AB280 - Health care coverage: provider directories.

Amended IN Senate August 21, 2026 Amended IN Senate July 15, 2025 Amended IN Senate June 30, 2025 Amended IN Assembly May 23, 2025 CALIFORNIA LEGISLATURE— 2025–2026 REGULAR SESSION Assembly Bill No. 280 Introduced by Assembly Member Members Aguiar-Curry and Papan January 21, 2025 An act to amend Section 1367.27 of the Health and Safety Code, and to amend Section 10133.15 of the Insurance Code, relating to health care coverage. LEGISLATIVE COUNSEL'S DIGEST AB 280, as amended, Aguiar-Curry. 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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan and a health insurer that contracts with providers for alternative rates of payment to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services enrollees or insureds, and requires a health care service plan and health insurer to regularly update its printed and online provider directory or directories, as specified. Existing law authorizes the departments to require a plan or insurer to provide coverage for all covered health care services provided to an enrollee or insured who reasonably relied on materially inaccurate, incomplete, or misleading information contained in a plan’s or insurer’s provider directory or directories. This bill would require a plan or insurer to annually verify and delete inaccurate listings from its provider directories, and would require a provider directory to be 60% accurate on July 1, 2026, with increasing required percentage accuracy benchmarks to be met each year until the directories are 95% accurate on or before July 1, 2029. The bill would subject a plan or insurer to administrative penalties for failure to meet the prescribed benchmarks. The This bill would require the Department of Managed Health Care to select a central utility and develop uniform provider directory standards requiring a health care service plan to use the designated central utility to collect, manage, and verify the consistency and completeness of their provider directories. The bill would also require health insurers to use the designated central utility and follow the uniform provider directory standards. The bill would require plans and health insurers to submit their provider directories to the central utility for analysis, and would require the central utility to create a consistency report for each directory. This bill would require a plan or insurer to provide coverage for all covered health care services benefits provided to an enrollee or insured who reasonably relied on inaccurate, incomplete, or misleading information contained in a health plan or policy’s the plan’s or insurer’s provider directory or directories and to reimburse the provider the out-of-network amount agreed upon amount, or, if none, a reasonable and customary amount, as specified, for those services. The bill would prohibit a provider from collecting an additional amount from an enrollee or insured other than the applicable in-network cost sharing, which would count toward the in-network deductible and out-of-pocket maximum. The bill would require a plan or insurer to provide information about in-network providers to enrollees and insureds upon request, including whether the provider is accepting new patients at the time, and would limit the cost-sharing amounts an enrollee or insured is required to pay for services from those providers under specified circumstances. The bill would require the health care service plan or the insurer, as applicable, to ensure the accuracy of a request to add back a provider who was previously removed from a directory and approve the request within 10 business days of receipt, if accurate. The bill would authorize a health care service plan or insurer to include a specified statement in the provider listing before removing the provider from the directory if the provider does not respond within 5 calendar days of the plan plan’s or insurer’s annual notification. The bill would require a plan or insurer to comply with its provisions on and after July 1, 2027. Because a violation of the bill’s requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program. On or before January 1, 2026, this bill would authorize the Department of Managed Health Care and the Department of Insurance to update uniform formats for plans and insurers to use to request directory information from providers and to establish a methodology and processes to ensure accuracy of provider directories and consistency with other laws, regulations, or standards. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason. Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES Bill Text The people of the State of California do enact as follows: SECTION 1. The Legislature finds and declares all of the following: (a) It has been the responsibility of each health care service plan and health insurer to maintain an accurate provider directory since the enactment of Chapter 649 of the Statutes of 2015. Despite the requirement in existing law that provider directories be accurate, both academic studies and reports of individual consumers indicate that inaccuracies in provider directories are common. Individual consumers and their representatives should be able to obtain care, including an appointment as a new patient, based on accurate information in the provider directory maintained by the health care service plan or health insurer. (b) Too often consumers find “ghost” networks in which the provider directories of health care service plans and health insurers include doctors, hospitals, and other providers who are not accepting new patients, not accepting patients for that network of the plan or insurer, have not been compensated by the carrier in the past year, or are inaccessible to consumers because of inaccurate contact information in the provider directory. Some health care service plans and insurers advertise that there are thousands or even tens of thousands of doctors, hospitals, and other providers of care in their network, but when a consumer tries to contact a health care provider, basic information such as name and address are too often inaccurate. Even if the consumer can reach the provider who appears to be in-network for that network of the carrier, too often the consumer discovers either that the provider is not accepting new patients or not accepting patients for that network of the carrier, putting the burden of the inaccurate provider directory on the consumer, not the health care service plan or insurer. These barriers to care are most problematic for those consumers who need care the most, such as persons with disabilities or behavioral health conditions, as well as those with other barriers to seeking care, such as limited English proficiency or lack of health care literacy. (c) To encourage the development of a provider directory utility that could be used by all health care service plans, in 2015, the Department of Managed Health Care required an undertaking to fund the development of such a provider directory utility as a condition of the department’s approval of the acquisition of CareFirst by Blue Shield of California. In the years from 2015 to the introduction of this act, the Integrated Healthcare Association, an association of health care service plans, health insurers, provider groups, and hospitals with no consumer representation, held numerous meetings and workgroups with health care industry entities to develop a provider directory utility. The Integrated Healthcare Association states that as of 2019, the provider directory utility was operational and able to assist health care service plans and health insurers in verifying and crosschecking the accuracy of provider directory information. There are also efforts by the federal Centers for Medicare and Medicaid Services to aid in the accuracy of provider updates to improve provider directories. (d) Inclusion in a health care service plan or health insurer directory is a form of marketing for health care providers, including hospitals, laboratory services, imaging, provider groups, and individual providers because those directories provide individual consumers information about whether or not the health care provider is available through the network of the plan or insurer. Removal from the provider directory of a health care service plan or health insurer constitutes a financial penalty for a health care provider because a consumer seeking in-network care or to receive referrals from other health care providers for in-network care is less likely to seek care from a provider not included in the provider directory. (e) It is the intent of the Legislature in enacting this act to ensure that provider directories of health care service plans and health insurers are substantially accurate and that consumers are able to rely on the information provided in those directories, including such basic information as the name of the provider, the telephone number, and the address where care may be sought. It is also the intent of the Legislature to require the improvement of accuracy of provider directories over a number of years. In addition to the financial penalties on providers for failure to provide accurate and timely information for inclusion in the provider directory of a health care service plan or health insurer, it is the intent of the Legislature that the relevant departments have the authority to impose financial penalties on health care service plans and insurers for any failure of a plan or insurer to maintain the accuracy of its own directory. SEC. 2. Section 1367.27 of the Health and Safety Code is amended to read: 1367.27. (a) A health care service plan shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan’s enrollees, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the plan. Commencing July 1, 2026, a health care service plan shall comply with this section as it read on January 1, 2026. (b) A health care service plan shall provide the directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, enrollees, potential enrollees, contracting providers, the department, and other state or federal agencies can easily identify the networks and plan products in which a provider participates. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, a health care service plan shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k). (c) (1) An online provider directory or directories shall be available on the plan’s internet website to the public, potential enrollees, enrollees, and providers without any restrictions or limitations. The directory or directories shall be accessible without any requirement that an individual seeking the directory information demonstrate coverage with the plan, indicate interest in obtaining coverage with the plan, provide a member identification or policy number, provide any other identifying information, or create or access an account. (2) The online provider directory or directories shall be accessible on the plan’s public internet website through an identifiable link or tab and in a manner that is accessible and searchable by enrollees, potential enrollees, the public, and providers. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, the plan’s public internet website shall allow provider searches by, at a minimum, name, practice address, city, ZIP Code, California license number, National Provider Identifier number, admitting privileges to an identified hospital, product, tier, provider language or languages, provider group, hospital name, facility name, or clinic name, as appropriate, and the information provided shall be verified and accurate, consistent with this section. (d) (1) A health care service plan shall allow enrollees, potential enrollees, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the plan through the plan’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) A health care service plan shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law. (3) A printed provider directory shall be dated with the date of its last update. (e) (1) The plan shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the plan of any of the following: (A) A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients. (B) A provider is no longer under contract for a particular plan product. (C) A 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 enrollee complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly. (E) Any other information that affects the content or accuracy of the provider directory or directories. (2) Upon confirmation of any of the following, the plan shall delete and remove a provider from the directory or directories when: (A) A provider has retired or otherwise has ceased to pra [Text truncated for display. Full text available on Congress.gov.]