On November 24, the Massachusetts Division of Insurance (DOI) published revisions to its managed care consumer protection regulation, including new requirements related to health care provider directories, telehealth and behavioral health coverage.
The Provider Directory Regulation follows a 2019 Massachusetts law that required commercial health plans to “ensure the accuracy” of information in their directories of in-network health care providers and a 2020 task force that studied the issue. The Directory Regulation adds detailed requirements—far beyond what was required under prior state or federal rules—for all Massachusetts health plans.
The revised regulations also implement a 2021 law that mandates coverage parity for telehealth services and rate parity for behavioral health services via telehealth, and a separate 2022 law requiring that “base fee schedule[s]” for reimbursement not be lower for behavioral health than for primary care providers.
Massachusetts Provider Directory Regulation
The new Regulation adds a long list of requirements for health plans’ provider directories related to: (1) the information to be displayed; (2) how plans verify, audit and update directory information; and (3) how plans make the directory available to their members.
First, the Regulation requires that health plans have systems for maintaining “detailed information about” their in-network providers. The Regulation specifies a laundry list of information that the provider directories must display related to individual providers, facilities and both. For individual providers, the health plan directory must display at least 18 data elements for each individual, including their specialty; office location; languages spoken; requirement that patient pay a concierge, facility or other fee; and their availability for telehealth visits, among other things. For facilities, the directories must show eight data elements, including all languages spoken by providers at the facility, the facility’s ADA status, its tier within the plan’s tiered network, and phone number and website for contacting providers. And for all providers, the directories must state the provider’s office location, which groups of patients the provider sees and the frequency the provider sees patients at each location.
Second, the Regulation requires that health plans verify, audit and update the directory. In addition to prior statutory obligations to verify and update the directory regularly, the Regulation requires that plans include a requirement that providers promptly inform plans of changes in availability in their new and renewing payer-provider contract. The Regulation also requires regular audits of the providers’ directory information, including quarterly audits of certain behavioral health providers, including all those who have not submitted a claim in the past 12 months, have not attested to the accuracy of their directory listing or otherwise been audited in the past 12 months. All other providers must be audited annually, and plans must retain audit information for seven years.
Third, the Regulation directs how health plans must make the provider directory available to their members. Plans must have an online provider directory that is searchable by the provider’s type, specialty, availability to see new patients, language spoken and geography from the member. Health plans must also maintain a phone number members can call to get help finding an in-network provider. And, as required by the statute, health plans still must maintain a paper directory that is updated monthly and delivered to members within five days of any request.
Implications
Massachusetts now has the most robust health plan provider directory regulation in the country. The additional requirements in the new Regulation are layered on top of the Massachusetts statutory requirements and federal rules governing provider directories for commercial plans under the No Surprises Act, Qualified Health Plans under the Affordable Care Act regulations, Medicare Advantage Plans and Medicaid managed care plans. Health plans operating in Massachusetts should carefully consider the overlapping requirements for provider directories of their different commercial and public plans.
The Regulation comes at a time of increased scrutiny over the accuracy of health plan provider directories in Congress and elsewhere, including what the directories mean for access to care. During the time between the 2019 legislation and publication of the new Regulation, many Massachusetts health plans appear to have upgraded their online directories to meet the Regulation’s new requirements. But the Massachusetts Regulation may signal more robust provider directory regulations to come in the near future from other states.
Telehealth
The Telehealth Regulation implements portions of a 2021 Massachusetts law. Consistent with the statute, the Regulation requires coverage parity for all telehealth services and rate parity for behavioral health services via telehealth. That is, health plans must cover telehealth services if the same services would be covered in person and the service is “appropriately” provided via telehealth. And health plans must reimburse at the same rate or higher for behavioral health services via telehealth as they do for behavioral health services in person. The 2021 law also provided rate parity for primary care and chronic disease management services via telehealth through January 1, 2023, but because that requirement has expired, it is not required in the Regulation.
New in the Regulation, health plans must submit to the Massachusetts DOI a “comprehensive” Telehealth Plan. Among other things, the Plan must include: (1) a list of services that won’t be covered via telehealth with an explanation why, (2) explanations of when cost sharing will apply to telehealth visits, (3) information about how plans will reimburse for each category of telehealth services and (4) billing codes that will be used for reimbursing telehealth services.
There are sure to be ongoing questions and disagreements about telehealth coverage, including whether particular services must be covered and, if so, at what reimbursement rate. The DOI is likely to follow these issues closely, relying on the Telehealth Plan and information shared by providers.
Behavioral Health
The new regulations also implement provisions of a 2022 Mental Health law, which requires that health plans “base fee schedule used for evaluation and management services for behavioral health providers . . . is not less than the base fee schedule” for equivalent primary care providers.
As this new Regulation shows, Massachusetts continues to be among the most proactive states in regulating health plans’ coverage, especially around mental health services.