CAA’s New Rules for Healthcare Provider Directories | Ballard Spahr LLP

Context. People whose health benefits may be determined by whether their health care provider participates in their health plan or insurer’s network need up-to-date and accurate information about the status of their health care provider’s network. suppliers.

New rules. The Consolidated Appropriations Act (CAA) requires each group health plan and health insurer with a provider network to maintain a database on its public website that lists the name, address, specialty, telephone number and numeric contact information for each supplier who directly or indirectly participates in the network. At least every 90 days, the health plan or insurer must verify directory information and update the database. The plan or insurer must have a procedure for removing providers for which it cannot verify information and must update the database within two business days of receiving new or revised information from a provider which affects the directory. A printed directory should contain a statement that it was accurate as of the date of publication and that the applicable website, plan or insurer should be consulted for the most current information.

Health plans and insurers should have a protocol in place for responding to enrollees requesting information over the phone or via the Internet, or other electronic means. In the case of a telephone request, the health plan or insurer must respond as soon as possible, but in any event within one business day. This response must include a written response provided in printed or electronic form, depending on the individual requests. The answer must be kept in the person’s file for at least two years.

If a registrant is misinformed that a provider is participating in the network, the network’s maximum deductible and disbursement will apply and the registrant will not have to pay a cost-sharing amount greater than the amount of the network that applied. .

Quotes. ERISA Section 720; Section 9820 of the Tax Code; Section 2799A-5 of the Public Health Services Act

Effective date. Plan years beginning on or after January 1, 2022.

Enforcement. For health plans subject to ERISA, the US Department of Labor and plan participants and beneficiaries may enforce compliance with these rules. Plans not subject to ERISA may be subject to enforcement by the US Department of Health and Human Services (HHS). HHS shares responsibility for enforcement against insurers with state agencies. In addition, the Internal Revenue Service may impose an excise tax of $100 per day per applicable person under Code Section 4980D for any failure to comply.

Pending the publication of the regulations, health plans and insurers must comply in good faith with a reasonable interpretation of the new rules. In the event that a registrant receives inaccurate network status information from an out-of-network provider and then obtains items or services from that provider, the plan or insurer will still not be considered non-compliant with the new directory rules if it imposes a cost-share amount not exceeding the in-network amount and counts such cost-share payments against any deductible or maximum disbursement.

Diet Considerations. Compliance with the new provider directory rules requires the cooperation of health plan providers and insurers. The provider directory requirements apply to all providers having a contractual relationship, direct or indirect, with the health plan or insurer and, therefore, extend to providers of a leased network or a similar arrangement.

The new requirements themselves do not supersede state law requirements applicable to provider directories, although ERISA’s general preemption provisions are preserved.

Recommended steps. Plan sponsors should consider the following actions:

  • Confirm that plan administrators and insurers maintain plan directories with appropriate information, keep them up-to-date, and have procedures in place to provide enrollees with appropriate network participation information upon request.
  • Make appropriate revisions to supplier and insurer contracts.
  • Review plan documents and summary plan descriptions and make changes, if necessary, to comply with the new rules.
  • Amend any printed directory to include the date it was last updated, a statement about its accuracy as of that date, and contact information for information updates.
  • Provide a link to the plan provider or insurer’s website for plan members to access the directory.

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