)If an enrollee or potential enrollee informs a plan of a possible inaccuracy in the provider directory or directories, the plan shall promptly investigate and, if necessary, undertake corrective action within 30 business days to ensure the accuracy of the directory or directories.
(k)(1)On or before December 31, 2016, the department shall develop uniform provider directory standards to permit consistency in accordance with subdivision (b) and paragraph (2) of subdivision (c) and development of a multiplan directory by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2021. No more than two revisions of those standards shall be exempt from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) pursuant to this subdivision.
(2)In developing the standards under this subdivision, the department shall seek input from interested parties throughout the process of developing the standards and shall hold at least one public meeting. The department shall take into consideration any requirements for provider directories established by the federal Centers for Medicare and Medicaid Services and the State Department of Health Care Services.
(3)By July 31, 2017, or 12 months after the date provider directory standards are developed under this subdivision, whichever occurs later, a plan shall use the standards developed by the department for each product offered by the plan.
(l)(1)A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans provider directory or directories in accordance with this section, and shall, at least annually, review and update the entire provider directory or directories for each product offered. Each calendar year the plan shall notify all contracted providers described in subdivisions (h) and (i) as follows:
(A)For individual providers who are not affiliated with a provider group described in subparagraph (A) or (B) of paragraph (8) of subdivision (h) and providers described in subdivision (i), the plan shall notify each provider at least once every six months.
(B)For all other providers described in subdivision (h) who are not subject to the requirements of subparagraph (A), the plan shall notify its contracted providers to ensure that all of the providers are contacted by the plan at least once annually.
(2)The notification shall include all of the following:
(A)The information the plan has in its directory or directories regarding the provider or provider group, including a list of networks and plan products that include the contracted provider or provider group.
(B)A statement that the failure to respond to the notification may result in a delay of payment or reimbursement of a claim pursuant to subdivision (p).
(C)Instructions on how the provider or provider group can update the information in the provider directory or directories using the online interface developed pursuant to subdivision (m).
(3)The plan shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The provider or provider group shall confirm that the information in the provider directory or directories is current and accurate or update the information required to be in the directory or directories pursuant to this section, including whether or not the provider or provider group is accepting new patients for each plan product.
(4)If the plan does not receive an affirmative response and confirmation from the provider that the information is current and accurate or, as an alternative, updates any information required to be in the directory or directories pursuant to this section, within 30 business days, the plan shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The plan shall document the receipt and outcome of each attempt to verify the information. If the plan is unable to verify whether the providers information is correct or requires updates, the plan shall notify the provider 10 business days in advance of removal that the provider will be removed from the provider directory or directories. The provider shall be removed from the provider directory or directories at the next required update of the provider directory or directories after the 10-business-day notice period. A provider shall not be removed from the provider directory or directories if the provider responds before the end of the 10-business-day notice period.
(5)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4).
(m)A plan shall establish policies and procedures with regard to the regular updating of its provider directory or directories, including the weekly, quarterly, and annual updates required pursuant to this section, or more frequently, if required by federal law or guidance.
(1)The policies and procedures described under this subdivision shall be submitted by a plan annually to the department for approval and in a format described by the department pursuant to Section 1367.035.
(2)Every health care service plan shall ensure processes are in place to allow providers to promptly verify or submit changes to the information required to be in the directory or directories pursuant to this section. Those processes shall, at a minimum, include an online interface for providers to submit verification or changes electronically and shall generate an acknowledgment of receipt from the health care service plan. Providers shall verify or submit changes to information required to be in the directory or directories pursuant to this section using the process required by the health care service plan.
(3)The plan shall establish and maintain a process for enrollees, potential enrollees, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the plans provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the plan will accept these reports, as well as a hyperlink on the plans provider directory internet website linking to a form where the information can be reported directly to the plan through its internet website.
(n)(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 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)(1)Notwithstanding Sections 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups information. As used in this subdivision, verify means to contact the provider or provider group in writing, electronically, and by telephone to confirm whether the providers or provider groups information is correct or requires updates. A plan may seek to delay payment or reimbursement owed to a provider or provider group only after the 10-business-day notice period described in paragraph (4) of subdivision (l) has lapsed.
(A)For a provider or provider group that receives compensation on a capitated or prepaid basis, the plan may delay no more than 50 percent of the next scheduled capitation payment for up to one calendar month.
(B)For any claims payment made to a provider or provider group, the plan may delay the claims payment for up to one calendar month beginning on the first day of the following month.
(2)A plan shall notify the provider or provider group 10 business days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the plan delays a payment or reimbursement pursuant to this subdivision, the plan shall reimburse the full amount of any payment or reimbursement subject to delay to the provider or provider group according to either of the following timelines, as applicable:
(A)No later than three business days following the date on which the plan receives the information required to be submitted by the provider or provider group pursuant to subdivision (l).
(B)At the end of the one-calendar-month delay described in subparagraph (A) or (B) of paragraph (1), as applicable, if the provider or provider group fails to provide the information required to be submitted to the plan pursuant to subdivision (l).
(3)A plan may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the plan to a change in the information required to be in the directory or directories pursuant to this section.
(4)A plan that delays payment or reimbursement under this subdivision shall document each instance a payment or reimbursement was delayed and report this information to the department in a format described by the department pursuant to Section 1367.035. This information shall be submitted along with the policies and procedures required to be submitted annually to the department pursuant to paragraph (1) of subdivision (m).
(5)With respect to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.
(q)In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee.
(r)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)If an enrollee contacts a health care service plan for assistance in finding an in-network provider, the plan shall respond within 24 hours one business day and shall provide search results within two business days. For purposes of this subdivision, search results means a list of providers covered by the enrollees contract that are accepting patients, which shall be confirmed by the health care service plan at the time of the enrollees request. Search results shall only include providers that have responded to requests to verify their listing information in the health care service plans last annual verification pursuant to subdivision (l).
(t)This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d).
(u)A health plan that contracts with multiple employer welfare agreements regulated pursuant to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 of the Insurance Code shall meet the requirements of this section.
(v)This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.
(w)As part of the departments routine examination of the fiscal and administrative affairs of a health care service plan pursuant to Section 1382, the department shall include a review of the health care service plans compliance with subdivision (p).
(x)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 2.Section 10133.15 of the Insurance Code is amended to read:10133.15.(a)Commencing July 1, 2016, a health insurer that contracts with providers for alternative rates of payment pursuant to Section 10133 shall publish and maintain provider directory or directories with information on contracting providers that deliver health care services to the insurers insureds, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the insurer.
(b)An insurer shall provide the online directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, insureds, potential insureds, the department, and other state or federal agencies can easily identify the networks and insurer products in which a provider participates. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, an insurer shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k).
(c)(1)An online provider directory or directories shall be available on the insurers internet website to the public, potential insureds, insureds, and providers without any restrictions or limitations. The directory or directories shall be accessible without any requirement that an individual seeking the directory information demonstrate coverage with the insurer, indicate interest in obtaining coverage with the insurer, provide a member identification or policy number, provide any other identifying information, or create or access an account.
(2)The online provider directory or directories shall be accessible on the insurers public internet website through an identifiable link or tab and in a manner that is accessible and searchable by insureds, potential insureds, the public, and providers. By July 1, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, the insurers public internet website shall allow provider searches by, at a minimum, name, practice address, city, ZIP Code, California license number, National Provider Identifier number, admitting privileges to an identified hospital, product, tier, provider language or languages, provider group, hospital name, facility name, or clinic name, as appropriate.
(d)(1)An insurer shall allow insureds, potential insureds, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the insurer through the insurers toll-free telephone number, electronically, or in writing. A printed copy of the provider directory or directories shall include the information required in subdivisions (h) and (i). The printed copy of the provider directory or directories shall be provided to the requester by mail postmarked no later than five business days following the date of the request and may be limited to the geographic region in which the requester resides or works or intends to reside or work.
(2)An insurer shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law.
(e)(1)The insurer shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the insurer of any of the following:
(A)A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients.
(B)A contracted provider is no longer under contract for a particular product.
(C)A providers practice location or other information required under subdivision (h) or (i) has changed.
(D)Upon the completion of the investigation described in subdivision (o), a change is necessary based on an insured complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly.
(E)Any other information that affects the content or accuracy of the provider directory or directories.
(2)Upon confirmation of any of the following, the insurer shall delete a provider from the directory or directories when:
(A)A provider has retired or otherwise has ceased to practice.
(B)A provider or provider group is no longer under contract with the insurer for any reason.
(C)The contracting provider group has informed the insurer that the provider is no longer associated with the provider group and is no longer under contract with the insurer.
(f)The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the insurer if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the insurers internet website.
(g)The provider directory or directories shall include the following disclosures informing insureds that they are entitled to both of the following:
(1)Language interpreter services, at no cost to the insured, including how to obtain interpretation services in accordance with Section 10133.8.
(2)Full and equal access to covered services, including insureds with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.
(h)The insurer and a specialized mental health insurer shall include all of the following information in the provider directory or directories:
(1)The providers name, practice location or locations, and contact information.
(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.
(7)The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds.
(8)A listing for each of the following providers that are under contract with the insurer:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the insurer.
(B)Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in Section 10144.51, nurse-midwives, and dentists.
(C)For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic.
(D)For any provider described in subparagraph (A) or (B) who is employed by a federally qualified health center or primary care clinic, and to the extent their services may be accessed and are covered through the contract with the insurer, the name of the provider, and the name of the federally qualified health center or clinic.
(E)Facilities, including, but not limited to, general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities.
(F)Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services.
(9)The provider directory or directories may note that authorization or referral may be required to access some providers.
(10)Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, 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 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.
(13)A statement at the top of the directory advising an insured to contact the insurer for assistance in finding an in-network provider.
(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.
(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.
(7)The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.
(8)The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the insurer.
(9)The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, if any, on the providers staff.
(10)Identification of providers who no longer accept new patients for some or all of the insurers products.
(11)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(j)(1)The contract between the insurer and a provider shall include a requirement that the provider inform the insurer within five business days when either of the following occurs:
(A)The provider is not accepting new patients.
(B)If the provider had previously not accepted new patients, the provider is currently accepting new patients.
(2)If a provider who is not accepting new patients is contacted by an insured or potential insured seeking to become a new patient, the provider shall direct the insurer or potential insured to both the insurer for additional assistance in finding a provider and to the department to report any inaccuracy with the insurers directory or directories.
(3)If an insured or potential insured informs an insurer of a possible inaccuracy in the provider directory or directories, the insurer shall promptly investigate and, if necessary, undertake corrective action within 30 business days to ensure the accuracy of the directory or directories.
(k)(1)On or before December 31, 2016, the department shall develop uniform provider directory standards to permit consistency in accordance with subdivision (b) and paragraph (2) of subdivision (c) and development of a multiplan directory by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2021. No more than two revisions of those standards shall be exempt from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) pursuant to this subdivision.
(2)In developing the standards under this subdivision, the department shall seek input from interested parties throughout the process of developing the standards and shall hold at least one public meeting. The department shall take into consideration any requirements for provider directories established by the federal Centers for Medicare and Medicaid Services and the State Department of Health Care Services.
(3)By July 31, 2017, or 12 months after the date provider directory standards are developed under this subdivision, whichever occurs later, an insurer shall use the standards developed by the department for each product offered by the insurer.
(l)(1)An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurers provider directory or directories in accordance with this section, and shall, at least annually, review and update the entire provider directory or directories for each product offered. Each calendar year the insurer shall notify all contracted providers described in subdivisions (h) and (i) as follows:
(A)For individual providers who are not affiliated with a provider group described in subparagraph (A) or (B) of paragraph (8) of subdivision (h) and providers described in subdivision (i), the insurer shall notify each provider at least once every six months.
(B)For all other providers described in subdivision (h) who are not subject to the requirements of subparagraph (A), the insurer shall notify its contracted providers to ensure that all of the providers are contacted by the insurer at least once annually.
(2)The notification shall include all of the following:
(A)The information the insurer has in its directory or directories regarding the provider or provider group, including a list of networks and products that include the contracted provider or provider group.
(B)A statement that the failure to respond to the notification may result in a delay of payment or reimbursement of a claim pursuant to subdivision (p).
(C)Instructions on how the provider or provider group can update the information in the provider directory or directories using the online interface developed pursuant to subdivision (m).
(3)The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The provider or provider group shall confirm that the information in the provider directory or directories is current and accurate or update the information required to be in the directory or directories pursuant to this section, including whether or not the provider group is accepting new patients for each product.
(4)If the insurer does not receive an affirmative response and confirmation from the provider that the information is current and accurate or, as an alternative, updates any information required to be in the directory or directories pursuant to this section, within 30 business days, the insurer shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The insurer shall document the receipt and outcome of each attempt to verify the information. If the insurer is unable to verify whether the providers information is correct or requires updates, the insurer shall notify the provider 10 business days in advance of removal that the provider will be removed from the directory or directories. The provider shall be removed from the directory or directories at the next required update of the provider directory or directories after the 10-business-day notice period. A provider shall not be removed from the provider directory or directories if the provider responds before the end of the 10-business-day notice period.
(5)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4).
(m)An insurer shall establish policies and procedures with regard to the regular updating of its provider directory or directories, including the weekly, quarterly, and annual updates required pursuant to this section, or more frequently, if required by federal law or guidance.
(1)The policies and procedures described under this subdivision shall be submitted by an insurer annually to the department for approval and in a format described by the department.
(2)Every insurer shall ensure processes are in place to allow providers to promptly verify or submit changes to the information required to be in the directory or directories pursuant to this section. Those processes shall, at a minimum, include an online interface for providers to submit verification or changes electronically and shall generate an acknowledgment of receipt from the insurer. Providers shall verify or submit changes to information required to be in the directory or directories pursuant to this section using the process required by the insurer.
(3)The insurer shall establish and maintain a process for insureds, potential insureds, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the insurers provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the insurer will accept these reports, as well as a hyperlink on the insurers provider directory internet website linking to a form where the information can be reported directly to the insurer through its internet website.
(n)(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 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)(1)Notwithstanding Sections 10123.13 and 10123.147, an insurer may delay payment or reimbursement owed to a provider or provider group for any claims payment made to a provider or provider group for up to one calendar month beginning on the first day of the following month, if the provider or provider group fails to respond to the insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups information. As used in this subdivision, verify means to contact the provider or provider group in writing, electronically, and by telephone to confirm whether the providers or provider groups information is correct or requires updates. An insurer may seek to delay payment or reimbursement owed to a provider or provider group only after the 10-business-day notice period described in paragraph (4) of subdivision (l) has lapsed.
(2)An insurer shall notify the provider or provider group 10 days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the insurer delays a payment or reimbursement pursuant to this subdivision, the insurer shall reimburse the full amount of any payment or reimbursement subject to delay to the provider or provider group according to either of the following timelines, as applicable:
(A)No later than three business days following the date on which the insurer receives the information required to be submitted by the provider or provider group pursuant to subdivision (l).
(B)At the end of the one-calendar-month delay described in paragraph (1), if the provider or provider group fails to provide the information required to be submitted to the insurer pursuant to subdivision (l).
(3)An insurer may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the insurer to a change in the information required to be in the directory or directories pursuant to this section.
(4)An insurer that delays payment or reimbursement under this subdivision shall document each instance a payment or reimbursement was delayed and report this information to the department in a format described by the department. This information shall be submitted along with the policies and procedures required to be submitted annually to the department pursuant to paragraph (1) of subdivision (m).
(q)In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurers provider directory or directories, the department may require the insurer to provide coverage for all covered health care services provided to the insured and to reimburse the insured for any amount beyond what the insured would have paid, had the services been delivered by an in-network provider under the insureds health insurance policy. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the insured were covered services under the insureds health insurance policy. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-network provider shall not be used as a basis to deny reimbursement to the insured.
(r)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)If an insured contacts an insurer for assistance in finding an in-network provider, the insurer shall respond within 24 hours one business day and shall provide search results within two business days. For purposes of this subdivision, search results means a list of providers covered by the insureds policy that are accepting patients, which shall be confirmed by the insurer at the time of the insureds request. Search results shall only include providers that have responded to requests to verify their listing information in the insurers last annual verification pursuant to subdivision (l).
(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 (p).
(w)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
(a)Commencing July 1, 2016, a health care service plan shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plans enrollees, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the plan.
(b)A health care service plan shall provide the directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, enrollees, potential enrollees, the department, and other state or federal agencies can easily identify the networks and plan products in which a provider participates. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, a health care service plan shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k).
(c)(1)An online provider directory or directories shall be available on the plans Internet Web site internet website to the public, potential enrollees, enrollees, and providers without any restrictions or limitations. The directory or directories shall be accessible without any requirement that an individual seeking the directory information demonstrate coverage with the plan, indicate interest in obtaining coverage with the plan, provide a member identification or policy number, provide any other identifying information, or create or access an account.
(2)The online provider directory or directories shall be accessible on the plans public Internet Web site internet website through an identifiable link or tab and in a manner that is accessible and searchable by enrollees, potential enrollees, the public, and providers. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, the plans public Internet Web site internet website shall allow provider searches by, at a minimum, name, practice address, city, ZIP Code, California license number, National Provider Identifier number, admitting privileges to an identified hospital, product, tier, provider language or languages, provider group, hospital name, facility name, or clinic name, as appropriate.
(d)(1)A health care service plan shall allow enrollees, potential enrollees, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the plan through the plans toll-free telephone number, electronically, or in writing. A printed copy of the provider directory or directories shall include the information required in subdivisions (h) and (i). The printed copy of the provider directory or directories shall be provided to the requester by mail postmarked no later than five business days following the date of the request and may be limited to the geographic region in which the requester resides or works or intends to reside or work.
(2)A health care service plan shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law.
(e)(1)The plan shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the plan of any of the following:
(A)A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients.
(B)A provider is no longer under contract for a particular plan product.
(C)A providers practice location or other information required under subdivision (h) or (i) has changed.
(D)Upon completion of the investigation described in subdivision (o), a change is necessary based on an enrollee complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly.
(E)Any other information that affects the content or accuracy of the provider directory or directories.
(2)Upon confirmation of any of the following, the plan shall delete a provider from the directory or directories when:
(A)A provider has retired or otherwise has ceased to practice.
(B)A provider or provider group is no longer under contract with the plan for any reason.
(C)The contracting provider group has informed the plan that the provider is no longer associated with the provider group and is no longer under contract with the plan.
(f)The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the plan if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the plans Internet Web site. internet website.
(g)The provider directory or directories shall include the following disclosures informing enrollees that they are entitled to both of the following:
(1)Language interpreter services, at no cost to the enrollee, including how to obtain interpretation services in accordance with Section 1367.04.
(2)Full and equal access to covered services, including enrollees with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.
(h)A full service health care service plan and a specialized mental health plan shall include all of the following information in the provider directory or directories:
(1)The providers name, practice location or locations, and contact information.
(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.
(7)The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
(8)A listing for each of the following providers that are under contract with the plan:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the plan.
(B)Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in Section 1374.73, nurse midwives, nurse-midwives, and dentists.
(C)For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic.
(D)For any provider described in subparagraph (A) or (B) who is employed by a federally qualified health center or primary care clinic, and to the extent their services may be accessed and are covered through the contract with the plan, the name of the provider, and the name of the federally qualified health center or clinic.
(E)Facilities, including, but not limited to, general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities.
(F)Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services.
(9)The provider directory or directories may note that authorization or referral may be required to access some providers.
(10)Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 1367.04, if any, on the providers staff.
(11)Identification of providers who no longer accept new patients for some or all of the plans products.
(12)The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. Nothing in this section shall be construed to This section does not require the use of network tiers other than contract and noncontracting tiers.
(13)A statement at the top of the directory advising an enrollee to contact the health care service plan for assistance in finding an in-network provider.
(13)(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.
(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.
(7)The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.
(8)The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the plan.
(9)The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 1367.04, if any, on the providers staff.
(10)Identification of providers who no longer accept new patients for some or all of the plans products.
(11)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(j)(1)The contract between the plan and a provider shall include a requirement that the provider inform the plan within five business days when either of the following 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 by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2021. No more than two revisions of those standards shall be exempt from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) pursuant to this subdivision.
(2)In developing the standards under this subdivision, the department shall seek input from interested parties throughout the process of developing the standards and shall hold at least one public meeting. The department shall take into consideration any requirements for provider directories established by the federal Centers for Medicare and Medicaid Services and the State Department of Health Care Services.
(3)By July 31, 2017, or 12 months after the date provider directory standards are developed under this subdivision, whichever occurs later, a plan shall use the standards developed by the department for each product offered by the plan.
(l)(1)A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans provider directory or directories in accordance with this section, and shall, at least annually, review and update the entire provider directory or directories for each product offered. Each calendar year the plan shall notify all contracted providers described in subdivisions (h) and (i) as follows:
(A)For individual providers who are not affiliated with a provider group described in subparagraph (A) or (B) of paragraph (8) of subdivision (h) and providers described in subdivision (i), the plan shall notify each provider at least once every six months.
(B)For all other providers described in subdivision (h) who are not subject to the requirements of subparagraph (A), the plan shall notify its contracted providers to ensure that all of the providers are contacted by the plan at least once annually.
(2)The notification shall include all of the following:
(A)The information the plan has in its directory or directories regarding the provider or provider group, including a list of networks and plan products that include the contracted provider or provider group.
(B)A statement that the failure to respond to the notification may result in a delay of payment or reimbursement of a claim pursuant to subdivision (p).
(C)Instructions on how the provider or provider group can update the information in the provider directory or directories using the online interface developed pursuant to subdivision (m).
(3)The plan shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The provider or provider group shall confirm that the information in the provider directory or directories is current and accurate or update the information required to be in the directory or directories pursuant to this section, including whether or not the provider or provider group is accepting new patients for each plan product.
(4)If the plan does not receive an affirmative response and confirmation from the provider that the information is current and accurate or, as an alternative, updates any information required to be in the directory or directories pursuant to this section, within 30 business days, the plan shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The plan shall document the receipt and outcome of each attempt to verify the information. If the plan is unable to verify whether the providers information is correct or requires updates, the plan shall notify the provider 10 business days in advance of removal that the provider will be removed from the provider directory or directories. The provider shall be removed from the provider directory or directories at the next required update of the provider directory or directories after the 10-business-day notice period. A provider shall not be removed from the provider directory or directories if he or she the provider responds before the end of the 10-business-day notice period.
(5)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4).
(m)A plan shall establish policies and procedures with regard to the regular updating of its provider directory or directories, including the weekly, quarterly, and annual updates required pursuant to this section, or more frequently, if required by federal law or guidance.
(1)The policies and procedures described under this subdivision shall be submitted by a plan annually to the department for approval and in a format described by the department pursuant to Section 1367.035.
(2)Every health care service plan shall ensure processes are in place to allow providers to promptly verify or submit changes to the information required to be in the directory or directories pursuant to this section. Those processes shall, at a minimum, include an online interface for providers to submit verification or changes electronically and shall generate an acknowledgment of receipt from the health care service plan. Providers shall verify or submit changes to information required to be in the directory or directories pursuant to this section using the process required by the health care service plan.
(3)The plan shall establish and maintain a process for enrollees, potential enrollees, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the plans provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the plan will accept these reports, as well as a hyperlink on the plans provider directory Internet Web site internet website linking to a form where the information can be reported directly to the plan through its Internet Web site. internet website.
(n)(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 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)(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)In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee.
(r)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)If an enrollee contacts a health care service plan for assistance in finding an in-network provider, the plan shall respond within 24 hours and shall provide search results within two business days. For purposes of this subdivision, search results means a list of providers covered by the enrollees contract that are accepting patients, which shall be confirmed by the health care service plan at the time of the enrollees request.
(s)(t)This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d).
(t)(u)A health plan that contracts with multiple employer welfare agreements regulated pursuant to Article 4.7 (commencing with Section 742.20) of Chapter 1 of Part 2 of Division 1 of the Insurance Code shall meet the requirements of this section.
(u)(v)This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.
(v)(w)As part of the departments routine examination of the fiscal and administrative affairs of a health care service plan pursuant to Section 1382, the department shall include a review of the health care service plans compliance with subdivision (p).
(w)(x)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 2.Section 10133.15 of the Insurance Code is amended to read:10133.15.(a)Commencing July 1, 2016, a health insurer that contracts with providers for alternative rates of payment pursuant to Section 10133 shall publish and maintain provider directory or directories with information on contracting providers that deliver health care services to the insurers insureds, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the insurer.
(b)An insurer shall provide the online directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, insureds, potential insureds, the department, and other state or federal agencies can easily identify the networks and insurer products in which a provider participates. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, an insurer shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k).
(c)(1)An online provider directory or directories shall be available on the insurers Internet Web site internet website to the public, potential insureds, insureds, and providers without any restrictions or limitations. The directory or directories shall be accessible without any requirement that an individual seeking the directory information demonstrate coverage with the insurer, indicate interest in obtaining coverage with the insurer, provide a member identification or policy number, provide any other identifying information, or create or access an account.
(2)The online provider directory or directories shall be accessible on the insurers public Internet Web site internet website through an identifiable link or tab and in a manner that is accessible and searchable by insureds, potential insureds, the public, and providers. By July 1, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, the insurers public Internet Web site internet website shall allow provider searches by, at a minimum, name, practice address, city, ZIP Code, California license number, National Provider Identifier number, admitting privileges to an identified hospital, product, tier, provider language or languages, provider group, hospital name, facility name, or clinic name, as appropriate.
(d)(1)An insurer shall allow insureds, potential insureds, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the insurer through the insurers toll-free telephone number, electronically, or in writing. A printed copy of the provider directory or directories shall include the information required in subdivisions (h) and (i). The printed copy of the provider directory or directories shall be provided to the requester by mail postmarked no later than five business days following the date of the request and may be limited to the geographic region in which the requester resides or works or intends to reside or work.
(2)An insurer shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law.
(e)(1)The insurer shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the insurer of any of the following:
(A)A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients.
(B)A contracted provider is no longer under contract for a particular product.
(C)A providers practice location or other information required under subdivision (h) or (i) has changed.
(D)Upon the completion of the investigation described in subdivision (o), a change is necessary based on an insured complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly.
(E)Any other information that affects the content or accuracy of the provider directory or directories.
(2)Upon confirmation of any of the following, the insurer shall delete a provider from the directory or directories when:
(A)A provider has retired or otherwise has ceased to practice.
(B)A provider or provider group is no longer under contract with the insurer for any reason.
(C)The contracting provider group has informed the insurer that the provider is no longer associated with the provider group and is no longer under contract with the insurer.
(f)The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the insurer if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the insurers Internet Web site. internet website.
(g)The provider directory or directories shall include the following disclosures informing insureds that they are entitled to both of the following:
(1)Language interpreter services, at no cost to the insured, including how to obtain interpretation services in accordance with Section 10133.8.
(2)Full and equal access to covered services, including insureds with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.
(h)The insurer and a specialized mental health insurer shall include all of the following information in the provider directory or directories:
(1)The providers name, practice location or locations, and contact information.
(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.
(7)The name of each affiliated provider group currently under contract with the insurer through which the provider sees enrollees. insureds.
(8)A listing for each of the following providers that are under contract with the insurer:
(A)For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the insurer.
(B)Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in Section 10144.51, nurse midwives, nurse-midwives, and dentists.
(C)For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic.
(D)For any provider described in subparagraph (A) or (B) who is employed by a federally qualified health center or primary care clinic, and to the extent their services may be accessed and are covered through the contract with the insurer, the name of the provider, and the name of the federally qualified health center or clinic.
(E)Facilities, including, but not limited to, general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities.
(F)Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services.
(9)The provider directory or directories may note that authorization or referral may be required to access some providers.
(10)Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, 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 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.
(13)A statement at the top of the directory advising an insured to contact the insurer for assistance in finding an in-network provider.
(13)(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.
(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.
(7)The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.
(8)The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the insurer.
(9)The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 10133.8, if any, on the providers staff.
(10)Identification of providers who no longer accept new patients for some or all of the insurers products.
(11)All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c).
(j)(1)The contract between the insurer and a provider shall include a requirement that the provider inform the insurer within five business days when either of the following occurs:
(A)The provider is not accepting new patients.
(B)If the provider had previously not accepted new patients, the provider is currently accepting new patients.
(2)If a provider who is not accepting new patients is contacted by an insured or potential insured seeking to become a new patient, the provider shall direct the insurer or potential insured to both the insurer for additional assistance in finding a provider and to the department to report any inaccuracy with the insurers directory or directories.
(3)If an insured or potential insured informs an insurer of a possible inaccuracy in the provider directory or directories, the insurer shall promptly investigate and, if necessary, undertake corrective action within 30 business days to ensure the accuracy of the directory or directories.
(k)(1)On or before December 31, 2016, the department shall develop uniform provider directory standards to permit consistency in accordance with subdivision (b) and paragraph (2) of subdivision (c) and development of a multiplan directory by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code), until January 1, 2021. No more than two revisions of those standards shall be exempt from the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) pursuant to this subdivision.
(2)In developing the standards under this subdivision, the department shall seek input from interested parties throughout the process of developing the standards and shall hold at least one public meeting. The department shall take into consideration any requirements for provider directories established by the federal Centers for Medicare and Medicaid Services and the State Department of Health Care Services.
(3)By July 31, 2017, or 12 months after the date provider directory standards are developed under this subdivision, whichever occurs later, an insurer shall use the standards developed by the department for each product offered by the insurer.
(l)(1)An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurers provider directory or directories in accordance with this section, and shall, at least annually, review and update the entire provider directory or directories for each product offered. Each calendar year the insurer shall notify all contracted providers described in subdivisions (h) and (i) as follows:
(A)For individual providers who are not affiliated with a provider group described in subparagraph (A) or (B) of paragraph (8) of subdivision (h) and providers described in subdivision (i), the insurer shall notify each provider at least once every six months.
(B)For all other providers described in subdivision (h) who are not subject to the requirements of subparagraph (A), the insurer shall notify its contracted providers to ensure that all of the providers are contacted by the insurer at least once annually.
(2)The notification shall include all of the following:
(A)The information the insurer has in its directory or directories regarding the provider or provider group, including a list of networks and products that include the contracted provider or provider group.
(B)A statement that the failure to respond to the notification may result in a delay of payment or reimbursement of a claim pursuant to subdivision (p).
(C)Instructions on how the provider or provider group can update the information in the provider directory or directories using the online interface developed pursuant to subdivision (m).
(3)The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The provider or provider group shall confirm that the information in the provider directory or directories is current and accurate or update the information required to be in the directory or directories pursuant to this section, including whether or not the provider group is accepting new patients for each product.
(4)If the insurer does not receive an affirmative response and confirmation from the provider that the information is current and accurate or, as an alternative, updates any information required to be in the directory or directories pursuant to this section, within 30 business days, the insurer shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The insurer shall document the receipt and outcome of each attempt to verify the information. If the insurer is unable to verify whether the providers information is correct or requires updates, the insurer shall notify the provider 10 business days in advance of removal that the provider will be removed from the directory or directories. The provider shall be removed from the directory or directories at the next required update of the provider directory or directories after the 10-business day 10-business-day notice period. A provider shall not be removed from the provider directory or directories if he or she the provider responds before the end of the 10-business day 10-business-day notice period.
(5)General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4).
(m)An insurer shall establish policies and procedures with regard to the regular updating of its provider directory or directories, including the weekly, quarterly, and annual updates required pursuant to this section, or more frequently, if required by federal law or guidance.
(1)The policies and procedures described under 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)(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 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)(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)In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurers provider directory or directories, the department may require the insurer to provide coverage for all covered health care services provided to the insured and to reimburse the insured for any amount beyond what the insured would have paid, had the services been delivered by an in-network provider under the insureds health insurance policy. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the insured were covered services under the insureds health insurance policy. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-network provider shall not be used as a basis to deny reimbursement to the insured.
(r)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)If an insured contacts an insurer for assistance in finding an in-network provider, the insurer shall respond within 24 hours and shall provide search results within two business days. For purposes of this subdivision, search results means a list of providers covered by the insureds policy that are accepting patients, which shall be confirmed by the insurer at the time of the insureds request.
(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).
(v)(w)For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.
SEC. 3.No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.
SECTION 1.Section 127345 of the Health and Safety Code is amended to read:127345.As used in this article, the following terms have the following meanings:(a)Charity care means free health services provided without expectation of payment to persons who meet the organizations criteria for financial assistance and are unable to pay for all or a portion of the services. Charity care shall be reported at cost, as reported to the Department of Health Care Access and Information. Charity care does not include bad debt, defined as uncollectible charges that the organization recorded as revenue but wrote off due to a patients failure to pay.(b)Community benefits plan means the written document prepared for annual submission to the Department of Health Care Access and Information that shall include, but shall not be limited to, a description of the activities that the hospital has undertaken in order to address identified community needs within its mission and financial capacity, and the process by which the hospital developed the plan in consultation with the community.(c)Community means the service areas or patient populations for which the hospital provides health care services.(d)(1)Solely for the planning and reporting purposes of this article, community benefit means a hospitals activities that are intended to address community needs and priorities primarily through disease prevention and improvement of health status, including, but not limited to, any of the following:(A)Health care services, rendered to vulnerable populations, including, but not limited to, charity care and the unreimbursed cost of providing services to the uninsured, underinsured, and those eligible for Medi-Cal, Medicare, California Childrens Services Program, or county indigent programs.(B)The unreimbursed cost of services included in subdivision (d) of Section 127340.(C)Financial or in-kind support of public health programs.(D)Donation of funds, property, or other resources that contribute to a community priority.(E)Health care cost containment.(F)Enhancement of access to health care or related services that contribute to a healthier community.(G)Services offered without regard to financial return because they meet a community need in the service area of the hospital, and other services including health promotion, health education, prevention, and social services.(H)Food, shelter, clothing, education, transportation, and other goods or services that help to maintain a persons health.(2)Community benefit does not mean activities or programs that are provided primarily for marketing purposes or are more beneficial to the organization than to the community.(e)Community needs assessment means the process by which the hospital identifies, for its primary service area as determined by the hospital, unmet community needs.(f)Community needs means those requisites for improvement or maintenance of health status in the community.(g)Hospital means a private not-for-profit acute hospital licensed under subdivision (a), (b), or (f) of Section 1250 and is owned by a corporation that has been determined to be exempt from taxation under the United States Internal Revenue Code. Hospital does not mean any of the following:(1)Hospitals that are dedicated to serving children and that do not receive direct payment for services to any patient.(2)Small and rural hospitals, as defined in Section 124840, unless the hospital is part of a hospital system.(3)A district hospital organized and governed pursuant to the Local Health Care District Law (Division 23 (commencing with Section 32000)) or a nonprofit corporation that is affiliated with the health care district hospital owner by means of the districts status as the nonprofit corporations sole corporate member pursuant to subparagraph (B) of paragraph (1) of subdivision (h) of Section 14169.31 of the Welfare and Institutions Code.(h)Mission statement means a hospitals primary objectives for operation as adopted by its governing body.(i)Vulnerable populations means any population that is exposed to medical or financial risk by virtue of being uninsured, underinsured, or eligible for Medi-Cal, Medicare, California Childrens Services Program, or county indigent programs. Vulnerable populations also includes both of the following:(1)Racial and ethnic groups experiencing disparate health outcomes, including Black/African American, American Indian, Alaska Native, Asian Indian, Cambodian, Chinese, Filipino, Hmong, Japanese, Korean, Laotian, Vietnamese, Native Hawaiian, Guamanian or Chamorro, Samoan, or other nonwhite racial groups, as well as individuals of Hispanic/Latino origin, including Mexicans, Mexican Americans, Chicanos, Salvadorans, Guatemalans, Cubans, and Puerto Ricans.(2)Socially disadvantaged groups, including all of the following:(A)The unhoused.(B)Communities with inadequate access to clean air and safe drinking water, as defined by an environmental California Healthy Places Index score of 50 percent or lower.(C)People with disabilities.(D)People identifying as lesbian, gay, bisexual, transgender, or queer.(E)Individuals with limited English proficiency.As used in this article, the following terms have the following meanings:
(a)Charity care means free health services provided without expectation of payment to persons who meet the organizations criteria for financial assistance and are unable to pay for all or a portion of the services. Charity care shall be reported at cost, as reported to the Department of Health Care Access and Information. Charity care does not include bad debt debt, defined as uncollectible charges that the organization recorded as revenue but wrote off due to a patients failure to pay.
(b)Community benefits plan means the written document prepared for annual submission to the Department of Health Care Access and Information that shall include, but shall not be limited to, a description of the activities that the hospital has undertaken in order to address identified community needs within its mission and financial capacity, and the process by which the hospital developed the plan in consultation with the community.
(c)Community means the service areas or patient populations for which the hospital provides health care services.
(d)(1)Solely for the planning and reporting purposes of this article, community benefit means a hospitals activities that are intended to address community needs and priorities primarily through disease prevention and improvement of health status, including, but not limited to, any of the following:
(A)Health care services, rendered to vulnerable populations, including, but not limited to, charity care and the unreimbursed cost of providing services to the uninsured, underinsured, and those eligible for Medi-Cal, Medicare, California Childrens Services Program, or county indigent programs.
(B)The unreimbursed cost of services included in subdivision (d) of Section 127340.
(C)Financial or in-kind support of public health programs.
(D)Donation of funds, property, or other resources that contribute to a community priority.
(E)Health care cost containment.
(F)Enhancement of access to health care or related services that contribute to a healthier community.
(G)Services offered without regard to financial return because they meet a community need in the service area of the hospital, and other services including health promotion, health education, prevention, and social services.
(H)Food, shelter, clothing, education, transportation, and other goods or services that help to maintain a persons health.
(2)Community benefit does not mean activities or programs that are provided primarily for marketing purposes or are more beneficial to the organization than to the community.
(e)Community needs assessment means the process by which the hospital identifies, for its primary service area as determined by the hospital, unmet community needs.
(f)Community needs means those requisites for improvement or maintenance of health status in the community.
(g)Hospital means a private not-for-profit acute hospital licensed under subdivision (a), (b), or (f) of Section 1250 and is owned by a corporation that has been determined to be exempt from taxation under the United States Internal Revenue Code. Hospital does not mean any of the following:
(1)Hospitals that are dedicated to serving children and that do not receive direct payment for services to any patient.
(2)Small and rural hospitals hospitals, as defined in Section 124840, unless the hospital is part of a hospital system.
(3)A district hospital organized and governed pursuant to the Local Health Care District Law (Division 23 (commencing with Section 32000)) or a nonprofit corporation that is affiliated with the health care district hospital owner by means of the districts status as the nonprofit corporations sole corporate member pursuant to subparagraph (B) of paragraph (1) of subdivision (h) of Section 14169.31 of the Welfare and Institutions Code.
(h)Mission statement means a hospitals primary objectives for operation as adopted by its governing body.
(i)Vulnerable populations means any population that is exposed to medical or financial risk by virtue of being uninsured, underinsured, or eligible for Medi-Cal, Medicare, California Childrens Services Program, or county indigent programs. Vulnerable populations also includes both of the following:
(1)Racial and ethnic groups experiencing disparate health outcomes, including Black/African American, American Indian, Alaska Native, Asian Indian, Cambodian, Chinese, Filipino, Hmong, Japanese, Korean, Laotian, Vietnamese, Native Hawaiian, Guamanian or Chamorro, Samoan, or other nonwhite racial groups, as well as individuals of Hispanic/Latino origin, including Mexicans, Mexican Americans, Chicanos, Salvadorans, Guatemalans, Cubans, and Puerto Ricans.
(2)Socially disadvantaged groups, including all of the following:
(A)The unhoused.
(B)Communities with inadequate access to clean air and safe drinking water, as defined by an environmental California Healthy Places Index score of 50 percent or lower.
(C)People with disabilities.
(D)People identifying as lesbian, gay, bisexual, transgender, or queer.
(E)Individuals with limited English proficiency.
|
Date
|
Status
|
|---|---|
| Aug 29, 2025 | In committee: Held under submission. |
| Jul 7, 2025 | In committee: Referred to APPR. suspense file. |
| Jun 23, 2025 | Read second time and amended. Re-referred to Com. on APPR. |
| Jun 19, 2025 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 8. Noes 0.) (June 18). |
| May 14, 2025 | Referred to Com. on HEALTH. |
| May 6, 2025 | In Senate. Read first time. To Com. on RLS. for assignment. |
| May 5, 2025 | Read third time. Passed. Ordered to the Senate. (Ayes 77. Noes 0. Page 1426.) |
| Apr 24, 2025 | Read second time. Ordered to third reading. |
| Apr 23, 2025 | From committee: Do pass. (Ayes 15. Noes 0.) (April 23). |
| Apr 8, 2025 | Re-referred to Com. on APPR. |
| Apr 7, 2025 | Read second time and amended. |
| Apr 3, 2025 | From committee: Amend, and do pass as amended and re-refer to Com. on APPR. (Ayes 15. Noes 0.) (April 1). |
| Mar 18, 2025 | Re-referred to Com. on HEALTH. |
| Mar 17, 2025 | Referred to Com. on HEALTH. |
| Mar 17, 2025 | From committee chair, with author's amendments: Amend, and re-refer to Com. on HEALTH. Read second time and amended. |
| Feb 19, 2025 | From printer. May be heard in committee March 21. |
| Feb 18, 2025 | Read first time. To print. |
|
Date
|
Description
|
Location
|
Votes
|
|
|---|---|---|---|---|
| Jul 7, 2025 | Placed on suspense file | Senate Standing Committee on Appropriations |
Passed |
|
| Jun 18, 2025 | Do pass as amended, but first amend, and re-refer to the Committee on [Appropriations] | Senate Standing Committee on Health |
Passed |
|
| May 5, 2025 | AB 787 Papan Assembly Third Reading | Assembly Floor |
Passed |
|
| Apr 23, 2025 | Do pass. | Assembly Standing Committee on Appropriations |
Passed |
|
| Apr 1, 2025 | Do pass as amended and be re-referred to the Committee on [Appropriations] | Assembly Standing Committee on Health |
Passed |
This list shows positions taken on this bill by organizations on the date displayed, which is linked to the original source.
Positions by individuals are not included.
|
Organization
|
Position
|
Date
|
|---|---|---|
| California Behavioral Health Association | ** Support | |
| California Black Health Network | ** Support | |
| California Medical Association | ** Support | |
| Health Access California | ** Support | |
| Mental Health America of California | ** Support | |
| National Health Law Program | ** Support | |
| Steinberg Institute | ** Support | |
| The Kennedy Forum | ** Support | |
| Western Center on Law & Poverty, INC. | ** Support |
SENATE COMMITTEE ON HEALTH
Senator Caroline Menjivar, Chair
BILL NO: AB 787
AUTHOR: | Papan | ||
VERSION: | April 7, 2025 | ||
HEARING DATE: | June 18, 2025 | ||
CONSULTANT: | Teri Boughton | ||
SUBJECT: Provider directory disclosures
SUMMARY:
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 a 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.
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 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 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 in circumstances where DMHC or CDI find that an enrollee or insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a provider directory or directories, to require the health plan or insurer to provide coverage for all covered health care services and to reimburse the enrollee or insured for any amount beyond what would have been paid, had the services been delivered by an in-network provider under the plan contract or insurance policy. Requires prior to requiring reimbursement in these circumstances, DMHC or 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-plan provider from being used as a basis to deny reimbursement to the enrollee or insured. [HSC §1367.27 and INS §10133.15]
- Requires information described below in 9) through 11) to be published in a separate section of the provider director titled “Timely Access to Care.” [HSC §1367.032 and INS §10133.53]
- Requires a health plan and health insurer to provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the enrollee’s or insured’s condition consistent with good professional practice., and, establish and maintain networks, policies, procedures, and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard. [HSC §1367.03 and INS §10133.54]
- Requires a health plan and health insurer to ensure that its network has adequate capacity and availability of licensed health care providers to offer enrollees and insureds appointments that meet the following timeframes:
- Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment.
- Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment.
- Nonurgent appointments for primary care: within 10 business days of the request for appointment.
- Nonurgent appointments with specialist physicians: within 15 business days of the request for appointment.
- Nonurgent appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the request for appointment.
- Nonurgent follow up appointments with a nonphysician mental health or substance use disorder provider within 10 business days of the prior appointment if undergoing a course of treatment for an ongoing condition.
- Nonurgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within 15 business days of the request for appointment.
- Waiting times may be extended if the referring or treating licensed health care provider, or health professional providing triage or screening services had determined and noted in the record a longer waiting time will not have a detrimental impact. [HSC §1367.03 and INS §10133.54]
- Requires dental plans to ensure that dental networks have adequate capacity and availability to offer appointments for covered dental services in accordance with the following timelines:
- Urgent appointments within offered within 72 hours of the time of request for appointment, if consistent with the enrollee’s or insureds individual needs and as required by professionally recognized standards of dental practice.
- Nonurgent appointments offered within 36 business days of the request for appointment.
- Preventive dental care appointments offered within 40 business days of the request for appointment. [HSC §1367.03 and INS §10133.54]
- Requires a health plan to arrange for the provision of covered services from providers outside the plan’s network if unavailable within the network if medically necessary for the enrollee’s condition. Requires a health plan to ensure that enrollee’s costs for medically necessary referrals to non-network providers do not exceed applicable in-network copayments, coinsurance, and deductibles. Requires a health plan to arrange coverage outside the plan’s network if medically necessary treatment of a mental health or substance use disorder is not available in network within the geographic and timely access standards set by law or regulation. [HSC §1367.03]
- Requires if services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the disability insurer to arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary follow-up services that, to the maximum extent possible, meet those geographic and timely access standards. “Arrange coverage to ensure the delivery of medically necessary out-of-network services” includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the insured within geographic and timely access standards. Limits the insured from paying no more than the same cost-sharing that the insured would pay for the same covered services received from an in-network provider. [INS §10144.5]
- Requires health insurer networks to provide access to medically appropriate care from a qualified provider. Requires if medically appropriate care cannot be provided within the network, the insurer to arrange for the required care with available and accessible providers outside the network, with the patient responsible for paying only cost-sharing in an amount equal to the cost-sharing they would have paid for provision of that or a similar service in-network. In addition to in-network copayments and coinsurance, in-network cost sharing includes applicability of the in-network deductible and accrual of cost sharing to the in-network out-of-pocket maximum. [10 CCR §2240.1(e)]
This bill:
- Requires health plans and insurers to add 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.
- Requires the plan or insurer, if an enrollee or insured contacts a health plan or insurer for assistance finding an in-network provider, to respond within one business day and to provide search results within two business days. Defines “search results” as a list of providers covered by the enrollee’s contract or insured’s policy that are accepting patients, confirmed by the plan or insurer, at the time of the request. Requires search results to only include providers who have responded to requests to verify their listing in the plan’s or insurer’s last annual verification, as specified.
FISCAL EFFECT:
According to Assembly Committee on Appropriations, no costs to the CDI. Minor and absorbable costs to DMHC.
PRIOR VOTES:
Assembly Floor: | 77 - 0 |
Assembly Appropriations Committee: | 15 - 0 |
Assembly Health Committee: | 15 - 0 |
COMMENTS:
- Author’s statement. According to the author, this bill strengthens California’s healthcare system by ensuring that provider directories are accurate and accessible, eliminating barriers that prevent patients from receiving timely medical care. Outdated and inaccurate provider directories create unnecessary obstacles for patients seeking in-network healthcare providers. Studies show that nearly half of all listings in these directories contain incorrect information, forcing patients to navigate a frustrating and time-consuming process that can delay essential treatment. When patients struggle to find an available provider, they may postpone necessary care or turn to more expensive options like emergency room visits, exacerbating healthcare costs and inequities. This bill directly addresses this issue by requiring provider directories to inform patients of their right to contact their health plan for assistance in finding an in-network provider. It also mandates that health plans respond to such requests within one business day and provide an updated list of available providers within two business days. These critical steps ensure that patients receive the care they need without delay. California has a responsibility to protect patients and remove systemic barriers to healthcare access. This bill is a necessary reform to guarantee transparency, efficiency, and patient-centered healthcare navigation.
- Frustrated patients. The author provided an article published in Health Affairs in 2016 that was based on a 2015 secret shopper survey of California health plans. In less than 30% of cases, consumers were able to schedule an appointment with an initially selected physician provider. The author provided an anecdote from another study where a patient was referred to a specialist, and using her insurer’s online provider directory made sure that the specialist she selected was in-network, meaning she would pay between $10 and $50. The bill she received for her visit was nearly $700 because the provider directory had incorrect information and the provider was not actually in-network. The patient “was so spooked by this completely unexpected, extremely large bill that she had none of the tests and other follow-up that the specialist recommended.”
- Federal requirements. Under the federal Consolidated Appropriations Act (CAA) of 2021, “No Surprises Act,” providers and health care facilities must generally refund enrollees amounts paid in excess of in-network cost-sharing amounts with interest, if the enrollee has inadvertently received out-of-network care due to inaccurate provider directory information, and if the provider or facility billed the enrollee for an amount in excess of in-network cost-sharing amounts, and the enrollee paid the bill. In addition, providers and health care facilities must maintain business processes to submit provider directory information at specified times to support plan and issuers in maintaining accurate, up to date provider directories. Contract provisions can require a provider to be removed at the time of the contract termination, and the plan to bear financial responsibility for providing inaccurate network status information to an enrollee.
- Related legislation. AB 280 (Aguiar-Curry) requires health plans and insurers to maintain an accurate provider directory and annually verify and delete inaccurate listings from its provider directory. 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. AB 280 is pending in this Committee.
- 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 in the Senate Appropriations Committee.
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. National Health Law Program (NHLP) writes that this bill responds to the continued difficulty that Californians experience in accessing care. NHLP believes too often, people cannot easily determine whether a particular provider participates in their plan, and, as a result, people experience delays in care, and at worst, billing for services due to miscommunications about whether a provider is included in their plan’s network. Health Access California describes a situation where a consumer called 73 doctors and found some were retired, not alive, not accepting their insurance and had disconnected phone numbers. Health Access California believes with this bill the health plan will curate the results to ensure providers shared with the consumer have updated information, are for the service they need, and are accepting new patients. Black Health Network writes that this bill is particularly important for vulnerable and underserved populations who are disproportionately impacted by provider directory inaccuracies. The Steinberg Institute writes individuals struggling with mental health challenges face unnecessary obstacles when seeking care, and, this bill represents a pragmatic solution that puts consumers first, ensuring they can easily navigate their health plan's mental health coverage and receive the support they need.
- Oppose unless amended. The California Association of Health Plans (CAHP) and the Association of California Life and Health Insurance Companies (ACLHIC) write “While plans/insurers strive for prompt responses, the strict response windows in this bill, especially when they involve confirming provider availability, are problematic. It would be helpful for the plans/insurers to have sufficient time to confirm with the provider that they can see the member before providing a list. Provider offices are not open around the clock, and many are closed on weekends. Providers are often hesitant to indicate that they are not accepting new patients, and if a provider does not communicate that to the health plan or insurer, there is no reliable way for us to know this real-time when a patient calls. As written, it is unclear if the provider's status of "accepting new patients" must be determined every time a member calls to request a list. This would be incredibly labor-intensive and exceedingly difficult to consistently determine within the timeframes in this bill. The current turnaround time is especially unfeasible for print directories. If a member requests a print directory instead of using the website, plans/insurers would not be able to abide by the specified timelines. Printed directories typically take a number of days to be processed from the point of order to be delivered. We urge the committee to consider different, more realistic timelines for print directories or limit the bill to online directories.”
- Amendments. The author’s office is requesting the committee adopt amendments to:
- Require the statement advising enrollees and insureds to contact plans and insurers is in either on the first page or on the front coverage in 16 point type font for a print directory, or appear at the top of each page for a PDF directory, and appear as affixed banner visible at the top of each page, for a navigable or searchable directory on an internet website page.
- Require the statement include that an enrollee or insured can contact their plan for an explanation of their rights regarding out-of-network coverage when contacting the plan.
- Ensure that dental plans also comply with the directory requirements described in this bill.
SUPPORT AND OPPOSITION:
Support: California Behavioral Health Association
California Black Health Network
California Medical Association
Health Access California
Mental Health America of California
National Health Law Program
Steinberg Institute
The Kennedy Forum
Western Center on Law & Poverty, Inc.
Oppose: Association of California Life and Health Insurance Companies (unless amended)
California Association of Health Plans (unless amended)
-- END --
ASSEMBLY THIRD READING
ATR Bill Id:AB 787
Author:(Papan)
As Amended Ver:April 7, 2025
Majority vote
SUMMARY
Requires a health care service plan (health plan) or health insurer to include a statement at the top of a provider directory advising an enrollee or insured to contact the health plan or insurer for assistance in finding an in-network provider. Requires the health plan or insurer to respond to an enrollee within one business day and provide a list of in-network providers confirmed to be accepting new patients within two business days.
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. California state law 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.
- 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:
- Department of Managed Health Care (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.
- 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:
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. 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.
According to the Author
This bill strengthens California's healthcare system by ensuring that provider directories are accurate and accessible, eliminating barriers that prevent patients from receiving timely medical care. The author continues that outdated and inaccurate provider directories create unnecessary obstacles for patients seeking in-network healthcare providers. The author states that studies show nearly half of all listings in these directories contain incorrect information, forcing patients to navigate a frustrating and time-consuming process that can delay essential treatment. The author argues that this bill directly addresses this issue by requiring provider directories to inform patients of their right to contact their health plan for assistance in finding an in-network provider. The author concludes that California has a responsibility to protect patients and remove systemic barriers to health care access, and this bill is a necessary reform to guarantee transparency, efficiency, and patient-centered healthcare navigation.
Arguments in Support
The Steinberg Institute supports this bill, stating that it addresses a fundamental need in our healthcare system: ensuring that consumers fully understand their rights to mental health and substance use disorder treatment. The Steinberg Institute continues that by requiring health plans to provide clear, accessible information about covered mental health services, this bill will empower consumers with critical information about their healthcare benefits, reduce barriers to accessing essential mental health and substance use disorder treatments, and promote transparency and accountability in health plan communication. The Steinberg Institute argues that too often individuals struggling with mental health challenges face unnecessary obstacles when seeking care, and this bill represents a pragmatic solution that puts consumers first, ensuring they can easily navigate their health plan's mental health coverage and receive the support they need.
Arguments in Opposition
None on file.
FISCAL COMMENTS
According to Assembly Committee on Appropriations, no costs to the Department of Insurance. Minor and absorbable costs to the Department of Managed Health Care.
VOTES
ASM HEALTH: 15-0-0
YES: Bonta, Chen, Addis, Aguiar-Curry, Arambula, Carrillo, Flora, Mark González, Krell, Patel, Celeste Rodriguez, Sanchez, Schiavo, Sharp-Collins, Stefani
ASM APPROPRIATIONS: 15-0-0
YES: Wicks, Sanchez, Arambula, Calderon, Caloza, Dixon, Elhawary, Fong, Mark González, Hart, Pacheco, Pellerin, Solache, Ta, Tangipa
UPDATED
VERSION: April 7, 2025
CONSULTANT: Riana King / HEALTH / (916) 319-2097 FN: 0000274
Date of Hearing: April 23, 2025
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Buffy Wicks, Chair
ABPCA Bill Id:AB 787
Author:(Papan) – As Amended Ver:April 7, 2025
Policy Committee: | Health | Vote: | 15 - 0 |
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Urgency: No State Mandated Local Program: Yes Reimbursable: No
SUMMARY:
This bill requires a full service health plan, specialized mental health plan, health insurer, or specialized mental health insurer to include in its provider directory a statement advising an enrollee or insured to contact the plan or insurer for assistance in finding an in-network provider, and requires the health plan or insurer to respond within one business day if contacted for assistance and provide an updated list of available providers within two working days.
FISCAL EFFECT:
No costs to the Department of Insurance.
Minor and absorbable costs to the Department of Managed Health Care.
COMMENTS:
- Purpose. According to the author:
Outdated and inaccurate provider directories create unnecessary obstacles for patients seeking in-network healthcare providers. Studies show that nearly half of all listings in these directories contain incorrect information, forcing patients to navigate a frustrating and time-consuming process that can delay essential treatment. When patients struggle to find an available provider, they may postpone necessary care or turn to more expensive options like emergency room visits, exacerbating healthcare costs and inequities. AB 787 directly addresses this issue by requiring provider directories to inform patients of their right to contact their health plan for assistance in finding an in-network provider.
- Provider Directories. Provider directories help patients identify clinicians based on specialty, location, and hours. Provider directories can also be 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 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 DMHC and CDI to develop uniform provider directory standards and take steps to ensure the accuracy of the information contained in directories, and requires the plan or insurer, at least annually, to review and update the entire provider directory or directories for each product offered.
Studies have revealed high error rates across provider directories in California. In one study, even the lowest error rate identified was 21%, while at the high end, more than half of all provider listings in a provider directory led to a dead end. A 2015 secret shopper study of California qualified health plans (QHPs; offered through Covered California) found 73% of calls to providers listed in network directories were unable to secure appointments. A recent secret shopper survey in Los Angeles revealed only 15% of phone calls seeking psychiatric appointments for Medi-Cal patients led to a scheduled appointment.
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 for both health plans and the DMHC. The regulatory process is still underway, and DMHC anticipates it to be completed by this summer.
- Related and Prior Legislation.
AB 280 (Aguiar-Curry), of the current legislative session, requires a 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. AB 280 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. AB 280 imposes fines on health plans and insurers that fail to meet the benchmark rates. AB 280 is pending in this committee.
AB 236 (Holden), of the 2023-24 Legislative Session, would have phased in provider directory accuracy benchmarks of 60% by July 1, 2025, to 95% accurate by July 1, 2028, and imposed fines on health plans and insurers that fail to meet the benchmark rates. 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 787
Author:(Papan) – As Amended Ver:March 17, 2025
SUBJECT: Provider directory disclosures.
SUMMARY: Requires a health care service plan (health plan) or health insurer to include a statement at the top of a provider directory advising an enrollee or insured to contact the health plan or insurer for assistance in finding an in-network provider. Requires the health plan or insurer to respond to an enrollee within 24 hours and provide a list of in-network providers confirmed to be accepting new patients within two business days.
EXISTING LAW:
- Establishes the Department of Managed Health Care (DMHC) to regulate health plans and California Department of Insurance (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. 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, this bill strengthens California’s healthcare system by ensuring that provider directories are accurate and accessible, eliminating barriers that prevent patients from receiving timely medical care. The author continues that outdated and inaccurate provider directories create unnecessary obstacles for patients seeking in-network healthcare providers. The author states that studies show nearly half of all listings in these directories contain incorrect information, forcing patients to navigate a frustrating and time-consuming process that can delay essential treatment. The author argues that this bill directly addresses this issue by requiring provider directories to inform patients of their right to contact their health plan for assistance in finding an in-network provider. The author concludes that California has a responsibility to protect patients and remove systemic barriers to health care access, and this bill is a necessary reform to guarantee transparency, efficiency, and patient-centered healthcare navigation.
- 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. California state law 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. California state law 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.
- SUPPORT. The Steinberg Institute supports this bill, stating that it addresses a fundamental need in our healthcare system: ensuring that consumers fully understand their rights to mental health and substance use disorder treatment. The Steinberg Institute continues that by requiring health plans to provide clear, accessible information about covered mental health services, this bill will empower consumers with critical information about their healthcare benefits, reduce barriers to accessing essential mental health and substance use disorder treatments, and promote transparency and accountability in health plan communication. The Steinberg Institute argues that too often individuals struggling with mental health challenges face unnecessary obstacles when seeking care, and this bill represents a pragmatic solution that puts consumers first, ensuring they can easily navigate their health plan's mental health coverage and receive the support they need.
- RELATED LEGISLATION. AB 280 (Aguiar-Curry) would require a 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. AB 280 would require 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. AB 280 would impose fines on health plans and insurers that fail to meet the benchmark rates.
- 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.
- PROPOSED AMENDMENT. The definition of search results in this bill could be interpreted to be a reiteration of the existing provider directory that is already available to an enrollee. Additionally, this bill is amending the same code sections as another bill before this committee, AB 280 (Aguiar-Curry), which uses differing timelines and terminology for similar health plan correspondence requirements. The committee may wish to consider the following amendments to further clarify the definition of search results and better align timelines with those detailed in AB 280 (Aguiar-Curry):
If an enrollee contacts a health care service plan for assistance in finding an in-network provider, the plan shall respond within 24 hours one business day and shall provide search results within two business days. For this subdivision, search results shall be defined as a list of provider(s) covered by the plan that are accepting patients, which shall be confirmed by the health plan at the time of the enrollee’s request. Search results shall only include providers that have responded to requests to verify their listing information in the health plan's last annual verification under subdivision (l).
REGISTERED SUPPORT / OPPOSITION:
Support
Steinberg Institute
Opposition
None on file.
Analysis Prepared by: Riana King / HEALTH / (916) 319-2097
Discussed in Hearing
40MIN
Senate Standing Committee on Health
1MIN
Assembly Floor
2MIN
Assembly Standing Committee on Appropriations
8MIN
Assembly Standing Committee on Health
Bill Author
Bill Co-Author(s):