AMENDED IN SENATE AUGUST 20, 2026
AMENDED IN SENATE JUNE 25, 2026
AMENDED IN SENATE JUNE 3, 2026
CALIFORNIA LEGISLATURE— 2025–2026 REGULAR SESSION
96
Introduced by Assembly Member Haney
(Coauthor: Assembly Member Addis)
January 26, 2026
An act to amend Section 1680 Sections 1680 and 1950.5 of the Business and Professions Code, to amend Section 1367.03 of, and to add Section 1374.191 to, the Health and Safety Code, and to amend Section 10133.54 of, and to add Section 10120.6 to, the Insurance Code, relating to health care coverage.
Vote: majority Appropriation: no Fiscal committee: yes Local program: yes
LEGISLATIVE COUNSEL’S DIGEST
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’s requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law prohibits a contract between a plan or insurer and a dentist from requiring a dentist to accept an amount set by the plan or insurer as payment for dental care services provided to an enrollee or insured that are not covered services under the enrollee’s contract or the insured’s policy. Existing law requires a plan or insurer to make specified disclosures to an enrollee or insured regarding noncovered dental services.
Existing law requires a health care service plan or health insurer to comply with specified timely access requirements. Under existing law, a health care service plan is required to annually report to the Department of Managed Health Care on this compliance. Existing law authorizes the Department of Insurance to issue guidance to insurers regarding annual timely access and network reporting methodologies.
This bill would require a plan or insurer, including a specialized plan or insurer, covering dental services, upon written and dated consent of the enrollee or insured, to pay a noncontracting dental provider provider, which includes a registered dental hygienist in alternative practice, directly for covered services rendered to the enrollee or insured in accordance with the
benefit provided in the contract or policy. policy when the noncontracting dental provider submits to the plan or insurer an assignment of benefits. The bill would require a noncontracting dental provider to obtain a signed and dated consent to collect an assignment of benefits from an enrollee or insured. The bill would prohibit a noncontracting dental provider accepting collecting an enrollee’s or insured’s assignment of benefits from charging an enrollee or insured, prior to the plan or insurer payment, more than an
estimate of the enrollee’s or the insured’s cost sharing for the treatment or a deposit that approximates that cost share. The bill would require a noncontracting dental provider to make specified disclosures to an enrollee or insured before accepting an assignment of benefits. Because a willful violation of these provisions relative to health care service plans would be a crime, this bill would impose a state-mandated local program.
This bill would require a plan or insurer to certify, under penalty of perjury, that specified information submitted to its regulator regarding network adequacy is true and correct, thus creating a crime and imposing a state-mandated local program.
Existing law, the Dental Practice Act, provides for the licensure and regulation of dentists and dental assistants by the Dental Board of California and the licensure and regulation of dental hygienists by the Dental Hygiene Board of California, and defines unprofessional conduct by a licensee, including, among other things, the violation of any provision of the act. Existing law authorizes the respective board to discipline a licensee under the act by placing the licensee on probation under various specified terms and conditions.
This bill would require a noncontracting dental provider, including a registered dental hygienist in alternative practice, to make specified disclosures to a patient before collecting the patient’s signed and dated consent to an assignment of benefits. The bill would expand the definition of unprofessional conduct under the act to include
the failure to comply with the requirements and prohibitions described above relating to the payment of a noncontracting provider by a plan or insurer, the amount a noncontracting provider may charge an enrollee or insured, and the provision of disclosures by a noncontracting provider. that disclosure requirement and the above-described prohibition relating to the charging of a patient more than an estimate of their cost sharing and the failure to maintain a signed and dated copy of the patient’s consent.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
The people of the State of California do enact as follows:
SECTION 1.
The Legislature finds and declares all of the following:
(a) It is the intent of the Legislature to hold dental plans and insurers accountable for meeting network adequacy requirements.
(b) Nearly one-half of Californians with commercial dental plans have coverage that is self-insured, administrative services only, or managed by a third-party administrator, which have not been included in the state’s assessment of network adequacy for fully insured coverage, despite the large overlap of provider networks serving both self-insured and fully insured dental plans and insurers.
(c) Provider network adequacy is more clearly established by commercial dental plans and insurers accurately assessing and ensuring that their reporting data includes all enrollees, including those under self-funded or administrative services-only coverage.
(d) This act is not intended to provide the state with authority to regulate dental plans or insurers outside of its current jurisdiction.
(e) The Legislature does not intend to prevent the Department of Managed Health Care or the Department of Insurance from developing additional standards or audit methodologies for network adequacy purposes.
SEC. 2.
Section 1680 of the Business and Professions Code is amended to read:
1680.
Unprofessional conduct by a person licensed under this chapter is defined as, but is not limited to, any one of the following:
(a) The obtaining of any fee by fraud or misrepresentation.
(b) The employment directly or indirectly of any student or suspended or unlicensed dentist to practice dentistry as defined in this chapter.
(c) The aiding or abetting of any unlicensed person to practice dentistry.
(d) The aiding or abetting of a licensed person to practice dentistry unlawfully.
(e) The committing of any act or acts of sexual abuse, misconduct, or relations with a patient that are substantially related to the practice of dentistry.
(f) The use of any false, assumed, or fictitious name, either as an individual, firm, corporation, or otherwise, or any name other than the name under which the person is licensed to practice, in advertising or in any other manner indicating that the person is practicing or will practice dentistry, except that name as is specified in a valid permit issued pursuant to Section 1701.5.
(g) The practice of accepting or receiving any commission or the rebating in any form or manner of fees for professional services, radiograms, prescriptions, or other services or articles supplied to patients.
(h) The making use by the licensee or any agent of the licensee of any advertising statements of a character tending to deceive or mislead the public.
(i) The advertising of either professional superiority or the advertising of performance of professional services in a superior manner. This subdivision shall not prohibit advertising permitted by subdivision (h) of Section 651.
(j) The employing or the making use of solicitors.
(k) The advertising in violation of Section 651.
(l) The advertising to guarantee any dental service, or to perform any dental operation painlessly. This subdivision shall not prohibit advertising permitted by Section 651.
(m) The violation of any of the provisions of law regulating the procurement, dispensing, or administration of dangerous drugs, as defined in Chapter 9 (commencing with Section 4000) or controlled substances, as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code.
(n) The violation of any of the provisions of this division.
(o) The permitting of any person to operate dental radiographic equipment who has not met the requirements of Section 1656.
(p) The clearly excessive prescribing or administering of drugs or treatment, or the clearly excessive use of diagnostic procedures, or the clearly excessive use of diagnostic or treatment facilities, as determined by the customary practice and standards of the dental profession.
Any person who violates this subdivision is guilty of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100) or more than six hundred dollars ($600), or by imprisonment for a term of not less than 60 days or more than 180 days, or by both a fine and imprisonment.
(q) The use of threats or harassment against any patient or licensee for providing evidence in any possible or actual disciplinary action, or other legal action; or the discharge of an employee primarily based on the employee’s attempt to comply with the provisions of this chapter or to aid in the compliance.
(r) Suspension or revocation of a license issued, or discipline imposed, by another state or territory on grounds that would be the basis of discipline in this state.
(s) The alteration of a patient’s record with intent to deceive.
(t) Unsanitary or unsafe office conditions, as determined by the customary practice and standards of the dental profession.
(u) The abandonment of the patient by the licensee, without written notice to the patient that treatment is to be discontinued and before the patient has ample opportunity to secure the services of another dentist, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions and provided the health of the patient is not jeopardized.
(v) The willful misrepresentation of facts relating to a disciplinary action to the patients of a disciplined licensee.
(w) Use of fraud in the procurement of any license issued pursuant to this chapter.
(x) Any action or conduct that would have warranted the denial of the license.
(y) The aiding or abetting of a licensed dentist, dental assistant, registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions to practice dentistry in a negligent or incompetent manner.
(z) (1) The failure to report to the board in writing within seven days any of the following: (A) the death of the licensee’s patient during the performance of any dental or dental hygiene procedure; (B) the discovery of the death of a patient whose death is related to a dental or dental hygiene procedure performed by the licensee; or (C) except for a scheduled hospitalization, the removal to a hospital or emergency center for medical treatment of any patient to whom oral conscious sedation, conscious sedation, or general anesthesia was administered, or any patient as a result of dental or dental hygiene treatment. With the exception of patients to whom oral conscious sedation, conscious sedation, or general anesthesia was administered, removal to a hospital or emergency center that is the normal or expected treatment for the underlying dental condition is not required to be reported. Upon receipt of a report pursuant to this subdivision the board may conduct an inspection of the dental office if the board finds that it is necessary. A dentist shall report to the board all deaths occurring in the licensee’s practice with a copy sent to the Dental Hygiene Board of California if the death was the result of treatment by a registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions. A registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions shall report to the Dental Hygiene Board of California all deaths occurring as the result of dental hygiene treatment, and a copy of the notification shall be sent to the board.
(2) The report required by this subdivision shall be on a form or forms approved by the board. The form or forms approved by the board shall require the licensee to include, but not be limited to, the following information for cases in which patients received anesthesia: the date of the procedure; the patient’s age in years and months, weight, and sex; the patient’s American Society of Anesthesiologists (ASA) physical status; the patient’s primary diagnosis; the patient’s coexisting diagnoses; the procedures performed; the sedation setting; the medications used; the monitoring equipment used; the category of the provider responsible for sedation oversight; the category of the provider delivering sedation; the category of the provider monitoring the patient during sedation; whether the person supervising the sedation performed one or more of the procedures; the planned airway management; the planned depth of sedation; the complications that occurred; a description of what was unexpected about the airway management; whether there was transportation of the patient during sedation; the category of the provider conducting resuscitation measures; and the resuscitation equipment utilized. Disclosure of individually identifiable patient information shall be consistent with applicable law. A report required by this subdivision shall not be admissible in any action brought by a patient of the licensee providing the report.
(3) For the purposes of paragraph (2), categories of provider are: General Dentist, Pediatric Dentist, Oral Surgeon, Dentist Anesthesiologist, Physician Anesthesiologist, Dental Assistant, Registered Dental Assistant, Dental Sedation Assistant, Registered Nurse, Certified Registered Nurse Anesthetist, or Other.
(4) The form shall state that this information shall not be considered an admission of guilt, but is for educational, data, or investigative purposes.
(5) The board may assess a penalty on any licensee who fails to report an instance of an adverse event as required by this subdivision. The licensee may dispute the failure to file within 10 days of receiving notice that the board had assessed a penalty against the licensee.
(aa) Participating in or operating any group advertising and referral services that are in violation of Section 650.2.
(ab) The failure to use a fail-safe machine with an appropriate exhaust system in the administration of nitrous oxide. The board shall, by regulation, define what constitutes a fail-safe machine.
(ac) Engaging in the practice of dentistry with an expired license.
(ad) Except for good cause, the knowing failure to protect patients by failing to follow infection control guidelines of the board, thereby risking transmission of bloodborne infectious diseases from dentist, dental assistant, registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions to patient, from patient to patient, and from patient to dentist, dental assistant, registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions. In administering this subdivision, the board shall consider referencing the standards, regulations, and guidelines of the State Department of Public Health developed pursuant to Section 1250.11 of the Health and Safety Code and the standards, guidelines, and regulations pursuant to the California Occupational Safety and Health Act of 1973 (Part 1 (commencing with Section 6300) of Division 5 of the Labor Code) for preventing the transmission of HIV, hepatitis B, and other bloodborne pathogens in health care settings. The board shall review infection control guidelines, if necessary, on an annual basis and proposed changes shall be reviewed by the Dental Hygiene Board of California to establish a consensus. The hygiene board shall submit any recommended changes to the infection control guidelines for review to establish a consensus. As necessary, the board shall consult with the Medical Board of California, the California Board of Podiatric Medicine, the Board of Registered Nursing, and the Board of Vocational Nursing and Psychiatric Technicians, to encourage appropriate consistency in the implementation of this subdivision.
The board shall seek to ensure that all appropriate dental personnel are informed of the responsibility to follow infection control guidelines, and of the most recent scientifically recognized safeguards for minimizing the risk of transmission of bloodborne infectious diseases.
(ae) The utilization by a licensed dentist of any person to perform the functions of any registered dental assistant, registered dental assistant in extended functions, dental sedation assistant permitholder, orthodontic assistant permitholder, registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions who, at the time of initial employment, does not possess a current, valid license or permit to perform those functions.
(af) The prescribing, dispensing, or furnishing of dangerous drugs or devices, as defined in Section 4022, in violation of Section 2242.1.
(ag) Using water, or other methods used for irrigation, that are not sterile or that do not contain recognized disinfecting or antibacterial properties when performing dental procedures on exposed dental pulp.
(ah) The failure by the treating dentist, prior to the initial diagnosis and correction of malpositions of human teeth or initial use of orthodontic appliances, to perform an examination pursuant to subdivision (b) of Section 1684.5, including the review of the patient’s most recent diagnostic digital or conventional radiographs or other equivalent bone imaging suitable for orthodontia. New radiographs or other equivalent bone imaging shall be ordered if deemed appropriate by the treating dentist.
(ai) (1) The failure to comply with provide the disclosures described
in paragraph (2) to a patient before collecting a signed and dated consent to an assignment of benefits, as described under Section 1374.191 of the Health and Safety Code or Section 10120.6 of the Insurance Code.
(2) A noncontracting dental provider shall disclose all of the following to a patient before collecting an assignment of benefits:
(A) That the licensee is a noncontracting dental provider with respect to the patient’s dental benefit plan or policy.
(B) That the patient may experience lower out-of-pocket costs if services are rendered by a dental provider who is under contract with the dental benefit plan or policy.
(C) An estimate of the planned treatment cost and an estimate of the patient’s portion of that cost or a deposit that approximates cost share.
(D) That the patient’s plan or policy benefits may not apply to the treatment, and the noncontracting dental provider is not subject to requirements of the patient’s dental benefit plan or policy.
(E) That the patient has the right to confirm their dental benefit or coverage information from their health care service plan or insurer before beginning treatment.
(F) That an agreement to assignment of benefits is optional and may be revoked with respect to services not yet rendered by contacting in writing the noncontracting dental provider and health care service plan or insurance policy covering dental services or the specialized health insurance policy or plan covering dental services.
(aj) The failure to maintain a signed and dated copy of the consent described under Section 1374.191 of the Health and Safety Code or Section 10120.6 of the Insurance Code.
(ak) When collecting a signed and dated consent to an assignment of benefits, as described under Section 1374.191 of the Health and Safety Code or Section 10120.6 of the Insurance Code, charging the patient prior to the plan or insurer payment more than an estimate of the patient’s cost sharing for the treatment or a deposit that approximates cost share.
Section 1367.03 of the Health and Safety Code is amended to read:
1367.03.
(a) A health care service plan that provides or arranges for the provision of hospital or physician services, including a specialized mental health plan that provides physician or hospital services, or that provides mental health services pursuant to a contract with a full service plan, shall comply with the following timely access requirements:
(1) A health care service plan shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the enrollee’s condition consistent with good professional practice. A plan shall establish and maintain networks, policies, procedures, and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard. A health care service plan that uses a tiered network shall demonstrate compliance with the standards established by this section based on providers available at the lowest cost-sharing tier.
(2) A health care service plan shall ensure that all plan and provider processes necessary to obtain covered health care services, including, but not limited to, prior authorization processes, are completed in a manner that ensures the provision of covered health care services to an enrollee in a timely manner appropriate for the enrollee’s condition and in compliance with this section.
(3) If it is necessary for a provider or an enrollee to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the enrollee’s health care needs and ensures continuity of care consistent with good professional practice, and consistent with this section and the regulations adopted thereunder.
(4) Interpreter services required by Section 1367.04 of this code and Section 1300.67.04 of Title 28 of the California Code of Regulations shall be coordinated with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment without imposing delay on the scheduling of the appointment. This subdivision does not modify the requirements established in Section 1300.67.04 of Title 28 of the California Code of Regulations, or approved by the department pursuant to Section 1300.67.04 of Title 28 of the California Code of Regulations for a plan’s language assistance program.
(5) In addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), a health care service plan shall ensure that its network has adequate capacity and availability of licensed health care providers to offer enrollees appointments that meet the following timeframes:
(A) Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment, except as provided in subparagraph (H).
(B) Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment, except as provided in subparagraph (H).
(C) Nonurgent appointments for primary care: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(D) Nonurgent appointments with specialist physicians: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(E) Nonurgent appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(F) Commencing July 1, 2022, nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the prior appointment for those undergoing a course of treatment for an ongoing mental health or substance use disorder condition, except as provided in subparagraph (H). This subparagraph does not limit coverage for nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider to once every 10 business days.
(G) Nonurgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(H) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee.
(I) Preventive care services, as defined in subdivision (e), and periodic followup care, including standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac, mental health, or substance use disorder conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of their practice.
(J) A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard in subparagraph (A), (B), or (D), unless the requirements in subparagraph (H) or (I) are met, and shall be subject to the other provisions of this section.
(K) A plan may demonstrate compliance with the primary care time-elapsed standards established by this subdivision through implementation of standards, processes, and systems providing advanced access to primary care appointments, as defined in subdivision (e).
(6) In addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), each dental plan, and each full service plan offering coverage for dental services, shall ensure that dental networks have adequate capacity and availability of licensed health care providers to offer enrollees appointments for covered dental services in accordance with the following requirements:
(A) Urgent appointments within the dental plan network shall be offered within 72 hours of the time of request for appointment, if consistent with the enrollee’s individual needs and as required by professionally recognized standards of dental practice.
(B) Nonurgent appointments shall be offered within 36 business days of the request for appointment, except as provided in subparagraph (C).
(C) Preventive dental care appointments shall be offered within 40 business days of the request for appointment.
(7) A plan shall ensure it has sufficient numbers of network providers to maintain compliance with the standards established by this section.
(A) This section does not modify the requirements regarding provider-to-enrollee ratio or geographic accessibility established by Section 1300.51, 1300.67.2, or 1300.67.2.1 of Title 28 of the California Code of Regulations.
(B) A plan operating in a network service area that has a shortage of one or more types of providers shall ensure timely access to covered health care services as required by this section, including applicable time-elapsed standards, by referring an enrollee to, or, in the case of a preferred provider network, by assisting an enrollee to locate available and accessible network providers in neighboring network service areas consistent with patterns of practice for obtaining health care services in a timely manner appropriate for the enrollee’s health needs.
(C) A plan shall arrange for the provision of covered services from providers outside the plan’s network if unavailable within the network if medically necessary for the enrollee’s condition. A plan shall ensure that enrollee costs for medically necessary referrals to nonnetwork providers shall not exceed applicable in-network copayments, coinsurance, and deductibles. This requirement does not prohibit a plan or its delegated provider group from accommodating an enrollee’s preference to wait for a later appointment from a specific network provider. If medically necessary treatment of a mental health or substance use disorder is not available in network within the geographic and timely access standards set by law or regulation, a health care service plan shall arrange coverage outside the plan’s network in accordance with subdivision (d) of Section 1374.72.
(8) A plan shall provide or arrange for the provision, 24 hours per day, 7 days per week, of triage or screening services by telephone, as defined in subdivision (e).
(A) A plan shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the enrollee’s condition, and that the triage or screening waiting time does not exceed 30 minutes.
(B) A plan may provide or arrange for the provision of telephone triage or screening services through one or more of the following means: plan-operated telephone triage or screening services, telephone medical advice services pursuant to Section 1348.8, the plan’s primary care and mental health care or substance use disorder network, or another method that provides triage or screening services consistent with this section.
(i) A plan that arranges for the provision of telephone triage or screening services through network primary care, mental health care, and substance use disorder providers shall require those providers to maintain a procedure for triaging or screening enrollee telephone calls, which, at a minimum, shall include the employment, during and after business hours, of a telephone answering machine, an answering service, or office staff, that shall inform the caller of both of the following:
(I) Regarding the length of wait for a return call from the provider.
(II) How the caller may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by telephone, or, if needed, deliver urgent or emergency care.
(ii) A plan that arranges for the provision of triage or screening services through network primary care, mental health care, and substance use disorder providers who are unable to meet the time-elapsed standards established in subparagraph (A) shall also provide or arrange for the provision of plan-contracted or operated triage or screening services, which shall, at a minimum, be made available to enrollees affected by that portion of the plan’s network.
(iii) An unlicensed staff person handling enrollee calls may ask questions on behalf of a licensed staff person to help ascertain the condition of an insured so that the enrollee may be referred to licensed staff. However, an unlicensed staff person shall not, under any circumstances, use the answers to those questions in an attempt to assess, evaluate, advise, or make a decision regarding the condition of an enrollee or determine when an enrollee needs to be seen by a licensed medical professional.
(9) Dental, vision, chiropractic, and acupuncture plans shall ensure that network providers employ an answering service or a telephone answering machine during nonbusiness hours, which provide instructions regarding how an enrollee may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by telephone, or, if needed, deliver urgent or emergency care.
(10) A plan shall ensure that, during normal business hours, the waiting time for an enrollee to speak by telephone with a plan customer service representative knowledgeable and competent regarding the enrollee’s questions and concerns shall not exceed 10 minutes.
(b) With regard to subdivision (a), dental, vision, chiropractic, and acupuncture plans shall comply with paragraphs (1), (3), (4), (7), (9), and (10).
(c) The obligation of a plan to comply with this section shall not be waived if the plan delegates to its provider groups or other contracting entities any services or activities that the plan is required to perform. A plan’s implementation of this section shall be consistent with the Health Care Providers’ Bill of Rights, and a material change in the obligations of a plan’s network providers shall be considered a material change to the provider contract, within the meaning of subdivision (b) and paragraph (2) of subdivision (h) of Section 1375.7.
(d) A health care service plan shall incorporate the standards set forth in subdivision (a) into the health plan’s quality assurance systems and the processes set forth in Sections 1367 and 1370 of this code and Title 28 of the California Code of Regulations, including Sections 1300.67.2, 1300.67.2.2, 1300.68, and 1300.70. A plan shall not prevent, discourage, or discipline a network provider or employee for informing an enrollee or subscriber about the timely access standards.
(e) For purposes of this section:
(1) “Advanced access” means the provision, by a network provider, or by the provider group to which an enrollee is assigned, of appointments with a primary care physician, or other qualified primary care provider such as a nurse practitioner or physician’s assistant, within the same or next business day from the time an appointment is requested, and advance scheduling of appointments at a later date if the enrollee prefers not to accept the appointment offered within the same or the next business day.
(2) “Appointment waiting time” means the time from the initial request for health care services by an enrollee or the enrollee’s treating provider to the earliest date offered for the appointment for services inclusive of time for obtaining authorization from the plan or completing any other condition or requirement of the plan or its network providers.
(3) “Preventive care” means health care provided for prevention and early detection of disease, illness, injury, or another health condition and, in the case of a full service plan, includes all of the basic health care services required by Sections 1345, 1367.002, 1367.3, and 1367.35 of this code and subdivision (f) of Section 1300.67 of Title 28 of the California Code of Regulations.
(4) “Provider group” has the meaning set forth in subdivision (g) of Section 1373.65.
(5) “Triage” or “screening” means the assessment of an enrollee’s health concerns and symptoms via communication with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an enrollee who may need care for the purpose of determining the urgency of the enrollee’s need for care.
(6) “Triage or screening waiting time” means the time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an enrollee who may need care.
(7) “Urgent care” means health care for a condition that requires prompt attention, consistent with paragraph (2) of subdivision (h) of Section 1367.01.
(f) (1) Contracts between health care service plans and health care providers shall ensure compliance with the standards developed under this chapter. These contracts shall require reporting by health care providers to health care service plans and by health care service plans to the department to ensure compliance with the standards.
(2) Health care service plans shall report annually to the department on compliance with the standards in a manner specified by the department. The reported information shall allow consumers to compare the performance of plans and their network providers in complying with the standards, as well as changes in the compliance of plans with these standards.
(3) The department shall develop standardized methodologies for reporting that shall be used by health care service plans to demonstrate compliance with this section and any regulations adopted pursuant to it, including demonstration of the average waiting time for each class of appointment regulated under this section, except the department may develop methodologies to demonstrate compliance with, and the average appointment wait time for, each class of appointments regulated under paragraph (6) of subdivision (a). The methodologies shall be sufficient to determine compliance with the standards developed under this section for different networks of providers if a health care service plan uses a different network for Medi-Cal managed care products than for other products or if a health care service plan uses a different network for individual market products than for small group market products. The development and adoption of these methodologies shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until December 31, 2025. The department shall consult with stakeholders in developing standardized methodologies under this paragraph.
(4) Notwithstanding paragraph (3), the department may take compliance or disciplinary action, including assessment of administrative penalties, on the basis of noncompliance with any of the provisions of this section, including, but not limited to, timeframes for appointments and followup appointments.
(5) A plan, as defined in Section 1374.194, shall certify, under penalty of perjury, that information and data submitted to the department as required pursuant to this section is true and correct, as referenced in Section 1300.67.2.2(h)(2) of Title 28 of the California Code of Regulations. This shall include an attestation that, in determining and reporting on network adequacy, the plan has evaluated and taken into consideration the total number of lives utilizing the same provider network and if those enrolled lives impact network adequacy pursuant to paragraph (2). The department may audit plans for compliance pursuant to this paragraph or in response to consumer complaints regarding network adequacy. The department may adopt additional standards consistent with subdivision (l).
(6) The department may review and adopt standards, in addition to those specified in this article, concerning the availability of primary care physicians, specialty physicians, hospital care, and other health care, so that consumers have timely access to care. In so doing, the department shall consider the nature of physician practices, including individual and group practices, as well as the nature of the plan network. The department shall also consider various circumstances affecting the delivery of care, including urgent care, care provided on the same day, and requests for specific providers. If the department finds that health care service plans and health care providers have difficulty meeting these standards, the department may make recommendations to the Assembly Committee on Health and the Senate Committee on Health pursuant to subdivision (i). The development and adoption of standards under this paragraph shall not be subject to the Administrative Procedure Act until December 31, 2028. The department shall consult with stakeholders in developing the standards and methodologies described in this section.
(g) (1) The director may investigate and, by order, take enforcement action against plans, including, but not limited to, assessing administrative penalties subject to appropriate notice of, and the opportunity for, a hearing in accordance with Section 1397, regarding noncompliance with the requirements of this section. The director shall consider, as an aggravating factor when assessing administrative penalties, if harm to an enrollee, including financial or health impacts to an enrollee or substantial harm as defined in Section 3428 of the Civil Code, has occurred as a result of plan noncompliance. The director has the discretion to determine what harm constitutes harm to an enrollee. The plan may provide to the director, and the director may consider, information regarding the plan’s overall compliance with the requirements of this section. When taking enforcement action against a plan, the director may consider patterns of noncompliance. The administrative penalties shall not be deemed an exclusive remedy available to the director. These penalties shall be paid to the Managed Care Administrative Fines and Penalties Fund and shall be used for the purposes specified in Section 1341.45. The director shall periodically evaluate grievances to determine if any audit, investigative, or enforcement actions should be undertaken by the department.
(2) The director may, after appropriate notice and opportunity for hearing in accordance with Section 1397, by order, assess administrative penalties if the director determines that a health care service plan has knowingly committed, or has performed with a frequency that indicates a general business practice, either of the following:
(A) Repeated failure to act promptly and reasonably to ensure timely access to care consistent with this chapter.
(B) Repeated failure to act promptly and reasonably to require network providers to ensure timely access that the plan is required to perform under this chapter and that have been delegated by the plan to the network provider when the obligation of the plan to the enrollee or subscriber is reasonably clear.
(3) The administrative penalties available to the director pursuant to this section are not exclusive and may be sought and employed in any combination with civil, criminal, and other administrative remedies deemed warranted by the director to enforce this chapter.
(4) The administrative penalties shall be paid to the Managed Care Administrative Fines and Penalties Fund and shall be used for the purposes specified in Section 1341.45.
(h) The department shall work with the patient advocate to ensure that the quality of care report card incorporates information provided pursuant to subdivision (f) regarding the degree to which health care service plans and health care providers comply with the requirements for timely access to care.
(i) The department shall annually review information regarding compliance with the standards developed under this section and shall make recommendations for changes that further protect enrollees. Commencing no later than December 1, 2015, and annually thereafter, the department shall post its final findings from the review on its internet website.
(j) The department shall post on its internet website any waivers or alternative standards that the department approves under this section on or after January 1, 2015.
(k) This section applies to a licensed health care service plan that provides services to Medi-Cal beneficiaries. Except for appointment wait time standards set forth in paragraph (5) of subdivision (a) of this section and in Section 1300.67.2.2 of Title 28 of the California Code of Regulations, this section does not alter the requirements or standards of the State Department of Health Care Services specified in Section 14197 of the Welfare and Institutions Code.
(l) This section does not prevent the department from developing additional standards to improve timely access to care and network adequacy.
SEC. 3.
Section 1950.5 of the Business and Professions Code is amended to read:
1950.5.
Unprofessional conduct by a person licensed under this article is defined as, but is not limited to, any one of the following:
(a) The obtaining of any fee by fraud or misrepresentation.
(b) The aiding or abetting of any unlicensed person to practice dentistry or dental hygiene.
(c) The aiding or abetting of a licensed person to practice dentistry or dental hygiene unlawfully.
(d) The committing of any act or acts of sexual abuse, misconduct, or relations with a patient that are substantially related to the practice of dental hygiene.
(e) The use of any false, assumed, or fictitious name, either as an individual, firm, corporation, or otherwise, or any name other than the name under which the person is licensed to practice, in advertising or in any other manner indicating that the person is practicing or will practice dentistry, except the name specified in a valid permit issued pursuant to Section 1962.
(f) The practice of accepting or receiving any commission or the rebating in any form or manner of fees for professional services, radiographs, prescriptions, or other services or articles supplied to patients.
(g) The making use by the licensee or any agent of the licensee of any advertising statements of a character tending to deceive or mislead the public.
(h) The advertising of either professional superiority or the advertising of performance of professional services in a superior manner. This subdivision shall not prohibit advertising permitted by subdivision (h) of Section 651.
(i) The employing or the making use of solicitors.
(j) Advertising in violation of Section 651.
(k) Advertising to guarantee any dental hygiene service, or to perform any dental hygiene procedure painlessly. This subdivision shall not prohibit advertising permitted by Section 651.
(l) The violation of any of the provisions of this division.
(m) The permitting of any person to operate dental radiographic equipment who has not met the requirements to do so, as determined by the dental hygiene board.
(n) The clearly excessive administering of drugs or treatment, or the clearly excessive use of treatment procedures, or the clearly excessive use of treatment facilities, as determined by the customary practice and standards of the dental hygiene profession.
Any person who violates this subdivision is guilty of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100) or more than six hundred dollars ($600), or by imprisonment for a term of not less than 60 days or more than 180 days, or by both a fine and imprisonment.
(o) The use of threats or harassment against any patient or licensee for providing evidence in any possible or actual disciplinary action, or other legal action; or the discharge of an employee primarily based on the employee’s attempt to comply with the provisions of this chapter or to aid in the compliance.
(p) Suspension or revocation of a license issued, or discipline imposed, by another state or territory on grounds that would be the basis of discipline in this state.
(q) The alteration of a patient’s record with intent to deceive.
(r) Unsanitary or unsafe office conditions, as determined by the customary practice and standards of the dental hygiene profession.
(s) The abandonment of the patient by the licensee, without written notice to the patient that treatment is to be discontinued and before the patient has ample opportunity to secure the services of another registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions and provided the health of the patient is not jeopardized.
(t) The willful misrepresentation of facts relating to a disciplinary action to the patients of a disciplined licensee.
(u) Use of fraud in the procurement of any license issued pursuant to this article.
(v) Any action or conduct that would have warranted the denial of the license.
(w) The aiding or abetting of a registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions to practice dental hygiene in a negligent or incompetent manner.
(x) The failure to report to the dental hygiene board in writing within seven days any of the following: (1) the death of the licensee’s patient during the performance of any dental hygiene procedure; (2) the discovery of the death of a patient whose death is related to a dental hygiene procedure performed by the licensee; or (3) except for a scheduled hospitalization, the removal to a hospital or emergency center for medical treatment for a period exceeding 24 hours of any patient as a result of dental or dental hygiene treatment. Upon receipt of a report pursuant to this subdivision, the dental hygiene board may conduct an inspection of the dental hygiene practice office if the dental hygiene board finds that it is necessary.
(y) A registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions shall report to the dental hygiene board all deaths occurring in their practice with a copy sent to the dental board if the death occurred while working as an employee in a dental office. A dentist shall report to the dental board all deaths occurring in their practice with a copy sent to the dental hygiene board if the death was the result of treatment by a registered dental hygienist, registered dental hygienist in alternative practice, or registered dental hygienist in extended functions.
(z) Knowingly making a statement or signing a certificate or other document that falsely represents the existence or nonexistence of a fact directly or indirectly related to the practice of dental hygiene.
(aa) (1) For a registered dental hygienist in alternative practice, the failure to provide the disclosures described in paragraph (2) to a patient before collecting a signed and dated consent to an assignment of benefits, as described under Section 1374.191 of the Health and Safety Code or Section 10120.6 of the Insurance Code.
(2) A registered dental hygienist in alternative practice shall disclose all of the following to a patient before collecting an assignment of benefits:
(A) That the licensee is a noncontracting dental provider with respect to the patient’s dental benefit plan or policy.
(B) That the patient may experience lower out-of-pocket costs if services are rendered by a dental provider who is under contract with the dental benefit plan or policy.
(C) An estimate of the planned treatment cost and an estimate of the patient’s portion of that cost or a deposit that approximates cost share.
(D) That the patient’s plan or policy benefits may not apply to the treatment, and the noncontracting dental provider is not subject to requirements of the patient’s dental benefit plan or policy.
(E) That the patient has the right to confirm their dental benefit or coverage information from their health care service plan or insurer before beginning treatment.
(F) That an agreement to assignment of benefits is optional and may be revoked with respect to services not yet rendered by contacting in writing the noncontracting dental provider and health care service plan or insurance policy covering dental services or the specialized health insurance policy or plan covering dental services.
(ab) The failure of a registered dental hygienist in alternative practice to maintain a signed and dated copy of the consent described under Section 1374.191 of the Health and Safety Code or Section 10120.6 of the Insurance Code.
(ac) When collecting a signed and dated consent to an assignment of benefits, as described under Section 1374.191 of the Health and Safety Code or Section 10120.6 of the Insurance Code, charging the patient prior to the plan or insurer payment more than an estimate of the patient’s cost sharing for the treatment or a deposit that approximates cost share.
SEC. 4.
Section 1367.03 of the Health and Safety Code, as amended by Section 11 of Chapter 27 of the Statutes of 2026, is amended to read:
1367.03.
(a) A health care service plan that provides or arranges for the provision of hospital or physician services, including a specialized mental health plan that provides physician or hospital services, or that provides mental health services pursuant to a contract with a full service plan, shall comply with the following timely access requirements:
(1) A health care service plan shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the enrollee’s condition consistent with good professional practice. A plan shall establish and maintain networks, policies, procedures, and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard. A health care service plan that uses a tiered network shall demonstrate compliance with the standards established by this section based on providers available at the lowest cost-sharing tier.
(2) A health care service plan shall ensure that all plan and provider processes necessary to obtain covered health care services, including, but not limited to, prior authorization processes, are completed in a manner that assures ensures the provision of covered health care services to an enrollee in a timely manner appropriate for the enrollee’s condition and in compliance with this section.
(3) If it is necessary for a provider or an enrollee to reschedule an appointment, the appointment
shall be promptly rescheduled in a manner that is appropriate for the enrollee’s health care needs,
needs and ensures continuity of care consistent with good professional practice, and consistent with this section and the regulations adopted thereunder.
(4) Interpreter services required by Section 1367.04 of this code and Section 1300.67.04 of Title 28 of the California Code of Regulations shall be coordinated with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment without imposing delay on the scheduling of the appointment. This subdivision does not modify the requirements established in Section 1300.67.04 of Title 28 of the California Code of Regulations, or approved by the department pursuant to Section 1300.67.04 of Title 28 of the California Code of Regulations for a plan’s language assistance program.
(5) In addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), a health care service plan shall ensure that its network has adequate capacity and availability of licensed health care providers to offer enrollees appointments that meet the following timeframes:
(A) Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment, except as provided in subparagraph (H).
(B) Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment, except as provided in subparagraph (H).
(C) Nonurgent appointments for primary care: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(D) Nonurgent appointments with specialist physicians: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(E) Nonurgent appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(F) Commencing July 1, 2022, nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the prior appointment for those undergoing a course of treatment for an ongoing mental health or substance use disorder condition, except as provided in subparagraph (H). This subparagraph does not limit coverage for nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider to once every 10 business days.
(G) Nonurgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(H) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee.
(I) Preventive care services, as defined in subdivision (e), and periodic followup care, including standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac, mental health, or substance use disorder conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of their practice.
(J) A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard in subparagraph (A), (B), or (D), unless the requirements in subparagraph (H) or (I) are met, and shall be subject to the other provisions of this section.
(K) A plan may demonstrate compliance with the primary care time-elapsed standards established by this subdivision through implementation of standards, processes, and systems providing advanced access to primary care appointments, as defined in subdivision (e).
(6) In addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), each dental plan, and each full service plan offering coverage for dental services, shall ensure that dental networks have adequate capacity and availability of licensed health care providers to offer enrollees appointments for covered dental services in accordance with the following requirements:
(A) Urgent appointments within the dental plan network shall be offered within 72 hours of the time of request for appointment, if consistent with the enrollee’s individual needs and as required by professionally recognized standards of dental practice.
(B) Nonurgent appointments shall be offered within 36 business days of the request for appointment, except as provided in subparagraph (C).
(C) Preventive dental care appointments shall be offered within 40 business days of the request for appointment.
(7) A plan shall ensure it has sufficient numbers of network providers to maintain compliance with the standards established by this section.
(A) This section does not modify the requirements regarding provider-to-enrollee ratio or geographic accessibility established by Section 1300.51, 1300.67.2, or 1300.67.2.1 of Title 28 of the California Code of Regulations.
(B) A plan operating in a network service area that has a shortage of one or more types of providers shall ensure timely access to covered health care services as required by this section, including applicable time-elapsed standards, by referring an enrollee to, or, in the case of a preferred provider network, by assisting an enrollee to locate available and accessible network providers in neighboring network service areas consistent with patterns of practice for obtaining health care services in a timely manner appropriate for the enrollee’s health needs.
(C) A plan shall arrange for the provision of covered services from providers outside the plan’s network if unavailable within the network if medically necessary for the enrollee’s condition. A plan shall ensure that enrollee costs for medically necessary referrals to nonnetwork providers shall not exceed applicable in-network copayments, coinsurance, and deductibles. This requirement does not prohibit a plan or its delegated provider group from accommodating an enrollee’s preference to wait for a later appointment from a specific network provider. If medically necessary treatment of a mental health or substance use disorder is not available in network within the geographic and timely access standards set by law or regulation, a health care service plan shall arrange coverage outside the plan’s network in accordance with subdivision (d) of Section 1374.72.
(8) A plan shall provide or arrange for the provision, 24 hours per day, 7 days per week, of triage or screening services by telephone, as defined in subdivision (e).
(A) A plan shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the enrollee’s condition, and that the triage or screening waiting time does not exceed 30 minutes.
(B) A plan may provide or arrange for the provision of telephone triage or screening services through one or more of the following means: plan-operated telephone triage or screening services, telephone medical advice services pursuant to Section 1348.8, the plan’s primary care and mental health care or substance use disorder network, or another method that provides triage or screening services consistent with this section.
(i) A plan that arranges for the provision of telephone triage or screening services through network primary care, mental health care, and substance use disorder providers shall require those providers to maintain a procedure for triaging or screening enrollee telephone calls, which, at a minimum, shall include the employment, during and after business hours, of a telephone answering machine, an answering service, or office staff, that shall inform the caller of both of the following:
(I) Regarding the length of wait for a return call from the provider.
(II) How the
caller may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by phone, or telephone, or, if needed, deliver urgent or emergency care.
(ii) A plan that arranges for the provision of triage or screening services through network primary care, mental health care, and substance use disorder providers who are unable to meet the time-elapsed standards established in subparagraph (A) shall also provide or arrange for the provision of plan-contracted or operated triage or screening services, which shall, at a minimum, be made available to enrollees affected by that portion of the plan’s network.
(iii) An unlicensed staff person handling enrollee calls may ask questions on behalf of a licensed staff person to help ascertain the condition of an insured so that the enrollee may be referred to licensed staff. However, an unlicensed staff person shall not, under any circumstances, use the answers to those questions in an attempt to assess, evaluate, advise, or make a decision regarding the condition of an enrollee or determine when an enrollee needs to be seen by a licensed medical professional.
(9) Dental, vision, chiropractic, and acupuncture plans shall ensure that network providers employ an answering service or a telephone answering machine during nonbusiness hours, which provide instructions regarding how an enrollee may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by phone, or
telephone, or,
if needed, deliver urgent or emergency care.
(10) A plan shall ensure that, during normal business hours, the waiting time for an enrollee to speak by telephone with a plan customer service representative knowledgeable and competent regarding the enrollee’s questions and concerns shall not exceed 10 minutes.
(b) With regard to subdivision (a), dental, vision, chiropractic, and acupuncture plans shall comply with paragraphs (1), (3), (4), (7), (9), and (10).
(c) The obligation of a plan to comply with this section shall not be waived if the plan delegates to its provider groups or other contracting entities any services or activities that the plan is required to perform. A plan’s implementation of this section shall be consistent with the Health Care Providers’ Bill of Rights, and a material change in the obligations of a plan’s network providers shall be considered a material change to the provider contract, within the meaning of subdivision (b) and paragraph (2) of subdivision (h) of Section 1375.7.
(d) A health care service plan shall incorporate the standards set forth in subdivision (a) into the health plan’s quality assurance systems and the processes set forth in Sections 1367 and 1370 of this code and Title 28 of the California Code of Regulations, including Sections 1300.67.2, 1300.67.2.2, 1300.68, and 1300.70. A plan shall not prevent, discourage, or discipline a network provider or employee for informing an enrollee or subscriber about the timely access standards.
(e) For purposes of this section:
(1) “Advanced access” means the provision, by a network provider, or by the provider group to which an enrollee is assigned, of appointments with a primary care physician, or other qualified primary care provider such as a nurse practitioner or physician’s assistant, within the same or next business day from the time an appointment is requested, and advance scheduling of appointments at a later date if the enrollee prefers not to accept the appointment offered within the same or the next business day.
(2) “Appointment waiting time” means the time from the initial request for health care services by an enrollee or the enrollee’s treating provider to the earliest date offered for the appointment for services inclusive of time for obtaining authorization from the plan or completing any other condition or requirement of the plan or its network providers.
(3) “Preventive care” means health care provided for prevention and early detection of disease, illness, injury, or another health
condition and, in the case of a full service plan plan, includes all of the basic health care services required by Sections 1345, 1367.002, 1367.3, and 1367.35 of this code and subdivision (f) of Section 1300.67 of Title 28 of the California Code of Regulations.
(4) “Provider group” has the meaning set forth in subdivision (g) of Section 1373.65.
(5) “Triage” or “screening” means the assessment of an enrollee’s health concerns and symptoms via communication with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an enrollee who may need care for the purpose of determining the urgency of the enrollee’s need for care.
(6) “Triage or screening waiting time” means the time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an enrollee who may need care.
(7) “Urgent care” means health care for a condition that requires prompt attention, consistent with paragraph (2) of subdivision (h) of Section 1367.01.
(f) (1) Contracts between health care service plans and health care providers shall ensure compliance with the standards developed under this chapter. These contracts shall require reporting by health care providers to health care service plans and by health care service plans to the department to ensure compliance with the standards.
(2) Health care service plans shall report annually to the department on compliance with the standards in a manner specified by the department. The reported information shall allow consumers to compare the performance of plans and their network providers in complying with the standards, as well as changes in the compliance of plans with these standards.
(3) The department shall develop standardized methodologies for reporting that shall be used by health care service plans to demonstrate compliance with this section and any regulations adopted pursuant to it, including demonstration of the average waiting time for each class of appointment regulated under this section, except the department may develop methodologies to demonstrate compliance with, and the average appointment wait time for, each class of appointments regulated under paragraph (6) of subdivision (a). The methodologies shall be sufficient to determine compliance with the standards developed under this section for different networks of providers if a health care service plan uses a different network for Medi-Cal managed care products than for other products or if a health care service plan uses a different network for individual market products than for small group market products. The development and adoption of these methodologies shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until December 31, 2025. The department shall consult with stakeholders in developing standardized methodologies under this paragraph.
(4) Notwithstanding paragraph (3), the department may take compliance or disciplinary action, including assessment of administrative penalties, on the basis of noncompliance with any of the provisions of this section, including, but not limited to, timeframes for appointments and followup appointments.
(5) A plan, as defined in Section 1374.194, shall certify, under penalty of perjury, that information and data submitted to the department as required pursuant to this section is true and correct, as referenced in Section 1300.67.2.2(h)(2) of Title 28 of the California Code of Regulations. This shall include an attestation that, in determining and reporting on network adequacy, the plan has evaluated and taken into consideration the total number of lives utilizing the same provider network and if those enrolled lives impact network adequacy pursuant to paragraph (2). The department may audit plans for compliance pursuant to this paragraph or in response to consumer complaints regarding network adequacy. The department may adopt additional standards consistent with subdivision (l).
(6) The department may review and adopt standards, in addition to those specified in this article, concerning the availability of primary care physicians, specialty physicians, hospital care, and other health care, so that consumers have timely access to care. In so doing, the department shall consider the nature of physician practices, including individual and group practices, as well as the nature of the plan network. The department shall also consider various circumstances affecting the delivery of care, including urgent care, care provided on the same day, and requests for specific providers. If the department finds that health care service plans and health care providers have difficulty meeting these standards, the department may make recommendations to the Assembly Committee on Health and the Senate Committee on Health pursuant to subdivision (i). The development and adoption of standards under this paragraph shall not be subject to the Administrative Procedure Act until December 31, 2028. The department shall consult with stakeholders in developing the standards and methodologies described in this section.
(g) (1) The director may investigate and, by order, take enforcement action against plans, including, but not limited to, assessing administrative penalties subject to appropriate notice of, and the opportunity for, a hearing in accordance with Section 1397, regarding noncompliance with the requirements of this section. The director shall consider, as an aggravating factor when assessing administrative penalties, if harm to an enrollee, including financial or health impacts to an enrollee or substantial harm as defined in Section 3428 of the Civil Code, has occurred as a result of plan noncompliance. The director has the discretion to determine what harm constitutes harm to an enrollee. The plan may provide to the director, and the director may consider, information regarding the plan’s overall compliance with the requirements of this section. When taking enforcement action against a plan, the director may consider patterns of noncompliance. The administrative penalties shall not be deemed an exclusive remedy available to the director. These penalties shall be paid to the Managed Care Administrative Fines and Penalties Fund and shall be used for the purposes specified in Section 1341.45. The director shall periodically evaluate grievances to determine if any audit, investigative, or enforcement actions should be undertaken by the department.
(2) The director may, after appropriate notice and opportunity for hearing in accordance with Section 1397, by order, assess administrative penalties if the director determines that a health care service plan has knowingly committed, or has performed with a frequency that indicates a general business practice, either of the following:
(A) Repeated failure to act promptly and reasonably to assure ensure timely access to care consistent with this chapter.
(B) Repeated failure to act promptly and reasonably to require network providers to assure
ensure timely access that the plan is required to perform under this chapter and that have been delegated by the plan to the network provider when the obligation of the plan to the enrollee or subscriber is reasonably clear.
(3) The administrative penalties available to the director pursuant to this section are not exclusive, exclusive and may be sought and employed in any combination with civil, criminal, and other administrative remedies
deemed warranted by the director to enforce this chapter.
(4) The administrative penalties shall be paid to the Managed Care Administrative Fines and Penalties Fund and shall be used for the purposes specified in Section 1341.45.
(h) The department shall work with the Department of Health Care Access and Information to assure ensure that the quality of care report card incorporates information provided pursuant to
subdivision (f) regarding the degree to which health care service plans and health care providers comply with the requirements for timely access to care.
(i) The department shall annually review information regarding compliance with the standards developed under this section and shall make recommendations for changes that further protect enrollees. Commencing no later than December 1, 2015, and annually thereafter, the department shall post its final findings from the review on its internet website.
(j) The department shall post on its internet website any waivers or alternative standards that the department approves under this section on or after January 1, 2015.
(k) This section applies to a licensed health care service plan that provides services to Medi-Cal beneficiaries. Except for appointment wait time standards set forth in paragraph (5) of subdivision (a) of this section and in Section 1300.67.2.2 of Title 28 of the California Code of Regulations, this section does not alter the requirements or standards of the State Department of Health Care Services specified in Section 14197 of the Welfare and Institutions Code.
(l) This section does not prevent the department from developing additional standards to improve timely access to care and network adequacy.
SEC. 4.SEC. 5.
Section 1374.191 is added to the Health and Safety Code, to read:
1374.191.
(a) Upon written and dated consent of the enrollee, a A health care service plan covering dental services or a specialized health care service plan covering dental services shall pay the noncontracting dental provider provider, which includes a registered dental hygienist in alternative practice, directly for covered services rendered to the enrollee in accordance with the benefit provided in
the enrollee’s contract.
contract when the noncontracting dental provider submits to the plan an assignment of benefits in accordance with this section.
(b) Before accepting collecting an assignment of benefits, a noncontracting dental provider shall disclose all of the following to the enrollee:
(1) That the licensee is a noncontracting dental provider with respect to the enrollee’s dental benefit plan.
(2) That the enrollee may experience lower out-of-pocket costs if services are rendered by a dentist who is under contract with the dental benefit plan.
(3) An estimate of the planned treatment cost and an estimate of the enrollee’s portion of that cost or a deposit that approximates cost share.
(4) That the enrollee’s plan benefits may not apply to the treatment, and the noncontracting dental provider is not subject to contract requirements of the enrollee’s dental benefit plan.
(5) That the enrollee has the right to confirm their dental benefit or coverage information from their plan before beginning treatment.
(6) That an agreement to assignment of benefits is optional and may be revoked with respect to services not yet rendered by contacting in writing the noncontracting dental provider and health care service plan covering dental services or the specialized health care service plan covering dental services.
(c) (1) The noncontracting dental provider, which includes a registered dental hygienist in alternative practice, shall obtain a signed and dated consent to collect an assignment of benefits from an enrollee. The enrollee’s consent shall not be required to be submitted to the health care service plan as long as the noncontracting dental provider maintains a record of the signed and dated consent.
(2) A noncontracting dental provider accepting collecting an enrollee’s
assignment of benefits under paragraph (1) shall not charge the enrollee prior to the plan payment more than an estimate of the enrollee’s cost sharing for the treatment or a deposit that approximates cost share.
(d) A health care service plan covering dental services and a specialized health care service plan covering dental services shall be considered a third-party payor under Section 732 of the Business and Professions Code.
(e) For purposes of this section, “assignment of benefits” means the transfer of reimbursement or other rights provided for under a health care service plan contract to a treating provider for services or items rendered to an enrollee.
(f) This section applies only to a health care service plan contract covering out-of-network dental services or a specialized health care service plan contract covering out-of-network dental services pursuant to this chapter.
(g) This section does not apply to Medi-Cal managed care plan contracts, including dental managed care contracts, authorized under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.
SEC. 5.SEC. 6.
Section 10120.6 is added to the Insurance Code, to read:
10120.6.
(a) Upon written and dated consent of the insured, a A health insurance policy covering dental services or a specialized health insurance policy covering dental services shall pay the noncontracting dental provider provider, which includes a registered dental hygienist in alternative practice, directly for covered services rendered to the insured in accordance with the benefit provided in
the insured’s policy. policy when the noncontracting dental provider submits to the insurer an assignment of benefits in compliance with subdivisions (ai) and (aj) of Section 1680 of, or subdivisions (aa) and (ab) of Section 1950.5 of, the Business and Professions Code.
(1) That the licensee is a noncontracting dental provider with respect to the insured’s dental benefit policy.
(2) That the insured may experience lower out-of-pocket costs if services are rendered by a dentist who is under contract with the dental benefit policy.
(3) An estimate of the planned treatment cost and an estimate of the insured’s portion of that cost or a deposit that approximates cost share.
(4) That the insured’s policy benefits may not apply to the treatment, and the noncontracting dental provider is not subject to requirements of the insured’s dental benefit policy.
(5) That the insured has the right to confirm their dental benefit or coverage information from their insurer before beginning treatment.
(6) That an agreement to assignment of benefits is optional and may be revoked with respect to services not yet rendered by contacting in writing the noncontracting dental provider and health insurance policy covering dental services or the specialized health insurance policy covering dental services.
(b) (1) A noncontracting dental provider, which includes a registered dental hygienist in alternative practice, shall obtain a signed and dated consent to collect an assignment of benefits from an insured. The insured’s consent shall not be required to be submitted to the health insurer as long as the noncontracting dental provider maintains a record of the signed and dated consent.
(2) A noncontracting dental provider accepting
collecting an insured’s assignment of benefits
under paragraph (1)
shall not charge the insured prior to the insurer payment more than an estimate of the insured’s cost sharing for the treatment or a deposit that approximates cost share.
(c) A health insurance policy covering dental services and a specialized health insurance policy covering dental services shall be considered a third-party payor under Section 732 of the Business and Professions Code.
(d) For purposes of this section, “assignment of benefits” means the transfer of reimbursement or other rights provided for under a health insurance policy to a treating provider for services or items rendered to an insured.
(e) This section applies only to a health insurance policy covering out-of-network dental services or a specialized health insurance policy covering out-of-network dental services pursuant to this part.
SEC. 6.SEC. 7.
Section 10133.54 of the Insurance Code is amended to read:
10133.54.
(a) This section applies to policies of health insurance, as defined by subdivision (b) of Section 106. The requirements of this section apply to all health care services covered by a health insurance policy.
(b) Notwithstanding Section 10133.5, a health insurer shall comply with the timely access requirements in this section, but a specialized health insurance policy as defined in subdivision (c) of Section 106, other than a specialized mental health insurance policy, is exempt from the provisions of this section, except as specified in paragraph (6) and subdivision (c).
(1) A health insurer shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the insured’s condition, consistent with good professional practice. An insurer shall establish and maintain provider networks, policies, procedures, and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard. An insurer that uses a tiered network shall demonstrate compliance with the standards established by this section based on providers available at the lowest cost-sharing tier.
(2) A health insurer shall ensure that all insurer and provider processes necessary to obtain covered health care services, including, but not limited to, prior authorization processes, are completed in a manner that ensures the provision of covered health care services to an insured in a timely manner appropriate for the insured’s condition and in compliance with this section.
(3) If it is necessary for a provider or an insured to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the insured’s health care needs, and ensures continuity of care consistent with good professional practice, and consistent with the objectives of Section 10133.5, the regulations adopted pursuant to Section 10133.5, and this section.
(4) Interpreter services required by Section 10133.8 of this code and Article 12.1 (commencing with Section 2538.1) of Title 10 of the California Code of Regulations shall be coordinated with scheduled appointments for health care services in a manner that ensures the provision of interpreter services at the time of the appointment, consistent with Section 2538.6 of Title 10 of the California Code of Regulations, without imposing delay on the scheduling of the appointment. This subdivision does not modify the requirements established in Sections 10133.8 and 10133.9 of this code and Section 2538.6 of Title 10 of the California Code of Regulations, or approved by the department pursuant to Section 2538.6 of Title 10 of the California Code of Regulations, for an insurer’s language assistance program.
(5) In addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), a health insurer shall ensure that its contracted provider network has adequate capacity and availability of licensed health care providers to offer insureds appointments that meet the following timeframes:
(A) Urgent care appointments for services that do not require prior authorization: within 48 hours of the request for appointment, except as provided in subparagraph (H).
(B) Urgent care appointments for services that require prior authorization: within 96 hours of the request for appointment, except as provided in subparagraph (H).
(C) Nonurgent appointments for primary care: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(D) Nonurgent appointments with specialist physicians: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(E) Nonurgent appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(F) Commencing July 1, 2022, nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider: within 10 business days of the prior appointment for those undergoing a course of treatment for an ongoing mental health or substance use disorder condition, except as provided in subparagraph (H). This subparagraph does not limit coverage for nonurgent followup appointments with a nonphysician mental health care or substance use disorder provider to once every 10 business days.
(G) Nonurgent appointments for ancillary services for the diagnosis or treatment of injury, illness, or other health condition: within 15 business days of the request for appointment, except as provided in subparagraphs (H) and (I).
(H) The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of their practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the insured.
(I) Preventive care services, as defined in subdivision (e), and periodic followup care, including standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac, mental health, or substance use disorder conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of their practice.
(J) A referral to a specialist by a primary care provider or another specialist shall be subject to the relevant time-elapsed standard in subparagraph (A), (B), or (D), unless the requirements in subparagraph (H) or (I) are met, and shall be subject to the other provisions of this section.
(6) (A) The following types of health insurance policies shall be subject to the requirements in subparagraph (B):
(i) A health insurance policy covering the pediatric oral or vision essential health benefit.
(ii) A specialized health insurance policy that provides coverage for the pediatric oral essential health benefit, as defined in paragraph (5) of subdivision (a) of Section 10112.27.
(iii) A specialized health insurance policy that covers dental benefits only, as defined in subdivision (c) of Section 106.
(B) In addition to ensuring compliance with the clinical appropriateness standard set forth in paragraph (1), each health insurance policy specified in subparagraph (A) shall ensure that contracted oral or vision provider networks have adequate capacity and availability of licensed health care providers, including generalist and specialist dentists, ophthalmologists, optometrists, and opticians, to offer insureds appointments for covered oral or vision services in accordance with the following requirements:
(i) Urgent appointments within the plan network shall be offered within 72 hours of the time of request for appointment, if consistent with the insured’s individual needs and as required by professionally recognized standards of dental practice.
(ii) Nonurgent appointments shall be offered within 36 business days of the request for appointment, except as provided in clause (iii).
(iii) Preventive care appointments shall be offered within 40 business days of the request for appointment.
(iv) The applicable waiting time for a particular appointment in this paragraph may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of the provider’s practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the insured.
(7) An insurer shall ensure it has sufficient numbers of contracted providers to maintain compliance with the standards established by this section.
(A) This section does not modify the requirements regarding accessibility established by Article 6 (commencing with Section 2240) of Title 10 of the California Code of Regulations.
(B) An insurer shall ensure timely access to covered health care services as required by this section, including applicable time-elapsed standards, by assisting an insured to locate available and accessible contracted providers in a timely manner appropriate for the insured’s health needs. An insurer shall arrange for the provision of services outside the insurer’s contracted network if unavailable within the network if medically necessary for the insured’s condition. Insured costs for medically necessary referrals to nonnetwork providers shall not exceed applicable in-network copayments, coinsurance, and deductibles.
(8) An insurer shall provide or arrange for the provision, 24 hours per day, 7 days per week, of triage or screening services by telephone, as defined in subdivision (f).
(A) An insurer shall ensure that telephone triage or screening services are provided in a timely manner appropriate for the insured’s condition and that the triage or screening waiting time does not exceed 30 minutes.
(B) An insurer may provide or arrange for the provision of telephone triage or screening services through one or more of the following means: insurer-operated telephone triage or screening services, telephone medical advice services pursuant to Section 10279, the insurer’s contracted primary care and mental health care or substance use disorder provider network, or other method that provides triage or screening services consistent with this section.
(i) An insurer that arranges for the provision of telephone triage or screening services through contracted primary care and mental health care and substance use disorder providers shall require those providers to maintain a procedure for triaging or screening insured telephone calls, which, at a minimum, shall include the employment, during and after business hours, of a telephone answering machine, an answering service, or office staff, that shall inform the caller of both of the following:
(I) Regarding the length of wait for a return call from the provider.
(II) How the caller may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by telephone, or, if needed, deliver urgent or emergency care.
(ii) An insurer that arranges for the provision of triage or screening services through contracted primary care and mental health care and substance use disorder providers who are unable to meet the time-elapsed standards established in subparagraph (A) shall also provide or arrange for the provision of insurer-contracted or operated triage or screening services, which shall, at a minimum, be made available to insureds affected by that portion of the insurer’s network.
(iii) An unlicensed staff person handling insured calls may ask questions on behalf of a licensed staff person to help ascertain the condition of an insured so that the insured may be referred to licensed staff. However, an unlicensed staff person shall not, under any circumstances, use the answers to those questions in an attempt to assess, evaluate, advise, or make a decision regarding the condition of an insured or determine when an insured needs to be seen by a licensed medical professional.
(9) A health insurance policy providing coverage for the pediatric oral and vision essential health benefit, and a specialized health insurance policy that provides coverage for dental care expenses only, shall require that contracted providers employ an answering service or a telephone answering machine during nonbusiness hours, which provides instructions regarding how an insured may obtain urgent or emergency care, including, if applicable, how to contact another provider who has agreed to be on call to triage or screen by telephone, or, if needed, deliver urgent or emergency care.
(10) An insurer shall ensure that, during normal business hours, the waiting time for an insured to speak by telephone with an insurer customer service representative knowledgeable and competent regarding the insured’s questions and concerns shall not exceed 10 minutes, or that the covered person will receive a scheduled call-back within 30 minutes.
(c) Notwithstanding subdivision (b), a specialized health insurance policy, as defined in subdivision (c) of Section 106, other than a specialized mental health insurance policy, is exempt from this section, except as specified in this subdivision. A specialized health insurance policy that provides coverage for dental care expenses only shall comply with paragraphs (1), (3), (4), (6), (7), (9), and (10) of subdivision (b).
(d) An insurer shall incorporate the standards set forth in the insurer’s quality assurance systems and processes, as set forth in subdivision (b), and the processes as set forth in Title 10 of the California Code of Regulations, including Sections 2240.1, 2240.15, and 2240.16. An insurer shall not prevent, discourage, or discipline a contracting provider or employee for informing an insured or policyholder about the timely access standards.
(e) For purposes of this section:
(1) “Appointment waiting time” means the time from the initial request for health care services by an insured or the insured’s treating provider to the earliest date offered for the appointment for services inclusive of time for obtaining authorization from the insurer or completing any other condition or requirement of the insurer or its contracting providers.
(2) “Preventive care” means health care provided for prevention and early detection of disease, illness, injury, or other health conditions, and includes, but is not limited to, all of the services required by all of the following laws:
(A) Section 146.130 of Title 45 of the Code of Federal Regulations.
(B) Section 10112.2 (incorporating the requirements of Section 2713 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-13)).
(C) Clause (ii) of subparagraph (A) of paragraph (2) of subdivision (a) of Section 10112.27.
(3) “Provider group” has the meaning set forth in subdivision (v) of Section 10133.15.
(4) “Triage” or “screening” means the assessment of an insured’s health concerns and symptoms via communication with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an insured who may need care for the purpose of determining the urgency of the insured’s need for care.
(5) “Triage or screening waiting time” means the time waiting to speak by telephone with a physician, registered nurse, or other qualified health professional acting within their scope of practice and who is trained to screen or triage an insured who may need care.
(6) “Urgent care” means health care for a condition that requires prompt attention, consistent with paragraph (2) of subdivision (h) of Section 10123.135.
(f) (1) The department may issue guidance to insurers regarding annual timely access and network reporting methodologies. The development and adoption of these methodologies shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code) until December 31, 2025.
(2) Notwithstanding paragraph (1), the department may take compliance or disciplinary action, including imposition of administrative penalties, on the basis of noncompliance with any of the provisions of this section, including, but not limited to, timeframes for appointments and followup appointments.
(3) A health insurer, as defined in Section 10120.41, shall certify, under penalty of perjury, that information and data submitted to the department as required pursuant to this section is true and correct. This shall include an attestation that, in determining and reporting on network adequacy, the insurer has evaluated and taken into consideration the total number of lives utilizing the same provider network and if those enrolled lives impact network adequacy. The department may audit plans for compliance pursuant to this paragraph or in response to consumer complaints regarding network adequacy. The department may adopt additional standards consistent with subdivision (g).
(4) The department may review and adopt standards, in addition to those specified in this article, concerning the availability of primary care physicians, specialty physicians, hospital care, and other health care, so that consumers have timely access to care. In so doing, the department shall consider the nature of physician practices, including individual and group practices, as well as the nature of the network. The department shall also consider various circumstances affecting the delivery of care, including urgent care, care provided on the same day, and requests for specific providers. If the department finds that insurers and health care providers have difficulty meeting these standards, the department may make recommendations to the Assembly Committee on Health and the Senate Committee on Health. The development and adoption of standards under this paragraph shall not be subject to the Administrative Procedure Act until December 31, 2028. The department shall consult with stakeholders in developing the standards and methodologies described in this section.
(g) Nothing in this section shall be construed to prevent the department from developing additional standards to improve timely access to care and network adequacy.
SEC. 7.SEC. 8.
No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution.