Health care coverage: autism.

SB 402

California Bills

20250SB__040295CHP INTRODUCED 2025-02-14 AMENDED_ASSEMBLY 2025-08-27 AMENDED_ASSEMBLY 2025-09-05 PASSED_ASSEMBLY 2025-09-09 PASSED_SENATE 2025-09-11 ENROLLED 2025-09-16 CHAPTERED 2025-10-06 APPROVED 2025-10-06 FILED 2025-10-06 2025 SB CHP CHP 0 Introduced by Senator Valladares LEAD_AUTHOR SENATE Valladares

An act to amend

Section 2290.5 of, and to add

Chapter 17 (commencing with

Section 4999.200) to Division 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. health care coverage 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. This bill would incorporate additional changes to

Section 1367.27 of the Health and Safety Code and

Section 10133.15 of the Insurance Code proposed by AB to be operative only if this bill and AB are enacted and this bill is enacted last. This bill would incorporate additional changes to

Section 1374.73 of the Health and Safety Code and

Section 10144.51 of the Insurance Code proposed by AB to be operative only if this bill and AB are enacted and this bill is enacted last. This bill would incorporate additional changes to

Section 11165.7 of the Penal Code proposed by AB and SB 848, to be operative only if this bill and either or both of those bills are enacted and this bill is enacted last. MAJORITY NO NO NO NO NO NO NO NO NO NO The people of the State of California do enact as follows:

SECTION

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 patient’s 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 certified by a national entity 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 patient’s 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 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 patient’s rights to the patient’s 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 provider’s 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 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 of the Code of Federal Regulations.

SEC. 2.

Chapter 17 (commencing with

Section 4999.200) is added to Division of the Business and Professions Code , to read: 17. Qualified Autism Service Providers 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. 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 of Title 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 of Title 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.

Section 1367.27 of the Health and Safety Code is amended to read: 1367.27. (

a) Commencing July 1, 2016, a health care service plan shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan’s enrollees, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the plan. (

b) A health care service plan shall provide the directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, enrollees, potential enrollees, the department, and other state or federal agencies can easily identify the networks and plan products in which a provider participates. By July 31, 2017, or months after the date provider directory standards are developed under subdivision (k), whichever occurs later, a health care service plan shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k). (c)

(1) An online provider directory or directories shall be available on the plan’s internet website to the public, potential enrollees, enrollees, and providers without any restrictions or limitations. The directory or directories shall be accessible without any requirement that an individual seeking the directory information demonstrate coverage with the plan, indicate interest in obtaining coverage with the plan, provide a member identification or policy number, provide any other identifying information, or create or access an account.

(2) The online provider directory or directories shall be accessible on the plan’s public internet website through an identifiable link or tab and in a manner that is accessible and searchable by enrollees, potential enrollees, the public, and providers.

By July 31, 2017, or months after the date provider directory standards are developed under subdivision (k), whichever occurs later, the plan’s public internet website shall allow provider searches by, at a minimum, name, practice address, city, ZIP Code, California license number, National Provider Identifier number, admitting privileges to an identified hospital, product, tier, provider language or languages, provider group, hospital name, facility name, or clinic name, as appropriate. (d)

(1) A health care service plan shall allow enrollees, potential enrollees, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the plan through the plan’s toll-free telephone number, electronically, or in writing. A printed copy of the provider directory or directories shall include the information required in subdivisions (

h) and (i). The printed copy of the provider directory or directories shall be provided to the requester by mail postmarked no later than five business days following the date of the request and may be limited to the geographic region in which the requester resides or works or intends to reside or work.

(2) A health care service plan shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law. (e)

(1) The plan shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the plan of any of the following: (

A) A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients. (

B) A provider is no longer under contract for a particular plan product. (

C) A provider’s practice location or other information required under subdivision (

h) or (

i) has changed. (

D) Upon completion of the investigation described in subdivision (o), a change is necessary based on an enrollee complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly. (

E) Any other information that affects the content or accuracy of the provider directory or directories.

(2) Upon confirmation of any of the following, the plan shall delete a provider from the directory or directories when: (

A) A provider has retired or otherwise has ceased to practice. (

B) A provider or provider group is no longer under contract with the plan for any reason. (

C) The contracting provider group has informed the plan that the provider is no longer associated with the provider group and is no longer under contract with the plan. (

f) The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the plan if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the plan’s internet website. (

g) The provider directory or directories shall include the following disclosures informing enrollees that they are entitled to both of the following:

(1) Language interpreter services, at no cost to the enrollee, including how to obtain

interpretation services in accordance with

Section 1367.04.

(2) Full and equal access to covered services, including enrollees with disabilities as required under the federal Americans with Disabilities Act of and

Section of the Rehabilitation Act of 1973. (

h) A full service health care service plan and a specialized mental health plan shall include all of the following information in the provider directory or directories:

(1) The provider’s name, practice location or locations, and contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) The provider’s office email address, if available.

(7) The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.

(8) A listing for each of the following providers that are under contract with the plan: (

A) For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the plan. (

B) Nurse practitioners, physician assistants, psychologists, acupuncturists, optometrists, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in

Section 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 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 provider’s staff.

(11) Identification of providers who no longer accept new patients for some or all of the plan’s products.

(12) The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. 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 provider’s name, practice location or locations, and contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license, if applicable.

(5) The area of specialty, including board certification, or other accreditation, if any.

(6) The provider’s office email address, if available.

(7) The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.

(8) The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the plan.

(9) The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with

Section 1367.04, if any, on the provider’s staff.

(10) Identification of providers who no longer accept new patients for some or all of the plan’s products.

(11) All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c). (j)

(1) The contract between the plan and a provider shall include a requirement that the provider inform the plan within five business days when either of the following occurs: (

A) The provider is not accepting new patients. (

B) If the provider had previously not accepted new patients, the provider is currently accepting new patients.

(2) If a provider who is not accepting new patients is contacted by an enrollee or potential enrollee seeking to become a new patient, the provider shall direct the enrollee or potential enrollee to both the plan for additional assistance in finding a provider and to the department to report any inaccuracy with the plan’s directory or directories.

(3) If an enrollee or potential enrollee informs a plan of a possible inaccuracy in the provider directory or directories, the plan shall promptly investigate, and, if necessary, undertake corrective action within 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 of Division of Title 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 of Division of Title 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 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 plan’s provider directory or directories in accordance with this section, and shall, at least annually, review and update the entire provider directory or directories for each product offered. Each calendar year the 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 business days, the plan shall take no more than business days to verify whether the provider’s 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 provider’s information is correct or requires updates, the plan shall notify the provider 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 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). (

(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 plan’s 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 plan’s provider directory internet website linking to a form where the information can be reported directly to the plan through its 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 group’s attempt to verify the provider’s information. As used in this paragraph, “verify” means to contact the provider in writing, electronically, and by telephone to confirm whether the provider’s information is correct or requires updates. (

B) The provider group documents its efforts to verify the provider’s information. (

C) The provider group reports to the 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 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 provider’s name, location, and a description of the plan’s investigation, the outcome of the investigation, and any changes or updates made to its provider directory or directories. (

C) If changes to a plan’s provider directory or directories are required as a result of the plan’s investigation, the changes to the online provider directory or directories shall be made no later than the next scheduled weekly update, or the update immediately following that update, or sooner if required by federal law or regulations. For printed provider directories, the change shall be made no later than the next required update, or sooner if required by federal law or regulations. (p)

(1) Notwithstanding Sections 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 plan’s attempts to verify the provider’s or provider group’s information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the provider’s or provider group’s information. As used in this subdivision, “verify” means to contact the provider or provider group in writing, electronically, and by telephone to confirm whether the provider’s or provider group’s information is correct or requires updates. 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 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 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 of Division 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 plan’s 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 enrollee’s 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 enrollee’s 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 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 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 of Division 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 of Part of Division of the Insurance Code shall meet the requirements of this section. (

u) This

section shall not be construed to alter a provider’s obligation to provide health care services to an enrollee pursuant to the provider’s contract with the plan. (

v) As part of the department’s 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 plan’s 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. 3.5.

Section 1367.27 of the Health and Safety Code is amended to read: 1367.27. (

a) A health care service plan shall publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan’s enrollees, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the plan. Commencing July 1, 2026, a health care service plan shall comply with this

section as it read on January 1, 2026. (

By July 31, 2017, or 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)

(2) A health care service plan shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law.

(3) A printed provider directory shall be dated with the date of its last update. (e)

A) A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients. (

B) A provider is no longer under contract for a particular plan product. (

C) A provider’s practice location or other information required under subdivision (

h) or (

i) has changed. (

D) Upon the completion of the investigation described in subdivision (o), a change is necessary based on an enrollee complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly. (

E) Any other information that affects the content or accuracy of the provider directory or directories.

(2) Upon confirmation of any of the following, the plan shall delete and remove a provider from the directory or directories when: (

A) A provider has retired or otherwise has ceased to 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)

(1) The provider directory or directories shall display the date of the most recent update. The provider directory or directories shall also display a dedicated email address, telephone number, and reporting hyperlink for members of the public and providers to report possible inaccurate, incomplete, or misleading directory information. The provider directory or directories shall also state that the enrollee may submit a complaint if the enrollee believes they reasonably relied upon inaccurate, incomplete, or misleading directory information. This information shall be disclosed prominently in the directory or directories and on the plan’s internet website.

(2) A health care service plan shall include prominent disclosure on its print and online provider directories of its duty to arrange coverage when behavioral health benefits are not available in-network within applicable geographic and timely access standards. The disclosure shall be included within the “Timely Access to Care”

section of the directory that is required by

Section 1367.031 and shall also include the geographic accessibility standards. (

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 and

Section of the Rehabilitation Act of 1973. (

h) A full service health care service plan and a specialized mental health plan shall include all of the following information in the provider directory or directories:

(1) The provider’s name, practice location or locations, and contact information, including telephone number.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) The provider’s office email address, if available to an enrollee or the public.

(7) The population served, meaning adult, pediatric, or both.

(8) The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.

(9) 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, dispensing optometrists and opticians, podiatrists, chiropractors, licensed clinical social workers, marriage and family therapists, professional clinical counselors, qualified autism service providers, as defined in

Section 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 a provider described in subparagraph (

A) or (

F) Pharmacies, clinical laboratories, imaging centers, optical dispensaries, and other facilities providing contracted health care services.

(10) The provider directory or directories may note that authorization or referral may be required to access some providers.

(11) Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with

Section 1367.04, if any, on the provider’s staff.

(12) Identification of providers who no longer accept new patients for some or all of the plan’s products.

(13) Whether or not the provider is in the lowest cost-sharing tier, if the product has more than one cost-sharing tier, and the network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. This

section does not require the use of network tiers other than contract and noncontracting tiers.

(14) All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c). (

(1) The provider’s name, practice location or locations, and contact information, including telephone number.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license, if applicable.

(5) The area of specialty, including board certification, or other accreditation, if any.

(6) The provider’s office email address, if available to an enrollee or the public.

(7) The population served, meaning adult, pediatric, or both.

(8) The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.

(9) 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.

(10) The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with

Section 1367.04, if any, on the provider’s staff.

(11) Identification of providers who no longer accept new patients for some or all of the plan’s products.

(12) 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.

(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 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 central utility by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with

Section 11340) of Part of Division of Title of the Government Code) pursuant to this subdivision.

(4) On or before January 1, 2026, the department may update a uniform format with standardized naming conventions and other aspects for each plan to use to request directory information from its providers, consistent with current law. (5) (

A) On or before January 1, 2026, the department may establish a methodology and processes to ensure accuracy of provider directories and consistency with other state or federal laws, regulations, or standards. The department shall take into account existing methods, including surveys, plan-reported information, and benchmarks or submission information from a central utility by another entity. (

B) The department may require a health care service plan to use or designate a central utility or central utilities for those providers included in the directory and may take into consideration impact on provider financial interests, enrollee access to providers, and health care service plans. If the department requires or designates a central utility or central utilities, in developing the methodology under this section, the department shall seek input from interested parties, including providers, health care service plans, consumers, and consumer advocates, and may hold one or more public meetings.

Standards developed pursuant to paragraph (4) and this paragraph shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with

Section 11340) of Part of Division of Title of the Government Code) until January 1, 2029. (

i) If the department designates or requires a health care service plan to use a central utility or central utilities, the health care service plan’s contract with the utility shall require that incomplete or incorrect information submitted to the central utility shall not be conveyed to the health care service plan.

The contract shall also require that the central utility notify the submitter of incomplete or inaccurate information. (ii) If the department determines that a central utility designated or required pursuant to this subparagraph is frequently failing to provide accurate information to health care service plans, the department may consider no longer requiring or designating that central utility for use. (iii) A health care service plan may require providers to update their information through the central utility to update the health care service plan’s provider directory.

However, if the department requires a health care service plan to use or designate a central utility or central utilities, the health care service plan shall require providers to update their information through the central utility to update the health care service plan’s provider directory. (

C) If the plan can demonstrate it will meet the benchmarks required in paragraph (2) of subdivision (

n) without using the central utility designated in subparagraph (B), the department may allow the plan to not use the central utility. If the plan fails to meet the benchmark in the future, the department may require the plan to use the central utility as a method to achieve higher accuracy of provider directory listings to comply with paragraph (2) of subdivision (n). (l)

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: (

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 (q). (

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). (

D) A statement that failure to respond to the notification within five calendar days may result in a notice in their provider listing that states: “As of the last directory update, this provider is actively contracting with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.”

(3) The plan shall require an affirmative response from the provider or provider group acknowledging that the notification was received. Within calendar days of receiving the notification, 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.

If the plan is unable to verify whether the provider’s information is correct or requires updates, the plan shall notify the provider 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 the provider responds before the end of the 10-business-day notice period.

(5) If a provider that was previously removed from the provider directory or directories requests to be added back to the provider directory or directories, or if a plan requests that a provider that was previously removed from the provider directory or directories be added back to the provider directory or directories, the health care service plan shall ensure the accuracy of the information required under this

section and approve the request within business days of receipt if accurate.

(6) If a provider does not respond within five calendar days, a health care service plan may include the following statement in the provider listing before removing the provider from the directory: “As of the last directory update, this provider is actively contracting with the plan. However, the provider has not responded to verify their listing information in the last update, so information may not be up to date.”

(7) General acute care hospitals shall be exempt from the requirements in paragraphs (3) to (5), inclusive. (

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. Providers shall submit any changes to the information required to be in the directory within calendar days of any change.

(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.

section using the process required by the health care service plan.

n) A plan shall be responsible for maintaining an accurate provider directory.

(1) An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (

h) and (i).

(2) The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (

h) or (

i) is accurate. If there is one error that would impact a patient’s access to care on a listing for a provider, that listing is considered inaccurate. (

A) On July 1, 2026, a plan’s directories shall be at least percent accurate. (

B) On or before July 1, 2027, a plan’s directories shall be at least percent accurate. (

C) On or before July 1, 2028, a plan’s directories shall be at least percent accurate. (

D) On or before July 1, 2029, a plan’s directories shall be at least percent accurate.

(3) A plan shall annually verify its provider directories for accuracy of all of the information required pursuant to subdivisions (

h) and (i). If the department develops a methodology and standards that permit the use of a central utility or central utilities, and if a health care service plan uses a central utility for some or all of the plan’s provider directory, the plan shall ensure that information derived from the central utility is incorporated in the plan’s provider directory unless the plan can demonstrate that the information from the central utility is inaccurate. The plan using a central utility shall continue to retain responsibility for ensuring that the requirements of this

section are satisfied, including in any contract or other agreement with the central utility. The department shall develop procedures and policies on how a plan shall conduct the verifications. In addition to verifying the information required under subdivisions (

h) and (i), the plan shall do all of the following: (

A) In verifying the accuracy of information in the provider directory or directories, determine if a provider is actively contracting, as defined by the department pursuant to subdivision (s). (

B) Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the department to ensure compliance with this section. (

C) Publicly post its accuracy verification reports annually on its internet website. (

D) Verification of the accuracy of the printed directory shall be based on the date of printing, which shall be provided on each page of the printed directory.

(4) Failure by a health care service plan to comply with this section, including failure to meet the required benchmarks for accuracy, shall result in an administrative penalty consistent with this

section and this chapter. In determining the appropriate amount of an administrative penalty, a listing inaccuracy that would impact a patient’s access to care shall be treated as a denial of access to care for covered benefits.

(5) When assessing administrative penalties against a health care service plan, the director shall determine the appropriate penalty amount for each violation based on one or more factors as applicable, including the factors outlined in subdivision (

d) of

Section 1386. The director shall take into consideration evidence provided by the plan of the plan’s policies and procedures to obtain accurate provider information pursuant to this

section and the plan’s use of a central utility in assessing penalties pursuant to this section.

(6) Beginning January 1, 2029, and every five years thereafter, the penalty amounts specified in this

section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment. (o)

(1) This

section are satisfied.

(4) A provider group is not subject to the payment delay described in subdivision (

q) if all of the following occurs: (

B) The provider group documents its efforts to verify the provider’s 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. (p)

(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. (

(1) Notwithstanding Sections 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 plan’s attempts to verify the provider’s or provider group’s information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the provider’s or provider group’s information. As used in this subdivision, “verify” means to contact the provider or provider group in writing, electronically, and by telephone to confirm whether the provider’s or provider group’s information is correct or requires updates. 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. (

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.

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).

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 of Division of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance. (r)

(1) In circumstances where the department finds that an enrollee reasonably relied upon inaccurate, incomplete, or misleading information contained in a health care service plan’s provider directory or directories, the health care service plan shall arrange care and provide coverage for all covered health care services provided to the enrollee, hold the enrollee harmless for any amount beyond what the enrollee would have paid, had the services been delivered by an in-network provider under the enrollee’s plan contract, and reimburse the provider the out-of-network amount.

The provider shall not collect any additional amount from the enrollee other than the applicable in-network cost sharing, which shall count toward any in-network deductible and the out-of-pocket maximum. Before requiring reimbursement in these circumstances, the department shall conclude that the services received by the enrollee were covered services under the enrollee’s 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.

(2) If an enrollee, by telephone call or electronic means, requests information on whether or not a provider is contracted as an in-network provider to provide covered benefits, the health care service plan shall, if the request is by telephone, tell the enrollee verbally and follow up in writing or electronic format no later than two business days after receiving the request. If the request is by electronic means, the plan shall respond in writing or electronic format no later than one business day after receiving the request.

The plan shall also check if the provider is accepting new patients at the time and inform the enrollee. The plan shall retain a record of the request and the plan’s response in the enrollee’s file for at least two years after the date of the request.

(3) If an enrollee obtained information through the plan’s online directory or a request consistent with paragraph (2) that a provider was an in-network provider, subsequently receives covered benefits from that provider, and the enrollee receives a bill for an amount exceeding in-network cost sharing, the enrollee shall pay no more than in-network cost sharing if any of the following apply: (

A) The provider is not contracting with the health care service plan as an in-network provider for that product at the time the enrollee receives otherwise covered benefits from that provider. (

B) The information provided regarding the provider’s network status is otherwise inaccurate, misleading, or incomplete. (

C) The online provider directory of the health care service plan is not accessible to enrollees at the time the enrollee seeks information and the enrollee requests information consistent with paragraph (2).

(4) If the health care service plan contract uses a tiered network with two or more in-network tiers with differential cost sharing, the plan shall document the cost-sharing tier that the provider is contracted to accept and shall provide that information to the enrollee when the enrollee seeks information about the provider. If the plan provides information indicating that a provider is on a lower cost-sharing tier and that information is not accurate, then the enrollee shall owe no more than the cost sharing for the lower cost-sharing tier.

(5) For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing.

(6) For purposes of this subdivision, “information” is inaccurate, incomplete, or misleading if any information in subdivision (

h) or (

i) regarding the provider’s network status is inaccurate, incomplete, or misleading. (s)

(1) 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 of the California Code of Regulations.

(2) For a health care service plan issued, amended, or renewed on or after July 1, 2026, if the number of providers who are not actively contracting pursuant to this

section and have not responded to a plan’s notifications pursuant to subdivision (

l) for at least months amounts to percent or greater of the providers in the network for a product in a region, then the plan shall file an amendment to the plan application consistent with subdivision (

f) of

Section 1300.52 of Title of the California Code of Regulations.

(3) A plan shall not use information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provision of this

chapter if the plan cannot demonstrate to the department that the provider is actively contracting as determined by the department. (4) (

A) The department shall determine the definition of “actively contracting,” and consider the degree of utilization for that provider by considering if the provider has one or more claims or encounters for covered benefits to enrollees in the relevant network, unless a special circumstance applies. In determining the utilization threshold for these purposes, the department shall not set a threshold greater than at least one claim or encounter for covered benefits for an enrollee every three calendar years. (

B) A special circumstance may include a provider in a rural area, a highly specialized specialist who did not provide covered benefits for an enrollee in the prior three calendar years, or other circumstances as determined by the department through the regulatory or other rulemaking process. The department may issue guidance to implement, interpret, or make specific the requirements under this subparagraph. The guidance shall be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with

Section 11340) of Part of Division of Title of the Government Code).

(5) Consistent with

Section 1360, a plan shall not advertise or otherwise represent the extent of its network, including the number or type of contracting providers, unless it is able to demonstrate that each provider is contracting. (t)

(1) 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 the Welfare and Institutions Code to the extent consistent with federal law, rules, guidance, and regulations and state law and guidance issued after January 1, 2016, and not prohibited or otherwise contrary to federal law, rules, guidance, and regulations.

(2) 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). All other provisions of this

section apply to plans with Medi-Cal managed care contracts. (

u) A health care service plan that contracts with multiple employer welfare agreements regulated pursuant to

Article 4.7 (commencing with

Section 742.20) of

Chapter of Part of Division of the Insurance Code shall meet the requirements of this section. (

v) This

section shall not be construed to alter a provider’s obligation to provide health care services to an enrollee pursuant to the provider’s contract with the plan. (

w) As part of the department’s 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 plan’s compliance with subdivision (q). (

x) For purposes of this section, “provider group” means a medical group, independent practice association, or other similar group of providers. (y) Paragraphs (2), (4), (5), (6), (7), and (8) of subdivision (

n) of this

section do not apply to a Medi-Cal managed care plan that contracts with the State Department of Health Care Services pursuant to

Chapter 7 (commencing with

Section 14000) or

Chapter 8 (commencing with

Section 14200) of Part of Division of the Welfare and Institutions Code.

SEC.

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 Association’s Diagnostic and Statistical Manual of Mental Disorders or the World Health Organization’s 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 certified by a national entity 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 of the Business and Professions Code. (

H) A psychology trainee or person supervised as set forth in

Section or of, or subdivision (

d) of

Section 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 plan’s subsequent rescission, cancellation, or modification of the enrollee’s or subscriber’s contract, or the plan’s subsequent determination that it did not make an accurate determination of the enrollee’s or subscriber’s 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 of Division 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 of the Business and Professions Code. (

g) This

section shall not be construed to deny or restrict in any way the department’s 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.

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 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 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 does not affect or reduce any obligation to provide services under an individualized education program, as defined in

Section 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 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 patient’s 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 plan’s goal and objectives, and the frequency at which the patient’s 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) “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 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 of Division 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. 5.5.

Section 1374.73 of the Health and Safety Code is amended to read: 1374.73. (a)

Section 1374.72.

(2) Notwithstanding paragraph (1), as of the date that the 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 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 does not affect or reduce any obligation to provide services under an individualized education program, as defined in

Section 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

(1) A health care service plan contract issued, amended, or renewed on or after January 1, 2026, shall not require an enrollee previously diagnosed with pervasive developmental disorder or autism to receive a rediagnosis to maintain coverage for behavioral health treatment for pervasive developmental disorder or autism.

(2) This subdivision does not prohibit or restrict a treating provider from reevaluating an enrollee for purposes of determining the appropriate treatment. The treatment plan shall be made available to the health care service plan upon request.

(3) This subdivision does not prohibit a treating provider from prescribing a rediagnosis at the discretion of the physician licensed pursuant to

Chapter 5 (commencing with

Section 2000) of Division of the Business and Professions Code or a psychologist licensed pursuant to

Chapter 6.6 (commencing with

Section 2900) of Division of the Business and Professions Code.

(4) A health care service plan shall not discontinue or delay existing treatment while waiting for a rediagnosis to be completed.

(5) This subdivision does not prohibit a health care service plan from requiring utilization review. For the purpose of this section, utilization review is distinct from a rediagnosis. (

d) For the purposes of this section, the following

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 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: (

Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following: (

D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, 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) “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. (5) “Rediagnosis” means a subsequent undertaking by any method, device, or procedure, whether gratuitous or not, to ascertain or establish if a person is suffering from a physical or mental health disorder, pursuant to

Section of the Business and Professions Code. “Rediagnosis” also means prescription of a subsequent diagnosis of pervasive developmental disorders or autism to ascertain or establish if a person is suffering from a pervasive developmental disorder or autism. (6) “Utilization review” means utilization review or utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians licensed pursuant to

Chapter 5 (commencing with

Section 2000) of Division of the Business and Professions Code before, after, or concurrent with the provision of medical treatment services. “Utilization review” refers to an evaluation of existing treatment to ensure an enrollee receives the proper care at the proper time. (

e) This

section does not apply to either 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 of Division of the Welfare and Institutions Code). (

f) This

section does not limit the obligation to provide services under

Section 1374.72. (

g) As provided in

SEC.

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 shall publish and maintain provider directory or directories with information on contracting providers that deliver health care services to the insurer’s insureds, including those that accept new patients. A provider directory shall not list or include information on a provider that is not currently under contract with the insurer. (

b) An insurer shall provide the online directory or directories for the specific network offered for each product using a consistent method of network and product naming, numbering, or other classification method that ensures the public, insureds, potential insureds, the department, and other state or federal agencies can easily identify the networks and insurer products in which a provider participates. By July 31, 2017, or months after the date provider directory standards are developed under subdivision (k), whichever occurs later, an insurer shall use the naming, numbering, or classification method developed by the department pursuant to subdivision (k). (c)

(1) An online provider directory or directories shall be available on the insurer’s internet 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 insurer’s public 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 months after the date provider directory standards are developed under subdivision (k), whichever occurs later, the insurer’s public internet website shall allow provider searches by, at a minimum, name, practice address, city, ZIP Code, California license number, National Provider Identifier number, admitting privileges to an identified hospital, product, tier, provider language or languages, provider group, hospital name, facility name, or clinic name, as appropriate. (d)

(1) An insurer shall allow insureds, potential insureds, providers, and members of the public to request a printed copy of the provider directory or directories by contacting the insurer through the insurer’s toll-free telephone number, electronically, or in writing. A printed copy of the provider directory or directories shall include the information required in subdivisions (

(2) An insurer shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law. (e)

(1) The insurer shall update the online provider directory or directories, at least weekly, or more frequently, if required by federal law, when informed of and upon confirmation by the insurer of any of the following: (

A) A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients. (

B) A contracted provider is no longer under contract for a particular product. (

C) A provider’s practice location or other information required under subdivision (

h) or (

i) has changed. (

D) Upon the completion of the investigation described in subdivision (o), a change is necessary based on an insured complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly. (

E) Any other information that affects the content or accuracy of the provider directory or directories.

(2) Upon confirmation of any of the following, the insurer shall delete a provider from the directory or directories when: (

A) A provider has retired or otherwise has ceased to practice. (

B) A provider or provider group is no longer under contract with the insurer for any reason. (

C) The contracting provider group has informed the insurer that the provider is no longer associated with the provider group and is no longer under contract with the insurer. (

f) The provider directory or directories shall include both an email address and a telephone number for members of the public and providers to notify the insurer if the provider directory information appears to be inaccurate. This information shall be disclosed prominently in the directory or directories and on the insurer’s internet 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 and

Section of the Rehabilitation Act of 1973. (

h) The insurer and a specialized mental health insurer shall include all of the following information in the provider directory or directories:

(1) The provider’s name, practice location or locations, and contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) The provider’s office email address, if available.

(7) The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds.

(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. (

Section 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 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. (

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 provider’s staff.

(11) Identification of providers who no longer accept new patients for some or all of the insurer’s products.

(12) The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. Nothing in this

section shall be construed to require the use of network tiers other than contract and noncontracting tiers.

(13) All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c). (

i) A vision, dental, or other specialized insurer, except for a specialized mental health insurer, shall include all of the following information for each provider directory or directories used by the insurer for its networks:

(1) The provider’s name, practice location or locations, and contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license, if applicable.

(5) The area of specialty, including board certification, or other accreditation, if any.

(6) The provider’s office email address, if available.

(7) The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.

(8) The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the insurer.

(9) The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with

Section 10133.8, if any, on the provider’s staff.

(10) Identification of providers who no longer accept new patients for some or all of the insurer’s products.

(11) All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c). (j)

(1) The contract between the insurer and a provider shall include a requirement that the provider inform the insurer within five business days when either of the following 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 insurer’s directory or directories.

(3) If an insured or potential insured informs an insurer of a possible inaccuracy in the provider directory or directories, the insurer shall promptly investigate and, if necessary, undertake corrective action within 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 of Division of Title of the Government Code) pursuant to this subdivision.

(3) By July 31, 2017, or months after the date provider directory standards are developed under this subdivision, whichever occurs later, an insurer shall use the standards developed by the department for each product offered by the insurer. (l)

(1) An insurer shall take appropriate steps to ensure the accuracy of the information concerning each provider listed in the insurer’s provider directory or directories in accordance with this section, and shall, at least annually, review and update the entire provider directory or directories for each product offered. Each calendar year the insurer shall notify all contracted providers described in subdivisions (

h) and (

i) as follows: (

A) For individual providers who are not affiliated with a provider group described in subparagraph (

A) or (

B) of paragraph (8) of subdivision (

h) and providers described in subdivision (i), the insurer shall notify each provider at least once every six months. (

B) For all other providers described in subdivision (

h) who are not subject to the requirements of subparagraph (A), the insurer shall notify its contracted providers to ensure that all of the providers are contacted by the insurer at least once annually.

(2) The notification shall include all of the following: (

A) The information the insurer has in its directory or directories regarding the provider or provider group, including a list of networks and products that include the contracted provider or provider group. (

B) A statement that the failure to respond to the notification may result in a delay of payment or reimbursement of a claim pursuant to subdivision (p). (

C) Instructions on how the provider or provider group can update the information in the provider directory or directories using the online interface developed pursuant to subdivision (m).

(3) The insurer shall require an affirmative response from the provider or provider group acknowledging that the notification was received. The provider or provider group shall confirm that the information in the provider directory or directories is current and accurate or update the information required to be in the directory or directories pursuant to this section, including whether or not the provider group is accepting new patients for each product.

(4) If the insurer does not receive an affirmative response and confirmation from the provider that the information is current and accurate or, as an alternative, updates any information required to be in the directory or directories pursuant to this section, within business days, the insurer shall take no more than business days to verify whether the provider’s information is correct or requires updates. The insurer shall document the receipt and outcome of each attempt to verify the information.

If the insurer is unable to verify whether the provider’s information is correct or requires updates, the insurer shall notify the provider 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 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 insurer’s 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 insurer’s provider directory internet website linking to a form where the information can be reported directly to the insurer through its internet website. (n) (1

Document details

Collection	California Bills
Citation	SB 402
Date	2025-10-06
Type	bill
Language	en
Source	CA_BILL
Identifier	20250SB40295CHP

Health care coverage: autism.

SB 402

California Bills

An act to amend

Section 2290.5 of, and to add

Chapter 17 (commencing with

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. This bill would incorporate additional changes to

Section 1367.27 of the Health and Safety Code and

Section 10133.15 of the Insurance Code proposed by AB to be operative only if this bill and AB are enacted and this bill is enacted last. This bill would incorporate additional changes to

Section 1374.73 of the Health and Safety Code and

Section 10144.51 of the Insurance Code proposed by AB to be operative only if this bill and AB are enacted and this bill is enacted last. This bill would incorporate additional changes to

SECTION

Section 2290.5 of the Business and Professions Code is amended to read: 2290.5. (

a) For purposes of this division, 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 certified by a national entity 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

Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers. (

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 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 patient’s rights to the patient’s medical information shall apply to telehealth interactions. (

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)

SEC. 2.

Chapter 17 (commencing with

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

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. (

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 of Title 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.

Section 1367.27 of the Health and Safety Code is amended to read: 1367.27. (

(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)

A) A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients. (

B) A provider is no longer under contract for a particular plan product. (

C) A provider’s practice location or other information required under subdivision (

h) or (

i) has changed. (

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. (

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 and

Section of the Rehabilitation Act of 1973. (

h) A full service health care service plan and a specialized mental health plan shall include all of the following information in the provider directory or directories:

(1) The provider’s name, practice location or locations, and contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) The provider’s office email address, if available.

(7) The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.

(8) A listing for each of the following providers that are under contract with the plan: (

A) For physicians and surgeons, the provider group, and admitting privileges, if any, at hospitals contracted with the plan. (

Section 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 a provider described in subparagraph (

A) or (

F) Pharmacies, clinical laboratories, imaging centers, and other facilities providing contracted health care services.

(9) The provider directory or directories may note that authorization or referral may be required to access some providers.

(10) Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with

Section 1367.04, if any, on the provider’s staff.

(11) Identification of providers who no longer accept new patients for some or all of the plan’s products.

(12) The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. 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). (

(1) The provider’s name, practice location or locations, and contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license, if applicable.

(5) The area of specialty, including board certification, or other accreditation, if any.

(6) The provider’s office email address, if available.

(7) The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.

(8) The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the plan.

(9) The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with

Section 1367.04, if any, on the provider’s staff.

(10) Identification of providers who no longer accept new patients for some or all of the plan’s products.

(11) All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c). (j)

(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.

(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 of Division of Title of the Government Code) pursuant to this subdivision.

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: (

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).

(5) General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4). (

(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.

section using the process required by the health care service plan.

(1) This

section are satisfied.

(4) A provider group is not subject to the payment delay described in subdivision (

p) if all of the following occurs: (

B) The provider group documents its efforts to verify the provider’s 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)

(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. (

(1) Notwithstanding Sections and 1371.35, a plan may delay payment or reimbursement owed to a provider or provider group as specified in subparagraph (

l) has lapsed. (

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.

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).

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 of Division of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance. (

r) Whenever a plan determines as a result of this

section that there has been a 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 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 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 of Part of Division of the Insurance Code shall meet the requirements of this section. (

u) This

section shall not be construed to alter a provider’s obligation to provide health care services to an enrollee pursuant to the provider’s contract with the plan. (

v) As part of the department’s 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 plan’s 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. 3.5.

Section 1367.27 of the Health and Safety Code is amended to read: 1367.27. (

section as it read on January 1, 2026. (

(2) A health care service plan shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law.

(3) A printed provider directory shall be dated with the date of its last update. (e)

A) A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients. (

B) A provider is no longer under contract for a particular plan product. (

C) A provider’s practice location or other information required under subdivision (

h) or (

i) has changed. (

E) Any other information that affects the content or accuracy of the provider directory or directories.

(2) Upon confirmation of any of the following, the plan shall delete and remove a provider from the directory or directories when: (

A) A provider has retired or otherwise has ceased to 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)

section of the directory that is required by

Section 1367.031 and shall also include the geographic accessibility standards. (

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 and

Section of the Rehabilitation Act of 1973. (

h) A full service health care service plan and a specialized mental health plan shall include all of the following information in the provider directory or directories:

(1) The provider’s name, practice location or locations, and contact information, including telephone number.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) The provider’s office email address, if available to an enrollee or the public.

(7) The population served, meaning adult, pediatric, or both.

(8) The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.

(9) 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. (

Section 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 a provider described in subparagraph (

A) or (

F) Pharmacies, clinical laboratories, imaging centers, optical dispensaries, and other facilities providing contracted health care services.

(10) The provider directory or directories may note that authorization or referral may be required to access some providers.

(11) Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with

Section 1367.04, if any, on the provider’s staff.

(12) Identification of providers who no longer accept new patients for some or all of the plan’s products.

section does not require the use of network tiers other than contract and noncontracting tiers.

(14) All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c). (

(1) The provider’s name, practice location or locations, and contact information, including telephone number.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license, if applicable.

(5) The area of specialty, including board certification, or other accreditation, if any.

(6) The provider’s office email address, if available to an enrollee or the public.

(7) The population served, meaning adult, pediatric, or both.

(8) The name of each affiliated provider group or specialty plan practice group currently under contract with the plan through which the provider sees enrollees.

(9) 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.

(10) The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with

Section 1367.04, if any, on the provider’s staff.

(11) Identification of providers who no longer accept new patients for some or all of the plan’s products.

(12) 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.

(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 central utility by another entity. Those standards shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with

Section 11340) of Part of Division of Title of the Government Code) pursuant to this subdivision.

Standards developed pursuant to paragraph (4) and this paragraph shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with

Section 11340) of Part of Division of Title of the Government Code) until January 1, 2029. (

C) If the plan can demonstrate it will meet the benchmarks required in paragraph (2) of subdivision (

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: (

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 (q). (

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). (

If the plan is unable to verify whether the provider’s information is correct or requires updates, the plan shall notify the provider 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 the provider responds before the end of the 10-business-day notice period.

section and approve the request within business days of receipt if accurate.

(7) General acute care hospitals shall be exempt from the requirements in paragraphs (3) to (5), inclusive. (

(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.

section using the process required by the health care service plan.

n) A plan shall be responsible for maintaining an accurate provider directory.

(1) An accurate provider directory maintains accurate information for all information to be included in the directories pursuant to subdivisions (

h) and (i).

(2) The accuracy percentage of a directory shall be determined by the percentage of providers for which all information required in subdivision (

h) or (

i) is accurate. If there is one error that would impact a patient’s access to care on a listing for a provider, that listing is considered inaccurate. (

A) On July 1, 2026, a plan’s directories shall be at least percent accurate. (

B) On or before July 1, 2027, a plan’s directories shall be at least percent accurate. (

C) On or before July 1, 2028, a plan’s directories shall be at least percent accurate. (

D) On or before July 1, 2029, a plan’s directories shall be at least percent accurate.

(3) A plan shall annually verify its provider directories for accuracy of all of the information required pursuant to subdivisions (

h) and (i), the plan shall do all of the following: (

A) In verifying the accuracy of information in the provider directory or directories, determine if a provider is actively contracting, as defined by the department pursuant to subdivision (s). (

B) Annually submit its accuracy verification reports and a declaration that the accuracy verification report is true and correct to the department to ensure compliance with this section. (

C) Publicly post its accuracy verification reports annually on its internet website. (

D) Verification of the accuracy of the printed directory shall be based on the date of printing, which shall be provided on each page of the printed directory.

(4) Failure by a health care service plan to comply with this section, including failure to meet the required benchmarks for accuracy, shall result in an administrative penalty consistent with this

d) of

Section 1386. The director shall take into consideration evidence provided by the plan of the plan’s policies and procedures to obtain accurate provider information pursuant to this

section and the plan’s use of a central utility in assessing penalties pursuant to this section.

(6) Beginning January 1, 2029, and every five years thereafter, the penalty amounts specified in this

section shall be adjusted based on the average rate of change in premium rates for the individual and small group markets, and weighted by enrollment, since the previous adjustment. (o)

(1) This

section are satisfied.

(4) A provider group is not subject to the payment delay described in subdivision (

q) if all of the following occurs: (

B) The provider group documents its efforts to verify the provider’s 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. (p)

(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. (

(1) Notwithstanding Sections 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 plan’s attempts to verify the provider’s or provider group’s information as required under subdivision (l). The plan shall not delay payment unless it has attempted to verify the provider’s or provider group’s information. As used in this subdivision, “verify” means to contact the provider or provider group in writing, electronically, and by telephone to confirm whether the provider’s or provider group’s information is correct or requires updates. 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. (

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.

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).

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 of Division of the Welfare and Institutions Code, this subdivision shall be implemented only to the extent consistent with federal law and guidance. (r)

A) The provider is not contracting with the health care service plan as an in-network provider for that product at the time the enrollee receives otherwise covered benefits from that provider. (

B) The information provided regarding the provider’s network status is otherwise inaccurate, misleading, or incomplete. (

(5) For purposes of this subdivision, the in-network cost sharing amount for a contracted provider includes copayments, deductibles, coinsurance, and any other form of cost sharing.

(6) For purposes of this subdivision, “information” is inaccurate, incomplete, or misleading if any information in subdivision (

h) or (

i) regarding the provider’s network status is inaccurate, incomplete, or misleading. (s)

(1) 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 of the California Code of Regulations.

(2) For a health care service plan issued, amended, or renewed on or after July 1, 2026, if the number of providers who are not actively contracting pursuant to this

section and have not responded to a plan’s notifications pursuant to subdivision (

f) of

Section 1300.52 of Title of the California Code of Regulations.

(3) A plan shall not use information about a provider for purposes of compliance with timely access requirements, network adequacy determination, or compliance with any other provision of this

chapter if the plan cannot demonstrate to the department that the provider is actively contracting as determined by the department. (4) (

Section 11340) of Part of Division of Title of the Government Code).

(5) Consistent with

(1) 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 shall not be required to distribute a printed provider directory or directories, except as required by paragraph (1) of subdivision (d). All other provisions of this

section apply to plans with Medi-Cal managed care contracts. (

u) A health care service plan that contracts with multiple employer welfare agreements regulated pursuant to

Article 4.7 (commencing with

Section 742.20) of

Chapter of Part of Division of the Insurance Code shall meet the requirements of this section. (

v) This

section shall not be construed to alter a provider’s obligation to provide health care services to an enrollee pursuant to the provider’s contract with the plan. (

w) As part of the department’s 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 plan’s compliance with subdivision (q). (

n) of this

section do not apply to a Medi-Cal managed care plan that contracts with the State Department of Health Care Services pursuant to

Chapter 7 (commencing with

Section 14000) or

Chapter 8 (commencing with

Section 14200) of Part of Division of the Welfare and Institutions Code.

SEC.

Section 1374.72 of the Health and Safety Code is amended to read: 1374.72. (a)

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) (

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 certified by a national entity 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 of the Business and Professions Code. (

H) A psychology trainee or person supervised as set forth in

Section or of, or subdivision (

d) of

Section 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.

(8) A health care service plan that authorizes a specific type of treatment by a provider pursuant to 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. (

(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. (

e) This

section shall not apply to contracts entered into pursuant to

Chapter 7 (commencing with

Section 14000) or

Chapter 8 (commencing with

(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.

Section 1374.76 of this code, and

Section of the Business and Professions Code. (

g) This

section shall not be construed to deny or restrict in any way the department’s authority to ensure plan compliance with this chapter. (

SEC.

Section 1374.73 of the Health and Safety Code is amended to read: 1374.73. (a)

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 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 does not affect or reduce any obligation to provide services under an individualized education program, as defined in

Section 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

c) For the purposes of this section, the following

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 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: (

Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following: (

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 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 of Division 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

SEC. 5.5.

Section 1374.73 of the Health and Safety Code is amended to read: 1374.73. (a)

Section 1374.72.

(2) Notwithstanding paragraph (1), as of the date that the 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 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 does not affect or reduce any obligation to provide services under an individualized education program, as defined in

Section 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

(3) This subdivision does not prohibit a treating provider from prescribing a rediagnosis at the discretion of the physician licensed pursuant to

Chapter 5 (commencing with

Section 2000) of Division of the Business and Professions Code or a psychologist licensed pursuant to

Chapter 6.6 (commencing with

Section 2900) of Division of the Business and Professions Code.

(4) A health care service plan shall not discontinue or delay existing treatment while waiting for a rediagnosis to be completed.

(5) This subdivision does not prohibit a health care service plan from requiring utilization review. For the purpose of this section, utilization review is distinct from a rediagnosis. (

d) For the purposes of this section, the following

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 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: (

Section 4686.2 of the Welfare and Institutions Code pursuant to which the qualified autism service provider does all of the following: (

D) The treatment plan is not used for purposes of providing or for the reimbursement of respite, daycare, 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) “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

Chapter 5 (commencing with

e) This

section does not apply to either 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 of Division of the Welfare and Institutions Code). (

f) This

section does not limit the obligation to provide services under

Section 1374.72. (

g) As provided in

SEC.

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

(2) An insurer shall update its printed provider directory or directories at least quarterly, or more frequently, if required by federal law. (e)

A) A contracting provider is no longer accepting new patients for that product, or an individual provider within a provider group is no longer accepting new patients. (

B) A contracted provider is no longer under contract for a particular product. (

C) A provider’s practice location or other information required under subdivision (

h) or (

i) has changed. (

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. (

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 and

Section of the Rehabilitation Act of 1973. (

h) The insurer and a specialized mental health insurer shall include all of the following information in the provider directory or directories:

(1) The provider’s name, practice location or locations, and contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license.

(5) The area of specialty, including board certification, if any.

(6) The provider’s office email address, if available.

(7) The name of each affiliated provider group currently under contract with the insurer through which the provider sees insureds.

(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. (

Section 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 a provider described in subparagraph (

A) or (

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 provider’s staff.

(11) Identification of providers who no longer accept new patients for some or all of the insurer’s products.

(12) The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. Nothing in this

section shall be construed to require the use of network tiers other than contract and noncontracting tiers.

(13) All other information necessary to conduct a search pursuant to paragraph (2) of subdivision (c). (

(1) The provider’s name, practice location or locations, and contact information.

(2) Type of practitioner.

(3) National Provider Identifier number.

(4) California license number and type of license, if applicable.

(5) The area of specialty, including board certification, or other accreditation, if any.

(6) The provider’s office email address, if available.

(7) The name of each affiliated provider group or specialty insurer practice group currently under contract with the insurer through which the provider sees insureds.

(8) The names of each allied health care professional to the extent there is a direct contract for those services covered through a contract with the insurer.

(9) The non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with

Section 10133.8, if any, on the provider’s staff.

(10) Identification of providers who no longer accept new patients for some or all of the insurer’s products.

(11) All other applicable information necessary to conduct a provider search pursuant to paragraph (2) of subdivision (c). (j)

(1) The contract between the insurer and a provider shall include a requirement that the provider inform the insurer within five business days when either of the following 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.

(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 of Division of Title of the Government Code) pursuant to this subdivision.

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 (

(2) The notification shall include all of the following: (

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).

(5) General acute care hospitals shall be exempt from the requirements in paragraphs (3) and (4). (

(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.

section using the process required by the insurer.

Document details

Collection	California Bills
Citation	SB 402
Date	2025-10-06
Type	bill
Language	en
Source	CA_BILL
Identifier	20250SB40295CHP