Health care coverage: health care provider credentials.

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 disability and health insurers by the Department of Insurance. This bill would require every full service health care service plan or health insurer, or its delegate, to subscribe to and use the Council for Affordable Quality Healthcare credentialing form on and after January 1, 2028, except as specified. Existing law requires a health care service plan or disability insurer that provides coverage for mental health and substance use disorders and that credentials health care providers of those services for its networks to assess and verify the qualifications of a health care provider within 60 days after receiving a completed provider credentialing application. This bill would, except as provided above and within one year of the bill's operative date, require every health care service plan or health insurer, or its delegate, that credentials health care providers for its networks to make a determination regarding the credentials of a provider within 90 days after receiving a completed provider credentialing application. The bill would require every health care service plan or health insurer to activate the provider upon successful approval and notify the applicant of the activation, as specified. If the health care service plan or health insurer, or its delegate, does not meet the 90-day requirement, the bill would require the applicant's credentials to be provisionally approved for 120 days unless specified circumstances apply, including that the applicant is subject to discipline by the licensing entity for that applicant. The bill would exclude Medi-Cal managed care plans from these provisions. Because a willful violation of these provisions by a health care service plan would be a crime, this bill would impose a state-mandated local program. 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.