Fill - Free fillable Hmo (Commonwealth of Massachusetts) PDF form

Managed Care: Health Maintenance Organization (Rev. 103017) Page 1

MANAGED CARE CHECKLIST:

REVIEW OF HEALTH MAINTENANCE ORGANIZATIONS

LICENSED UNDER M.G.L. c. 176G

NOTE TO CARRIERS COMPLETING THIS CHECKLIST:

Pursuant to Bulletin No. 2001-05 and 2008-19, include a completed checklist when submitting (1) an

application for accreditation; (2) a material change to accreditation; (3) an application for an

insured preferred provider plan.

When completing a checklist, please indicate for each requirement the page number(s), and/or

section(s), where the required information may be found in the submitted materials.

 For items requiring company confirmation, please place a checkmark (√) next to the

requirement acknowledging confirmation.

 If a requirement is not applicable, please place “N/A” next to the requirement and explain,

either within the checklist or on a separate sheet, the legal basis under which the requirement

does not apply to the filed materials.

Carrier Name & NAIC #:

Contact Name & Title:

Address:

Telephone & Fax:

Email Address:

Product Name & Form #:

Date Submitted:

Carrier Certification:

I _____________________________ a duly authorized representative of

___________________________ certify that it is my good faith belief based on the review of this

checklist and submitted evidence of coverage and additional materials that the evidence of coverage and

additional submitted materials comply with applicable Massachusetts law.

RESET FROM

Managed Care: Health Maintenance Organization (Rev. 103017) Page 2

ADDITIONAL CHECKLISTS

Review the following checklists below; complete and forward those that apply to your submission.

 CHECKLIST FOR THE INITIAL APPROVAL OF AN INSURED PREFERRED PROVIDER

PLAN (Form# Application For Approval - Insured Preferred Provider Plan ver091217.pdf);

 MANAGED CARE CHECKLIST: FILING CONTENT FOR RENEWAL APPLICATION OF

ACCREDITATION UNDER M.G.L. c. 176O (Form# MC_RenewalAccred_090117.pdf); and

 MANAGED CARE CHECKLIST: REQUIREMENTS FOR PROVIDER CONTRACTS

(Form# Managed Care Provider Contracts (Rev. 083017) FINAL.pdf).

SPECIFIC TO MATERIAL CHANGE SUBMISSIONS

(Pursuant to M.G.L. c. 176I & c. 176O and regulations 211 CMR 51.00 & 211 CMR 52.00)

According to 211 CMR 52.02 the term “material change” is defined as “[a] modification to any of

a Carrier's, including a Dental or Vision Carrier's, procedures or documents required by

211 CMR 52.00 that substantially affects the rights or responsibilities of:

an Insured;

a Carrier, including a Dental or Vision Carrier; and/or

a Health, Dental, or Vision Care Provider.”

According to 211 CMR 51.06(1), “[e]ach Organization with a Preferred Provider Health

Plan…shall file with the Commissioner any material changes or additions to the material

previously submitted on or before their effective date, including amendments to an Evidence of

Coverage and significant changes to the lists of Preferred Providers.”

IF the submission is a material change, review all pages of this checklist;

 complete only those sections of the checklist(s) specific to the submission; and

 include red-line version(s) of the previously filed document(s).

Managed Care: Health Maintenance Organization (Rev. 103017) Page 3

HIGH DEDUCTIBLE PLANS THAT QUALIFY FOR USE WITH AN HSA

As stated in M.G.L.176G §16A, “[t]he commissioner shall not disapprove a health maintenance

contract: (i) if it complies with the requirements of 42 U.S.C. Sec. 18022(e); or (ii) on the basis that it

includes a deductible that is consistent with the requirements for a high deductible plan as defined in

section 223 of the Internal Revenue Code and implementing regulations or guidelines; provided,

however, that the maximum deductible shall not be greater than the maximum annual contribution to a

health savings account permitted under said section 223 of the Internal Revenue Code; and, provided

further, that a deductible equal to the maximum annual contribution to a health savings account shall

only be approved for products which include a health savings account permitted under said section 223

of the Internal Revenue Code.

Include a statement to explain the maximum individual and Family deductible options that the carrier

intends to offer.

If offering an HSA compatible plan please complete the following:

Deductible & out-of-Pocket Limits for High-Deductible Health Plans for use with an HSA

Plan Features In-network – Ind/Fam.

Out-of-Network – Ind/Fam

as applicable

Maximum Deductibles

In-Network/Out-of-network as applicable

Maximum out-of-pocket Maximum

In-Network/Out-of-network as applicable

Family Deductible Feature

1) Embedded Deductible per Member; or

2) Aggregate Deductible

RATE FILING REQUIREMENTS - (“Filing Guidance Notice 2012-E” issued on July 11, 2012)

Applies to all health benefit plans [does not apply to stand alone dental or vision plans] for which

rates are filed on a periodic basis, including merged market (small group and individual) plans, HMO

plans and Blue Cross Blue Shield of Massachusetts plans.

Please advise whether submission will have an impact on rates.

YES____ NO___

IF YES, forward the applicable rates with your quarterly rate filing via SERFF. Rates will not be

approved until the forms review is complete.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 4

READABILITY OF POLICY FORM; DEFINITION; APPROVAL; ACTIONS

BASED ON LANGUAGE - [M.G.L. CHAPTER 175 §2B]

Applies to policy forms, all certificates and subscription agreements or contracts of insurance issued pursuant

to M.G.L. c. 176, c. 176A, c. 176B, c. 176G. Policyholder shall include, in addition to all insurance

policyholders, all subscribers and holders of certificates issued pursuant to M.G.L. c. 176, c. 176A, c. 176B, c.

176G - M.G.L. c. 175 §2B. 2.

Every policy form filed with the commissioner under this section shall be accompanied by a certificate

stating the Flesch scale readability score achieved by such form(s).

[Statutory citation should be stated within the certification]

The term “text” as used in this section shall include all printed matter except the name and address of the

insurer, name or title of the policy, the brief description if any, captions and subcaptions, and schedule

pages and tables.

No policy form of insurance shall be delivered or issued for delivery to more than fifty policyholders in the

commonwealth until a copy of the policy form has been on file for thirty days with the commissioner,

unless before the expiration of said thirty days the commissioner shall have approved the form of the

policy in writing as complying with this section; nor shall any such policy be delivered or issued for

delivery if the commissioner notifies the company in writing within said thirty days that in his opinion the

form of said policy does not comply with the provisions of this section, specifying the reasons for his

opinion, provided that such action of the commissioner shall be subject to review by the supreme judicial

court, but during any such review the form shall not be delivered or issued for delivery in the

commonwealth; nor shall any such policy form be so delivered or issued for delivery unless:

The text achieves a minimum Flesch scale readability score of fifty; M.G.L. c. 175 §2B. 1.(a)

It is printed, except for tables, in not less than ten point type, one point leaded;

M.G.L. c. 175 §2B. 1.(b)

The style, arrangement and overall appearance of the policy give no undue prominence to any

portion of the text of the policy and any endorsements or riders; M.G.L. c. 175 §2B. 1.(c)

It contains a table of contents or an alphabetical subject index; M.G.L. c. 175 §2B. 1.(d)

The width of margins and ink to paper contrast do not unreasonably interfere with the readability of

the form; and

M.G.L. c. 175 §2B. 1.(e)

The organization of the content of the policy and the summary of the policy is conducive to

understandability of the form.

M.G.L. c. 175 §2B. 1.(f)

The certification identifies each form by form identifier and identifies the actual Flesch score for each

form - a statement to the effect that the score exceeds 50 is not permitted.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 5

MINIMUM CREDITABLE COVERAGE NOTICES

(BULLETIN 2008-02 & BULLETIN 2010-07)

As of January 1, 2009, the Massachusetts Health Care Reform Law requires each Massachusetts

resident, eighteen (18) years of age and older, to have health coverage that meets the Minimum

Creditable Coverage (“MCC”) standards set by the Commonwealth Health Insurance Connector.

In order to help individuals determine if the health coverage they have or intend to purchase is

sufficient to satisfy the individual mandate all commercial health insurers, Blue Cross and Blue Shield

of Massachusetts, Inc., and Health Maintenance Organizations (collectively “carriers”) that offer or

renew an individual or group insured health plan in Massachusetts, as defined in M.G.L. c. 176N, with

coverage effective on or after February 1, 2008...are to disclose to insureds and potential insureds a

plan’s MCC status and whether the plan satisfies the individual coverage mandate of the Massachusetts

Health Care Reform Law.

The insured health plan’s MCC status will be based on compliance with applicable standards in effect

on and after January 1, 2009 as set forth by the Connector either by regulation or administrative

bulletin.

In the case of an employer-sponsored group insured health plan, said disclosure requirement also

applies to marketing materials that describe the insured health plan benefits that are used during the

employer’s open enrollment period.

Please confirm that the carrier complies with this requirement.

_____________________________________________________________________________

The filed product meets MCC standards;

The filed product does not meet MCC standards;

The filed product is not considered a "health plan", as defined in M.G.L. c. 176N.

Please confirm that the carrier complies with this requirement.

_________________________________________________________________________________

_____________________________________________________________________________

Managed Care: Health Maintenance Organization (Rev. 103017) Page 6

IF THE INSURED HEALTH PLAN MEETS MCC STANDARDS:

______

The following disclosure notice must be included on the face or the first page of the text

of the policy or certificate or on any required notice submitted with the product in

substantially the same language and format:

______

In addition, the following disclosure shall be placed within the body of the policy,

certificate, or schedule of benefits in substantially the same language and format:

MASSACHUSETTS REQUIREMENT TO PURCHASE HEALTH INSURANCE:

As of January 1, 2009, the Massachusetts Health Care Reform Law requires that

Massachusetts residents, eighteen (18) years of age and older, must have health coverage

that meets the Minimum Creditable Coverage standards set by the Commonwealth Health

Insurance Connector, unless waived from the health insurance requirement based on

affordability or individual hardship. For more information call the Connector at 1-877-

MA-ENROLL or visit the Connector website (www.mahealthconnector.org ).

This health plan meets Minimum Creditable Coverage standards that are effective

[January 1, 20XX - (carriers are to substitute applicable date)] as part of the

Massachusetts Health Care Reform Law. If you purchased this plan, you will satisfy the

statutory requirement that you have health insurance meeting these standards.

THIS DISCLOSURE IS FOR MINIMUM CREDITABLE COVERAGE STANDARDS THAT

ARE EFFECTIVE [JANUARY 1, 20XX (carriers are to substitute applicable

date)]. BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH

PLAN MATERIAL EACH YEAR TO DETERMINE WHETHER YOUR PLAN MEETS THE

LATEST STANDARDS.

This health plan meets Minimum Creditable Coverage standards and will satisfy

the individual mandate that you have health insurance. Please see page # for

additional information.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 7

IF THE INSURED HEALTH PLAN DOES NOT MEET MCC STANDARDS

______

The following disclosure notice must be included on the face or the first page of the text of the

policy or certificate or on any required notice submitted with the product in substantially the

same language and format: :

______

In addition, the following disclosure shall be placed within the body of the policy, certificate, or

schedule of benefits in substantially the same language and format:

MASSACHUSETTS REQUIREMENT TO PURCHASE HEALTH INSURANCE:

As of January 1, 2009, the Massachusetts Health Care Reform Law requires that

Massachusetts residents, eighteen (18) years of age and older, must have health coverage

that meets the Minimum Creditable Coverage standards set by the Commonwealth Health

Insurance Connector, unless waived from the health insurance requirement based on

affordability or individual hardship. For more information call the Connector at 1-877-

MA-ENROLL or visit the Connector website (www.mahealthconnector.org ).

This health plan, alone, does not meet Minimum Creditable Coverage standards that are

effective [January 1, 20XX - (carriers are to substitute applicable date)] as part of

the Massachusetts Health Care Reform Law because (carriers are to substitute applicable

minimum creditable coverage standards as set by the Connector):

 The in-network deductible is more than $2,050 for an individual and/or $4,100 for a family.

 A broad range of medical benefits, as defined by the Connector, are not covered.

 Prescription drugs are not covered.

 The deductible for prescription drug coverage is more than $250 for an individual and/or

$500 for a family.

 The health plan includes deductibles or coinsurance for in-network core services, but does

not include an out-of-pocket maximum for in-network covered services.

 The out-of-pocket maximum for in-network covered services exceeds [$$$$].

[Note: Insert the appropriate dollar amount in effect for taxable year.]

 The sum of the out-of-pocket maximums [e.g. separate medical and RX deductibles] for in-

network covered services exceeds [$$$$]. [Note: Insert the appropriate dollar amount in

effect for taxable year.]

 The out-of-pocket maximum does not include [note: select appropriate service(s):

deductibles, co-insurance, co-payments, or similar charges],

 The health plan imposes an overall annual maximum benefit limitation for the plan that

applies to all covered services collectively;

This health plan, alone, does not meet Minimum Creditable Coverage

standards and will not satisfy the individual mandate that you have health

insurance. Please see page # for additional information.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 8

 The health plan imposes an overall annual maximum dollar benefit limitation.

 The health plan imposes utilization a cap on covered core services, The health plan imposes

impose an overall annual maximum dollar benefit limitation on prescription drugs;

 The health plan limits benefits to an Indemnity Schedule of Benefits for the coverage of

core services.

 The health plan applies covered preventive health services to the deductible.

If you purchased this health plan only, you will not satisfy the statutory requirement that you

have health insurance meeting these standards.

If this health plan is offered to you through your place of employment, contact your employer or

other plan sponsor to determine if it offers other health plan options that meet Minimum

Creditable Coverage standards. Your employer or other plan sponsor also may offer

supplemental plans you can add to this insured health plan in order to meet Minimum

Creditable Coverage.

If this health plan is not offered to you through your place of employment and you want to learn

about other health plan options available to individuals, you may contact the Division of

Insurance by calling (617) 521-7794 or visiting its website at www.mass.gov/doi, or the

Connector by calling 1-877-MA-ENROLL or visiting its website at

www.mahealthconnector.org.

THIS DISCLOSURE IS FOR MINIMUM CREDITABLE COVERAGE STANDARDS THAT

ARE EFFECTIVE [JANUARY 1, 20XX (carriers are to substitute applicable

date)]. BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH

PLAN MATERIAL EACH YEAR TO DETERMINE WHETHER YOUR PLAN MEETS THE

LATEST STANDARDS.

If you have questions about this notice, you may contact the Division of Insurance by calling (617)

521-7794 or visiting its website at www.mass.gov/doi

Managed Care: Health Maintenance Organization (Rev. 103017) Page 9

MANAGED CARE

DEFINITIONS MANAGED CARE [

M.G.L. c. 176O §1 and 211 CMR 52.03 (if used)]:

Insert page number(s), and/or section(s)

Pg#_____

Accreditation. A written determination by the Bureau of Managed Care of compliance

with M.G.L. c. 176O, 211 CMR 52.00 and 958 CMR 3.000: Health Insurance Consumer

Protection.

Pg#_____

Actively Practices. A Health Care Professional who regularly treats patients in a

clinical setting.

Pg#_____

Administrative Disenrollment. A change in the status of an Insured whereby the Insured

remains with the same Carrier but his or her membership may appear under a

different identification number. Examples of an Administrative Disenrollment are a

change in employers, a move from an individual plan to a spouse's plan, or any similar

change that maybe recorded by the Carrier as both a disenrollment and an enrollment.

Pg#_____

Adverse Determination. A determination, based upon a review of information provided, by a

Carrier or its designated Utilization Review Organization, to deny, reduce, modify, or

terminate an admission, continued inpatient stay, or the availability of any other Health

Care Services, for failure to meet the requirements for coverage based on Medical

Necessity, appropriateness of health care setting and level of care, or effectiveness,

including a determination that a requested or recommended Health Care Service or

treatment is experimental or investigational.

Pg#_____

Alternative Payment Contract. Any contract between a Carrier and a Provider or Provider

organization that utilizes alternative payment methodologies, which are methods of

payment that are not solely based on fee-for-service reimbursements and that may include,

but is not limited to, shared savings arrangements, bundled payments, global payments,

and fee-for-service payments that are settled or reconciled with a bundled or global

payment.

Pg#_____

Ambulatory Review. Utilization Review of Health Care Services performed or provided in

an outpatient setting, including, but not limited to, outpatient or ambulatory surgical,

diagnostic and therapeutic services provided at any medical, surgical, obstetrical,

psychiatric and chemical dependency Facility, as well as other locations such as

laboratories, radiology facilities, Provider offices and patient homes.

Pg#_____

Behavioral Health Manager. a company, organized under the laws of the Commonwealth of

Massachusetts or organized under the laws of another state and qualified to do business in

the Commonwealth, that has entered into a contractual arrangement with a Carrier to

provide or arrange for the provision of behavioral, substance use disorder and mental

health services to voluntarily enrolled members of the Carrier.

Pg#_____

Bureau of Managed Care or Bureau. The bureau in the Division of Insurance established

by M.G.L. c. 176O, § 2.

Pg#_____

Capitation. A set payment per patient per unit of time made by a Carrier to a licensed Health

Care Professional, Health Care Provider group, or organization that employs or

utilizes services of Health Care Professionals to cover a specified set of services and

administrative costs without regard to the actual number of services provided.

Pg#_____

Carrier. An insurer licensed or otherwise authorized to transact accident or health insurance

under M.G.L. c. 175; a nonprofit hospital service corporation organized under M.G.L. c.

176A; a nonprofit medical service corporation organized under M.G.L. c. 176B; a health

maintenance organization organized under M.G.L. c. 176G; and an organization entering

into a preferred provider arrangement under M.G.L. c. 176I, but not including an employer

Managed Care: Health Maintenance Organization (Rev. 103017) Page 10

purchasing coverage or acting on behalf of its employees or the employees of one or more

subsidiaries or affiliated corporations of the employer. Unless otherwise noted, the term

"Carrier" shall not include any entity to the extent it offers a policy, certificate, or

contract that is not a health benefit plan as defined in M.G.L. c. 176J, § 1.

Pg#_____

Case Management. A coordinated set of activities conducted for individual patient

management of serious, complicated, protracted or other health conditions.

Pg#_____

Clean and Complete Credentialing Application. A credentialing application which is

appropriately signed and dated by the Provider, and which includes all of the

applicable information requested from the Provider by the Carrier.

Pg#_____

Clinical Peer Reviewer. A physician or other Health Care Professional, other than the

physician or other Health Care Professional who made the initial decision, who holds

a nonrestricted license from the appropriate professional licensing board in

Massachusetts, current board certification from a specialty board approved by the American

Board of Medical Specialties or of the Advisory Board of Osteopathic Specialists from the

major areas of clinical services or, for non-physician Health Care Professionals, the

recognized professional board for their specialty, who Actively Practices in the Same or

Similar Specialty as typically manages the medical condition, procedure or treatment under

review, and whose compensation does not directly or indirectly depend upon the quantity,

type or cost of the services that such person approves or denies.

Pg#_____

Clinical Review Criteria. The written screening procedures, decisions, abstracts, clinical

protocols and practice guidelines used by a Carrier to determine the Medical Necessity

and appropriateness of Health Care Services.

Pg#_____

Commissioner. The Commissioner of Insurance, appointed pursuant to M.G.L. c. 26, § 6, or

his or her designee.

Pg#_____

Complaint.

(a) any Inquiry made by or on behalf of an Insured to a Carrier or Utilization

Review Organization that is not explained or resolved to the Insured's

satisfaction within three business Days of the Inquiry;

(b) any matter concerning an Adverse Determination; or

an internal Inquiry process, a Complaint means any Inquiry.

Pg#_____

Concurrent Review. Utilization Review conducted during an Insured's inpatient hospital stay

or course of treatment.

Pg#_____

Cost Sharing or Cost-sharing. Includes deductibles, coinsurance, copayments, or similar

charges required of an Insured, but does not include premiums, balance-billing amounts

for out-of-network Providers, or spending for non-covered Benefits.

Pg#_____

Covered Benefits or Benefits. Health Care Services to which an Insured is entitled under the

terms of the Health Benefit Plan.

Pg#_____

Days. Calendar days unless otherwise specified in 211 CMR 52.00; provided, that

computation of days specified in 211 CMR 52.00 begins with the first day following

the referenced action, and provided further that if the final day of a period specified in 211

CMR52.00 falls on a Saturday, Sunday or state holiday, the final day of the period will be

deemed to occur on the next working day.

Pg#_____

Dental Benefit Plan. A policy, contract, certificate or agreement of insurance entered into,

offered or issued by a Dental Carrier to provide, deliver, arrange for, pay for, or reimburse

any of the costs solely for Dental Care Services.

Pg#_____

Dental Care Professional. A dentist or other dental care practitioner licensed, accredited or

certified to perform specified Dental Services consistent with the law.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 11

Pg#_____

Dental Care Provider. A Dental Care Professional or Facility licensed to provide Dental Care

Services.

Pg#_____

Dental Care Services or Dental Services. Services for the diagnosis, prevention, treatment,

cure or relief of a dental condition, illness, injury or disease.

Pg#_____

Dental Carrier. An entity that offers a policy, certificate or contract that provides coverage

solely for Dental Care Services and is: an insurer licensed or otherwise authorized to

transact accident or health insurance under M.G.L. c. 175; a nonprofit hospital service

corporation organized under M.G.L. c. 176A; a nonprofit medical service corporation

organized under M.G.L. c. 176B; a dental service corporation organized under M.G.L. c.

176E, or an organization entering into a preferred provider arrangement under M.G.L. c.

176I, but not including an employer purchasing coverage or acting on behalf of its

employees or the employees or one or more subsidiaries or affiliated corporations of the

employer, that offers a policy, certificate or contract that provides coverage solely for

Dental Care Services.

Pg#_____

Discharge Planning. The formal process for determining, prior to discharge from a Facility,

the coordination and management of the care that an Insured receives following discharge

from a Facility.

Pg#_____ Division. The Division of Insurance established pursuant to M.G.L. c. 26, § 1.

Pg#_____

Emergency Medical Condition. A medical condition, whether physical, behavioral, related to

substance use disorder, or mental, manifesting itself by symptoms of sufficient

severity, including severe pain, that the absence of prompt medical attention could

reasonably be expected by a prudent layperson who possesses an average knowledge of

health and medicine, to result in placing the health of an Insured or another person in

serious jeopardy, serious impairment to body function, or serious dysfunction of any body

organ or part, or, with respect to a pregnant woman, as further defined in § 1867(e)(l)(B) of

the Social Security Act, 42 U.S.C. § 1395dd(e)(1)(B).

Pg#_____

Evidence of Coverage. Any certificate, contract or agreement of health insurance including

riders, amendments, endorsements and any other supplementary inserts or a summary

plan description pursuant to § 104(b)(1) of the Employee Retirement Income Security Act of

1974, 29 U.S.C. § 1024(b), issued to an Insured specifying the Benefits to which the

Insured is entitled. For workers' compensation preferred provider arrangements, the

Evidence of Coverage will be considered to be the information annually distributed

pursuant to 211 CMR 51.04(3)(i)1. through 3.

Pg#_____

Facility. A licensed institution providing Health Care Services or a health care setting,

including, but not limited to, hospitals and other licensed inpatient centers, ambulatory

surgical or treatment centers, skilled nursing centers, residential treatment centers,

diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health

settings.

Pg#_____

Finding of Neglect. A written determination by the Commissioner that a Carrier has failed to

make and file the materials required by M.G.L. c. 176O or 211 CMR 52.00 in the form

and within the time required.

Pg#_____

Grievance. Any oral or written Complaint submitted to the Carrier that has been initiated by

an Insured, or on behalf of an Insured with the consent of the Insured, concerning any

aspect or action of the Carrier relative to the Insured, including, but not limited to, review of

Adverse Determinations regarding scope of coverage, denial of services, rescission of

coverage, quality of care and administrative operations, in accordance with the

requirements of M.G.L. c. 176O and 958 CMR 3.000: Health Insurance Consumer

Protection.

Pg#_____ Health Benefit Plan. A policy, contract, certificate or agreement of insurance entered into,

Managed Care: Health Maintenance Organization (Rev. 103017) Page 12

offered or issued by a Carrier to provide, deliver, arrange for, pay for, or reimburse any of

the costs of Health Care Services. Unless otherwise noted, Health Benefit Plan shall not

include any policy, certificate, or contract that is not a health benefit plan as defined in

M.G.L. c. 176J, § 1.

Pg#_____

Health Care Professional. A physician or other health care practitioner licensed, accredited

or certified to perform specified Health Services consistent with the law.

Pg#_____ Health Care Provider or Provider. A Health Care Professional or Facility.

Pg#_____

Health Care Services or Health Services. Services for the diagnosis, prevention, treatment,

cure or relief of a physical, behavioral, substance use disorder or mental health

condition, illness, injury or disease.

Pg#_____ HMO. A health maintenance organization licensed pursuant to M.G.L. c. 176G.

Pg#_____

Incentive Plan. Any compensation arrangement between a Carrier and Health Care

Professional or Licensed Health Care Provider Group or organization that employs or

utilizes services of one or more licensed Health Care Professionals that may directly or

indirectly have the effect of reducing or limiting specific services furnished to Insureds of

the organization. Incentive Plan shall not mean contracts that involve general payments

such as Capitation payments or shared risk agreements that are made with respect to Health

Care Professionals or Providers, or Health Care Professional groups or Provider groups

which are made with respect to groups of Insureds if such contracts, which impose

risk on such Health Care Professionals or Providers or Health Care Professional groups or

Provider groups for the cost of medical care, services and equipment provided or

authorized by another Health Care Professional or Provider or by another Health Care

Professional group or Provider group, comply with 211 CMR 52.00.

Pg#_____

Inquiry. Any communication by or on behalf of an Insured to the Carrier or Utilization

Review Organization that has not been the subject of an Adverse Determination and

that requests redress of an action, omission or policy of the Carrier.

Pg#_____

Insured. An enrollee, covered person, Insured, member, policy holder or subscriber of a

Carrier, including a Dental or Vision Carrier, including an individual whose eligibility as

an Insured of a Carrier is in dispute or under review, or any other individual whose care

may be subject to review by a Utilization Review program or entity as described under the

provisions of M.G.L. c. 176O, 211 CMR 52.00 and 958 CMR 3.000: Health Insurance

Consumer Protection.

Pg#_____

Internet Website. Includes, but shall not be limited to, an internet website, an intranet

website, a web portal, or electronic mail.

Pg#_____ JCAHO. The Joint Commission on Accreditation of Healthcare Organizations.

Pg#_____

Licensed Health Care Provider Group. A partnership, association, corporation, individual

practice association, or other group that distributes income from the practice among

members. An individual practice association is a Licensed Health Care Provider Group

only if it is composed of individual Health Care Professionals and has no subcontracts

with Licensed Health Care Provider Groups.

Pg#_____

Limited Health Services. Pharmaceutical services, and such other services as may be

determined by the Commissioner to be Limited Health Services. Limited Health Services

shall not include hospital, medical, surgical or emergency services except as such services

are provided in conjunction with the Limited Health Services set forth in the preceding

sentence.

Pg#_____

Limited Network Plan. A limited network plan as defined in 211 CMR 152.00: Health

Benefit Plans Using Limited, Regional or Tiered Provider Networks.

Pg#_____

Managed Care Organization or MCO. A Carrier subject to M.G.L. c. 176O.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 13

Pg#_____

Material Change. A modification to any of a Carrier's, including a Dental or Vision Carrier's,

procedures or documents required by 211 CMR 52.00 that substantially affects the rights

or responsibilities of:

an Insured;

a Carrier, including a Dental or Vision Carrier; and/or

a health, Dental, or Vision Care Provider.

Pg#_____

Medical Necessity or Medically Necessary. Health Care Services that are consistent with

generally accepted principles of professional medical practice as determined by whether:

a) the service is the most appropriate available supply or level of service for the

Insured in question considering potential benefits and harms to the individual;

b) is known to be effective, based on scientific evidence, professional standards

and expert opinion, in improving health outcomes; or

c) for services and interventions not in widespread use, is based on scientific evidence.

Pg#_____

National Accreditation Organization. JCAHO, NCQA, URAC or any other national

accreditation entity approved by the Division that accredits Carriers that are subject to

the provisions of M.G.L. c. 176O and 211 CMR 52.00.

Pg#_____ NCQA. The National Committee for Quality Assurance.

Pg#_____

NCQA Standards. The Standards and Guidelines for the Accreditation of Health

Plans published annually by the NCQA.

Pg#_____

Network or Provider Network. A group of health, Dental or Vision Care Providers who

contract with a Carrier, including a Dental or Vision Carrier, or affiliate to provide

health, Dental or Vision Care Services to Insureds covered by any or all of the Carrier's,

including a Dental or Vision Carrier's or affiliate's, plans, policies, contracts or other

arrangements. Network shall not mean those Participating Providers who provide services to

subscribers of a nonprofit hospital service corporation organized under M.G.L. c. 176A, or a

nonprofit medical service corporation organized under M.G.L. c. 176B.

Pg#_____

Nongatekeeper Preferred Provider Plan. An insured preferred provider plan approved for

offer under M.G.L. c. 176I which offers preferred Benefits when a covered person

receives care from preferred Network Providers but does not require the Insured to designate

a Primary Care Provider to coordinate the delivery of care or receive referrals from the

Carrier or any Network Provider as a condition of receiving Benefits at the preferred benefit

level.

Pg#_____

Nurse Practitioner. A registered nurse who holds authorization in advanced nursing practice

as a nurse practitioner under M.G.L. c. 112, § 80B.

Pg#_____

Office of Patient Protection. The office within the Health Policy Commission established

by M.G.L. c. 6D, § 16, responsible for the administration and enforcement of M.G.L. c.

176O, §§ 13, 14, 15 and 16.

Pg#_____

Participating Provider. A Provider who, under a contract with the Carrier, including a Dental

or Vision Carrier, or with its contractor or subcontractor, has agreed to provide health,

Dental or Vision Care Services to Insureds with an expectation of receiving payment,

other than coinsurance, copayments or deductibles, directly or indirectly from the Carrier,

including a Dental or Vision Carrier.

Pg#_____

Physician Assistant. A person who is a graduate of an approved program for the training of

physician assistants who is supervised by a registered physician in accordance

with M.G.L. c. 112, §§ 9C through 9H and who has passed the Physician Assistant

National Certifying Exam or its equivalent.

Pg#_____

Preventive Health Services. Any periodic, routine, screening or other services designed for

the prevention and early detection of illness that a Carrier is required to provide pursuant

to Massachusetts or federal law.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 14

Pg#_____

Primary Care Provider. A Health Care Professional qualified to provide general medical care

for common health care problems, who supervises, coordinates, prescribes, or

otherwise provides or proposes Health Care Services; initiates referrals for specialist care;

and maintains continuity of care within the scope of his or her practice.

Pg#_____

Prospective Review. Utilization Review conducted prior to an admission or a course of

treatment. Prospective Review shall include any pre-authorization and pre-certification

requirements of a Carrier or Utilization Review Organization.

Pg#_____

Regional Network Plan. A regional network plan as defined in 211 CMR 152.00: Health

Benefit Plans Using Limited, Regional or Tiered Provider Networks.

Pg#_____

Religious Non-medical Provider. A Provider who provides no medical care but who provides

only religious non-medical treatment or religious non-medical nursing care.

Pg#_____

Retrospective Review. Utilization Review of Medical Necessity that is conducted after

services have been provided to a patient. Retrospective Review shall not include the review

of a claim that is limited to an evaluation of reimbursement levels, veracity of

documentation, accuracy of coding or adjudication for payment.

Pg#_____

Same or Similar Specialty. The Health Care Professional has similar credentials and licensure

as those who typically provide the treatment in question and has experience treating the

same condition that is the subject of the Grievance. Such experience shall extend to the

treatment of children in a Grievance involving a child where the age of the patient is

relevant to the determination of whether a requested service or supply is Medically

Necessary.

Pg#_____

Second Opinion. An opportunity or requirement to obtain a clinical evaluation by a Health

Care Professional other than the Health Care Professional who made the original

recommendation for a proposed Health Service, to assess the clinical necessity and

appropriateness of the initial proposed Health Service.

Pg#_____

Service Area. The geographical area as approved by the Commissioner within which the

Carrier, including a Dental or Vision Carrier, has developed a Network of Providers to

afford adequate access to members for covered Health, Dental or Vision Services.

Pg#_____

Terminally Ill or Terminal Illness. An illness that is likely, within a reasonable degree of

medical certainty, to cause one's death within six months, or as otherwise defined in

section 1861(dd)(3)(A) of the Social Security Act, 42 U.S.C. section 1395x(dd)(3)(A).

Pg#_____

Tiered Network Plan. A tiered network plan as defined in 211 CMR 152.00: Health Benefit

Plans Using Limited, Regional or Tiered Provider Networks.

Pg#_____

URAC. The American Accreditation HealthCare Commission/URAC, formerly known as the

Utilization Review Accreditation Commission.

Pg#_____

Utilization Review. Set of formal techniques designed to monitor the use of, or evaluate the

clinical necessity, appropriateness, efficacy, or efficiency of, Health Care Services,

procedures or settings. Such techniques may include, but are not limited to,

Ambulatory Review, Prospective Review, Second Opinion, certification, Concurrent

Review, Case Management, Discharge Planning or Retrospective Review.

Pg#_____

Utilization Review Organization. An entity that conducts Utilization Review under contract

with or on behalf of a Carrier, but does not include a Carrier performing Utilization

Review for its own Health Benefit Plans. A Behavioral Health Manager is considered a

Utilization Review Organization.

Pg#_____

Vision Benefit Plan. A policy, contract, certificate or agreement of insurance entered into,

offered or issued by a Carrier to provide, deliver, arrange for, pay for, or reimburse any of

the costs solely for Vision Care Services.

Pg#_____

Vision Care Professional. An ophthalmologist, optometrist or other practitioner licensed,

accredited or certified to perform specified Vision Services consistent with the law.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 15

Pg#_____

Vision Care Provider. A Vision Care Professional; or a Facility licensed to perform and

provide Vision Care Services.

Pg#_____

Vision Care Services or Vision Services. Services for the diagnosis, prevention, treatment,

cure or relief of a vision condition, illness, injury or disease.

Pg#_____

Vision Carrier. An entity that offers a policy, certificate or contract that provides coverage

solely for Vision Care Services and is: an insurer licensed or otherwise authorized to

transact accident or health insurance under M.G.L. c. 175; an optometric service corporation

organized under M.G.L. c. 176F, or an organization entering into a preferred provider

arrangement under M.G.L. c. 176I, but not including an employer purchasing coverage or

acting on behalf of its employees or the employees of one or more subsidiaries or

affiliated corporations of the employer, that offers a policy, certificate or contract that

provides coverage solely for Vision Care Services.

STANDARDS FOR UTILIZATION REVIEW - 211 CMR 52.06

Carriers shall meet the requirements identified in 211 CMR 52.07(2) through (10). In cases where the

standards in 211 CMR 52.07(2) through (10) differ from those in the NCQA Standards, the standards

in 211 CMR 52.07(2) through (10) shall apply. According to 211 CMR 52.13(3)(o), evidences of

coverage shall contain a summary description of utilization review procedures as follows:

211 CMR 52.06(2): Written Plan.

Pg#_____

Utilization Review conducted by a Carrier or a Utilization Review Organization shall be

conducted pursuant to a written plan under the supervision of a physician and staffed by

appropriately trained and qualified personnel and shall include a documented process to:

a) review and evaluate its effectiveness;

b) ensure the consistent application of Utilization Review criteria; and

c) ensure the timeliness of Utilization Review determinations.

211 CMR 52.07(3): Criteria.

A Carrier or Utilization Review Organization shall adopt Utilization Review criteria and conduct all

Utilization Review activities pursuant to said criteria.

Pg#_____

a) The criteria shall be, to the maximum extent feasible, scientifically derived and

evidence-based, and developed with the input of Participating Providers, consistent

with the development of Medical Necessity criteria consistent with 958 CMR 3.101:

Carrier's Medical Necessity Guidelines.

Pg#_____

b) Utilization Review criteria shall be up to date and applied consistently by a Carrier or

the Utilization Review Organization and made easily accessible to subscribers, Health

Care Providers and the general public on a Carrier's website; or, in the alternative,

on the Carrier's Utilization Review Organization's website so long as the Carrier

provides a link on its website to the Utilization Review Organization's website;

provided, however, that a Carrier shall not be required to disclose licensed, proprietary

criteria purchased by a Carrier or Utilization Review Organization on its website, but

must disclose such criteria to a Provider or subscriber upon request.

Pg#_____

c) Any new or amended preauthorization requirement or restriction shall not be

implemented unless the Carrier's and/or Utilization Review Organization's

respective website has been updated to clearly reflect the new or amended requirement

or restriction.

Pg#_____

d) Adverse Determinations rendered by a program of Utilization Review, or other denials

of requests for Health Services, shall be made by a person licensed in the

appropriate specialty related to such Health Services and, where applicable, by a

Provider in the same licensure category as the ordering Provider.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 16

211 CMR 52.07(4) Initial Determination Regarding a Proposed Admission, Procedure or Service.

Pg#_____

(a) When requiring prior authorization for a Health Care Service or Benefit, a Carrier shall use

and accept, or a Carrier shall require and ensure that its Utilization Review Organization

use and accept, only the prior authorization forms designated by the Commissioner for

the specific types of Health Care Services and Benefits identified in the designated forms.

Pg#_____

(b) If the Carrier fails to use or accept the designated prior authorization form, or fails to

respond within two business days after receiving a completed prior authorization request

from a Provider, pursuant to the submission of the prior authorization form under 211 CMR

52.07(4)(a), the prior authorization request shall be deemed to have been granted.

Pg#_____

Carrier shall require and ensure that its Utilization Review Organization makes, an initial

determination regarding a proposed admission, procedure or service that requires such a

determination within two working days of obtaining all necessary information. For

purposes of 211 CMR 52.07, "necessary information" shall include the results of any

face-to-face clinical evaluation or Second Opinion that may be required.

Pg#_____

(d) In the case of a determination to approve an admission, procedure or service, the

Carrier or Utilization Review Organization shall notify the Provider rendering the service

by telephone within 24 hours, and shall send written or electronic confirmation of the

telephone notification to the Insured and the Provider within two working days thereafter.

Pg#_____

(e) In the case of an Adverse Determination, the Carrier or the Utilization Review

Organization shall notify the Provider rendering the service by telephone within 24 hours,

and shall send written or electronic confirmation of the telephone notification to the Insured

and the Provider within one working day thereafter.

Pg#_____

(f) Any new or amended Prospective Review requirement or restriction shall not be

effective unless and until the Carrier's or Utilization Review Organization's website has

been updated to reflect the new or amended requirement or restriction.

Pg#_____

(g) Subject to 211 CMR 52.07(4)(a) through (f), nothing in 211 CMR 52.07(4) shall:

1. require a treating Health Care Provider to obtain information regarding whether a

proposed admission, procedure or service is Medically Necessary on behalf of

an Insured;

2. restrict the ability of a Carrier or Utilization Review Organization to deny a claim

for an admission, procedure or service if the admission, procedure or service was

not Medically Necessary, based on information provided at the time of claim; or

3. shall restrict the ability of a Carrier or Utilization Review Organization to deny a

claim for an admission, procedure or service if other terms and conditions of

coverage are not met at the time of service or time of claim.

211 CMR 52.07(5) Concurrent Review.

Pg#_____

A Carrier or the Utilization Review Organization shall make a Concurrent Review

determination within one working day of obtaining all necessary information.

a) In the case of a determination to approve an extended stay or additional services, the

Carrier or Utilization Review Organization shall notify the Provider rendering the

service by telephone within one working day, and shall send written or electronic

confirmation to the Insured and the Provider within one working day thereafter. A

written or electronic notification shall include the number of extended Days or the

next review date, the new total number of Days or services approved, and the date

of admission or initiation of services.

b) In the case of an Adverse Determination, the Carrier or Utilization Review

Organization shall notify the Provider rendering the service by telephone within 24

Managed Care: Health Maintenance Organization (Rev. 103017) Page 17

hours, and shall send written or electronic notification to the Insured and the Provider

within one working Day thereafter.

c) The service shall be continued without liability to the Insured until the Insured has

been notified of the determination.

211 CMR 52.07(6) Written Notice. (See also Bulletin 2016-02)

Pg#_____

The written notification of an Adverse Determination shall include a substantive clinical

justification that is consistent with generally accepted principles of professional medical

practice, and shall, at a minimum:

(a) include information about the claim including, if applicable, the date(s) of service, the

Health Care Provider(s), the claim amount, and any diagnosis, treatment, and denial code(s)

and their corresponding meaning(s);

(b) identify the specific information upon which the Adverse Determination was based shall

explain the reason for any denial, including the specific Utilization Review criteria or

Benefits provisions used in the determination, and;

interventions;

(d) explain in a reasonable level of detail the specific reasons such medical evidence fails to

meet the relevant medical review criteria;

(e) reference and include, or provide a website link(s) to the specifically applicable,

clinical practice guidelines, medical review criteria, or other clinical basis for the Adverse

Determination;

(f) a description of any additional material or information necessary for the Insured to

perfect the claim and an explanation of why such material or information is necessary;

(g) if the carrier specifies alternative treatment options which are Covered Benefits,

include identification of providers who are currently accepting new patients;

(h) prominently explain all appeal rights applicable to the denial, including a clear,

concise and complete description of the Carrier's formal internal Grievance process and the

procedures for obtaining external review pursuant to 958 CMR 3.000: Health Insurance

Consumer Protection, and a clear, prominent description of the process for seeking

expedited internal review and concurrent expedited internal and external reviews, including

applicable timelines, pursuant to 958 CMR 3.000; and a clear and prominent notice of a

patient's right to file a grievance with the with the Office of Patient Protection; and

information on how to file a grievance with the Office of Patient Protection.

(i) prominently notify the Insured of the availability of, and contact information for, the

consumer assistance toll-free number maintained by the Office of Patient Protection, and

if applicable, the Massachusetts consumer assistance program; and

(j) include a statement, prominently displayed in at least the languages identified by the

Centers for Medicare & Medicaid Services as the top non-English languages in

Massachusetts, that clearly indicates how the Insured can request oral interpretation and

written translation services from the Carrier consistent with 958 CMR 3.000: Health

Insurance Consumer Protection.

211 CMR 52.07(7) Reconsideration of an Adverse Determination.

Pg#_____

A Carrier or Utilization Review Organization shall give a Provider treating an Insured a

opportunity to seek reconsideration of an Adverse Determination from a Clinical Pee

Reviewer in any case involving an initial determination or a Concurrent Review determination.

(a) The reconsideration process shall occur within one working day of the receipt of the

request and shall be conducted between the Provider rendering the service and the Clinical

Peer Reviewer or a clinical peer designated by the Clinical Peer Reviewer if the reviewer

Managed Care: Health Maintenance Organization (Rev. 103017) Page 18

Pg#_____

cannot be available within one working day.

(b) If the Adverse Determination is not reversed by the reconsideration process, the

Insured, or the Provider on behalf of the Insured, may pursue the Grievance process

established pursuant to 958 CMR 3.000: Health Insurance Consumer Protection.

prerequisite to the internal Grievance process or an expedited appeal required by 958 CMR

3.000: Health Insurance Consumer Protection.

211 CMR 52.07(10) Annual Survey

A Carrier or Utilization Review Organization shall conduct an annual survey of Insureds to assess

satisfaction with access to primary care services, specialist services, ancillary services, hospitalization

services, durable medical equipment and other covered services.

(a) The survey shall compare the actual satisfaction of Insureds with projected measures of their

satisfaction.

(b) Carriers that utilize Incentive Plans shall establish mechanisms for monitoring the satisfaction,

quality of care and actual utilization compared with projected utilization of Health Care Services

of Insureds.

Please confirm the carrier understands their responsibilities noted above.

__________________________________________________________________________________

211 CMR 52.07(11) Religious Non-medical Treatment and Providers.

Nothing in 211 CMR 52.07 shall be construed to require Health Benefit Plans to use medical professionals or

criteria to decide insured access to Religious Non-medical Providers, utilize medical professionals or criteria in

making decisions in internal appeals from decisions denying or limiting coverage or care by Religious Non-

medical Providers, compel an Insured to undergo a medical examination or test as a condition of receiving

coverage for treatment by a Religious Non-medical Provider, or require Health Benefit Plans to exclude

Religious Non-medical Providers because they do not provide medical or other data otherwise required, if such

data is inconsistent with the religious non-medical treatment or nursing care provided by the Provider.

Please confirm the carrier understands their responsibilities noted above.

__________________________________________________________________________________

Managed Care: Health Maintenance Organization (Rev. 103017) Page 19

DESCRIPTION OF STANDARD HMO SERVICES

[M.G.L. c. 176G §1 and 211 CMR 43.00]

Description of services should be identified within the policy forms – identify the page number for each

identified “health service.”

Health Services at least reasonably comprehensive inpatient, outpatient, and emergency care services

including: preventive services, such as:

Pg ____ immunizations;

Pg ____ periodic health exams for adults;

Pg ____ prenatal maternity care;

Pg ____ well child care including vision and auditory screening;

Pg ____ voluntary family planning;

Pg ____ nutrition counseling, and health education;

Pg ____ pediatric care;

Pg ____ minimum of 100 days in a 12-month period or 365 lifetime days of noncustodial care

in a skilled nursing facility; and

Pg ____ which may include, but not be limited to chiropractic services; optometric services; and

podiatric services.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 20

REQUIREMENTS OF AN EVIDENCE OF COVERAGE

[M.G.L. c. 176O §6 211 CMR 52.13]:

211 CMR 52.13(1): Evidences of Coverage as to a Carrier.

It shall constitute delivery of an Evidence of Coverage if a carrier chooses to, upon or after

enrollment, require the Insured to designate whether the Insured wants to receive an Evidence of

Coverage electronically or in writing. If no option is designated, the Evidence of Coverage shall be

provided electronically. If the insured designates written notice, a carrier shall issue and deliver to at

least one adult Insured in the household an Evidence of Coverage. If the Insured designates

electronic notice, a carrier shall refer the insured to a resource where the information described in such

Evidence of Coverage can be accessed, including, but not limited to, an Internet Website. In such

instance, the Evidence of Coverage must meet the requirements of 211 CMR 52.13(4). An electronic

copy of the Evidence of Coverage shall always be delivered to the group representative in the case of

a group policy.

Based on the above, please provide a detailed statement describing how the carrier delivers its

evidence of coverage to insureds upon or after enrollment as well as to the group representative,

as applicable.

___________________________________________________________________________________

__________________________________________________________________________________

211 CMR 52.13(3): Evidences of Coverage Requirements.

An Evidence of Coverage shall contain a clear, concise and complete statement of all of the

information described at 211 CMR 52.13(3)(a) through (aa). In addition, for Limited, Regional and

Tiered Network Plans, an Evidence of Coverage shall also contain any information as required by 211

CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks.

Pg#_____

a) The health, Dental or Vision Care Services and any other Benefits to which the Insured is

entitled on a nondiscriminatory basis, including Benefits mandated by state or federal

law;

b) The prepaid fee which must be paid by or on behalf of the Insured and an explanation of

any grace period for the payment of any Health Benefit Plan premium;

c) The toll-free telephone number and website established by the Carrier to present

Provider cost information and an explanation of the information that a Insured may

obtain through such toll-free number and website.

d) The limitations on the scope of:

1. Health Care Services and any other Benefits to be provided, including:

a. an explanation of any Facility fee, allowed amount, coinsurance,

copayment, deductible or other amount that the Insured may be

responsible to pay to obtain Covered Benefits from Network or Out-of-

network Providers; and

b. an explanation of the information that an Insured may obtain through

the toll-free number and website established by the Carrier under 211 CMR

52.14(4).

2. Dental or Vision Care Services and any other Benefits to be provided, including an

explanation of any deductible or copayment feature.

e) All restrictions relating to preexisting condition limitations or exclusions, or a statement

that there are no preexisting condition limitations or exclusions if there are none under

the Health, Dental or Vision Benefit Plan;

f) A description of the locations where, and the manner in which, Health, Dental or

Managed Care: Health Maintenance Organization (Rev. 103017) Page 21

Pg#_____

Vision Care Services and other Benefits may be obtained, and, additionally, for

Health Care Services:

1. the method to locate Provider directory information on a Carrier's website and the

method to obtain a paper Provider directory;

2. an explanation that whenever a proposed admission, procedure or covered service

that is Medically Necessary is not available to an Insured within the Carrier's

Network, the Carrier will cover the out-of-Network admission, procedure or

service, and the Insured will not be responsible for paying more than the

amount which would be required for a similar admission, procedure or service

offered within the Carrier's Network; and

3. an explanation that whenever a location where Health Care Services are provided

is part of a Carrier's Network, the Carrier will cover Medically Necessary

covered Benefits delivered at that location, and an explanation that the Insured

will not be responsible for paying more than the amount required for Network

services delivered at that location even if part of the Medically Necessary Covered

Benefits are performed by out-of-Network Provider(s), unless the Insured has a

reasonable opportunity to choose to have the service performed by a Network

Provider.

g) A description of eligibility of coverage for dependents, including a summary

description of the procedure by which dependents may be added to the plan;

h) The criteria by which an Insured may be disenrolled or denied enrollment. 211 CMR

52.13(3)(h) shall apply to Carriers, including Dental and Vision Carriers.

i) The involuntary disenrollment rate among Insureds of the Carrier. 211 CMR

52.13(3)(i) shall apply to Carriers, including Dental and Vision Carriers.

1. For the purposes of 211 CMR 52.13(3)(i), Carriers shall exclude all Administrative

Disenrollments, Insureds who are disenrolled because they have moved out of a

health plan's Service Area, Insureds whose continuation of coverage periods

have expired, former dependents who no longer qualify as dependents, or Insureds

who lose coverage under an employer-sponsored plan because they have ceased

employment or because their employer group has cancelled coverage under the

plan, reduced the numbers of hours worked, become disabled, retired or died.

2. For the purposes of 211 CMR 52.13(3)(i), the term "involuntary disenrollment"

means that a Carrier has terminated the coverage of the Insured due to any of

the reasons contained in 211 CMR 52.13(3)(j)2. and 3.

j) The requirement that an Insured's coverage may be canceled, or its renewal refused

may arise only in the circumstances listed in 211 CMR 52.13(3)(j)1. through 5. 211 CMR

52.13(3)(j) shall apply to Carriers, including Dental and Vision Carriers.

1. failure by the insured or other responsible party to make payments required under

the contract;

2. m

isrepresentation or fraud on the part of the Insured;

3. commission of acts of physical or verbal abuse by the Insured which pose a threat

to Providers or other Insureds of the Carrier and which are unrelated to the

physical or mental condition of the Insured; provided, that the Commissioner

prescribes or approves the procedures for the implementation of the provisions of

211 CMR 52.13(3)(i)3.;

4. relocation of the Insured outside the service area of the carrier; or

5. non-renewal or cancellation of the group contract through which the Insured

receives coverage;

k) A description of the Carrier's, including a Dental or Vision Carrier's, method for

Managed Care: Health Maintenance Organization (Rev. 103017) Page 22

Pg#_____

resolving Insured Inquiries and Complaints. For a Health Benefit Plan, this description

shall include a description of the internal Grievance process and the external review

process consistent with 958 CMR 3.000: Health Insurance Consumer Protection,

including a description of the process for seeking expedited internal review and

concurrent expedited internal and external reviews pursuant to 958 CMR 3.000;

l) A statement telling Insureds how to obtain the report regarding Grievances pursuant to

958 CMR 3.600(1)(d) from the Office of Patient Protection;

m) A description of the Office of Patient Protection, including its toll-free telephone

number, facsimile number, and Internet Website;

n) A summary description of the procedure, if any, for out-of-Network referrals and any

additional charge for utilizing out-of-network Providers. 211 CMR 52.13(3)(n) shall

apply to Carriers, including Dental and Vision Carriers;

o) A summary description of the Utilization Review procedures and quality assurance

programs used by the Carrier, including a Dental or Vision Carrier, including the toll-

free telephone number to be established by the Carrier that enables consumers to

determine the status or outcome of Utilization Review decisions;

p) A statement detailing what translator and interpretation services are available to assist

Insureds, including that the Carrier will provide, upon request, interpreter and

translation services related to administrative procedures. The statement must appear in

at least the languages identified by the Centers for Medicare & Medicaid Services as

the top non- English languages in Massachusetts, 211 CMR 52.13(3)(p) shall

apply to Carriers, including Dental and Vision Carriers.

q) A list of prescription drugs excluded from any closed or restricted formulary available to

Insureds under the Health Benefit Plan; provided, that the Carrier shall annually disclose

any changes in such a formulary, and shall provide a toll-free telephone number to

enable consumers to determine whether a particular drug is included in the closed or

restricted formulary. A Carrier will be deemed to have met the requirements of 211

CMR 52.13(3)(q) if the Carrier does all of the following:

1. provides a complete list of prescription drugs that are included in any closed or

restricted formulary;

2. clearly states that all other prescription drugs are excluded;

3. provides a toll-free number that is updated within 48 hours of any change in the

closed or restricted formulary to enable Insureds to determine whether a particular

drug is included in or excluded from the closed or restricted formulary;

4. provide

s an Internet Website that is updated as soon as practicable relative to any

change in the closed or restricted formulary to enable Insureds to determine

whether a particular drug is included in or excluded from the closed or restricted

formulary; and

5. clearly states that there shall be no financial penalty for a patient's choice to receive

a lesser quantity of any opioid contained in schedule II or III of M.G.L. c. 94C, § 3,

and lists each of such schedule II or III drugs.

r) A summary description of the procedures followed by the Carrier in making decisions

about the experimental or investigational nature of individual drugs, medical devices

or treatments in clinical trials;

s) Requirements for continuation of coverage mandated by state and federal law;

t) A description of coordination of Benefits consistent with 211 CMR 38.00: Coordination

of Benefits (COB);

u) A description of coverage for emergency care and a statement that Insureds have the

opportunity to obtain Health Care Services for an Emergency Medical Condition,

Managed Care: Health Maintenance Organization (Rev. 103017) Page 23

Pg#_____

including the option of calling the local pre-hospital emergency medical service

system, whenever the Insured is confronted with an Emergency Medical Condition

which in the judgment of a prudent layperson would require pre-hospital emergency

services;

v) If the Carrier offers services through a Network or through Participating Providers, the

following statements regarding continued treatment:

1. If the Carrier allows or requires the designation of a Primary Care Provider, a

statement that the Carrier will notify an Insured at least 30 Days before the

disenrollment of such Insured's Primary Care Provider and shall permit such

Insured to continue to be covered for Health Services, consistent with the terms

of the Evidence of Coverage, by such Primary Care Provider for at least 30 Days

after said Provider is disenrolled, other than disenrollment for quality related

reasons or for fraud. The statement shall also include a description of the

procedure for choosing an alternative Primary Care Provider.

2. A statement that the Carrier will allow any female Insured who is in her second or

third trimester of pregnancy and whose Provider in connection with her

pregnancy is involuntarily disenrolled, other than disenrollment for quality-

related reasons or for fraud, to continue treatment with said Provider,

consistent with the terms of the Evidence of Coverage, for the period up to and

including the Insured's first postpartum visit.

3. A statement that the Carrier will allow any Insured who is Terminally Ill and whose

Provider in connection with said illness is involuntarily disenrolled, other than

disenrollment for quality related reasons or for fraud, to continue treatment with

said Provider, consistent with the terms of the Evidence of Coverage, until the

Insured's death.

4. A statement that the Carrier will provide coverage for Health Services for up to 30

Days from the effective date of coverage to a new Insured by a Provider who is

not a Participating Provider in the Carrier's Network if:

a. the Insured's employer only offers the Insured a choice of Carriers in which

said Provider is not a Participating Provider; and

b. said Provider is providing the Insured with an ongoing course of treatment

or is the Insured's Primary Care Provider; and

c. With respect to an Insured in her second or third trimester of

pregnancy, 211 CMR 52.13(3)(v)4. shall apply to services rendered

through the first postpartum visit. With respect to an Insured with a

Terminal Illness, 211 CMR 52.13(3)(v)4. shall apply to services rendered

until death;

5. A Carrier may condition coverage of continued treatment by a Provider under

211 CMR 52.13(3)(v)1. through 4. upon the Provider's agreeing as follows:

a. to accept reimbursement from the Carrier at the rates applicable prior to

notice of disenrollment as payment in full and not to impose Cost Sharing

with respect to the Insured in an amount that would exceed the Cost

Sharing that could have been imposed if the Provider had not been

disenrolled;

b. to adhere to the quality assurance standards of the Carrier and to provide

the Carrier with necessary medical information related to the care provided;

and

c. to adhere to the Carrier's policies and procedures, including

procedures regarding referrals, obtaining prior authorization and providing

Managed Care: Health Maintenance Organization (Rev. 103017) Page 24

Pg#_____

services pursuant to a treatment plan, if any, approved by the Carrier;

6. Nothing in 211 CMR 52.13(3)(v) shall be construed to require the coverage of

Benefits that would not have been covered if the Provider involved remained

a Participating Provider;

w) If a Carrier requires an Insured to designate a Primary Care Provider, a statement that the

Carrier will allow the Primary Care Provider to authorize a standing referral for

specialty health care provided by a Health Care Provider participating in the

Carrier's Network when:

1. the Primary Care Provider determines that such referrals are appropriate;

2. the Provider of specialty health care agrees to a treatment plan for the Insured and

provides the Primary Care Provider with all necessary clinical and

administrative information on a regular basis; and

3. the Health Care Services to be provided are consistent with the terms of the

Evidence of Coverage.

Nothing in 211 CMR 52.13(3)(w) shall be construed to permit a Provider of specialty

health care who is the subject of a referral to authorize any further referral of an Insured

to any other Provider without the approval of the Insured's Carrier;

x) If a Carrier requires an Insured to obtain referrals or prior authorization from a Primary

Care Provider for specialty care, a statement that the Carrier will not require an Insured

to obtain a referral or prior authorization from a Primary Care Provider for the

following specialty care provided by an obstetrician, gynecologist, certified nurse

midwife or family practitioner participating in such Carrier's Health Care Provider

Network and that the Carrier will not require higher copayments, coinsurance,

deductibles or additional Cost-Sharing features for such services provided to such

Insureds in the absence of a referral from a Primary Care Provider:

1. annual preventive gynecologic health examinations, including any subsequent

obstetric or gynecological services determined by such obstetrician,

gynecologist, certified nurse midwife or family practitioner to be Medically

Necessary as a result of such examination;

2. maternity care; and

3. medically necessary evaluations and resultant Health Care Services for acute or

emergency gynecological conditions.

Carriers may establish reasonable requirements for participating obstetricians,

gynecologists, certified nurse midwives or family practitioners to communicate

with an Insured's Primary Care Provider regarding the Insured's condition,

treatment, and need for follow-up care; and nothing in 211 CMR 52.13(3)(x)

shall be construed to permit an obstetrician, gynecologist, certified nurse

midwife or family practitioner to authorize any further referral of an Insured to

any other Provider without the approval of the Insured's Carrier;

y) A statement that the Carrier will provide coverage of pediatric specialty care, including,

for the purposes of 211 CMR 52.13(3)(y), mental health care, by persons with

recognized expertise in specialty pediatrics to Insureds requiring such services.

z) If a Carrier allows or requires an Insured to designate a Primary Care Provider, a

statement that the Carrier shall provide the Insured with an opportunity to select a

Participating Provider Nurse Practitioner or a Participating Provider Physician Assistant

as a Primary Care Provider or to change his or her Primary Care Provider to a

Participating Provider Nurse Practitioner or a Participating Provider Physician

Assistant at any time during the Insured's coverage period.

(aa) Evidence that the Carrier will provide coverage on a nondiscriminatory basis for

Managed Care: Health Maintenance Organization (Rev. 103017) Page 25

Pg#_____

covered services when delivered or arranged for by a Participating Provider Nurse

Practitioner or a Participating Provider Physician Assistant. For the purposes of 211 CMR

52.13(3)(aa), nondiscriminatory basis shall mean that a Carrier's plan does not contain

any annual or lifetime dollar or unit of service limitation imposed on coverage for the

care provided by a Participating Provider Nurse Practitioner or Participating Provider

Physician Assistant which is less than any annual or lifetime dollar or unit of

service limitation imposed on coverage for the same services by other Participating

Providers, in accordance with M.G.L. c. 176R, § 16(1) and c. 176S, § 1;

(bb) A statement that the Carrier shall be required to pay for Health Care Services ordered by

a treating physician or a Primary Care Provider if the Health Services are a Covered

Benefit under the Insured's Health Benefit Plan and the Health Services are

Medically Necessary.

REQUIRED DISCLOSURES - For Carriers and Behavioral Health Managers

Pg#_____

211 CMR 51.14(1):

A Carrier shall provide to at least one adult Insured in each household upon enrollment,

and to a prospective Insured upon request, the following information:

(a) a statement that physician profiling information, so-called, may be available from the

Board of Registration in Medicine for physicians licensed to practice in

Massachusetts;

(b) a summary description of the process by which clinical guidelines and Utilization

Review criteria are developed;

1. For the purposes of 211 CMR 52.14(1)(c), Carriers shall exclude all

Administrative Disenrollments, Insureds who are disenrolled because they

have moved out of a health plan's Service Area, Insureds whose continuation

of coverage periods have expired, former dependents who no longer qualify

as dependents, or Insureds who lose coverage under an employer-sponsored

plan because they have ceased employment or because their employer group

has cancelled coverage under the plan, reduced the numbers of hours worked,

retired or died.

2. For the purposes of 211 CMR 52.14(1)(c), the term "voluntary disenrollment"

means that an Insured has terminated coverage with the Carrier by

nonpayment of premium.

3. For the purposes of 211 CMR 52.14(1)(c), the term "involuntary

disenrollment" means that a Carrier has terminated the coverage of the

Insured due to any of the reasons contained in 211 CMR 52.13(3)(j)2. and 3.

(d) a notice to Insureds regarding Emergency Medical Conditions that states all of the

following:

1. that Insureds have the opportunity to obtain Health Care Services for an

Emergency Medical Condition, including the option of calling the local pre-

hospital emergency medical service system by dialing the emergency

telephone access number 911, or its local equivalent, whenever the Insured is

confronted with an Emergency Medical Condition which in the judgment of a

prudent layperson would require pre-hospital emergency services.

2. that no Insured shall in any way be discouraged from using the local pre

hospital emergency medical service system, the 911 telephone number, or the

local equivalent;

3. that no Insured will be denied coverage for medical and transportation

Managed Care: Health Maintenance Organization (Rev. 103017) Page 26

Pg#_____

expenses incurred as a result of such Emergency Medical Condition; and

4. if the Carrier requires an Insured to contact either the Carrier or its designee

or the Primary Care Provider of the Insured within 48 hours of receiving

emergency services, that notification already given to the Carrier, designee or

Primary Care Provider by the attending emergency Provider shall satisfy that

requirement.

(e) a description of the Office of Patient Protection and a statement that the information

specified in 211 CMR 52.16 is available to the Insured or prospective Insured from the

Office of Patient Protection; and

(f) a statement:

1. that an Insured has the right to request referral assistance from a Carrier if the

Insured or the Insured's Primary Care Provider has difficulty identifying

Medically Necessary services within the Carrier's Network;

2. that the Carrier, upon request by the Insured, shall identify and confirm the

availability of these services directly; and

3. that the Carrier, if necessary, shall obtain or arrange for Out-of-network

services if they are unavailable within the Network.

211 CMR 52.14(2):

The information required of Carriers by 211 CMR 52.14(1)(a) through (f) may be

contained in the Evidence of Coverage and need not be provided in a separate document.

211 CMR 52.14(3):

Every disclosure required of Carriers and described in 211 CMR 52.14(1)(a) through (f)

must contain the effective date, date of issue and, if applicable, expiration date.

211 CMR 52.14(4):

A Carrier must maintain a toll-free telephone number and website available to Insureds to

present Provider cost information to Insureds that meets the following requirements:

(a) the Insured may request and obtain the following, in real time:

1. the estimated or maximum allowed amount or charge for a proposed admission,

procedure or service and

2. the estimated amount the Insured will be responsible to pay for a proposed

admission, procedure or service that is a Medically Necessary Covered Benefit, based

on the information available to the Carrier at the time the request is made, including any

facility fee, copayment, deductible, coinsurance or other Cost-sharing requirements for

any Covered Benefits;

(b) notwithstanding anything to the contrary in 211 CMR 52.14(4)(a), the Insured shall not be

required to pay more than the disclosed amounts for the Covered Benefits that were

actually provided;

requirements disclosed in the Insured's Evidence of Coverage for unforeseen services that

arise out of the proposed admission, procedure or service;

(d) the Carrier must alert the Insured that these are estimated costs, and that the actual amount

the Insured will be responsible to pay may vary due to unforeseen services that arise out

of the proposed admission, procedure or service.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 27

211 CMR 52.14(5):

To provide information to Insureds about the disposition of Provider claims submitted to the Carrier,

the Carrier shall issue to Insureds the summary of payments form, as authorized by the Commissioner,

and the form shall be issued to the individual Insured rather than to the subscriber, and the form may be

issued in paper or through an Internet Website, provided that a Carrier will issue the form by paper

upon request by the Insured.

Please confirm the carrier understands their responsibilities noted above.

________________________________________________________________________

211 CMR 52.14(6):

Carriers shall submit Material Changes to the disclosures required by 211 CMR 52.14 to the Bureau at

least 30 Days before their effective dates.

Please confirm the carrier understands their responsibilities noted above.

________________________________________________________________________

211 CMR 52.14(7):

Carriers shall submit Material Changes to the disclosures required by 211 CMR 52.14(1)(a) through (f)

to at least one adult Insured in every household residing in Massachusetts at least once every two years.

Please confirm the carrier understands their responsibilities noted above.

________________________________________________________________________

211 CMR 52.14(9):

A Carrier, including a Dental or Vision Carrier, shall provide to a health, Dental or Vision Care

Provider, a written reason or reasons for denying the application of any health, Dental, or Vision Care

Provider who has applied to be a Participating Provider.

Please confirm the carrier understands their responsibilities noted above.

________________________________________________________________________

Please advise whether your company contracts with a “behavioral health manager” in

administering behavioral health services.

YES____ NO___

If YES, please respond to the following:

Name of Behavioral Health Manager: _________________________________________________

Regulatory Contact Person and Title: _________________________________________________

Office Address: _________________________________________________

Telephone: ________________________

Facsimile: ________________________

Managed Care: Health Maintenance Organization (Rev. 103017) Page 28

211 CMR 52.14(10):

A Carrier for whom a Behavioral Health Manager is administering behavioral Health Services shall

state on its new enrollment cards issued in the normal course of business, within one year, the name and

telephone number of the Behavioral Health Manager.

FORWARD a sample ID Card that includes the name and telephone number of the Behavioral

Health Manager.

Pg#_____

211 CMR 52.14(11):

A Behavioral Health Manager (“BHM”) shall provide the following information to at least

one adult Insured in each household covered by their services:

(a) a notice to the Insured regarding emergency mental Health Services

that states:

1. that the Insured may obtain emergency mental Health Services, including the

option of calling the local pre-hospital emergency medical service system by dialing

the 911 emergency telephone number or its local equivalent, if the Insured has an

emergency mental health condition that would be judged by a prudent layperson to

require pre-hospital emergency services;

2. that no Insured shall be discouraged from using the local pre-hospital emergency

medical service system, the 911 emergency telephone number or its local

equivalent;

3. that no Insured shall be denied coverage for medical and transportation expenses

incurred as a result of such emergency mental health condition; and

4. if the Behavioral Health Manager requires an Insured to contact either the

Behavioral Health Manager, Carrier or Primary Care Provider of the Insured within

48 hours of receiving emergency services, notification already given to the

Behavioral Health Manager, Carrier or Primary Care Provider by the attending

emergency Provider shall satisfy that requirement;

(b) a summary of the process by which clinical guidelines and Utilization Review criteria

are developed for behavioral Health Services; and

description of the Grievance and review processes available to consumers, and

relevant contact information to access the Office of Patient Protection and these

processes.

Either (1) FORWARD a copy of the notice highlighting each item and where it may be located

within the notice or (2) similarly highlight the page(s) of the Evidence of Coverage that meet the

notice requirements.

211 CMR 52.14(12):

The information required of Behavioral Health Managers by 211 CMR 52.14(11) may be contained in

the Carrier's Evidence of Coverage and need not be provided in a separate document. Every disclosure

described in 211 CMR 52.14(11) shall contain the effective date, date of issue and, if applicable,

expiration date.

Provide a statement how the carrier provides the noted information.

___________________________________________________________________________________

Managed Care: Health Maintenance Organization (Rev. 103017) Page 29

211 CMR 52.14(13):

A Behavioral Health Manager shall submit a Material Change to the information required by 211 CMR

52.14(11) to the Bureau at least 30 Days before its effective date and to at least one adult Insured in

every household residing in the Commonwealth at least biennially.

Provide a statement to confirm that the carrier/BHM understands their responsibilities.

___________________________________________________________________________________

211 CMR 52.14(15):

A Carrier for whom a Behavioral Health Manager is administering behavioral Health Services shall be

responsible for the Behavioral Health Manager's failure to comply with the requirements of 211 CMR

52.00 in the same manner as if the Carrier failed to comply and shall be subject to the provisions of 211

CMR 52.17.

Provide a statement to confirm that the carrier understands their responsibilities.

___________________________________________________________________________________

DEPENDENT ELIGIBILITY

pg____

Federal Health Care Reform - Section 2714 of the PHSA/Section 1001 of the PPACA

Effective September 23, 2010, upon renewal, insurers are required to permit a subscriber to

include a child(ren) on a policy that has dependent coverage until age the child(ren) turns age 26.

This applies to all plans in the individual market, new employer plans, and existing employer

plans, unless the adult child has an offer of coverage through his or her employer.

pg____ Plant Closing According to M.G.L. c. 176G, § 4A, there is a 90-day eligibility for continued

coverage in the event of a plant closing or partial plant closing.

pg____

Divorce or Separation According to M.G.L. c. 176G, § 5A(a)-(b),

“(a) In the event of the granting of a judgment absolute of divorce or of separate support to

which a member of a group health maintenance contract is a party, the person who was the

spouse of said member prior to the issuance of such judgment shall be and remain eligible for

benefits under said contract, whether or not said judgment was entered prior to the effective date

of said contract, without additional premium or examination therefor, as if said judgment had not

been entered; provided, however, that such eligibility shall not be required if said judgment so

provides. Such eligibility shall continue through the member's participation in the contract until

the remarriage of either the member or such spouse, or until such time as provided by said

judgment, whichever is earlier.

(b) In the event of the remarriage of the member referred to in paragraph (a), the former spouse

thereafter shall have the right, if so provided in said judgment, to continue to receive benefits as

are available to the member, by means of the addition of a rider to the family contract or the

issuance of an individual contract, either of which may be at additional premium rates

determined by the commissioner of insurance to be just and reasonable in accordance with the

additional insuring risks involved.”

pg____ Small Group. There must be a provision for continuation of coverage for any individual,

general, blanket or group policy of health, accident and sickness insurance (excludes

supplements to Medicare or other governmental programs) if sold to an eligible small business

or group with between 2-19 employees and the provisions for continuation of coverage should

be in compliance with M.G.L. c. 176J, § 9.

pg____ Group Health Care Insurers. According to 940 CMR 9.04, it shall be considered an unfair

and deceptive act or practice in violation of M.G.L. c. 93A, § 2, for a carrier to deny a member’s

claim for covered health care services on the grounds that, prior to the date covered health care

Managed Care: Health Maintenance Organization (Rev. 103017) Page 30

services were received, the employer’s plan has been terminated for nonpayment of premiums,

unless the carrier has sent written notice of the termination to the member prior to the date the

covered health care services were received in the manner set forth in 940 CMR 9.05.

MANDATED BENEFITS

According to 211 CMR 52.13(3)(a), evidences of coverage shall contain a clear, concise and complete

statement of the health, dental or vision care services and any other benefits to which the insured is entitled on

a nondiscriminatory basis, including benefits mandated by state or federal law as follows:

Requirements for emergency services provided to members for emergency medical conditions

pg____ According to M.G.L. c. 176G, § 5(b), “[a] health maintenance organization shall cover

emergency services provided to members for emergency medical conditions. After the member

has been stabilized for discharge or transfer, the health maintenance organization or its designee

may require a hospital emergency department to contact the physician on-call designated by the

health maintenance organization or its designee for authorization of post-stabilization services to

be provided. The hospital emergency department shall take all reasonable steps to initiate

contact with the health maintenance organization or its designee within 30 minutes of

stabilization. Such authorization shall be deemed granted if the health maintenance organization

or its designee has not responded to said call within 30 minutes…in the event the attending

physician and said on-call physician do not agree on what constitutes appropriate medical

treatment, the opinion of the attending physician shall prevail and such treatment shall be

considered appropriate treatment for an emergency medical condition provided that such

treatment is consistent with generally accepted principles of professional medical practice and a

covered benefit under the member's evidence of coverage.” (See also Bulletin No. 00-14)

pg____ According to M.G.L. c. 176G, § 5(c), “[a] health maintenance organization may require a

member to contact either the health maintenance organization or its designee or the primary care

provider of the member within 48 hours of receiving such emergency services, but notification

already given to the health maintenance organization or to said primary care provider by the

attending physician shall satisfy the requirements of this paragraph.”

pg____ According to M.G.L. c. 176G, § 5(e), “[a] health maintenance organization shall clearly state in

its brochures, contracts, policy manuals and printed materials that members shall have the option

of calling the local pre-hospital emergency medical service system by dialing the emergency

telephone access number 911, or its local equivalent, whenever an enrollee is confronted with an

emergency medical condition which in the judgment of a prudent layperson would require pre-

hospital emergency services. No member shall in any way be discouraged from using the local

pre-hospital emergency medical service system, the 911 telephone number, or the local

equivalent, or be denied coverage for medical and transportation expenses incurred as a result of

an emergency medical condition.”

Mental Health Parity

According to M.G.L. c. 176G, § 4M(a), “[a]A health maintenance contract issued or renewed within

or without the commonwealth shall provide mental health benefits on a nondiscriminatory basis to

residents of the commonwealth and to all members or enrollees having a principal place of

employment in the commonwealth for the diagnosis and treatment of the following biologically-

based mental disorders, as described in the most recent edition of the Diagnostic and Statistical

Manual of Mental Disorders published by the American Psychiatric Association, referred to in this

section as the

DSM:

(1) schizophrenia; (7) panic disorder;

(2) schizoaffective disorder; (8) delirium and dementia;

(3) major depressive disorder; (9) affective disorders;

Managed Care: Health Maintenance Organization (Rev. 103017) Page 31

(4) bipolar disorder; (10) eating disorders;

(5) paranoia and other psychotic disorders; (11) post traumatic stress disorder;

(6) obsessive-compulsive disorder; (12) substance abuse disorders; and

(13) autism

A health maintenance contract issued or renewed within or without the commonwealth shall

provide mental health benefits on a nondiscriminatory basis to residents of the commonwealth

and to all members or enrollees having a principal place of employment in the commonwealth

for the diagnosis and medically necessary and active treatment of any mental disorder, as

described in the most recent edition of the DSM, that is approved by the commissioner of mental

health.

pg____

Rape-Related Mental or Emotional Disorders. According to M.G.L. c. 176G, § 4M(b), “any

such health maintenance contract shall also provide benefits on a non-discriminatory basis for

the diagnosis and treatment of rape-related mental or emotional disorders to victims of a rape or

victims of an assault with intent to commit rape, as defined by sections 22 and 24 of chapter 265

[of the Massachusetts General Laws], whenever the costs of such diagnosis and treatment

exceed the maximum compensation awarded to such victims pursuant to subparagraph (C) of

paragraph (2) of subsection (b) of section 3 of M.G.L. c. 258C.”

pg____

Children and Adolescents under the age of 19. According to M.G.L. c. 176G, § 4M(c), “any

such health maintenance contract shall also provide benefits on a non-discriminatory basis to

children and adolescents under the age of 19 for the diagnosis and treatment of non-biologically-

based mental, behavioral or emotional disorders, as described in the most recent edition of the

DSM, which substantially interfere with or substantially limit the functioning and social

interactions of such a child or adolescent; provided, that said interference or limitation is

documented by and the referral for said diagnosis and treatment is made by the primary care

provider, primary pediatrician or a licensed mental health professional of such a child or

adolescent or is evidenced by conduct, including, but not limited to:

(1) an inability to attend school as a result of such a disorder,

(2) the need to hospitalize the child or adolescent as a result of such a disorder,

(3) a pattern of conduct or behavior caused by such a disorder which poses a serious danger to

self or others.

The health maintenance organization shall continue to provide such benefits to any adolescent

who is engaged in an ongoing course of treatment beyond the adolescent's nineteenth birthday

until said course of treatment, as specified in said adolescent's treatment plan, is completed and

while the benefit contract under which such benefits first became available remains in effect, or

subject to a subsequent benefits contract which is in effect.”

Nondiscriminatory basis - means that copayments, coinsurance, deductibles, unit of service

limits (e.g., hospital days, outpatient visits), and/or annual or lifetime maximums are not greater

for mental disorders than those required for physical conditions, and office visit copayments are

not greater than those required for primary care visits. [refer to Bulletin 2009-04]

Please confirm that all plan designs conform to the above-note Nondiscriminatory

requirement.

pg____

All Other Mental Disorders. According to M.G.L. c. 176G, § 4M(e), “[a]ny such health

maintenance contract shall also provide benefits for the diagnosis and treatment of all other

mental disorders not otherwise provided for in this section and which are described in the most

Managed Care: Health Maintenance Organization (Rev. 103017) Page 32

recent edition of the DSM

“… health insurance coverage offered by an issuer … that provides both medical/surgical and

mental health/substance use disorder benefits may not apply any financial requirement or

treatment limitation to mental health/substance use disorder benefits … that is more restrictive

than the predominant financial requirement or treatment limitation of that type applied to

substantially all medical/surgical benefits in the same classification.” 45 CFR 146.136 (c) (2)

Carriers may continue, however, to review the medical necessity of treatments and coordinate

care in the least restrictive, clinically appropriate setting, provided that the reviews are consistent

with state and federal requirements.

pg____

Psychopharmacological Services and Neuropsychological Assessment Services. According

to M.G.L. c. 176G, § 4M(i), “psychopharmacological services and neuropsychological

assessment services shall be treated as a medical benefit and shall be covered in a manner

identical to all other medical services.”

pg____

LICENSED MENTAL HEALTH PROFESSIONALS

[M.G.L. c. 175, § 47B(i) (or M.G.L. c. 176A, § 8A(i) or M.G.L. c. 176B, § 4A(i)) -]

physician who specializes in the practice of psychiatry;

psychologist;

independent clinical social worker;

mental health counselor;

nurse mental health clinical specialist;

a licensed alcohol and drug counselor I or

marriage and family therapist within the lawful scope of practice for such therapist.

pg____

Where Services may be Provided. According to M.G.L. c. 176G, § 4M(g), “[b]enefits authorized

pursuant to this section shall consist of a range of inpatient, intermediate, and outpatient services that

shall permit medically necessary and active and noncustodial treatment for said mental disorders to

take place in the least restrictive clinically appropriate setting. For purposes of this section:

INPATIENT SERVICES

“[m]ay be provided in

a general hospital licensed to provide such services,

in a facility under the direction and supervision of the department of mental health,

in a private mental hospital licensed by the department of mental health, or

in a substance abuse facility licensed by the department of public health.”

pg____

INTERMEDIATE SERVICES

As stated in Bulletin No. 09-11, please include a provision that clearly notes the following: -

“Intermediate Services” - “[a] range of non-inpatient services that provide more intensive and

extensive treatment interventions when outpatient services alone are not sufficient to meet the

patient’s needs. Intermediate Services, include, but are not limited to, the following:

Acute and other residential treatment;

Partial hospitalization;

Day treatment;

In-home therapy services;

Clinically managed detoxification services;

Intensive Outpatient Programs (IOP); and

Crisis stabilization.

Level of Benefits for Intermediate Care Services

The duration of intermediate care services authorized for any particular individual will vary

Managed Care: Health Maintenance Organization (Rev. 103017) Page 33

according to that person’s individual needs. Because Chapter 80 of the Acts of 2000 and Chapter

256 of the Acts of 2008 do not specify a minimum benefit for intermediate care, authorizations for

intermediate care should be based on medical necessity rather than any arbitrary number of days or

number of visits..

Please confirm that the carrier complies with this requirement and highlight the page number

where the carrier includes a provision that clearly states this information.

_____________________________________________________________________________

pg____

OUTPATIENT SERVICES

“[m]ay be provided in:

a licensed hospital,

a mental health or substance abuse clinic licensed by the department of public health,

a public community mental health center,

a professional office, or

home-based services, provided, however, services delivered in such offices or settings are rendered

by a licensed mental health professional acting within the scope of his license.”

(See also Bulletin No. 03-11)”

Disclosure. According to M.G.L. c. 176G, § 4M(h), “[n]o health maintenance organization shall require as

a condition to receiving benefits mandated by this section consent to the disclosure of information

regarding services for mental disorders under different terms and conditions than consent is required for

disclosure of information for other medical conditions. A determination by a health maintenance

organization that services authorized pursuant to this section are not medically necessary shall only be

made by a licensed mental health professional; provided, that this provision shall not be construed as

applying to denials of service resulting from an insured's lack of insurance coverage or use of a facility or

professional which has not entered into a negotiated agreement with the health maintenance organization.

The benefits provided in any health maintenance contract pursuant to this section shall meet all other terms

and conditions of the health maintenance contract not inconsistent with this section.”

Please confirm that the carrier complies with this requirement.

Access to Services to Treat Substance Use Disorders

[refer to [Bulletin 2015-05; Access to Services to Treat Substance Use Disorders; Issued July 31, 2015]

Access to Acute Treatment Services and Clinical Stabilization Services

pg____

Chapter 258 requires insured health plans

[1]

offered under M.G.L. chapters 175, 176A, 176B,

and 176G (hereinafter referred to as an insured health plan) that are issued, delivered or

renewed within the commonwealth and considered creditable coverage under section 1 of

chapter 111M to provide coverage for medically necessary acute treatment services and

medically necessary clinical stabilization services for at least 14 consecutive days. Medical

necessity is to be determined by the treating clinician in consultation with the patient.

Insured health plans shall cover and shall not require preauthorization for the 14-day period

of medically necessary acute treatment and clinical stabilization services (American Society

of Addiction Medicine Levels 4, 3.7 and 3.5) for an insured obtaining acute treatment

services or clinical stabilization services; as long as the facility providing the noted services

provides the carrier with appropriate notification of the admission within 48 hours of

admission. Carriers shall not require that any facility provide notification beyond the name

of the patient, information regarding the patient’s coverage with the carrier’s plan and the

initial treatment plan that has been developed for the patient.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 34

pg____

Carriers may initiate utilization review procedures on the 7

day of a patient’s stay for acute

treatment services or the 7

day of a patient’s stay for clinical stabilization services,

including but not limited to discussions about coordination of care and discussions of

treatment plans, but a carrier may not make any utilization review decisions that impose any

restriction or deny any future medically necessary acute treatment or clinical stabilization

services unless a patient has received at least 14 consecutive days of acute treatment and/or

clinical stabilization services. Any such decisions must follow the requirements of M.G.L. c.

176O regarding the transmission of adverse determination notifications to patients and

clinicians and processes for internal and external appeals of carrier decisions.

For plans that provide or arrange for the delivery of care through a closed network of health

care providers, acute treatment service and clinical stabilization services delivered by

providers who are not part of an insured health plan’s closed network of providers are subject

to prior authorization procedures unless the health plan’s provider network is found to be

inadequate to provide access to acute treatment or clinical stabilization services for plan

members.

Preauthorization Protocols for All Other Substance Use Disorder Services

Insured health plans issued, delivered or renewed within the Commonwealth, which are

considered creditable coverage under section 1 of chapter 111M, shall not require a member

or treating clinician to obtain a preauthorization for covered substance use disorder treatment

services if the provider is certified or licensed by the Department of Public Health (DPH).

Substance use disorder treatment services include early intervention services for substance

use disorder treatment, outpatient services, including medically assisted therapies, intensive

outpatient and partial hospitalization services, residential or inpatient services, and medically

intensive inpatient services. The term provider includes facilities as well as individual

practitioners certified or licensed by the DPH.

If a service is not covered by an insured health plan, a carrier should take all appropriate

steps to notify relevant contracting providers and identify that a substance use disorder

service is not covered within the insured health plan’s benefits.

Identify the system that the carrier has in place to comply with the above.

__________________________________________________________________________

Managed Care: Health Maintenance Organization (Rev. 103017) Page 35

Treatment of Autism Spectrum Disorders (ASD)

According to M.G.L. c. 176G §4V fully insured health plans issued or renewed by health

insurance carriers on and after January 1, 2011 must provide benefits for the diagnosis and

treatment of ASD on a nondiscriminatory basis to all residents of Massachusetts and to all

insureds having a principal place of employment in Massachusetts.

pg____

ASD includes any of the pervasive developmental disorders, as defined by the most recent

edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder,

Asperger’s disorder and pervasive developmental disorders not otherwise specified.

pg____

Diagnosis includes medically necessary assessments, evaluations including neuropsychological

evaluations, genetic testing or other tests to diagnose whether an individual has an ASD.

pg____

There may be no annual or lifetime dollar or unit of service limitations on coverage for the

diagnosis and treatment of ASD that is less than the annual or lifetime dollar or unit of service

limitation imposed on coverage for the diagnosis and treatment of physical conditions.

pg____

There may not be limits on the number of visits a covered individual may make to an autism

services provider.

pg____

There shall not be limits to benefits for the diagnosis and treatment of ASD that are otherwise

available to an individual under the health plan.

pg____

Treatment includes the following medically necessary care prescribed, provided or ordered for

an individual diagnosed with an ASD by a licensed physician or a licensed psychologist:

pg____

Habilitative or Rehabilitative Care: Professional, counseling and guidance services and

treatment programs, including, but not limited to, applied behavioral analysis supervised by a

board certified behavior analyst, that are necessary to develop, maintain and restore, to the

maximum extent practicable, the functioning of an individual. Applied behavior analysis

includes the design, implementation and evaluation of environmental modifications, using

behavioral stimuli and consequences, to produce socially significant improvement in human

behavior, including in the use of direct observation, measurement and functional analysis of the

relationship between environment and behavior.

pg____

Pharmacy Care: Medications prescribed by a licensed physician and health-related services

deemed medically necessary to determine the need or effectiveness of the medications, to the

same extent that pharmacy care is provided by the health plan for other medical conditions.

pg____

Psychiatric Care: Direct or consultative services provided by a psychiatrist licensed in the state

in which the psychiatrist practices.

pg____

Psychological Care: Direct or consultative services provided by a psychologist licensed in the

state in which the psychologist practices.

pg____

Therapeutic Care: Services provided by licensed or certified speech therapists, occupational

therapists, physical therapists or social workers.

INCLUDE THE FOLLOWING DEFINED TERMS

Applied behavior analysis: the design, implementation and evaluation of environmental modifications,

using behavioral stimuli and consequences, to produce socially significant improvement in human

behavior, including the use of direct observation, measurement and functional analysis of the relationship

between environment and behavior.

Autism services provider: a person, entity or group that provides treatment of autism spectrum disorders.

Autism spectrum disorders: any of the pervasive developmental disorders as defined by the most recent

edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder,

Asperger’s disorder and pervasive developmental disorders not otherwise specified.

Board certified behavior analyst: a behavior analyst credentialed by the behavior analyst certification

board as a board certified behavior analyst.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 36

Diagnosis of autism spectrum disorders: medically necessary assessments, evaluations including

neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has 1 of the

autism spectrum disorders.

Treatment of autism spectrum disorders: includes the following care prescribed, provided or ordered for

n individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed

psychologist who determines the care to be medically necessary: habilitative or rehabilitative care;

pharmacy care; psychiatric care; psychological care; and therapeutic care.

pg____

Autism Services Providers/Networks - [refer to Bulletin 2010-15]

An autism services provider is a person, entity or group that provides treatment of ASD. This

includes:

board certified behavior analysts,

psychiatrists, psychologists,

licensed or certified speech therapists,

occupational therapists,

physical therapists, and social workers and pharmacies.

Such providers shall work with populations and in areas within the boundaries of their competence, based

on their education, training, supervised experience, consultation, study, or professional experience. A

carrier that provides benefits through a network(s) or has contracts with participating providers must

provide an adequate network of available ASD providers. Each network must, at a minimum, include

board certified behavior analysts who have been credentialed by the Behavior Analyst Certification

Board. The network must provide adequate access to all mandated ASD services, including, but not

limited to, applied behavior analysis. The network must include sufficient numbers of providers to

provide access to all medically necessary habilitative and rehabilitative services for ASD. In the event

that a carrier’s network does not provide adequate access to ASD providers at any time and such services

are unavailable within the network, the carrier must obtain or arrange for out-of-network services as

needed.

Please confirm that the carrier conforms to the above-note requirement.

pg____

Access/Provider Directory

If any covered autism services provider is not available in a network, information on the way to

obtain or arrange for out-of-network services must be provided in a clear and understandable

manner. [Bulletin 2010-15]

1. Certify that all covered autism services provider are available in the carrier’s network,

2. Identify the way a member may obtain or arrange for out-of-network services in a

clear and understandable manner both in the evidence of coverage and provider

directory; and

3. Forward a copy of the information forwarded to members regarding access to out-of-

network autism service providers.

Preventive and Primary Care Services for Children

pg____

Dependent Definition. According to M.G.L. c. 176G, § 4, a dependent includes

 newborn infants and newborn infants of a dependent of a policyholder domiciled in the

commonwealth

 immediately from the moment of birth and thereafter

Managed Care: Health Maintenance Organization (Rev. 103017) Page 37

pg____

 [and] adoptive children of a policyholder domiciled in the commonwealth . . .

immediately from the date of the filing of a petition to adopt . . . and thereafter if the

child has been residing in the home of the policyholder . . .

 as a foster child for whom the holder…has been receiving foster care payments, or,

 in all other cases, immediately from the date of placement by a licensed placement

agency of the child for purposes of adoption in the home of a policyholder . . . and

thereafter.”

 if payment of a specific premium is required to provide coverage for a child, the policy

or contract may require that notification of birth of a newly born child or of filing of a

petition to adopt a foster child or of placement of a child for purposes of adoption and

payment of the required premium must be furnished to the insurer or indemnity

corporation. For the purposes of this section "notification'' may mean submission of a

claim.”

pg____

According to M.G.L. c. 176G, § 4 “[t]he coverage for newly born infants and adoptive children

shall consist of coverage of injury or sickness including the necessary care and treatment of

medically diagnosed congenital defects and birth abnormalities, or premature birth.”

According to M.G.L. c. 176G, § 4 “[s]uch coverage [for newly born infants and adoptive

children] shall also include those special medical formulas which are approved by the

commissioner of the department of public health, prescribed by a physician, and are medically

necessary for treatment of phenylketonuria, tyrosinemia, homocystinuria, maple syrup urine

disease, propionic acidemia, or methylmalonic acidemia in infants and children or medically

necessary to protect the unborn fetuses of pregnant women with phenylketonuria.”

According to M.G.L. c. 176G, § 4 “[s]uch coverage [for newly born infants and adoptive

children] shall also include screening for lead poisoning as required by the regulations

promulgated pursuant to section one hundred and ninety-three of chapter one hundred and

eleven [of the Massachusetts General Laws; 958 CMR 3.000].”

According to M.G.L. c. 176G, § 4, policies must include coverage for the following services to

the dependent child of an insured member from the date of birth through the attainment of six (6)

years of age:

“physical examination, history, measurements, sensory screening, neuropsychiatric

evaluation and development screening, and assessment at the following intervals: six (6)

times during the child's first year after birth, three (3) times during the next year,

annually until age six.”

“Such services shall also include hereditary and metabolic screening at birth, appropriate

immunizations, and tuberculin tests, hematrocrit, hemoglobin or other appropriate blood

tests, and urinalysis as recommended by the physician.”

According to M.G.L. c. 176G, § 4, policies shall provide “coverage for the cost of a newborn

hearing screening test to be performed before the newborn infant is discharged from the hospital

or birthing center to the care of the parent or guardian or as provided by regulations of the

department of public health.” (See also Bulletin No. 98-13)

Managed Care: Health Maintenance Organization (Rev. 103017) Page 38

Preventive health services 45 CFR§147.130

pg____

A group health plan, or a health insurance issuer offering group or individual health insurance

coverage, must provide coverage for all of the following items and services, and may not impose

any cost-sharing requirements (such as a copayment, coinsurance, or a deductible) with

respect to those items and services:

(i) Evidence-based items or services that have in effect a rating of A or B in the current

recommendations of the United States Preventive Services Task Force with respect to the

individual involved (except as otherwise provided in paragraph (c) of this section);

(ii) Immunizations for routine use in children, adolescents, and adults that have in effect a

recommendation from the Advisory Committee on Immunization Practices of the Centers for

Disease Control and Prevention with respect to the individual involved (for this purpose, a

recommendation from the Advisory Committee on Immunization Practices of the Centers for

Disease Control and Prevention is considered in effect after it has been adopted by the Director

of the Centers for Disease Control and Prevention, and a recommendation is considered to be for

routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and

Prevention);

(iii) With respect to infants, children, and adolescents, evidence-informed preventive care and

screenings provided for in comprehensive guidelines supported by the Health Resources and

Services Administration.

Early Intervention

pg____

According to M.G.L. c. 176G §4, “[t]he dependent coverage of any such policy shall also

provide coverage for medically necessary early intervention services delivered by certified early

intervention specialists, as defined in the early intervention operational standards by the

department of public health and in accordance with applicable certification requirements. Such

medically necessary services shall be provided by early intervention specialists who are working

in early intervention programs certified by the department of public health, as provided in

sections 1 and 2 of chapter 111G, for children from birth until their third birthday.

Reimbursement of costs for such services shall be part of a basic benefits package offered by the

insurer or a third party and shall not require co-payments, coinsurance or deductibles; provided,

however, that co-payments, coinsurance or deductibles shall be required if the applicable plan is

governed by the Federal Internal Revenue Code and would lose its tax-exempt status as a result

of the prohibition on co-payments, coinsurance or deductibles for these services.

Identify the page number(s) specifically noting that the plan does not include any maximum

benefit for early intervention services [see Section 86 of Chapter 27 of the Acts of 2009 and

Bulletin 2009-08] nor require co-payments, coinsurance or deductibles [Section 97 of Chapter

131 of the Acts of 2010 and Section 20 of Chapter 409 of the Acts of 2010.

Hearing Aids For Children

(Except a policy which provides supplemental coverage to Medicare or other governmental programs)

pg____ According to M.G.L. c. 176G, § 4N , policies shall provide “[c]overage for any child, 21 years

of age or younger…for the cost of 1 hearing aid per hearing impaired ear up to $2,000 for each

hearing aid…every 36 months upon a written statement from the child’s treating physician that

the hearing aids are necessary regardless of etiology. Coverage under this section shall include

Managed Care: Health Maintenance Organization (Rev. 103017) Page 39

all related services prescribed by a licensed audiologist or hearing instrument

specialist…including the initial hearing aid evaluation, fitting and adjustments and supplies,

including ear molds. The insured may choose a higher priced hearing aid and may pay the

difference in cost above the $2,000 limit in this section without any financial or contractual

penalty to the insured or to the provider of the hearing aid. The benefits in this section shall not

be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any

other benefits provided by the insurer.

[Section 5 of Chapter 233 of the Acts of 2012 (the “Act”); this act shall apply to all policies,

contracts and certificates which are delivered, issued or renewed on or after January 1,

2013]

Treatment for Cleft Lip and Cleft Palate

pg____ According to M.G.L. c. 176G, § 4W (or M.G.L. c. 176I, § 12), policies shall provide coverage

for a child under the age of 18 “[t]he cost of treating cleft lip and cleft palate…[t]he coverage

shall include benefits for medical, dental, oral and facial surgery, surgical management and

follow-up care by oral and plastic surgeons, orthodontic treatment and management,

preventative and restorative dentistry to ensure good health and adequate dental structures for

orthodontic treatment or prosthetic management therapy, speech therapy, audiology and

nutrition services, if such services are prescribed by the treating physician or surgeon and such

physician or surgeon certifies that such services are medically necessary and consequent to the

treatment of the cleft lip, cleft palate or both. The coverage required…shall be subject to the

terms and conditions applicable to other benefits.”

[Sections 6 and 7 of Chapter 234 of the Acts of 2012 (the “Act”); this act shall apply to all

policies, contracts and certificates which are delivered, issued or renewed within or

without the commonwealth on or after January 1, 2013]

Maternity Coverage

(Except a policy which provides supplemental coverage to Medicare or other governmental programs)

pg____ According to M.G.L. c. 176G, § 4, policies “shall provide benefits . . . for the expense of

prenatal care, childbirth and post partum care to the same extent as provided for medical

conditions not related to pregnancy.” (See also Bulletin Nos. 97-01 and 96-02)

pg____

According to M.G.L. c. 176G, § 4, policies “shall provide coverage of a minimum of forty-eight

[48] hours of in-patient care following a vaginal delivery and a minimum of ninety-six [96]

hours of in-patient care following a caesarean section for a mother and her newly born child.

Any decision to shorten such minimum coverages shall be made by the attending physician in

consultation with the mother. Any such decision shall be made in accordance with rules and

regulations promulgated by the department of public health. Said regulations shall be relative to

early discharge, defined as less than forty-eight hours for a vaginal delivery and ninety-six hours

for a caesarean delivery, and post-delivery care and shall include, but not be limited to, home

visits, parent education, assistance and training in breast or bottle feeding and the performance

of any necessary and appropriate clinical tests; provided, however, that the first home visit shall

be conducted by a registered nurse, physician, or certified nurse midwife; and provided, further,

that any subsequent home visit determined to be clinically necessary shall be provided by a

licensed health care provider.” (See also Bulletin Nos. 97-01 and 96-02)

According to M.G.L. c. 176G, § 4, “[f]or the purposes of this section [M.G.L. c. 176G, § 4]

Managed Care: Health Maintenance Organization (Rev. 103017) Page 40

attending physician shall include the attending obstetrician, pediatrician, or certified nurse

midwife attending the mother and newly born child.” (See also Bulletin Nos. 97-01 and 96-02)

Infertility Benefits

(Except a policy which provides supplemental coverage to Medicare or other governmental programs and

Dioceses)

pg____

According to M.G.L. c. 176G, § 4, policies “shall provide, to the same extent that benefits are

provided for other pregnancy-related procedures, coverage for medically necessary expenses of

diagnosis and treatment of infertility to persons residing within the commonwealth . . . [and]

‘infertility’ shall mean the condition of an individual who is unable to conceive or produce

conception during a period of 1 year if the female is age 35 or younger or during a period of 6

months if the female is over the age of 35.

For purposes of meeting the criteria for infertility in this section, if a person conceives but is

unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to

achieving that pregnancy shall be included in the calculation of the 1 year or 6 month period, as

applicable [see Sections 15 of Chapter 288 of the Acts of 2010].

pg____

According to 211 CMR 37.05, “[s]ubject to any reasonable limitations as described in

211 CMR 37.08, insurers shall provide benefits for all non-experimental infertility procedures

including, but not limited to:

(1) Artificial Insemination (AI) and Intrauterine Insemination (IUI);

(2) In Vitro Fertilization and Embryo Transfer (IVF-ET);

(3) Gamete Intra fallopian Transfer (GIFT);

(4) Sperm, egg and/or inseminated egg procurement and processing, and banking of sperm or

inseminated eggs, to the extent such costs are not covered by the donor's insurer, if any;

(5) Intracytoplasmic Sperm Injection (ICSI) for the treatment of male factor infertility;

(6) Zygote Intrafallopian Transfer (ZIFT);

(7) Assisted Hatching; and

(8) Cryopreservation of eggs.

pg____ According to 211 CMR 37.06, “[I]nsurers shall not impose exclusions, limitations or other

restrictions on coverage for infertility-related drugs that are different from those imposed on any

other prescription drugs.”

According to 211 CMR 37.08 -

(1) No insurer shall impose deductibles, copayments, coinsurance, benefit maximums, waiting

periods or any other limitations on coverage for required infertility benefits which are different from

those imposed upon benefits for services not related to infertility.

(2) No insurer shall impose pre-existing condition exclusions or pre-existing condition waiting

periods on coverage for required infertility benefits. No insurer shall use any prior diagnosis of or

prior treatment for infertility as a basis for excluding, limiting or otherwise restricting the availability

of coverage for required infertility benefits.

(3) No insurer shall impose limitations on coverage based solely on arbitrary factors, including but

not limited to number of attempts or dollar amounts.

Please confirm that the carrier complies with this requirement.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 41

Hormone Replacement Therapy and Contraceptive Services

(Except contracts purchased by a subscriber that is a church or qualified church-controlled

organization as those terms are defined in 26 U.S.C. section 3121(w)(3)(A) and (B))

pg____

According to M.G.L. c. 176G, § 4O(a), “[a]ny individual or group health maintenance contract

that is issued, renewed or delivered within or without the commonwealth and that provides

benefits for outpatient services shall provide to residents of the commonwealth and to persons

having a principal place of employment within the commonwealth benefits for

hormone replacement therapy services for peri and post menopausal women and

outpatient contraceptive services under the same terms and conditions as for such other

outpatient services.

Outpatient contraceptive services shall mean consultations, examinations, procedures and

medical services provided on an outpatient basis and related to the use of all contraceptive

methods to prevent pregnancy that have been approved by the United States Food and Drug

Administration.” (See also Bulletin No. 02-09)

pg____

According to M.G.L. c. 176G, § 4O(b) “[a]ny individual or group health maintenance contract

that is issued, renewed or delivered within or without the commonwealth and that provides

benefits for outpatient prescription drugs or devices shall

provide benefits for hormone replacement therapy for peri and post menopausal women and…

outpatient prescription contraceptive drugs or devices that have been approved by the United

States Food and Drug Administration under the same terms and conditions as for such other

prescription drugs or devices, provided that in covering all FDA approved prescription

contraceptive methods, nothing in this section precludes the use of closed or restricted

formulary.” (See also Bulletin No. 02-09)

Bulletin 2016-03; Federal Requirement that Carriers Cover Certain Contraceptives

Without Any Consumer Cost-Sharing; Issued 1/19/16

The full range of FDA-approved contraceptive methods as specified in guidelines supported by

the Health Resources and Services Administration (HRSA) must be covered without cost-

sharing. (Section 2713 of the Public Health Service Act (PHS Act), added by the Patient

Protection and Affordable Care Act (ACA), as amended, and incorporated into the Employee

Retirement Income Security Act of 1974 and the Internal Revenue Code. Also, the HRSA

Guidelines).

Cytologic screening and mammographic examination expense benefits

pg____ According to M.G.L. c. 176G, § 4, policies “shall provide benefits for the expense…of cytologic

screening and mammographic examination. Said benefits shall be at least equal to the following

minimum requirements: (a) in the case of benefits for cytologic screening, said benefits shall

provide for an annual cytologic screening for women eighteen years of age and older; and (b), in

the case of benefits for mammographic examination said benefits shall provide for a baseline

mammogram for women between the ages of thirty-five and forty and for a mammogram on an

annual basis for women forty years of age and older.”

Managed Care: Health Maintenance Organization (Rev. 103017) Page 42

Bone Marrow Transplants for Breast Cancer

pg____ According to M.G.L. c. 176G, § 4F, “[a]ny group health maintenance contract shall provide

coverage for a bone marrow transplant or transplants for persons who have been diagnosed with

breast cancer that has progressed to metastatic disease; provided, however, that said person shall

meet the criteria established by the department of public health [105 CMR 240.00].”

Federal Mastectomy Mandate

pg____ According to the Women’s Health and Cancer Rights Act of 1998, “[a] group health plan, and a

health insurance issuer providing health insurance coverage in connection with a group health

plan, that provides medical and surgical benefits with respect to a mastectomy shall provide, in a

case of a participant or beneficiary who is receiving benefits in connection with a mastectomy

and who elects breast reconstruction in connection with such mastectomy, coverage for: (1)

reconstruction of the breast on which the mastectomy has been performed; (2) surgery and

reconstruction of the other breast to produce a symmetrical appearance; and (3) prostheses and

physical complications all stages of mastectomy, including lymphedemas; in a manner

determined in consultation with the attending physician and the patient. Such coverage may be

subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as

are consistent with those established for other benefits under the plan or coverage. Written

notice of the availability of such coverage shall be delivered to the participant upon enrollment

and annually thereafter.”

Coverage for Human Leukocyte Antigen Testing for Certain Individuals and Patients

pg____ According to M.G.L. c. 176G, § 4Q, policies shall provide coverage “for the cost of human

leukocyte antigen testing or histocompatibility locus antigen testing that is necessary to establish

[such member’s or enrollee’s] bone marrow transplant donor suitability. The coverage shall

cover the costs of testing for A, B or DR antigens, or any combination thereof, consistent with

rules, regulations and criteria established by the department of public health pursuant to section

218 of chapter 111 [of the Massachusetts General Laws].” (See also Bulletin Nos. 01-16 and

01-04) Except a policy which provides supplemental coverage to Medicare or other governmental programs

Cardiac Rehabilitation Coverage

pg____ According to M.G.L. c. 176G, § 4, policies “shall provide benefits for the expense of cardiac

rehabilitation. Cardiac rehabilitation shall mean multidisciplinary, medically necessary treatment

persons with documented cardiovascular disease, which shall be provided in either a hospital or ot

setting and which shall meet standards promulgated by the commissioner of public health after

reviewing proposals submitted by the Massachusetts Society for Cardiac Rehabilitation, Inc. and

notice and public hearing on the proposed standards. Such standards shall include, but not be limi

outpatient treatment which is to be initiated within twenty-six weeks after the diagnosis of such di

[105 CMR 143.00].”

(Except a policy which provides supplemental coverage to Medicare or other governmental programs

Hospice Care - [see also 105 CMR 141.00]

pg____ According to M.G.L. c. 176G, § 4L, “[a]ny group health maintenance contract shall provide

coverage for hospice services as defined in section 57D of chapter 111 [of the Massachusetts

General Laws] during the life of the patient, to terminally ill patients with a life expectancy of

six months or less; provided, however, that such services are determined to be appropriate and

authorized by the patient’s primary care or treating physician and are equivalent to those

services provided by a licensed hospice program regulated by the department of public health.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 43

Home Health Care Coverage

pg____

According to M.G.L. c. 176G, §4C, ""Home care services'', shall mean health care services for a

patient provided by a public or private home health agency which meets the standards of service

of the purchaser of service, provided in a patient's residence; provided, however, that such

residence is neither a hospital nor an institution primarily engaged in providing skilled nursing

or rehabilitation services.

Said services shall include, but not be limited to…

nursing and physical therapy;

occupational therapy;

speech therapy;

medical social work;

nutritional consultation;

the services of a home health aid; and

the use of durable medical equipment and supplies shall be provided to the extent such

additional services are determined to be a medically necessary component of said nursing

and physical therapy. Benefits for home care services shall apply only when such services

are medically necessary and provided in conjunction with a physician approved home health

services plan.”

Speech, Hearing and Language Disorders

pg____ According to M.G.L. c. 176G, § 4N, policies shall provide “for the expenses incurred in the

medically necessary diagnosis and treatment of speech, hearing and language disorders by

individuals licensed as speech-language pathologists or audiologists under [the provisions of]

chapter 112 [of the Massachusetts General Laws], if such services are rendered within the lawful

scope of practice for such speech-language pathologists or audiologists regardless of whether the

services are provided in a hospital, clinic or a private office, and if such coverage shall not

extend to the diagnosis or treatment of speech, hearing and language disorders in a school-based

setting. The benefits provided by this section shall be subject to the same terms and conditions

established for any other medical condition covered by such individual or group health

maintenance contract.” (See also Bulletin No. 01-03)

Non-prescription Enteral Formulas for Home Use

pg____ According to M.G.L. c. 176G, § 4D, “[a] group health maintenance contract shall provide

coverage for nonprescription enteral formulas for home use for which a physician has issued a

written order and which are medically necessary for the treatment of malabsorption caused by

Crohn's disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility, chronic

intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids. Coverage

for inherited diseases of amino acids and organic acids shall include shall include food products

modified to be low protein in an amount not to exceed $5,000 annually for any insured

individual.” (See Bulletin 2008-16 and Chapter 214 of the Acts of 2008 - AN ACT

INCREASING COVERAGE OF NONPRESCRIPTION ENTERAL FORMULAS)

HIV and Hepatitis C Prevention

pg____

According to M.G.L. c. 176G §4U, “[n]o individual or group health maintenance contract shall

restrict or discontinue coverage for medically necessary hypodermic syringes or needles,

notwithstanding section 27 of chapter 94C. The term “medical necessity” shall be construed in

accordance with the guidelines set forth in subsection (b) of section 16 of chapter 176O.”

Managed Care: Health Maintenance Organization (Rev. 103017) Page 44

pg____ For plans that do not include a prescription drug benefit, the Division would consider it

reasonable for carriers to require a copayment or coinsurance for a 30-day supply of hypodermic

syringes or needles that is equal to the copayment or coinsurance required for a primary care

office visit. [See also Chapter 172 of the Acts of 2006 & Section 141 of Chapter 451 of the Acts

of 2008]

HIV Associated Lipodystrophy Treatment

pg____

According to M.G.L. c. 176G §4CC, polices shall “[p]rovide coverage for medical or drug

treatments to correct or repair disturbances of body composition caused by HIV associated

lipodystrophy syndrome including, but not limited to, reconstructive surgery, such as suction assisted

lipectomy, other restorative procedures and dermal injections or fillers for reversal of facial

lipoatrophy syndrome…[c]overage shall be subject to a statement from a treating provider that the

treatment is necessary for correcting, repairing or ameliorating the effects of HIV associated

lipodystrophy syndrome. The benefits in this section shall not be subject to any greater deductible,

coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.”

(Refer to Bulletin 2016-14 – “On August 10, 2016, Chapter 233 of the Acts of2016, "An Act

Relative to HIV Associated Lipodystrophy Treatment' ("Chapter 233") was signed into law.

Chapter 233 is effective as of Tuesday, November 8, 2016.”)

Off-Label Use of Drugs for the treatment of Cancer and HIV/AIDS

pg____ According to M.G.L. c. 176G, § 4E, no policy “shall exclude coverage of any such drug used for

the treatment of cancer on the grounds that the off-label use of the drug has not been approved

by the United States Food and Drug Administration for that indication; provided, however, that

such drug is recognized for treatment of such indication in one of the standard reference

compendia, or in the medical literature, or by the commissioner under the provisions of section

forty-seven L [of chapter 175 of the Massachusetts General Laws]. Any coverage of a drug

required by this section shall also include medically necessary services associated with the

administration of the drug.”

pg____ According to M.G.L. c. 176G, § 4G, no policy “shall exclude coverage of any such drug for

HIV/AIDS treatment on the grounds that the off-label use of the drug has not been approved by

the federal food and drug administration for that indication, if such drug is recognized for

treatment of such indication in one of the standard reference compendia, or in the medical

literature, or by the commissioner under the provisions of section forty-seven P of [chapter 175

of the Massachusetts General Laws]. Any coverage of a drug required by this section shall also

include medically necessary services associated with the administration of the drug.” (See also

Bulletin Nos. 97-09, 96-06, 96-05, and 95-05)

Oral Cancer Therapy

pg____ According to M.G.L. c. 176G, § 4X “[a]ny individual or group health maintenance contract that

provides coverage for cancer chemotherapy treatment shall provide coverage for prescribed,

orally administered anticancer medications used to kill or slow the growth of cancerous cells on

a basis not less favorable than intravenously administered or injected cancer medications that are

covered as medical benefits. An increase in patient cost sharing for anticancer medications shall

not be allowed to achieve compliance with this section.”

[refer to Section 5 of Chapter 403 of the Acts of 2012]

Managed Care: Health Maintenance Organization (Rev. 103017) Page 45

Diabetes Cost Reduction

(Except a policy which provides supplemental coverage to Medicare or other governmental programs)

pg____

According to M.G.L. c. 176G, § 4H, policies shall provide “coverage for the following items if such items

are within a category of benefits or services for which coverage is otherwise afforded by the contract, have

been prescribed by a health care professional legally authorized to prescribe such items and if the items are

medically necessary for the diagnosis or treatment of insulin-dependent, insulin-using, gestational and

non-insulin-dependent diabetes: blood glucose monitors; blood glucose monitoring strips for home use;

voice-synthesizers for blood glucose monitors for use by the legally blind; visual magnifying aids for use

y the legally blind; urine glucose strips; ketone strips; lancets; insulin; insulin syringes; prescribed oral

diabetes medications that influence blood sugar levels; laboratory tests, including glycosylated

hemoglobin, or HbAlc, tests; urinary protein/microalbumin and lipid profiles; insulin pumps and insulin

pump supplies; insulin pens, so-called; therapeutic/molded shoes and shoe inserts for people who have

severe diabetic foot disease when the need for therapeutic shoes and inserts has been certified by the

treating doctor and prescribed by a podiatrist or other qualified doctor and furnished by a podiatrist,

orthotist, prosthetist or pedorthist; supplies and equipment approved by the Federal Drug Administration

for the purposes for which they have been prescribed and diabetes outpatient self-management training

and education, including medical nutrition therapy, when provided by a certified diabetes health care

provider participating with the health maintenance contract or affiliated with a provider participating with

the health maintenance contract.”

pg____

According to Bulletin No. 00-05, “nondiscriminatory treatment of benefits for diabetes-related

services is mandated. The Division will consider a carrier to be in compliance . . . if the mandated

services and supplies are covered within the following categories of benefits:

 outpatient services: outpatient diabetes self-management training and education;

 laboratory/radiological services: all laboratory tests and urinary profiles;

 durable medical equipment: blood glucose monitors, voice-synthesizers and visual

magnifying aids;

 prosthetics: therapeutic/molded shoes and shoe inserts; and

 prescription drugs:

lood glucose monitoring strips, urine glucose strips, ketone strips, lancets,

insulin syringes, insulin pumps and insulin pump supplies, insulin pens, insulin and oral

medications.

For items in the last category, with the exception of an insulin pump, the Division will consider a

carrier to be in compliance if a co-payment is applied for no less than a 30-day supply of the

mandated item. The Division will consider it to be a violation . . . if a carrier excludes from a

particular category any of the above-noted items for diabetics.”

Please confirm that the carrier complies with this requirement.

_____________________________________________________________________________

Coverage For Certain Prosthetic Devices

pg____

According to M.G.L. c. 176G, § 4S(a), “[i]ndividual and group health maintenance contracts

shall provide coverage for prosthetic devices and repairs. If prosthetic devices are covered as a

durable medical equipment benefit, coverage shall be provided under the same terms and

conditions that apply to other durable medical equipment covered under the contracts, except as

otherwise provided in this section. If prosthetic devices are covered as a stand-alone prosthetic

benefit, coverage shall be consistent with the terms and conditions as described in this section.”

(b) In this section, “prosthetic device” shall mean an artificial limb device to replace, in whole or

in part, an arm or leg.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 46

pg____

coverage for prosthetic devices other than an annual or lifetime dollar maximum that applies in

the aggregate to all items and services covered under the contract.

(d) A health maintenance contract shall not apply amounts paid for prosthetic devices to any

annual or lifetime dollar maximum applicable to other durable medical equipment covered under

the contract other than an annual or lifetime dollar maximum that applies in the aggregate to all

items and services covered under the contract.

(e) A health maintenance contract may include a reasonable coinsurance requirement for

prosthetic devices and repairs, not to exceed 20 per cent of the allowable cost of the prosthetic

device or repair, unless all covered benefits applying coinsurance under the plan do so at a

higher amount. If the health maintenance contract provides coverage for services from

nonparticipating providers, the contract may include a reasonable coinsurance requirement for

prosthetic devices and repairs, not to exceed 40 per cent of the allowable cost of the prosthetic

device or repair when obtained from a nonparticipating provider, unless all covered benefits

applying coinsurance under the plan do so at a higher amount.

pg____

(f) A health maintenance contract may require prior authorization as a condition of coverage for

prosthetic devices.

(g) A health maintenance contract shall only be required to provide coverage for the most

appropriate medically necessary model that adequately meets the medical needs of the policyholder.

Scalp Hair Prosthesis for Cancer Patients

pg____

According to M.G.L. c. 176G, § 4J, “[a] group health maintenance contract which provides coverage for

any other prosthesis, shall provide coverage for expenses for scalp hair prostheses worn for hair loss

suffered as a result of the treatment of any form of cancer or leukemia; provided, however, that such

coverage shall be subclinicalject to a written statement by the treating physician that the scalp hair

prosthesis is medically necessary; and provided, further, that such coverage shall be subject to the same

limitations and guidelines as other prostheses. (See also Bulletin No. 98-09)

Insurance Coverage of Qualified Clinical Trials

(Except Medicare Supplement Plans or contracts purchased by a subscriber that is a church or qualified

church-controlled organization)

pg____ According to M.G.L. c. 176G, § 4P, “[a]ny individual or group health maintenance contract shall

provide for the coverage of patient care services furnished pursuant to qualified clinical trials as

defined in, and subject to the requirements and limitations of, section 110L of chapter 175 [of

the Massachusetts General Laws].” According to M.G.L. c. 175, § 110L(b), “[a]ny policy,

contract, agreement, plan or certificate of insurance issued, delivered or renewed within the

commonwealth shall cover and reimburse for patient care services provided pursuant to a

qualified clinical trial to the same extent as they would be covered and reimbursed if the patient

did not receive care in a qualified clinical trial.” (See also M.G.L. c. 176A, § 8X or M.G.L. c.

176B, § 4X, and Bulletin No. 02-13)

Managed Care: Health Maintenance Organization (Rev. 103017) Page 47

Long Term Antibiotic Therapy for the Treatment of Lyme Disease

pg____

According to M.G.L. c. 176G, § 4BB(b),a “[c]ontract shall provide coverage for long-term antibiotic

therapy for a patient with Lyme disease when determined to be medically necessary and ordered by a

licensed physician after making a thorough evaluation of the patient’s symptoms, diagnostic test

results or response to treatment. An experimental drug shall be covered as a long-term antibiotic

therapy if it is approved for an indication by the United States Food and Drug Administration;

provided, however, that a drug, including an experimental drug, shall be covered for an off-label use

in the treatment of Lyme disease if the drug has been approved by the United States Food and Drug

Administration.”

(See also Bulletin No. 2016-13 “[o]n July 31, 2016, Chapter 183 of the Acts of 2016, "An Act

Relative to Long-Term Antibiotic Therapy for the Treatment of Lyme Disease" ("Chapter 183")

was enacted, retroactively effective as of July 1, 2016.)

PRIMARY CARE PROVIDER ASSIGNMENT

According to M.G.L. c. 176G, § 31 (M.G.L. c. 176J, §16); “[t]o the maximum extent possible, every

carrier shall “[a]ttribute every member to a primary care provider. Members may change their primary care

provider, provided that the member gives notice to the carrier.”

[Sections 173 and 188 of Chapter 224 of the Acts of 2012 (the “Act”); effective November 4, 2012]

Explain how your company complies with this requirement.

_____________________________________________________________________________________________

NON-DISCRIMINATION

Victims of Domestic Abuse. According to M.G.L. c. 176G, § 19, “[n]o health maintenance organization

subject to this chapter, and no officer or agent thereof, shall cancel, refuse to issue or renew, or in any way

make or permit any distinction or discrimination in the amount or payment of premiums or rates charged,

in the length of coverage, or in any other of the terms and conditions of a health maintenance contract

based on information that an individual has been a victim of abuse, as defined by section one of chapter

two hundred and nine A [of the Massachusetts General Laws]. No health maintenance organization subject

to this chapter, and no officer or agent thereof, shall seek information that such person has been a victim of

abuse as defined by said section one of said chapter two hundred and nine A [of the Massachusetts General

Laws]. The practices prohibited under this section shall include not only those overtly discriminatory but

also practices and devices which are fair in form but discriminatory in practice. Nothing in this section

shall be construed as creating a special class of insureds who have been victims of abuse as defined by said

section one of said chapter two hundred and nine A [of the Massachusetts General Laws]. Any violation of

this section shall constitute an unfair method of competition or an unfair or deceptive act or practice in

violation of chapters ninety-three A and one hundred and seventy-six D [of the Massachusetts General

Laws].”

Please confirm that the carrier complies with this requirement.

_____________________________________________________________________________________

Genetic Testing and Privacy Protection. According to M.G.L. c. 176G, § 24, “[n]o health maintenance

organization subject to this chapter, and no officer or agent thereof, shall cancel, refuse to issue or renew,

or in any way make or permit any distinction or discrimination in the amount of payment of premium or

rates charged, in the length of coverage or in any of the terms and conditions of a health maintenance

contact based on genetic information as defined in this section. No health maintenance organization

subject to the provisions of this chapter and no officer of agent thereof, shall require genetic tests or private

genetic information, as defined in this section, as a condition of the issuance or renewal of a health

maintenance contract. Any violation of this section shall constitute an unfair method of competition or

Managed Care: Health Maintenance Organization (Rev. 103017) Page 48

deceptive act or practice in violation of chapters 93A and 176D.” [also see Bulletin No. 00-16]

Please confirm that the carrier complies with this requirement.

_____________________________________________________________________________________

pg____

pg_____

Consumer Choice of Nurse Practitioners According to M.G.L. c. 176R, “[t]he commissioner

and the group insurance commission shall require that all carriers recognize nurse practitioners

as participating providers…and shall include coverage on a nondiscriminatory basis to their

insureds for care provided by nurse practitioners for the purposes of health maintenance,

diagnosis and treatment. Such coverage shall include benefits for primary care, intermediate

care and inpatient care, including care provided in a hospital, clinic, professional office, home

care setting, long-term care setting, mental health or substance abuse program, or any other

setting when rendered by a nurse practitioner who is a participating provider and is practicing

within the scope of his professional license to the extent that such policy or contract currently

provides benefits for identical services rendered by a provider of health care licensed by the

commonwealth.

According to M.G.L. c. 176R §3, “[a] participating provider nurse practitioner practicing within

the scope of his license including all regulations requiring collaboration with a physician under

section 80B of chapter 112, shall be considered qualified within the carrier’s definition of

primary care provider to an insured.

According to M.G.L. c. 176R §4, “[n]otwithstanding any general or special law to the contrary,

a carrier that requires the designation of a primary care provider shall provide its insured with

an opportunity to select a participating provider nurse practitioner as a primary care provider or

to change its primary care provider to a participating provider nurse practitioner at any time

during their coverage period.

According to M.G.L. c. 176R §5, “[n]otwithstanding any general or special law to the contrary,

a carrier shall ensure that all participating provider nurse practitioners are included on any

publicly accessible list of participating providers for the carrier.

MANDATED COVERAGE FROM CERTAIN TYPES OF PROVIDERS

pg____ Certified Registered Nurse Anesthetist and Nurse Practitioner. According to M.G.L. c.

176G, § 4, policies shall provide benefits “for services rendered by a certified registered nurse

anesthetist or nurse practitioner designated as such certified registered nurse anesthetist or nurse

practitioner by the board of registration in nursing pursuant to the provisions of section eighty B

of chapter one hundred and twelve; provided, however, that the following conditions are met: (1)

the service rendered is within the scope of the certified registered nurse anesthetist's license or

the nurse practitioner's authorization to practice by the board of registration in nursing; and (2)

the policy or contract currently provides benefits for identical services rendered by a provider of

health care licensed by the commonwealth.”

pg____

Consumer Choice of Physician Assistant Services. According to M.G.L. c. 176S carriers

“[s]hall include coverage on a nondiscriminatory basis to their insureds for care provided by

physician assistants for the purposes of health maintenance, diagnosis and treatment. Such

coverage shall include benefits for primary care, intermediate care and inpatient care, including

care provided in a hospital, clinic, professional office, home care setting, long-term care setting,

mental health or substance abuse program, or any other setting when rendered by a physician

Managed Care: Health Maintenance Organization (Rev. 103017) Page 49

pg____

assistant who is a participating provider and is practicing within the scope of his or her

professional authority as defined by statute, rule and physician delegation to the extent that such

policy or contract currently provides benefits for identical services rendered by a provider of

health care licensed by the commonwealth.”

 A carrier that requires the designation of a primary care provider shall provide its insured

with an opportunity to select a participating provider physician assistant as a primary care

provider.

 A carrier shall ensure that all participating provider physician assistants are included on any

publicly accessible list of participating providers for the carrier.

Highlight the section of the certificate that addresses the above-noted requirements.

[See Sections 216 of Chapter 224 of the Acts of 2012 (the “Act”); this act shall apply to all

policies, contracts and certificates on or after November 4, 2012]

pg____ Podiatrist. According to M.G.L. c. 176G §1, “[a]ny individual who has entered into a group

health maintenance contract that provides for any podiatric medical or surgical service which is

within the lawful scope of practice of a licensed podiatrist, shall be entitled to such services

whether the service is performed by a physician or licensed podiatrist, including authorized

referral services on a nondiscriminatory basis.”

Managed Care: Health Maintenance Organization (Rev. 103017) Page 50

Bulletin 2016-01; Federal Requirement that Carriers Cover Certain Tobacco Cessation Products

Without Consumer Cost Sharing - Tobacco Cessation Products

pg____

The ACA requires coverage, with no cost-sharing, for certain evidence-based preventive items

and services given a rating of “A” or “B” by the U.S. Preventive Services Task Force

(“USPSTF”).

The USPSTF indicate that clinicians should screen all adults for tobacco use and provide

tobacco cessation interventions for those who use tobacco.

Screening and tobacco interventions are required to be covered without cost-sharing and that

plan benefits should not include any blanket benefit exclusions or limitations that apply to

tobacco cessation items or services.

Tobacco Cessation Products

HHS has issued guidance that identifies the following types of tobacco cessation products as

items that it believes are appropriate for smoking cessation:

Nicotine gum,

Nicotine patch,

Nicotine lozenge,

Nicotine oral or nasal spray,

Nicotine inhaler,

Bupropion, and

Varenicline

The Division would consider a health plan to be in compliance with the preventive care

requirements of the ACA relative to tobacco cessation products if the health plan’s drug benefit

includes at least one product within each of the above-noted tobacco cessation product types

without cost-sharing (e.g., the health plan’s drug benefit includes coverage, without cost sharing,

for at least one nicotine gum, one nicotine patch, one nicotine lozenge, etc.). Coverage

requirements pertain to both over-the-counter and prescription products.

Covered persons should be “[g]iven access to at least one of the tobacco cessation products

without prior authorization and the managed care methods are consistent with all state and

federal laws. Whenever carriers make an adverse determination that denies or limits access to a

requested product based on medical necessity criteria, they must provide all necessary

notifications to patients and providers and follow all appropriate procedures for internal and

external appeals.

Bulletin 2016-05; Federal Requirement that Carriers Cover Certain Lactation Services Without

Any Consumer Cost-Sharing

pg____

Federal Rules for Preventive Health Care Services

“Section 2713 of the Public Health Service Act, as amended by the ACA…[r]equire that non-

grandfathered insured health plans in the individual and group markets provide benefits, without

cost-sharing (i.e., copayments, coinsurance or deductibles) for certain preventive items and

services listed in the current recommendations of the United States Preventive Services Task

Force, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization

Practices, and in specific guidelines supported by the Health Resources and Services

Administration (“HRSA”).”

Managed Care: Health Maintenance Organization (Rev. 103017) Page 51

pg____

Coverage for Lactation Support and Counseling (or Lactation Services)

“[s]specific guidelines associated with lactation support, supplies and counseling. Carriers must

cover comprehensive prenatal and postnatal lactation support, counseling and equipment

purchase and/or rental as preventive care services, but may use reasonable medical management

techniques to control costs and promote efficient delivery of care.”

In accordance with 45 CFR §147.130(a)(2), if a lactation item or service is not billed separately

(or is not tracked as individual encounter data separately) from an office visit and the primary

purpose of the office visit is the delivery of such lactation item or service, then a Carrier may not

impose cost-sharing requirements with respect to the office visit. If a lactation item or service is

not billed separately (or is not traced as individual encounter data separately) from an office visit

and the primary purpose of the office visit is not the delivery of the lactation item or service,

then a Carrier may impose cost-sharing requirements with respect to the office visit.

In FAQ Part XXIX, the Departments clarify that coverage for comprehensive prenatal and

postnatal lactation support, supplies, and counseling includes lactation counseling as long as the

service is performed by a provider acting within the scope of his or her license or certification

under applicable state law. Carriers may limit coverage without cost-sharing to a network of

providers. However, if a Carrier does not have providers in its network who can provide

lactation counseling services, then the Carrier must cover the items or service when performed

by an out-of-network provider and not impose cost-sharing with respect to the lactation items or

services. Moreover, coverage for lactation support services and items without cost-sharing must

extend for the duration of the breastfeeding, and it may not be limited to services provided on an

in-patient basis.

According to FAQ Part XXIX, Carriers must provide information to covered persons about

lactation counseling providers available under the Carriers’ plans. In order to update their

managed care accreditation files, Carriers will need to submit information to the Division that

identifies the lactation counseling providers within their networks or that explains that services

provided for lactation counseling will be covered by non-network providers without cost-sharing

until a Carrier has established contracts to include an adequate number of lactation counseling

providers within its networks.

Rehabilitative and Habilitative Services and Devices within Insured Health Benefit Plans

[Filing Guidance 2016-D]

pg____

Filings for insured health benefit plans utilizing the Massachusetts Essential Health Benefits

Benchmark Plan that are intended to be offered on and after January 1, 2017 should be consistent

with the provisions of 45 CFR 156.115(a)(5)(i) – (iii), including the following:

 benefits for habilitative services and devices are to include health care services and devices

that help a person keep, learn, or improve skills and functioning for daily living and may

include, for example, therapy for a child who is not walking or talking at the expected age,

as well as physical and occupational therapy, speech-language pathology and other services

for persons with disabilities in a variety of inpatient and/or outpatient settings;

 coverage for habilitative services and devices is not limited in a manner that is less favorable

than any such limits imposed on coverage for rehabilitative services and devices; and

 there are not any combined limits on habilitative and rehabilitative services and devices.

 In addition, the Division would not consider any plan provisions to be appropriate that:

 discriminate based on an individual's age, expected length of life, present or predicted

disability, degree of medical dependency, quality of life, or other health conditions; or

 apply annual or lifetime dollar limits to any habilitative and rehabilitative services and

Managed Care: Health Maintenance Organization (Rev. 103017) Page 52

devices. (Annual or lifetime limits may be converted to actuarially equivalent treatment or

service limitations.)”

Please confirm that the carrier complies with this requirement.

_________________________________________________________________

AN ACT ESTABLISHING THE CHILDHOOD VACCINE PROGRAM

pg____ Every surcharge payor [pursuant to section 64 of chapter 118E], to the extent not preempted by

federal law, shall provide benefits for: (i) routine childhood immunizations for residents of the

commonwealth; and (ii) immunizations for residents of the commonwealth who are 19 years of

age and older according to the most recent schedules recommended by the Advisory Committee

on Immunization Practices of the federal Centers for Disease Control and Prevention. These

benefits shall be exempt from any copayment, coinsurance, deductible or dollar limit provisions

in the health insurance policy or contract.

Highlight the section of the certificate that addresses the above-noted Department of Public

Health requirements. [See Section 1 of Chapter 28 of the Acts of 2014 (the “Act”) that inserts

Section 24N (

M.G.L. c. 111, §24N(f)). This section of the act shall take effect June 30, 2014].

REQUIREMENTS FOR PROVIDER DIRECTORIES

In addition to Provider directory requirements under 211 CMR 152.08: Provider Directories for

Limited, Regional and Tiered Provider Network Plans, if applicable:

_______

211 CMR 52.15(1):

A Carrier shall deliver a Provider directory to at least one adult Insured in each household

upon enrollment and to a prospective or current Insured upon request. Annually, thereafter, a

Carrier shall deliver to at least one adult Insured in each household, or in the case of a group

policy, to the group representative, a Provider directory. The Carrier may deliver a Provider

directory through an Internet Website, provided that any Provider directory available through

an Internet Website be updated at least on a monthly basis.

(a) The Provider directory 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 and summarizing on its Internet Website for each such Provider:

1. The method used to compensate or reimburse such Provider, including details

of measures and compensation percentages tied to any Incentive Plan or pay

for performance provision;

2. the Provider price relativity, as defined in and reported under M.G.L. c. 12C, §

10;

3. the Provider's health status adjusted total medical expenses, as defined in

and reported under M.G.L. c. 12C, § 10; and

4. current measures of the Provider's quality based on measures from the

Standard Quality Measure Set, as defined in 957 CMR 4.00: Uniform Provider

Reporting of the Standard Quality Measure Set promulgated by the Center for

Health Information and Analysis established by M.G.L. c. 12C, § 2; provided, that

the Carrier shall prominently promote Providers based on quality performance as

measured by the standard quality measure set and cost performance as measured

by health status adjusted total medical expenses and relative prices.

a. Nothing in 211 CMR 52.15(1)(a) shall be construed to require disclosure

of the specific details of any financial arrangements between a Carrier

and a Provider.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 53

_______

b. If any specific Providers or type of Providers requested by an Insured

are not available in said Network, or are not a covered benefit, or if

any Primary Care Provider or behavioral health or substance use

disorder Health Care Professional is not accepting new patients, such

information shall be provided in an easily obtainable manner, including

in the Provider directory.

c. Notwithstanding any general or specific law to the contrary, a Carrier

shall ensure that all Participating Provider Nurse Practitioners and

Participating Provider Physician Assistants are included and displayed in

a nondiscriminatory manner on any publicly accessible list of

Participating Providers for the Carrier.

(b) The Provider directory must contain a toll-free number that Insureds can call to

determine whether a particular Health Care Provider is affiliated with the Carrier.

can visit to determine whether a particular Provider is affiliated with the Carrier.

(d) The Carrier must be able to demonstrate compliance with the following:

1. The Carrier has issued and delivered written notice to the Insured that

includes:

a. All necessary information and a clear explanation of the manner by

which Insureds can access their specific Provider directory through an

Internet Website;

b. A list of the specific information to be furnished by the Carrier

through an Internet Website;

c. The significance of such information to the Insured;

d. The Insured's right to receive, free of charge, a paper copy of the

Provider directory at any time;

e. The manner by which the Insured can exercise the right to receive a

paper copy at no cost to the Insured; and

f. A toll-free number for the Insured to call with any questions or requests.

FORWARD A COPY OF THE WRITTEN NOTICE HIGHLITING WITHIN THE

DOCUMENT COMPLIANCE WITH THE LISTED ITEMS ABOVE.

2. The Carrier has taken reasonable measures to ensure that the information

and documents furnished in an Internet Website is substantially the same as that

contained in its paper documents.

3. All notice and time requirements applicable to Evidences of Coverage shall

apply to information and documents made available by internet. Information

contained in the documents furnished in an Internet Website shall include the

effective date and the published date of any updates, modifications or Material

Changes.

4. The Carrier updates the Internet Website as soon as practicable, and at

least monthly.

5. In the case of a group policy, the Carrier delivers a paper copy of the

Provider directory to the group representative.

6. The Carrier has taken reasonable measures to ensure that it furnishes, upon request

of the Insured, a paper copy of the Provider directory.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 54

211 CMR 52.15(2):

A Carrier shall not be required to deliver a Provider directory upon enrollment if a Provider

directory is delivered to the prospective or current Insured, or in the case of a group policy, to the

group representative, during applicable open enrollment periods.

Please confirm that the carrier complies with this requirement.

211 CMR 52.15(3):

If delivering a paper copy of the Provider directory, a Carrier shall be deemed to have met the

requirements of 211 CMR 52.15(1) if the Carrier:

(a) provides to at least one adult Insured in each household, or in the case of a group policy, to

the group representative, at least once per calendar year an addendum, insert, or other update to

the Provider directory originally provided under 211 CMR 52.15(1); and

(b) updates its toll-free number within 48 hours and Internet Website as soon as

practicable.

Please confirm that the carrier complies with this requirement.

_________________________________________________________________

211 CMR 52.15(4):

Every Provider directory described in 211 CMR 52.15 must contain the effective date, date of issue

and expiration date if applicable, and reference to any government-sponsored website(s) providing

quality and cost information, as may be designated by the Commissioner.

Highlight where the effective date, date of issue and expiration date along with

government website is located within the directory.

_________________________________________________________________________

DIRECT PRIMARY CARE PRACTICE/CONCIERGE MEDICINE

Early in 2002, the Division became aware that certain providers in the Massachusetts market intended

to modify their practices in April 2002 by charging an annual fee to members as a condition to continue

to be part of the providers’ panel of patients. The Division was formally requested by certain carriers to

opine as to whether carriers would be permitted to continue to include providers within their managed

care networks if those providers required such fees as a condition for treatment. As is noted in a letter

dated March 6, 2002 to Tufts Health Plan, the Division’s General Counsel indicated that it does not

believe that the providers’ annual fee proposal “violates the current statutory and regulatory framework

governing contracts between carriers and providers.” The Division’s General Counsel’s letter of March

6, 2002 instructs all carriers to:

1) confirm that the carrier monitors its network of providers;

2) confirm whether the carrier’s network includes network providers that require patients to

pay an annual fee as a condition for inclusion within that provider’s panel of patients

3) if the network includes such providers, confirm that the carrier has amended its provider

directory(ies) to clearly identify those providers that will be unavailable to its members who

do not or cannot pay the annual fee to be part of the providers’ panel and highlight the

page(s) that such information may be located within the directory(ies);”

4) Include with the filing a document that lists those contracted providers that charge an annual

fee to members as a condition to continue to be a part of the providers’ panel of patients.

5) Confirm that the carrier will continue to monitor its network and will advise the Division as

necessary regarding contracted providers that charge an annual fee as described above.

Please attach a separate document that addresses each noted item above to consider the filing

complete.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 55

BEHAVIORAL HEALTH PROVIDER TYPES

pg____

As noted in Bulletin No. 02-07, in meeting the provisions of Chapter 80 of the Acts of 2000

(“Chapter 80”), carriers are to provide or arrange for the “full range of mandated services,

including specific treatment modalities appropriate for all ages of patients and all types of

covered mental conditions.” In addition, it is noted that carriers are to have “sufficient numbers

of providers available in the network so that no patient must wait a medically inappropriate

amount of time to receive care for acute conditions” and that “care is being delivered promptly

and appropriately and that insureds are being provided adequate access as required by law.” In

order to satisfy the provisions of Chapter 80 and Bulletin No. 02-07, it would appear that

provider directories should include lists that address at least the following types of behavioral

health providers:

(a) general behavioral health providers;

(b) child/pediatric and adolescent behavioral health providers;

(d) substance abuse providers or addictionologists; and

(e) eating disorder specialists.

pg____ According to Chapter 80, carriers are required to provide or arrange for “a range of inpatient,

intermediate, and outpatient services that shall permit medically necessary and active and

noncustodial treatment for said mental disorders to take place in the least restrictive clinically

appropriate setting . . . inpatient services may be provided in a general hospital licensed to

provide such services, in a facility under the direction and supervision of the department of

mental health, in a private mental hospital licensed by the department of mental health, or in a

substance abuse facility licensed by the department of public health. Intermediate services shall

include, but not be limited to, Level III community-based detoxification, acute residential

treatment, partial hospitalization, day treatment and crisis stabilization licensed or approved by

the department of public health or the department of mental health. Outpatient services may be

provided in a licensed hospital, a mental health or substance abuse clinic licensed by the

department of public health, a public community mental health center, or a professional office,

or through home-based services, provided, however, services delivered in such offices or

settings are rendered by a licensed mental health professional acting within the scope of his [or

her] license.”

pg____ Consistent with the requirements of 211 CMR 52.15(1)(a), indicate next to each provider in the

directory their professional licensure designation(s) and clarify with footnotes or other

prominent notes whether providers are or are not taking new patients and if they only see

patients in certain settings (for example, in an inpatient or intermediate care setting).

Managed Care: Health Maintenance Organization (Rev. 103017) Page 56

INTERNET WEBSITES - 211 CMR 52.13(4)

Please advise whether your company’s delivery system for evidences of coverage is an internet

website.

YES____ NO___

If YES, please respond to the following:

Check the following products for which the evidence of coverage is made available electronically:

___ MEDICAL ___ DENTAL

___ MENTAL HEALTH/SUBSTANCE ABUSE ___ VISION

___ PHARMACY ___ OTHER [specify]__________

______

If the carrier, including any dental or vision carrier, refers the insured to resources where the

information described in the evidence of coverage can be accessed, including, but not limited to,

an internet website, such carrier must be able to demonstrate compliance with the following with

respect to the internet website, where the term “internet website” shall include “intranet

website,” “electronic mail,” or “e-mail”:

(a) The carrier has issued and delivered written notice to the insured that includes:

1. All necessary information and a clear explanation of the manner by which insureds can

access their specific evidences of coverage and any amendments thereto through such

internet website;

2. A list of the specific information to be furnished by the carrier through an internet

website;

3. The significance of such information to the insured;

4. The insured’s right to receive, free of charge, a paper copy of evidences of coverage and

any amendments thereto at any time;

5. The manner by which the insured can exercise the right to receive a paper copy at no cost

to the insured; and

6. A toll-free number for the insured to call with any questions or requests.

1) Forward sample copy(ies) of the notice(s) highlighting the requirements noted

within 211 CMR 52.13(4)(a)(1-6).

2) Forward sample copy(ies) of the website address(es) and documents appearing on

its website(s) highlighting the provisions that are substantially the same as those

required in its paper documents.

(b) The carrier has taken reasonable measures to ensure that the information and documents

furnished in an internet website is substantially the same as that contained in its paper

documents. All notice and time requirements applicable to evidences of coverage shall apply to

information and documents furnished by an internet website.

insured, a paper copy of evidences of coverage and any amendments thereto.

Include a statement that confirms the carrier has read items b&c and are in

compliance with these provisions.

_________________________________________________________________________

Managed Care: Health Maintenance Organization (Rev. 103017) Page 57

Group Plans 211 CMR 52.13(5)

A Carrier, including a Dental and Vision Carrier, shall always deliver at least one Evidence of

Coverage to the group representative of a group plan, notwithstanding the provisions of 211 CMR

52.13, 52.14 or 52.15.

Include a statement that confirms the carrier has read the above and is in compliance with

the provision.

_____________________________________________________________________________

General Notice of Material Changes 211 CMR 52.13(6)

A Carrier, including a Dental and Vision Carrier, shall provide to at least one adult Insured in each

household residing in Massachusetts, or in the case of a group policy, to the group representative,

notice of all Material Changes to the Evidence of Coverage.

Include a statement that confirms the carrier has read the above and is in compliance with

the provision.

_____________________________________________________________________________

Advance Notice of Material Modifications 211 CMR 52.13(7)

A Carrier, including a Dental or Vision Carrier, shall issue and deliver to at least one adult

Insured in each household residing in Massachusetts, or in the case of a group policy, to the group

representative, prior notice of material modifications in covered services under the health, Dental or

Vision Plan, at least 60 Days before the effective date of the modifications. Such notices shall include

the following:

a) any changes in Clinical Review Criteria; and

b) a statement of the effect of such changes on the personal liability of the Insured for the

ost of any such changes.

Include a statement that confirms the carrier (1) is in compliance and (2) highlight the page and

section of the evidence of coverage that includes a statement that addresses the above.

_____________________________________________________________________________

Advance Filing of Evidence of Coverage. CMR 52.13(8)

A Carrier, including a Dental or Vision Carrier, shall submit all Evidences of Coverage to the

Bureau at least 30 Days prior to their effective dates.

Include a statement that confirms the carrier has read the above and understands their

responsibilities.

_____________________________________________________________________________

Dates Required. CMR 52.13(9)

Every Evidence of Coverage described in 211 CMR 52.13 must contain the effective date, date of issue

and, if applicable, expiration date.

Include a statement that confirms the carrier has read the above and certify that the evidence of

coverage includes this information as well as the location of such information.

_____________________________________________________________________________

Managed Care: Health Maintenance Organization (Rev. 103017) Page 58

NETWORK ADEQUACY (211 CMR 52.12)

According to 211 CMR 52.12(1), “[a] Carrier offering a plan(s) that includes a Network(s) shall

maintain such Network(s) such that it is adequate in numbers and types of Providers to assure that all

covered services will be accessible to Insureds without unreasonable delay. Adequacy shall be

determined in accordance with the requirements of this 211 CMR 52.12, and shall be established by

reference to reasonable criteria used by the Carrier, which shall include, but not be limited to, the

reasonableness of cost-sharing in relation to the Benefits provided. In any case where the Carrier has

an inadequate number or type of Participating Provider(s) to provide services for a Covered Benefit, the

Carrier shall ensure that the Insured receives the Covered Benefit at the same benefit level as if the

Benefit was obtained from a Participating Provider, or shall make other arrangements acceptable to the

Commissioner.”

pg____

211 CMR 52.12(2)

In accordance with 211 CMR 52.05(3) and (4), a Carrier shall file with the Commissioner an

access analysis that meets the requirements of 211 CMR 52.12 for each plan that includes a

Network that the Carrier offers in the Commonwealth. The Carrier shall also prepare an

access analysis prior to offering a plan that includes a Provider Network, and shall update

an existing access analysis whenever the Carrier makes any Material Change to such an

existing plan. The access plan shall describe or contain at least the following:

(a) The Carrier's Network(s);

(b) A summary of the Carrier's Network adequacy standards;

sufficiency of the Network(s) to meet the health care needs of populations that

enroll in plans with Provider Networks;

(d) The Carrier's efforts to address the ability of the Network(s) to meet the needs

of Insureds with limited English proficiency and illiteracy, with diverse cultural

and ethnic backgrounds, or with disabilities;

(e) The Carrier's methods for assessing the health care needs of Insureds, including

but not limited to the Insureds' needs set forth in 211 CMR 52.12(2)(d), and the

Insureds' satisfaction with services in relation to the development of the Network(s);

(f) The Carrier's methods for monitoring the ability of Insureds to access services out-

of- Network;

(g) A report developed using a Network accessibility analysis system such as

GeoNetworks, which shall include the following, or, for Carriers in a new

geographic area(s) or an area(s) that does not currently have Insureds, estimates for

the following, as applicable;

1. maps showing the residential location of Insureds in Massachusetts, Primary

Care Providers for both adults and children, specialty care practitioners, and

institutional Providers;

2. the Carrier's Network adequacy standards;

3. geographic access tables illustrating the geographic relationship between

Providers and Insureds, or for proposed plans or Service Areas, the population

according to the Carrier's standards for every city and town, including at a

minimum:

a. The total number of Insureds, if applicable;

b. The total number of Network Primary Care Providers who are accepting

new patients;

c. The total number of Network Primary Care Providers who are not

accepting new patients;

Managed Care: Health Maintenance Organization (Rev. 103017) Page 59

pg____

d. The total number of Network Health Care Professionals who specialize in

the treatment of behavioral health and substance use disorders who are

accepting new patients;

e. The total number of Network Health Care Professionals who specialize in

the treatment of behavioral health and substance use disorders but are not

accepting new patients;

f. The total number of Network Health Care Professionals who specialize in

the top five types of specialty care by volume of utilization who are

accepting new patients;

g. The total number of Network Health Care Professionals who specialize in

the top five types of specialty care by volume of utilization who are not

accepting new patients;

h. The total number of Network inpatient hospitals that provide treatment for

acute and tertiary care;

i. The total number of Network inpatient hospitals that provide treatment

for behavioral health and substance use disorders;

j. The percentage of Insureds meeting the Carrier's standard(s) for access

through its Network to Primary Care Providers;

k. The percentage of Insureds meeting the Carrier's standard(s) for access

through its Network to behavioral health and substance use disorder

Health Care Professionals Practitioners:

l. The percentage of Insureds, meeting the Carrier's standard(s) for access

through its Network to specialty care Health Care Professionals;

m. The percentage of Insureds meeting the Carrier's standard(s) for access

throughits Network to inpatient behavioral health and substance use disorder

treatment;

n. The percentage of the number of Insureds meeting the Carrier's standard(s)

for access through its Network to inpatient acute tertiary care.

(h) If, at any time, the Carrier becomes aware of changes to the numbers of Health Care

Professionals or Providers within its Network that would cause the Carrier to not

meet any of its standard(s) for access, then within 30 Days of becoming aware the

Carrier will submit a corrective action plan for the Commissioner's review and

approval that will identify the steps that the Carrier will take to address the

geographic areas where it is not meeting its standard(s) and how the Carrier plans to

address access to care in those areas until Network changes are made so that the

Carrier can once again satisfy its standard(s) for access to care.

Please confirm the carrier is aware of their responsibilities.

________________________________________________________________________

(i) In tiered Networks and/or other instances where the Commissioner finds that cost-

sharing levels could cause inadequate access to Provider types, Carriers shall provide

at the Commissioner's request: a cost-sharing access analysis, illustrating the

relationship between Providers at various cost-sharing levels and Insureds; or, for

proposed plans or Service Areas, the relationship between Providers and the

population, according to the Carrier's standard, for every city and town. For tiered

Networks, the analysis shall indicate the relationship between Providers at each

tier and associated cost-sharing level and Insureds; or, for proposed plans or

Service Areas, the relationship between Providers and the population, according to

the Carrier's standard, for every city and town.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 60

Please confirm the carrier is aware of their responsibilities.

________________________________________________________________________

211 CMR 52.12(3)

A Carrier shall make its selection standards for Participating Providers available for review by

the Commissioner.

Confirm carrier will make available as noted above.

_____________________________________________________________________

MATERIAL TO BE PROVIDED TO THE OFFICE OF PATIENT

PROTECTION

211 CMR 52.16(1)

A Carrier shall provide the following to the Office of Patient Protection at the same time the Carrier provides

such material to the Bureau of Managed Care:

a) A copy of every Evidence of Coverage and amendments thereto offered by the Carrier.

b) A copy of the Provider directory described in 211 CMR 52.15.

c) A copy of the materials specified in 211 CMR 52.14.

211 CMR 52.16(2)

A Carrier shall provide the following to the Office of Patient Protection by no later than April 1

(a) A list of sources of independently published information assessing Insured satisfaction and evaluating the

quality of Health Care Services offered by the Carrier.

(b) A report of the percentage of physicians and Nurse Practitioners and Physician Assistants who

voluntarily and involuntarily terminated participation contracts with the Carrier during the previous

calendar year for which such data has been compiled and the three most common reasons for voluntary

and involuntary Provider disenrollment;

1. For the purposes of 211 CMR 52.16(2)(b), Carriers shall exclude physicians, Nurse Practitioners, and

Physician Assistants who have moved from one physician and/or Nurse Practitioner or Physician

Assistant group to another but are still under contract with the Carrier.

2. For the purposes of 211 CMR 52.16(2)(b) "voluntarily terminated" means that the physician, Nurse

Practitioner, or Physician Assistant terminated the contract with the Carrier.

3. For the purposes of 211 CMR 52.16(2)(b) "involuntarily terminated" means that the Carrier

terminated its contract with the physician, Nurse Practitioner, or Physician Assistant;

for the most recent year for which information is available;

(d) A report detailing, for the previous calendar year, the total number of:

1. filed Grievances, Grievances that were approved internally, Grievances that were denied internally,

and Grievances that were withdrawn before resolution; and

2. external appeals pursued after exhausting the internal Grievance process and the resolution of all

such external appeals. The report shall identify for each such category, to the extent such

information is available, the demographics of such Insureds, which shall include, but need not be

limited to, race, gender and age; and

(e) A report detailing for the previous calendar year the total number of:

1. medical or surgical claims submitted to the carrier;

2. medical or surgical claims denied by the carrier;

3. mental health or substance use disorder claims submitted to the carrier;

4. mental health or substance use disorder claims denied by the carrier; and

5. medical or surgical claims and mental health or substance use disorder claims denied by

the carrier because:

a. the insured failed to obtain pre-treatment authorization or referral for services;

b. the service was not medically necessary;

Managed Care: Health Maintenance Organization (Rev. 103017) Page 61

c. the service was experimental or investigational;

d. the insured was not covered or eligible for benefits at the time services occurred;

e. the carrier does not cover the service or the provider under the insured's plan;

f. duplicate claims had been submitted;

g. incomplete claims had been submitted;

h. coding errors had occurred; or

i. of any other specified reason.

(f) A Carrier that provides specified services through a workers' compensation preferred provider

arrangement shall be deemed to have meet the requirements of 211 CMR 52.16(1)(a) through (c)

and (2)(c) through (e).

Please confirm the carrier complies with the above-noted requirements.

Fully Insured Student Health Plans Offered Within Massachusetts

BULLETIN 2016-06 July 6, 2016

As stated within the Bulletin, “[c]arriers are reminded that they must comply with all relevant federal

requirements when issuing or renewing student health plan coverage in Massachusetts. As noted in

federal guidance, Carriers must ensure that they only issue or renew student health plan coverage that:

 satisfies Centers for Medicare & Medicaid Services (“CMS”) actuarial value requirements for

individual health plans;

 meets Essential Health Benefits requirements for Massachusetts; and

 satisfies all federal rating rules for Massachusetts offered plans.

For further information regarding federal requirements for student health plans, see CMS-9981–F,

Student Health Insurance Coverage, issued on March 21, 2012, and CMS-9972-F, Patient Protection

and Affordable Care Act: Health Insurance Market Rules; Rate Review, issued February 27, 2013, at

page 13424, as well as associated guidances.

Carriers are also reminded about guidance issued by CMS regarding rate review for student health

plans, including guidance most recently issued on February 29, 2016. The Division reminds Carriers

that they are to make all appropriate filings as described in such guidance. The Division expects that

Carriers will submit the materials required by CMS.

In addition, Carriers shall submit the following materials to the Division via the SERFF system as

soon as practical after July 1 for plans with effective dates beginning on or after July 1 of the

same year:

1. A screenshot of the federal Actuarial Value Calculator printout that illustrates the actuarial

value for the plan.

2. A copy of documents used to summarize the terms of coverage that disclose the actuarial value

of the coverage and the “metal level” or next lowest metal level which the coverage would satisfy if

the plan’s actuarial value falls outside the actuarial value ranges for metal levels.

3. An actuarial certification stating how the plans:

o satisfy CMS actuarial value requirements for individual health plans;

o meet Essential Health Benefits requirements for Massachusetts;

o satisfy federal rating rules for Massachusetts.

Forward the appropriate information, if applicable, and document where within the submission this

information may be lcated.

____________________________________________________________________________________

Managed Care: Health Maintenance Organization (Rev. 103017) Page 62

SMALL GROUP PRODUCTS [M.G.L. c. 176J and regulation 211 CMR 66.00]

Please confirm whether the filed plan is intended to be offered to individuals or groups with between one

and fifty eligible employees.

YES____ NO____

If NO, please provide the legal basis why the filed plan is not subject to the above-noted statute and

regulation within your cover letter.

If YES, please review Massachusetts small group law M.G.L. c. 176J and regulation 211 CMR 66.00

including guaranteed issue and guaranteed renewal requirements. Please review that law and include

provisions as required. In addition, please identify the section(s) and page number(s) of the documents

filed that address the following issues:

DEFINITIONS [M.G.L. c. 176J §1]

Pg#_____

“Affordable Care Act'', the federal Patient Protection and Affordable Care Act, Public Law

111-148, adopted March 23, 2010, as amended by the federal Health Care and Education

Reconciliation Act of 2010, Public Law 111-152, and federal regulations adopted pursuant to

that act.

"Benefit level'', the health benefits, including the benefit payment structure or service delivery

and network, provided by a health benefit plan.

"Carrier'', an insurer licensed or otherwise authorized to transact accident and health insurance

under chapter 175; a nonprofit hospital service corporation organized under chapter 176A; a

non-profit medical service corporation organized under chapter 176B; or a health maintenance

organization organized under chapter 176G.

"Catastrophic plan'', a health benefits plan limited exclusively for sale to eligible individuals

who also meet the requirements of eligibility for catastrophic plans as defined in 42 U.S.C. §

18022(e) with premium rates that are consistent with section 3.

"Class of business'', all or a distinct grouping of eligible insureds as shown on the records of

the carrier which is provided with a health benefit plan through a health care delivery system

operating under a license distinct from that of another grouping.

"Connector'', the commonwealth health insurance connector, established by chapter 176Q.

"Connector seal of approval'', the approval given by the board of the connector to indicate that

a health benefit plan meets certain standards regarding quality and value.

"Creditable coverage'', coverage of an individual under any of the following health plans with

no lapse of coverage of more than 63 days: (a) a group health plan; (b) a health plan,

including, but not limited to, a health plan issued, renewed or delivered within or without the

commonwealth to an individual who is enrolled in a qualifying student health insurance

program under section 18 of chapter 15A or a qualifying student health program of another

state; (c) Part A or Part B of Title XVIII of the Social Security Act; (d) Title XIX of the Social

Security Act, other than coverage consisting solely of benefits under section 1928; (e) 10

U.S.C. 55; (f) a medical care program of the Indian Health Service or of a tribal organization;

(g) a state health benefits risk pool; (h) a health plan offered under 5 U.S.C. 89; (i) a public

Managed Care: Health Maintenance Organization (Rev. 103017) Page 63

Pg#_____

health plan as defined in federal regulations authorized by the Public Health Service Act,

section 2701(c)(I)(I), as amended by Public Law 104-191; (j) a health benefit plan under the

Peace Corps Act, 22 U.S.C. 2504(e); (k) coverage for young adults as offered under section 10

of chapter 176J; or (l) any other qualifying coverage required by the Health Insurance

Portability and Accountability Act of 1996, as it is amended, or by regulations promulgated

under that act.

"Date of enrollment'', with respect to an individual covered under a group health plan or health

insurance coverage, the date of enrollment of the individual in the plan or coverage or, if

earlier, the first day of the waiting period for such enrollment.

"Eligible child'', an eligible individual who, as of the beginning of a plan year, has not attained

the age of 21 and who is seeking to enroll in a child-only plan offered by a carrier.

"Eligible employee'', an employee who: (1) works on a full-time basis with a normal work

week of thirty or more hours, and includes an owner, a sole proprietor or a partner of a

partnership; provided however, that such owner, sole proprietor or partner is included as an

employee under a health care plan of an eligible small business but does not include an

employee who works on a temporary or substitute basis, and (2) is hired to work for a period

of not less than five months.

"Eligible dependent'', the spouse or child of an eligible person, subject to the applicable terms

of the health benefit plan covering such employee. The child of an eligible individual or

eligible employee shall be considered an eligible dependent until the end of the child's twenty-

sixth year of age.

"Eligible individual'', an individual who is a resident of the commonwealth.

"Eligible small business'' or "group'', any sole proprietorship, firm, corporation, partnership or

association actively engaged in business who, on at least fifty percent of its working days

during the preceding year employed from among one to not more than fifty eligible

employees, the majority of whom worked in the commonwealth; provided, however, that a

health carrier may offer health insurance to a business of more than fifty employees in

accordance with the provisions of this chapter. In determining the number of eligible

employees, a business shall be considered to be 1 eligible small business or group if: (1) it is

eligible to file a combined tax return for purpose of state taxation, or (2) its companies are

affiliated companies through the same corporate parent. Except as otherwise specifically

provided, provisions of this chapter which apply to an eligible small business shall continue to

apply through the end of the rating period in which an eligible insured no longer meets the

requirements of this definition. An eligible small business that exists within a MEWA shall be

subject to this chapter.

"Emergency services'', services to treat a medical condition, whether physical or mental,

manifesting itself by symptoms of sufficient severity, including severe pain, that the absence

of prompt medical attention could reasonably be expected by a prudent layperson who

possesses an average knowledge of health and medicine, to result in placing the health of an

insured or another person in serious jeopardy, serious impairment to body function, or serious

dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined

in section 1867(e)(l)(B) of the Social Security Act, 42 U.S.C. 1395dd(e)(l)(B).

Managed Care: Health Maintenance Organization (Rev. 103017) Page 64

Pg#_____

"Health benefit plan'', any individual, general, blanket or group policy of health, accident and

sickness insurance issued by an insurer licensed under chapter 175; an individual or group

hospital service plan issued by a non-profit hospital service corporation under chapter 176A;

an individual or group medical service plan issued by a nonprofit medical service corporation

under chapter 176B; and an individual or group health maintenance contract issued by a health

maintenance organization under chapter 176G. Health benefit plans shall not include: accident

only, credit only, limited scope vision or dental benefits if offered separately; hospital

indemnity insurance policies that provide a benefit to be paid to an insured or a dependent,

including the spouse of an insured, on the basis of a hospitalization of the insured or a

dependent, that are sold as a supplement and not as a substitute for a health benefit plan and

that meet any requirements set by the commissioner by regulation; disability income

insurance; coverage issued as a supplement to liability insurance; specified disease insurance

that is purchased as a supplement and not as a substitute for a health plan and meets any

requirements the commissioner by regulation may set; insurance arising out of a workers'

compensation law or similar law; automobile medical payment insurance; insurance under

which benefits are payable with or without regard to fault and which is statutorily required to

be contained in a liability insurance policy or equivalent self insurance; long-term care if

offered separately; coverage supplemental to the coverage provided under 10 U.S.C. 55 if

offered as a separate insurance policy; travel insurance; or any policy subject to chapter 176K

or any similar policies issued on a group basis, Medicare Advantage plans or Medicare

Prescription drug plans. A health plan issued, renewed or delivered within or without the

commonwealth to an individual who is enrolled in a qualifying student health insurance

program under section 18 of chapter 15A shall not be considered a health plan for the purposes

of this chapter and shall be governed by said chapter 15A. Travel insurance for the purpose of

this chapter is insurance coverage for personal risks incident to planned travel, including but

not limited to: (i) interruption or cancellation of trip or event; (ii) loss of baggage or personal

effects; (iii) damages to accommodations or rental vehicles; or (iv) sickness, accident,

disability or death occurring during travel, provided that the health benefits are not offered on

a stand-alone basis and are incidental to other coverages. The term, "travel insurance'' shall not

include major medical plans, which provide comprehensive medical protection for travelers

with trips lasting 6 months or longer, including for example, those working overseas as an ex-

patriot or military personnel being deployed. The commissioner may by regulation define

other health coverage as a health benefit plan for the purposes of this chapter.

"Intermediary'', a chamber of commerce, trade association, or other organization, formed for

purposes other than obtaining insurance, as determined by the commissioner, which offers as a

service to its members the option of purchasing a health benefit plan.

"Qualified association'', a Massachusetts nonprofit or not-for-profit corporation or other entity

organized and maintained for the purposes of advancing the occupational, professional, trade

or industry interests of its association members, other than that of obtaining health insurance,

and that has been in active existence for at least 5 years, that comprises at least 100 association

members and membership in which is generally available to potential association members of

such occupation, profession, trade or industry without regard to the health condition or status

of a prospective association member or the employees and dependents of a prospective

association member.

"Qualifying health plan'', any (i) blanket or general policy of medical, surgical or hospital

Managed Care: Health Maintenance Organization (Rev. 103017) Page 65

Pg#_____

insurance described in subdivision (A), (C) or (D) of section one hundred and ten of chapter

one hundred and seventy-five; (ii) policy of accident or sickness insurance as described in

section one hundred and eight of chapter one hundred and seventy-five which provides

hospital or surgical expense coverage; (iii) nongroup or group hospital or medical service plan

issued by a non-profit hospital or medical service corporation under chapters one hundred and

seventy-six A and one hundred and seventy-six B; (iv) nongroup or group health maintenance

contract issued by a health maintenance organization under chapter one hundred and seventy-

six G; (v) insured group health benefit plan that includes a preferred provider arrangement

under chapter one hundred and seventy-six I; (vi) self-insured or self-funded employer group

health plan; (vii) health coverage provided to persons serving in the armed forces of the United

States; or (viii) medical assistance provided under chapter one hundred and eighteen E. The

commissioner may, by regulation, define other health coverage as a qualifying health plan for

the purposes of this chapter.

"Resident'', a natural person living in the commonwealth, but the confinement of a person in a

nursing home, hospital or other institution shall not by itself be sufficient to qualify a person as

a resident.

"Wellness program'', or "health management program'', an organized system designed to

improve the overall health of participants through activities that may include, but shall not be

limited to, education, health risk assessment, lifestyle coaching, behavior modification and

targeted disease management.

GUARANTEE ISSUE/GUARANTEE RENEWABLE

Pg#_____

Section 4. (a)(1) Every carrier shall make available to every eligible individual and every

small business, including an eligible small group or eligible individual, a certificate that

evidences coverage under a policy or contract issued or renewed to a trust, association or

other entity that is not a group health plan, and their eligible dependents, every health benefit

plan that it provides to any other eligible individual or eligible small business. No health plan

shall be offered to an eligible individual or an eligible small business unless it complies with

this chapter. Upon the request of an eligible small business or an eligible individual, a carrier

shall provide that group or individual with a price for every health benefit plan that it

provides to any eligible small business or eligible individual. Except under the conditions set

forth in paragraph (2) of subsection (b), each carrier shall enroll any eligible small business or

eligible individual which seeks to enroll in a health benefit plan. Each carrier shall permit

each eligible small business group to enroll all eligible employees and all eligible dependents;

provided, however, that the commissioner shall promulgate regulations which limit the

circumstances under which coverage shall be required to be made available to an eligible

employee who seeks to enroll in a health benefit plan significantly later than when such

eligible employee was initially eligible to enroll in a group plan. Notwithstanding the

foregoing, this section shall not apply to health benefit plans sold exclusively as child-only

plans or catastrophic plans.

(2) A carrier shall enroll eligible individuals, as defined by section 1, and eligible individuals,

as defined in section 2741 of the Health Insurance Portability and Accountability Act of

1996, 42 U.S.C. section 300gg?41(b), into a health plan if those individuals request coverage

within 63 days of termination of any prior creditable coverage. A carrier shall also enroll

eligible individuals, as permitted under the Patient Protection and Affordable Care Act,

Public Law 111?148, and any rules, regulations and guidances applicable thereto, as amended

Managed Care: Health Maintenance Organization (Rev. 103017) Page 66

Pg#_____

from time to time. A carrier shall enable any such eligible individual to renew coverage if that

coverage is available to other eligible individuals. Coverage shall become effective in

accordance with said Patient Protection and Affordable Care Act, and any rules, regulations

and guidances applicable thereto, as amended from time to time, subject to reasonable

verification of eligibility, and shall be effective through December 31 of that same year.

Carriers shall notify any such eligible individuals that:

(i) coverage shall be in effect only through December 31 of the year of enrollment;

(ii) if any such eligible individual is in a health plan with a plan-year deductible or out-of-

pocket maximum, an explanation of how that deductible or out-of-pocket maximum and

premiums will be impacted for the period between the plan effective date and December 31

of the enrollment year; and

(iii) the next open enrollment period during which any such eligible individual shall have the

opportunity to enroll in a health plan that will begin on January 1 of the following calendar

year.

A carrier shall not impose a pre-existing condition exclusion or waiting period of any

duration on a health plan.

(3) Notwithstanding paragraph (2), a carrier shall only enroll an eligible individual, as defined

in said paragraph (2) who does not meet the requirements of said paragraph (2) into a health

plan during the annual open enrollment period for eligible individuals and their dependents.

The open enrollment period shall be from October 15 to December 7, inclusive, unless

otherwise designated by the commissioner and coverage shall begin on January 1 of the

following year.

(4) Notwithstanding this section or any other general or special law to the contrary, the office

of patient protection may administer and grant enrollment waivers to permit enrollment not

during a mandatory open enrollment period to the extent permitted under the federal Patient

Protection and Affordable Care Act, or any rules, regulations or guidances applicable thereto,

and in accordance with chapter 6D and any other applicable laws.

(b)(1) Notwithstanding any other provision in this section, a carrier may deny an eligible

individual or eligible small group enrollment in a health benefit plan if the carrier certifies to

the commissioner that the carrier intends to discontinue selling that health benefit plan to new

eligible individuals or eligible small businesses. A health benefit plan closed to new members

may be cancelled and discontinued to all members upon the approval of the commissioner of

insurance when such plan has been closed to enrollment for new individuals and small groups

and the carrier has complied with the requirements of 42 U.S.C. Sec. 300gg?12; provided,

however, that cancellation of the plan shall be effective on the individual or small group's

next enrollment anniversary after such cancellation is approved by the commissioner of

insurance. The commissioner may promulgate regulations prohibiting a carrier from using

this paragraph to circumvent the intent of this chapter.

(2) A carrier shall not be required to issue a health benefit plan to an eligible individual or

eligible small business if the carrier can demonstrate to the satisfaction of the commissioner

that within the prior 12 months, (a) the eligible individual or eligible small business has

Managed Care: Health Maintenance Organization (Rev. 103017) Page 67

Pg#_____



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repeatedly failed to pay on a timely basis the required health premiums; or, (b) the eligible

individual or eligible small business has committed fraud, misrepresented whether or not a

person is an eligible individual or eligible employee, or misrepresented other information

necessary to determine the size of a group, the participation rate of a group, or the premium

rate for a group; or (c) the eligible individual or eligible small business has failed to comply

in a material manner with a health benefit plan provision, including for an eligible small

business, compliance with carrier requirements regarding employer contributions to group

premiums; or (d) the eligible individual voluntarily ceases coverage under a health benefit

plan; provided that the carrier shall be required to credit the time such person was covered

under prior creditable coverage provided by a carrier if the previous coverage was continuous

to a date not more than 63 days prior to the date of the request for the new coverage. A carrier

shall not be required to issue a health benefit plan to an eligible individual or eligible small

business if the individual or small business fails to comply with the carrier's requests for

information which the carrier deems necessary to verify the application for coverage under

the health benefit plan.

(3) A carrier shall not be required to issue a health benefit plan to an eligible individual or

eligible small business if the carrier can demonstrate to the satisfaction of the commissioner

that:

(i) the small business fails at the time of issuance or renewal to meet a participation

requirement established under the definition of participation rate in section 1; or

(ii) acceptance of an application or applications would create for the carrier a condition of

financial impairment, and the carrier makes such a demonstration to the same commissioner.

(4) Notwithstanding any other provision in this section, a carrier may deny an eligible

individual or an eligible small business with 5 or fewer eligible employees enrollment in a

health benefit plan unless the eligible individual or eligible small business enrolls through an

intermediary or the connector. If an eligible individual or an eligible small business with 5 or

fewer eligible employees elects to enroll through an intermediary or the connector, a carrier

may not deny that eligible individual or eligible small business enrollment. The carrier shall

implement such requirements consistently, treating all similarly situated eligible individuals

and eligible small businesses in a similar manner.

(5) Notwithstanding any other provision in this section, with respect to a health benefit plan

offered only through a public exchange that pursuant to federal law and regulation does not

include pediatric dental benefits, a carrier may deny an eligible individual or eligible small

business of any size enrollment in such health benefit plan unless the eligible individual or

eligible small business enrolls through the connector. If an eligible individual or eligible

small business elects to enroll through the connector, a carrier may not deny that eligible

individual or eligible small business enrollment. The carrier shall implement such

requirements consistently, treating all eligible individuals and eligible small business in a

similar manner.

(c)(1) Every health benefit plan shall be renewable as required by the Health Insurance

Portability and Accountability Act of 1996 as amended, or by regulations promulgated under

that act.

Managed Care: Health Maintenance Organization (Rev. 103017) Page 68

Pg#_____

(2) A carrier shall not be required to renew the health benefit plan of an eligible individual or

eligible small business if the individual or small business: (i) has not paid the required

premiums; (ii) has committed fraud, misrepresented whether or not a person is an eligible

individual or eligible employee, or misrepresented information necessary to determine the

size of a group, the participation of a group, or the premium rate for a group; (iii) failed to

comply in a material manner with health benefit plan provisions including, for employers,

carrier requirements regarding employer contributions to group premiums; (iv) fails, at the

time of renewal, to meet the participation requirements of the plan; (v) fails, at the time of

renewal, to satisfy the definition of an eligible individual or eligible small business; or, (vi) in

the case of a group, is not actively engaged in business.

(3) A carrier may refuse to renew enrollment for an eligible individual, eligible employee or

eligible dependent if: (i) the eligible individual, eligible employee or eligible dependent has

committed fraud, misrepresented whether or not he or she is an eligible individual, eligible

employee or eligible dependent, or misrepresented information necessary to determine his

eligibility for a health benefit plan or for specific health benefits; or (ii) the eligible

individual, eligible employee or eligible dependent fails to comply in a material manner with

health benefit plan provisions.

(d) Nothing in this chapter shall prohibit a carrier from offering coverage in a group to a

person, and his dependents, who does not satisfy the hours per week or period employed

portions of the definition of eligible employee.

ANNUAL ACTUARIAL OPINION [M.G.L. c. 176J §7]:

According to M.G.L. c. 176J §7(a)2, “[e]very carrier shall make reasonable disclosure to prospective small

business insureds, as part of its solicitation and sales material of...(2) the participation requirements or

participation rate adjustments of the carrier for each health benefit plan.

Please confirm that the carrier will comply with this requirement.

_____________________________________________________________________________________

Managed Care: Health Maintenance Organization (Rev. 103017) Page 69

INDIVIDUAL PROTECTIONS –

APPLICATION FORM - Application form must conform to requirements of M.G.L. c. 175I:

Please confirm that the carrier is in compliance with M.G.L. c. 175I as well as the Federal HIPAA Privacy

Notice [Title 45 of the Code of Federal Regulations ("CFR") Parts 160 and 164].

_____________________________________________________________________________________

pg____

Form and Content of Policy Applications – [211 CMR 40.13]:

When a person uses an application form to be completed by the applicant as an offer to contract

for an insured health plan, such application form shall contain statements disclosing to the

applicant the nature of the policy offered for sale. In complying with 211 CMR 40.13 the

following guidelines as to the contents and applicability of disclosure requirements shall be

used.

1. If the advertised or marketed policy contains a provision which allows the carrier to deny

claims for any loss, where the cause of such loss is in some manner traceable to a condition

existing prior to the effective date of the policy, the application shall state clearly and

unambiguously in negative terms the nature and extent of that exclusion in accordance with

guidelines spelled out in 211 CMR 40.07(3)(a).

[Pre-Existing Conditions - 211 CMR 40.07(3)(a).

A marketing method shall, in negative terms, disclose the extent to which any loss is

not covered if the cause of such loss is traceable to a condition existing prior to the

effective date of the policy or it shall be considered misleading and therefore

prohibited. The use of the term "pre-existing condition" without an appropriate

definition or description shall not be used or it shall be considered misleading, and

therefore prohibited.]

2. If the application is for a policy whose benefits are subject to a waiting period either of the

deductible kind, e.g. "fifth day for sickness" or of the one-time exclusionary kind, "30 day"

or "six months for certain conditions," the application must disclose in negative terms the

nature of such exclusion.

3. The application must disclose for all health policies whether or not and to what extent

benefits are or are not contingent upon hospital confinement.

4. The application must disclose the premium rate for the policy being solicited.

5. The application must disclose clearly and unambiguously the terms of renewability and

premium guarantee, if any.

At the completion of the above required statements of disclosure space shall be made for the

applicant's signature acknowledging understanding of such disclosures.

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