Health care coverage: network modification: contracting providers.

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 also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a plan to obtain department approval prior to a material modification of its plan or operations and requires a plan to take specified actions prior to terminating a contract with a provider group or a general acute care hospital. Existing law imposes specified requirements with respect to the accessibility of services provided by both plans and insurers. This bill would require a plan or an insurer that contracts with providers to obtain approval from its regulating department prior to implementing a network modification, as defined, and would require the plan or insurer, in order to obtain approval, to demonstrate that the modified network would meet certain access requirements. The bill would require plans and insurers to notify affected providers and enrollees or insureds of the modification, as specified. Existing law requires a health care service plan or a health insurer to include in its disclosure form and evidence of coverage a statement describing how participation in the plan or policy may affect the choice of provider, among other things. Existing law requires a health care service plan to, upon request, provide an enrollee or prospective enrollee with a list of certain contracting providers within his or her general geographic area. This bill would require the list to include additional information regarding hospital-based physicians. Existing law requires health insurers that contract with providers to provide group policyholders with a current roster of contracting providers and to make this list available for public inspection, as specified. This bill would instead require those health insurers to provide a list of certain contracting providers to insureds and prospective insureds upon request and would require that the list be updated, as specified. The bill would also require these health insurers to make information available, upon request, concerning a contracting provider's degree, certifications, or subspecialty qualifications. The bill would prohibit both plans and health insurers that contract with providers from including out-of-network or noncontracting providers in their lists. The bill would require those plans and insurers to provide a mechanism enabling enrollees, insureds, and providers to easily report provider directory errors to the plan or insurer and would require plans and insurers to correct confirmed errors within a specified period of time. The bill would enact other related provisions. Existing law requires the Department of Managed Health Care, as often as the director of the department deems necessary, but not less frequently than once every 3 years, to conduct an onsite medical survey of the health delivery system of each plan to ensure protection of subscribers and enrollees, as specified. Existing law requires that the survey include a review of, among other things, the procedures for obtaining health services, the procedures for regulating utilization, and the internal procedures for assuring quality of care. This bill would require the survey to also include a review of the plan's compliance with certain accessibility standards and with the contracting provider listing requirements described above. Because a willful violation of the bill's requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.