Health care coverage: provider directories.

The Department of Managed Health Care is now required to select a central utility and develop uniform provider directory standards. Health care service plans must use the designated central utility to collect, manage, and verify the consistency and completeness of their provider directories. Health insurers are also required to use the designated central utility and follow the uniform standards. Plans and insurers must submit their directories to the central utility for analysis, and the utility must create a consistency report for each directory.

The reimbursement amount owed to a provider when an enrollee reasonably relied on inaccurate directory information changed from 'the out-of-network amount' to 'the agreed upon amount, or, if none, a reasonable and customary amount.' This shifts the standard from a fixed benchmark (out-of-network rate) to a contract-based or market-rate determination.

A new compliance date of July 1, 2027 was added, requiring plans and insurers to comply with the bill's provisions on and after that date.

The central utility requirement now explicitly applies to health insurers in addition to health care service plans, broadening the scope of entities that must use the designated utility and follow uniform directory standards.

Assembly Member Papan was added as a co-author alongside Aguiar-Curry. The word 'develop' was changed to 'update' in reference to uniform formats for requesting directory information, indicating these formats already exist and are being refined rather than created from scratch.

Plans must now include whether a provider is accepting new patients at the time when providing in-network provider information to enrollees upon request.

Plans are authorized to include a specified statement in the provider listing before removing a provider from the directory if the provider does not respond within 5 calendar days of the plan's annual notification. This gives plans a procedural step before removal.

Removed the requirement for plans to display a provider's contract termination date in the directory and to delete the provider within five days after that termination date. This provision was removed from both full service plan directories (subdivision h) and specialized plan directories (subdivision i).

Expanded the stakeholder consultation requirement when developing methodology for central utilities from 'interested parties' to specifically include 'providers, health care service plans, consumers, and consumer advocates.'

Changed 'develop uniform formats' to 'update uniform formats' in both the fiscal note and Section 1367.27(k)(4), acknowledging that formats already exist and this bill updates them rather than creating new ones. Also added 'consistent with current law' as a qualifier.

New subparagraph (iii) in Section 1367.27(k)(5)(B) provides that if the department requires or designates a central utility, plans SHALL require providers to update their information through that central utility. Without a department mandate, plans MAY (but are not required to) require providers to use the central utility.

Added language requiring the department to take into consideration 'impact on provider financial interests, enrollee access to providers, and health care service plans' when developing methodology for directory accuracy.

Cost-sharing amounts that enrollees or insureds pay for services from providers listed in inaccurate directories now explicitly count toward the in-network deductible and out-of-pocket maximum. This protects patients from being penalized twice when they relied on bad directory data.

New requirement that if a central utility is designated or required, the plan's contract with the utility must ensure incomplete or incorrect information submitted to the utility is not conveyed to the health care service plan, and the utility must notify the submitter of any incomplete or inaccurate information.

New provision allowing the Department of Managed Health Care to consider no longer requiring or designating a central utility if it frequently fails to provide accurate information to health care service plans. This creates an accountability mechanism for utility performance.

The central utility methodology provision was clarified to be conditional: input-seeking and public meeting requirements now apply only 'if the department requires or designates a central utility' rather than unconditionally.

New placeholder items were inserted in the required directory data elements for both general plans (subdivision h) and specialized plans (subdivision i), creating space for additional required data fields to be specified. The catch-all 'all other information' items were renumbered accordingly.

Removed the outdated phrase 'Commencing July 1, 2016' from subdivision (a) of Section 1367.27, since that date has already passed and the requirement is now in effect.

Standardized terminology throughout the bill, changing 'Internet Web site' to 'internet website' in multiple locations.

Fixed duplicate numbering in subdivisions (h) and (i) of Section 1367.27, where items had been numbered with repeated numbers (e.g., two item 7s, two item 8s, etc.) and are now sequentially numbered.

Removed a duplicated word in subdivision (j)(3), changing 'promptly investigate, investigate and' to 'promptly investigate and.'

In subdivision (h)(9)(B), removed the duplicate listing of 'nurse midwives' alongside 'nurse-midwives,' keeping only the hyphenated form.

Simplified language in subdivision (k)(1) from 'multiplan directory central utility' to 'central utility.'

Reorganized the digest section of the bill, moving it to a different page position while retaining the same substantive content about accuracy benchmarks and penalties.