QUESTION: We’ve heard that our group health plan’s provider directories are subject to federal transparency requirements. What are they?
ANSWER: A group health plan is required to establish a database on its public website that contains a list with directory information for each health care provider and facility with which it has a direct or indirect contractual relationship for furnishing items and services. Required information includes the provider’s name, address, specialty, telephone number, and digital contact information. If the group health plan maintains a print provider directory in addition to the database, it must include a notification in the print directory that the printed information was accurate as of the date of publication and that enrollees should consult the plan’s public website database or contact the plan for the most current provider directory information.
In addition, a plan must establish a process to verify and update, at least once every 90 days, the information included in the website database. The process must include a procedure for removing a provider or facility from the database if the plan has been unable to verify the directory information during a period specified by the plan and must also provide for updating the database within two business days after the plan receives new provider or facility information. Furthermore, the plan must establish a protocol under which it responds to a request by an individual enrolled in the plan about whether a provider or facility has a contractual relationship to furnish items or services under the plan.
Although these transparency requirements for provider directories (established by the Consolidated Appropriations Act, 2021) apply to plan years beginning on or after January 1, 2022, the agencies have not issued regulations and have advised that plans are expected to implement these provisions using a good faith, reasonable interpretation of the statute. The agencies will not deem plans or insurers to be out of compliance if, when an individual is inaccurately informed that a nonparticipating provider or facility is a participating provider or facility, the plan or insurer (1) imposes a cost-sharing amount that is not greater than the cost-sharing amount for a participating provider, and (2) counts those cost-sharing amounts toward any in-network deductible or out-of-pocket maximum.
For more information, see EBIA’s Health Care Reform manual at Section XXXVII.E.4 (“Provider Directory Disclosures”). See also EBIA’s Self-Insured Health Plans manual at Section XXVIII.I (“Surprise Medical Billing Transparency Disclosures”).
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