Health care coverage: provider directories.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. A willful violation of the act is a crime. Existing law requires a health care service plan to provide a list of contracting providers within a requesting enrollee's or prospective enrollee's general geographic area. Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires health insurers subject to regulation by the commissioner to provide group policyholders with a current roster of institutional and professional providers under contract to provide services at alternative rates. Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. One of the methods by which Medi-Cal services are provided is pursuant to contracts with various types of managed health care plans. This bill, commencing July 1, 2016, would require a health care service plan, and a health insurer that contracts with providers for alternative rates of payment, to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan's enrollees or the health insurer's insureds, and would require the plan or health insurer to make an online provider directory or directories available on the plan or health insurer's Internet Web site, as specified. This bill would require the Department of Managed Health Care and the Department of Insurance to develop uniform provider directory standards. The bill would require a health care service plan or health insurer to take appropriate steps to ensure the accuracy of the information contained in the plan or health insurer's directory or directories, and would require the plan or health insurer, at least annually, to review and update the entire provider directory or directories for each product offered, as specified. The bill would require a plan or insurer, at least weekly, to update its online provider directory or directories, and would require a plan or insurer, at least quarterly, to update its printed provider directory or directories. The bill would require a health care service plan or health insurer to reimburse an enrollee or insured for any amount beyond what the enrollee or insured would have paid for in-network services, if the enrollee or insured reasonably relied on the provider directory, as specified. The bill would authorize a plan or health insurer to delay payment or reimbursement owed to a provider or provider group, as specified, if the provider or provider group fails to respond to the plan's or health insurer's attempts to verify the provider's or provider group's information. By placing additional requirements on health care service plans, the violation of which is a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.