February 24, 2015

State Activity on Provider Directories

Responding to consumer complaints on network access and accuracy of provider listings, legislators and regulators in several states are taking steps this year to establish or tighten standards on provider directories, and while generally aimed at medical plans are also applying to dental plans as well. The Government Relations Workgroup (GRW) has discussed efforts in California, Illinois, Ohio and New Jersey and anticipates the trend may be growing. Arguably the most worrisome element of the proposals is a requirement that plans drop dentists from directories if they have not submitted a claim within the past three months. The GRW will continue to discuss these state developments and consider appropriate advocacy steps.

California SB 137 on Health Care Coverage & Provider Directories

Proposed California Senate Bill (SB) 137 would establish requirements on health plans and carriers to make available updated provider directories to include the bulleted information below:

Among other items, the bill would require directories to include:

  • Provider’s location and contact information;
  • Area of specialty, including board certification, if any;
  • Medical group, if any;
  • Whether the provider or staff speaks any non-English language;
  • Access to persons with disabilities and
  • Whether a provider is accepting new patients with the product selected.

As with other state bills mentioned here, CA SB 137 would require directories not include information on a provider that does not have a current contract with the plan and that has not submitted a claim within the past three months.

The bill requires directories to be updated weekly and available on carrier websites without requiring searchers to create or access an account or commit to signing up for the plan. The bill also requires the Department of Managed Health Care and the Department of Insurance to develop a standard provider directory by Sept. 15, 2016 or within in six months of that date.

Illinois SB 750 on Dental Service Plans

Current Illinois law includes criteria for “standardization of terms and coverage” at 215 ILCS 5/355a. This section allows the Director of Insurance to issue rules regarding disclosure of several insurance terms and conditions.

Current section 355a (5)(c) requires qualified health plans offered on the Exchange to provide the most recently published provider directory where a consumer can view the provider network that applies to each qualified health plan and information about each provider, including location, contact information, specialty, medical group, if any, any institutional affiliation, and whether the provider is accepting new patients.

Proposed Illinois SB 750 amends this requirement for Exchange plans and appears to expand the provision to sections of state law regulating managed dental care plans, dental service plans and dental service plan corporations.

In addition to the requirement to make provider directories available as noted above, IL SB 750 would require:

  • Provider directories be updated monthly
  • Provider directories must be offered in a manner that accommodates individuals with limited English proficiency and with disabilities.
  • A dentist would be considered an active network participant and listed in the directory if the dentist has filed a claim for a patient enrolled with the dental plan at least once in the previous 3-month period.
  • Any dentist not meeting this criterion must be removed from the published provider directory for that specific location.

Ohio Proposed Rule on Provider Network Disclosures for Consumers

This past month, the Ohio Department of Insurance (ODI) received informal comment on draft rules regarding provider network disclosures that would likely impact dental plans.

Among other provisions, the draft rules would require plans:

  • Make directories available in paper and online;
  • Review and update directories at least quarterly and update the online directory within fifteen days of the addition or termination or a provider from the network;
  • Offer directories to accommodate individuals with limited English proficiency or disabilities;
  • Offer directories without requiring enrollees log-in for online access;
  • Include the following information for each in-network provider:

o   Location and contact information;

o   The specialty area or areas for which the provider is licensed to practice;

o   Any in-network institutional affiliation of the provider;

o   Whether the provider may be accessed without referral;

o   Any languages, other than English, spoken by the provider; and

o   A notation of any provider whose practice is closed to new patients.

  • As part of the directory, include a clear description of the methodology used by the carrier to determine reimbursement for out-of-network health care services with examples of anticipated out-of-pocket costs for frequently billed out-of-network health care services as compared to the costs for such services when received in-network.

We anticipate the Department will publish an updated copy of this draft for formal comment on the proposal.

New Jersey Statute on Provider Directories

As noted above, states are considering provisions to limit directories to providers that have filed claims within the previous three months. New Jersey has a somewhat similar provision in statute and requires managed care plans to confirm the network participation of any provider who has not submitted a claim for 12 months or who has not otherwise communicated with the plan in a manner indicating an intention to continue participating in the network.

Following is background information provided by a GRW volunteer for reference: The regulations pertaining to Organized Delivery Systems (ODSs) were amended, effective Jan. 1, 2014, and added requirements set forth at N.J.A.C. 11:24C-4, a new rule for provider networks under managed care plans.  Carriers must confirm the participation of any provider who has not submitted a claim for a period of 12 months or otherwise communicated with the carrier in a manner evidencing the provider’s intention to continue to participate in the carrier’s network and for whom no change in provider status has been reported by the Council for Affordable Quality Healthcare (CAQH). In order to confirm participation, the carrier must contact the provider and request that the provider confirm his or her intention to continue to participate in the carrier’s provider network. If the provider fails to respond to a communication by the carrier, the carrier must mail a follow-up request to the provider by certified mail, return receipt requested. If the provider fails to respond to such requests within 30 days, the carrier must remove the provider from its network and update its directories as necessary.









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