Like a Surgeon… Got Providers on my Mind

Holland & Hart - The Benefits Dial

Holland & Hart - The Benefits Dial

The myriad health and welfare plan requirements in the Consolidated Appropriations Act, 2021 include those for a group or individual health plan to maintain a cost comparison tool and an accurate and up-to-date network provider/facility directory for participant use. Each of these requirements is effective for plan years beginning on and after January 1, 2022. While the group health plan is responsible for compliance, in most cases the plan’s TPA will in practice be supplying this information to participants.

Price Comparison Tool – Group and individual health plans will be required to offer a price comparison tool to participants by phone and on the plan’s (or TPA’s) website. This cost comparison tool should (to the extent practicable) allow an individual enrolled in the plan to compare the amount of cost-sharing required from the participant for a specific item or service furnished by any network provider. Users must be able to access up-to-date cost-sharing information for the plan’s participating providers by geographic region.

Provider Directory – Group and individual health plans will be responsible for ensuring that the plan’s in-network provider directory is accurate and up to date. The consequence of having a participant rely on incorrect or improperly provided information is steep in that the plan would be required to reimburse the participant’s costs from the applicable provider using the in-network rates.

The plan must establish a searchable provider and facility database on the website of the plan or TPA that lists providers and facilities by specialty and includes directory or contact information. If in print, the print directory needs to include a statement that it is correct as of a specific date and advising users that they can find the latest information on the website. The plan must maintain a process to regularly verify the provider information and update the directory at least once every 90 days. Updated information must be entered in the directory within 2 business days of receipt. If a provider’s information cannot be verified during a regular review, the Plan must establish a procedure for removing the provider from the directory. Finally, the plan must have a response protocol for individuals who request directory information. The plan is obligated to respond in writing to a telephone request no later than one business day after the phone call in either electronic or print form as requested by the participant. In addition, the plan must maintain a record of any such communications in participant files for at least two years.

Action items for Plan sponsors –

  • establish that these requirements will be met by the TPA by the January 1, 2022 deadline;
  • review any disclaimer language drafted by the TPA that will accompany the information given to participants who make an inquiry;
  • ensure that the TPA has a procedure to maintain the required documentation from a phone inquiry (and that such documentation will be transferred to the next TPA if the plan changes TPAs in the future);
  • review and negotiate service agreements to address the responsibilities of each party; and
  • ensure that service agreements require the TPA to indemnify the employer against any additional costs due to inaccuracies or improperly providing information from the Cost Sharing Tool or Provider Directory.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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