NOTICES
Provider Directories; Notice 2015-07
[45 Pa.B. 5744]
[Saturday, September 19, 2015]This notice is issued to all entities (insurers) issuing health insurance policies subject to the Insurance Department's (Department) jurisdiction (health insurance policies). The Department has become aware of situations when consumers believe they are seeking services from an in-network provider based on information in an insurer's provider directory, only to be subsequently informed that the provider is not in-network. This notice is issued to remind insurers of their obligations with respect to the adequacy of their provider directories—that is, their provider directories are current, accurate, complete and easily accessible.
Commonwealth law prohibits unfair or deceptive acts or practices in the business of insurance and defines these acts or practices to include: ''[m]aking, issuing, publishing or circulating in any manner an advertisement, announcement or statement containing any representation or statement with respect to the business of insurance or with respect to any person in the conduct of his insurance business which is untrue, deceptive or misleading.'' Further, Commonwealth law states that if ''performed with such frequency as to indicate a business practice,'' it is an unfair claim settlement practice to ''[m]isrepresent[ ] pertinent facts or policy or contract provisions relating to coverages at issue'' or ''[a]ttempt[ ] to settle a claim for less than the amount to which a reasonable man would have believed he was entitled by reference to written or printed advertising material accompanying or made part of an application.'' See sections 4 and 5(a)(2) and (10)(i) and (viii) of the Unfair Insurance Practices Act (act) (40 P. S. §§ 1171.4 and 1171.5(a) and (10)(i) and (viii)).
When a policyholder purchases a health insurance policy that covers services when provided by an in-network provider, and a person covered under that policy seeks services from a provider identified in the insurer's provider directory as being in-network at the time services are sought, the policyholder may reasonably believe that coverage for the services provided by that provider will be covered as in-network services. A policyholder may hold this reasonable belief even if the insurer issues a disclaimer—whether on its web site, in member materials or in response to an inquiry from the policyholder—as to the potential unreliability of the provider directory.
Therefore, when a person covered under a health insurance policy seeks covered services from a provider identified in the insurer's provider directory as being in-network, the Department interprets the provisions of the act previously cited to mean that an insurer that denies the in-network status of that provider has made a representation that is untrue, deceptive or misleading, and any attempt to settle a claim for services by that provider as if that provider were out-of-network to be an unfair claim settlement practice.
Further, in situations when the provider directory is not accurate, but a consumer seeks services from a provider identified as in-network in a provider directory at the time services are sought, that consumer should be subject to no more cost-sharing than if the provider is in fact in-network. The Department also reminds insurers of their obligations regarding continuity of care in the situation of a network modification (see, for example, section 2117 of The Insurance Company Law of 1921 (40 P. S. § 991.2117) and 31 Pa. Code § 154.15 (relating to continuity of care)).
Finally, the Department notes that the Federal government has issued regulations detailing provider directory requirements, and the Department views compliance with that regulation (as it may be amended from time to time) as constituting a safe harbor vis-a-vis the in-network status of a provider with respect to the fairness of its advertising and marketing materials and the propriety of its claims settlement practices.1
(b) Access to provider directory.
(1) A QHP issuer must make its provider directory for a QHP available to the Exchange for publication online in accordance with guidance from HHS and to potential enrollees in hard copy upon request. In the provider directory, a QHP issuer must identify providers that are not accepting new patients.
(2) For plan years beginning on or after January 1, 2016, a QHP issuer must publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, the provider's location, contact information, specialty, medical group and any institutional affiliations, in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS and OPM. A provider directory is easily accessible when—
(i) The general public is able to view all of the current providers for a plan in the provider directory on the issuer's public web site through a clearly identifiable link or tab and without creating or accessing an account or entering a policy number; and
(ii) If a health plan issuer maintains multiple provider networks, the general public is able to easily discern which providers participate in which plans and which provider networks.
See also the preamble discussion at 80 FR 10750, 10830 (February 27, 2015) specifying monthly updating of the directory information.
Questions concerning this notice may be directed to the Bureau of Consumer Services, 1209 Strawberry Square, Harrisburg, PA 17120, ra-insresponse@pa.gov.
TERESA D. MILLER,
Insurance Commissioner
[Pa.B. Doc. No. 15-1705. Filed for public inspection September 18, 2015, 9:00 a.m.] _______
1 See 45 CFR 156.230(b) (relating to network adequacy standards):
(b) Access to provider directory.
(1) A QHP issuer must make its provider directory for a QHP available to the Exchange for publication online in accordance with guidance from HHS and to potential enrollees in hard copy upon request. In the provider directory, a QHP issuer must identify providers that are not accepting new patients.
(2) For plan years beginning on or after January 1, 2016, a QHP issuer must publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, the provider's location, contact information, specialty, medical group and any institutional affiliations, in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the Exchange, HHS and OPM. A provider directory is easily accessible when—
(i) The general public is able to view all of the current providers for a plan in the provider directory on the issuer's public web site through a clearly identifiable link or tab and without creating or accessing an account or entering a policy number; and
(ii) If a health plan issuer maintains multiple provider networks, the general public is able to easily discern which providers participate in which plans and which provider networks.
See also the preamble discussion at 80 FR 10750, 10830 (February 27, 2015) specifying monthly updating of the directory information.
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