Current through Register 1531, September 27, 2024
All Provider directory requirements set forth in
211
CMR 52.15 shall be in addition to any
applicable Provider directory requirements under
211
CMR 152.08 for insured Health Benefit Plans
that use limited, regional or tiered Provider Networks:
(1) Carriers shall establish appropriate
systems to collect, store, and maintain detailed information about each Health
Care Provider within their Provider Network systems. The systems are to be
developed in a manner that facilitates a Health Care Provider's ability to
update personal and practice information to the maximum extent feasible.
Carriers shall ensure that Provider directories educate persons covered by
plans providing services through Networks of Providers about how they may
obtain in-Network care from an out-of-Network Provider when an in-Network
Provider is not available.
(2) The
detailed information that the Carrier is required to collect, store and
maintain about Health Care Providers who are a part of the Carrier's Network,
shall include at least the following information for each Health Care Provider:
(a) Health Care Provider's primary Specialty,
secondary Specialty (if applicable), tertiary Specialty (if applicable),
Behavioral Health sub-Specialty (if applicable)
1. The reporting of a Specialty or
sub-Specialty should be based on the Provider's actual training and experience
in treatment of this Specialty or sub-Specialty in the past 24
months.;
(b) license
type, practice credentials (education, including all relevant licensure(s),
professional designations, and relevant certifications, including but not
limited to board certifications);
(c) Health Care Facilities with which a
Health Care Provider is affiliated (e.g., where a Provider has
admitting privileges);
(d) if a
hospital or Facility, the type of hospital\Facility and its Accreditation
status;
(e) if a non-hospital
behavioral health Facility, the standard services as identified by the
Commissioner, that are available in the Facility;
(f) practice group affiliation;
(g) office locations for a Provider, and for
each location whether the individual Providersees patients in that location:
1. at least once per week;
2. at least once per month; or
3. as a cover/fill-in as needed;
(h) whether the Health Care
Provider is:
1. is available to accept new
patients covered by the Carrier;
2.
is not accepting new patients covered by the Carrier; or
3. has limited availability to accept new
patients covered by the Carrier with a waitlist of 4 weeks of less to schedule
an appointment;
(i)
operating hours for each office location, including whether the office is
available for evening and weekend appointments;
(j) main phone number(s) available for
members' use in setting up appointments;
(k) all languages understood and/or spoken by
the Health Care Provider;
(l)
whether the setting in which a Provider treats patients is ADA accessible and a
description of the accommodations available to address physical, developmental,
and intellectual disabilities;
(m)
whether the practice specializes in the treatment of specific genders and
identification of those specific genders or gender identities based upon the
Provider's actual treatment of members of such populations or groups in the
last 24 months.;
(n) any specific
age groups treated by the Health Care Provider, if the Provider so
chooses;
(o) any special
populations or cultural groups that the Health Care Provider wishes to
highlight that the Health Care Provider serves, as well as the Provider's race
and nationality, if the Provider so chooses;
(p) whether the Health Care Provider has
conditions to treating a patient, including the following:
1. requiring a patient to pay a concierge
medicine fee, Facility fee, or other administrative fee in order to be treated
by the Health Care Provider,
2. if
a Health Care Provider practice requires that the care is limited to hospital
or Facility inpatients;
3. for
Health Care Providers who work in clinics or community health centers,
requiring that a patient receive other health care at the clinic or community
health center; or
4. for Health
Care Providers who work at university or school health centers, requiring that
patients are enrolled students in the university or school.
(q) if a Tiered Network Plan, the
Provider's tier, an explanation of how the Carrier identifies the Provider's
tier, and the impact of the tier on Cost-sharing under the health plan;
and
(r) which Health Care Providers
within a Facility are available for consultation via Telehealth and the
modalities of Telehealth the Health Care Provider offers to patients or whether
the Health Care Provider is available for consultation only via
Telehealth.
(3) detailed
information that the Carrier is required to display in the Provider directory
shall present information about the Health Care Professionals who see patients
at each office location identifying whether the Health Care Professional is
limiting patients to a subset of the Carrier's members and information
according to the following categories:
a.
Health Care Professional sees patients at the location at least once per
week;
b. Health Care Professional
sees patients at the location at least once per month; and
c. Health Care Professional sees patients as
a cover/fill-in or when needed.
(4) detailed information that the Carrier is
required to display in the Provider directory shall include at least the
following information about non-Facility Health Care Providers who are apart of
the Carrier's Network:
(a) Health Care
Provider's primary Specialty, secondary Specialty (if applicable), tertiary
Specialty (if applicable), Behavioral Health sub-Specialty (if
applicable);
(b) license type,
practice credentials (education, including all relevant licensure(s),
professional designations, and relevant certifications including but not
limited to board certifications);
(c) Health Care Facilities with which a
Health Care Provider is affiliated (e.g., where a Provider has
admitting privileges);
(d) whether
the Health Care Provider is:
1. accepting new
patients that are covered by the Carrier
2. closed to new patients covered by the
Carrier; or
3. accepting new
patients but with a wait list of 4 weeks or less to schedule an
appointment);
(e) group
practice affiliations;
(f) office
locations for a Provider where the Provider will see patients and for each
location whether the Provider sees patients:
1. at least once per week; or
2. at least once per month;
(g) operating hours for each
office location, including whether the office is open for evening and weekend
appointments;
(h) phone number(s)
or other contact information a member may use in setting up an
appointment;
(i) whether the office
at which a Provider treats patients is ADA accessible and a description of the
accommodations available to address physical, developmental, and intellectual
disabilities;
(j) languages spoken
by the Health Care Provider;
(k)
age groups and special populations, genders or cultural groups that the Health
Care Provider treats on a regular basis, as well as the Provider's race and
nationality, if the Provider so chooses;
(l) whether the Health Care Provider requires
a patient to pay a concierge medicine, Facility fee, or other administrative
fee in order to be treated by the Health Care Provider;
(m) if a covered member is in a Tiered
Network Plan, the Carrier shall provide access to information that will
identify the Provider's tier within the covered members' Tiered Network Plan,
an explanation of how the Carrier identifies the Provider's tier, and the
impact of the tier on Cost-sharing under the health plan; and
(n) whether the Health Care Provider is
available for consultation via Telehealth and the modalities of Telehealth the
Health Care Provider offers to patients.
(5) The detailed information that the Carrier
is required to display in the Provider directory shall include at least the
following information about Facility Health Care Providers who are a part of
the Carrier's Network:
(a) the type of
hospital/Facility and its Accreditation status;
(b) if a non-hospital behavioral health
Facility, the standard services as identified by the Commissioner that are
available in the Facility;
(c) the
main phone number(s) for members to use in contacting the Facility;
(d) all languages spoken by Providers within
the Facility;
(e) whether the
office is ADA compliant and list a description of accommodations to address
physical and intellectual disabilities;
(f) if Facilities are tiered within a Tiered
Network Plan, the Provider's tier, an explanation of how the Carrier identifies
the Provider's tier, and the impact of the tier on Cost-sharing under the
health plan;
(g) how the Health
Care Provider may be contacted by a patient, including phone numbers and
internet portals; and.
(h) whether
the Facility's practitioners may be available for consultation via
Telehealth.
(6) A Carrier
shall ensure the accuracy of the information concerning each Provider listed in
the Carrier's Provider directories for each Network plan and shall review and
update the entire Provider directory for each Network plan.
(7) If delivering a paper copy of the
Provider directory, a Carrier shall be deemed to have met the requirements of
211
CMR 52.15(1) if the
Carrier:
(a) provides to at least one adult
Insured in each household, or in the case of a group policy, to the group
representative, at least once per calendar year an addendum, insert, or other
update to the Provider directory originally provided under
211
CMR 52.15(1);
(b) updates its toll-free number within 48
hours and Internet Website as soon as practicable, or as directed by the
Commissioner.
(8) Every
Provider directory described in
211
CMR 52.15 must contain the effective date,
date of issue, expiration date, if applicable, and reference to any
government-sponsored website(s) providing quality and cost information, as may
be designated by the Commissioner.
(9) A Carrier shall deliver a Provider
directory through an Internet Website A Carrier may also deliver a Provider
directory via "intranet websites," "electronic mail," and "e-mail." If the
Carrier refers an Insured to access directory information through an Internet
Website, the Carrier must be able to demonstrate compliance with the following:
(a) The Carrier shall deliver notice of the
Provider directory to at least one adult in the household of each Insured, by
direct mail, or by electronic mail if the Insured has agreed to communicate
electronically, that includes:
1. all
necessary information and a clear explanation of the manner by which Insured
scan access their specific Provider directory through an Internet
Website;
2. a list of the specific
information to be furnished by the Carrier through an Internet
Website;
3. the Insured's right to
receive, free of charge, a paper copy of the Provider directory at any
time;
4. the manner by which the
Insured can exercise the right to receive a paper copy at no cost to the
Insured; and
5. a toll-free number
for the Insured to call with any questions or requests and instructions about
how the Insured can contact the Carrier if they want assistance in locating an
available Provider. The Carrier shall take reasonable measures to ensure that
the Provider directory information and documents furnished in an Internet
Website are substantially the same as that contained in the Carrier's paper
documents.
(b) The
Carrier takes reasonable measures to ensure that it furnishes, upon request of
an individual, a paper copy of the Provider directory.
(10) A Provider directory that is
electronically available shall:
(a) be in a
format which will be searchable by
1. Provider
type,
2. Specialty in treating
specific populations, if applicable,
3. whether the Provider is accepting new
patients/is closed to new patients,
4. language spoken, and
5. distance from a geographic starting point
selected by a consumer.;
(b) shall identify that it is current as of a
certain date;
(c) be accessible to
the general public through a clearly identifiable link or tab without requiring
the general public to create or access an account, enter a policy or contract
number, provide other identifying information, or demonstrate coverage or an
interest in obtaining coverage with the Network plan;
(d) be updated as soon as practicable and not
less often than monthly or as directed by the Commissioner; provided, however,
that an electronic Network plan Provider directory shall be updated within two
business days, or sooner if consistent with federal guidelines, when the
Carrier is informed of and upon confirmation that:
1. a contracting Provider is no longer
accepting new patients for that Network plan or an individual Provider within a
Provider group is no longer accepting new patients;
2. a Provider or Provider group is no longer
being under contract for a particular Network plan;
3. a Provider's practice location or other
Provider directory information has changed;
4. a Provider has retired or ceased practice;
or
5. any other information that
affects the content or accuracy of the Provider directory has
changed.
(11) A
Provider directory shall include a dedicated customer service email address and
telephone number and electronic link, set forth prominently in both the
directory and on the Carrier's website, to assist with the Provider directory
information and to provide information about a Provider's participation in the
Carrier's Network, consistent with federal requirements for providing this
information. The Provider directory will educate members to notify the Carrier
of inaccurate Provider directory information, consistent with federal
requirements.
The Carrier shall investigate reports of Provider directory
inaccuracies within 30 Days of receiving notice of an inaccuracy, and the
Carrier shall modify the Provider directory as soon as practicable, but not
longer than 30 Days after finding an inaccuracy. Carrier will establish a
dedicated toll-free telephone number or add an option to its existing toll-free
number to assist covered persons to schedule an appointment with an available
and appropriate Health Care Provider when they are unable to locate or schedule
an appointment with a Health Care Provider who is listed in the Carrier's
Provider directory information as accepting new patients to treat the patients
of a certain age or health condition Specialty.
The Carrier will also contact each of the Health Care Providers
who were unavailable to schedule an appointment with the patient in order to
understand the reasons that an appointment was not scheduled, and the Carrier
shall modify the Provider directory information as necessary to reflect the
correct availability of the Health Care Provider to treat conditions and
certain age groups. Carriers shall conduct staff training regarding
communications about inaccurate Provider information so as to ensure that
Provider directory inaccuracies are promptly investigated and corrected.
Carriers will maintain files of all such follow-up calls so that they may be
reviewed by Division staff upon request.
(12) The Provider directory must contain a
list of Health Care Providers in the Carrier's Network available to Insureds
residing in Massachusetts, organized by Specialty, location, and distance from
a starting point selected by the searching individual, and the directory shall
summarize on the Carrier's Internet Website for each such Provider:
(a) the method used to compensate or
reimburse such Provider;
(b) the
Provider price relativity, as defined in and reported under section 10 of
chapter 12C;
(c) the Provider's
health status adjusted total medical expenses, as defined in and reported under
said section 10 of said chapter 12C;
(d) current measures of the Provider's
quality based on measures from the Standard Quality Measure Set, as defined in
the regulations promulgated by the Center for Health Information Analysis
established by M.G.L. c. 12C, § 2; provided, that the Carrier shall
prominently promote Providers based on quality performance as measured by the
standard quality measure set and cost performance as measured by health status
adjusted total medical expenses and relative prices;
(e) such information about Providers may be
provided directly by Carrier or by reference to a third-party source that
facilitates comparison of Providers' performance.
(13) Carriers shall display information in
the Provider directory about how to access coverage for community-based
Behavioral Health Service Providers that provide crisis, urgent care, and
stabilization services, including but not limited to mobile crisis intervention
and the emergency services program.
(14) Nothing in
211
CMR 52.15(8) shall be
construed to require disclosure of the specific details of any financial
arrangements between a Carrier and a Provider.
(15) If any specific Providers or type of
Providers requested by an Insured are not available in said Network, or are not
a covered benefit, or if any Primary Care Provider or Behavioral Health or
substance use disorder Health Care Professional is not accepting new patients,
such information shall be provided in an easily obtainable manner, including in
the Provider directory.
(16)
Notwithstanding any general or specific law to the contrary, a Carrier shall
ensure that all Participating Provider Nurse Practitioners and Participating
Provider Physician Assistants with whom a member can make an appointment are
included and displayed in a nondiscriminatory manner in the Carrier's Provider
Directory.
(17) Carriers' new and
renewing Provider contracts shall require Providers to inform the Carrier
promptly when the Provider availability to see new patients changes (including
whether they have a wait list) and Carriers shall prioritize updating
directories to reflect these changes within two business days of receiving
notice of a Provider's change in status.
(18) Consistent with federal guidelines,
Carriers shall contact Providers every 90 days, or as directed by the
Commissioner, to remind Providers to check and verify their profiles so that
Carriers can certify that the Provider's information is correct. As part of
such reminders, Carriers shall educate Providers about the importance of making
Provider changes as soon as Provider changes occur so that Carriers may make
the appropriate Provider directory updates as soon as possible.
(19) Consistent with federal guidelines,
Carriers that have received notice of potentially inaccurate information
through a consumer, Provider, or audit and have been unable to validate the
accuracy of the listing shall take the following steps:
(a) If the potential inaccuracy relates to
the physical address or telephone number of the Provider, the Carrier should
either immediately remove the information from the online directory until the
information is updated, or designate the information as "unverified" for no
longer than 90 days, after which the information must be immediately
removed;
(b) If the potential
inaccuracy relates to whether a Provider is accepting new patients, the Carrier
shall remove the designation "accepting new patients" for that Provider until
the information is updated;
(c) If
the potential inaccuracy relates to whether a Provider is or continues to be an
in-Network Provider, the Carrier should remove the full Provider listing from
the online directory until it is updated.
(20) Carriers shall employ policies to ensure
that directory information provided, updated and verified by behavioral health
Providers is accurately uploaded and displayed in its directory and shall audit
licensed behavioral health Providers' and licensed non-hospital behavioral
health facilities' Provider directory information on a quarterly basis,
including information with respect to:
(a) all
licensed behavioral health Providers who have not submitted a claim within 12
months of the audit and who have not otherwise been audited or have not
received an attestation in the past 12 months or for whom the Carrier has not
received a written or electronic attestation certifying that all elements of
the licensed behavioral health Provider's directory profile have been reviewed,
updated as necessary and then confirmed as accurate has not been received in
the past 12 months; and
(b) a
representative sample of no less than 15% of all licensed behavioral health
Providers who have not been audited in the last 12 months or for whom as a
written or electronic attestation certifying that all elements of the licensed
behavioral health Provider's directory profile have been reviewed, updated, as
necessary, and then confirmed as accurate has not been received in the past 120
days; and
(c) Carriers should
compare at least 2% of the attestations received in the prior 120 days to the
related information or changes in their Provider directories to confirm that
the data elements match the data elements in the directory.
(21) Quarterly behavioral health
audits shall exclude licensed behavioral health Providers that have been
audited in the last 12 months, or which have been removed from the Provider
directory. In the event that three successive quarterly audits demonstrate that
at least 85% of the auditable licensed behavioral health Providers are listed
in a manner that is 100% accurate, the Carrier may shift to conducting
behavioral health audits on a semi-annual basis.
(22) Non-behavioral Health Care Providers'
Provider directory information should be audited to ensure accuracy of Provider
directory information on at least an annual basis, or as directed by the
Commissioner. Carriers shall initiate these required audits no later than the
start of the second calendar quarter after these regulations are promulgated in
final form.
(23) Carriers will
maintain files of all Provider audits for no less than seven years from the
completion of any audit so that they may be reviewed by Division staff upon
request.
(24) A Carrier shall
deliver a notice to at least one adult Insured in each household upon
enrollment annually about how to access the Carrier's Provider
directory.
(25) A Carrier shall
deliver a Provider directory to an Insured or a prospective Insured upon
request. The print copy of the requested Provider directory information shall
be provided to the requester by mail postmarked no more than five business days
after the date of the request, and the print copy may be limited to the
geographic region in which the requester resides or works or intends to reside
or work.
(26) In the case of a
group policy, the Carrier shall deliver a Provider directory to the group
representative on at least an annual basis.
(27) A Carrier shall update the print copies
of the Carrier's Provider directory not less frequently than annually, and a
Carrier shall include a disclosure in the print format of the Provide
rdirectory that the information included in the Provider directory is accurate
as of the date of printing and that an individual may consult the Carrier's
electronic Provider directory on its website or call a specified customer
service telephone number to obtain the most current Provider directory
information;
(28) A Carrier shall
not be required to deliver a Provider directory upon enrollment if a Provider
directory is delivered to the prospective or current Insured, or in the case of
a group policy, to the group representative, during applicable open enrollment
periods.
(29) A Carrier that
provides specified services through a workers' compensation preferred Provider
arrangement shall be deemed to have met the requirements of
211
CMR 52.15 if it has met the requirements of
211 CMR
51.00 and
452 CMR
6.00.
(30)
If a Carrier offers a Site of Service Plan, the Provider directory for this
plan is to clearly and prominently specify which certain Network Providers or
service locations will only be available for covered care when the care is
deemed medically necessary to be provided by the Provider or a certain service
location.
