PRIA, Government Policy, Made Personal

Summary

Starting with plan years beginning on or after January 1, 2022, your employer health plan must keep an accurate, public online directory of the doctors and facilities in its network. The plan has to verify and update that directory at least every 90 days, remove providers it can't verify, and post updates within 2 business days of getting new information from a provider. If you call to ask whether a doctor is in network, the plan must answer in writing within 1 business day and keep a copy of that answer in your file for at least 2 years. Printed directories must warn you that they were accurate only as of their publication date and point you to the online database. There's a real protection behind this: if the plan's directory or its phone response told you a provider was in network, but the provider was actually out of network, the plan can only charge you the in-network cost-sharing amount, and the visit counts toward your regular deductible and out-of-pocket maximum. Plans must also publish plain-language information about the rules against surprise balance billing and tell you which state and federal agencies to contact if a provider breaks those rules.

Title 26, §9820

Internal Revenue Code, Source: USLM XML via OLRC

(a)(1)For plan years beginning on or after January 1, 2022, each group health plan shall—

(A)establish the verification process described in paragraph (2);

(B)establish the response protocol described in paragraph (3);

(C)establish the database described in paragraph (4); and

(D)include in any directory (other than the database described in subparagraph (C)) containing provider directory information with respect to such plan the information described in paragraph (5).

(2)The verification process described in this paragraph is, with respect to a group health plan, a process—

(A)under which, not less frequently than once every 90 days, such plan verifies and updates the provider directory information included on the database described in paragraph (4) of such plan or issuer of each health care provider and health care facility included in such database;

(B)that establishes a procedure for the removal of such a provider or facility with respect to which such plan or issuer has been unable to verify such information during a period specified by the plan or issuer; and

(C)that provides for the update of such database within 2 business days of such plan or issuer receiving from such a provider or facility information pursuant to section 2799B–9 of the Public Health Service Act.

(3)The response protocol described in this paragraph is, in the case of an individual enrolled under a group health plan who requests information through a telephone call or electronic, web-based, or Internet-based means on whether a health care provider or health care facility has a contractual relationship to furnish items and services under such plan, a protocol under which such plan or such issuer (as applicable), in the case such request is made through a telephone call—

(A)responds to such individual as soon as practicable and in no case later than 1 business day after such call is received, through a written electronic or print (as requested by such individual) communication; and

(B)retains such communication in such individual’s file for at least 2 years following such response.

(4)The database described in this paragraph is, with respect to a group health plan, a database on the public website of such plan or issuer that contains—

(A)a list of each health care provider and health care facility with which such plan or such issuer has a direct or indirect contractual relationship for furnishing items and services under such plan; and

(B)provider directory information with respect to each such provider and facility.

(5)The information described in this paragraph is, with respect to a print directory containing provider directory information with respect to a group health plan, a notification that such information contained in such directory was accurate as of the date of publication of such directory and that an individual enrolled under such plan should consult the database described in paragraph (4) with respect to such plan or contact such plan to obtain the most current provider directory information with respect to such plan.

(6)For purposes of this subsection, the term “provider directory information” includes, with respect to a group health plan, the name, address, specialty, telephone number, and digital contact information of each health care provider or health care facility with which such plan has a contractual relationship for furnishing items and services under such plan.

(7)Nothing in this section shall be construed to preempt any provision of State law relating to health care provider directories.

(b)(1)For plan years beginning on or after January 1, 2022, in the case of an item or service furnished to a participant or beneficiary of a group health plan by a nonparticipating provider or a nonparticipating facility, if such item or service would otherwise be covered under such plan if furnished by a participating provider or participating facility and if either of the criteria described in paragraph (2) applies with respect to such participant or beneficiary and item or service, the plan—

(A)shall not impose on such participant or beneficiary a cost-sharing amount for such item or service so furnished that is greater than the cost-sharing amount that would apply under such plan had such item or service been furnished by a participating provider; and

(B)shall apply the deductible or out-of-pocket maximum, if any, that would apply if such services were furnished by a participating provider or a participating facility.

(2)For purposes of paragraph (1), the criteria described in this paragraph, with respect to an item or service furnished to a participant or beneficiary of a group health plan by a nonparticipating provider or a nonparticipating facility, are the following:

(A)The participant or beneficiary received through a database, provider directory, or response protocol described in subsection (a) information with respect to such item and service to be furnished and such information provided that the provider was a participating provider or facility was a participating facility, with respect to the plan for furnishing such item or service.

(B)The information was not provided, in accordance with subsection (a), to the participant or beneficiary and the participant or beneficiary requested through the response protocol described in subsection (a)(3) of the plan information on whether the provider was a participating provider or facility was a participating facility with respect to the plan for furnishing such item or service and was informed through such protocol that the provider was such a participating provider or facility was such a participating facility.

(c)For plan years beginning on or after January 1, 2022, each group health plan shall make publicly available, post on a public website of such plan or issuer, and include on each explanation of benefits for an item or service with respect to which the requirements under section 9816 applies—

(1)information in plain language on—

(A)the requirements and prohibitions applied under section 2799B–1 and 2799B–2 of the Public Health Service Act (relating to prohibitions on balance billing in certain circumstances);

(B)if provided for under applicable State law, any other requirements on providers and facilities regarding the amounts such providers and facilities may, with respect to an item or service, charge a participant or beneficiary of such plan with respect to which such a provider or facility does not have a contractual relationship for furnishing such item or service under the plan after receiving payment from the plan for such item or service and any applicable cost sharing payment from such participant or beneficiary; and

(C)the requirements applied under section 9816; and

(2)information on contacting appropriate State and Federal agencies in the case that an individual believes that such a provider or facility has violated any requirement described in paragraph (1) with respect to such individual.

Notes & Related Subsidiaries

Editorial Notes

References in Text

section 2799B–9 of the Public Health Service Act, referred to in subsec. (a)(2)(C), is classified to section 300gg–139 of Title 42, The Public Health and Welfare. section 2799B–1 and 2799B–2 of the Public Health Service Act, referred to in subsec. (c)(1)(A), are classified to section 300gg–131 and 300gg–132, respectively, of Title 42, The Public Health and Welfare.

§9820 Protecting Patients and Improving the Accuracy of Provider Directory Information

Summary

Title 26, §9820

Notes & Related Subsidiaries

Editorial Notes

References in Text

Citations & Metadata