| 1 | 1 | | CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION Senate Bill No. 402Introduced by Senator ValladaresFebruary 14, 2025 An act to amend Section 2290.5 of, and to add Chapter 17 (commencing with Section 4999.200) to Division 2 of, the Business and Professions Code, to amend Sections 1367.27, 1374.72, and 1374.73 of the Health and Safety Code, to amend Sections 10133.15, 10144.5, and 10144.51 of the Insurance Code, and to amend Section 11165.7 of the Penal Code, relating to health care coverage.LEGISLATIVE COUNSEL'S DIGESTSB 402, as introduced, Valladares. Health care coverage: autism.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 also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism and defines behavioral health treatment to mean specified services and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional. Existing law defines qualified autism service provider, qualified autism service professional, and qualified autism service paraprofessional for those purposes. Those definitions are contained in the Health and Safety Code and the Insurance Code.This bill would move those definitions to the Business and Professions Code. The bill would also make technical and conforming changes.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: NO Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 2290.5 of the Business and Professions Code is amended to read:2290.5. (a) For purposes of this division, the following definitions apply:(1) Asynchronous store and forward means the transmission of a patients medical information from an originating site to the health care provider at a distant site.(2) Distant site means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system.(3) Health care provider means any of the following:(A) A person who is licensed under this division.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. as defined in Section 4999.200 or a qualified autism service professional as defined in Section 4999.201.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2.(E) An associate professional clinical counselor or clinical counselor trainee functioning pursuant to Section 4999.46.3.(4) Originating site means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.(5) Synchronous interaction means a real-time interaction between a patient and a health care provider located at a distant site.(6) Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patients health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.(b) Before the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. The consent shall be documented.(c) This section does not preclude a patient from receiving in-person health care delivery services during a specified course of health care and treatment after agreeing to receive services via telehealth.(d) The failure of a health care provider to comply with this section shall constitute unprofessional conduct. Section 2314 shall not apply to this section.(e) This section does not alter the scope of practice of a health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.(f) All laws regarding the confidentiality of health care information and a patients rights to the patients medical information shall apply to telehealth interactions.(g) All laws and regulations governing professional responsibility, unprofessional conduct, and standards of practice that apply to a health care provider under the health care providers license shall apply to that health care provider while providing telehealth services.(h) This section shall not apply to a patient under the jurisdiction of the Department of Corrections and Rehabilitation or any other correctional facility.(i) (1) Notwithstanding any other law and for purposes of this section, the governing body of the hospital whose patients are receiving the telehealth services may grant privileges to, and verify and approve credentials for, providers of telehealth services based on its medical staff recommendations that rely on information provided by the distant-site hospital or telehealth entity, as described in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.(2) By enacting this subdivision, it is the intent of the Legislature to authorize a hospital to grant privileges to, and verify and approve credentials for, providers of telehealth services as described in paragraph (1).(3) For the purposes of this subdivision, telehealth shall include telemedicine as the term is referenced in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.SEC. 2. Chapter 17 (commencing with Section 4999.200) is added to Division 2 of the Business and Professions Code, to read: CHAPTER 17. Qualified Autism Service Providers4999.200. Qualified autism service provider means an individual who meets either of the following criteria:(a) Is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the individual who is nationally certified.(b) Is licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500), and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.4999.201. Qualified autism service professional means an individual who meets all of the following criteria:(a) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(b) Is supervised by a qualified autism service provider.(c) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(d) Is either of the following:(1) A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(2) (A) A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(B) If an individual meets the requirement described in subparagraph (A), they shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(e) (1) Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(f) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.4999.202. Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(a) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(b) Provides treatment and implements services pursuant to a treatment plan that was developed and approved by the qualified autism service provider.(c) Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(d) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(e) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.SEC. 3. 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 plans 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), 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 plans Internet Web site 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 plans public Internet Web site 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 plans public Internet Web site 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 plans 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 providers practice location or other information required under subdivision (h) or (i) has changed.(D) Upon 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 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 plans Internet Web site. 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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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 providers staff.(11) Identification of providers who no longer accept new patients for some or all of the plans 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 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 providers 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 providers 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 providers staff.(10) Identification of providers who no longer accept new patients for some or all of the plans 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 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 plans 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) (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, a plan shall use the standards developed by the department for each product offered by the plan.(l) (1) A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 plan 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 plan 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 plan shall notify its contracted providers to ensure that all of the providers are contacted by the plan at least once annually.(2) The notification shall include all of the following:(A) The information the plan has in its directory or directories regarding the provider or provider group, including a list of networks and plan 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 plan 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 or provider group is accepting new patients for each plan product.(4) If the plan 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 plan shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The plan shall document the receipt and outcome of each attempt to verify the information. If the plan is unable to verify whether the providers information is correct or requires updates, the plan shall notify the provider 10 business days in advance of removal that the provider will be removed from the provider directory or directories. The provider shall be removed from the provider 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 they respond 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) A plan 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 this subdivision shall be submitted by a plan annually to the department for approval and in a format described by the department pursuant to Section 1367.035.(2) Every health care service plan 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 health care service plan. 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 health care service plan.(3) The plan shall establish and maintain a process for enrollees, potential enrollees, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the plans provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the plan will accept these reports, as well as a hyperlink on the plans provider directory Internet Web site internet website linking to a form where the information can be reported directly to the plan through its Internet Web site. internet website.(n) (1) This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan.(2) If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan 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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the plan that the provider should be deleted from the provider group in the plan directory or directories.(5) Section 1375.7, 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 a health care service plan receives a report indicating that information listed in its provider directory or directories is inaccurate, the plan 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 plan 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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to a plans provider directory or directories are required as a result of the plans 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 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups information is correct or requires updates. A plan 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.(A) For a provider or provider group that receives compensation on a capitated or prepaid basis, the plan may delay no more than 50 percent of the next scheduled capitation payment for up to one calendar month.(B) For any claims payment made to a provider or provider group, the plan may delay the claims payment for up to one calendar month beginning on the first day of the following month.(2) A plan shall notify the provider or provider group 10 business days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the plan delays a payment or reimbursement pursuant to this subdivision, the plan 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 plan 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 plan pursuant to subdivision (l).(3) A plan may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the plan to a change in the information required to be in the directory or directories pursuant to this section.(4) A plan 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 pursuant to Section 1367.035. 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).(5) With respect to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.(q) In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee.(r) Whenever a plan 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 plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.(s) This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d).(t) A health plan 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 of the Insurance Code shall meet the requirements of this section.(u) This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.(v) As part of the departments routine examination of the fiscal and administrative affairs of a health care service plan pursuant to Section 1382, the department shall include a review of the health care service plans compliance with subdivision (p).(w) For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.SEC. 4. Section 1374.72 of the Health and Safety Code is amended to read:1374.72. (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an enrollee or subscriber under this chapter.(4) For purposes of this section, health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 10144.51 of the Insurance Code and Section 1374.73. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological associate, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 1374.721.(6) A health care service plan shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations by the health care service plan concerning service intensity, level of care placement, continued stay, and transfer or discharge of enrollees diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 1374.721. This paragraph does not deprive an enrollee of the other protections of this chapter, including, but not limited to, grievances, appeals, independent medical review, discharge, transfer, and continuity of care.(8) A health care service plan that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the plans subsequent rescission, cancellation, or modification of the enrollees or subscribers contract, or the plans subsequent determination that it did not make an accurate determination of the enrollees or subscribers eligibility. This section shall not be construed to expand or alter the benefits available to the enrollee or subscriber under a plan.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the plan contract includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the plan contract, shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum annual and lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the health care service plan shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the enrollee within geographic and timely access standards. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider.(e) This section shall not apply to contracts entered into pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, between the State Department of Health Care Services and a health care service plan for enrolled Medi-Cal beneficiaries.(f) (1) For the purpose of compliance with this section, a health care service plan may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health care service plan or mental health plan, and shall not be required to obtain an additional or specialized license for this purpose.(2) A health care service plan shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, health care service plan contracts that provide benefits to enrollees through preferred provider contracting arrangements are not precluded from requiring enrollees who reside or work in geographic areas served by specialized health care service plans or mental health plans to secure all or part of their mental health services within those geographic areas served by specialized health care service plans or mental health plans, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 1374.76 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure plan compliance with this chapter.(h) A health care service plan shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A health care service plan shall not adopt, impose, or enforce terms in its plan contracts or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.SEC. 5. Section 1374.73 of the Health and Safety Code is amended to read:1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 1374.72.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any of the following:(1) A specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(2) A health care service plan contract in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.SEC. 6. Section 10133.15 of the Insurance Code is amended to read:10133.15. (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 insurers 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 insurers Internet Web site internet website 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 insurers public Internet Web site internet website 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 insurers public Internet Web site 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) 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 insurers 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 providers 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 insurers Internet Web site. internet website.(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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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, if any, on the providers staff.(11) Identification of providers who no longer accept new patients for some or all of the insurers 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 providers 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 providers 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, if any, on the providers staff.(10) Identification of providers who no longer accept new patients for some or all of the insurers 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 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 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 insurers 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 insurers 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 providers 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 providers 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 they respond 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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory Internet Web site internet website linking to a form where the information can be reported directly to the insurer through its Internet Web site. internet website.(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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to an insurers provider directory or directories are required as a result of the insurers 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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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 insurers 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 insureds 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 insureds 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) This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.(u) As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers 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.SEC. 7. Section 10144.5 of the Insurance Code is amended to read:10144.5. (a) (1) Every disability insurance policy issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the World Health Organizations International Statistical Classification of Diseases and Related Health Problems, or that is listed in the most recent version of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the disability insurer and insureds or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an insured or policyholder under this chapter.(4) Health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological assistant, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 10144.52.(6) A disability insurer shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations made by the disability insurer concerning service intensity, level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 10144.52.(8) A disability insurer that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the insurers subsequent rescission, cancellation, or modification of the insureds or policyholders contract, or the insurers subsequent determination that it did not make an accurate determination of the insureds or policyholders eligibility. This section shall not be construed to expand or alter the benefits available to the insured or policyholder under an insurance policy.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345 of the Health and Safety Code.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the policy includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the disability insurance policy shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum and annual lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the disability insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the insured within geographic and timely access standards. The insured shall pay no more than the same cost sharing that the insured would pay for the same covered services received from an in-network provider.(e) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies.(f) (1) For the purpose of compliance with this section, a disability insurer may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health insurance policy or mental health policy. This paragraph shall not apply to policies that are subject to Section 10112.27.(2) A disability insurer shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, disability insurance policies that provide benefits to insureds through preferred provider contracting arrangements are not precluded from requiring insureds who reside or work in geographic areas served by specialized health insurance policies or mental health insurance policies to secure all or part of their mental health services within those geographic areas served by specialized health insurance policies or mental health insurance policies, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a disability insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 10144.4 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure a disability insurers compliance with this code.(h) A disability insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A disability insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.(j) If the commissioner determines that a disability insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation.SEC. 8. Section 10144.51 of the Insurance Code is amended to read:10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 10144.5.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any the following:(1) A specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(2) A health insurance policy in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.SEC. 9. Section 11165.7 of the Penal Code is amended to read:11165.7. (a) As used in this article, mandated reporter is defined as any of the following:(1) A teacher.(2) An instructional aide.(3) A teachers aide or teachers assistant employed by a public or private school.(4) A classified employee of a public school.(5) An administrative officer or supervisor of child welfare and attendance, or a certificated pupil personnel employee of a public or private school.(6) An administrator of a public or private day camp.(7) An administrator or employee of a public or private youth center, youth recreation program, or youth organization.(8) An administrator, board member, or employee of a public or private organization whose duties require direct contact and supervision of children, including a foster family agency.(9) An employee of a county office of education or the State Department of Education whose duties bring the employee into contact with children on a regular basis.(10) A licensee, an administrator, or an employee of a licensed community care or child daycare facility.(11) A Head Start program teacher.(12) A licensing worker or licensing evaluator employed by a licensing agency, as defined in Section 11165.11.(13) A public assistance worker.(14) An employee of a childcare institution, including, but not limited to, foster parents, group home personnel, and personnel of residential care facilities.(15) A social worker, probation officer, or parole officer.(16) An employee of a school district police or security department.(17) A person who is an administrator or presenter of, or a counselor in, a child abuse prevention program in a public or private school.(18) A district attorney investigator, inspector, or local child support agency caseworker, unless the investigator, inspector, or caseworker is working with an attorney appointed pursuant to Section 317 of the Welfare and Institutions Code to represent a minor.(19) A peace officer, as defined in Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2, who is not otherwise described in this section.(20) A firefighter, except for volunteer firefighters.(21) A physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse, dental hygienist, optometrist, marriage and family therapist, clinical social worker, professional clinical counselor, or any other person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(22) An emergency medical technician I or II, paramedic, or other person certified pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code.(23) A psychological assistant registered pursuant to Section 2913 of the Business and Professions Code.(24) A marriage and family therapist trainee, as defined in subdivision (c) of Section 4980.03 of the Business and Professions Code.(25) An unlicensed associate marriage and family therapist registered under Section 4980.44 of the Business and Professions Code.(26) A state or county public health employee who treats a minor for venereal disease or any other condition.(27) A coroner.(28) A medical examiner or other person who performs autopsies.(29) A commercial film and photographic print or image processor as specified in subdivision (e) of Section 11166. As used in this article, commercial film and photographic print or image processor means a person who develops exposed photographic film into negatives, slides, or prints, or who makes prints from negatives or slides, or who prepares, publishes, produces, develops, duplicates, or prints any representation of information, data, or an image, including, but not limited to, any film, filmstrip, photograph, negative, slide, photocopy, videotape, video laser disc, computer hardware, computer software, computer floppy disk, data storage medium, CD-ROM, computer-generated equipment, or computer-generated image, for compensation. The term includes any employee of that person; it does not include a person who develops film or makes prints or images for a public agency.(30) A child visitation monitor. As used in this article, child visitation monitor means a person who, for financial compensation, acts as a monitor of a visit between a child and another person when the monitoring of that visit has been ordered by a court of law.(31) An animal control officer or humane society officer. For the purposes of this article, the following terms have the following meanings:(A) Animal control officer means a person employed by a city, county, or city and county for the purpose of enforcing animal control laws or regulations.(B) Humane society officer means a person appointed or employed by a public or private entity as a humane officer who is qualified pursuant to Section 14502 or 14503 of the Corporations Code.(32) A clergy member, as specified in subdivision (d) of Section 11166. As used in this article, clergy member means a priest, minister, rabbi, religious practitioner, or similar functionary of a church, temple, or recognized denomination or organization.(33) Any custodian of records of a clergy member, as specified in this section and subdivision (d) of Section 11166.(34) An employee of any police department, county sheriffs department, county probation department, or county welfare department.(35) An employee or volunteer of a Court Appointed Special Advocate program, as defined in Rule 5.655 of the California Rules of Court.(36) A custodial officer, as defined in Section 831.5.(37) A person providing services to a minor child under Section 12300 or 12300.1 of the Welfare and Institutions Code.(38) An alcohol and drug counselor. As used in this article, an alcohol and drug counselor is a person providing counseling, therapy, or other clinical services for a state licensed or certified drug, alcohol, or drug and alcohol treatment program. However, alcohol or drug abuse, or both alcohol and drug abuse, is not, in and of itself, a sufficient basis for reporting child abuse or neglect.(39) A clinical counselor trainee, as defined in subdivision (g) of Section 4999.12 of the Business and Professions Code.(40) An associate professional clinical counselor registered under Section 4999.42 of the Business and Professions Code.(41) An employee or administrator of a public or private postsecondary educational institution, whose duties bring the administrator or employee into contact with children on a regular basis, or who supervises those whose duties bring the administrator or employee into contact with children on a regular basis, as to child abuse or neglect occurring on that institutions premises or at an official activity of, or program conducted by, the institution. Nothing in this paragraph shall be construed as altering the lawyer-client privilege as set forth in Article 3 (commencing with Section 950) of Chapter 4 of Division 8 of the Evidence Code.(42) An athletic coach, athletic administrator, or athletic director employed by any public or private school that provides any combination of instruction for kindergarten, or grades 1 to 12, inclusive.(43) (A) A commercial computer technician as specified in subdivision (e) of Section 11166. As used in this article, commercial computer technician means a person who works for a company that is in the business of repairing, installing, or otherwise servicing a computer or computer component, including, but not limited to, a computer part, device, memory storage or recording mechanism, auxiliary storage recording or memory capacity, or any other material relating to the operation and maintenance of a computer or computer network system, for a fee. An employer who provides an electronic communications service or a remote computing service to the public shall be deemed to comply with this article if that employer complies with Section 2258A of Title 18 of the United States Code.(B) An employer of a commercial computer technician may implement internal procedures for facilitating reporting consistent with this article. These procedures may direct employees who are mandated reporters under this paragraph to report materials described in subdivision (e) of Section 11166 to an employee who is designated by the employer to receive the reports. An employee who is designated to receive reports under this subparagraph shall be a commercial computer technician for purposes of this article. A commercial computer technician who makes a report to the designated employee pursuant to this subparagraph shall be deemed to have complied with the requirements of this article and shall be subject to the protections afforded to mandated reporters, including, but not limited to, those protections afforded by Section 11172.(44) Any athletic coach, including, but not limited to, an assistant coach or a graduate assistant involved in coaching, at public or private postsecondary educational institutions.(45) An individual certified by a licensed foster family agency as a certified family home, as defined in Section 1506 of the Health and Safety Code.(46) An individual approved as a resource family, as defined in Section 1517 of the Health and Safety Code and Section 16519.5 of the Welfare and Institutions Code.(47) A qualified autism service provider, a qualified autism service professional, or a qualified autism service paraprofessional, as defined in Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. paraprofessional as defined in Chapter 17 (commencing with Section 4999.200) of Division 2 of the Business and Professions Code.(48) A human resource employee of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code that employs minors. For purposes of this section, a human resource employee is the employee or employees designated by the employer to accept any complaints of misconduct as required by Chapter 6 (commencing with Section 12940) of Part 2.8 of Division 3 of Title 2 of the Government Code.(49) An adult person whose duties require direct contact with and supervision of minors in the performance of the minors duties in the workplace of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code is a mandated reporter of sexual abuse, as defined in Section 11165.1. Nothing in this paragraph shall be construed to modify or limit the persons duty to report known or suspected child abuse or neglect when the person is acting in some other capacity that would otherwise make the person a mandated reporter.(b) Except as provided in paragraph (35) of subdivision (a), volunteers of public or private organizations whose duties require direct contact with and supervision of children are not mandated reporters but are encouraged to obtain training in the identification and reporting of child abuse and neglect and are further encouraged to report known or suspected instances of child abuse or neglect to an agency specified in Section 11165.9.(c) (1) Except as provided in subdivision (d) and paragraph (2), employers are strongly encouraged to provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. Whether or not employers provide their employees with training in child abuse and neglect identification and reporting, the employers shall provide their employees who are mandated reporters with the statement required pursuant to subdivision (a) of Section 11166.5.(2) Employers subject to paragraphs (48) and (49) of subdivision (a) shall provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. The training requirement may be met by completing the general online training for mandated reporters offered by the Office of Child Abuse Prevention in the State Department of Social Services.(d) Pursuant to Section 44691 of the Education Code, school districts, county offices of education, state special schools and diagnostic centers operated by the State Department of Education, and charter schools shall annually train their employees and persons working on their behalf specified in subdivision (a) in the duties of mandated reporters under the child abuse reporting laws. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(e) (1) On and after January 1, 2018, pursuant to Section 1596.8662 of the Health and Safety Code, a childcare licensee applicant shall take training in the duties of mandated reporters under the child abuse reporting laws as a condition of licensure, and a childcare administrator or an employee of a licensed child daycare facility shall take training in the duties of mandated reporters during the first 90 days when that administrator or employee is employed by the facility.(2) A person specified in paragraph (1) who becomes a licensee, administrator, or employee of a licensed child daycare facility shall take renewal mandated reporter training every two years following the date on which that person completed the initial mandated reporter training. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(f) Unless otherwise specifically provided, the absence of training shall not excuse a mandated reporter from the duties imposed by this article.(g) Public and private organizations are encouraged to provide their volunteers whose duties require direct contact with and supervision of children with training in the identification and reporting of child abuse and neglect. |
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| 3 | 3 | | CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION Senate Bill No. 402Introduced by Senator ValladaresFebruary 14, 2025 An act to amend Section 2290.5 of, and to add Chapter 17 (commencing with Section 4999.200) to Division 2 of, the Business and Professions Code, to amend Sections 1367.27, 1374.72, and 1374.73 of the Health and Safety Code, to amend Sections 10133.15, 10144.5, and 10144.51 of the Insurance Code, and to amend Section 11165.7 of the Penal Code, relating to health care coverage.LEGISLATIVE COUNSEL'S DIGESTSB 402, as introduced, Valladares. Health care coverage: autism.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 also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism and defines behavioral health treatment to mean specified services and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional. Existing law defines qualified autism service provider, qualified autism service professional, and qualified autism service paraprofessional for those purposes. Those definitions are contained in the Health and Safety Code and the Insurance Code.This bill would move those definitions to the Business and Professions Code. The bill would also make technical and conforming changes.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: NO Local Program: NO |
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| 9 | 9 | | CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION |
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| 11 | 11 | | Senate Bill |
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| 13 | 13 | | No. 402 |
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| 15 | 15 | | Introduced by Senator ValladaresFebruary 14, 2025 |
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| 17 | 17 | | Introduced by Senator Valladares |
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| 18 | 18 | | February 14, 2025 |
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| 20 | 20 | | An act to amend Section 2290.5 of, and to add Chapter 17 (commencing with Section 4999.200) to Division 2 of, the Business and Professions Code, to amend Sections 1367.27, 1374.72, and 1374.73 of the Health and Safety Code, to amend Sections 10133.15, 10144.5, and 10144.51 of the Insurance Code, and to amend Section 11165.7 of the Penal Code, relating to health care coverage. |
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| 22 | 22 | | LEGISLATIVE COUNSEL'S DIGEST |
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| 24 | 24 | | ## LEGISLATIVE COUNSEL'S DIGEST |
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| 26 | 26 | | SB 402, as introduced, Valladares. Health care coverage: autism. |
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| 28 | 28 | | 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 also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism and defines behavioral health treatment to mean specified services and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional. Existing law defines qualified autism service provider, qualified autism service professional, and qualified autism service paraprofessional for those purposes. Those definitions are contained in the Health and Safety Code and the Insurance Code.This bill would move those definitions to the Business and Professions Code. The bill would also make technical and conforming changes. |
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| 30 | 30 | | 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 also provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or a health insurance policy to provide coverage for behavioral health treatment for pervasive developmental disorder or autism and defines behavioral health treatment to mean specified services and treatment programs, including treatment provided pursuant to a treatment plan that is prescribed by a qualified autism service provider and administered either by a qualified autism service provider or by a qualified autism service professional or qualified autism service paraprofessional. Existing law defines qualified autism service provider, qualified autism service professional, and qualified autism service paraprofessional for those purposes. Those definitions are contained in the Health and Safety Code and the Insurance Code. |
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| 32 | 32 | | This bill would move those definitions to the Business and Professions Code. The bill would also make technical and conforming changes. |
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| 34 | 34 | | ## Digest Key |
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| 36 | 36 | | ## Bill Text |
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| 38 | 38 | | The people of the State of California do enact as follows:SECTION 1. Section 2290.5 of the Business and Professions Code is amended to read:2290.5. (a) For purposes of this division, the following definitions apply:(1) Asynchronous store and forward means the transmission of a patients medical information from an originating site to the health care provider at a distant site.(2) Distant site means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system.(3) Health care provider means any of the following:(A) A person who is licensed under this division.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. as defined in Section 4999.200 or a qualified autism service professional as defined in Section 4999.201.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2.(E) An associate professional clinical counselor or clinical counselor trainee functioning pursuant to Section 4999.46.3.(4) Originating site means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.(5) Synchronous interaction means a real-time interaction between a patient and a health care provider located at a distant site.(6) Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patients health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.(b) Before the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. The consent shall be documented.(c) This section does not preclude a patient from receiving in-person health care delivery services during a specified course of health care and treatment after agreeing to receive services via telehealth.(d) The failure of a health care provider to comply with this section shall constitute unprofessional conduct. Section 2314 shall not apply to this section.(e) This section does not alter the scope of practice of a health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.(f) All laws regarding the confidentiality of health care information and a patients rights to the patients medical information shall apply to telehealth interactions.(g) All laws and regulations governing professional responsibility, unprofessional conduct, and standards of practice that apply to a health care provider under the health care providers license shall apply to that health care provider while providing telehealth services.(h) This section shall not apply to a patient under the jurisdiction of the Department of Corrections and Rehabilitation or any other correctional facility.(i) (1) Notwithstanding any other law and for purposes of this section, the governing body of the hospital whose patients are receiving the telehealth services may grant privileges to, and verify and approve credentials for, providers of telehealth services based on its medical staff recommendations that rely on information provided by the distant-site hospital or telehealth entity, as described in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.(2) By enacting this subdivision, it is the intent of the Legislature to authorize a hospital to grant privileges to, and verify and approve credentials for, providers of telehealth services as described in paragraph (1).(3) For the purposes of this subdivision, telehealth shall include telemedicine as the term is referenced in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.SEC. 2. Chapter 17 (commencing with Section 4999.200) is added to Division 2 of the Business and Professions Code, to read: CHAPTER 17. Qualified Autism Service Providers4999.200. Qualified autism service provider means an individual who meets either of the following criteria:(a) Is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the individual who is nationally certified.(b) Is licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500), and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.4999.201. Qualified autism service professional means an individual who meets all of the following criteria:(a) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(b) Is supervised by a qualified autism service provider.(c) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(d) Is either of the following:(1) A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(2) (A) A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(B) If an individual meets the requirement described in subparagraph (A), they shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(e) (1) Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(f) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.4999.202. Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(a) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(b) Provides treatment and implements services pursuant to a treatment plan that was developed and approved by the qualified autism service provider.(c) Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(d) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(e) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.SEC. 3. 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 plans 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), 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 plans Internet Web site 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 plans public Internet Web site 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 plans public Internet Web site 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 plans 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 providers practice location or other information required under subdivision (h) or (i) has changed.(D) Upon 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 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 plans Internet Web site. 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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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 providers staff.(11) Identification of providers who no longer accept new patients for some or all of the plans 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 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 providers 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 providers 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 providers staff.(10) Identification of providers who no longer accept new patients for some or all of the plans 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 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 plans 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) (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, a plan shall use the standards developed by the department for each product offered by the plan.(l) (1) A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 plan 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 plan 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 plan shall notify its contracted providers to ensure that all of the providers are contacted by the plan at least once annually.(2) The notification shall include all of the following:(A) The information the plan has in its directory or directories regarding the provider or provider group, including a list of networks and plan 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 plan 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 or provider group is accepting new patients for each plan product.(4) If the plan 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 plan shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The plan shall document the receipt and outcome of each attempt to verify the information. If the plan is unable to verify whether the providers information is correct or requires updates, the plan shall notify the provider 10 business days in advance of removal that the provider will be removed from the provider directory or directories. The provider shall be removed from the provider 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 they respond 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) A plan 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 this subdivision shall be submitted by a plan annually to the department for approval and in a format described by the department pursuant to Section 1367.035.(2) Every health care service plan 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 health care service plan. 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 health care service plan.(3) The plan shall establish and maintain a process for enrollees, potential enrollees, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the plans provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the plan will accept these reports, as well as a hyperlink on the plans provider directory Internet Web site internet website linking to a form where the information can be reported directly to the plan through its Internet Web site. internet website.(n) (1) This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan.(2) If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan 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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the plan that the provider should be deleted from the provider group in the plan directory or directories.(5) Section 1375.7, 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 a health care service plan receives a report indicating that information listed in its provider directory or directories is inaccurate, the plan 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 plan 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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to a plans provider directory or directories are required as a result of the plans 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 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups information is correct or requires updates. A plan 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.(A) For a provider or provider group that receives compensation on a capitated or prepaid basis, the plan may delay no more than 50 percent of the next scheduled capitation payment for up to one calendar month.(B) For any claims payment made to a provider or provider group, the plan may delay the claims payment for up to one calendar month beginning on the first day of the following month.(2) A plan shall notify the provider or provider group 10 business days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the plan delays a payment or reimbursement pursuant to this subdivision, the plan 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 plan 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 plan pursuant to subdivision (l).(3) A plan may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the plan to a change in the information required to be in the directory or directories pursuant to this section.(4) A plan 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 pursuant to Section 1367.035. 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).(5) With respect to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.(q) In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee.(r) Whenever a plan 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 plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.(s) This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d).(t) A health plan 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 of the Insurance Code shall meet the requirements of this section.(u) This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.(v) As part of the departments routine examination of the fiscal and administrative affairs of a health care service plan pursuant to Section 1382, the department shall include a review of the health care service plans compliance with subdivision (p).(w) For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers.SEC. 4. Section 1374.72 of the Health and Safety Code is amended to read:1374.72. (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an enrollee or subscriber under this chapter.(4) For purposes of this section, health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 10144.51 of the Insurance Code and Section 1374.73. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological associate, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 1374.721.(6) A health care service plan shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations by the health care service plan concerning service intensity, level of care placement, continued stay, and transfer or discharge of enrollees diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 1374.721. This paragraph does not deprive an enrollee of the other protections of this chapter, including, but not limited to, grievances, appeals, independent medical review, discharge, transfer, and continuity of care.(8) A health care service plan that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the plans subsequent rescission, cancellation, or modification of the enrollees or subscribers contract, or the plans subsequent determination that it did not make an accurate determination of the enrollees or subscribers eligibility. This section shall not be construed to expand or alter the benefits available to the enrollee or subscriber under a plan.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the plan contract includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the plan contract, shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum annual and lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the health care service plan shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the enrollee within geographic and timely access standards. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider.(e) This section shall not apply to contracts entered into pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, between the State Department of Health Care Services and a health care service plan for enrolled Medi-Cal beneficiaries.(f) (1) For the purpose of compliance with this section, a health care service plan may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health care service plan or mental health plan, and shall not be required to obtain an additional or specialized license for this purpose.(2) A health care service plan shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, health care service plan contracts that provide benefits to enrollees through preferred provider contracting arrangements are not precluded from requiring enrollees who reside or work in geographic areas served by specialized health care service plans or mental health plans to secure all or part of their mental health services within those geographic areas served by specialized health care service plans or mental health plans, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 1374.76 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure plan compliance with this chapter.(h) A health care service plan shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A health care service plan shall not adopt, impose, or enforce terms in its plan contracts or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.SEC. 5. Section 1374.73 of the Health and Safety Code is amended to read:1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 1374.72.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any of the following:(1) A specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(2) A health care service plan contract in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.SEC. 6. Section 10133.15 of the Insurance Code is amended to read:10133.15. (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 insurers 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 insurers Internet Web site internet website 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 insurers public Internet Web site internet website 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 insurers public Internet Web site 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) 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 insurers 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 providers 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 insurers Internet Web site. internet website.(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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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, if any, on the providers staff.(11) Identification of providers who no longer accept new patients for some or all of the insurers 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 providers 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 providers 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, if any, on the providers staff.(10) Identification of providers who no longer accept new patients for some or all of the insurers 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 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 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 insurers 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 insurers 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 providers 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 providers 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 they respond 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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory Internet Web site internet website linking to a form where the information can be reported directly to the insurer through its Internet Web site. internet website.(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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to an insurers provider directory or directories are required as a result of the insurers 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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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 insurers 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 insureds 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 insureds 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) This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.(u) As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers 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.SEC. 7. Section 10144.5 of the Insurance Code is amended to read:10144.5. (a) (1) Every disability insurance policy issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the World Health Organizations International Statistical Classification of Diseases and Related Health Problems, or that is listed in the most recent version of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the disability insurer and insureds or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an insured or policyholder under this chapter.(4) Health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological assistant, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 10144.52.(6) A disability insurer shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations made by the disability insurer concerning service intensity, level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 10144.52.(8) A disability insurer that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the insurers subsequent rescission, cancellation, or modification of the insureds or policyholders contract, or the insurers subsequent determination that it did not make an accurate determination of the insureds or policyholders eligibility. This section shall not be construed to expand or alter the benefits available to the insured or policyholder under an insurance policy.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345 of the Health and Safety Code.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the policy includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the disability insurance policy shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum and annual lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the disability insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the insured within geographic and timely access standards. The insured shall pay no more than the same cost sharing that the insured would pay for the same covered services received from an in-network provider.(e) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies.(f) (1) For the purpose of compliance with this section, a disability insurer may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health insurance policy or mental health policy. This paragraph shall not apply to policies that are subject to Section 10112.27.(2) A disability insurer shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, disability insurance policies that provide benefits to insureds through preferred provider contracting arrangements are not precluded from requiring insureds who reside or work in geographic areas served by specialized health insurance policies or mental health insurance policies to secure all or part of their mental health services within those geographic areas served by specialized health insurance policies or mental health insurance policies, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a disability insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 10144.4 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure a disability insurers compliance with this code.(h) A disability insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A disability insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.(j) If the commissioner determines that a disability insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation.SEC. 8. Section 10144.51 of the Insurance Code is amended to read:10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 10144.5.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any the following:(1) A specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(2) A health insurance policy in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing.SEC. 9. Section 11165.7 of the Penal Code is amended to read:11165.7. (a) As used in this article, mandated reporter is defined as any of the following:(1) A teacher.(2) An instructional aide.(3) A teachers aide or teachers assistant employed by a public or private school.(4) A classified employee of a public school.(5) An administrative officer or supervisor of child welfare and attendance, or a certificated pupil personnel employee of a public or private school.(6) An administrator of a public or private day camp.(7) An administrator or employee of a public or private youth center, youth recreation program, or youth organization.(8) An administrator, board member, or employee of a public or private organization whose duties require direct contact and supervision of children, including a foster family agency.(9) An employee of a county office of education or the State Department of Education whose duties bring the employee into contact with children on a regular basis.(10) A licensee, an administrator, or an employee of a licensed community care or child daycare facility.(11) A Head Start program teacher.(12) A licensing worker or licensing evaluator employed by a licensing agency, as defined in Section 11165.11.(13) A public assistance worker.(14) An employee of a childcare institution, including, but not limited to, foster parents, group home personnel, and personnel of residential care facilities.(15) A social worker, probation officer, or parole officer.(16) An employee of a school district police or security department.(17) A person who is an administrator or presenter of, or a counselor in, a child abuse prevention program in a public or private school.(18) A district attorney investigator, inspector, or local child support agency caseworker, unless the investigator, inspector, or caseworker is working with an attorney appointed pursuant to Section 317 of the Welfare and Institutions Code to represent a minor.(19) A peace officer, as defined in Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2, who is not otherwise described in this section.(20) A firefighter, except for volunteer firefighters.(21) A physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse, dental hygienist, optometrist, marriage and family therapist, clinical social worker, professional clinical counselor, or any other person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(22) An emergency medical technician I or II, paramedic, or other person certified pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code.(23) A psychological assistant registered pursuant to Section 2913 of the Business and Professions Code.(24) A marriage and family therapist trainee, as defined in subdivision (c) of Section 4980.03 of the Business and Professions Code.(25) An unlicensed associate marriage and family therapist registered under Section 4980.44 of the Business and Professions Code.(26) A state or county public health employee who treats a minor for venereal disease or any other condition.(27) A coroner.(28) A medical examiner or other person who performs autopsies.(29) A commercial film and photographic print or image processor as specified in subdivision (e) of Section 11166. As used in this article, commercial film and photographic print or image processor means a person who develops exposed photographic film into negatives, slides, or prints, or who makes prints from negatives or slides, or who prepares, publishes, produces, develops, duplicates, or prints any representation of information, data, or an image, including, but not limited to, any film, filmstrip, photograph, negative, slide, photocopy, videotape, video laser disc, computer hardware, computer software, computer floppy disk, data storage medium, CD-ROM, computer-generated equipment, or computer-generated image, for compensation. The term includes any employee of that person; it does not include a person who develops film or makes prints or images for a public agency.(30) A child visitation monitor. As used in this article, child visitation monitor means a person who, for financial compensation, acts as a monitor of a visit between a child and another person when the monitoring of that visit has been ordered by a court of law.(31) An animal control officer or humane society officer. For the purposes of this article, the following terms have the following meanings:(A) Animal control officer means a person employed by a city, county, or city and county for the purpose of enforcing animal control laws or regulations.(B) Humane society officer means a person appointed or employed by a public or private entity as a humane officer who is qualified pursuant to Section 14502 or 14503 of the Corporations Code.(32) A clergy member, as specified in subdivision (d) of Section 11166. As used in this article, clergy member means a priest, minister, rabbi, religious practitioner, or similar functionary of a church, temple, or recognized denomination or organization.(33) Any custodian of records of a clergy member, as specified in this section and subdivision (d) of Section 11166.(34) An employee of any police department, county sheriffs department, county probation department, or county welfare department.(35) An employee or volunteer of a Court Appointed Special Advocate program, as defined in Rule 5.655 of the California Rules of Court.(36) A custodial officer, as defined in Section 831.5.(37) A person providing services to a minor child under Section 12300 or 12300.1 of the Welfare and Institutions Code.(38) An alcohol and drug counselor. As used in this article, an alcohol and drug counselor is a person providing counseling, therapy, or other clinical services for a state licensed or certified drug, alcohol, or drug and alcohol treatment program. However, alcohol or drug abuse, or both alcohol and drug abuse, is not, in and of itself, a sufficient basis for reporting child abuse or neglect.(39) A clinical counselor trainee, as defined in subdivision (g) of Section 4999.12 of the Business and Professions Code.(40) An associate professional clinical counselor registered under Section 4999.42 of the Business and Professions Code.(41) An employee or administrator of a public or private postsecondary educational institution, whose duties bring the administrator or employee into contact with children on a regular basis, or who supervises those whose duties bring the administrator or employee into contact with children on a regular basis, as to child abuse or neglect occurring on that institutions premises or at an official activity of, or program conducted by, the institution. Nothing in this paragraph shall be construed as altering the lawyer-client privilege as set forth in Article 3 (commencing with Section 950) of Chapter 4 of Division 8 of the Evidence Code.(42) An athletic coach, athletic administrator, or athletic director employed by any public or private school that provides any combination of instruction for kindergarten, or grades 1 to 12, inclusive.(43) (A) A commercial computer technician as specified in subdivision (e) of Section 11166. As used in this article, commercial computer technician means a person who works for a company that is in the business of repairing, installing, or otherwise servicing a computer or computer component, including, but not limited to, a computer part, device, memory storage or recording mechanism, auxiliary storage recording or memory capacity, or any other material relating to the operation and maintenance of a computer or computer network system, for a fee. An employer who provides an electronic communications service or a remote computing service to the public shall be deemed to comply with this article if that employer complies with Section 2258A of Title 18 of the United States Code.(B) An employer of a commercial computer technician may implement internal procedures for facilitating reporting consistent with this article. These procedures may direct employees who are mandated reporters under this paragraph to report materials described in subdivision (e) of Section 11166 to an employee who is designated by the employer to receive the reports. An employee who is designated to receive reports under this subparagraph shall be a commercial computer technician for purposes of this article. A commercial computer technician who makes a report to the designated employee pursuant to this subparagraph shall be deemed to have complied with the requirements of this article and shall be subject to the protections afforded to mandated reporters, including, but not limited to, those protections afforded by Section 11172.(44) Any athletic coach, including, but not limited to, an assistant coach or a graduate assistant involved in coaching, at public or private postsecondary educational institutions.(45) An individual certified by a licensed foster family agency as a certified family home, as defined in Section 1506 of the Health and Safety Code.(46) An individual approved as a resource family, as defined in Section 1517 of the Health and Safety Code and Section 16519.5 of the Welfare and Institutions Code.(47) A qualified autism service provider, a qualified autism service professional, or a qualified autism service paraprofessional, as defined in Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. paraprofessional as defined in Chapter 17 (commencing with Section 4999.200) of Division 2 of the Business and Professions Code.(48) A human resource employee of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code that employs minors. For purposes of this section, a human resource employee is the employee or employees designated by the employer to accept any complaints of misconduct as required by Chapter 6 (commencing with Section 12940) of Part 2.8 of Division 3 of Title 2 of the Government Code.(49) An adult person whose duties require direct contact with and supervision of minors in the performance of the minors duties in the workplace of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code is a mandated reporter of sexual abuse, as defined in Section 11165.1. Nothing in this paragraph shall be construed to modify or limit the persons duty to report known or suspected child abuse or neglect when the person is acting in some other capacity that would otherwise make the person a mandated reporter.(b) Except as provided in paragraph (35) of subdivision (a), volunteers of public or private organizations whose duties require direct contact with and supervision of children are not mandated reporters but are encouraged to obtain training in the identification and reporting of child abuse and neglect and are further encouraged to report known or suspected instances of child abuse or neglect to an agency specified in Section 11165.9.(c) (1) Except as provided in subdivision (d) and paragraph (2), employers are strongly encouraged to provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. Whether or not employers provide their employees with training in child abuse and neglect identification and reporting, the employers shall provide their employees who are mandated reporters with the statement required pursuant to subdivision (a) of Section 11166.5.(2) Employers subject to paragraphs (48) and (49) of subdivision (a) shall provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. The training requirement may be met by completing the general online training for mandated reporters offered by the Office of Child Abuse Prevention in the State Department of Social Services.(d) Pursuant to Section 44691 of the Education Code, school districts, county offices of education, state special schools and diagnostic centers operated by the State Department of Education, and charter schools shall annually train their employees and persons working on their behalf specified in subdivision (a) in the duties of mandated reporters under the child abuse reporting laws. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(e) (1) On and after January 1, 2018, pursuant to Section 1596.8662 of the Health and Safety Code, a childcare licensee applicant shall take training in the duties of mandated reporters under the child abuse reporting laws as a condition of licensure, and a childcare administrator or an employee of a licensed child daycare facility shall take training in the duties of mandated reporters during the first 90 days when that administrator or employee is employed by the facility.(2) A person specified in paragraph (1) who becomes a licensee, administrator, or employee of a licensed child daycare facility shall take renewal mandated reporter training every two years following the date on which that person completed the initial mandated reporter training. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(f) Unless otherwise specifically provided, the absence of training shall not excuse a mandated reporter from the duties imposed by this article.(g) Public and private organizations are encouraged to provide their volunteers whose duties require direct contact with and supervision of children with training in the identification and reporting of child abuse and neglect. |
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| 39 | 39 | | |
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| 40 | 40 | | The people of the State of California do enact as follows: |
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| 41 | 41 | | |
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| 42 | 42 | | ## The people of the State of California do enact as follows: |
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| 43 | 43 | | |
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| 44 | 44 | | SECTION 1. Section 2290.5 of the Business and Professions Code is amended to read:2290.5. (a) For purposes of this division, the following definitions apply:(1) Asynchronous store and forward means the transmission of a patients medical information from an originating site to the health care provider at a distant site.(2) Distant site means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system.(3) Health care provider means any of the following:(A) A person who is licensed under this division.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. as defined in Section 4999.200 or a qualified autism service professional as defined in Section 4999.201.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2.(E) An associate professional clinical counselor or clinical counselor trainee functioning pursuant to Section 4999.46.3.(4) Originating site means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.(5) Synchronous interaction means a real-time interaction between a patient and a health care provider located at a distant site.(6) Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patients health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.(b) Before the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. The consent shall be documented.(c) This section does not preclude a patient from receiving in-person health care delivery services during a specified course of health care and treatment after agreeing to receive services via telehealth.(d) The failure of a health care provider to comply with this section shall constitute unprofessional conduct. Section 2314 shall not apply to this section.(e) This section does not alter the scope of practice of a health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.(f) All laws regarding the confidentiality of health care information and a patients rights to the patients medical information shall apply to telehealth interactions.(g) All laws and regulations governing professional responsibility, unprofessional conduct, and standards of practice that apply to a health care provider under the health care providers license shall apply to that health care provider while providing telehealth services.(h) This section shall not apply to a patient under the jurisdiction of the Department of Corrections and Rehabilitation or any other correctional facility.(i) (1) Notwithstanding any other law and for purposes of this section, the governing body of the hospital whose patients are receiving the telehealth services may grant privileges to, and verify and approve credentials for, providers of telehealth services based on its medical staff recommendations that rely on information provided by the distant-site hospital or telehealth entity, as described in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.(2) By enacting this subdivision, it is the intent of the Legislature to authorize a hospital to grant privileges to, and verify and approve credentials for, providers of telehealth services as described in paragraph (1).(3) For the purposes of this subdivision, telehealth shall include telemedicine as the term is referenced in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations. |
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| 45 | 45 | | |
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| 46 | 46 | | SECTION 1. Section 2290.5 of the Business and Professions Code is amended to read: |
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| 47 | 47 | | |
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| 48 | 48 | | ### SECTION 1. |
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| 49 | 49 | | |
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| 50 | 50 | | 2290.5. (a) For purposes of this division, the following definitions apply:(1) Asynchronous store and forward means the transmission of a patients medical information from an originating site to the health care provider at a distant site.(2) Distant site means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system.(3) Health care provider means any of the following:(A) A person who is licensed under this division.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. as defined in Section 4999.200 or a qualified autism service professional as defined in Section 4999.201.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2.(E) An associate professional clinical counselor or clinical counselor trainee functioning pursuant to Section 4999.46.3.(4) Originating site means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.(5) Synchronous interaction means a real-time interaction between a patient and a health care provider located at a distant site.(6) Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patients health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.(b) Before the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. The consent shall be documented.(c) This section does not preclude a patient from receiving in-person health care delivery services during a specified course of health care and treatment after agreeing to receive services via telehealth.(d) The failure of a health care provider to comply with this section shall constitute unprofessional conduct. Section 2314 shall not apply to this section.(e) This section does not alter the scope of practice of a health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.(f) All laws regarding the confidentiality of health care information and a patients rights to the patients medical information shall apply to telehealth interactions.(g) All laws and regulations governing professional responsibility, unprofessional conduct, and standards of practice that apply to a health care provider under the health care providers license shall apply to that health care provider while providing telehealth services.(h) This section shall not apply to a patient under the jurisdiction of the Department of Corrections and Rehabilitation or any other correctional facility.(i) (1) Notwithstanding any other law and for purposes of this section, the governing body of the hospital whose patients are receiving the telehealth services may grant privileges to, and verify and approve credentials for, providers of telehealth services based on its medical staff recommendations that rely on information provided by the distant-site hospital or telehealth entity, as described in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.(2) By enacting this subdivision, it is the intent of the Legislature to authorize a hospital to grant privileges to, and verify and approve credentials for, providers of telehealth services as described in paragraph (1).(3) For the purposes of this subdivision, telehealth shall include telemedicine as the term is referenced in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations. |
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| 51 | 51 | | |
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| 52 | 52 | | 2290.5. (a) For purposes of this division, the following definitions apply:(1) Asynchronous store and forward means the transmission of a patients medical information from an originating site to the health care provider at a distant site.(2) Distant site means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system.(3) Health care provider means any of the following:(A) A person who is licensed under this division.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. as defined in Section 4999.200 or a qualified autism service professional as defined in Section 4999.201.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2.(E) An associate professional clinical counselor or clinical counselor trainee functioning pursuant to Section 4999.46.3.(4) Originating site means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.(5) Synchronous interaction means a real-time interaction between a patient and a health care provider located at a distant site.(6) Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patients health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.(b) Before the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. The consent shall be documented.(c) This section does not preclude a patient from receiving in-person health care delivery services during a specified course of health care and treatment after agreeing to receive services via telehealth.(d) The failure of a health care provider to comply with this section shall constitute unprofessional conduct. Section 2314 shall not apply to this section.(e) This section does not alter the scope of practice of a health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.(f) All laws regarding the confidentiality of health care information and a patients rights to the patients medical information shall apply to telehealth interactions.(g) All laws and regulations governing professional responsibility, unprofessional conduct, and standards of practice that apply to a health care provider under the health care providers license shall apply to that health care provider while providing telehealth services.(h) This section shall not apply to a patient under the jurisdiction of the Department of Corrections and Rehabilitation or any other correctional facility.(i) (1) Notwithstanding any other law and for purposes of this section, the governing body of the hospital whose patients are receiving the telehealth services may grant privileges to, and verify and approve credentials for, providers of telehealth services based on its medical staff recommendations that rely on information provided by the distant-site hospital or telehealth entity, as described in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.(2) By enacting this subdivision, it is the intent of the Legislature to authorize a hospital to grant privileges to, and verify and approve credentials for, providers of telehealth services as described in paragraph (1).(3) For the purposes of this subdivision, telehealth shall include telemedicine as the term is referenced in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations. |
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| 53 | 53 | | |
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| 54 | 54 | | 2290.5. (a) For purposes of this division, the following definitions apply:(1) Asynchronous store and forward means the transmission of a patients medical information from an originating site to the health care provider at a distant site.(2) Distant site means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system.(3) Health care provider means any of the following:(A) A person who is licensed under this division.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. as defined in Section 4999.200 or a qualified autism service professional as defined in Section 4999.201.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2.(E) An associate professional clinical counselor or clinical counselor trainee functioning pursuant to Section 4999.46.3.(4) Originating site means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates.(5) Synchronous interaction means a real-time interaction between a patient and a health care provider located at a distant site.(6) Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patients health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.(b) Before the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. The consent shall be documented.(c) This section does not preclude a patient from receiving in-person health care delivery services during a specified course of health care and treatment after agreeing to receive services via telehealth.(d) The failure of a health care provider to comply with this section shall constitute unprofessional conduct. Section 2314 shall not apply to this section.(e) This section does not alter the scope of practice of a health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law.(f) All laws regarding the confidentiality of health care information and a patients rights to the patients medical information shall apply to telehealth interactions.(g) All laws and regulations governing professional responsibility, unprofessional conduct, and standards of practice that apply to a health care provider under the health care providers license shall apply to that health care provider while providing telehealth services.(h) This section shall not apply to a patient under the jurisdiction of the Department of Corrections and Rehabilitation or any other correctional facility.(i) (1) Notwithstanding any other law and for purposes of this section, the governing body of the hospital whose patients are receiving the telehealth services may grant privileges to, and verify and approve credentials for, providers of telehealth services based on its medical staff recommendations that rely on information provided by the distant-site hospital or telehealth entity, as described in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations.(2) By enacting this subdivision, it is the intent of the Legislature to authorize a hospital to grant privileges to, and verify and approve credentials for, providers of telehealth services as described in paragraph (1).(3) For the purposes of this subdivision, telehealth shall include telemedicine as the term is referenced in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations. |
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| 55 | 55 | | |
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| 56 | 56 | | |
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| 57 | 57 | | |
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| 58 | 58 | | 2290.5. (a) For purposes of this division, the following definitions apply: |
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| 59 | 59 | | |
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| 60 | 60 | | (1) Asynchronous store and forward means the transmission of a patients medical information from an originating site to the health care provider at a distant site. |
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| 61 | 61 | | |
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| 62 | 62 | | (2) Distant site means a site where a health care provider who provides health care services is located while providing these services via a telecommunications system. |
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| 63 | 63 | | |
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| 64 | 64 | | (3) Health care provider means any of the following: |
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| 65 | 65 | | |
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| 66 | 66 | | (A) A person who is licensed under this division. |
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| 67 | 67 | | |
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| 68 | 68 | | (B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3. |
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| 69 | 69 | | |
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| 70 | 70 | | (C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. as defined in Section 4999.200 or a qualified autism service professional as defined in Section 4999.201. |
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| 71 | 71 | | |
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| 72 | 72 | | (D) An associate clinical social worker functioning pursuant to Section 4996.23.2. |
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| 73 | 73 | | |
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| 74 | 74 | | (E) An associate professional clinical counselor or clinical counselor trainee functioning pursuant to Section 4999.46.3. |
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| 75 | 75 | | |
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| 76 | 76 | | (4) Originating site means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates. |
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| 77 | 77 | | |
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| 78 | 78 | | (5) Synchronous interaction means a real-time interaction between a patient and a health care provider located at a distant site. |
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| 79 | 79 | | |
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| 80 | 80 | | (6) Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patients health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers. |
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| 81 | 81 | | |
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| 82 | 82 | | (b) Before the delivery of health care via telehealth, the health care provider initiating the use of telehealth shall inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. The consent shall be documented. |
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| 83 | 83 | | |
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| 84 | 84 | | (c) This section does not preclude a patient from receiving in-person health care delivery services during a specified course of health care and treatment after agreeing to receive services via telehealth. |
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| 85 | 85 | | |
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| 86 | 86 | | (d) The failure of a health care provider to comply with this section shall constitute unprofessional conduct. Section 2314 shall not apply to this section. |
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| 87 | 87 | | |
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| 88 | 88 | | (e) This section does not alter the scope of practice of a health care provider or authorize the delivery of health care services in a setting, or in a manner, not otherwise authorized by law. |
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| 89 | 89 | | |
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| 90 | 90 | | (f) All laws regarding the confidentiality of health care information and a patients rights to the patients medical information shall apply to telehealth interactions. |
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| 91 | 91 | | |
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| 92 | 92 | | (g) All laws and regulations governing professional responsibility, unprofessional conduct, and standards of practice that apply to a health care provider under the health care providers license shall apply to that health care provider while providing telehealth services. |
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| 93 | 93 | | |
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| 94 | 94 | | (h) This section shall not apply to a patient under the jurisdiction of the Department of Corrections and Rehabilitation or any other correctional facility. |
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| 95 | 95 | | |
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| 96 | 96 | | (i) (1) Notwithstanding any other law and for purposes of this section, the governing body of the hospital whose patients are receiving the telehealth services may grant privileges to, and verify and approve credentials for, providers of telehealth services based on its medical staff recommendations that rely on information provided by the distant-site hospital or telehealth entity, as described in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations. |
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| 97 | 97 | | |
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| 98 | 98 | | (2) By enacting this subdivision, it is the intent of the Legislature to authorize a hospital to grant privileges to, and verify and approve credentials for, providers of telehealth services as described in paragraph (1). |
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| 99 | 99 | | |
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| 100 | 100 | | (3) For the purposes of this subdivision, telehealth shall include telemedicine as the term is referenced in Sections 482.12, 482.22, and 485.616 of Title 42 of the Code of Federal Regulations. |
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| 101 | 101 | | |
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| 102 | 102 | | SEC. 2. Chapter 17 (commencing with Section 4999.200) is added to Division 2 of the Business and Professions Code, to read: CHAPTER 17. Qualified Autism Service Providers4999.200. Qualified autism service provider means an individual who meets either of the following criteria:(a) Is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the individual who is nationally certified.(b) Is licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500), and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.4999.201. Qualified autism service professional means an individual who meets all of the following criteria:(a) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(b) Is supervised by a qualified autism service provider.(c) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(d) Is either of the following:(1) A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(2) (A) A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(B) If an individual meets the requirement described in subparagraph (A), they shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(e) (1) Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(f) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.4999.202. Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(a) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(b) Provides treatment and implements services pursuant to a treatment plan that was developed and approved by the qualified autism service provider.(c) Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(d) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(e) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 103 | 103 | | |
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| 104 | 104 | | SEC. 2. Chapter 17 (commencing with Section 4999.200) is added to Division 2 of the Business and Professions Code, to read: |
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| 105 | 105 | | |
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| 106 | 106 | | ### SEC. 2. |
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| 107 | 107 | | |
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| 108 | 108 | | CHAPTER 17. Qualified Autism Service Providers4999.200. Qualified autism service provider means an individual who meets either of the following criteria:(a) Is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the individual who is nationally certified.(b) Is licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500), and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.4999.201. Qualified autism service professional means an individual who meets all of the following criteria:(a) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(b) Is supervised by a qualified autism service provider.(c) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(d) Is either of the following:(1) A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(2) (A) A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(B) If an individual meets the requirement described in subparagraph (A), they shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(e) (1) Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(f) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.4999.202. Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(a) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(b) Provides treatment and implements services pursuant to a treatment plan that was developed and approved by the qualified autism service provider.(c) Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(d) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(e) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 109 | 109 | | |
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| 110 | 110 | | CHAPTER 17. Qualified Autism Service Providers4999.200. Qualified autism service provider means an individual who meets either of the following criteria:(a) Is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the individual who is nationally certified.(b) Is licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500), and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.4999.201. Qualified autism service professional means an individual who meets all of the following criteria:(a) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(b) Is supervised by a qualified autism service provider.(c) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(d) Is either of the following:(1) A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(2) (A) A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(B) If an individual meets the requirement described in subparagraph (A), they shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(e) (1) Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(f) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.4999.202. Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(a) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(b) Provides treatment and implements services pursuant to a treatment plan that was developed and approved by the qualified autism service provider.(c) Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(d) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(e) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 111 | 111 | | |
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| 112 | 112 | | CHAPTER 17. Qualified Autism Service Providers |
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| 113 | 113 | | |
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| 114 | 114 | | CHAPTER 17. Qualified Autism Service Providers |
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| 115 | 115 | | |
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| 116 | 116 | | 4999.200. Qualified autism service provider means an individual who meets either of the following criteria:(a) Is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the individual who is nationally certified.(b) Is licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500), and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee. |
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| 117 | 117 | | |
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| 118 | 118 | | |
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| 119 | 119 | | |
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| 120 | 120 | | 4999.200. Qualified autism service provider means an individual who meets either of the following criteria: |
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| 121 | 121 | | |
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| 122 | 122 | | (a) Is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the individual who is nationally certified. |
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| 123 | 123 | | |
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| 124 | 124 | | (b) Is licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist, pursuant to Division 2 (commencing with Section 500), and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee. |
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| 125 | 125 | | |
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| 126 | 126 | | 4999.201. Qualified autism service professional means an individual who meets all of the following criteria:(a) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(b) Is supervised by a qualified autism service provider.(c) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(d) Is either of the following:(1) A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(2) (A) A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(B) If an individual meets the requirement described in subparagraph (A), they shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(e) (1) Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(f) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 127 | 127 | | |
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| 128 | 128 | | |
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| 129 | 129 | | |
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| 130 | 130 | | 4999.201. Qualified autism service professional means an individual who meets all of the following criteria: |
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| 131 | 131 | | |
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| 132 | 132 | | (a) Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. |
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| 133 | 133 | | |
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| 134 | 134 | | (b) Is supervised by a qualified autism service provider. |
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| 135 | 135 | | |
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| 136 | 136 | | (c) Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider. |
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| 137 | 137 | | |
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| 138 | 138 | | (d) Is either of the following: |
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| 139 | 139 | | |
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| 140 | 140 | | (1) A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program. |
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| 141 | 141 | | |
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| 142 | 142 | | (2) (A) A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology. |
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| 143 | 143 | | |
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| 144 | 144 | | (B) If an individual meets the requirement described in subparagraph (A), they shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional. |
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| 145 | 145 | | |
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| 146 | 146 | | (e) (1) Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code. |
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| 147 | 147 | | |
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| 148 | 148 | | (f) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 149 | 149 | | |
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| 150 | 150 | | 4999.202. Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(a) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(b) Provides treatment and implements services pursuant to a treatment plan that was developed and approved by the qualified autism service provider.(c) Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(d) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(e) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 151 | 151 | | |
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| 152 | 152 | | |
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| 153 | 153 | | |
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| 154 | 154 | | 4999.202. Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria: |
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| 155 | 155 | | |
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| 156 | 156 | | (a) Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice. |
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| 157 | 157 | | |
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| 158 | 158 | | (b) Provides treatment and implements services pursuant to a treatment plan that was developed and approved by the qualified autism service provider. |
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| 159 | 159 | | |
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| 160 | 160 | | (c) Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations. |
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| 161 | 161 | | |
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| 162 | 162 | | (d) Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers. |
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| 163 | 163 | | |
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| 164 | 164 | | (e) Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 165 | 165 | | |
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| 166 | 166 | | SEC. 3. 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 plans 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), 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 plans Internet Web site 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 plans public Internet Web site 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 plans public Internet Web site 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 plans 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 providers practice location or other information required under subdivision (h) or (i) has changed.(D) Upon 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 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 plans Internet Web site. 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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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 providers staff.(11) Identification of providers who no longer accept new patients for some or all of the plans 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 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 providers 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 providers 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 providers staff.(10) Identification of providers who no longer accept new patients for some or all of the plans 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 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 plans 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) (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, a plan shall use the standards developed by the department for each product offered by the plan.(l) (1) A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 plan 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 plan 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 plan shall notify its contracted providers to ensure that all of the providers are contacted by the plan at least once annually.(2) The notification shall include all of the following:(A) The information the plan has in its directory or directories regarding the provider or provider group, including a list of networks and plan 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 plan 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 or provider group is accepting new patients for each plan product.(4) If the plan 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 plan shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The plan shall document the receipt and outcome of each attempt to verify the information. If the plan is unable to verify whether the providers information is correct or requires updates, the plan shall notify the provider 10 business days in advance of removal that the provider will be removed from the provider directory or directories. The provider shall be removed from the provider 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 they respond 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) A plan 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 this subdivision shall be submitted by a plan annually to the department for approval and in a format described by the department pursuant to Section 1367.035.(2) Every health care service plan 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 health care service plan. 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 health care service plan.(3) The plan shall establish and maintain a process for enrollees, potential enrollees, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the plans provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the plan will accept these reports, as well as a hyperlink on the plans provider directory Internet Web site internet website linking to a form where the information can be reported directly to the plan through its Internet Web site. internet website.(n) (1) This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan.(2) If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan 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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the plan that the provider should be deleted from the provider group in the plan directory or directories.(5) Section 1375.7, 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 a health care service plan receives a report indicating that information listed in its provider directory or directories is inaccurate, the plan 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 plan 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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to a plans provider directory or directories are required as a result of the plans 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 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups information is correct or requires updates. A plan 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.(A) For a provider or provider group that receives compensation on a capitated or prepaid basis, the plan may delay no more than 50 percent of the next scheduled capitation payment for up to one calendar month.(B) For any claims payment made to a provider or provider group, the plan may delay the claims payment for up to one calendar month beginning on the first day of the following month.(2) A plan shall notify the provider or provider group 10 business days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the plan delays a payment or reimbursement pursuant to this subdivision, the plan 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 plan 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 plan pursuant to subdivision (l).(3) A plan may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the plan to a change in the information required to be in the directory or directories pursuant to this section.(4) A plan 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 pursuant to Section 1367.035. 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).(5) With respect to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.(q) In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee.(r) Whenever a plan 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 plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.(s) This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d).(t) A health plan 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 of the Insurance Code shall meet the requirements of this section.(u) This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.(v) As part of the departments routine examination of the fiscal and administrative affairs of a health care service plan pursuant to Section 1382, the department shall include a review of the health care service plans compliance with subdivision (p).(w) For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers. |
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| 167 | 167 | | |
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| 168 | 168 | | SEC. 3. Section 1367.27 of the Health and Safety Code is amended to read: |
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| 169 | 169 | | |
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| 170 | 170 | | ### SEC. 3. |
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| 171 | 171 | | |
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| 172 | 172 | | 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 plans 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), 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 plans Internet Web site 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 plans public Internet Web site 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 plans public Internet Web site 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 plans 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 providers practice location or other information required under subdivision (h) or (i) has changed.(D) Upon 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 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 plans Internet Web site. 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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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 providers staff.(11) Identification of providers who no longer accept new patients for some or all of the plans 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 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 providers 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 providers 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 providers staff.(10) Identification of providers who no longer accept new patients for some or all of the plans 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 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 plans 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) (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, a plan shall use the standards developed by the department for each product offered by the plan.(l) (1) A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 plan 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 plan 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 plan shall notify its contracted providers to ensure that all of the providers are contacted by the plan at least once annually.(2) The notification shall include all of the following:(A) The information the plan has in its directory or directories regarding the provider or provider group, including a list of networks and plan 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 plan 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 or provider group is accepting new patients for each plan product.(4) If the plan 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 plan shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The plan shall document the receipt and outcome of each attempt to verify the information. If the plan is unable to verify whether the providers information is correct or requires updates, the plan shall notify the provider 10 business days in advance of removal that the provider will be removed from the provider directory or directories. The provider shall be removed from the provider 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 they respond 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) A plan 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 this subdivision shall be submitted by a plan annually to the department for approval and in a format described by the department pursuant to Section 1367.035.(2) Every health care service plan 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 health care service plan. 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 health care service plan.(3) The plan shall establish and maintain a process for enrollees, potential enrollees, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the plans provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the plan will accept these reports, as well as a hyperlink on the plans provider directory Internet Web site internet website linking to a form where the information can be reported directly to the plan through its Internet Web site. internet website.(n) (1) This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan.(2) If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan 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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the plan that the provider should be deleted from the provider group in the plan directory or directories.(5) Section 1375.7, 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 a health care service plan receives a report indicating that information listed in its provider directory or directories is inaccurate, the plan 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 plan 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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to a plans provider directory or directories are required as a result of the plans 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 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups information is correct or requires updates. A plan 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.(A) For a provider or provider group that receives compensation on a capitated or prepaid basis, the plan may delay no more than 50 percent of the next scheduled capitation payment for up to one calendar month.(B) For any claims payment made to a provider or provider group, the plan may delay the claims payment for up to one calendar month beginning on the first day of the following month.(2) A plan shall notify the provider or provider group 10 business days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the plan delays a payment or reimbursement pursuant to this subdivision, the plan 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 plan 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 plan pursuant to subdivision (l).(3) A plan may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the plan to a change in the information required to be in the directory or directories pursuant to this section.(4) A plan 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 pursuant to Section 1367.035. 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).(5) With respect to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.(q) In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee.(r) Whenever a plan 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 plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.(s) This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d).(t) A health plan 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 of the Insurance Code shall meet the requirements of this section.(u) This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.(v) As part of the departments routine examination of the fiscal and administrative affairs of a health care service plan pursuant to Section 1382, the department shall include a review of the health care service plans compliance with subdivision (p).(w) For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers. |
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| 174 | 174 | | 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 plans 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), 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 plans Internet Web site 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 plans public Internet Web site 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 plans public Internet Web site 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 plans 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 providers practice location or other information required under subdivision (h) or (i) has changed.(D) Upon 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 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 plans Internet Web site. 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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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 providers staff.(11) Identification of providers who no longer accept new patients for some or all of the plans 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 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 providers 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 providers 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 providers staff.(10) Identification of providers who no longer accept new patients for some or all of the plans 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 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 plans 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) (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, a plan shall use the standards developed by the department for each product offered by the plan.(l) (1) A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 plan 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 plan 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 plan shall notify its contracted providers to ensure that all of the providers are contacted by the plan at least once annually.(2) The notification shall include all of the following:(A) The information the plan has in its directory or directories regarding the provider or provider group, including a list of networks and plan 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 plan 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 or provider group is accepting new patients for each plan product.(4) If the plan 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 plan shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The plan shall document the receipt and outcome of each attempt to verify the information. If the plan is unable to verify whether the providers information is correct or requires updates, the plan shall notify the provider 10 business days in advance of removal that the provider will be removed from the provider directory or directories. The provider shall be removed from the provider 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 they respond 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) A plan 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 this subdivision shall be submitted by a plan annually to the department for approval and in a format described by the department pursuant to Section 1367.035.(2) Every health care service plan 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 health care service plan. 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 health care service plan.(3) The plan shall establish and maintain a process for enrollees, potential enrollees, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the plans provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the plan will accept these reports, as well as a hyperlink on the plans provider directory Internet Web site internet website linking to a form where the information can be reported directly to the plan through its Internet Web site. internet website.(n) (1) This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan.(2) If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan 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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the plan that the provider should be deleted from the provider group in the plan directory or directories.(5) Section 1375.7, 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 a health care service plan receives a report indicating that information listed in its provider directory or directories is inaccurate, the plan 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 plan 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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to a plans provider directory or directories are required as a result of the plans 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 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups information is correct or requires updates. A plan 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.(A) For a provider or provider group that receives compensation on a capitated or prepaid basis, the plan may delay no more than 50 percent of the next scheduled capitation payment for up to one calendar month.(B) For any claims payment made to a provider or provider group, the plan may delay the claims payment for up to one calendar month beginning on the first day of the following month.(2) A plan shall notify the provider or provider group 10 business days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the plan delays a payment or reimbursement pursuant to this subdivision, the plan 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 plan 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 plan pursuant to subdivision (l).(3) A plan may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the plan to a change in the information required to be in the directory or directories pursuant to this section.(4) A plan 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 pursuant to Section 1367.035. 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).(5) With respect to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.(q) In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee.(r) Whenever a plan 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 plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.(s) This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d).(t) A health plan 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 of the Insurance Code shall meet the requirements of this section.(u) This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.(v) As part of the departments routine examination of the fiscal and administrative affairs of a health care service plan pursuant to Section 1382, the department shall include a review of the health care service plans compliance with subdivision (p).(w) For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers. |
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| 175 | 175 | | |
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| 176 | 176 | | 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 plans 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), 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 plans Internet Web site 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 plans public Internet Web site 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 plans public Internet Web site 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 plans 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 providers practice location or other information required under subdivision (h) or (i) has changed.(D) Upon 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 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 plans Internet Web site. 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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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 providers staff.(11) Identification of providers who no longer accept new patients for some or all of the plans 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 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 providers 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 providers 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 providers staff.(10) Identification of providers who no longer accept new patients for some or all of the plans 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 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 plans 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) (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, a plan shall use the standards developed by the department for each product offered by the plan.(l) (1) A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 plan 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 plan 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 plan shall notify its contracted providers to ensure that all of the providers are contacted by the plan at least once annually.(2) The notification shall include all of the following:(A) The information the plan has in its directory or directories regarding the provider or provider group, including a list of networks and plan 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 plan 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 or provider group is accepting new patients for each plan product.(4) If the plan 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 plan shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The plan shall document the receipt and outcome of each attempt to verify the information. If the plan is unable to verify whether the providers information is correct or requires updates, the plan shall notify the provider 10 business days in advance of removal that the provider will be removed from the provider directory or directories. The provider shall be removed from the provider 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 they respond 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) A plan 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 this subdivision shall be submitted by a plan annually to the department for approval and in a format described by the department pursuant to Section 1367.035.(2) Every health care service plan 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 health care service plan. 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 health care service plan.(3) The plan shall establish and maintain a process for enrollees, potential enrollees, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the plans provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the plan will accept these reports, as well as a hyperlink on the plans provider directory Internet Web site internet website linking to a form where the information can be reported directly to the plan through its Internet Web site. internet website.(n) (1) This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan.(2) If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan 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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the plan that the provider should be deleted from the provider group in the plan directory or directories.(5) Section 1375.7, 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 a health care service plan receives a report indicating that information listed in its provider directory or directories is inaccurate, the plan 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 plan 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 providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to a plans provider directory or directories are required as a result of the plans 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 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups information is correct or requires updates. A plan 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.(A) For a provider or provider group that receives compensation on a capitated or prepaid basis, the plan may delay no more than 50 percent of the next scheduled capitation payment for up to one calendar month.(B) For any claims payment made to a provider or provider group, the plan may delay the claims payment for up to one calendar month beginning on the first day of the following month.(2) A plan shall notify the provider or provider group 10 business days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the plan delays a payment or reimbursement pursuant to this subdivision, the plan 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 plan 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 plan pursuant to subdivision (l).(3) A plan may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the plan to a change in the information required to be in the directory or directories pursuant to this section.(4) A plan 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 pursuant to Section 1367.035. 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).(5) With respect to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance.(q) In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee.(r) Whenever a plan 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 plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations.(s) This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d).(t) A health plan 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 of the Insurance Code shall meet the requirements of this section.(u) This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan.(v) As part of the departments routine examination of the fiscal and administrative affairs of a health care service plan pursuant to Section 1382, the department shall include a review of the health care service plans compliance with subdivision (p).(w) For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers. |
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| 177 | 177 | | |
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| 178 | 178 | | |
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| 179 | 179 | | |
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| 180 | 180 | | 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 plans 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. |
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| 181 | 181 | | |
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| 182 | 182 | | (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), whichever occurs later, a health care service plan shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k). |
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| 183 | 183 | | |
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| 184 | 184 | | (c) (1) An online provider directory or directories shall be available on the plans Internet Web site 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. |
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| 185 | 185 | | |
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| 186 | 186 | | (2) The online provider directory or directories shall be accessible on the plans public Internet Web site 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 plans public Internet Web site 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. |
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| 187 | 187 | | |
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| 188 | 188 | | (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 plans 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. |
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| 189 | 189 | | |
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| 190 | 190 | | (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. |
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| 191 | 191 | | |
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| 192 | 192 | | (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: |
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| 193 | 193 | | |
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| 194 | 194 | | (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. |
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| 195 | 195 | | |
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| 196 | 196 | | (B) A provider is no longer under contract for a particular plan product. |
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| 197 | 197 | | |
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| 198 | 198 | | (C) A providers practice location or other information required under subdivision (h) or (i) has changed. |
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| 199 | 199 | | |
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| 200 | 200 | | (D) Upon 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. |
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| 201 | 201 | | |
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| 202 | 202 | | (E) Any other information that affects the content or accuracy of the provider directory or directories. |
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| 203 | 203 | | |
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| 204 | 204 | | (2) Upon confirmation of any of the following, the plan shall delete a provider from the directory or directories when: |
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| 205 | 205 | | |
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| 206 | 206 | | (A) A provider has retired or otherwise has ceased to practice. |
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| 207 | 207 | | |
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| 208 | 208 | | (B) A provider or provider group is no longer under contract with the plan for any reason. |
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| 209 | 209 | | |
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| 210 | 210 | | (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. |
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| 211 | 211 | | |
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| 212 | 212 | | (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 plans Internet Web site. internet website. |
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| 213 | 213 | | |
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| 214 | 214 | | (g) The provider directory or directories shall include the following disclosures informing enrollees that they are entitled to both of the following: |
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| 215 | 215 | | |
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| 216 | 216 | | (1) Language interpreter services, at no cost to the enrollee, including how to obtain interpretation services in accordance with Section 1367.04. |
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| 217 | 217 | | |
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| 218 | 218 | | (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. |
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| 219 | 219 | | |
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| 220 | 220 | | (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: |
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| 221 | 221 | | |
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| 222 | 222 | | (1) The providers name, practice location or locations, and contact information. |
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| 223 | 223 | | |
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| 224 | 224 | | (2) Type of practitioner. |
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| 225 | 225 | | |
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| 226 | 226 | | (3) National Provider Identifier number. |
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| 227 | 227 | | |
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| 228 | 228 | | (4) California license number and type of license. |
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| 229 | 229 | | |
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| 230 | 230 | | (5) The area of specialty, including board certification, if any. |
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| 231 | 231 | | |
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| 232 | 232 | | (6) The providers office email address, if available. |
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| 233 | 233 | | |
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| 234 | 234 | | (7) The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees. |
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| 235 | 235 | | |
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| 236 | 236 | | (8) A listing for each of the following providers that are under contract with the plan: |
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| 237 | 237 | | |
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| 238 | 238 | | (A) For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the plan. |
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| 239 | 239 | | |
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| 240 | 240 | | (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, 4999.200 of the Business and Professions Code, nurse midwives, and dentists. |
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| 241 | 241 | | |
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| 242 | 242 | | (C) For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic. |
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| 243 | 243 | | |
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| 244 | 244 | | (D) For any a 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. |
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| 245 | 245 | | |
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| 246 | 246 | | (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. |
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| 247 | 247 | | |
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| 248 | 248 | | (F) Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services. |
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| 249 | 249 | | |
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| 250 | 250 | | (9) The provider directory or directories may note that authorization or referral may be required to access some providers. |
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| 251 | 251 | | |
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| 252 | 252 | | (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 providers staff. |
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| 253 | 253 | | |
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| 254 | 254 | | (11) Identification of providers who no longer accept new patients for some or all of the plans products. |
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| 255 | 255 | | |
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| 256 | 256 | | (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. |
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| 257 | 257 | | |
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| 258 | 258 | | (13) All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c). |
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| 259 | 259 | | |
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| 260 | 260 | | (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: |
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| 261 | 261 | | |
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| 262 | 262 | | (1) The providers name, practice location or locations, and contact information. |
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| 263 | 263 | | |
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| 264 | 264 | | (2) Type of practitioner. |
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| 265 | 265 | | |
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| 266 | 266 | | (3) National Provider Identifier number. |
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| 267 | 267 | | |
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| 268 | 268 | | (4) California license number and type of license, if applicable. |
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| 269 | 269 | | |
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| 270 | 270 | | (5) The area of specialty, including board certification, or other accreditation, if any. |
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| 271 | 271 | | |
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| 272 | 272 | | (6) The providers office email address, if available. |
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| 273 | 273 | | |
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| 274 | 274 | | (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. |
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| 275 | 275 | | |
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| 276 | 276 | | (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. |
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| 277 | 277 | | |
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| 278 | 278 | | (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 providers staff. |
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| 279 | 279 | | |
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| 280 | 280 | | (10) Identification of providers who no longer accept new patients for some or all of the plans products. |
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| 281 | 281 | | |
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| 282 | 282 | | (11) All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c). |
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| 283 | 283 | | |
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| 284 | 284 | | (j) (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: |
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| 285 | 285 | | |
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| 286 | 286 | | (A) The provider is not accepting new patients. |
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| 287 | 287 | | |
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| 288 | 288 | | (B) If the provider had previously not accepted new patients, the provider is currently accepting new patients. |
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| 289 | 289 | | |
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| 290 | 290 | | (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 plans directory or directories. |
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| 291 | 291 | | |
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| 292 | 292 | | (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. |
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| 293 | 293 | | |
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| 294 | 294 | | (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. |
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| 295 | 295 | | |
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| 296 | 296 | | (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. |
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| 297 | 297 | | |
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| 298 | 298 | | (3) By July 31, 2017, or 12 months after the date provider directory standards are developed under this subdivision, whichever occurs later, a plan shall use the standards developed by the department for each product offered by the plan. |
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| 299 | 299 | | |
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| 300 | 300 | | (l) (1) A plan shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the plans 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 plan shall notify all contracted providers described in subdivisions (h) and (i) as follows: |
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| 301 | 301 | | |
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| 302 | 302 | | (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 plan shall notify each provider at least once every six months. |
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| 303 | 303 | | |
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| 304 | 304 | | (B) For all other providers described in subdivision (h) who are not subject to the requirements of subparagraph (A), the plan shall notify its contracted providers to ensure that all of the providers are contacted by the plan at least once annually. |
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| 305 | 305 | | |
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| 306 | 306 | | (2) The notification shall include all of the following: |
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| 307 | 307 | | |
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| 308 | 308 | | (A) The information the plan has in its directory or directories regarding the provider or provider group, including a list of networks and plan products that include the contracted provider or provider group. |
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| 309 | 309 | | |
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| 310 | 310 | | (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). |
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| 311 | 311 | | |
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| 312 | 312 | | (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). |
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| 313 | 313 | | |
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| 314 | 314 | | (3) The plan 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 or provider group is accepting new patients for each plan product. |
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| 315 | 315 | | |
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| 316 | 316 | | (4) If the plan 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 plan shall take no more than 15 business days to verify whether the providers information is correct or requires updates. The plan shall document the receipt and outcome of each attempt to verify the information. If the plan is unable to verify whether the providers information is correct or requires updates, the plan shall notify the provider 10 business days in advance of removal that the provider will be removed from the provider directory or directories. The provider shall be removed from the provider 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 they respond before the end of the 10-business-day notice period. |
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| 317 | 317 | | |
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| 318 | 318 | | (5) General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4). |
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| 319 | 319 | | |
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| 320 | 320 | | (m) A plan 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. |
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| 321 | 321 | | |
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| 322 | 322 | | (1) The policies and procedures described under this subdivision shall be submitted by a plan annually to the department for approval and in a format described by the department pursuant to Section 1367.035. |
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| 323 | 323 | | |
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| 324 | 324 | | (2) Every health care service plan 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 health care service plan. 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 health care service plan. |
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| 325 | 325 | | |
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| 326 | 326 | | (3) The plan shall establish and maintain a process for enrollees, potential enrollees, other providers, and the public to identify and report possible inaccurate, incomplete, or misleading information currently listed in the plans provider directory or directories. This process shall, at a minimum, include a telephone number and a dedicated email address at which the plan will accept these reports, as well as a hyperlink on the plans provider directory Internet Web site internet website linking to a form where the information can be reported directly to the plan through its Internet Web site. internet website. |
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| 327 | 327 | | |
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| 328 | 328 | | (n) (1) This section does not prohibit a plan from requiring its provider groups or contracting specialized health care service plans to provide information to the plan that is required by the plan to satisfy the requirements of this section for each of the providers that contract with the provider group or contracting specialized health care service plan. This responsibility shall be specifically documented in a written contract between the plan and the provider group or contracting specialized health care service plan. |
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| 329 | 329 | | |
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| 330 | 330 | | (2) If a plan requires its contracting provider groups or contracting specialized health care service plans to provide the plan with information described in paragraph (1), the plan shall continue to retain responsibility for ensuring that the requirements of this section are satisfied. |
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| 331 | 331 | | |
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| 332 | 332 | | (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. |
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| 333 | 333 | | |
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| 334 | 334 | | (4) A provider group is not subject to the payment delay described in subdivision (p) if all of the following occurs: |
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| 335 | 335 | | |
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| 336 | 336 | | (A) A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates. |
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| 337 | 337 | | |
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| 338 | 338 | | (B) The provider group documents its efforts to verify the providers information. |
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| 339 | 339 | | |
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| 340 | 340 | | (C) The provider group reports to the plan that the provider should be deleted from the provider group in the plan directory or directories. |
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| 341 | 341 | | |
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| 342 | 342 | | (5) Section 1375.7, known as the Health Care Providers Bill of Rights, applies to any material change to a provider contract pursuant to this section. |
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| 343 | 343 | | |
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| 344 | 344 | | (o) (1) Whenever a health care service plan receives a report indicating that information listed in its provider directory or directories is inaccurate, the plan 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. |
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| 345 | 345 | | |
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| 346 | 346 | | (2) When investigating a report regarding its provider directory or directories, the plan shall, at a minimum, do the following: |
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| 347 | 347 | | |
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| 348 | 348 | | (A) Contact the affected provider no later than five business days following receipt of the report. |
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| 349 | 349 | | |
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| 350 | 350 | | (B) Document the receipt and outcome of each report. The documentation shall include the providers name, location, and a description of the plans investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories. |
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| 351 | 351 | | |
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| 352 | 352 | | (C) If changes to a plans provider directory or directories are required as a result of the plans 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. |
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| 353 | 353 | | |
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| 354 | 354 | | (p) (1) Notwithstanding Sections 1371 and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (A) or (B), if the provider or provider group fails to respond to the plans attempts to verify the providers or provider groups information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups information is correct or requires updates. A plan 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. |
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| 355 | 355 | | |
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| 356 | 356 | | (A) For a provider or provider group that receives compensation on a capitated or prepaid basis, the plan may delay no more than 50 percent of the next scheduled capitation payment for up to one calendar month. |
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| 357 | 357 | | |
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| 358 | 358 | | (B) For any claims payment made to a provider or provider group, the plan may delay the claims payment for up to one calendar month beginning on the first day of the following month. |
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| 359 | 359 | | |
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| 360 | 360 | | (2) A plan shall notify the provider or provider group 10 business days before it seeks to delay payment or reimbursement to a provider or provider group pursuant to this subdivision. If the plan delays a payment or reimbursement pursuant to this subdivision, the plan 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: |
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| 361 | 361 | | |
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| 362 | 362 | | (A) No later than three business days following the date on which the plan receives the information required to be submitted by the provider or provider group pursuant to subdivision (l). |
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| 363 | 363 | | |
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| 364 | 364 | | (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 plan pursuant to subdivision (l). |
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| 365 | 365 | | |
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| 366 | 366 | | (3) A plan may terminate a contract for a pattern or repeated failure of the provider or provider group to alert the plan to a change in the information required to be in the directory or directories pursuant to this section. |
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| 367 | 367 | | |
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| 368 | 368 | | (4) A plan 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 pursuant to Section 1367.035. 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). |
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| 369 | 369 | | |
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| 370 | 370 | | (5) With respect to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance. |
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| 371 | 371 | | |
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| 372 | 372 | | (q) In circumstances where the department finds that an enrollee reasonably relied upon materially inaccurate, incomplete, or misleading information contained in a health plans provider directory or directories, the department may require the health plan to provide coverage for all covered health care services provided to the enrollee and to reimburse the enrollee for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollees plan contract. Prior to requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollees plan contract. In those circumstances, the fact that the services were rendered or delivered by a noncontracting or out-of-plan provider shall not be used as a basis to deny reimbursement to the enrollee. |
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| 373 | 373 | | |
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| 374 | 374 | | (r) Whenever a plan 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 plan shall file an amendment to the plan application with the department consistent with subdivision (f) of Section 1300.52 of Title 28 of the California Code of Regulations. |
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| 375 | 375 | | |
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| 376 | 376 | | (s) This section applies to plans with Medi-Cal managed care contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code to the extent consistent with federal law and guidance and state law guidance issued after January 1, 2016. Notwithstanding any other provision to the contrary in a plan contract with the State Department of Health Care Services, and to the extent consistent with federal law and guidance and state guidance issued after January 1, 2016, a Medi-Cal managed care plan that complies with the requirements of this section shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d). |
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| 377 | 377 | | |
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| 378 | 378 | | (t) A health plan 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 of the Insurance Code shall meet the requirements of this section. |
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| 379 | 379 | | |
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| 380 | 380 | | (u) This section shall not be construed to alter a providers obligation to provide health care services to an enrollee pursuant to the providers contract with the plan. |
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| 381 | 381 | | |
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| 382 | 382 | | (v) As part of the departments routine examination of the fiscal and administrative affairs of a health care service plan pursuant to Section 1382, the department shall include a review of the health care service plans compliance with subdivision (p). |
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| 383 | 383 | | |
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| 384 | 384 | | (w) For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers. |
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| 385 | 385 | | |
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| 386 | 386 | | SEC. 4. Section 1374.72 of the Health and Safety Code is amended to read:1374.72. (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an enrollee or subscriber under this chapter.(4) For purposes of this section, health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 10144.51 of the Insurance Code and Section 1374.73. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological associate, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 1374.721.(6) A health care service plan shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations by the health care service plan concerning service intensity, level of care placement, continued stay, and transfer or discharge of enrollees diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 1374.721. This paragraph does not deprive an enrollee of the other protections of this chapter, including, but not limited to, grievances, appeals, independent medical review, discharge, transfer, and continuity of care.(8) A health care service plan that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the plans subsequent rescission, cancellation, or modification of the enrollees or subscribers contract, or the plans subsequent determination that it did not make an accurate determination of the enrollees or subscribers eligibility. This section shall not be construed to expand or alter the benefits available to the enrollee or subscriber under a plan.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the plan contract includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the plan contract, shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum annual and lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the health care service plan shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the enrollee within geographic and timely access standards. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider.(e) This section shall not apply to contracts entered into pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, between the State Department of Health Care Services and a health care service plan for enrolled Medi-Cal beneficiaries.(f) (1) For the purpose of compliance with this section, a health care service plan may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health care service plan or mental health plan, and shall not be required to obtain an additional or specialized license for this purpose.(2) A health care service plan shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, health care service plan contracts that provide benefits to enrollees through preferred provider contracting arrangements are not precluded from requiring enrollees who reside or work in geographic areas served by specialized health care service plans or mental health plans to secure all or part of their mental health services within those geographic areas served by specialized health care service plans or mental health plans, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 1374.76 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure plan compliance with this chapter.(h) A health care service plan shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A health care service plan shall not adopt, impose, or enforce terms in its plan contracts or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section. |
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| 387 | 387 | | |
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| 388 | 388 | | SEC. 4. Section 1374.72 of the Health and Safety Code is amended to read: |
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| 389 | 389 | | |
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| 390 | 390 | | ### SEC. 4. |
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| 391 | 391 | | |
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| 392 | 392 | | 1374.72. (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an enrollee or subscriber under this chapter.(4) For purposes of this section, health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 10144.51 of the Insurance Code and Section 1374.73. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological associate, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 1374.721.(6) A health care service plan shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations by the health care service plan concerning service intensity, level of care placement, continued stay, and transfer or discharge of enrollees diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 1374.721. This paragraph does not deprive an enrollee of the other protections of this chapter, including, but not limited to, grievances, appeals, independent medical review, discharge, transfer, and continuity of care.(8) A health care service plan that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the plans subsequent rescission, cancellation, or modification of the enrollees or subscribers contract, or the plans subsequent determination that it did not make an accurate determination of the enrollees or subscribers eligibility. This section shall not be construed to expand or alter the benefits available to the enrollee or subscriber under a plan.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the plan contract includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the plan contract, shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum annual and lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the health care service plan shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the enrollee within geographic and timely access standards. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider.(e) This section shall not apply to contracts entered into pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, between the State Department of Health Care Services and a health care service plan for enrolled Medi-Cal beneficiaries.(f) (1) For the purpose of compliance with this section, a health care service plan may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health care service plan or mental health plan, and shall not be required to obtain an additional or specialized license for this purpose.(2) A health care service plan shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, health care service plan contracts that provide benefits to enrollees through preferred provider contracting arrangements are not precluded from requiring enrollees who reside or work in geographic areas served by specialized health care service plans or mental health plans to secure all or part of their mental health services within those geographic areas served by specialized health care service plans or mental health plans, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 1374.76 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure plan compliance with this chapter.(h) A health care service plan shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A health care service plan shall not adopt, impose, or enforce terms in its plan contracts or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section. |
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| 393 | 393 | | |
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| 394 | 394 | | 1374.72. (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an enrollee or subscriber under this chapter.(4) For purposes of this section, health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 10144.51 of the Insurance Code and Section 1374.73. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological associate, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 1374.721.(6) A health care service plan shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations by the health care service plan concerning service intensity, level of care placement, continued stay, and transfer or discharge of enrollees diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 1374.721. This paragraph does not deprive an enrollee of the other protections of this chapter, including, but not limited to, grievances, appeals, independent medical review, discharge, transfer, and continuity of care.(8) A health care service plan that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the plans subsequent rescission, cancellation, or modification of the enrollees or subscribers contract, or the plans subsequent determination that it did not make an accurate determination of the enrollees or subscribers eligibility. This section shall not be construed to expand or alter the benefits available to the enrollee or subscriber under a plan.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the plan contract includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the plan contract, shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum annual and lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the health care service plan shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the enrollee within geographic and timely access standards. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider.(e) This section shall not apply to contracts entered into pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, between the State Department of Health Care Services and a health care service plan for enrolled Medi-Cal beneficiaries.(f) (1) For the purpose of compliance with this section, a health care service plan may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health care service plan or mental health plan, and shall not be required to obtain an additional or specialized license for this purpose.(2) A health care service plan shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, health care service plan contracts that provide benefits to enrollees through preferred provider contracting arrangements are not precluded from requiring enrollees who reside or work in geographic areas served by specialized health care service plans or mental health plans to secure all or part of their mental health services within those geographic areas served by specialized health care service plans or mental health plans, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 1374.76 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure plan compliance with this chapter.(h) A health care service plan shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A health care service plan shall not adopt, impose, or enforce terms in its plan contracts or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section. |
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| 395 | 395 | | |
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| 396 | 396 | | 1374.72. (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an enrollee or subscriber under this chapter.(4) For purposes of this section, health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 10144.51 of the Insurance Code and Section 1374.73. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological associate, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 1374.721.(6) A health care service plan shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations by the health care service plan concerning service intensity, level of care placement, continued stay, and transfer or discharge of enrollees diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 1374.721. This paragraph does not deprive an enrollee of the other protections of this chapter, including, but not limited to, grievances, appeals, independent medical review, discharge, transfer, and continuity of care.(8) A health care service plan that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the plans subsequent rescission, cancellation, or modification of the enrollees or subscribers contract, or the plans subsequent determination that it did not make an accurate determination of the enrollees or subscribers eligibility. This section shall not be construed to expand or alter the benefits available to the enrollee or subscriber under a plan.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the plan contract includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the plan contract, shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum annual and lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the health care service plan shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the enrollee within geographic and timely access standards. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider.(e) This section shall not apply to contracts entered into pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, between the State Department of Health Care Services and a health care service plan for enrolled Medi-Cal beneficiaries.(f) (1) For the purpose of compliance with this section, a health care service plan may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health care service plan or mental health plan, and shall not be required to obtain an additional or specialized license for this purpose.(2) A health care service plan shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, health care service plan contracts that provide benefits to enrollees through preferred provider contracting arrangements are not precluded from requiring enrollees who reside or work in geographic areas served by specialized health care service plans or mental health plans to secure all or part of their mental health services within those geographic areas served by specialized health care service plans or mental health plans, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 1374.76 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure plan compliance with this chapter.(h) A health care service plan shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A health care service plan shall not adopt, impose, or enforce terms in its plan contracts or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section. |
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| 397 | 397 | | |
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| 398 | 398 | | |
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| 399 | 399 | | |
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| 400 | 400 | | 1374.72. (a) (1) Every health care service plan contract issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c). |
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| 401 | 401 | | |
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| 402 | 402 | | (2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties. |
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| 403 | 403 | | |
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| 404 | 404 | | (3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: |
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| 405 | 405 | | |
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| 406 | 406 | | (i) In accordance with the generally accepted standards of mental health and substance use disorder care. |
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| 407 | 407 | | |
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| 408 | 408 | | (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. |
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| 409 | 409 | | |
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| 410 | 410 | | (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. |
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| 411 | 411 | | |
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| 412 | 412 | | (B) This paragraph does not limit in any way the independent medical review rights of an enrollee or subscriber under this chapter. |
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| 413 | 413 | | |
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| 414 | 414 | | (4) For purposes of this section, health care provider means any of the following: |
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| 415 | 415 | | |
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| 416 | 416 | | (A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code. |
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| 417 | 417 | | |
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| 418 | 418 | | (B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code. |
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| 419 | 419 | | |
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| 420 | 420 | | (C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 10144.51 of the Insurance Code and Section 1374.73. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code. |
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| 421 | 421 | | |
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| 422 | 422 | | (D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code. |
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| 423 | 423 | | |
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| 424 | 424 | | (E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code. |
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| 425 | 425 | | |
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| 426 | 426 | | (F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code. |
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| 427 | 427 | | |
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| 428 | 428 | | (G) A registered psychological associate, as described in Section 2913 of the Business and Professions Code. |
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| 429 | 429 | | |
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| 430 | 430 | | (H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code. |
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| 431 | 431 | | |
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| 432 | 432 | | (5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 1374.721. |
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| 433 | 433 | | |
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| 434 | 434 | | (6) A health care service plan shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment. |
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| 435 | 435 | | |
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| 436 | 436 | | (7) All medical necessity determinations by the health care service plan concerning service intensity, level of care placement, continued stay, and transfer or discharge of enrollees diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 1374.721. This paragraph does not deprive an enrollee of the other protections of this chapter, including, but not limited to, grievances, appeals, independent medical review, discharge, transfer, and continuity of care. |
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| 437 | 437 | | |
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| 438 | 438 | | (8) A health care service plan that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the plans subsequent rescission, cancellation, or modification of the enrollees or subscribers contract, or the plans subsequent determination that it did not make an accurate determination of the enrollees or subscribers eligibility. This section shall not be construed to expand or alter the benefits available to the enrollee or subscriber under a plan. |
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| 439 | 439 | | |
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| 440 | 440 | | (b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following: |
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| 441 | 441 | | |
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| 442 | 442 | | (1) Basic health care services, as defined in subdivision (b) of Section 1345. |
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| 443 | 443 | | |
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| 444 | 444 | | (2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment. |
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| 445 | 445 | | |
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| 446 | 446 | | (3) Prescription drugs, if the plan contract includes coverage for prescription drugs. |
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| 447 | 447 | | |
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| 448 | 448 | | (c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the plan contract, shall include, but not be limited to, all of the following patient financial responsibilities: |
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| 449 | 449 | | |
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| 450 | 450 | | (1) Maximum annual and lifetime benefits, if not prohibited by applicable law. |
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| 451 | 451 | | |
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| 452 | 452 | | (2) Copayments and coinsurance. |
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| 453 | 453 | | |
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| 454 | 454 | | (3) Individual and family deductibles. |
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| 455 | 455 | | |
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| 456 | 456 | | (4) Out-of-pocket maximums. |
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| 457 | 457 | | |
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| 458 | 458 | | (d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the health care service plan shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the enrollee within geographic and timely access standards. The enrollee shall pay no more than the same cost sharing that the enrollee would pay for the same covered services received from an in-network provider. |
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| 459 | 459 | | |
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| 460 | 460 | | (e) This section shall not apply to contracts entered into pursuant to Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code, between the State Department of Health Care Services and a health care service plan for enrolled Medi-Cal beneficiaries. |
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| 461 | 461 | | |
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| 462 | 462 | | (f) (1) For the purpose of compliance with this section, a health care service plan may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health care service plan or mental health plan, and shall not be required to obtain an additional or specialized license for this purpose. |
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| 463 | 463 | | |
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| 464 | 464 | | (2) A health care service plan shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, health care service plan contracts that provide benefits to enrollees through preferred provider contracting arrangements are not precluded from requiring enrollees who reside or work in geographic areas served by specialized health care service plans or mental health plans to secure all or part of their mental health services within those geographic areas served by specialized health care service plans or mental health plans, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards. |
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| 465 | 465 | | |
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| 466 | 466 | | (3) Notwithstanding any other law, in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 1374.76 of this code, and Section 2052 of the Business and Professions Code. |
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| 467 | 467 | | |
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| 468 | 468 | | (g) This section shall not be construed to deny or restrict in any way the departments authority to ensure plan compliance with this chapter. |
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| 469 | 469 | | |
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| 470 | 470 | | (h) A health care service plan shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program. |
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| 471 | 471 | | |
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| 472 | 472 | | (i) A health care service plan shall not adopt, impose, or enforce terms in its plan contracts or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section. |
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| 473 | 473 | | |
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| 474 | 474 | | SEC. 5. Section 1374.73 of the Health and Safety Code is amended to read:1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 1374.72.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any of the following:(1) A specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(2) A health care service plan contract in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 475 | 475 | | |
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| 476 | 476 | | SEC. 5. Section 1374.73 of the Health and Safety Code is amended to read: |
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| 477 | 477 | | |
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| 478 | 478 | | ### SEC. 5. |
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| 479 | 479 | | |
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| 480 | 480 | | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 1374.72.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any of the following:(1) A specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(2) A health care service plan contract in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 481 | 481 | | |
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| 482 | 482 | | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 1374.72.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any of the following:(1) A specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(2) A health care service plan contract in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 483 | 483 | | |
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| 484 | 484 | | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 1374.72.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any of the following:(1) A specialized health care service plan that does not deliver mental health or behavioral health services to enrollees.(2) A health care service plan contract in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 1374.72.(f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 485 | 485 | | |
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| 486 | 486 | | |
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| 487 | 487 | | |
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| 488 | 488 | | 1374.73. (a) (1) Every health care service plan contract that provides hospital, medical, or surgical coverage shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 1374.72. |
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| 489 | 489 | | |
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| 490 | 490 | | (2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health plans will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152). |
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| 491 | 491 | | |
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| 492 | 492 | | (3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code. |
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| 493 | 493 | | |
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| 494 | 494 | | (4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations. |
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| 495 | 495 | | |
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| 496 | 496 | | (b) Every health care service plan subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health care service plan is not prevented from selectively contracting with providers within these requirements. |
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| 497 | 497 | | |
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| 498 | 498 | | (c) For the purposes of this section, the following definitions shall apply: |
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| 499 | 499 | | |
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| 500 | 500 | | (1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria: |
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| 501 | 501 | | |
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| 502 | 502 | | (A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code. |
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| 503 | 503 | | |
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| 504 | 504 | | (B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following: |
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| 505 | 505 | | |
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| 506 | 506 | | (i) A qualified autism service provider. |
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| 507 | 507 | | |
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| 508 | 508 | | (ii) A qualified autism service professional supervised by the qualified autism service provider. |
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| 509 | 509 | | |
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| 510 | 510 | | (iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional. |
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| 511 | 511 | | |
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| 512 | 512 | | (C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following: |
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| 513 | 513 | | |
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| 514 | 514 | | (i) Describes the patients behavioral health impairments or developmental challenges that are to be treated. |
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| 515 | 515 | | |
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| 516 | 516 | | (ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported. |
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| 517 | 517 | | |
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| 518 | 518 | | (iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism. |
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| 519 | 519 | | |
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| 520 | 520 | | (iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate. |
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| 521 | 521 | | |
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| 522 | 522 | | (D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the health care service plan upon request. |
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| 523 | 523 | | |
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| 524 | 524 | | (2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 1374.72. |
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| 525 | 525 | | |
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| 526 | 526 | | |
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| 527 | 527 | | |
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| 528 | 528 | | (3)Qualified autism service provider means either of the following: |
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| 529 | 529 | | |
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| 530 | 530 | | |
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| 531 | 531 | | |
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| 532 | 532 | | (A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified. |
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| 533 | 533 | | |
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| 534 | 534 | | |
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| 535 | 535 | | |
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| 536 | 536 | | (B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee. |
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| 537 | 537 | | |
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| 538 | 538 | | |
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| 539 | 539 | | |
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| 540 | 540 | | (4)Qualified autism service professional means an individual who meets all of the following criteria: |
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| 541 | 541 | | |
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| 542 | 542 | | |
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| 543 | 543 | | |
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| 544 | 544 | | (A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. |
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| 545 | 545 | | |
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| 546 | 546 | | |
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| 547 | 547 | | |
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| 548 | 548 | | (B)Is supervised by a qualified autism service provider. |
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| 549 | 549 | | |
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| 550 | 550 | | |
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| 551 | 551 | | |
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| 552 | 552 | | (C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider. |
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| 553 | 553 | | |
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| 554 | 554 | | |
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| 555 | 555 | | |
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| 556 | 556 | | (D)Is either of the following: |
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| 557 | 557 | | |
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| 558 | 558 | | |
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| 559 | 559 | | |
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| 560 | 560 | | (i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program. |
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| 561 | 561 | | |
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| 562 | 562 | | |
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| 563 | 563 | | |
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| 564 | 564 | | (ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology. |
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| 565 | 565 | | |
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| 566 | 566 | | |
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| 567 | 567 | | |
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| 568 | 568 | | (E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code. |
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| 569 | 569 | | |
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| 570 | 570 | | |
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| 571 | 571 | | |
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| 572 | 572 | | (ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional. |
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| 573 | 573 | | |
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| 574 | 574 | | |
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| 575 | 575 | | |
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| 576 | 576 | | (F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 577 | 577 | | |
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| 578 | 578 | | |
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| 579 | 579 | | |
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| 580 | 580 | | (5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria: |
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| 581 | 581 | | |
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| 582 | 582 | | |
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| 583 | 583 | | |
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| 584 | 584 | | (A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice. |
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| 585 | 585 | | |
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| 586 | 586 | | |
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| 587 | 587 | | |
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| 588 | 588 | | (B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider. |
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| 589 | 589 | | |
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| 590 | 590 | | |
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| 591 | 591 | | |
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| 592 | 592 | | (C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations. |
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| 593 | 593 | | |
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| 594 | 594 | | |
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| 595 | 595 | | |
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| 596 | 596 | | (D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers. |
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| 597 | 597 | | |
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| 598 | 598 | | |
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| 599 | 599 | | |
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| 600 | 600 | | (E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 601 | 601 | | |
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| 602 | 602 | | |
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| 603 | 603 | | |
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| 604 | 604 | | (2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code. |
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| 605 | 605 | | |
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| 606 | 606 | | (3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code. |
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| 607 | 607 | | |
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| 608 | 608 | | (4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code. |
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| 609 | 609 | | |
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| 610 | 610 | | (d) This section shall does not apply to any of the following: |
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| 611 | 611 | | |
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| 612 | 612 | | (1) A specialized health care service plan that does not deliver mental health or behavioral health services to enrollees. |
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| 613 | 613 | | |
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| 614 | 614 | | (2) A health care service plan contract in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code). |
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| 615 | 615 | | |
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| 616 | 616 | | (e) This section does not limit the obligation to provide services under Section 1374.72. |
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| 617 | 617 | | |
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| 618 | 618 | | (f) As provided in Section 1374.72 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health care service plan may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 619 | 619 | | |
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| 620 | 620 | | SEC. 6. Section 10133.15 of the Insurance Code is amended to read:10133.15. (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 insurers 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 insurers Internet Web site internet website 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 insurers public Internet Web site internet website 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 insurers public Internet Web site 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) 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 insurers 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 providers 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 insurers Internet Web site. internet website.(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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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, if any, on the providers staff.(11) Identification of providers who no longer accept new patients for some or all of the insurers 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 providers 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 providers 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, if any, on the providers staff.(10) Identification of providers who no longer accept new patients for some or all of the insurers 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 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 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 insurers 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 insurers 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 providers 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 providers 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 they respond 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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory Internet Web site internet website linking to a form where the information can be reported directly to the insurer through its Internet Web site. internet website.(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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to an insurers provider directory or directories are required as a result of the insurers 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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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 insurers 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 insureds 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 insureds 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) This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.(u) As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers 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. |
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| 621 | 621 | | |
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| 622 | 622 | | SEC. 6. Section 10133.15 of the Insurance Code is amended to read: |
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| 623 | 623 | | |
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| 624 | 624 | | ### SEC. 6. |
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| 625 | 625 | | |
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| 626 | 626 | | 10133.15. (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 insurers 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 insurers Internet Web site internet website 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 insurers public Internet Web site internet website 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 insurers public Internet Web site 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) 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 insurers 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 providers 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 insurers Internet Web site. internet website.(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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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, if any, on the providers staff.(11) Identification of providers who no longer accept new patients for some or all of the insurers 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 providers 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 providers 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, if any, on the providers staff.(10) Identification of providers who no longer accept new patients for some or all of the insurers 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 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 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 insurers 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 insurers 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 providers 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 providers 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 they respond 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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory Internet Web site internet website linking to a form where the information can be reported directly to the insurer through its Internet Web site. internet website.(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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to an insurers provider directory or directories are required as a result of the insurers 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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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 insurers 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 insureds 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 insureds 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) This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.(u) As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers 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. |
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| 628 | 628 | | 10133.15. (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 insurers 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 insurers Internet Web site internet website 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 insurers public Internet Web site internet website 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 insurers public Internet Web site 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) 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 insurers 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 providers 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 insurers Internet Web site. internet website.(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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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, if any, on the providers staff.(11) Identification of providers who no longer accept new patients for some or all of the insurers 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 providers 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 providers 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, if any, on the providers staff.(10) Identification of providers who no longer accept new patients for some or all of the insurers 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 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 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 insurers 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 insurers 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 providers 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 providers 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 they respond 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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory Internet Web site internet website linking to a form where the information can be reported directly to the insurer through its Internet Web site. internet website.(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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to an insurers provider directory or directories are required as a result of the insurers 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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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 insurers 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 insureds 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 insureds 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) This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.(u) As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers 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. |
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| 629 | 629 | | |
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| 630 | 630 | | 10133.15. (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 insurers 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 insurers Internet Web site internet website 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 insurers public Internet Web site internet website 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 insurers public Internet Web site 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) 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 insurers 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 providers 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 insurers Internet Web site. internet website.(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 providers 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 providers 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, 4999.200 of the Business and Professions Code, 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 a 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, if any, on the providers staff.(11) Identification of providers who no longer accept new patients for some or all of the insurers 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 providers 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 providers 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, if any, on the providers staff.(10) Identification of providers who no longer accept new patients for some or all of the insurers 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 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 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 insurers 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 insurers 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 providers 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 providers 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 they respond 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 this subdivision 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 insurers provider directory or directories. This process 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 insurers provider directory Internet Web site internet website linking to a form where the information can be reported directly to the insurer through its Internet Web site. internet website.(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 groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates.(B) The provider group documents its efforts to verify the providers information.(C) The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers 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 providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories.(C) If changes to an insurers provider directory or directories are required as a result of the insurers 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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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 paragraph (1), 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 insurers 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 insureds 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 insureds 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) This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer.(u) As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers 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. |
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| 631 | 631 | | |
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| 632 | 632 | | |
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| 633 | 633 | | |
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| 634 | 634 | | 10133.15. (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 insurers 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. |
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| 635 | 635 | | |
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| 636 | 636 | | (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). |
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| 637 | 637 | | |
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| 638 | 638 | | (c) (1) An online provider directory or directories shall be available on the insurers Internet Web site internet website 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. |
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| 639 | 639 | | |
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| 640 | 640 | | (2) The online provider directory or directories shall be accessible on the insurers public Internet Web site internet website 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 insurers public Internet Web site 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. |
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| 641 | 641 | | |
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| 642 | 642 | | (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 insurers 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. |
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| 643 | 643 | | |
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| 644 | 644 | | (2) An insurer shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law. |
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| 645 | 645 | | |
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| 646 | 646 | | (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: |
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| 647 | 647 | | |
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| 648 | 648 | | (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. |
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| 649 | 649 | | |
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| 650 | 650 | | (B) A contracted provider is no longer under contract for a particular product. |
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| 651 | 651 | | |
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| 652 | 652 | | (C) A providers practice location or other information required under subdivision (h) or (i) has changed. |
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| 653 | 653 | | |
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| 654 | 654 | | (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. |
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| 655 | 655 | | |
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| 656 | 656 | | (E) Any other information that affects the content or accuracy of the provider directory or directories. |
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| 657 | 657 | | |
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| 658 | 658 | | (2) Upon confirmation of any of the following, the insurer shall delete a provider from the directory or directories when: |
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| 659 | 659 | | |
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| 660 | 660 | | (A) A provider has retired or otherwise has ceased to practice. |
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| 661 | 661 | | |
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| 662 | 662 | | (B) A provider or provider group is no longer under contract with the insurer for any reason. |
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| 663 | 663 | | |
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| 664 | 664 | | (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. |
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| 665 | 665 | | |
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| 666 | 666 | | (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 insurers Internet Web site. internet website. |
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| 667 | 667 | | |
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| 668 | 668 | | (g) The provider directory or directories shall include the following disclosures informing insureds that they are entitled to both of the following: |
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| 669 | 669 | | |
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| 670 | 670 | | (1) Language interpreter services, at no cost to the insured, including how to obtain interpretation services in accordance with Section 10133.8. |
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| 671 | 671 | | |
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| 672 | 672 | | (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. |
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| 673 | 673 | | |
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| 674 | 674 | | (h) The insurer and a specialized mental health insurer shall include all of the following information in the provider directory or directories: |
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| 675 | 675 | | |
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| 676 | 676 | | (1) The providers name, practice location or locations, and contact information. |
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| 677 | 677 | | |
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| 678 | 678 | | (2) Type of practitioner. |
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| 679 | 679 | | |
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| 680 | 680 | | (3) National Provider Identifier number. |
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| 681 | 681 | | |
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| 682 | 682 | | (4) California license number and type of license. |
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| 683 | 683 | | |
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| 684 | 684 | | (5) The area of specialty, including board certification, if any. |
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| 685 | 685 | | |
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| 686 | 686 | | (6) The providers office email address, if available. |
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| 687 | 687 | | |
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| 688 | 688 | | (7) The name of each affiliated provider group currently under contract with the insurer through which the provider sees enrollees. |
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| 689 | 689 | | |
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| 690 | 690 | | (8) A listing for each of the following providers that are under contract with the insurer: |
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| 691 | 691 | | |
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| 692 | 692 | | (A) For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the insurer. |
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| 693 | 693 | | |
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| 694 | 694 | | (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, 4999.200 of the Business and Professions Code, nurse midwives, and dentists. |
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| 695 | 695 | | |
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| 696 | 696 | | (C) For federally qualified health centers or primary care clinics, the name of the federally qualified health center or clinic. |
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| 697 | 697 | | |
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| 698 | 698 | | (D) For any a 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. |
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| 699 | 699 | | |
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| 700 | 700 | | (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. |
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| 701 | 701 | | |
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| 702 | 702 | | (F) Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services. |
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| 703 | 703 | | |
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| 704 | 704 | | (9) The provider directory or directories may note that authorization or referral may be required to access some providers. |
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| 705 | 705 | | |
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| 706 | 706 | | (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, if any, on the providers staff. |
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| 707 | 707 | | |
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| 708 | 708 | | (11) Identification of providers who no longer accept new patients for some or all of the insurers products. |
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| 709 | 709 | | |
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| 710 | 710 | | (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. |
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| 711 | 711 | | |
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| 712 | 712 | | (13) All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c). |
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| 713 | 713 | | |
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| 714 | 714 | | (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: |
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| 715 | 715 | | |
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| 716 | 716 | | (1) The providers name, practice location or locations, and contact information. |
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| 717 | 717 | | |
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| 718 | 718 | | (2) Type of practitioner. |
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| 719 | 719 | | |
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| 720 | 720 | | (3) National Provider Identifier number. |
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| 721 | 721 | | |
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| 722 | 722 | | (4) California license number and type of license, if applicable. |
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| 723 | 723 | | |
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| 724 | 724 | | (5) The area of specialty, including board certification, or other accreditation, if any. |
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| 725 | 725 | | |
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| 726 | 726 | | (6) The providers office email address, if available. |
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| 727 | 727 | | |
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| 728 | 728 | | (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. |
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| 729 | 729 | | |
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| 730 | 730 | | (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. |
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| 731 | 731 | | |
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| 732 | 732 | | (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, if any, on the providers staff. |
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| 733 | 733 | | |
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| 734 | 734 | | (10) Identification of providers who no longer accept new patients for some or all of the insurers products. |
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| 735 | 735 | | |
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| 736 | 736 | | (11) All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c). |
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| 737 | 737 | | |
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| 738 | 738 | | (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 occurs: |
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| 739 | 739 | | |
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| 740 | 740 | | (A) The provider is not accepting new patients. |
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| 741 | 741 | | |
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| 742 | 742 | | (B) If the provider had previously not accepted new patients, the provider is currently accepting new patients. |
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| 743 | 743 | | |
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| 744 | 744 | | (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 insurers directory or directories. |
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| 745 | 745 | | |
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| 746 | 746 | | (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. |
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| 747 | 747 | | |
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| 748 | 748 | | (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. |
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| 749 | 749 | | |
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| 750 | 750 | | (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. |
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| 751 | 751 | | |
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| 752 | 752 | | (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. |
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| 753 | 753 | | |
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| 754 | 754 | | (l) (1) An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurers 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: |
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| 755 | 755 | | |
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| 756 | 756 | | (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. |
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| 757 | 757 | | |
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| 758 | 758 | | (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. |
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| 759 | 759 | | |
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| 760 | 760 | | (2) The notification shall include all of the following: |
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| 761 | 761 | | |
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| 762 | 762 | | (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. |
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| 763 | 763 | | |
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| 764 | 764 | | (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). |
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| 765 | 765 | | |
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| 766 | 766 | | (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). |
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| 767 | 767 | | |
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| 768 | 768 | | (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. |
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| 769 | 769 | | |
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| 770 | 770 | | (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 providers 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 providers 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 they respond before the end of the 10-business day notice period. |
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| 771 | 771 | | |
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| 772 | 772 | | (5) General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4). |
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| 773 | 773 | | |
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| 774 | 774 | | (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. |
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| 775 | 775 | | |
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| 776 | 776 | | (1) The policies and procedures described under this subdivision shall be submitted by an insurer annually to the department for approval and in a format described by the department. |
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| 777 | 777 | | |
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| 778 | 778 | | (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. |
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| 779 | 779 | | |
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| 780 | 780 | | (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 insurers provider directory or directories. This process 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 insurers provider directory Internet Web site internet website linking to a form where the information can be reported directly to the insurer through its Internet Web site. internet website. |
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| 781 | 781 | | |
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| 782 | 782 | | (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. |
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| 783 | 783 | | |
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| 784 | 784 | | (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. |
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| 785 | 785 | | |
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| 786 | 786 | | (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. |
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| 787 | 787 | | |
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| 788 | 788 | | (4) A provider group is not subject to the payment delay described in subdivision (p) if all of the following occurs: |
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| 789 | 789 | | |
|---|
| 790 | 790 | | (A) A provider does not respond to the provider groups attempt to verify the providers information. As used in this paragraph, verify means to contact the provider in writing, electronically, and by telephone to confirm whether the providers information is correct or requires updates. |
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| 791 | 791 | | |
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| 792 | 792 | | (B) The provider group documents its efforts to verify the providers information. |
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| 793 | 793 | | |
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| 794 | 794 | | (C) The provider group reports to the insurer that the provider should be deleted from the provider group in the insurers provider directory or directories. |
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| 795 | 795 | | |
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| 796 | 796 | | (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. |
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| 797 | 797 | | |
|---|
| 798 | 798 | | (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. |
|---|
| 799 | 799 | | |
|---|
| 800 | 800 | | (2) When investigating a report regarding its provider directory or directories, the insurer shall, at a minimum, do the following: |
|---|
| 801 | 801 | | |
|---|
| 802 | 802 | | (A) Contact the affected provider no later than five business days following receipt of the report. |
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| 803 | 803 | | |
|---|
| 804 | 804 | | (B) Document the receipt and outcome of each report. The documentation shall include the providers name, location, and a description of the insurers investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories. |
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| 805 | 805 | | |
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| 806 | 806 | | (C) If changes to an insurers provider directory or directories are required as a result of the insurers 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. |
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| 807 | 807 | | |
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| 808 | 808 | | (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 insurers attempts to verify the providers information as required under subdivision (l). The insurer shall not delay payment unless it has attempted to verify the providers or provider groups 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 providers or provider groups 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. |
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| 809 | 809 | | |
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| 810 | 810 | | (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: |
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| 811 | 811 | | |
|---|
| 812 | 812 | | (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). |
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| 813 | 813 | | |
|---|
| 814 | 814 | | (B) At the end of the one-calendar-month delay described in paragraph (1), if the provider or provider group fails to provide the information required to be submitted to the insurer pursuant to subdivision (l). |
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| 815 | 815 | | |
|---|
| 816 | 816 | | (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. |
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| 817 | 817 | | |
|---|
| 818 | 818 | | (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). |
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| 819 | 819 | | |
|---|
| 820 | 820 | | (q) In circumstances where the department finds that an insured reasonably relied upon materially inaccurate, incomplete, or misleading information contained in an insurers 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 insureds 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 insureds 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. |
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| 821 | 821 | | |
|---|
| 822 | 822 | | (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. |
|---|
| 823 | 823 | | |
|---|
| 824 | 824 | | (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. |
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| 825 | 825 | | |
|---|
| 826 | 826 | | (t) This section shall not be construed to alter a providers obligation to provide health care services to an insured pursuant to the providers contract with the insurer. |
|---|
| 827 | 827 | | |
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| 828 | 828 | | (u) As part of the departments routine examination of a health insurer pursuant to Section 730, the department shall include a review of the health insurers compliance with subdivision (p). |
|---|
| 829 | 829 | | |
|---|
| 830 | 830 | | (v) For purposes of this section, provider group means a medical group, independent practice association, or other similar group of providers. |
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| 831 | 831 | | |
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| 832 | 832 | | SEC. 7. Section 10144.5 of the Insurance Code is amended to read:10144.5. (a) (1) Every disability insurance policy issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the World Health Organizations International Statistical Classification of Diseases and Related Health Problems, or that is listed in the most recent version of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the disability insurer and insureds or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an insured or policyholder under this chapter.(4) Health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological assistant, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 10144.52.(6) A disability insurer shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations made by the disability insurer concerning service intensity, level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 10144.52.(8) A disability insurer that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the insurers subsequent rescission, cancellation, or modification of the insureds or policyholders contract, or the insurers subsequent determination that it did not make an accurate determination of the insureds or policyholders eligibility. This section shall not be construed to expand or alter the benefits available to the insured or policyholder under an insurance policy.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345 of the Health and Safety Code.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the policy includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the disability insurance policy shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum and annual lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the disability insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the insured within geographic and timely access standards. The insured shall pay no more than the same cost sharing that the insured would pay for the same covered services received from an in-network provider.(e) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies.(f) (1) For the purpose of compliance with this section, a disability insurer may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health insurance policy or mental health policy. This paragraph shall not apply to policies that are subject to Section 10112.27.(2) A disability insurer shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, disability insurance policies that provide benefits to insureds through preferred provider contracting arrangements are not precluded from requiring insureds who reside or work in geographic areas served by specialized health insurance policies or mental health insurance policies to secure all or part of their mental health services within those geographic areas served by specialized health insurance policies or mental health insurance policies, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a disability insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 10144.4 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure a disability insurers compliance with this code.(h) A disability insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A disability insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.(j) If the commissioner determines that a disability insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation. |
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| 833 | 833 | | |
|---|
| 834 | 834 | | SEC. 7. Section 10144.5 of the Insurance Code is amended to read: |
|---|
| 835 | 835 | | |
|---|
| 836 | 836 | | ### SEC. 7. |
|---|
| 837 | 837 | | |
|---|
| 838 | 838 | | 10144.5. (a) (1) Every disability insurance policy issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the World Health Organizations International Statistical Classification of Diseases and Related Health Problems, or that is listed in the most recent version of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the disability insurer and insureds or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an insured or policyholder under this chapter.(4) Health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological assistant, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 10144.52.(6) A disability insurer shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations made by the disability insurer concerning service intensity, level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 10144.52.(8) A disability insurer that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the insurers subsequent rescission, cancellation, or modification of the insureds or policyholders contract, or the insurers subsequent determination that it did not make an accurate determination of the insureds or policyholders eligibility. This section shall not be construed to expand or alter the benefits available to the insured or policyholder under an insurance policy.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345 of the Health and Safety Code.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the policy includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the disability insurance policy shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum and annual lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the disability insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the insured within geographic and timely access standards. The insured shall pay no more than the same cost sharing that the insured would pay for the same covered services received from an in-network provider.(e) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies.(f) (1) For the purpose of compliance with this section, a disability insurer may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health insurance policy or mental health policy. This paragraph shall not apply to policies that are subject to Section 10112.27.(2) A disability insurer shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, disability insurance policies that provide benefits to insureds through preferred provider contracting arrangements are not precluded from requiring insureds who reside or work in geographic areas served by specialized health insurance policies or mental health insurance policies to secure all or part of their mental health services within those geographic areas served by specialized health insurance policies or mental health insurance policies, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a disability insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 10144.4 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure a disability insurers compliance with this code.(h) A disability insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A disability insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.(j) If the commissioner determines that a disability insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation. |
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| 839 | 839 | | |
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| 840 | 840 | | 10144.5. (a) (1) Every disability insurance policy issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the World Health Organizations International Statistical Classification of Diseases and Related Health Problems, or that is listed in the most recent version of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the disability insurer and insureds or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an insured or policyholder under this chapter.(4) Health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological assistant, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 10144.52.(6) A disability insurer shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations made by the disability insurer concerning service intensity, level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 10144.52.(8) A disability insurer that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the insurers subsequent rescission, cancellation, or modification of the insureds or policyholders contract, or the insurers subsequent determination that it did not make an accurate determination of the insureds or policyholders eligibility. This section shall not be construed to expand or alter the benefits available to the insured or policyholder under an insurance policy.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345 of the Health and Safety Code.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the policy includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the disability insurance policy shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum and annual lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the disability insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the insured within geographic and timely access standards. The insured shall pay no more than the same cost sharing that the insured would pay for the same covered services received from an in-network provider.(e) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies.(f) (1) For the purpose of compliance with this section, a disability insurer may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health insurance policy or mental health policy. This paragraph shall not apply to policies that are subject to Section 10112.27.(2) A disability insurer shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, disability insurance policies that provide benefits to insureds through preferred provider contracting arrangements are not precluded from requiring insureds who reside or work in geographic areas served by specialized health insurance policies or mental health insurance policies to secure all or part of their mental health services within those geographic areas served by specialized health insurance policies or mental health insurance policies, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a disability insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 10144.4 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure a disability insurers compliance with this code.(h) A disability insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A disability insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.(j) If the commissioner determines that a disability insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation. |
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| 841 | 841 | | |
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| 842 | 842 | | 10144.5. (a) (1) Every disability insurance policy issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c).(2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the World Health Organizations International Statistical Classification of Diseases and Related Health Problems, or that is listed in the most recent version of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties.(3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the disability insurer and insureds or for the convenience of the patient, treating physician, or other health care provider.(B) This paragraph does not limit in any way the independent medical review rights of an insured or policyholder under this chapter.(4) Health care provider means any of the following:(A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code.(C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code.(D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code.(E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code.(F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code.(G) A registered psychological assistant, as described in Section 2913 of the Business and Professions Code.(H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code.(5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 10144.52.(6) A disability insurer shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment.(7) All medical necessity determinations made by the disability insurer concerning service intensity, level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 10144.52.(8) A disability insurer that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the insurers subsequent rescission, cancellation, or modification of the insureds or policyholders contract, or the insurers subsequent determination that it did not make an accurate determination of the insureds or policyholders eligibility. This section shall not be construed to expand or alter the benefits available to the insured or policyholder under an insurance policy.(b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following:(1) Basic health care services, as defined in subdivision (b) of Section 1345 of the Health and Safety Code.(2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment.(3) Prescription drugs, if the policy includes coverage for prescription drugs.(c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the disability insurance policy shall include, but not be limited to, all of the following patient financial responsibilities:(1) Maximum and annual lifetime benefits, if not prohibited by applicable law.(2) Copayments and coinsurance.(3) Individual and family deductibles.(4) Out-of-pocket maximums.(d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the disability insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the insured within geographic and timely access standards. The insured shall pay no more than the same cost sharing that the insured would pay for the same covered services received from an in-network provider.(e) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies.(f) (1) For the purpose of compliance with this section, a disability insurer may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health insurance policy or mental health policy. This paragraph shall not apply to policies that are subject to Section 10112.27.(2) A disability insurer shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, disability insurance policies that provide benefits to insureds through preferred provider contracting arrangements are not precluded from requiring insureds who reside or work in geographic areas served by specialized health insurance policies or mental health insurance policies to secure all or part of their mental health services within those geographic areas served by specialized health insurance policies or mental health insurance policies, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards.(3) Notwithstanding any other law, in the provision of benefits required by this section, a disability insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 10144.4 of this code, and Section 2052 of the Business and Professions Code.(g) This section shall not be construed to deny or restrict in any way the departments authority to ensure a disability insurers compliance with this code.(h) A disability insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program.(i) A disability insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section.(j) If the commissioner determines that a disability insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation. |
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| 843 | 843 | | |
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| 844 | 844 | | |
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| 845 | 845 | | |
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| 846 | 846 | | 10144.5. (a) (1) Every disability insurance policy issued, amended, or renewed on or after January 1, 2021, that provides hospital, medical, or surgical coverage shall provide coverage for medically necessary treatment of mental health and substance use disorders, under the same terms and conditions applied to other medical conditions as specified in subdivision (c). |
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| 847 | 847 | | |
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| 848 | 848 | | (2) For purposes of this section, mental health and substance use disorders means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the World Health Organizations International Statistical Classification of Diseases and Related Health Problems, or that is listed in the most recent version of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders. Changes in terminology, organization, or classification of mental health and substance use disorders in future versions of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders or the World Health Organizations International Statistical Classification of Diseases and Related Health Problems shall not affect the conditions covered by this section as long as a condition is commonly understood to be a mental health or substance use disorder by health care providers practicing in relevant clinical specialties. |
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| 849 | 849 | | |
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| 850 | 850 | | (3) (A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following: |
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| 851 | 851 | | |
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| 852 | 852 | | (i) In accordance with the generally accepted standards of mental health and substance use disorder care. |
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| 853 | 853 | | |
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| 854 | 854 | | (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. |
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| 855 | 855 | | |
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| 856 | 856 | | (iii) Not primarily for the economic benefit of the disability insurer and insureds or for the convenience of the patient, treating physician, or other health care provider. |
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| 857 | 857 | | |
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| 858 | 858 | | (B) This paragraph does not limit in any way the independent medical review rights of an insured or policyholder under this chapter. |
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| 859 | 859 | | |
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| 860 | 860 | | (4) Health care provider means any of the following: |
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| 861 | 861 | | |
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| 862 | 862 | | (A) A person who is licensed under Division 2 (commencing with Section 500) of the Business and Professions Code. |
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| 863 | 863 | | |
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| 864 | 864 | | (B) An associate marriage and family therapist or marriage and family therapist trainee functioning pursuant to Section 4980.43.3 of the Business and Professions Code. |
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| 865 | 865 | | |
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| 866 | 866 | | (C) A qualified autism service provider or qualified autism service professional certified by a national entity pursuant to Section 1374.73 of the Health and Safety Code and Section 10144.51. as defined in Section 4999.200 of the Business and Professions Code or a qualified autism service professional as defined in Section 4999.201 of the Business and Professions Code. |
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| 867 | 867 | | |
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| 868 | 868 | | (D) An associate clinical social worker functioning pursuant to Section 4996.23.2 of the Business and Professions Code. |
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| 869 | 869 | | |
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| 870 | 870 | | (E) An associate professional clinical counselor or professional clinical counselor trainee functioning pursuant to Section 4999.46.3 of the Business and Professions Code. |
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| 871 | 871 | | |
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| 872 | 872 | | (F) A registered psychologist, as described in Section 2909.5 of the Business and Professions Code. |
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| 873 | 873 | | |
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| 874 | 874 | | (G) A registered psychological assistant, as described in Section 2913 of the Business and Professions Code. |
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| 875 | 875 | | |
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| 876 | 876 | | (H) A psychology trainee or person supervised as set forth in Section 2910 or 2911 of, or subdivision (d) of Section 2914 of, the Business and Professions Code. |
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| 877 | 877 | | |
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| 878 | 878 | | (5) For purposes of this section, generally accepted standards of mental health and substance use disorder care has the same meaning as defined in paragraph (1) of subdivision (f) of Section 10144.52. |
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| 879 | 879 | | |
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| 880 | 880 | | (6) A disability insurer shall not limit benefits or coverage for mental health and substance use disorders to short-term or acute treatment. |
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| 881 | 881 | | |
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| 882 | 882 | | (7) All medical necessity determinations made by the disability insurer concerning service intensity, level of care placement, continued stay, and transfer or discharge of insureds diagnosed with mental health and substance use disorders shall be conducted in accordance with the requirements of Section 10144.52. |
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| 883 | 883 | | |
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| 884 | 884 | | (8) A disability insurer that authorizes a specific type of treatment by a provider pursuant to this section shall not rescind or modify the authorization after the provider renders the health care service in good faith and pursuant to this authorization for any reason, including, but not limited to, the insurers subsequent rescission, cancellation, or modification of the insureds or policyholders contract, or the insurers subsequent determination that it did not make an accurate determination of the insureds or policyholders eligibility. This section shall not be construed to expand or alter the benefits available to the insured or policyholder under an insurance policy. |
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| 885 | 885 | | |
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| 886 | 886 | | (b) The benefits that shall be covered pursuant to this section shall include, but not be limited to, the following: |
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| 887 | 887 | | |
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| 888 | 888 | | (1) Basic health care services, as defined in subdivision (b) of Section 1345 of the Health and Safety Code. |
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| 889 | 889 | | |
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| 890 | 890 | | (2) Intermediate services, including the full range of levels of care, including, but not limited to, residential treatment, partial hospitalization, and intensive outpatient treatment. |
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| 891 | 891 | | |
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| 892 | 892 | | (3) Prescription drugs, if the policy includes coverage for prescription drugs. |
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| 893 | 893 | | |
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| 894 | 894 | | (c) The terms and conditions applied to the benefits required by this section, that shall be applied equally to all benefits under the disability insurance policy shall include, but not be limited to, all of the following patient financial responsibilities: |
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| 895 | 895 | | |
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| 896 | 896 | | (1) Maximum and annual lifetime benefits, if not prohibited by applicable law. |
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| 897 | 897 | | |
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| 898 | 898 | | (2) Copayments and coinsurance. |
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| 899 | 899 | | |
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| 900 | 900 | | (3) Individual and family deductibles. |
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| 901 | 901 | | |
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| 902 | 902 | | (4) Out-of-pocket maximums. |
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| 903 | 903 | | |
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| 904 | 904 | | (d) If services for the medically necessary treatment of a mental health or substance use disorder are not available in network within the geographic and timely access standards set by law or regulation, the disability insurer shall arrange coverage to ensure the delivery of medically necessary out-of-network services and any medically necessary followup services that, to the maximum extent possible, meet those geographic and timely access standards. As used in this subdivision, to arrange coverage to ensure the delivery of medically necessary out-of-network services includes, but is not limited to, providing services to secure medically necessary out-of-network options that are available to the insured within geographic and timely access standards. The insured shall pay no more than the same cost sharing that the insured would pay for the same covered services received from an in-network provider. |
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| 905 | 905 | | |
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| 906 | 906 | | (e) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies. |
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| 907 | 907 | | |
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| 908 | 908 | | (f) (1) For the purpose of compliance with this section, a disability insurer may provide coverage for all or part of the mental health and substance use disorder services required by this section through a separate specialized health insurance policy or mental health policy. This paragraph shall not apply to policies that are subject to Section 10112.27. |
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| 909 | 909 | | |
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| 910 | 910 | | (2) A disability insurer shall provide the mental health and substance use disorder coverage required by this section in its entire service area and in emergency situations as may be required by applicable laws and regulations. For purposes of this section, disability insurance policies that provide benefits to insureds through preferred provider contracting arrangements are not precluded from requiring insureds who reside or work in geographic areas served by specialized health insurance policies or mental health insurance policies to secure all or part of their mental health services within those geographic areas served by specialized health insurance policies or mental health insurance policies, provided that all appropriate mental health or substance use disorder services are actually available within those geographic service areas within timeliness standards. |
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| 911 | 911 | | |
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| 912 | 912 | | (3) Notwithstanding any other law, in the provision of benefits required by this section, a disability insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing, provided that these practices are consistent with Section 10144.4 of this code, and Section 2052 of the Business and Professions Code. |
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| 913 | 913 | | |
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| 914 | 914 | | (g) This section shall not be construed to deny or restrict in any way the departments authority to ensure a disability insurers compliance with this code. |
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| 915 | 915 | | |
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| 916 | 916 | | (h) A disability insurer shall not limit benefits or coverage for medically necessary services on the basis that those services should be or could be covered by a public entitlement program, including, but not limited to, special education or an individualized education program, Medicaid, Medicare, Supplemental Security Income, or Social Security Disability Insurance, and shall not include or enforce a contract term that excludes otherwise covered benefits on the basis that those services should be or could be covered by a public entitlement program. |
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| 917 | 917 | | |
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| 918 | 918 | | (i) A disability insurer shall not adopt, impose, or enforce terms in its policies or provider agreements, in writing or in operation, that undermine, alter, or conflict with the requirements of this section. |
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| 919 | 919 | | |
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| 920 | 920 | | (j) If the commissioner determines that a disability insurer has violated this section, the commissioner may, after appropriate notice and opportunity for hearing in accordance with the Administrative Procedure Act (Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code), by order, assess a civil penalty not to exceed five thousand dollars ($5,000) for each violation, or, if a violation was willful, a civil penalty not to exceed ten thousand dollars ($10,000) for each violation. |
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| 921 | 921 | | |
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| 922 | 922 | | SEC. 8. Section 10144.51 of the Insurance Code is amended to read:10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 10144.5.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any the following:(1) A specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(2) A health insurance policy in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 923 | 923 | | |
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| 924 | 924 | | SEC. 8. Section 10144.51 of the Insurance Code is amended to read: |
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| 925 | 925 | | |
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| 926 | 926 | | ### SEC. 8. |
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| 927 | 927 | | |
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| 928 | 928 | | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 10144.5.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any the following:(1) A specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(2) A health insurance policy in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 929 | 929 | | |
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| 930 | 930 | | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 10144.5.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any the following:(1) A specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(2) A health insurance policy in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 931 | 931 | | |
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| 932 | 932 | | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 10144.5.(2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152).(3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations.(b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements.(c) For the purposes of this section, the following definitions shall apply:(1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and that meet all of the following criteria:(A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code.(B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following:(i) A qualified autism service provider.(ii) A qualified autism service professional supervised by the qualified autism service provider.(iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional.(C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following:(i) Describes the patients behavioral health impairments or developmental challenges that are to be treated.(ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported.(iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism.(iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate.(D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request.(2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5.(3)Qualified autism service provider means either of the following:(A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified.(B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee.(4)Qualified autism service professional means an individual who meets all of the following criteria:(A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider.(B)Is supervised by a qualified autism service provider.(C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider.(D)Is either of the following:(i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program.(ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology.(E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.(ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional.(F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria:(A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice.(B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider.(C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations.(D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers.(E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan.(2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code.(3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code.(4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code.(d) This section shall does not apply to any the following:(1) A specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy.(2) A health insurance policy in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code).(e) This section does not limit the obligation to provide services under Section 10144.5.(f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 933 | 933 | | |
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| 934 | 934 | | |
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| 935 | 935 | | |
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| 936 | 936 | | 10144.51. (a) (1) Every health insurance policy shall also provide coverage for behavioral health treatment for pervasive developmental disorder or autism no later than July 1, 2012. The coverage shall be provided in the same manner and shall be is subject to the same requirements as provided in Section 10144.5. |
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| 937 | 937 | | |
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| 938 | 938 | | (2) Notwithstanding paragraph (1), as of the date that proposed final rulemaking for essential health benefits is issued, this section does not require any benefits to be provided that exceed the essential health benefits that all health insurers will be required by federal regulations to provide under Section 1302(b) of the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152). |
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| 939 | 939 | | |
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| 940 | 940 | | (3) This section shall does not affect services for which an individual is eligible pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code. |
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| 941 | 941 | | |
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| 942 | 942 | | (4) This section shall does not affect or reduce any obligation to provide services under an individualized education program, as defined in Section 56032 of the Education Code, or an individual service plan, as described in Section 5600.4 of the Welfare and Institutions Code, or under the federal Individuals with Disabilities Education Act (20 U.S.C. Sec. 1400 et seq.) and its implementing regulations. |
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| 943 | 943 | | |
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| 944 | 944 | | (b) Pursuant to Article 6 (commencing with Section 2240) of Subchapter 2 of Chapter 5 of Title 10 of the California Code of Regulations, every health insurer subject to this section shall maintain an adequate network that includes qualified autism service providers who supervise or employ qualified autism service professionals or paraprofessionals who provide and administer behavioral health treatment. A health insurer is not prevented from selectively contracting with providers within these requirements. |
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| 945 | 945 | | |
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| 946 | 946 | | (c) For the purposes of this section, the following definitions shall apply: |
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| 947 | 947 | | |
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| 948 | 948 | | (1) Behavioral health treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism, and that meet all of the following criteria: |
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| 949 | 949 | | |
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| 950 | 950 | | (A) The treatment is prescribed by a physician and surgeon licensed pursuant to Chapter 5 (commencing with Section 2000) of, or is developed by a psychologist licensed pursuant to Chapter 6.6 (commencing with Section 2900) of, Division 2 of the Business and Professions Code. |
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| 951 | 951 | | |
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| 952 | 952 | | (B) The treatment is provided under a treatment plan prescribed by a qualified autism service provider and is administered by one of the following: |
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| 953 | 953 | | |
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| 954 | 954 | | (i) A qualified autism service provider. |
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| 955 | 955 | | |
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| 956 | 956 | | (ii) A qualified autism service professional supervised by the qualified autism service provider. |
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| 957 | 957 | | |
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| 958 | 958 | | (iii) A qualified autism service paraprofessional supervised by a qualified autism service provider or qualified autism service professional. |
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| 959 | 959 | | |
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| 960 | 960 | | (C) The treatment plan has measurable goals over a specific timeline that is developed and approved by the qualified autism service provider for the specific patient being treated. The treatment plan shall be reviewed no less than once every six months by the qualified autism service provider and modified whenever appropriate, and shall be consistent with Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following: |
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| 961 | 961 | | |
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| 962 | 962 | | (i) Describes the patients behavioral health impairments or developmental challenges that are to be treated. |
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| 963 | 963 | | |
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| 964 | 964 | | (ii) Designs an intervention plan that includes the service type, number of hours, and parent participation needed to achieve the plans goal and objectives, and the frequency at which the patients progress is evaluated and reported. |
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| 965 | 965 | | |
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| 966 | 966 | | (iii) Provides intervention plans that utilize evidence-based practices, with demonstrated clinical efficacy in treating pervasive developmental disorder or autism. |
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| 967 | 967 | | |
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| 968 | 968 | | (iv) Discontinues intensive behavioral intervention services when the treatment goals and objectives are achieved or no longer appropriate. |
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| 969 | 969 | | |
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| 970 | 970 | | (D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, day care, or educational services and is not used to reimburse a parent for participating in the treatment program. The treatment plan shall be made available to the insurer upon request. |
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| 971 | 971 | | |
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| 972 | 972 | | (2)Pervasive developmental disorder or autism shall have the same meaning and interpretation as used in Section 10144.5. |
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| 973 | 973 | | |
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| 974 | 974 | | |
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| 975 | 975 | | |
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| 976 | 976 | | (3)Qualified autism service provider means either of the following: |
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| 977 | 977 | | |
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| 978 | 978 | | |
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| 979 | 979 | | |
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| 980 | 980 | | (A)A person who is certified by a national entity, such as the Behavior Analyst Certification Board, with a certification that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person who is nationally certified. |
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| 981 | 981 | | |
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| 982 | 982 | | |
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| 983 | 983 | | |
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| 984 | 984 | | (B)A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the licensee. |
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| 985 | 985 | | |
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| 986 | 986 | | |
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| 987 | 987 | | |
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| 988 | 988 | | (4)Qualified autism service professional means an individual who meets all of the following criteria: |
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| 989 | 989 | | |
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| 990 | 990 | | |
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| 991 | 991 | | |
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| 992 | 992 | | (A)Provides behavioral health treatment, which may include clinical case management and case supervision under the direction and supervision of a qualified autism service provider. |
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| 993 | 993 | | |
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| 994 | 994 | | |
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| 995 | 995 | | |
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| 996 | 996 | | (B)Is supervised by a qualified autism service provider. |
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| 997 | 997 | | |
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| 998 | 998 | | |
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| 999 | 999 | | |
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| 1000 | 1000 | | (C)Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider. |
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| 1001 | 1001 | | |
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| 1002 | 1002 | | |
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| 1003 | 1003 | | |
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| 1004 | 1004 | | (D)Is either of the following: |
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| 1005 | 1005 | | |
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| 1006 | 1006 | | |
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| 1007 | 1007 | | |
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| 1008 | 1008 | | (i)A behavioral service provider who meets the education and experience qualifications described in Section 54342 of Title 17 of the California Code of Regulations for an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program. |
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| 1009 | 1009 | | |
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| 1010 | 1010 | | |
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| 1011 | 1011 | | |
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| 1012 | 1012 | | (ii)A psychological associate, an associate marriage and family therapist, an associate clinical social worker, or an associate professional clinical counselor, as defined and regulated by the Board of Behavioral Sciences or the Board of Psychology. |
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| 1013 | 1013 | | |
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| 1014 | 1014 | | |
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| 1015 | 1015 | | |
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| 1016 | 1016 | | (E)(i)Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code. |
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| 1017 | 1017 | | |
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| 1018 | 1018 | | |
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| 1019 | 1019 | | |
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| 1020 | 1020 | | (ii)If an individual meets the requirement described in clause (ii) of subparagraph (D), the individual shall also meet the criteria set forth in the regulations adopted pursuant to Section 4686.4 of the Welfare and Institutions Code for a Behavioral Health Professional. |
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| 1021 | 1021 | | |
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| 1022 | 1022 | | |
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| 1023 | 1023 | | |
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| 1024 | 1024 | | (F)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 1025 | 1025 | | |
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| 1026 | 1026 | | |
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| 1027 | 1027 | | |
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| 1028 | 1028 | | (5)Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the following criteria: |
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| 1029 | 1029 | | |
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| 1030 | 1030 | | |
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| 1031 | 1031 | | |
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| 1032 | 1032 | | (A)Is supervised by a qualified autism service provider or qualified autism service professional at a level of clinical supervision that meets professionally recognized standards of practice. |
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| 1033 | 1033 | | |
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| 1034 | 1034 | | |
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| 1035 | 1035 | | |
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| 1036 | 1036 | | (B)Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider. |
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| 1037 | 1037 | | |
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| 1038 | 1038 | | |
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| 1039 | 1039 | | |
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| 1040 | 1040 | | (C)Meets the education and training qualifications described in Section 54342 of Title 17 of the California Code of Regulations. |
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| 1041 | 1041 | | |
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| 1042 | 1042 | | |
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| 1043 | 1043 | | |
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| 1044 | 1044 | | (D)Has adequate education, training, and experience, as certified by a qualified autism service provider or an entity or group that employs qualified autism service providers. |
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| 1045 | 1045 | | |
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| 1046 | 1046 | | |
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| 1047 | 1047 | | |
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| 1048 | 1048 | | (E)Is employed by the qualified autism service provider or an entity or group that employs qualified autism service providers responsible for the autism treatment plan. |
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| 1049 | 1049 | | |
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| 1050 | 1050 | | |
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| 1051 | 1051 | | |
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| 1052 | 1052 | | (2) Qualified autism service provider means an individual described in Section 4999.200 of the Business and Professions Code. |
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| 1053 | 1053 | | |
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| 1054 | 1054 | | (3) Qualified autism service professional means an individual who meets all of the criteria set forth in Section 4999.201 of the Business and Professions Code. |
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| 1055 | 1055 | | |
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| 1056 | 1056 | | (4) Qualified autism service paraprofessional means an unlicensed and uncertified individual who meets all of the criteria set forth in Section 4999.202 of the Business and Professions Code. |
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| 1057 | 1057 | | |
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| 1058 | 1058 | | (d) This section shall does not apply to any the following: |
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| 1059 | 1059 | | |
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| 1060 | 1060 | | (1) A specialized health insurance policy that does not cover mental health or behavioral health services or an accident only, specified disease, hospital indemnity, or Medicare supplement policy. |
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| 1061 | 1061 | | |
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| 1062 | 1062 | | (2) A health insurance policy in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code). |
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| 1063 | 1063 | | |
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| 1064 | 1064 | | (e) This section does not limit the obligation to provide services under Section 10144.5. |
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| 1065 | 1065 | | |
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| 1066 | 1066 | | (f) As provided in Section 10144.5 and in paragraph (1) of subdivision (a), in the provision of benefits required by this section, a health insurer may utilize case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing. |
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| 1067 | 1067 | | |
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| 1068 | 1068 | | SEC. 9. Section 11165.7 of the Penal Code is amended to read:11165.7. (a) As used in this article, mandated reporter is defined as any of the following:(1) A teacher.(2) An instructional aide.(3) A teachers aide or teachers assistant employed by a public or private school.(4) A classified employee of a public school.(5) An administrative officer or supervisor of child welfare and attendance, or a certificated pupil personnel employee of a public or private school.(6) An administrator of a public or private day camp.(7) An administrator or employee of a public or private youth center, youth recreation program, or youth organization.(8) An administrator, board member, or employee of a public or private organization whose duties require direct contact and supervision of children, including a foster family agency.(9) An employee of a county office of education or the State Department of Education whose duties bring the employee into contact with children on a regular basis.(10) A licensee, an administrator, or an employee of a licensed community care or child daycare facility.(11) A Head Start program teacher.(12) A licensing worker or licensing evaluator employed by a licensing agency, as defined in Section 11165.11.(13) A public assistance worker.(14) An employee of a childcare institution, including, but not limited to, foster parents, group home personnel, and personnel of residential care facilities.(15) A social worker, probation officer, or parole officer.(16) An employee of a school district police or security department.(17) A person who is an administrator or presenter of, or a counselor in, a child abuse prevention program in a public or private school.(18) A district attorney investigator, inspector, or local child support agency caseworker, unless the investigator, inspector, or caseworker is working with an attorney appointed pursuant to Section 317 of the Welfare and Institutions Code to represent a minor.(19) A peace officer, as defined in Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2, who is not otherwise described in this section.(20) A firefighter, except for volunteer firefighters.(21) A physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse, dental hygienist, optometrist, marriage and family therapist, clinical social worker, professional clinical counselor, or any other person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(22) An emergency medical technician I or II, paramedic, or other person certified pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code.(23) A psychological assistant registered pursuant to Section 2913 of the Business and Professions Code.(24) A marriage and family therapist trainee, as defined in subdivision (c) of Section 4980.03 of the Business and Professions Code.(25) An unlicensed associate marriage and family therapist registered under Section 4980.44 of the Business and Professions Code.(26) A state or county public health employee who treats a minor for venereal disease or any other condition.(27) A coroner.(28) A medical examiner or other person who performs autopsies.(29) A commercial film and photographic print or image processor as specified in subdivision (e) of Section 11166. As used in this article, commercial film and photographic print or image processor means a person who develops exposed photographic film into negatives, slides, or prints, or who makes prints from negatives or slides, or who prepares, publishes, produces, develops, duplicates, or prints any representation of information, data, or an image, including, but not limited to, any film, filmstrip, photograph, negative, slide, photocopy, videotape, video laser disc, computer hardware, computer software, computer floppy disk, data storage medium, CD-ROM, computer-generated equipment, or computer-generated image, for compensation. The term includes any employee of that person; it does not include a person who develops film or makes prints or images for a public agency.(30) A child visitation monitor. As used in this article, child visitation monitor means a person who, for financial compensation, acts as a monitor of a visit between a child and another person when the monitoring of that visit has been ordered by a court of law.(31) An animal control officer or humane society officer. For the purposes of this article, the following terms have the following meanings:(A) Animal control officer means a person employed by a city, county, or city and county for the purpose of enforcing animal control laws or regulations.(B) Humane society officer means a person appointed or employed by a public or private entity as a humane officer who is qualified pursuant to Section 14502 or 14503 of the Corporations Code.(32) A clergy member, as specified in subdivision (d) of Section 11166. As used in this article, clergy member means a priest, minister, rabbi, religious practitioner, or similar functionary of a church, temple, or recognized denomination or organization.(33) Any custodian of records of a clergy member, as specified in this section and subdivision (d) of Section 11166.(34) An employee of any police department, county sheriffs department, county probation department, or county welfare department.(35) An employee or volunteer of a Court Appointed Special Advocate program, as defined in Rule 5.655 of the California Rules of Court.(36) A custodial officer, as defined in Section 831.5.(37) A person providing services to a minor child under Section 12300 or 12300.1 of the Welfare and Institutions Code.(38) An alcohol and drug counselor. As used in this article, an alcohol and drug counselor is a person providing counseling, therapy, or other clinical services for a state licensed or certified drug, alcohol, or drug and alcohol treatment program. However, alcohol or drug abuse, or both alcohol and drug abuse, is not, in and of itself, a sufficient basis for reporting child abuse or neglect.(39) A clinical counselor trainee, as defined in subdivision (g) of Section 4999.12 of the Business and Professions Code.(40) An associate professional clinical counselor registered under Section 4999.42 of the Business and Professions Code.(41) An employee or administrator of a public or private postsecondary educational institution, whose duties bring the administrator or employee into contact with children on a regular basis, or who supervises those whose duties bring the administrator or employee into contact with children on a regular basis, as to child abuse or neglect occurring on that institutions premises or at an official activity of, or program conducted by, the institution. Nothing in this paragraph shall be construed as altering the lawyer-client privilege as set forth in Article 3 (commencing with Section 950) of Chapter 4 of Division 8 of the Evidence Code.(42) An athletic coach, athletic administrator, or athletic director employed by any public or private school that provides any combination of instruction for kindergarten, or grades 1 to 12, inclusive.(43) (A) A commercial computer technician as specified in subdivision (e) of Section 11166. As used in this article, commercial computer technician means a person who works for a company that is in the business of repairing, installing, or otherwise servicing a computer or computer component, including, but not limited to, a computer part, device, memory storage or recording mechanism, auxiliary storage recording or memory capacity, or any other material relating to the operation and maintenance of a computer or computer network system, for a fee. An employer who provides an electronic communications service or a remote computing service to the public shall be deemed to comply with this article if that employer complies with Section 2258A of Title 18 of the United States Code.(B) An employer of a commercial computer technician may implement internal procedures for facilitating reporting consistent with this article. These procedures may direct employees who are mandated reporters under this paragraph to report materials described in subdivision (e) of Section 11166 to an employee who is designated by the employer to receive the reports. An employee who is designated to receive reports under this subparagraph shall be a commercial computer technician for purposes of this article. A commercial computer technician who makes a report to the designated employee pursuant to this subparagraph shall be deemed to have complied with the requirements of this article and shall be subject to the protections afforded to mandated reporters, including, but not limited to, those protections afforded by Section 11172.(44) Any athletic coach, including, but not limited to, an assistant coach or a graduate assistant involved in coaching, at public or private postsecondary educational institutions.(45) An individual certified by a licensed foster family agency as a certified family home, as defined in Section 1506 of the Health and Safety Code.(46) An individual approved as a resource family, as defined in Section 1517 of the Health and Safety Code and Section 16519.5 of the Welfare and Institutions Code.(47) A qualified autism service provider, a qualified autism service professional, or a qualified autism service paraprofessional, as defined in Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. paraprofessional as defined in Chapter 17 (commencing with Section 4999.200) of Division 2 of the Business and Professions Code.(48) A human resource employee of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code that employs minors. For purposes of this section, a human resource employee is the employee or employees designated by the employer to accept any complaints of misconduct as required by Chapter 6 (commencing with Section 12940) of Part 2.8 of Division 3 of Title 2 of the Government Code.(49) An adult person whose duties require direct contact with and supervision of minors in the performance of the minors duties in the workplace of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code is a mandated reporter of sexual abuse, as defined in Section 11165.1. Nothing in this paragraph shall be construed to modify or limit the persons duty to report known or suspected child abuse or neglect when the person is acting in some other capacity that would otherwise make the person a mandated reporter.(b) Except as provided in paragraph (35) of subdivision (a), volunteers of public or private organizations whose duties require direct contact with and supervision of children are not mandated reporters but are encouraged to obtain training in the identification and reporting of child abuse and neglect and are further encouraged to report known or suspected instances of child abuse or neglect to an agency specified in Section 11165.9.(c) (1) Except as provided in subdivision (d) and paragraph (2), employers are strongly encouraged to provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. Whether or not employers provide their employees with training in child abuse and neglect identification and reporting, the employers shall provide their employees who are mandated reporters with the statement required pursuant to subdivision (a) of Section 11166.5.(2) Employers subject to paragraphs (48) and (49) of subdivision (a) shall provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. The training requirement may be met by completing the general online training for mandated reporters offered by the Office of Child Abuse Prevention in the State Department of Social Services.(d) Pursuant to Section 44691 of the Education Code, school districts, county offices of education, state special schools and diagnostic centers operated by the State Department of Education, and charter schools shall annually train their employees and persons working on their behalf specified in subdivision (a) in the duties of mandated reporters under the child abuse reporting laws. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(e) (1) On and after January 1, 2018, pursuant to Section 1596.8662 of the Health and Safety Code, a childcare licensee applicant shall take training in the duties of mandated reporters under the child abuse reporting laws as a condition of licensure, and a childcare administrator or an employee of a licensed child daycare facility shall take training in the duties of mandated reporters during the first 90 days when that administrator or employee is employed by the facility.(2) A person specified in paragraph (1) who becomes a licensee, administrator, or employee of a licensed child daycare facility shall take renewal mandated reporter training every two years following the date on which that person completed the initial mandated reporter training. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(f) Unless otherwise specifically provided, the absence of training shall not excuse a mandated reporter from the duties imposed by this article.(g) Public and private organizations are encouraged to provide their volunteers whose duties require direct contact with and supervision of children with training in the identification and reporting of child abuse and neglect. |
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| 1069 | 1069 | | |
|---|
| 1070 | 1070 | | SEC. 9. Section 11165.7 of the Penal Code is amended to read: |
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| 1071 | 1071 | | |
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| 1072 | 1072 | | ### SEC. 9. |
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| 1073 | 1073 | | |
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| 1074 | 1074 | | 11165.7. (a) As used in this article, mandated reporter is defined as any of the following:(1) A teacher.(2) An instructional aide.(3) A teachers aide or teachers assistant employed by a public or private school.(4) A classified employee of a public school.(5) An administrative officer or supervisor of child welfare and attendance, or a certificated pupil personnel employee of a public or private school.(6) An administrator of a public or private day camp.(7) An administrator or employee of a public or private youth center, youth recreation program, or youth organization.(8) An administrator, board member, or employee of a public or private organization whose duties require direct contact and supervision of children, including a foster family agency.(9) An employee of a county office of education or the State Department of Education whose duties bring the employee into contact with children on a regular basis.(10) A licensee, an administrator, or an employee of a licensed community care or child daycare facility.(11) A Head Start program teacher.(12) A licensing worker or licensing evaluator employed by a licensing agency, as defined in Section 11165.11.(13) A public assistance worker.(14) An employee of a childcare institution, including, but not limited to, foster parents, group home personnel, and personnel of residential care facilities.(15) A social worker, probation officer, or parole officer.(16) An employee of a school district police or security department.(17) A person who is an administrator or presenter of, or a counselor in, a child abuse prevention program in a public or private school.(18) A district attorney investigator, inspector, or local child support agency caseworker, unless the investigator, inspector, or caseworker is working with an attorney appointed pursuant to Section 317 of the Welfare and Institutions Code to represent a minor.(19) A peace officer, as defined in Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2, who is not otherwise described in this section.(20) A firefighter, except for volunteer firefighters.(21) A physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse, dental hygienist, optometrist, marriage and family therapist, clinical social worker, professional clinical counselor, or any other person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(22) An emergency medical technician I or II, paramedic, or other person certified pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code.(23) A psychological assistant registered pursuant to Section 2913 of the Business and Professions Code.(24) A marriage and family therapist trainee, as defined in subdivision (c) of Section 4980.03 of the Business and Professions Code.(25) An unlicensed associate marriage and family therapist registered under Section 4980.44 of the Business and Professions Code.(26) A state or county public health employee who treats a minor for venereal disease or any other condition.(27) A coroner.(28) A medical examiner or other person who performs autopsies.(29) A commercial film and photographic print or image processor as specified in subdivision (e) of Section 11166. As used in this article, commercial film and photographic print or image processor means a person who develops exposed photographic film into negatives, slides, or prints, or who makes prints from negatives or slides, or who prepares, publishes, produces, develops, duplicates, or prints any representation of information, data, or an image, including, but not limited to, any film, filmstrip, photograph, negative, slide, photocopy, videotape, video laser disc, computer hardware, computer software, computer floppy disk, data storage medium, CD-ROM, computer-generated equipment, or computer-generated image, for compensation. The term includes any employee of that person; it does not include a person who develops film or makes prints or images for a public agency.(30) A child visitation monitor. As used in this article, child visitation monitor means a person who, for financial compensation, acts as a monitor of a visit between a child and another person when the monitoring of that visit has been ordered by a court of law.(31) An animal control officer or humane society officer. For the purposes of this article, the following terms have the following meanings:(A) Animal control officer means a person employed by a city, county, or city and county for the purpose of enforcing animal control laws or regulations.(B) Humane society officer means a person appointed or employed by a public or private entity as a humane officer who is qualified pursuant to Section 14502 or 14503 of the Corporations Code.(32) A clergy member, as specified in subdivision (d) of Section 11166. As used in this article, clergy member means a priest, minister, rabbi, religious practitioner, or similar functionary of a church, temple, or recognized denomination or organization.(33) Any custodian of records of a clergy member, as specified in this section and subdivision (d) of Section 11166.(34) An employee of any police department, county sheriffs department, county probation department, or county welfare department.(35) An employee or volunteer of a Court Appointed Special Advocate program, as defined in Rule 5.655 of the California Rules of Court.(36) A custodial officer, as defined in Section 831.5.(37) A person providing services to a minor child under Section 12300 or 12300.1 of the Welfare and Institutions Code.(38) An alcohol and drug counselor. As used in this article, an alcohol and drug counselor is a person providing counseling, therapy, or other clinical services for a state licensed or certified drug, alcohol, or drug and alcohol treatment program. However, alcohol or drug abuse, or both alcohol and drug abuse, is not, in and of itself, a sufficient basis for reporting child abuse or neglect.(39) A clinical counselor trainee, as defined in subdivision (g) of Section 4999.12 of the Business and Professions Code.(40) An associate professional clinical counselor registered under Section 4999.42 of the Business and Professions Code.(41) An employee or administrator of a public or private postsecondary educational institution, whose duties bring the administrator or employee into contact with children on a regular basis, or who supervises those whose duties bring the administrator or employee into contact with children on a regular basis, as to child abuse or neglect occurring on that institutions premises or at an official activity of, or program conducted by, the institution. Nothing in this paragraph shall be construed as altering the lawyer-client privilege as set forth in Article 3 (commencing with Section 950) of Chapter 4 of Division 8 of the Evidence Code.(42) An athletic coach, athletic administrator, or athletic director employed by any public or private school that provides any combination of instruction for kindergarten, or grades 1 to 12, inclusive.(43) (A) A commercial computer technician as specified in subdivision (e) of Section 11166. As used in this article, commercial computer technician means a person who works for a company that is in the business of repairing, installing, or otherwise servicing a computer or computer component, including, but not limited to, a computer part, device, memory storage or recording mechanism, auxiliary storage recording or memory capacity, or any other material relating to the operation and maintenance of a computer or computer network system, for a fee. An employer who provides an electronic communications service or a remote computing service to the public shall be deemed to comply with this article if that employer complies with Section 2258A of Title 18 of the United States Code.(B) An employer of a commercial computer technician may implement internal procedures for facilitating reporting consistent with this article. These procedures may direct employees who are mandated reporters under this paragraph to report materials described in subdivision (e) of Section 11166 to an employee who is designated by the employer to receive the reports. An employee who is designated to receive reports under this subparagraph shall be a commercial computer technician for purposes of this article. A commercial computer technician who makes a report to the designated employee pursuant to this subparagraph shall be deemed to have complied with the requirements of this article and shall be subject to the protections afforded to mandated reporters, including, but not limited to, those protections afforded by Section 11172.(44) Any athletic coach, including, but not limited to, an assistant coach or a graduate assistant involved in coaching, at public or private postsecondary educational institutions.(45) An individual certified by a licensed foster family agency as a certified family home, as defined in Section 1506 of the Health and Safety Code.(46) An individual approved as a resource family, as defined in Section 1517 of the Health and Safety Code and Section 16519.5 of the Welfare and Institutions Code.(47) A qualified autism service provider, a qualified autism service professional, or a qualified autism service paraprofessional, as defined in Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. paraprofessional as defined in Chapter 17 (commencing with Section 4999.200) of Division 2 of the Business and Professions Code.(48) A human resource employee of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code that employs minors. For purposes of this section, a human resource employee is the employee or employees designated by the employer to accept any complaints of misconduct as required by Chapter 6 (commencing with Section 12940) of Part 2.8 of Division 3 of Title 2 of the Government Code.(49) An adult person whose duties require direct contact with and supervision of minors in the performance of the minors duties in the workplace of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code is a mandated reporter of sexual abuse, as defined in Section 11165.1. Nothing in this paragraph shall be construed to modify or limit the persons duty to report known or suspected child abuse or neglect when the person is acting in some other capacity that would otherwise make the person a mandated reporter.(b) Except as provided in paragraph (35) of subdivision (a), volunteers of public or private organizations whose duties require direct contact with and supervision of children are not mandated reporters but are encouraged to obtain training in the identification and reporting of child abuse and neglect and are further encouraged to report known or suspected instances of child abuse or neglect to an agency specified in Section 11165.9.(c) (1) Except as provided in subdivision (d) and paragraph (2), employers are strongly encouraged to provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. Whether or not employers provide their employees with training in child abuse and neglect identification and reporting, the employers shall provide their employees who are mandated reporters with the statement required pursuant to subdivision (a) of Section 11166.5.(2) Employers subject to paragraphs (48) and (49) of subdivision (a) shall provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. The training requirement may be met by completing the general online training for mandated reporters offered by the Office of Child Abuse Prevention in the State Department of Social Services.(d) Pursuant to Section 44691 of the Education Code, school districts, county offices of education, state special schools and diagnostic centers operated by the State Department of Education, and charter schools shall annually train their employees and persons working on their behalf specified in subdivision (a) in the duties of mandated reporters under the child abuse reporting laws. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(e) (1) On and after January 1, 2018, pursuant to Section 1596.8662 of the Health and Safety Code, a childcare licensee applicant shall take training in the duties of mandated reporters under the child abuse reporting laws as a condition of licensure, and a childcare administrator or an employee of a licensed child daycare facility shall take training in the duties of mandated reporters during the first 90 days when that administrator or employee is employed by the facility.(2) A person specified in paragraph (1) who becomes a licensee, administrator, or employee of a licensed child daycare facility shall take renewal mandated reporter training every two years following the date on which that person completed the initial mandated reporter training. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(f) Unless otherwise specifically provided, the absence of training shall not excuse a mandated reporter from the duties imposed by this article.(g) Public and private organizations are encouraged to provide their volunteers whose duties require direct contact with and supervision of children with training in the identification and reporting of child abuse and neglect. |
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| 1075 | 1075 | | |
|---|
| 1076 | 1076 | | 11165.7. (a) As used in this article, mandated reporter is defined as any of the following:(1) A teacher.(2) An instructional aide.(3) A teachers aide or teachers assistant employed by a public or private school.(4) A classified employee of a public school.(5) An administrative officer or supervisor of child welfare and attendance, or a certificated pupil personnel employee of a public or private school.(6) An administrator of a public or private day camp.(7) An administrator or employee of a public or private youth center, youth recreation program, or youth organization.(8) An administrator, board member, or employee of a public or private organization whose duties require direct contact and supervision of children, including a foster family agency.(9) An employee of a county office of education or the State Department of Education whose duties bring the employee into contact with children on a regular basis.(10) A licensee, an administrator, or an employee of a licensed community care or child daycare facility.(11) A Head Start program teacher.(12) A licensing worker or licensing evaluator employed by a licensing agency, as defined in Section 11165.11.(13) A public assistance worker.(14) An employee of a childcare institution, including, but not limited to, foster parents, group home personnel, and personnel of residential care facilities.(15) A social worker, probation officer, or parole officer.(16) An employee of a school district police or security department.(17) A person who is an administrator or presenter of, or a counselor in, a child abuse prevention program in a public or private school.(18) A district attorney investigator, inspector, or local child support agency caseworker, unless the investigator, inspector, or caseworker is working with an attorney appointed pursuant to Section 317 of the Welfare and Institutions Code to represent a minor.(19) A peace officer, as defined in Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2, who is not otherwise described in this section.(20) A firefighter, except for volunteer firefighters.(21) A physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse, dental hygienist, optometrist, marriage and family therapist, clinical social worker, professional clinical counselor, or any other person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(22) An emergency medical technician I or II, paramedic, or other person certified pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code.(23) A psychological assistant registered pursuant to Section 2913 of the Business and Professions Code.(24) A marriage and family therapist trainee, as defined in subdivision (c) of Section 4980.03 of the Business and Professions Code.(25) An unlicensed associate marriage and family therapist registered under Section 4980.44 of the Business and Professions Code.(26) A state or county public health employee who treats a minor for venereal disease or any other condition.(27) A coroner.(28) A medical examiner or other person who performs autopsies.(29) A commercial film and photographic print or image processor as specified in subdivision (e) of Section 11166. As used in this article, commercial film and photographic print or image processor means a person who develops exposed photographic film into negatives, slides, or prints, or who makes prints from negatives or slides, or who prepares, publishes, produces, develops, duplicates, or prints any representation of information, data, or an image, including, but not limited to, any film, filmstrip, photograph, negative, slide, photocopy, videotape, video laser disc, computer hardware, computer software, computer floppy disk, data storage medium, CD-ROM, computer-generated equipment, or computer-generated image, for compensation. The term includes any employee of that person; it does not include a person who develops film or makes prints or images for a public agency.(30) A child visitation monitor. As used in this article, child visitation monitor means a person who, for financial compensation, acts as a monitor of a visit between a child and another person when the monitoring of that visit has been ordered by a court of law.(31) An animal control officer or humane society officer. For the purposes of this article, the following terms have the following meanings:(A) Animal control officer means a person employed by a city, county, or city and county for the purpose of enforcing animal control laws or regulations.(B) Humane society officer means a person appointed or employed by a public or private entity as a humane officer who is qualified pursuant to Section 14502 or 14503 of the Corporations Code.(32) A clergy member, as specified in subdivision (d) of Section 11166. As used in this article, clergy member means a priest, minister, rabbi, religious practitioner, or similar functionary of a church, temple, or recognized denomination or organization.(33) Any custodian of records of a clergy member, as specified in this section and subdivision (d) of Section 11166.(34) An employee of any police department, county sheriffs department, county probation department, or county welfare department.(35) An employee or volunteer of a Court Appointed Special Advocate program, as defined in Rule 5.655 of the California Rules of Court.(36) A custodial officer, as defined in Section 831.5.(37) A person providing services to a minor child under Section 12300 or 12300.1 of the Welfare and Institutions Code.(38) An alcohol and drug counselor. As used in this article, an alcohol and drug counselor is a person providing counseling, therapy, or other clinical services for a state licensed or certified drug, alcohol, or drug and alcohol treatment program. However, alcohol or drug abuse, or both alcohol and drug abuse, is not, in and of itself, a sufficient basis for reporting child abuse or neglect.(39) A clinical counselor trainee, as defined in subdivision (g) of Section 4999.12 of the Business and Professions Code.(40) An associate professional clinical counselor registered under Section 4999.42 of the Business and Professions Code.(41) An employee or administrator of a public or private postsecondary educational institution, whose duties bring the administrator or employee into contact with children on a regular basis, or who supervises those whose duties bring the administrator or employee into contact with children on a regular basis, as to child abuse or neglect occurring on that institutions premises or at an official activity of, or program conducted by, the institution. Nothing in this paragraph shall be construed as altering the lawyer-client privilege as set forth in Article 3 (commencing with Section 950) of Chapter 4 of Division 8 of the Evidence Code.(42) An athletic coach, athletic administrator, or athletic director employed by any public or private school that provides any combination of instruction for kindergarten, or grades 1 to 12, inclusive.(43) (A) A commercial computer technician as specified in subdivision (e) of Section 11166. As used in this article, commercial computer technician means a person who works for a company that is in the business of repairing, installing, or otherwise servicing a computer or computer component, including, but not limited to, a computer part, device, memory storage or recording mechanism, auxiliary storage recording or memory capacity, or any other material relating to the operation and maintenance of a computer or computer network system, for a fee. An employer who provides an electronic communications service or a remote computing service to the public shall be deemed to comply with this article if that employer complies with Section 2258A of Title 18 of the United States Code.(B) An employer of a commercial computer technician may implement internal procedures for facilitating reporting consistent with this article. These procedures may direct employees who are mandated reporters under this paragraph to report materials described in subdivision (e) of Section 11166 to an employee who is designated by the employer to receive the reports. An employee who is designated to receive reports under this subparagraph shall be a commercial computer technician for purposes of this article. A commercial computer technician who makes a report to the designated employee pursuant to this subparagraph shall be deemed to have complied with the requirements of this article and shall be subject to the protections afforded to mandated reporters, including, but not limited to, those protections afforded by Section 11172.(44) Any athletic coach, including, but not limited to, an assistant coach or a graduate assistant involved in coaching, at public or private postsecondary educational institutions.(45) An individual certified by a licensed foster family agency as a certified family home, as defined in Section 1506 of the Health and Safety Code.(46) An individual approved as a resource family, as defined in Section 1517 of the Health and Safety Code and Section 16519.5 of the Welfare and Institutions Code.(47) A qualified autism service provider, a qualified autism service professional, or a qualified autism service paraprofessional, as defined in Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. paraprofessional as defined in Chapter 17 (commencing with Section 4999.200) of Division 2 of the Business and Professions Code.(48) A human resource employee of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code that employs minors. For purposes of this section, a human resource employee is the employee or employees designated by the employer to accept any complaints of misconduct as required by Chapter 6 (commencing with Section 12940) of Part 2.8 of Division 3 of Title 2 of the Government Code.(49) An adult person whose duties require direct contact with and supervision of minors in the performance of the minors duties in the workplace of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code is a mandated reporter of sexual abuse, as defined in Section 11165.1. Nothing in this paragraph shall be construed to modify or limit the persons duty to report known or suspected child abuse or neglect when the person is acting in some other capacity that would otherwise make the person a mandated reporter.(b) Except as provided in paragraph (35) of subdivision (a), volunteers of public or private organizations whose duties require direct contact with and supervision of children are not mandated reporters but are encouraged to obtain training in the identification and reporting of child abuse and neglect and are further encouraged to report known or suspected instances of child abuse or neglect to an agency specified in Section 11165.9.(c) (1) Except as provided in subdivision (d) and paragraph (2), employers are strongly encouraged to provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. Whether or not employers provide their employees with training in child abuse and neglect identification and reporting, the employers shall provide their employees who are mandated reporters with the statement required pursuant to subdivision (a) of Section 11166.5.(2) Employers subject to paragraphs (48) and (49) of subdivision (a) shall provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. The training requirement may be met by completing the general online training for mandated reporters offered by the Office of Child Abuse Prevention in the State Department of Social Services.(d) Pursuant to Section 44691 of the Education Code, school districts, county offices of education, state special schools and diagnostic centers operated by the State Department of Education, and charter schools shall annually train their employees and persons working on their behalf specified in subdivision (a) in the duties of mandated reporters under the child abuse reporting laws. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(e) (1) On and after January 1, 2018, pursuant to Section 1596.8662 of the Health and Safety Code, a childcare licensee applicant shall take training in the duties of mandated reporters under the child abuse reporting laws as a condition of licensure, and a childcare administrator or an employee of a licensed child daycare facility shall take training in the duties of mandated reporters during the first 90 days when that administrator or employee is employed by the facility.(2) A person specified in paragraph (1) who becomes a licensee, administrator, or employee of a licensed child daycare facility shall take renewal mandated reporter training every two years following the date on which that person completed the initial mandated reporter training. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(f) Unless otherwise specifically provided, the absence of training shall not excuse a mandated reporter from the duties imposed by this article.(g) Public and private organizations are encouraged to provide their volunteers whose duties require direct contact with and supervision of children with training in the identification and reporting of child abuse and neglect. |
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| 1077 | 1077 | | |
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| 1078 | 1078 | | 11165.7. (a) As used in this article, mandated reporter is defined as any of the following:(1) A teacher.(2) An instructional aide.(3) A teachers aide or teachers assistant employed by a public or private school.(4) A classified employee of a public school.(5) An administrative officer or supervisor of child welfare and attendance, or a certificated pupil personnel employee of a public or private school.(6) An administrator of a public or private day camp.(7) An administrator or employee of a public or private youth center, youth recreation program, or youth organization.(8) An administrator, board member, or employee of a public or private organization whose duties require direct contact and supervision of children, including a foster family agency.(9) An employee of a county office of education or the State Department of Education whose duties bring the employee into contact with children on a regular basis.(10) A licensee, an administrator, or an employee of a licensed community care or child daycare facility.(11) A Head Start program teacher.(12) A licensing worker or licensing evaluator employed by a licensing agency, as defined in Section 11165.11.(13) A public assistance worker.(14) An employee of a childcare institution, including, but not limited to, foster parents, group home personnel, and personnel of residential care facilities.(15) A social worker, probation officer, or parole officer.(16) An employee of a school district police or security department.(17) A person who is an administrator or presenter of, or a counselor in, a child abuse prevention program in a public or private school.(18) A district attorney investigator, inspector, or local child support agency caseworker, unless the investigator, inspector, or caseworker is working with an attorney appointed pursuant to Section 317 of the Welfare and Institutions Code to represent a minor.(19) A peace officer, as defined in Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2, who is not otherwise described in this section.(20) A firefighter, except for volunteer firefighters.(21) A physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse, dental hygienist, optometrist, marriage and family therapist, clinical social worker, professional clinical counselor, or any other person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code.(22) An emergency medical technician I or II, paramedic, or other person certified pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code.(23) A psychological assistant registered pursuant to Section 2913 of the Business and Professions Code.(24) A marriage and family therapist trainee, as defined in subdivision (c) of Section 4980.03 of the Business and Professions Code.(25) An unlicensed associate marriage and family therapist registered under Section 4980.44 of the Business and Professions Code.(26) A state or county public health employee who treats a minor for venereal disease or any other condition.(27) A coroner.(28) A medical examiner or other person who performs autopsies.(29) A commercial film and photographic print or image processor as specified in subdivision (e) of Section 11166. As used in this article, commercial film and photographic print or image processor means a person who develops exposed photographic film into negatives, slides, or prints, or who makes prints from negatives or slides, or who prepares, publishes, produces, develops, duplicates, or prints any representation of information, data, or an image, including, but not limited to, any film, filmstrip, photograph, negative, slide, photocopy, videotape, video laser disc, computer hardware, computer software, computer floppy disk, data storage medium, CD-ROM, computer-generated equipment, or computer-generated image, for compensation. The term includes any employee of that person; it does not include a person who develops film or makes prints or images for a public agency.(30) A child visitation monitor. As used in this article, child visitation monitor means a person who, for financial compensation, acts as a monitor of a visit between a child and another person when the monitoring of that visit has been ordered by a court of law.(31) An animal control officer or humane society officer. For the purposes of this article, the following terms have the following meanings:(A) Animal control officer means a person employed by a city, county, or city and county for the purpose of enforcing animal control laws or regulations.(B) Humane society officer means a person appointed or employed by a public or private entity as a humane officer who is qualified pursuant to Section 14502 or 14503 of the Corporations Code.(32) A clergy member, as specified in subdivision (d) of Section 11166. As used in this article, clergy member means a priest, minister, rabbi, religious practitioner, or similar functionary of a church, temple, or recognized denomination or organization.(33) Any custodian of records of a clergy member, as specified in this section and subdivision (d) of Section 11166.(34) An employee of any police department, county sheriffs department, county probation department, or county welfare department.(35) An employee or volunteer of a Court Appointed Special Advocate program, as defined in Rule 5.655 of the California Rules of Court.(36) A custodial officer, as defined in Section 831.5.(37) A person providing services to a minor child under Section 12300 or 12300.1 of the Welfare and Institutions Code.(38) An alcohol and drug counselor. As used in this article, an alcohol and drug counselor is a person providing counseling, therapy, or other clinical services for a state licensed or certified drug, alcohol, or drug and alcohol treatment program. However, alcohol or drug abuse, or both alcohol and drug abuse, is not, in and of itself, a sufficient basis for reporting child abuse or neglect.(39) A clinical counselor trainee, as defined in subdivision (g) of Section 4999.12 of the Business and Professions Code.(40) An associate professional clinical counselor registered under Section 4999.42 of the Business and Professions Code.(41) An employee or administrator of a public or private postsecondary educational institution, whose duties bring the administrator or employee into contact with children on a regular basis, or who supervises those whose duties bring the administrator or employee into contact with children on a regular basis, as to child abuse or neglect occurring on that institutions premises or at an official activity of, or program conducted by, the institution. Nothing in this paragraph shall be construed as altering the lawyer-client privilege as set forth in Article 3 (commencing with Section 950) of Chapter 4 of Division 8 of the Evidence Code.(42) An athletic coach, athletic administrator, or athletic director employed by any public or private school that provides any combination of instruction for kindergarten, or grades 1 to 12, inclusive.(43) (A) A commercial computer technician as specified in subdivision (e) of Section 11166. As used in this article, commercial computer technician means a person who works for a company that is in the business of repairing, installing, or otherwise servicing a computer or computer component, including, but not limited to, a computer part, device, memory storage or recording mechanism, auxiliary storage recording or memory capacity, or any other material relating to the operation and maintenance of a computer or computer network system, for a fee. An employer who provides an electronic communications service or a remote computing service to the public shall be deemed to comply with this article if that employer complies with Section 2258A of Title 18 of the United States Code.(B) An employer of a commercial computer technician may implement internal procedures for facilitating reporting consistent with this article. These procedures may direct employees who are mandated reporters under this paragraph to report materials described in subdivision (e) of Section 11166 to an employee who is designated by the employer to receive the reports. An employee who is designated to receive reports under this subparagraph shall be a commercial computer technician for purposes of this article. A commercial computer technician who makes a report to the designated employee pursuant to this subparagraph shall be deemed to have complied with the requirements of this article and shall be subject to the protections afforded to mandated reporters, including, but not limited to, those protections afforded by Section 11172.(44) Any athletic coach, including, but not limited to, an assistant coach or a graduate assistant involved in coaching, at public or private postsecondary educational institutions.(45) An individual certified by a licensed foster family agency as a certified family home, as defined in Section 1506 of the Health and Safety Code.(46) An individual approved as a resource family, as defined in Section 1517 of the Health and Safety Code and Section 16519.5 of the Welfare and Institutions Code.(47) A qualified autism service provider, a qualified autism service professional, or a qualified autism service paraprofessional, as defined in Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. paraprofessional as defined in Chapter 17 (commencing with Section 4999.200) of Division 2 of the Business and Professions Code.(48) A human resource employee of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code that employs minors. For purposes of this section, a human resource employee is the employee or employees designated by the employer to accept any complaints of misconduct as required by Chapter 6 (commencing with Section 12940) of Part 2.8 of Division 3 of Title 2 of the Government Code.(49) An adult person whose duties require direct contact with and supervision of minors in the performance of the minors duties in the workplace of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code is a mandated reporter of sexual abuse, as defined in Section 11165.1. Nothing in this paragraph shall be construed to modify or limit the persons duty to report known or suspected child abuse or neglect when the person is acting in some other capacity that would otherwise make the person a mandated reporter.(b) Except as provided in paragraph (35) of subdivision (a), volunteers of public or private organizations whose duties require direct contact with and supervision of children are not mandated reporters but are encouraged to obtain training in the identification and reporting of child abuse and neglect and are further encouraged to report known or suspected instances of child abuse or neglect to an agency specified in Section 11165.9.(c) (1) Except as provided in subdivision (d) and paragraph (2), employers are strongly encouraged to provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. Whether or not employers provide their employees with training in child abuse and neglect identification and reporting, the employers shall provide their employees who are mandated reporters with the statement required pursuant to subdivision (a) of Section 11166.5.(2) Employers subject to paragraphs (48) and (49) of subdivision (a) shall provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. The training requirement may be met by completing the general online training for mandated reporters offered by the Office of Child Abuse Prevention in the State Department of Social Services.(d) Pursuant to Section 44691 of the Education Code, school districts, county offices of education, state special schools and diagnostic centers operated by the State Department of Education, and charter schools shall annually train their employees and persons working on their behalf specified in subdivision (a) in the duties of mandated reporters under the child abuse reporting laws. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(e) (1) On and after January 1, 2018, pursuant to Section 1596.8662 of the Health and Safety Code, a childcare licensee applicant shall take training in the duties of mandated reporters under the child abuse reporting laws as a condition of licensure, and a childcare administrator or an employee of a licensed child daycare facility shall take training in the duties of mandated reporters during the first 90 days when that administrator or employee is employed by the facility.(2) A person specified in paragraph (1) who becomes a licensee, administrator, or employee of a licensed child daycare facility shall take renewal mandated reporter training every two years following the date on which that person completed the initial mandated reporter training. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting.(f) Unless otherwise specifically provided, the absence of training shall not excuse a mandated reporter from the duties imposed by this article.(g) Public and private organizations are encouraged to provide their volunteers whose duties require direct contact with and supervision of children with training in the identification and reporting of child abuse and neglect. |
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| 1079 | 1079 | | |
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| 1080 | 1080 | | |
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| 1081 | 1081 | | |
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| 1082 | 1082 | | 11165.7. (a) As used in this article, mandated reporter is defined as any of the following: |
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| 1083 | 1083 | | |
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| 1084 | 1084 | | (1) A teacher. |
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| 1085 | 1085 | | |
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| 1086 | 1086 | | (2) An instructional aide. |
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| 1087 | 1087 | | |
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| 1088 | 1088 | | (3) A teachers aide or teachers assistant employed by a public or private school. |
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| 1089 | 1089 | | |
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| 1090 | 1090 | | (4) A classified employee of a public school. |
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| 1091 | 1091 | | |
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| 1092 | 1092 | | (5) An administrative officer or supervisor of child welfare and attendance, or a certificated pupil personnel employee of a public or private school. |
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| 1093 | 1093 | | |
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| 1094 | 1094 | | (6) An administrator of a public or private day camp. |
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| 1095 | 1095 | | |
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| 1096 | 1096 | | (7) An administrator or employee of a public or private youth center, youth recreation program, or youth organization. |
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| 1097 | 1097 | | |
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| 1098 | 1098 | | (8) An administrator, board member, or employee of a public or private organization whose duties require direct contact and supervision of children, including a foster family agency. |
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| 1099 | 1099 | | |
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| 1100 | 1100 | | (9) An employee of a county office of education or the State Department of Education whose duties bring the employee into contact with children on a regular basis. |
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| 1101 | 1101 | | |
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| 1102 | 1102 | | (10) A licensee, an administrator, or an employee of a licensed community care or child daycare facility. |
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| 1103 | 1103 | | |
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| 1104 | 1104 | | (11) A Head Start program teacher. |
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| 1105 | 1105 | | |
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| 1106 | 1106 | | (12) A licensing worker or licensing evaluator employed by a licensing agency, as defined in Section 11165.11. |
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| 1107 | 1107 | | |
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| 1108 | 1108 | | (13) A public assistance worker. |
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| 1109 | 1109 | | |
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| 1110 | 1110 | | (14) An employee of a childcare institution, including, but not limited to, foster parents, group home personnel, and personnel of residential care facilities. |
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| 1111 | 1111 | | |
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| 1112 | 1112 | | (15) A social worker, probation officer, or parole officer. |
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| 1113 | 1113 | | |
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| 1114 | 1114 | | (16) An employee of a school district police or security department. |
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| 1115 | 1115 | | |
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| 1116 | 1116 | | (17) A person who is an administrator or presenter of, or a counselor in, a child abuse prevention program in a public or private school. |
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| 1117 | 1117 | | |
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| 1118 | 1118 | | (18) A district attorney investigator, inspector, or local child support agency caseworker, unless the investigator, inspector, or caseworker is working with an attorney appointed pursuant to Section 317 of the Welfare and Institutions Code to represent a minor. |
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| 1119 | 1119 | | |
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| 1120 | 1120 | | (19) A peace officer, as defined in Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2, who is not otherwise described in this section. |
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| 1121 | 1121 | | |
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| 1122 | 1122 | | (20) A firefighter, except for volunteer firefighters. |
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| 1123 | 1123 | | |
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| 1124 | 1124 | | (21) A physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse, dental hygienist, optometrist, marriage and family therapist, clinical social worker, professional clinical counselor, or any other person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code. |
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| 1125 | 1125 | | |
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| 1126 | 1126 | | (22) An emergency medical technician I or II, paramedic, or other person certified pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code. |
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| 1127 | 1127 | | |
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| 1128 | 1128 | | (23) A psychological assistant registered pursuant to Section 2913 of the Business and Professions Code. |
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| 1129 | 1129 | | |
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| 1130 | 1130 | | (24) A marriage and family therapist trainee, as defined in subdivision (c) of Section 4980.03 of the Business and Professions Code. |
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| 1131 | 1131 | | |
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| 1132 | 1132 | | (25) An unlicensed associate marriage and family therapist registered under Section 4980.44 of the Business and Professions Code. |
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| 1133 | 1133 | | |
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| 1134 | 1134 | | (26) A state or county public health employee who treats a minor for venereal disease or any other condition. |
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| 1135 | 1135 | | |
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| 1136 | 1136 | | (27) A coroner. |
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| 1137 | 1137 | | |
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| 1138 | 1138 | | (28) A medical examiner or other person who performs autopsies. |
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| 1139 | 1139 | | |
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| 1140 | 1140 | | (29) A commercial film and photographic print or image processor as specified in subdivision (e) of Section 11166. As used in this article, commercial film and photographic print or image processor means a person who develops exposed photographic film into negatives, slides, or prints, or who makes prints from negatives or slides, or who prepares, publishes, produces, develops, duplicates, or prints any representation of information, data, or an image, including, but not limited to, any film, filmstrip, photograph, negative, slide, photocopy, videotape, video laser disc, computer hardware, computer software, computer floppy disk, data storage medium, CD-ROM, computer-generated equipment, or computer-generated image, for compensation. The term includes any employee of that person; it does not include a person who develops film or makes prints or images for a public agency. |
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| 1141 | 1141 | | |
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| 1142 | 1142 | | (30) A child visitation monitor. As used in this article, child visitation monitor means a person who, for financial compensation, acts as a monitor of a visit between a child and another person when the monitoring of that visit has been ordered by a court of law. |
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| 1143 | 1143 | | |
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| 1144 | 1144 | | (31) An animal control officer or humane society officer. For the purposes of this article, the following terms have the following meanings: |
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| 1145 | 1145 | | |
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| 1146 | 1146 | | (A) Animal control officer means a person employed by a city, county, or city and county for the purpose of enforcing animal control laws or regulations. |
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| 1147 | 1147 | | |
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| 1148 | 1148 | | (B) Humane society officer means a person appointed or employed by a public or private entity as a humane officer who is qualified pursuant to Section 14502 or 14503 of the Corporations Code. |
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| 1149 | 1149 | | |
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| 1150 | 1150 | | (32) A clergy member, as specified in subdivision (d) of Section 11166. As used in this article, clergy member means a priest, minister, rabbi, religious practitioner, or similar functionary of a church, temple, or recognized denomination or organization. |
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| 1151 | 1151 | | |
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| 1152 | 1152 | | (33) Any custodian of records of a clergy member, as specified in this section and subdivision (d) of Section 11166. |
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| 1153 | 1153 | | |
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| 1154 | 1154 | | (34) An employee of any police department, county sheriffs department, county probation department, or county welfare department. |
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| 1155 | 1155 | | |
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| 1156 | 1156 | | (35) An employee or volunteer of a Court Appointed Special Advocate program, as defined in Rule 5.655 of the California Rules of Court. |
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| 1157 | 1157 | | |
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| 1158 | 1158 | | (36) A custodial officer, as defined in Section 831.5. |
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| 1159 | 1159 | | |
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| 1160 | 1160 | | (37) A person providing services to a minor child under Section 12300 or 12300.1 of the Welfare and Institutions Code. |
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| 1161 | 1161 | | |
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| 1162 | 1162 | | (38) An alcohol and drug counselor. As used in this article, an alcohol and drug counselor is a person providing counseling, therapy, or other clinical services for a state licensed or certified drug, alcohol, or drug and alcohol treatment program. However, alcohol or drug abuse, or both alcohol and drug abuse, is not, in and of itself, a sufficient basis for reporting child abuse or neglect. |
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| 1163 | 1163 | | |
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| 1164 | 1164 | | (39) A clinical counselor trainee, as defined in subdivision (g) of Section 4999.12 of the Business and Professions Code. |
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| 1165 | 1165 | | |
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| 1166 | 1166 | | (40) An associate professional clinical counselor registered under Section 4999.42 of the Business and Professions Code. |
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| 1167 | 1167 | | |
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| 1168 | 1168 | | (41) An employee or administrator of a public or private postsecondary educational institution, whose duties bring the administrator or employee into contact with children on a regular basis, or who supervises those whose duties bring the administrator or employee into contact with children on a regular basis, as to child abuse or neglect occurring on that institutions premises or at an official activity of, or program conducted by, the institution. Nothing in this paragraph shall be construed as altering the lawyer-client privilege as set forth in Article 3 (commencing with Section 950) of Chapter 4 of Division 8 of the Evidence Code. |
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| 1169 | 1169 | | |
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| 1170 | 1170 | | (42) An athletic coach, athletic administrator, or athletic director employed by any public or private school that provides any combination of instruction for kindergarten, or grades 1 to 12, inclusive. |
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| 1171 | 1171 | | |
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| 1172 | 1172 | | (43) (A) A commercial computer technician as specified in subdivision (e) of Section 11166. As used in this article, commercial computer technician means a person who works for a company that is in the business of repairing, installing, or otherwise servicing a computer or computer component, including, but not limited to, a computer part, device, memory storage or recording mechanism, auxiliary storage recording or memory capacity, or any other material relating to the operation and maintenance of a computer or computer network system, for a fee. An employer who provides an electronic communications service or a remote computing service to the public shall be deemed to comply with this article if that employer complies with Section 2258A of Title 18 of the United States Code. |
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| 1173 | 1173 | | |
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| 1174 | 1174 | | (B) An employer of a commercial computer technician may implement internal procedures for facilitating reporting consistent with this article. These procedures may direct employees who are mandated reporters under this paragraph to report materials described in subdivision (e) of Section 11166 to an employee who is designated by the employer to receive the reports. An employee who is designated to receive reports under this subparagraph shall be a commercial computer technician for purposes of this article. A commercial computer technician who makes a report to the designated employee pursuant to this subparagraph shall be deemed to have complied with the requirements of this article and shall be subject to the protections afforded to mandated reporters, including, but not limited to, those protections afforded by Section 11172. |
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| 1175 | 1175 | | |
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| 1176 | 1176 | | (44) Any athletic coach, including, but not limited to, an assistant coach or a graduate assistant involved in coaching, at public or private postsecondary educational institutions. |
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| 1177 | 1177 | | |
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| 1178 | 1178 | | (45) An individual certified by a licensed foster family agency as a certified family home, as defined in Section 1506 of the Health and Safety Code. |
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| 1179 | 1179 | | |
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| 1180 | 1180 | | (46) An individual approved as a resource family, as defined in Section 1517 of the Health and Safety Code and Section 16519.5 of the Welfare and Institutions Code. |
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| 1181 | 1181 | | |
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| 1182 | 1182 | | (47) A qualified autism service provider, a qualified autism service professional, or a qualified autism service paraprofessional, as defined in Section 1374.73 of the Health and Safety Code and Section 10144.51 of the Insurance Code. paraprofessional as defined in Chapter 17 (commencing with Section 4999.200) of Division 2 of the Business and Professions Code. |
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| 1183 | 1183 | | |
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| 1184 | 1184 | | (48) A human resource employee of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code that employs minors. For purposes of this section, a human resource employee is the employee or employees designated by the employer to accept any complaints of misconduct as required by Chapter 6 (commencing with Section 12940) of Part 2.8 of Division 3 of Title 2 of the Government Code. |
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| 1185 | 1185 | | |
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| 1186 | 1186 | | (49) An adult person whose duties require direct contact with and supervision of minors in the performance of the minors duties in the workplace of a business subject to Part 2.8 (commencing with Section 12900) of Division 3 of Title 2 of the Government Code is a mandated reporter of sexual abuse, as defined in Section 11165.1. Nothing in this paragraph shall be construed to modify or limit the persons duty to report known or suspected child abuse or neglect when the person is acting in some other capacity that would otherwise make the person a mandated reporter. |
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| 1187 | 1187 | | |
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| 1188 | 1188 | | (b) Except as provided in paragraph (35) of subdivision (a), volunteers of public or private organizations whose duties require direct contact with and supervision of children are not mandated reporters but are encouraged to obtain training in the identification and reporting of child abuse and neglect and are further encouraged to report known or suspected instances of child abuse or neglect to an agency specified in Section 11165.9. |
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| 1189 | 1189 | | |
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| 1190 | 1190 | | (c) (1) Except as provided in subdivision (d) and paragraph (2), employers are strongly encouraged to provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. Whether or not employers provide their employees with training in child abuse and neglect identification and reporting, the employers shall provide their employees who are mandated reporters with the statement required pursuant to subdivision (a) of Section 11166.5. |
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| 1191 | 1191 | | |
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| 1192 | 1192 | | (2) Employers subject to paragraphs (48) and (49) of subdivision (a) shall provide their employees who are mandated reporters with training in the duties imposed by this article. This training shall include training in child abuse and neglect identification and training in child abuse and neglect reporting. The training requirement may be met by completing the general online training for mandated reporters offered by the Office of Child Abuse Prevention in the State Department of Social Services. |
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| 1193 | 1193 | | |
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| 1194 | 1194 | | (d) Pursuant to Section 44691 of the Education Code, school districts, county offices of education, state special schools and diagnostic centers operated by the State Department of Education, and charter schools shall annually train their employees and persons working on their behalf specified in subdivision (a) in the duties of mandated reporters under the child abuse reporting laws. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting. |
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| 1195 | 1195 | | |
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| 1196 | 1196 | | (e) (1) On and after January 1, 2018, pursuant to Section 1596.8662 of the Health and Safety Code, a childcare licensee applicant shall take training in the duties of mandated reporters under the child abuse reporting laws as a condition of licensure, and a childcare administrator or an employee of a licensed child daycare facility shall take training in the duties of mandated reporters during the first 90 days when that administrator or employee is employed by the facility. |
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| 1197 | 1197 | | |
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| 1198 | 1198 | | (2) A person specified in paragraph (1) who becomes a licensee, administrator, or employee of a licensed child daycare facility shall take renewal mandated reporter training every two years following the date on which that person completed the initial mandated reporter training. The training shall include, but not necessarily be limited to, training in child abuse and neglect identification and child abuse and neglect reporting. |
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| 1199 | 1199 | | |
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| 1200 | 1200 | | (f) Unless otherwise specifically provided, the absence of training shall not excuse a mandated reporter from the duties imposed by this article. |
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| 1201 | 1201 | | |
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| 1202 | 1202 | | (g) Public and private organizations are encouraged to provide their volunteers whose duties require direct contact with and supervision of children with training in the identification and reporting of child abuse and neglect. |
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