211 CMR 52.15 - Provider Directories

Current through Register 1466, April 1, 2022

In addition to Provider directory requirements under 211 CMR 152.08: Provider Directories for Limited, Regional and Tiered Provider Network Plans, if applicable:

(1) A Carrier shall deliver a Provider directory to at least one adult Insured in each household upon enrollment and to a prospective or current Insured upon request. Annually, thereafter, a Carrier shall deliver to at least one adult Insured in each household, or in the case of a group policy, to the group representative, a Provider directory. The Carrier may deliver a Provider directory through an Internet Website, provided that any Provider directory available through an Internet Website be updated at least on a monthly basis.

(a) 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 and by location and summarizing on its Internet Website for each such Provider:

1. The method used to compensate or reimburse such Provider, including details of measures and compensation percentages tied to any Incentive Plan or pay for performance provision;

2. the Provider price relativity, as defined in and reported under M.G.L. c. 12C, § 10;

3. the Provider's health status adjusted total medical expenses, as defined in and reported under M.G.L. c. 12C, § 10; and

4. current measures of the Provider's quality based on measures from the Standard Quality Measure Set, as defined in 957 CMR 4.00: Uniform Provider Reporting of the Standard Quality Measure Set promulgated by the Center for Health Information and 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.

a. Nothing in 211 CMR 52.15(1)(a) shall be construed to require disclosure of the specific details of any financial arrangements between a Carrier and a Provider.

b. 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.

c. Notwithstanding any general or specific law to the contrary, a Carrier shall ensure that all Participating Provider Nurse Practitioners and Participating Provider Physician Assistants are included and displayed in a nondiscriminatory manner on any publicly accessible list of Participating Providers for the Carrier.

(b) The Provider directory must contain a toll-free number that Insureds can call to determine whether a particular Health Care Provider is affiliated with the Carrier.

(c) The Provider directory must contain an Internet Website address or link that Insureds can visit to determine whether a particular Provider is affiliated with the Carrier.

(d) The Carrier must be able to demonstrate compliance with the following:

1. The Carrier has issued and delivered written notice to the Insured that includes:

a. All necessary information and a clear explanation of the manner by which Insureds can access their specific Provider directory through an Internet Website;

b. A list of the specific information to be furnished by the Carrier through an Internet Website;

c. The significance of such information to the Insured;

d. The Insured's right to receive, free of charge, a paper copy of the Provider directory at any time;

e. The manner by which the Insured can exercise the right to receive a paper copy at no cost to the Insured; and

f. A toll-free number for the Insured to call with any questions or requests.

2. The Carrier has taken reasonable measures to ensure that the information and documents furnished in an Internet Website is substantially the same as that contained in its paper documents.

3. All notice and time requirements applicable to Evidences of Coverage shall apply to information and documents made available by internet. Information contained in the documents furnished in an Internet Website shall include the effective date and the published date of any updates, modifications or Material Changes.

4. The Carrier updates the Internet Website as soon as practicable, and at least monthly.

5. In the case of a group policy, the Carrier delivers a paper copy of the Provider directory to the group representative.

6. The Carrier has taken reasonable measures to ensure that it furnishes, upon request of the Insured, a paper copy of the Provider directory.

(2) 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.

(3) 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); and

(b) updates its toll-free number within 48 hours and Internet Website as soon as practicable.

(4) Every Provider directory described in 211 CMR 52.15 must contain the effective date, date of issue and expiration date if applicable, and reference to any government-sponsored website(s) providing quality and cost information, as may be designated by the Commissioner.

(5) 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: Preferred Provider Health Plans and Workers' Compensation Preferred Provider Arrangements and 452 CMR 6.00: Utilization Review and Quality Assessment.

Notes

211 CMR 52.15

Amended by Mass Register Issue 1345, eff. 8/11/2017.