Health care coverage: provider directories

Consumers often rely on directories to find in-network care, but inaccurate listings can lead to unavailable providers or unexpected out-of-network bills. The law makes plans and insurers accountable when people reasonably rely on faulty directory information.

What the law does ​

• Requires the Department of Managed Health Care to designate a central utility and set uniform standards for collecting, checking, and comparing provider-directory data.
• Requires health plans and insurers to submit directories for annual consistency reports, attest to reviewing discrepancies, and explain how they will fix them.
• Requires plans and insurers to maintain accurate, publicly accessible directories; investigate reported errors within 30 business days; and update online listings at least weekly.
• Requires providers to update directory information through the central utility and allows plans and insurers, after notice, to temporarily delay payment or end contracts for repeated failures to provide required updates.
• Requires plans and insurers to cover covered services obtained in reasonable reliance on materially inaccurate directory information at in-network cost sharing, and bars providers from billing more.
• Requires timely confirmation of whether a provider is in-network and accepting new patients, and limits a consumer to the lower tier's cost sharing if wrongly told a provider was in that tier.

Who it affects ​

• Health care service plans and health insurers that maintain provider networks.
• Doctors, hospitals, clinics, pharmacies, laboratories, and other listed network providers.
• Enrollees, insured people, prospective customers, and the public using provider directories.
• The Department of Managed Health Care and the Department of Insurance.

Context ​

The Department of Managed Health Care must annually publish provider-directory consistency-report results, while plans and insurers remain responsible for their directories' accuracy.