AB787 - Provider directory disclosures.

Amended IN Senate June 23, 2025 Amended IN Assembly April 07, 2025 Amended IN Assembly March 17, 2025 CALIFORNIA LEGISLATURE— 2025–2026 REGULAR SESSION Assembly Bill No. 787 Introduced by Assembly Member Papan February 18, 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 787, as amended, Papan. Provider directory disclosures. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires specified health care service plans and health insurers to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to enrollees or insureds, and requires a health care service plan or health insurer to regularly update its printed and online provider directory or directories, as specified. Existing law requires provider directories to include specified information and disclosures. This bill would require a full service health care service plan, specialized mental health or dental plan, health insurer, or specialized mental health or dental insurer to include in its provider directory or directories a statement at the top of the directory advising an enrollee or insured to contact the plan or insurer for assistance in finding an in-network provider. provider and for an explanation of their rights regarding out-of-network coverage, and would specify the format of the statement. The bill would require the plan or insurer to respond acknowledge the request within one business day if contacted for that assistance, and to provide a list of in-network providers confirmed to be accepting new patients within 2 business days. days for a request deemed urgent by the enrollee or insured and 5 business days for a request deemed nonurgent by an enrollee or insured. Because a violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason. 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. Section 1367.27 of the Health and Safety Code is amended to read: 1367.27. (a) Commencing July 1, 2016, a health care service plan shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the 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. (b) A health care service plan shall provide the directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, enrollees, potential enrollees, the department, and other state or federal agencies can easily identify the networks and plan products in which a provider participates. By July 31, 2017, or 12 months after the date provider directory standards are developed under subdivision (k), (l), whichever occurs later, a health care service plan shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k). (l). (c) (1) An online provider directory or directories shall be available on the 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), (l), 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. (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. (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 completion of the investigation described in subdivision (o), (p), a change is necessary based on an enrollee complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly. (E) Any other information that affects the content or accuracy of the provider directory or directories. (2) Upon confirmation of any of the following, the plan shall delete a provider from the directory or directories when: (A) A provider has retired or otherwise has ceased to practice. (B) A provider or provider group is no longer under contract with the plan for any reason. (C) The contracting provider group has informed the plan that the provider is no longer associated with the provider group and is no longer under contract with the plan. (f) The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the plan if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the plan’s internet website. (g) The provider directory or directories shall include the following disclosures informing enrollees that they are entitled to both of the following: (1) Language interpreter services, at no cost to the enrollee, including how to obtain interpretation services in accordance with Section 1367.04. (2) Full and equal access to covered services, including enrollees with disabilities as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973. (h) A full service health care service plan and a specialized mental health plan shall include all of the following information in the provider directory or directories: (1) The 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 plan through which the provider sees enrollees. (8) A listing for each of the following providers that are under contract with the plan: (A) For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the plan. (B) Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in Section 1374.73, nurse-midwives, and dentists. (C) For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic. (D) For any provider described in subparagraph (A) or (B) who is employed by a federally qualified health center or primary care clinic, and to the extent their services may be accessed and are covered through the contract with the plan, the name of the provider, and the name of the federally qualified health center or clinic. (E) Facilities, including, but not limited to, general acute care hospitals, skilled nursing facilities, urgent care clinics, ambulatory surgery centers, inpatient hospice, residential care facilities, and inpatient rehabilitation facilities. (F) Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services. (9) The provider directory or directories may note that authorization or referral may be required to access some providers. (10) Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 1367.04, if any, on the provider’s staff. (11) Identification of providers who no longer accept new patients for some or all of the plan’s products. (12) The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. This section does not require the use of network tiers other than contract and noncontracting tiers. (13) A statement at the top of the directory advising an enrollee to contact the health care service plan for assistance in finding an in-network provider. provider and for an explanation of their rights regarding out-of-network coverage. The statement shall be drafted pursuant to both of the following: (A) The statement shall appear as follows: (i) For a printed directory, the statement shall appear either at the top of each page or on the front cover of the directory in 16-point type. (ii) For a PDF directory, the statement shall appear at the top of each page. (iii) For a navigable or searchable directory on an internet web page, the statement shall appear in a fixed banner visible at the top of each page. (B) The statement shall include a notice advising the enrollee that they may designate the request as either urgent or nonurgent. The statement shall contain language that advises the enrollee that urgent requests shall be responded to within two business days and nonurgent requests shall be responded to within five business days. (14) All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c). (i) A vision, dental, or other specialized health care service plan, except for a specialized mental health plan, shall include all of the following information for each provider directory or directories used by the plan for its networks: (1) The 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 plan practice group currently under contract with the plan through which the provider sees enrollees. (8) The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the plan. (9) The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 1367.04, if any, on the provider’s staff. (10) Identification of providers who no longer accept new patients for some or all of the plan’s products. (11) All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c). (j) A specialized dental plan shall include a statement in each provider directory or directories used by the plan for its networks advising an enrollee to contact the plan for assistance finding an in-network provider and for an explanation of their rights regarding out-of-network coverage, which shall meet the requirements of paragraph (13) of subdivision (h). (j) (k) (1) The contract between the plan and a provider shall include a requirement that the provider inform the plan within five business days when either of the following occurs: (A) The provider is not accepting new patients. (B) If the provider had previously not accepted new patients, the provider is currently accepting new patients. (2) If a provider who is not accepting new patients is contacted by an enrollee or potential enrollee seeking to become a new patient, the provider shall direct the enrollee or potential enrollee to both the plan for additional assistance in finding a provider and to the department to report any inaccuracy with the plan’s directory or directories. (3) If an enrollee or potential enrollee informs a plan of a possible inaccuracy in the provider directory or directories, the plan shall promptly investigate and, if necessary, undertake corrective action within 30 business days to ensure the accuracy of the directory or directories. (k) (l) (1) On or before December 31, 2016, the department shall develop uniform provider directory standards to permit consistency [Text truncated for display. Full text available on Congress.gov.]