Health care coverage: health care provider credentials.

Assembly Member Bennett, with coauthor Addis, advances a policy framework that standardizes provider credentialing by requiring the CAQH credentialing form and processes across full‑service health care service plans and health insurers, and it establishes a 90‑day credentialing determination clock with activation upon approval and a provisional credentialing option if delays occur. The proposals create parallel requirements in the Health and Safety Code and the Insurance Code, apply to most networks beginning in the 2028 timeframe for CAQH usage, and exclude Medi‑Cal managed care plans from these provisions. Willful noncompliance would constitute a crime, with implications described as a local-mandate matter without state reimbursement.

The core mechanism centers on CAQH as the mandated credentialing data platform. Health plans and insurers would subscribe to the most recent CAQH credentialing form, and any requests for additional information would be limited to clarifying details already on the CAQH form, with providers required to respond within 10 business days. The credentialing process would include a 10‑day notice of receipt and completeness, and activation would occur within 10 days of approval if this occurs before the end of the 90‑day credentialing window; if the 90‑day target is missed, the provider’s credentials would be provisionally approved for up to 120 days, subject to listed exceptions (discipline by the licensing authority, adverse action or malpractice reports in the NPDB, or prior credentialing within the past five years). The 90‑day timeline covers credentialing only and does not incorporate contracting.

The bill aligns these CAQH-based requirements across both the health plan and insurer contexts, with identical structures in the Health and Safety Code and the Insurance Code. It provides exemptions for contracts with the state Department of Health Care Services under specified chapters and frames enforcement through criminal penalties for willful violations, while noting no state reimbursement for local agencies addressing the associated costs. This creates a uniform credentialing framework that interacts with existing regulatory regimes under the Knox‑Keene Act and related insurance statutes, while preserving contracting processes outside the credentialing clock.

From a policy-implementation perspective, the measure places a clear CAQH adoption deadline (January 1, 2028) and sets a one-year operative window for establishing the 90‑day credentialing determination, separating credentialing from contracting timing. It also shapes the credentialing ecosystem by elevating CAQH as the standard data source and workflow, with potential impacts on plan IT systems, staffing, and provider communications. The draft acknowledges potential local fiscal considerations due to crime-based enforcement and the local mandate designation, while not providing state reimbursement for local costs.