DOL Alert: When an Incorrect Provider Directory Affects Cost Sharing
The U.S. Department of Labor issued an enforcement alert on 11/13/2026 addressing inaccurate health-plan provider directories. For covered group health plans, incorrect information identifying a provider as in-network can trigger existing protections against higher cost sharing. The announcement concerns enforcement guidance and directory-management practices; it does not introduce a new cost-sharing rule effective on the announcement date.
When does an incorrect listing trigger in-network cost sharing?
ERISA section 720, codified at 29 U.S.C. §1185i(b)(1)–(2), addresses services obtained from a nonparticipating provider or facility for plan years beginning on or after 01/01/2022. The service must otherwise have been covered if supplied in-network, and a statutory misinformation criterion must be met. When those conditions apply, the plan cannot impose a “cost-sharing amount” above the applicable in-network amount. That protects the participant's share of a covered service; a directory error does not itself mean that the plan must pay every medical expense in full.
One criterion concerns information received through the plan's database, directory or specified response protocol identifying the provider or facility as participating for the service concerned. Another covers information not supplied as required, followed by an inquiry through the response protocol and an answer identifying the provider or facility as participating. Section 1185i(b)(1)(B) also requires application of the in-network deductible or out-of-pocket maximum, if any. The relevant facts therefore include the particular plan, service and information received, rather than the provider's name alone.
What does the new enforcement alert emphasize?
The Labor Department's alert discusses maintaining directories, responding to network-status inquiries and monitoring complaints. Its management recommendations sit alongside existing statutory duties. Section 1185i(a)(2)–(3) requires verification and updates “not less frequently than once every 90 days,” and database updates within two business days after receipt of provider-submitted information under the specified statutory process. Telephone inquiries require a written electronic or printed response as soon as practicable, no later than one business day after receipt, with that communication retained for at least two years.
On billing, the department explains that participants told by their plan that a provider was in-network may be entitled to a refund if charged above in-network cost sharing after visiting that provider. The alert also recommends documenting directory complaints and corrective actions and monitoring service providers' responses. It does not establish that every inaccurate listing automatically produces a refund. Whether the statutory conditions are met depends on plan coverage, the information record and the service furnished; special circumstances require assessment by a qualified attorney.
Legal Disclaimer. Originally published: 11/14/2026. This article provides general information only and is not legal advice for any particular matter. Laws, policies, procedures, fees and agency practices may change; their application depends on the facts and jurisdiction. Consult a qualified attorney about your circumstances before acting on this information. Reading this article or contacting Blumsack & Canzano does not, by itself, create an attorney-client relationship. Past results do not guarantee future outcomes. This material may be considered attorney advertising in some jurisdictions.
