Health Provider Directory and Access Amendments

38
31A-22-663
31A-22-664
58-1-113
63I-2-258
0
Health Provider Directory and Access Amendments
2026 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Steve Eliason
Senate Sponsor: Kirk A. Cullimore
LONG TITLE
General Description:
This bill addresses provider directories and timely access to behavioral health services.
Highlighted Provisions:
This bill:
requires covered insurers to:
assist enrollees in accessing behavioral health services in a timely manner;
facilitate an insured obtaining behavioral health services from an out-of-network
provider if an in-network provider is not available in a timely manner;
publish health care provider directories;
regularly update health care provider directories; and
take certain steps to ensure the accuracy of provider directories;
authorizes Utah's insurance commissioner (commissioner) to make rules to implement
certain provisions of this bill;
requires providers to respond to an insurer's request for verification of provider directory
information within a certain period of time;
requires insurers and the commissioner to issue an educational letter to a provider that
demonstrates a pattern of violations of certain provisions;
requires the Division of Professional Licensing to convene a working group to study the
feasibility and cost of creating and maintaining a statewide behavioral health provider
directory (working group) and report to the Health and Human Services Interim
Committee;
provides a repeal date for the working group; and
defines terms.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
63I-2-258
, as last amended by Laws of Utah 2025, Chapter 277
ENACTS:
31A-22-663
, Utah Code Annotated 1953
31A-22-664
, Utah Code Annotated 1953
58-1-113
, Utah Code Annotated 1953
Be it enacted by the Legislature of the state of Utah:
Section 1. Section
31A-22-663
is enacted to read:
31A-22-663
. Timely access to behavioral health services -- Single case agreement.
(1)
As used in this section:
(a)
"Covered insurer" means an insurer that offers health insurance that includes
coverage for behavioral health services.
(b)
(i)
"Behavioral health services" means:
(A)
mental health treatment or services; or
(B)
substance use treatment or services.
(ii)
"Behavioral health services" includes telehealth services and telemedicine
services.
(c)
"Insurer" means the same as that term is defined in Section
31A-22-634
.
(d)
"Mental health provider" means the same as that term is defined in Section
31A-22-658
.
(e)
"Telehealth services" means the same as that term is defined in Section
26B-4-704
.
(f)
"Telemedicine services" means the same as that term is defined in Section
26B-4-704
.
(g)
"Timely manner" means:
(i)
no more than 15 days after the day on which an insured first attempts to access
behavioral health services; and
(ii)
no more than 24 hours after the date and time that an insured first seeks to access
urgent, emergency, or crisis behavioral health services.
(2)
Beginning January 1, 2027, a covered insurer shall:
(a)
establish a procedure to assist an enrollee to access behavioral health services from
an out-of-network mental health provider when no in-network mental health provider
is available in a timely manner; and
(b)
if an enrollee in a covered insurer's health benefit plan is unable to obtain covered
behavioral health services from an in-network mental health provider in a timely
manner, enter into a single case agreement that allows the enrollee to receive covered
behavioral health services from an out-of-network mental health provider.
(3)
(a)
A covered insurer shall include in a negotiated single case agreement described in
Subsection
(2)(b)
:
(i)
a requirement that the covered insurer reimburse the out-of-network mental health
provider for the covered behavioral health services at a rate negotiated by the
provider and insurer, subject to the member cost-sharing requirements imposed by
the health benefit plan;
(ii)
a requirement that the covered insurer apply the same coinsurance, copayments,
and deductibles that would apply for the behavioral health services if the
behavioral health services were provided by a mental health provider that is an
in-network mental health provider;
(iii)
any terms that a network provider is subject to under the health benefit plan; and
(iv)
the length and scope of the single case agreement.
(b)
Notwithstanding Subsection
(3)(a)(ii)
:
(i)
a covered insurer's payment under a single case agreement described in Subsection
(2)(b)
constitutes payment in full to the provider for the behavioral health services
the enrollee receives; and
(ii)
the provider may not seek additional payment from the enrollee except for
applicable cost sharing.
(4)
A covered insurer shall ensure that a single case agreement described in Subsection
(2)(b)
only permits an insured to receive behavioral health services:
(a)
that are:
(i)
within the out-of-network mental health provider's scope of practice; and
(ii)
behavioral health services that are otherwise covered under the enrollee's health
benefit plan; and
(b)
that are not experimental, unless the insurer covers experimental treatments for
physical health conditions in compliance with the Mental Health Parity and
Addiction Equity Act, Pub. L. No. 110-343.
(5)
A covered insurer shall:
(a)
document all payments the covered insurer makes under a health benefit plan to a
mental health provider under this section; and
(b)
provide the documentation described in Subsection
(5)(a)
to the department upon
request.
(6)
Subsections
(2)(b)
, (3), and (4) do not apply if behavioral health services are available
in a timely manner.
(7)
The commissioner may:
(a)
make rules in accordance with Title 63G, Chapter 3, Utah Administrative
Rulemaking Act, to implement this section; and
(b)
bring an action in accordance with Section
31A-2-308
and Title 63G, Chapter 4,
Administrative Procedures Act, for a violation of this section.
Section 2. Section
31A-22-664
is enacted to read:
31A-22-664
. Health care provider directories.
(1)
As used in this section:
(a)
"Division" means the Division of Professional Licensing created in Section
58-1-103
.
(b)
"Exempt health care professional" means a person exempt from licensure under a
title listed in Subsection
58-13-3(2)(c)
.
(c)
"Exempt mental health provider" means an individual exempt from licensure under
Section
58-60-107
.
(d)
"Health care facility" means the same as that term is defined in Section
26B-2-201
.
(e)
"Health care professional" means the same as that term is defined in Section
58-13-3
.
(f)
"Hospital" means a facility licensed under Title
26B, Chapter 2, Part 2
, Health Care
Facility Licensing and Inspection, as a general acute hospital or specialty hospital.
(g)
"Insurer" means the same as that term is defined in Section
31A-22-634
.
(h)
"Mental health provider" means the same as that term is defined in Section
31A-22-658
.
(i)
"Pharmacy" means the same as that term is defined in Section
58-17b-102
.
(j)
"Provider" means:
(i)
a health care professional;
(ii)
an exempt health care professional;
(iii)
a mental health provider;
(iv)
an exempt mental health provider; or
(v)
a pharmacy.
(k)
"Provider directory" means a list of in-network providers for each of an insurer's
health benefit plans.
(l)
"Telehealth services" means the same as that term is defined in Section
26B-4-704
.
(m)
"Telemedicine services" means the same as that term is defined in Section
26B-4-704
.
(2)
Beginning January 1, 2027, an insurer shall:
(a)
publish a provider directory for each of the insurer's health benefit plans; and
(b)
update the provider directory no less frequently than every 60 days.
(3)
An insurer shall ensure that, except as provided in Subsection
(7)
:
(a)
a provider directory:
(i)
is easily and publicly accessible:
(A)
through a conspicuous link on the home page of the insurer's website; and
(B)
without requiring an individual to create an account or submit a policy or
contract number; and
(ii)
is in a format that is searchable and downloadable; and
(b)
a provider may update the provider's information, including contact information and
whether the provider is accepting new patients, in the provider directory:
(i)
electronically;
(ii)
on the insurer's website; and
(iii)
through a conspicuous link on the home page of the insurer's website.
(4)
A provider directory shall include:
(a)
in plain language:
(i)
a description of the criteria the insurer used to build the health benefit plan's
provider network; and
(ii)
if applicable:
(A)
a description of the criteria the insurer used to tier health care providers;
(B)
how the health benefit plan designates health care provider tiers or levels; and
(C)
a notice that authorization or referral may be required to access some health
care providers; and
(b)
contact information an insured or member of the public may use to report to the
health benefit plan inaccurate information in a provider directory, which may include:
(i)
a phone number;
(ii)
an email address; or
(iii)
a link to a website or online reporting form.
(5)
In addition to the information required under Subsection
(4)
:
(a)
a provider directory of health care professionals and exempt health care professionals
shall include:
(i)
each health care professional's and exempt health care professional's:
(A)
name;
(B)
contact information, including:
(I)
internet address, if applicable;
(II)
physical address; and
(III)
phone number; and
(C)
specialty, if applicable;
(ii)
whether the health care professional or exempt health care professional is
accepting new patients; and
(iii)
whether the health care professional or exempt health care professional offers
telehealth services or telemedicine services;
(b)
a provider directory of health care facilities that are hospitals shall include each
hospital's:
(i)
name;
(ii)
if the hospital is a specialty hospital, specialty type;
(iii)
location or locations;
(iv)
accreditation status;
(v)
phone number; and
(vi)
internet address, if applicable;
(c)
a provider directory of health care facilities other than hospitals shall include each
health care facility's:
(i)
name;
(ii)
type;
(iii)
services provided;
(iv)
location or locations;
(v)
phone number; and
(vi)
internet address, if applicable;
(d)
a provider directory of pharmacies shall include each pharmacy's:
(i)
name;
(ii)
type;
(iii)
services provided, including whether the pharmacy offers mail-order or specialty
pharmacy services;
(iv)
location or locations;
(v)
phone number; and
(vi)
internet address, if applicable; and
(e)
a provider directory of mental health providers and exempt mental health providers
shall include:
(i)
each mental health provider's:
(A)
name;
(B)
contact information, including:
(I)
internet address, if applicable;
(II)
physical address; and
(III)
phone number; and
(C)
specialty, if applicable;
(ii)
whether the mental health provider or exempt mental health provider is accepting
new patients; and
(iii)
whether the mental health provider or exempt mental health provider offers
telehealth services or telemedicine services.
(6)
(a)
For purposes of Subsection
(5)(a)(ii)
, a health care professional is accepting new
patients if an exempt health care professional who treats patients under the
supervision of the health care professional is available to see new patients.
(b)
For purposes of Subsection
(5)(e)(ii)
, a mental health provider is accepting new
patients if an exempt mental health provider who treats patients under the supervision
of a mental health provider is available to see new patients.
(7)
(a)
An insurer may provide, in addition to an electronic provider directory, a provider
directory in print format.
(b)
An insurer shall provide a provider directory in print format to an insured upon
request of the insured.
(c)
In addition to the requirements described in Subsections
(4)
and (5), a provider
directory in print format shall include:
(i)
the internet address of the insurer's website where the insurer's electronic provider
directory is published;
(ii)
the health benefit plan's customer service phone number;
(iii)
a disclosure that the information in the provider directory is accurate, to the best
of the insurer's knowledge, based on the information the provider provided, as of
the date of printing; and
(iv)
a notice that an insured or prospective insured should consult the health benefit
plan's electronic provider directory or call the health benefit plan's customer
service phone number to obtain current provider directory information.
(8)
When an insurer receives a report of inaccurate information in a provider directory, the
insurer shall:
(a)
promptly investigate the report; and
(b)
no later than the end of the 20th business day after the day on which the insurer
receives the report:
(i)
verify the accuracy of the information in the provider directory; or
(ii)
for an electronic provider directory, update the inaccurate information with
accurate information.
(9)
(a)
An insurer shall take steps to ensure the accuracy of the information in a provider
directory, including contacting providers to verify that provider information is up to
date.
(b)
When an insurer contacts a provider to verify the accuracy of a provider's
information in a provider directory, the provider shall respond to the insurer's request
for verification no later than 15 business days after the day on which the insurer
contacts the provider.
(10)
(a)
An insurer shall, at least annually, audit each provider directory for accuracy.
(b)
(i)
(A)
include the two mental health specialties and four physical health
specialties most utilized by insureds; and
(B)
include at least one specialty related to mental health; or
(ii)
audit a reasonable sample size of providers, if the sample size includes mental
health providers.
(c)
An insurer shall:
(i)
retain documentation of each audit performed under this Subsection
(10)
;
(ii)
submit the audit to the commissioner upon the commissioner's request; and
(iii)
based on the results of the audit:
(A)
verify and attest to the accuracy of the information in a provider directory; and
(B)
update inaccurate information in a provider directory with accurate
information.
(11)
(a)
An insurer shall report to the commissioner upon request on:
(i)
the number of reports of inaccuracies in provider directories the insurer received;
(ii)
the timeliness of the insurer's response to a report of inaccuracies in a provider
directory;
(iii)
any corrective action the insurer took in response to a report of inaccuracies in a
provider directory;
(iv)
the identity of providers that failed to timely respond to the insurer's request for
verification as required under Subsection
(9)
;
(v)
all audits the insurer conducted in accordance with this section; and
(vi)
any other information related to provider directory accuracy the commissioner
considers relevant.
(b)
The commissioner may request the information described in Subsection
(11)(a)
no
more frequently than annually.
(c)
(i)
If an insurer finds that a provider demonstrates a repeated pattern of violations
of Subsection
(9)
, the insurer shall:
(A)
issue an educational letter to the provider; and
(B)
send a copy of the educational letter to the commissioner and the division.
(ii)
If an insurer notifies the commissioner that a provider demonstrates a repeated
pattern of violations of Subsection
(9)
, the commissioner shall send an educational
letter to the provider.
(12)
An insurer, a health care facility, a hospital, or a provider that is subject to this section
shall comply with all applicable requirements of the No Surprises Act, 42 U.S.C. Secs.
300gg-111 through 300gg-139, and federal regulations adopted in accordance with that
act.
(13)
The commissioner may make rules in accordance with Title 63G, Chapter 3, Utah
Administrative Rulemaking Act, to implement the provisions of this section.
(14)
In addition to the penalties authorized under Section
31A-2-308
, if the commissioner
determines that, when an insured received services under the insured's health benefit
plan, the insured reasonably relied on inaccurate information in a provider directory, the
commissioner may:
(a)
if the commissioner determines that the insurer knew or reasonably should have
known the information was inaccurate:
(i)
require the insurer to provide coverage for all covered health care services the
insured received; and
(ii)
reimburse the insured for the amount the insured paid for the health care services
that exceeds what the insured would have paid if the services were delivered by an
in-network provider; and
(b)
if the commissioner determines that the provider provided inaccurate information or
failed to update the information, require the insurer to reimburse the provider at the
in-network rate.
Section 3. Section
58-1-113
is enacted to read:
58-1-113
. Statewide behavioral health provider database study.
(1)
As used in this section:
(a)
"Accountable care organization" means a managed care organization, as defined in
42 C.F.R. Sec. 438, that contracts with the Department of Health and Human
Services under the provisions of Section
26B-3-202
.
(b)
"Behavioral health provider" means a mental health provider that provides
behavioral health services.
(c)
"Behavioral health services" means:
(i)
mental health treatment or services; or
(ii)
substance use treatment or services.
(d)
"Commissioner" means Utah's insurance commissioner.
(e)
"Database" means
the
statewide behavioral health provider database described in
Subsection
(2)
.
(f)
"Department of Health and Human Services" means the Department of Health and
Human Services created in Section
26B-1-201
.
(g)
"Division of Integrated Healthcare" means the Division of Integrated Healthcare
created in Section
26B-1-204
.
(h)
"Insurer" means:
(i)
an insurer as that term is defined in Section
31A-22-634
;
(ii)
an accountable care organization;
(iii)
a behavioral health plan as that term is defined in S
e
c
t
i
o
n

26B-3-203
; or
(iv)
for an adult who is covered through the traditional
fee-for-service
Medicaid
model in counties without Medicaid accountable care organizations or the state's
Medicaid accountable care organization delivery system, the Division of
Integrated Healthcare.
(i)
"Mental health provider" means the same as that term is defined in Section
31A-22-658
.
(j)
"PEHP" means the Public Employees' Benefit and Insurance Program created in
Section
49-20-103
.
(k)
"Provider directory" means a provider directory created in accordance with Section
31A-22-664
.
(l)
"Telehealth services" means the same as that term is defined in Section
26B-4-704
.
(m)
"Telemedicine services" means the same as that term is defined in Section
26B-4-704
.
(2)
On or before June 30, 2026, the division shall convene a working group to study and
develop recommendations regarding the feasibility and cost of creating and maintaining
a database of behavioral health providers in the state, including:
(a)
an analysis of the requirements for a statewide behavioral health provider database
that:
(i)
is accessible to the public;
(ii)
allows a person accessing the database to search behavioral health providers by:
(A)
license status;
(B)
areas of specialty the behavioral health provider provides, including treatment
of specific mental health diagnoses and disorders;
(C)
insurers with which the behavioral health provider is under contract; and
(D)
whether the behavioral health provider offers any or all of the following:
(I)
in-person services;
(II)
telehealth services; or
(III)
telemedicine services;
(iii)
indicates what methods of payment a behavioral health provider accepts,
including whether the behavioral health provider accepts cash only;
(iv)
indicates a behavioral health provider's availability for scheduling an
appointment;
(v)
for each insurer, codes by color or other method whether each behavioral health
provider in the insurer's network:
(A)
is accepting new patients;
(B)
requires a prospective new patient to call for availability; or
(C)
is not accepting new patients;
(vi)
allows an insurer to access the database and update information about behavioral
health providers in the insurer's network;
(vii)
allows a behavioral health provider to access the database and update and verify
the behavioral health provider's information;
(viii)
allows the division to communicate with a behavioral health provider in the
database to prompt the behavioral health provider to review and verify
information in the database;
(ix)
allows the division to import information from an insurer's provider directory
into the database; and
(x)
allows an insurer to import information about behavioral health providers in the
insurer's network into the insurer's provider directory; and
(b)
a determination of whether existing software or technology that PEHP owns or
controls meets, or could be modified to meet, the requirements for the features
described in Subsection
(2)(a)
.
(3)
The division shall coordinate with the Department of Health and Human Services,
PEHP, the Insurance Department, and accountable care organizations to determine the
membership of the working group described in Subsection
(2)
.
(4)
The division shall present to the Health and Human Services Interim Committee, on or
before the date of the committee's November 2026 meeting, on the recommendations
described in Subsection
(2)
.
Section 4. Section
63I-2-258
is amended to read:
63I-2-258
. Repeal dates: Title
58
.
Reserved.
Section
58-1-113
, Statewide behavioral health provider database study, is
repealed July 1, 2027.
Section 5.
Effective Date.
This bill takes effect on
May 6, 2026
.
3-10-26 10:52 AM