Health care coverage: provider directories.

Assembly Member Aguiar-Curry's legislation aims to enhance the accuracy of health care provider directories through a series of graduated benchmarks and enforcement mechanisms. The bill requires health plans and insurers to achieve specific accuracy thresholds for their provider directories, starting at 60% accuracy by July 2026 and increasing to 95% accuracy by July 2029.

The legislation mandates annual verification of directory information and requires plans to promptly remove inaccurate listings. Plans must document verification attempts and publicly post accuracy reports on their websites. Administrative penalties for failing to meet accuracy benchmarks range from $500 to $5,000 per 1,000 enrollees for initial violations, increasing to $1,000 to $10,000 per 1,000 enrollees for subsequent failures.

When enrollees rely on inaccurate directory information, plans must arrange coverage for all covered services and limit patient costs to in-network rates. The bill prohibits providers from collecting additional amounts beyond applicable in-network cost sharing in these situations. These patient costs will count toward in-network deductibles and out-of-pocket maximums.

The Departments of Managed Health Care and Insurance may develop standardized formats for directory information requests and establish processes to verify accuracy. The departments can require plans to use central utilities for maintaining provider information, though plans demonstrating compliance without such utilities may receive exemptions. The legislation includes provisions for regular review and updates of penalty amounts based on premium rate changes in the individual and small group markets.