Accessing Care with Network Providers; Issued 10/2/2018

[LOGO] COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation DIVISION OF INSURANCE 1000 Washington Street, Suite 810 • Boston, MA 02118-6200 (617) 521-7794 • Toll-free (877) 563-4467 http://www.mass.gov/doi CHARLES D. BAKER GOVERNOR KARYN E. POLITO LIEUTENANT GOVERNOR JAY ASH SECRETARY OF HOUSING AND ECONOMIC DEVELOPMENT JOHN C. CHAPMAN UNDERSECRETARY OF CONSUMER AFFAIRS AND BUSINESS REGULATION GARY D. ANDERSON COMMISSIONER OF INSURANCE ## BULLETIN 2018-06 TO: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations FROM: Gary D. Anderson, Commissioner of Insurance DATE: October 2, 2018 RE: Accessing Care with Network Providers The Division of Insurance (“Division”) issues this Bulletin to Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc. and Health Maintenance Organizations (“Carriers”) regarding the responsibility of managed care Carriers, which coordinate insured health plan benefits through a network of health care providers, to take appropriate steps to ensure that their provider directory systems can be used to locate providers to provide or arrange for the delivery of medically necessary covered health care to covered persons (“Members”). Under Massachusetts General Laws Chapter 176O, §6(a)(4), managed care Carriers are required to deliver Evidence of Coverage materials, including “the locations where, and the manner in which, health care services and other benefits may be obtained.” In 211 CMR 52.15(1)(a), the Division further clarifies that Carriers shall deliver or otherwise make available provider directories that “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.” As provider information changes, each Carrier is expected to update its provider directory information so that it accurately reflects the network of providers available to deliver care to Members. Carriers have an important responsibility to provide accurate information to their Members so that Members are able to contact network providers who can provide needed health care. Prospective Members and/or consumers also look at provider network information to help them choose/select a plan. Even though providers may not always routinely and regularly provide appropriate notification as required by the Carriers according to the terms of the provider contract Carriers are responsible to take appropriate steps to enable Members to arrange for needed care. Accordingly, Carriers shall have dedicated staff available to help Members who are not able to locate a network provider through the Carrier’s directories to find the appropriate types of Bulletin 2018-06 October 2, 2018 Page 2 of 2 providers to treat conditions based on age and type of treatment and to assist with any other questions related to the finding of a provider. Such staff are also to be available at the dedicated phone lines, extension, and/or menu option to contact providers and to help schedule appointments for certain difficult to treat ages or behavioral health conditions when Members indicate that they have not been able to locate an available practitioner listed within the provider directory. Carriers are to amend all relevant Evidence of Coverage materials, including any disclosures or Member-facing materials and provider directories - both hard copy and electronic - to identify the dedicated phone line, extension, and/or menu option that assists Members with locating a provider. The Division will collect and post the dedicated contact information for each Carrier on its website to assist covered Members. Please direct any questions about this Bulletin to Tracey McMillan at (617) 521-7347 or by email at Tracey.T.McMillan@mass.gov.