Amendment #1268 to H4400

Increasing Consumer Transparency about Insurance Provider Networks

Ms. Barber of Somerville moves to amend the bill by adding the following two sections:

SECTION XXXX. Chapter 176O of the General Laws is hereby amended by inserting after section 27 the following sections:-

Section 28. (a) 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. In making the directory available electronically in a searchable format, the carrier shall ensure that the general public is able to view all of the current health care providers for a network plan through a clearly identifiable link or tab and without creating or accessing an account, entering a policy or contract number, providing other identifying information, or demonstrating coverage or an interest in obtaining coverage with the network plan. Thereafter, the carrier shall update each online network plan provider directory at least monthly, or more frequently, if required by state or federal law or regulations promulgated by the commissioner pursuant to Section 29(j), when informed of and upon confirmation by the plan of any of the following:

(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 under contract for a particular network plan.

(3) A provider’s practice location or other information required under this section has changed.

(4) Upon completion of the investigation described in paragraph (a)(4), a change is necessary based on an enrollee complaint that a provider was not accepting new patients, was otherwise not available, or whose contact information was listed incorrectly.

(5) A provider has retired or otherwise has ceased to practice.

(6) Any other information that affects the content or accuracy of the provider directory or directories.

(b) A provider directory shall not list or include information on a provider that is not currently under contract with the network plan.

(c) A carrier shall periodically audit its provider directories for accuracy and retain documentation of such an audit to be made available to the commissioner upon request.

(d) A carrier shall provide a print copy, or a print copy of the requested directory information, of a current provider directory upon request of an insured or a prospective insured.  The printed copy of the provider directory or directories shall be provided to the requester by mail postmarked no later than five business days following the date of the request and may be limited to the geographic region in which the requester resides or works or intends to reside or work.

(e) The carrier shall include in both its electronic and print directories a dedicated customer service email address and telephone number or electronic link that insureds, providers and the general public may use to notify the carrier of inaccurate provider directory information. This information shall be disclosed prominently in the directory or directories and on the carrier’s web site. The carrier shall be required to investigate reports of inaccuracies within 30 days of notice and modify the directories in accordance with any findings within 30 days of such findings.

(f) The provider directory or directories shall inform enrollees and potential enrollees that they are entitled to: (A) language interpreter services, at no cost to the enrollee; and (B) full and equal access to covered services as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973. A provider directory, whether in electronic or print format, shall accommodate the communication needs of individuals with disabilities, and include a link to or information regarding available assistance for persons with limited English proficiency, including how to obtain interpretation and translation services.

(g) The carrier shall include a disclosure in the print directory that the information included in the directory is accurate as of the date of printing and that insureds or prospective insureds should 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.

(h) The carrier shall update its printed provider directory or directories at least annually, or more frequently, if required by federal law or regulations promulgated by the commissioner.

Section 29. (a) The division shall establish a task force to develop recommendations to ensure the current and accurate electronic posting of carrier provider directories in a searchable format for each of the carriers’ network plans available for viewing by the general public.

(b) The task force shall consist of the commissioner of insurance or a designee, who shall serve as chair, and 12 members: one of whom shall be a representative of the Massachusetts Association of Health Plans, one of whom shall be a representative of Blue Cross Blue Shield MA, one of whom shall be a representative of the Massachusetts Health and Hospital Association, one of whom shall be a representative of the Massachusetts Medical Society, one of whom shall be a representative of Healthcare Administrative Solutions, Inc., one of whom shall be a representative of the Children’s Mental Health Campaign, one of whom shall be a representative of the Massachusetts Association for Mental Health, and five members chosen by the commissioner: one of whom shall have expertise in the treatment of individuals with substance use disorder, , one of whom shall have expertise in the treatment of individuals with a mental illness, one of whom shall be from a health consumer advocacy organization, one of whom shall be a consumer representative, and one of whom shall be a representative from an employer group. The task force shall have the ability to form workgroups to develop the recommendations defined in subsection (a).

(c) The recommendations shall include measures for ensuring the accuracy of information concerning each provider listed in the carrier’s provider directories for each network plan. The task force shall develop recommendations that establish substantially similar processes and time frames for health care providers included in a carrier’s network to provide information to the carrier, and substantially similar processes and timeframes for carriers to include such information in their provider directories, regarding the following:

(1) when a contracting provider is no longer accepting new patients for that network plan and when a contracting provider is resuming acceptance of new patients, or an individual provider within a provider group is no longer accepting new patients and when an individual provider within a provider group is resuming acceptance of new patients;

(2) when a provider who is not accepting new patients is contacted by an enrollee or potential enrollee seeking to become a new patient, the provider may direct the enrollee or potential enrollee to the carrier for additional assistance in finding a provider and shall inform the carrier immediately if they have not done so already that the provider is not accepting new patients;

(3) when a provider is no longer under contract for a particular network plan;

(4) when a provider’s practice location or other information required under this section has changed;

(5) for health care professionals: (i) name; (ii) contact information; (iii) gender; (iv) participating office location(s); (v) specialty, if applicable; (vi) clinical and developmental areas of expertise; (vii) populations of interest; (viii) licensure and board certification(s); (ix) medical group affiliations, if applicable; (x) facility affiliations, if applicable; (xi) participating facility affiliations, if applicable; (xii) languages spoken other than English, if applicable; (xiii) whether accepting new patients; and (xiv)  information on access for people with disabilities, including but not limited to structural accessibility and presence of accessible examination and diagnostic equipment;

(6) for hospitals: (i) hospital name; (ii) hospital type; (iii) participating hospital location and telephone number; (iv) hospital accreditation status; (7) for facilities, other than hospitals, by type: (i) facility name; (ii) facility type; (iii) types of services performed; (iv) participating facility location(s) and telephone number; and

(7) Any other information that affects the content or accuracy of the provider directory or directories.

(d) The task force shall develop recommendations for carriers to include information in the provider directory that identifies the tier level for each specific provider, hospital or other type of facility in the network, when applicable.

(e) The task force shall develop recommendations for carriers to include in the provider directories substantially similar language to assist insureds with understanding and searching for behavioral health specialty providers.

(f) The task force shall consider the feasibility of carriers making updates to each online network plan provider directory in real time when health care providers included in a carrier’s network provide information to the carrier pursuant to subsection (c).

(g) The task force shall consider measures to address circumstances when an insured reasonably relies upon materially inaccurate information contained in a carrier’s provider directory.

(h) The task force shall develop recommendations for measures carriers shall take to ensure the accuracy of the information concerning each provider listed in the carrier's provider directories for each network plan based on the information provided to the carriers by network providers, as described in paragraph (c), including but not limited to periodic testing to ensure that the public interface of the directories accurately reflects the provider network, as required by state and federal laws and regulations.

(i) The task force shall recommend appropriate timelines for completion of its recommendations.

(j) The commissioner shall file the task force’s recommendations, including any proposed regulations, with the joint committee on health care financing not later than November 15, 2018.

(k) The commissioner shall promulgate regulations pursuant to section 28 and the recommendations of the task force no later than three months following the commissioner’s filing under subsection (j).

(l) The commissioner shall conduct quarterly implementation progress reports, which shall be available to the public, commencing on January 1, 2019 and continuing until the task force recommendations under subsection (j) are fully implemented.

SECTION XXXX. Carriers shall ensure the accuracy of the information pursuant to the regulations issued by the commissioner of insurance pursuant to section 29 of chapter 176O of the general laws for each network plan no later than January 1, 2020.

Additional co-sponsor(s) added to Amendment #1268 to H4400

Increasing Consumer Transparency about Insurance Provider Networks