Provider Directory
Task Force
A report filed with
the Joint Legislative Committee on Health Care Financing and
the Clerks of the Massachusetts Senate and House of Representatives
to be forwarded to
the President of the Senate,
the Speaker of the House of Representatives,
the Minority Leader of the Senate, and
the Minority Leader of the House of Representatives
2020
GARY ANDERSON
COMMISSIONER OF INSURANCE
Provider Directory Task Force Report Draft
Section 4 of Chapter 124 of the Acts of 2019
Acknowledgments
Kevin Beagan, Niels Puetthoff, Nicole Sharma, and other staff members of the Division of
Insurance (“Division”), have coordinated the work of the Provider Directory Task Force in
the preparation of this report to respond to Section 4 of Chapter 124 of the Acts of 2019.
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Provider Directory Task Force Report Draft
Section 4 of Chapter 124 of the Acts of 2019
Table of Contents
Page Title
2 Acknowledgments
3 Table of Contents
4 Executive Summary
7 Managed Care and Provider Directories
9 An Act Relative to Children’s Health and Wellness
9 Legislative Mandate for Provider Directory Task Force
11 Members of the Provider Directory Task Force
12 Collecting of Provider Information
14 Updating Provider Information
16 Presenting Information in Provider Directories
18 Auditing Provider Directory Information
20 Consequences for Incorrect Information
21 Next Steps
22 Appendices
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Provider Directory Task Force Report Draft
Section 4 of Chapter 124 of the Acts of 2019
EXECUTIVE SUMMARY
Insurance carriers who provide or arrange for the delivery of health services through a
network of providers are expected to provide covered persons with access to clear and
comprehensive information about the providers who are part of their networks. It is
essential for patients that carriers and providers establish systems and protocols that will
improve the accuracy and quality of provider directory information so that patients will be
able to find providers when they need to obtain access to necessary care.
The Provider Directory Task Force presents the following recommendations so that they
may be incorporated within Division of Insurance regulations affecting all managed care
plans offered in the Commonwealth of Massachusetts:
Collecting Information
• Carriers should explore the creation of one centralized portal to collect all provider
information to reduce administrative burden to providers and minimize errors
• Portals should collect information in a way that allows providers to choose from a
series of standard options to the greatest extent possible
• Facility information should clearly explain the type of hospital and, for non-hospital
behavioral health facilities, the range of services identified in DOI Bulletin 2009-11
that are available in the facility
• Non-facility providers need to report information about:
o Ability to accept new patients;
o Office location, including phone number, address, office hours, disability
access, and interpreter availability;
o How often the provider practices at that location;
o Provider languages spoken, gender, age groups served, and populations of
interest;
o Telehealth availability;
o Specialty of care; and
o If a behavioral health provider
 Subspecialty and whether treated subspecialty in past year
 Modality of treatment.
o Race and ethnicity information would be optional
Updating Information
• Providers should be educated about the importance of updating information
regularly and should take steps to update information regularly
• Carriers should take steps to improve provider directory updates with the goal of
eventually making real-time changes.
• Carriers should send reminders every 90 days for a provider or their designee to
verify information
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Section 4 of Chapter 124 of the Acts of 2019
Presenting Information
• Provider directories should present information in a searchable way based on the
following characteristics:
o Whether the provider is available to accept new patients;
o Hours that the practice is open to see patients;
o Provider's availability on evenings and weekends (optional) 1;
o Provider’s specialty:
 For behavioral health, subspecialty;
 For behavioral health, treatment modality;
o Ages treated (grouped for example by Child, Adolescent, Adult, Geriatric);
o Provider’s race/ethnicity (optional);
o Languages spoken;
o Populations served;
o Office’s accommodations for physical/intellectual disabilities;
o Office’s access to public transportation;
o Affiliations with specific hospitals;
o Availability for telehealth appointments; and
o Distance from a specified starting location.
• In addition the provider’s profile should include the following, 2:
o Provider’s name, board certification, education, and for behavioral health,
provider’s licensure level;
o Whether a provider’s panel is (a) closed to new patients, (b) has limited
availability to accept new patients, or (c) is open to new patients (which
may still require a wait time) 3;
o Locations (addresses and phone numbers) of provider practices;
o Availability by location (more than once per week, more than once per
month);
o Business hours of the locations;
o Whether locations are available for telehealth appointments;
o Limitations on practice (e.g., only treating concierge patients or only
providing inpatient services);
o Languages spoken;
o Populations served (as optionally reported by the provider); and
o If a tiered network plan, the provider’s tier and an explanation of how that
tier was identified by plan, and impact on cost-sharing under the plan.
1
The following Task Force members voted for carriers to optionally collect and display provider availability:
Mr. Katzman, Ms. Miller, Ms. Granoff, Ms. Burgiel, Mr. Nefussy, Mr. Rennie, and Ms. Leahy. The
following Task Force members voted to require carriers to collect and display provider availability: Mr.
Wilkinson, Dr. Warkentin, and Ms. Vangeli.
2
See Appendix L for more information about non-facility providers.
3
Specific definitions for “closed to new patients,” “limited availability to accept new patients,” and “open to
new patients” will be provided in the corresponding regulation.
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Section 4 of Chapter 124 of the Acts of 2019
• For a hospital facility:
o Hospital name and hospital type;
o Location (address and phone number) of hospital; and
o Hospital accreditation status.
• For a non-hospital facility:
o Facility name and facility type;
o Types of services performed and, for non-hospital behavioral health
facilities, the services identified in Division of Insurance Bulletin 2009-11;
o Location (address and phone number) of facility; and
o Facility accreditation status.
Auditing Information
• Carriers should explore and make the best efforts to create a consolidated process
among carriers to arrange audits via telephone, email, or other methods, so that
providers are not called by numerous carriers.
• Carriers should investigate and work with providers to correct any directory
inaccuracies that covered persons or providers bring to their attention.
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Section 4 of Chapter 124 of the Acts of 2019
Managed Care and Provider Directories
Beginning in the 1970s, insurance carriers began offering health plans that provided benefits
based on the insured’s receiving care from a network of health care providers. Carriers and
providers entered into contracts whereby the provider agreed to accept carriers’ levels of
reimbursement and would follow the carriers’ billing and utilization system requirements in
order to be considered for the inclusion as part of the carriers’ networks.
In order for covered persons to effectively access covered benefits under these network
health plans, it became essential for each insured to have a clear and comprehensive
understanding of which providers were contractually part of a carrier’s network. In the early
history of these products, carriers relied on paper directories. Today, each carrier maintains
web-based directories so that consumers can search for providers among those listed in the
carrier’s provider directory database. However, upon request carriers are required to provide
a hard copy of the existing directory.
Original Managed Care Statute and Regulation
When enacted, Chapter 141 of the Acts of 2000 created M.G.L. c. 176O (“Chapter 141” or
“Health Insurance Consumer Protections”) so that the Bureau of Managed Care within the
Massachusetts Division of Insurance (“Division”) and the Office of Patient Protection 4
(“OPP”) could establish standards for managed care and oversee health insurance carriers’
managed care practices. The managed care requirements apply to all insured health products
offered in Massachusetts that provide or arrange for health coverage through a network of
providers or employ utilization review processes to evaluate whether services are medically
necessary and appropriate to be covered under health plan benefits. In order to implement
M.G.L. c. 176O, the Division promulgated 211 CMR 52.00 (“Managed Care Consumer
Protections and Accreditation of Carriers”).
Within M.G.L. c. 176O, § 6(a) requires the following:
“A carrier shall issue and deliver to at least one adult insured in each household residing in the
commonwealth, upon enrollment, an evidence of coverage and any amendments thereto. Said
evidence of coverage shall contain a clear, concise and complete statement of…
(4) the locations where, and the manner in which, health care services and other benefits may be
obtained.”
Within 211 CMR 52.02, an Evidence of Coverage is defined as any “certificate, contract or
agreement of health insurance including riders, amendments, endorsements and any other
supplementary inserts or a summary plan description pursuant to § 104(b)(1) of the
Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1024(b), issued to an
4
Chapter 141 of the Acts of 2000 created the Office of Patient Protection within the Massachusetts
Department of Public Health. This Office was transferred to be within the Health Policy Commission with
the enactment of Chapter 224 of the Acts of 2012.
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Section 4 of Chapter 124 of the Acts of 2019
Insured specifying the Benefits to which the Insured is entitled.” As noted in 211 CMR
52.13(3)(f), the Evidence of Coverage is to include the following:
(f) A description of the locations where, and the manner in which, Health, Dental or Vision Care Services
and other Benefits may be obtained, and, additionally, for Health Care Services:
1. the method to locate Provider directory information on a Carrier’s website and the method to
obtain a paper Provider directory;
2. an explanation that whenever a proposed admission, procedure or covered service that is
Medically Necessary is not available to an Insured within the Carrier’s Network, the Carrier will
cover the out-of-Network admission, procedure or service, and the Insured will not be
responsible for paying more than the amount which would be required for a similar admission,
procedure or service offered within the Carrier’s Network; and
3. an explanation that whenever a location where Health Care Services are provided is part of a
Carrier’s Network, the Carrier will cover Medically Necessary covered Benefits delivered at that
location, and an explanation that the Insured will not be responsible for paying more than the
amount required for Network services delivered at that location even if part of the Medically
Necessary Covered Benefits are performed by out-of-Network Provider(s), unless the Insured
has a reasonable opportunity to choose to have the service performed by a Network Provider.
Within 211 CMR 52.15, there is a requirement that carriers which coordinate care through a
network of providers shall comply with the following provisions regarding provider
directories:
(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…”
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Provider Directory Task Force Report Draft
Section 4 of Chapter 124 of the Acts of 2019
An Act Relative to Children’s Health and Wellness
On November 26, 2019, Chapter 124 of the Acts of 2019 (“Chapter 124”) was enacted, and
sections 2, 4, 5, and 6 established the following requirements to improving carriers’ provider
directories:
Section 2 amends M.G.L c. 176O to add section 28 that establishes standards for carriers’
provider directories to present clear, accurate and understandable listings of network
providers.
Section 4 directs the Division to establish a task force to develop recommendations about
the implementation of section 28 of M.G.L. c. 17O and forward them to the Legislature
by March 1, 2020.
Section 5 directs the Division to promulgate regulations to implement section 28 of
M.G.L. c. 176O by July 1, 2020.
Section 6 indicated that carriers are to implement steps consistent with Division
regulations by October 1, 2020.
Legislative Mandate for Provider Directory Task Force
Subsection (a) of Section 4 of Chapter 124 of the Acts of 2019 requires that the Division
“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.” As noted in subsection
(f) of Section 4,” [t]he task force shall file its recommendations, including any proposed
regulations, with the clerks of the senate and house of representatives and the joint committee
on health care financing not later than March 1, 2020.” This report presents the work of the
Provider Directory Task Force convened by the Division to accomplish the work of Section
4.
In completing its work, the Task Force is directed to consider the following as noted in
Section 4:
(c) The task force shall develop recommendations on establishing:
(i) measures to ensure the accuracy of information concerning each provider listed in the carrier’s
provider directories for each network plan;
(ii) substantially similar processes and timeframes for health care providers included in a carrier’s
network to provide information to the carrier; and
(iii) substantially similar processes and timeframes for carriers to include such information in their
provider directories when:
(A) 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;
(B) a provider who is not accepting new patients is contacted by an enrollee or potential enrollee
seeking to become a new patient; provided, however, that 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 the provider has not done so already, that the provider is
not accepting new patients;
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Section 4 of Chapter 124 of the Acts of 2019
(C) a provider is no longer under contract for a particular network plan;