Article 2. Transfer of California Insurance Code >> Division 2. >> Part 2. >> Chapter 1. >> Article 2.
Sections 10130 and 10131 do not apply to group life
policies, to group disability policies, or to individual disability
policies providing a benefit for loss of time and which are
noncancellable and guaranteed renewable for not less than five years,
when any of such group life policies, group disability policies or
individual disability policies expressly provide that benefits
payable thereunder are not assignable, and in such case the benefits
shall be paid only as provided in the policy.
Sections 10130 and 10131 do not apply to annuity contracts
which are within the scope of Section 401(g) of the Internal Revenue
Code of the United States.
A life or disability policy may pass by transfer, will or
succession to any person, whether or not the transferee has an
insurable interest. Such transferee may recover upon it whatever the
insured might have recovered.
Notice to an insurer of a transfer of a life or disability
policy is not necessary to preserve the validity of the policy unless
expressly required by the policy.
The beneficiary under a life policy which provides for the
payment of its proceeds in periodical installments, may be restrained
by its provisions from disposing of or incumbering his interest in
any such installment prior to the date when it becomes due and
payable by the insurer.
(a) Upon written consent of the insured first obtained with
respect to a particular claim, any disability insurer shall pay group
insurance benefits contingent upon, or for expenses incurred on
account of, hospitalization or medical or surgical aid to the person
or persons furnishing the hospitalization or medical or surgical aid,
or, on and after January 1, 1994, to the person or persons having
paid for the hospitalization or medical or surgical aid, but the
amount of any such payment shall not exceed the amount of benefit
provided by the policy with respect to the service or billing of the
provider of aid, and the amount of the payments pursuant to one or
more assignments shall not exceed the amount of expenses incurred on
account of the hospitalization or medical or surgical aid. Payments
so made shall discharge the insurer's obligation with respect to the
amount so paid.
(b) Nothing in this section shall be construed to authorize an
insurer to furnish or directly provide services of hospitals, or
psychiatric health facilities, as defined in Section 1250.2 of the
Health and Safety Code, or physicians and surgeons, or psychologists
or in any manner to direct, participate in, or control the selection
of the hospital or health facility or physician and surgeon or
psychologist from whom the insured secures services or exercise
medical or dental or psychological professional judgment, except that
an insurer may negotiate and enter into contracts for alternative
rates of payment with institutional providers, and offer the benefit
of these alternative rates to insureds who select those providers.
(c) Alternatively, insurers may, by agreement with group
policyholders, limit payments under a policy to services secured by
insureds from institutional providers, and after July 1, 1983, from
professional providers, charging alternative rates pursuant to
contract with the insurer.
(d) Pursuant to subdivision (c), when alternate rates of payment
to providers are applicable to contracts with group policyholders,
the contracts shall include programs for the continuous review of the
quality of care, performance of medical or psychological personnel
included in the plan, utilization of services and facilities, and
costs, by professionally recognized unrelated third parties utilizing
in the case of professional providers similarly licensed providers
for each medical, psychological, or dental service covered under the
plan and utilizing in the case of institutional providers appropriate
professional providers. All provisions of the laws of the state
relating to immunity from liability and discovery privileges for
medical, psychological, and dental peer review shall apply to the
licensed providers performing the foregoing activities.
(e) On or after July 1, 1983, the amendments made to this section
during the 1982 portion of the 1981-82 Regular Session, shall also be
applicable with respect to both professional and institutional
providers.
Insurers shall provide group policyholders with a current
roster of institutional and professional providers under contract to
provide services at alternative rates under their group policy and
shall also make such lists available for public inspection during
regular business hours at the insurer's or plan's principal office
within the state.
(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 insurer's 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 insurer's Internet Web site 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 insurer's public Internet Web site 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 insurer's public Internet Web site 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 insurer's 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 provider's 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 insurer's
Internet Web site.
(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 provider's 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 provider's 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.
(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 of the Insurance Code, if any, on the provider's
staff.
(11) Identification of providers who no longer accept new patients
for some or all of the insurer's 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 require the use of network tiers other
than contract and noncontracting tiers.
(13) 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 provider's 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 provider's 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 of the Insurance Code, if any, on the provider's
staff.
(10) Identification of providers who no longer accept new patients
for some or all of the insurer's 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 occur:
(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 insurer's 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
insurer's 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 provider's 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 provider's information is correct or requires
updates, the insurer shall notify the provider 10 business days in
advance of removal that the provider will be removed from the
directory or directories. The provider shall be removed from the
directory or directories at the next required update of the provider
directory or directories after the 10-business day notice period. A
provider shall not be removed from the provider directory or
directories if he or she 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 subdivision (l)
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 insurer's provider directory or
directories. These processes 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 insurer's
provider directory Internet Web site linking to a form where the
information can be reported directly to the insurer through its
Internet Web site.
(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 group's attempt to
verify the provider's information. As used in this paragraph,
"verify" means to contact the provider in writing, electronically,
and by telephone to confirm whether the provider's information is
correct or requires updates.
(B) The provider group documents its efforts to verify the
provider's information.
(C) The provider group reports to the insurer that the provider
should be deleted from the provider group in the insurer's 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 provider's name, location, and a
description of the insurer's investigation, the outcome of the
investigation, and any changes or updates made to its provider
directory or directories.
(C) If changes to an insurer's provider directory or directories
are required as a result of the insurer's 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 insurer's attempts to verify the provider's information as
required under subdivision (l). The insurer shall not delay payment
unless it has attempted to verify the provider's or provider group's
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 provider's or provider group's
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
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 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 insurer's 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 insured's 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 insured's 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) 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) Nothing in this section shall be construed to alter a provider'
s obligation to provide health care services to an insured pursuant
to the provider's contract with the insurer.
(u) As part of the department's routine examination of a health
insurer pursuant to Section 730, the department shall include a
review of the health insurer's compliance with subdivision (p).
(v) For purposes of this section, "provider group" means a medical
group, independent practice association, or other similar group of
providers.
When any disability insurer negotiates and enters into a
contract with professional or institutional providers to provide
services at alternative rates of payment of the type described in
Sections 10133 and 11512 of the Insurance Code, the amount of patient
copayment shall be calculated exclusively from the negotiated
alternative rate for the service rendered. No disability insurer or
professional or institutional provider, negotiating and entering into
a contract pursuant to this section, shall charge or collect
copayment amounts greater than those calculated in accordance with
this section.
This section shall become operative on January 1, 1993.
When any self-insured governmental plan, as defined in
Section 12671, negotiates and enters into a contract with
professional or institutional providers to provide services at
alternative rates of payment of the type described in Sections 10133
and 11512 of the Insurance Code, the amount of patient copayment
shall be calculated exclusively from the negotiated alternative rate
for the service rendered. No self-insured governmental plan or
professional or institutional provider, negotiating and entering into
a contract pursuant to this section, shall charge or collect
copayment amounts greater than those calculated in accordance with
this section.
This section shall become operative on January 1, 1993.
(a) For purposes of insurers that contract with providers
for alternate rates pursuant to Section 10133, a primary care
provider includes a "nonphysician medical practitioner," which is
defined as a physician assistant performing services under the
supervision of a primary care physician in compliance with Chapter
7.7 (commencing with Section 3500) of Division 2 of the Business and
Professions Code or a nurse practitioner performing services in
collaboration with a physician pursuant to Chapter 6 (commencing with
Section 2700) of Division 2 of the Business and Professions Code.
(b) This section shall not require a primary care provider to
accept the assignment of a number of insureds that would exceed
standards of good health care as provided in Section 10133.5.
(c) This section shall not be interpreted to modify subdivision
(e) of Section 2836.1 of the Business and Professions Code or
subdivision (b) of Section 3516 of the Business and Professions Code.
(a) The commissioner shall, on or before January 1, 2004,
promulgate regulations applicable to health insurers which contract
with providers for alternative rates pursuant to Section 10133 to
ensure that insureds have the opportunity to access needed health
care services in a timely manner.
(b) These regulations shall be designed to assure accessibility of
provider services in a timely manner to individuals comprising the
insured or contracted group, pursuant to benefits covered under the
policy or contract. The regulations shall insure:
1. Adequacy of number and locations of institutional facilities
and professional providers, and consultants in relationship to the
size and location of the insured group and that the services offered
are available at reasonable times.
2. Adequacy of number of professional providers, and license
classifications of such providers, in relationship to the projected
demands for services covered under the group policy or plan. The
department shall consider the nature of the specialty in determining
the adequacy of professional providers.
3. The policy or contract is not inconsistent with standards of
good health care and clinically appropriate care.
4. All contracts including contracts with providers, and other
persons furnishing services, or facilities shall be fair and
reasonable.
(c) In developing standards under subdivision (a), the department
shall also consider requirements under federal law; requirements
under other state programs and law, including utilization review; and
standards adopted by other states, national accrediting
organizations and professional associations. The department shall
further consider the accessability to provider services in rural
areas.
(d) In designing the regulations the commissioner shall consider
the regulations in Title 28, of the California Administrative Code of
Regulations, commencing with Section 1300.67.2, which are applicable
to Knox-Keene plans, and all other relevant guidelines in an effort
to accomplish maximum accessibility within a cost efficient system of
indemnification. The department shall consult with the Department of
Managed Health Care concerning regulations developed by that
department pursuant to Section 1367.03 of the Health and Safety Code
and shall seek public input from a wide range of interested parties.
(e) Health insurers that contract for alternative rates of payment
with providers shall report annually on complaints received by the
insurer regarding timely access to care. The department shall review
these complaints and any complaints received by the department
regarding timeliness of care and shall make public this information.
(f) The department shall report to the Assembly Committee on
Health and the Senate Committee on Insurance of the Legislature on
March 1, 2003, and on March 1, 2004, regarding the progress towards
the implementation of this section.
(g) Every three years, the commissioner shall review the latest
version of the regulations adopted pursuant to subdivision (a) and
shall determine if the regulations should be updated to further the
intent of this section.
(a) (1) Except as provided in paragraph (2), every
disability insurer covering hospital, medical, and surgical expenses
on a group basis that contracts with providers for alternative rates
pursuant to Section 10133 and limits payments under those policies to
services secured by insureds and subscribers from providers charging
alternative rates pursuant to these contracts, shall file with the
Department of Insurance, a written policy describing how the insurer
shall facilitate the continuity of care for new insureds or enrollees
receiving services during a current episode of care for an acute
condition from a noncontracting provider. This written policy shall
describe the process used to facilitate continuity of care, including
the assumption of care by a contracting provider.
(2) On or before July 1, 2002, every disability insurer covering
hospital, medical, and surgical expenses on a group basis that
contracts with providers for alternative rates pursuant to Section
10133 and limits payments under those policies to services secured by
insureds and subscribers from providers charging alternative rates
pursuant to these contracts, shall file with the department a written
policy describing how the insurer shall facilitate the continuity of
care for new enrollees who have been receiving services for an
acute, serious, or chronic mental health condition from a
nonparticipating mental health provider when the enrollee's employer
has changed policies. Every written policy shall allow the new
enrollee a reasonable transition period to continue his or her course
of treatment with the nonparticipating mental health provider prior
to transferring to another participating provider and shall include
the provision of mental health services on a timely, appropriate, and
medically necessary basis from the nonparticipating provider. The
policy may provide that the length of the transition period take into
account the severity of the enrollee's condition and the amount of
time reasonably necessary to effect a safe transfer on a case-by-case
basis. Nothing in this paragraph shall be construed to require the
insurer to accept a nonparticipating mental health provider onto its
panel for treatment of other enrollees. For purposes of the
continuing treatment of the transferring enrollee, the insurer may
require the nonparticipating mental health provider, as a condition
of the right conferred under this section, to enter into the standard
mental health provider contract.
(b) Notice of the policy and information regarding how enrollees
may request a review under the policy shall be provided to all new
enrollees, except those enrollees who are not eligible as described
in subdivision (e). A copy of the written policy shall be provided to
eligible enrollees upon request. The written policy required to be
filed under subdivision (a) shall describe how requests to continue
services with an existing noncontracting provider are reviewed by the
insurer. The policy shall ensure that reasonable consideration is
given to the potential clinical effect that a change of provider
would have on the insured's or subscriber's treatment for the acute
condition.
(c) An insurer may require any nonparticipating provider whose
services are continued pursuant to the written policy to agree in
writing to meet the same contractual terms and conditions that are
imposed upon the insurer's participating providers, including
location within the service area, reimbursement methodologies, and
rates of payment. If the insurer determines that a patient's health
care treatment should temporarily continue with the patient's
existing provider or nonparticipating mental health provider, the
insurer shall not be liable for actions resulting solely from the
negligence, malpractice, or other tortious or wrongful acts arising
out of the provision of services by the existing provider or
nonparticipating mental health provider.
(d) Nothing in this section shall require an insurer to cover
services or provide benefits that are not otherwise covered under the
terms and conditions of the policy contract.
(e) The written policy shall not apply to any insured or
subscriber who is offered an out-of-network option, or who had the
option to continue with his or her previous health benefits carrier
or provider and instead voluntarily chose to change.
(f) This section shall not apply to insurer contracts that include
out-of-network coverage under which the insured or subscriber is
able to obtain services from the insured's or subscriber's existing
provider or nonparticipating mental health provider.
(g) (1) For purposes of this section, "provider" refers to a
person who is described in subdivision (f) of Section 900 of the
Business and Professions Code.
(2) For purposes of this section, "nonparticipating mental health
provider" refers to a psychiatrist, licensed psychologist, licensed
marriage and family therapist, licensed clinical social worker, or
licensed professional clinical counselor who is not part of the
insurer's contracted provider network.
(h) This section shall only apply to a group disability insurance
policy if it provides coverage for hospital, medical, or surgical
benefits.
(a) (1) A health insurer that enters into a contract with
a professional or institutional provider to provide services at
alternative rates of payment pursuant to Section 10133 shall, at the
request of an insured, arrange for the completion of covered services
by a terminated provider, if the insured is undergoing a course of
treatment for any of the following conditions:
(A) An acute condition. An acute condition is a medical condition
that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and
that has a limited duration. Completion of covered services shall be
provided for the duration of the acute condition.
(B) A serious chronic condition. A serious chronic condition is a
medical condition due to a disease, illness, or other medical problem
or medical disorder that is serious in nature and that persists
without full cure or worsens over an extended period of time or
requires ongoing treatment to maintain remission or prevent
deterioration. Completion of covered services shall be provided for a
period of time necessary to complete a course of treatment and to
arrange for a safe transfer to another provider, as determined by the
health insurer in consultation with the insured and the terminated
provider and consistent with good professional practice. Completion
of covered services under this paragraph shall not exceed 12 months
from the contract termination date or 12 months from the effective
date of coverage for a newly covered insured.
(C) A pregnancy. A pregnancy is the three trimesters of pregnancy
and the immediate postpartum period. Completion of covered services
shall be provided for the duration of the pregnancy.
(D) A terminal illness. A terminal illness is an incurable or
irreversible condition that has a high probability of causing death
within one year or less. Completion of covered services shall be
provided for the duration of a terminal illness, which may exceed 12
months from the contract termination date or 12 months from the
effective date of coverage for a new insured.
(E) The care of a newborn child between birth and age 36 months.
Completion of covered services under this paragraph shall not exceed
12 months from the contract termination date or 12 months from the
effective date of coverage for a newly covered insured.
(F) Performance of a surgery or other procedure that has been
recommended and documented by the provider to occur within 180 days
of the contract's termination date or within 180 days of the
effective date of coverage for a newly covered insured.
(2) The insurer may require the terminated provider whose services
are continued beyond the contract termination date pursuant to this
subdivision, to agree in writing to be subject to the same
contractual terms and conditions that were imposed upon the provider
prior to termination, including, but not limited to, credentialing,
hospital privileging, utilization review, peer review, and quality
assurance requirements. If the terminated provider does not agree to
comply or does not comply with these contractual terms and
conditions, the insurer is not required to continue the provider's
services beyond the contract termination date.
(3) Unless otherwise agreed upon between the terminated provider
and the insurer or between the terminated provider and the provider
group, the agreement shall be construed to require a rate and method
of payment to the terminated provider, for the services rendered
pursuant to this subdivision, that are the same as the rate and
method of payment for the same services while under contract with the
insurer and at the time of termination. The provider shall accept
the reimbursement as payment in full and shall not bill the insured
for any amount in excess of the reimbursement rate, with the
exception of copayments and deductibles pursuant to subdivision (c).
(b) Notice as to the process by which an insured may request
completion of covered services pursuant to this section shall be
provided in any insurer evidence of coverage and disclosure form
issued after March 31, 2004. An insurer shall provide a written copy
of this information to its contracting providers and provider groups.
An insurer shall also provide a copy to its insureds upon request.
(c) The payment of copayments, deductibles, or other cost-sharing
components by the insured during the period of completion of covered
services with a terminated provider pursuant to subdivision (a) or a
nonparticipating provider pursuant to subdivision (i) shall be the
same copayments, deductibles, or other cost-sharing components that
would be paid by the insured when receiving care from a provider
currently contracting with the insurer.
(d) If an insurer delegates the responsibility of complying with
this section to its contracting entities, the insurer shall ensure
that the requirements of this section are met.
(e) For the purposes of this section, the following terms have the
following meanings:
(1) "Provider" means a person who is a licentiate as defined in
Section 805 of the Business and Professions Code or a person licensed
under Chapter 2 (commencing with Section 1000) of Division 2 of the
Business and Professions Code.
(2) "Provider group" includes a medical group, independent
practice association, or any other similar organization.
(3) "Nonparticipating provider" means a provider who is not
contracted with the insured's health insurer to provide services
under the insured's policy. A nonparticipating provider does not
include a terminated provider.
(4) "Terminated provider" means a provider whose contract to
provide services to insureds is terminated or not renewed by the
insurer or one of the insurer's contracting provider groups. A
terminated provider is not a provider who voluntarily leaves the
insurer or contracting provider group.
(f) This section shall not require an insurer or provider group to
provide for the completion of covered services by a provider whose
contract with the insurer or provider group has been terminated or
not renewed for reasons relating to medical disciplinary cause or
reason, as defined in paragraph (6) of subdivision (a) of Section 805
of the Business and Professions Code, or fraud or other criminal
activity.
(g) This section shall not require an insurer to cover services or
provide benefits that are not otherwise covered under the terms and
conditions of the insurer contract.
(h) The provisions contained in this section are in addition to
any other responsibilities of insurers to provide continuity of care
pursuant to this chapter. Nothing in this section shall preclude an
insurer from providing continuity of care beyond the requirements of
this section.
(i) (1) A health insurer shall, at the request of a newly covered
insured under an individual insurance policy, arrange for the
completion of covered services as set forth in this section by a
nonparticipating provider for one of the conditions described in
subdivision (a) if the newly covered insured meets both of the
following:
(A) The newly covered insured's prior coverage was terminated
under subdivision (d) or (e) of Section 10273.6 or paragraph (5) or
(6) of subdivision (a) of Section 1365 of the Health and Safety Code
between December 1, 2013, and March 31, 2014, inclusive.
(B) At the time his or her coverage became effective, the newly
covered insured was receiving services from that provider for one of
the conditions described in subdivision (a).
(2) The completion of covered services required to be provided
under this subdivision shall apply to services rendered to the newly
covered insured on and after the effective date of his or her new
coverage.
(3) (A) The insurer may require a nonparticipating provider whose
services are continued pursuant to this subdivision for a newly
covered insured to agree in writing to be subject to the same
contractual terms and conditions that are imposed upon currently
participating providers providing similar services who are practicing
in the same or a similar geographic area as the nonparticipating
provider, including, but not limited to, credentialing, hospital
privileging, utilization review, peer review, and quality assurance
requirements. If the nonparticipating provider does not agree to
comply or does not comply with these contractual terms and
conditions, the insurer is not required to continue the provider's
services.
(B) Unless otherwise agreed upon by the nonparticipating provider
and the insurer, the services rendered pursuant to this subdivision
shall be compensated at rates and methods of payment similar to those
used by the insurer for currently participating providers providing
similar services who are practicing in the same or a similar
geographic area as the nonparticipating provider. Neither the insurer
nor the provider group is required to continue the services of a
nonparticipating provider if the provider does not accept the payment
rates provided for in this paragraph. The provider who agrees to
provide services pursuant to this subdivision shall accept the
reimbursement as payment in full and shall not bill the insured for
any amount in excess of the reimbursement rate, with the exception of
copayments and deductibles pursuant to subdivision (c).
(C) A provider's agreement to contractual terms and conditions and
acceptance of payment rates to provide the completion of covered
services to an insured pursuant to this subdivision shall not be
construed as an agreement to contractual terms and conditions or
acceptance of payment rates for any other insureds or for any
services other than covered services pursuant to this subdivision,
nor shall it be construed as agreement to any other contract.
It is the intent of the Legislature to ensure that the
citizens of this state receive high-quality health care coverage in
the most efficient and cost-effective manner possible. In furtherance
of this intent, the Legislature finds and declares that it is in the
public interest to promote various types of contracts between public
or private payers of health care coverage, and institutional or
professional providers of health care services. This intent has been
demonstrated by the recent enactment of Chapters 328, 329, and 1594
of the Statutes of 1982 authorizing various types of contracts to be
entered into between public or private payers of health care
coverage, and institutional or professional providers of health care
services. The Legislature further finds and declares that individual
providers, whether institutional or professional and individual
purchasers, have not proven to be efficient-sized bargaining units
for these contracts, and that the formation of groups and
combinations of institutional and professional providers and
purchasing groups for the purpose of creating efficient-sized
contracting units represents a meaningful addition to the health care
marketplace. The Legislature further finds and declares that the
public interest in ensuring that citizens of this state receive
high-quality health care coverage in the most efficient and
cost-effective manner possible is furthered by permitting
negotiations for alternative rate contracts between purchasers and
payers and both institutional and professional providers, or through
a person or entity acting for, or on behalf of, a health insurer or
an institutional or professional provider, pursuant to Sections 10133
and 11512. It is the intent of the Legislature, therefore, that the
formation of groups and combinations of purchasers, payers, and
institutional and professional providers of health care services for
the purpose of creating efficient-sized contracting units be
recognized as the creation of a new product within the health care
marketplace, and be subject, therefore, only to those antitrust
prohibitions applicable to the conduct of other presumptively
legitimate enterprises.
This section does not change existing antitrust law as it relates
to any agreement or arrangement to exclude from any of the
above-described groups or combinations, any person who is lawfully
qualified to perform the services to be performed by the members of
the group or combination, where the ground for the exclusion is
failure to possess the same license or certification as is possessed
by the members of the group or combination.
(a) A contract issued, amended, renewed, or delivered on
or after January 1, 2015, by or on behalf of a health insurer and a
provider or supplier shall not contain any provision that restricts
the ability of the health insurer to furnish consumers or purchasers
information concerning any of the following:
(1) The cost range of a procedure or a full course of treatment,
including, but not limited to, facility, professional, and diagnostic
services, prescription drugs, durable medical equipment, and other
items and services related to the treatment.
(2) The quality of services performed by the provider or supplier.
(b) Any contractual provision inconsistent with this section shall
be void and unenforceable.
(c) A health insurer shall provide the provider or supplier an
advance opportunity of 30 days to review the methodology and data
developed and compiled by the health insurer, and used pursuant to
subdivision (a), before cost or quality information is provided to
consumers or purchasers, including material revisions or additions of
new information. At the time the health insurer provides a provider
or supplier with the opportunity to review the methodology and data,
it shall also notify the provider or supplier in writing of their
opportunity to provide an Internet Web site link pursuant to
subdivision (f).
(d) If the information proposed to be furnished to policyholders
and insureds on the quality of services performed by a provider or
supplier is data that the insurer has developed and compiled, the
insurer shall utilize appropriate risk adjustment factors to account
for different characteristics of the population, such as case mix,
severity of patient's condition, comorbidities, outlier episodes, and
other factors to account for differences in the use of health care
resources among providers and suppliers.
(e) Any Internet Web site owned or controlled by a health insurer,
or operated by another person or entity under contract with or on
behalf of a health insurer, that displays the information developed
and compiled by the health insurer as referenced by this section
shall prominently post the following statement:
"Individual health care facilities or providers may disagree with
the methodology used to define the cost ranges, the cost data, or
quality measures. Many factors may influence cost or quality,
including, but not limited to, the cost of uninsured and charity
care, the type and severity of procedures, the case mix of a
facility, special services such as trauma centers, burn units,
medical and other educational programs, research, transplant
services, technology, payer mix, and other factors affecting
individual health care facilities and providers."
A health insurer and a provider or supplier shall not be precluded
from mutually agreeing in writing to an alternative method of
conveying this statement.
(f) If a provider or supplier chooses to provide an Internet Web
site link where a response to the health insurer's posting may be
found, it shall do so in a timely manner in order to satisfy the
requirements of this section. If a provider or supplier chooses to
provide a response, an insurer shall post, in an easily identified
manner, a prominent link to the provider's or supplier's Internet Web
site where a response to the health insurer's posting may be found.
A health insurer and a provider or supplier shall not be precluded
from mutually agreeing in writing to an alternative method to convey
a provider's or supplier's response.
(g) For the purposes of this section, the following definitions
shall apply:
(1) "Consumers" means policyholders or insureds of the health
insurer or beneficiaries of a self-funded health coverage arrangement
administered by the health insurer or other persons entitled to
access services through a network established by the health insurer.
(2) "Provider" has the same meaning as that term is defined in
Section 10117.52.
(3) "Purchasers" means the sponsors of a self-funded health
coverage arrangement administered by the health insurer.
(4) "Supplier" has the same meaning as that term is defined in
Section 10117.52.
(a) This section shall be known and may be cited as the
Health Care Providers' Bill of Rights.
(b) No contract issued, amended, or renewed on or after January 1,
2003, between a health insurer and a health care provider for the
provision of covered benefits at alternative rates of payment to an
insured shall contain any of the following terms:
(1) A provision that requires a health care provider to accept
additional patients beyond the contracted number or in the absence of
a number if, in the reasonable professional judgment of the
provider, accepting additional patients would endanger patients'
access to, or continuity of, care.
(2) A requirement to comply with quality improvement or
utilization management programs or procedures of a health insurer,
unless the requirement is fully disclosed to the health care provider
at least 15 business days prior to the provider executing the
contract. However, the health insurer may make a change to the
quality improvement or utilization management programs or procedures
at any time if the change is necessary to comply with state or
federal law or regulations or any accreditation requirements of a
private sector accreditation organization. A change to the quality
improvement or utilization management programs or procedures shall be
made pursuant to subdivision (c).
(3) A provision that waives or conflicts with any provision of the
Insurance Code.
(4) A requirement to permit access to patient information in
violation of federal or state laws concerning the confidentiality of
patient information.
(c) If a contract is with a health insurer that negotiates and
arranges for alternative rates of payment with the provider to
provide benefits to insureds, the contract may contain provisions
permitting a material change to the contract by the health insurer if
the health insurer provides at least 45 business days' notice to the
provider of the change, and the provider has the right to terminate
the contract prior to implementation of the change.
(d) With respect to a health insurance policy covering dental
services or a specialized health insurance policy covering dental
services, all of the following shall apply:
(1) If a material change is made to the health insurer's rules,
guidelines, policies, or procedures concerning dental provider
contracting or coverage of or payment for dental services, the
insurer shall provide at least 45 business days' written notice to
the dentists contracting with the health insurer to provide services
under the insurer's individual or group health insurance policies,
including specialized health insurance policies. For purposes of this
paragraph, written notice shall include notice by electronic mail or
facsimile transmission. This paragraph shall apply in addition to
the other applicable requirements imposed under this section.
(2) For purposes of paragraph (1), a material change made to a
health insurer's rules, guidelines, policies, or procedures
concerning dental provider contracting or coverage of or payment for
dental services is a change to the system by which the insurer
adjudicates and pays claims for treatment that may cause delays or
disruptions in processing claims or making eligibility
determinations, or a change to the general coverage or general
policies of the insurer that affect rates and fees paid to providers.
(3) An insurer that automatically renews a contract with a dental
provider shall annually make available to the provider, within 60
days following a request by the provider, either online, via email,
or in paper form, a copy of its current contract and a summary of the
changes described in subdivision (c) that have been made since the
contract was issued or last renewed.
(e) Any contract provision that violates subdivision (b), (c), or
(d) shall be void, unlawful, and unenforceable.
(f) The Department of Insurance shall annually compile all
provider complaints that it receives under this section, and shall
report to the Legislature and the Governor the number and nature of
those complaints by March 15 of each calendar year.
(g) Nothing in this section shall be construed or applied as
setting the rate of payment to be included in contracts between
health insurers and health care providers.
(h) For purposes of this section, the following definitions apply:
(1) "Health care provider" means any professional person, medical
group, independent practice association, organization, health
facility, or other person or institution licensed or authorized by
the state to deliver or furnish health care services.
(2) "Health insurer" means any admitted insurer writing health
insurance, as defined in Section 106, that enters into a contract
with a provider to provide covered benefits at alternative rates of
payment.
(3) "Material" means a provision in a contract to which a
reasonable person would attach importance in determining the action
to be taken upon the provision.
A health insurer shall comply with all the following:
(a) Deadlines shall not be imposed for the receipt of a claim
from a professional provider who submits a claim on behalf of an
insured or pursuant to a professional provider's contract with a
health insurer that is less than 90 days for contracted providers and
180 days for noncontracted providers after the date of service,
except as required by any state or federal law or regulation. If a
health insurer is not the primary payor under coordination of
benefits, the insurer shall not impose a deadline for submitting
supplemental or coordination of benefits claims to any secondary
payor that is less than 90 days from the date of payment or date of
contest, denial, or notice from the primary payor. A health insurer
that denies a claim because it was filed beyond the claim filing
deadline shall, upon provider's demonstration of good cause for the
delay, accept and adjudicate the claim according to Section 10123.13
or 10123.147, whichever is applicable. This subdivision shall not
alter or affect any rights providers may have under any applicable
statute of limitations or antiforfeiture provisions available under
the laws of the State of California.
(b) Reimbursement requests for the overpayment of a claim shall
not be made, including requests made pursuant to Section 10123.145,
unless a written request for reimbursement is sent to the provider
within 365 days of the date of payment on the overpaid claim. The
written notice shall clearly identify the claim, the name of the
patient, and the date of service, and shall include a clear
explanation of the basis upon which it is believed the amount paid on
the claim was in excess of the amount due, including interest and
penalties on the claim. The 365-day time limit shall not apply if the
overpayment was caused in whole or in part by fraud or
misrepresentation on the part of the provider.
(c) The receipt of each claim shall be identified and
acknowledged, whether or not complete, and the recorded date of
receipt shall be disclosed in the same manner as the claim was
submitted or provided through an electronic means, by telephone, Web
site, or another mutually agreeable accessible method of
notification, by which the provider may readily confirm the insurer's
receipt of the claim and the recorded date of receipt within 15
working days of the date of receipt of the claim by the office
designated to receive the claim.
If a claimant submits a claim to a health insurer using a claims
clearinghouse, its identification and acknowledgment to the
clearinghouse within the timeframes set forth above shall constitute
compliance with this section.
(d) Beginning July 1, 2006, prior to contracting, annually
thereafter on or before the contract anniversary date, and in
addition, upon the contracted provider's written request, the health
insurer shall disclose to contracting providers all of the following
information in an electronic format:
(1) The amount of payment for each service to be provided under
the contract, including any fee schedules or other factors or units
used in determining the fees for each service. To the extent that
reimbursement is made pursuant to a specified fee schedule, the
contract shall incorporate that fee schedule by reference, including
the year of the schedule. For any proprietary fee schedule, the
contract shall include sufficient detail that payment amounts related
to that fee schedule can be accurately predicted.
(2) The detailed payment policies and rules and nonstandard coding
methodologies used to adjudicate claims, that shall, unless
otherwise prohibited by state law do all of the following:
(A) When available, be consistent with Current Procedural
Terminology (CPT), and standards accepted by nationally recognized
medical societies and organizations, federal regulatory bodies, and
major credentialing organizations.
(B) Clearly and accurately state what is covered by any global
payment provisions for both professional and institutional services,
any global payment provisions for all services necessary as part of a
course of treatment in an institutional setting, and any other
global arrangements such as per diem hospital payments.
(C) At a minimum, clearly and accurately state the policies
regarding all of the following:
(i) Consolidation of multiple services or charges, and payment
adjustments due to coding changes.
(ii) Reimbursement for multiple procedures.
(iii) Reimbursement for assistant surgeons.
(iv) Reimbursement for the administration of immunizations and
injectable medications.
(v) Recognition of CPT modifiers.
The information disclosures required by this section shall be in
sufficient detail and in an understandable format that does not
disclose proprietary trade secret information or violate copyright
law or patented processes, so that a reasonable person with
sufficient training, experience, and competence in claims processing
can determine the payment to be made according to the terms of the
contract.
A health insurer may disclose the fee schedules mandated by this
section through the use of a Web site so long as it provides written
notice to the contracted provider at least 45 days prior to
implementing a Web site transmission format or posting any changes to
the information on the Web site.
On or before July 1, 2006, the commissioner, pursuant to
his or her authority under Section 12921.1, shall also complete all
of the following duties:
(a) Provide announcements that inform health insurance consumers
and their health care providers of the department's toll-free
telephone number that is dedicated to the handling of complaints and
of the availability of the Internet Web page established under this
section, and the process to register a complaint with the department
and to submit an inquiry to it.
(b) Establish an Internet Web page located on the department's
public Internet Web site dedicated exclusively to processing
complaints and inquiries relating to health insurance issues from
insureds and their health care providers. The Web page shall provide
insureds and their health care providers with information concerning
filing a complaint and making an inquiry concerning a health insurer
and, at a minimum, shall provide the following information:
(1) The department's toll-free telephone number.
(2) A list of all health insurers licensed by the department.
(3) Educational and informational guides for health insurance
consumers and health care providers describing their rights under
this code. The guides shall be easy to read and understand and shall
be made available to the public, including access on the department's
Internet Web site.
(4) A separate, standardized complaint form for health care
providers to file a complaint.
(c) An insured or health care provider may file a written
complaint with the department with respect to the handling of a claim
or other obligation under a health insurance policy by a health
insurer or production agency, or with respect to the alleged
misconduct by a health insurer or production agency. The commissioner
shall notify the complainant of the receipt of the complaint within
10 business days of its receipt. The commissioner shall make a
determination on the complaint within 60 calendar days of the date of
its receipt, unless the commissioner, in his or her discretion,
determines that additional time is reasonably necessary to fully and
fairly evaluate the complaint. The commissioner shall notify the
complainant of the final action taken on his or her complaint within
30 days of the final action. The notification shall include a summary
explaining the commissioner's reasons for the final action.
Pursuant to Section 12921, the commissioner may also
agree to payment to a health care provider who submitted a claim for
health care benefits provided to an insured that are covered under
the insured's health insurance policy.
(a) On and after January 1, 1994, any disability insurer
shall pay group insurance benefits contingent upon, or for expenses
incurred on account of, hospitalization or medical or surgical aid to
the person or persons having provided or having paid for the
hospitalization or medical or surgical aid where that person has
qualified for reimbursement by submitting the items and information
specified in subdivisions (b) and (c). The amount of any such payment
shall not exceed the amount of benefit provided by the policy with
respect to the service or billing of the provider of aid, and the
amount of payments shall not exceed the amount of expenses incurred
on account of the hospitalization or medical or surgical aid. Payment
so made shall discharge the insurer's obligation with respect to the
amount so paid.
(b) The items which shall be submitted to the insurer for
reimbursement pursuant to subdivision (a) are as follows:
(1) Proof of payment of medical services and a provider's itemized
bill for service.
(2) In the case where the insured does not reside with the person
or persons seeking hospitalization or medical or surgical aid, either
a copy of the judicial order requiring the insured to provide
dependent coverage or a state approved form verifying the existence
of a judicial order to be filed with the insurer on an annual basis.
(3) In the case where the insured does not reside with the person
or persons seeking hospitalization or medical or surgical aid, and
the provider is seeking direct reimbursement, an itemized bill with
the signature of the custodial parent or guardian certifying that
services being billed for have been provided and, on an annual basis,
either a copy of the judicial order requiring the insured to provide
dependent coverage or a state approved form verifying the existence
of a judicial order.
(c) When seeking payment from an insurer, a person shall provide
an insurer the items specified in subdivision (b) with the name and
address of the person to be reimbursed, the name and policy number of
the insured, the name of the individual for whom hospitalization or
medical or surgical aid has been provided, and other necessary
information directly related to coverage under the policy.
(d) In the case of a Medi-Cal beneficiary, where the State
Department of Health Services has paid for the hospitalization or
medical or surgical aid, any disability insurer shall pay group
insurance benefits to the State Department of Health Services for
expenses contingent upon, or incurred on account of hospitalization
or medical or surgical aid. Payment so made shall discharge the
insurer's obligation with respect to the amount so paid. The amount
of any such payment shall not exceed the amount of benefit provided
by the policy with respect to the service or billing of the provider
of aid, and the amount of payments shall not exceed the amount of
expenses incurred on account of hospitalization or medical or
surgical aid.
(a) The commissioner shall, on or before January 1, 2006,
promulgate regulations applicable to all individual and group
policies of health insurance establishing standards and requirements
to provide insureds with appropriate access to translated materials
and language assistance in obtaining covered benefits. A health
insurer that participates in the Healthy Families Program may assess
the Healthy Families Program enrollee population separately from the
remainder of its population for purposes of subparagraph (A) of
paragraph (3) of subdivision (b). An insurer that chooses to separate
its Healthy Families Program enrollment from the remainder of its
population shall treat the Healthy Families Program population
separately for purposes of determining whether subparagraph (A) of
paragraph (3) of subdivision (b) is applicable and shall also treat
the Healthy Families Program population separately for purposes of
applying the percentage and numerical thresholds in subparagraph (A)
of paragraph (3) of subdivision (b).
(b) The regulations described in subdivision (a) shall include the
following:
(1) A requirement to conduct an assessment of the needs of the
insured group, pursuant to this subdivision.
(2) Requirements for surveying the language preferences and
assessment of linguistic needs of insureds within one year of the
effective date of the regulations that permit health insurers to
utilize various survey methods, including, but not limited to, the
use of existing enrollment and renewal processes, newsletters, or
other mailings. Health insurers shall update the linguistic needs
assessment, demographic profile, and language translation
requirements every three years. However, the regulations may provide
that the surveys and assessments by insurers of supplemental
insurance products may be conducted less frequently than three years
if the commissioner determines that the results are unlikely to
affect the translation requirements.
(3) Requirements for the translation of vital documents that
include the following:
(A) A requirement that all vital documents, as defined pursuant to
subparagraph (B), be translated into an indicated language, as
follows:
(i) A health insurer with an insured population of 1,000,000 or
more shall translate vital documents into the top two languages other
than English as determined by the needs assessment pursuant to
paragraph (2) of subdivision (b) and any additional languages when
0.75 percent or 15,000 of the insured population, whichever number is
less, indicates in the needs assessment pursuant to paragraph (2) of
subdivision (b) a preference for written materials in that language.
(ii) A health insurer with an insured population of 300,000 or
more but less than 1,000,000 shall translate vital documents into the
top one language other than English as determined by the needs
assessment pursuant to paragraph (2) of subdivision (b) and any
additional languages when 1 percent or 6,000 of the insured
population, whichever number is less, indicates in the needs
assessment pursuant to paragraph (2) of subdivision (b) a preference
for written materials in that language.
(iii) A health insurer with an insured population of less than
300,000 shall translate vital documents into a language other than
English when 3,000 or more or 5 percent of the insured population,
whichever number is less, indicates in the needs assessment pursuant
to paragraph (2) of subdivision (b) a preference for written
materials in that language.
(B) Specification of vital documents produced by the insurer that
are required to be translated. The specification of vital documents
shall not exceed that of the Department of Health and Human Services
(HHS) Office of Civil Rights (OCR) Policy Guidance (65 Federal
Register 52762 (August 30, 2000)), but shall include all of the
following:
(i) Applications.
(ii) Consent forms.
(iii) Letters containing important information regarding
eligibility or participation criteria.
(iv) Notices pertaining to the denial, reduction, modification, or
termination of services and benefits, the right to file a complaint
or appeal.
(v) Notices advising limited-English-proficient persons of the
availability of free language assistance and other outreach materials
that are provided to insureds.
(vi) Translated documents shall not include an insurer's
explanation of benefits or similar claim processing information that
are sent to insureds unless the document requires a response by the
insured.
(C) For those documents described in subparagraph (B) that are not
standardized but contain insured specific information, health
insurers shall not be required to translate the documents into the
threshold languages identified by the needs assessment pursuant to
paragraph (2) of subdivision (b) but rather shall include with the
document a written notice of the availability of interpretation
services in the threshold languages identified by the needs
assessment pursuant to paragraph (2) of subdivision (b).
(i) Upon request, the insured shall receive a written translation
of those documents. The health insurer shall have up to, but not to
exceed, 21 days to comply with the insured's request for a written
translation. If an enrollee requests a translated document, all
timeframes and deadlines requirements related to the documents that
apply to the health insurer and insureds under the provisions of this
chapter and under any regulations adopted pursuant to this chapter
shall begin to run upon the health insurer's issuance of the
translated document.
(ii) For appeals that require expedited review and response in
accordance with the statutes and regulations of this chapter, the
health insurer may satisfy this requirement by providing notice of
the availability and access to oral interpretation services.
(D) A requirement that health insurers advise
limited-English-proficient insureds of the availability of
interpreter services.
(4) Standards to ensure the quality and accuracy of the written
translation and that a translated document meets the same standards
required for the English version of the document. The English
language documents shall determine the rights and obligations of the
parties, and the translated documents shall be admissible in evidence
only if there is a dispute regarding a substantial difference in the
material terms and conditions of the English language document and
the translated document.
(5) Requirements for individual access to interpretation services.
(6) Standards to ensure the quality and timeliness of oral
interpretation services provided by health insurers.
(c) In developing the regulations, standards, and requirements
described in this section, the commissioner shall consider the
following:
(1) Publications and standards issued by federal agencies,
including the Culturally and Linguistically Appropriate Services
(CLAS) in Health Care issued by the United States Department of
Health and Human Services Office of Minority Health in December 2000,
and the Department of Health and Human Services (HHS) Office of
Civil Rights (OCR) Policy Guidance 65 (65 Federal Register 52762
(August 30, 2000)).
(2) Other cultural and linguistic requirements under state
programs, including the Medi-Cal Managed Care Policy Letters,
cultural and linguistic requirements imposed by the State Department
of Health Services on health care service plans that contract to
provide Medi-Cal managed care services, and cultural and linguistic
requirements imposed by the Managed Risk Medical Insurance Board on
health insurers that contract to provide services in the Healthy
Families Program.
(3) Standards adopted by other states pertaining to language
assistance requirements for health insurers.
(4) Standards established by California or nationally recognized
accrediting, certifying, or licensing organizations and medical and
health care interpreter professional associations regarding
interpretation services.
(5) Publications, guidelines, reports, and recommendations issued
by state agencies or advisory committees, such as the report card to
the public on the comparative performance of plans and reports on
cultural and linguistic services issued by the Office of Patient
Advocate and the report to the Legislature from the Task Force on
Culturally and Linguistically Competent Physicians and Dentists
required pursuant to Section 852 of the Business and Professions
Code.
(6) Examples of best practices relating to language assistance
services by health care providers and health insurers that contract
for alternative rates of payment with providers, including existing
practices.
(7) Information gathered from complaints to the commissioner and
consumer assistance help lines regarding language assistance
services.
(8) The cost of compliance and the availability of translation and
interpretation services and professionals.
(9) Flexibility to accommodate variations in networks and method
of service delivery. The commissioner shall allow for health insurer
flexibility in determining compliance with the standards for oral and
written interpretation services.
(d) In designing the regulations, the commissioner shall consider
all other relevant guidelines in an effort to accomplish maximum
accessibility within a cost-efficient system of indemnification. The
commissioner shall seek public input from a wide range of interested
parties.
(e) Services, verbal communications, and written materials
provided by or developed by the health insurers that contract for
alternative rates of payment with providers, shall comply with the
standards developed under this section.
(f) Beginning on January 1, 2008, the department shall report
biennially to the Legislature regarding health insurer compliance
with the standards established by this section, including results of
compliance audits made in conjunction with other audits and reviews.
The department shall also utilize the reported information to make
recommendations for changes that further enhance standards pursuant
to this section. The commissioner shall work to ensure that the
biennial reports required by this section, and the data collected for
the reports, do not require duplicative or conflicting data
collection with other reports that may be required by
government-sponsored programs. The commissioner may also delay or
otherwise phase in implementation of the standards and requirements
in recognition of costs and availability of translation and
interpretation services and professionals.
(g) Nothing in this section shall prohibit government purchasers
from including in their contracts additional translation or
interpretation requirements, to meet the linguistic and cultural
needs, beyond those set forth pursuant to this section.
Within a year after the health insurer's assessment
pursuant to paragraph (2) of subdivision (b) of Section 10133.8,
health insurers shall report to the Department of Insurance on
internal policies and procedures related to cultural appropriateness,
in a format specified by the department, in the following ways:
(a) Collection of data regarding the insured population based on
the needs assessment as required by paragraph (2) of subdivision (b)
of Section 10133.8.
(b) Education of health insurer staff who have routine contact
with insureds regarding the diverse needs of the insured population.
(c) Recruitment and retention efforts that encourage workforce
diversity.
(d) Evaluation of the health insurer's programs and services with
respect to the insurer's enrollee populations, using processes such
as an analysis of complaints and satisfaction survey results.
(e) The periodic provision of information regarding the ethnic
diversity of the insurer's insured population and any related
strategies to insurers providers. Insurers may use existing means of
communication.
(f) The periodic provision of educational information to insureds
on the insurer's services and programs. Insurers may use existing
means of communication.
(a) An insurer that markets, advertises, or produces
educational materials for a health insurance policy, as defined in
Section 106, in the individual or small group health insurance
markets, or allows any other person or business to market or
advertise on its behalf in the individual or small group health
insurance markets, in a non-English language that does not meet the
requirements set forth in Sections 10133.8 and 10133.9, shall provide
the following documents in the same non-English language:
(1) Welcome letters or notices of initial coverage, if applicable.
(2) Applications for health insurance and any information
pertinent to eligibility or participation.
(3) Notices advising limited-English-proficient persons of the
availability of no-cost translation and interpretation services.
(4) Notices pertaining to the right and instructions on how an
insured may file a grievance.
(5) The uniform summary of benefits and coverage required pursuant
to paragraph (2) of subdivision (a) of Section 10603.
(b) An insurer shall use trained and qualified translators for the
translation of all marketing and advertising materials relating to
health insurance products and for all of the documents specified in
subdivision (a).
(c) This section shall not apply to a specialized health insurance
policy that does not offer an essential health benefit as defined in
Section 10112.27.