Fill - Free fillable Managed Care Group Stand-Alone Vision & Dental Products Pursuant to the Requirements of M.G.L. c. 176I & c. 176O and Regulations 211 CMR 52.00 PDF form

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 1

MANAGED CARE INDIVIDUAL STAND-ALONE VISION & DENTAL

PRODUCTS

Pursuant to the Requirements of

M.G.L. c. 176I & c. 176O and regulations 211 CMR 52.00

NOTE TO CARRIERS COMPLETING THIS CHECKLIST:

When completing this 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 (N/A), 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. Any section of this checklist that is not complete will be returned for

completion.

NOTE: A FILING THAT DOES NOT INCLUDE ALL APPLICABLE MATERIALS AND

SUPPORTING DOCUMENTATION WILL BE RETURNED AND NOT REVIEWED.

Date:

Carrier Name & NAIC #:

Contact Name & Title:

Address:

Telephone & Fax:

Email Address:

Product Name & Form #:

(Attach a separate sheet if

necessary.)

NEW APPLICATION SUBMISSIONS

(Pursuant to M.G.L. c. 176I & 211 CMR 51.00)

CARRIERS SEEKING APPROVAL OF AN INTIAL APPLICATION MUST COMPLETE ALL

PAGES OF THIS DOCUMENT.

MATRIAL CHANGE SUBMISSIONS

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

CARRIERS SUBMITTING A MATERIAL CHANGE SHOULD REVIEW ALL PAGES AND

COMPLETE OLNY THOSE PAGES THAT ARE APPLICABLE TO ANY ADDITION(S) OR

CHANGE(S) TO MATERIAL(S) PREVIOUSLY 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 materials that

the submitted materials comply with applicable Massachusetts law.

RESET FORM

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 2

PLEASE REVIEW THE FOLLOWING ADDITIONAL CHECKLIST,

COMPLETE AND FORWARD WITH YOUR SUBMISSION:

 Checklist For The Initial Approval Of An Insured Preferred Provider Plan

(Form# Application For Approval - Insured Preferred Provider Plan ver091217)

Initials______

CARRIER ACKNOWLEGMENTS:

According to 211 CMR 51.05, “[t]he Evidence of Coverage, including all amendments and material

changes, must be submitted to the Commissioner for approval. The Evidence of Coverage must meet

the requirements of M.G.L. c. 176I, M.G.L. c. 176O, 211 CMR 51.00 and 52.00: Managed Care

Consumer Protections and Accreditation of Carriers.”

Initials______

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.”

Initials______

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.”

Initials______

According to 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. .”

Initials______

When submitting a material change to a previously filed application for approval of an insured preferred

provider plan –

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

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

Initials______

According to M.G.L. c. 176O §2(d), “[a] carrier that contracts with another entity to perform some or

all of the functions governed by this chapter shall be responsible for ensuring compliance by said entity

with the provisions of this chapter. Any failure by said entity to meet the requirements of this chapter

shall be the responsibility of the carrier to remedy and shall subject the carrier to any and all

enforcement actions, including financial penalties, authorized under this chapter.”

Initials______

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 3

BULLETIN 2013-07

The Commonwealth Health Insurance Connector Authority (“Health Connector”), is the designated state-

based Exchange for health and dental coverage for individuals, families and small businesses. It is the

Health Connector that certifies stand-alone dental plans [Qualified Dental Plans - “QDPs”] in

Massachusetts and it is only those carriers that have been certified by the Health Connector that may offer

“QDPs.”

As stated in Bulletin 2013-07, “[w]hen a Carrier files a stand-alone dental plan [including riders to be

attached to a stand-alone dental plan] with the Division intended to be offered outside of the Exchange, the

Carrier must indicate in the filing whether the stand-alone dental plan incorporates, at a minimum, the same

benefits as a QDP that the Carrier [emphasis added] is offering within the Exchange…”.”

NOTICES IN STAND-ALONE DENTAL CERTIFICATES:

Identify the section where the appropriate notification language has been included within the certificate

1. According to Bulletin 2013-07, “[a]ll Carriers that are offering or renewing health plans must disclose,

at the time of solicitation, whether a plan covers dental benefits at the pediatric dental EHB level. The

Division recommends that Carriers use the following example of notification language for plans sold

outside the Exchange that include the pediatric dental EHB:

_______

This policy includes coverage of pediatric dental services as required under the federal Patient

Protection and Affordable Care Act.

2. The Division recommends that Carriers use the following example of notification language for plans

sold outside the Exchange that do not include dental benefits at the pediatric dental EHB level:

_______

This policy DOES NOT include coverage of pediatric dental services as required under the

federal Patient Protection and Affordable Care Act. It will only be offered when the Carrier is

reasonably assured that an applicant is covered by a stand-alone dental plan with the required

level of coverage for pediatric dental services.

3. The Division recommends that Carriers use the following example of notification language for plans

sold inside the Exchange that do not include dental benefits at the pediatric dental EHB level:

_______

This policy DOES NOT include coverage of pediatric dental services as required under the

federal Patient Protection and Affordable Care Act. Coverage of the appropriate level of

pediatric dental services may be purchased as a stand-alone plan. You can purchase an

Exchange-certified stand-alone dental plan that includes the appropriate level of coverage for

pediatric dental services from products offered by the Commonwealth Health Insurance

Connector Authority.

In order to be clear that the filed plan IS NOT an Exchange certified stand-alone dental plan, consider the

following example of notification language:

_______

“This policy may include coverage of pediatric dental services as required under the federal

Patient Protection and Affordable Care Act. However, this plan IS NOT an Exchange-certified

stand-alone dental plan. You can purchase an Exchange-certified stand-alone dental plan that

includes the appropriate level of coverage for pediatric dental services from products offered by

the Commonwealth Health Insurance Connector Authority.”

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 4

MATERIALS NECESSARY FOR COMPLIANCE

MANAGED CARE STAND-ALONE VISION OR DENTAL PLANS

(Pursuant to M.G.L. c. 176O and 211 CMR 52.00)

DEFINITIONS (if used) [211 CMR 52.02]:

INSERT PAGE#&SECTION

_______

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

setting.

_______

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

may be recorded by the Carrier as both a disenrollment and an enrollment.

_______

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.

_______

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.

_______

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

by M.G.L. c. 176O, § 2.

_______

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.

_______

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 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.

_______

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.

_______

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

6, or his or her designee.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 5

INSERT PAGE#&SECTION

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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

internal Inquiry process, a Complaint means any Inquiry.

_______

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

stay or course of treatment.

_______

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.

_______

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

the terms of the Health Benefit Plan.

_______

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.

_______

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

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

_______

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

Care Services.

_______

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

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

_______

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.

_______

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

_______

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).

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 6

INSERT PAGE#&SECTION

_______

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.

_______

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.

_______

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

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

_______

Health Care Provider or Provider. A Health Care Professional or Facility.

_______

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.

_______

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.

_______

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.

_______

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.

_______

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

website, a web portal, or electronic mail.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 7

INSERT PAGE#&SECTION

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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.

_______

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.

_______

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: (a) an Insured; (b) a Carrier, including a Dental or

Vision Carrier; and/or (c) a health, Dental, or Vision Care Provider.

_______

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.

_______

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.

_______

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.

_______

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.

_______

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.

_______

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.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 8

INSERT PAGE#&SECTION

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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.

_______

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.

_______

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.

_______

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.

_______

Vision Care Professional. An ophthalmologist, optometrist or other practitioner

licensed, accredited or certified to perform specified Vision Services consistent with the

law.

_______

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

provide Vision Care Services.

_______

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

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

_______

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.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 9

STANDARDS FOR PROVIDER CONTRACTS [211 CMR 52.11]:

INSERT PAGE#&SECTION

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Contracts between Carriers and Providers shall state that a Carrier shall not refuse to

contract with or compensate for covered services an otherwise eligible Health Care

Provider solely because such Provider has in good faith:

(a) communicated with or advocated on behalf of one or more of his or her

prospective, current or former patients regarding the provisions, terms or

requirements of the Carrier's Health Benefit Plans as they relate to the needs of

such Provider's patients; or

(b) communicated with one or more of his or her prospective, current or former

patients with respect to the method by which such Provider is compensated by the

Carrier for services provided to the patient. [211 CMR 52.11(1)]

_______

Contracts between Carriers and Providers shall state that the Provider is not required

to indemnify the Carrier for any expenses and liabilities, including, without limitation,

judgments, settlements, attorneys' fees, court costs and any associated charges, incurred

in connection with any claim or action brought against the Carrier based on the Carrier's

management decisions, Utilization Review provisions or other policies, guidelines or

actions.

[211 CMR 52.11(2)]

_______

No contract between a Carrier and a Licensed Health Care Provider Group may contain

any Incentive Plan that includes a specific payment made to a Health Care Professional

as an inducement to reduce, delay or limit specific, Medically Necessary services

covered by the health care contract.

(a) Health Care Professionals shall not profit from provision of covered services that

are not Medically Necessary or medically appropriate.

(b) Carriers shall not profit from denial or withholding of covered services that are

Medically Necessary or medically appropriate.

contain Incentive Plans that involve general payments such as Capitation

payments or shared risk agreements between Carriers and Providers, so long as

such contracts, which impose risk on such Providers for the costs of care,

services and equipment provided or authorized by another Health Care Provider,

comply with 211 CMR 52.11(4) and 155.00: Risk-bearing Provider

Organizations.

(d) In the event that a Provider with which a Carrier has a contract makes any

decisions about coverage of requested care, then the Carrier remains responsible

to ensure compliance with all applicable utilization review processes, including

but not limited to adverse determination notices that describe rights to appeal

medical necessity denials. [211 CMR 52.11(3)]

Identify the section(s) and page number(s) of the provider contracts(s) that address the

above-noted requirement by line item.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 10

No Carrier may enter into a new contract, revise the risk arrangements in an existing contract, or revise

the fee schedule in an existing contract with a Health Care Provider which imposes financial risk on

such Provider for the costs of care, services or equipment provided or authorized by another Provider

unless such contract includes specific provisions with respect to the following:

(a) stop loss protection;

(b) minimum patient population size for the Provider group; and

Provide a statement that advises whether the carrier has issued new contracts as described above, and

if so, reference the section(s) of the provider contract that address the above. [211 CMR 52.11(4)]

__________________________________________________________________________________________

Contracts between Carriers and Health Care Providers shall require Providers to comply with the

Carrier's requirements for Utilization Review, quality management and improvement, credentialing

and the delivery of Preventive Health Services. [211 CMR 52.11(11)]

Identify the section(s) and page number(s) of the provider contracts(s) that address this requirement.

__________________________________________________________________________________________

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 11

PROMPT PAYMENT

(see also M.G.L. c. 176A, § 8(e); M.G.L. c. 176B, § 7; M.G.L. c. 176G, § 6; M.G.L. c. 176I, § 2)

INSERT PAGE#&SECTION

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According to M.G.L. c. 175, § 110(G), “[w]ithin forty-five days from . . . receipt of notice [of a

claim by a claimant] if payment is not made the insurer shall notify the claimant in writing

specifying the reasons for the nonpayment or whatever further documentation is necessary for

payment of said claim within the terms of the policy. If the insurer fails to comply with the

provisions of this paragraph, said insurer shall pay, in addition to any benefits which inure to

such claimant or provider, interest on such benefits, which shall accrue beginning forty-five

days after the insurer's receipt of notice of claim at the rate of one and one-half percent per

month, not to exceed eighteen percent per year. The provisions of this paragraph relating to

interest payments shall not apply to a claim which an insurer is investigating because of

suspected fraud.”

Please identify the section(s) and page number(s) of the provider contracts(s) that clearly

identify the above-noted statute (See also Bulletin 00-13)

STANDARDS FOR CREDENTIALING [211 CMR 52.14(9) - M.G.L. C. 176O §15(I)]:

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.

Confirm that the carrier complies with this requirement.

__________________________________________________________________________________________

EVIDENCES OF COVERAGE 211 CMR 52.13(2)

Dental and Vision Carriers shall issue and deliver to at least one adult Insured in each household

residing in Massachusetts, upon enrollment:

a) an Evidence of Coverage;

b) a summary of the information contained in the Evidence of Coverage; or

c) refer the Insured to resources where the information described in such Evidence of Coverage can

be accessed, including, but not limited to, an Internet Website.

Provide a detailed narrative explaining how the carrier complies with items a-c., as applicable. Indicating

NA is not acceptable.

__________________________________________________________________________________________

FLESCH SCORE DOCUMENTATION (M.G.L. c. 175 §2B)

FORWARD certification by a company official that each form meets the standards of M.G.L. c. 175, § 2B.

If insurer feels that any form is exempt from M.G.L. c. 175, § 2B, certification should state reason(s) for

exemption. The term "text" includes all printed matter except the name and address of the insurer, name or

title of the policy, captions and subcaptions, and schedule pages and tables used in the policy.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 12

EVIDENCE OF COVERAGE [211 CMR 52.13(3) - M.G.L. c. 176O §6(b)]:

INSERT PAGE#&SECTION

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(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;

(d) The limitations on the scope of:

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;

(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.

[211 CMR 52.14(1)( c)]

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.]

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

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 13

_______

process for seeking expedited internal review and concurrent expedited internal and external

reviews pursuant to 958 CMR 3.000

(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.

INTERNET WEBSITE [211 CMR 52.13(4)

Does the carrier refer Insureds to an Internet Website where information described within the Evidence

of Coverage can be accessed? [Internet Websites. 211 CMR 52.13(4)]

YES ___ NO ___

IF YES ADDRESS THE FOLLOWING:

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 applicable law, and with

the following with respect to the Internet Website:

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 Evidence 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. [211 CMR 52.13(4)(a)]

ATTACH A COPY OF THE WRITTEN NOTICE ADRESSING ITEMS 1-6

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 14

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. . [211 CMR 52.13(4)(b)]

Certify that the carrier complies with this requirement.

__________________________________________________________________________________________

The Carrier has taken reasonable measures to ensure that it furnishes, upon request of the Insured, a

paper copy of the Evidence of Coverage and any amendments thereto. . [211 CMR 52.13(4)(c)]

Certify that the carrier complies with this requirement.

__________________________________________________________________________________________

EVIDENCE OF COVERAGE - ADDITONALCARRIER RESPONSIBILITIES

Identify the page and section of the form that address the following:

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 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. [211 CMR 52.14(1)(d)]

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. [Group Plans. 211 CMR 52.13(5)]

Certify that the carrier complies with this requirement.

__________________________________________________________________________________________

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 15

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.

[General Notice of Material Changes. 211 CMR 52.13(6)]

Certify that the carrier complies with this requirement.

__________________________________________________________________________________________

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 cost of any

such changes. [Advance Notice of Material Modifications. 211 CMR 52.13(7)]

Certify that (1) the carrier complies with this requirement and (2) identify the page & section of the

evidence of coverage where this statement may be found.

__________________________________________________________________________________________

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. [Advance Filing of Evidence of Coverage.

211 CMR 52.13(8)]

Certify that (1) the carrier complies with this requirement and (2) identify the page & section of the

evidence of coverage where this statement may be found.

__________________________________________________________________________________________

Every Evidence of Coverage described in 211 CMR 52.13 must contain the effective date, date of issue

and, if applicable, expiration date. [Dates Required. 211 CMR 52.13(9)]

Confirm where this information is located within the face page or secondary page location of the evidence

of coverage.

__________________________________________________________________________________________

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 16

DEPENDENT ELIGIBILITY – Applicable to Vision Stand-Alone Only

According to M.G.L. c. 176A §8BB and M.G.L. c. 176B §4BB, “[a]ny subscription certificate under an

individual or group nonprofit hospital service agreement, except certificates which provide stand-alone dental

services, supplemental coverage to Medicare or other governmental programs, that is delivered, issued or

renewed in the commonwealth, shall provide, as benefits to all individuals or to all group members having a

principal place of employment within the commonwealth, coverage to eligible dependents under 26 years of

age.”

Please identify the section(s) and page number(s) of the evidence of coverage(s) that clearly identify the

above-noted statute.

__________________________________________________________________________________________

CONTINUATION OF COVERAGE PROVISIONS

According to 211 CMR 52.13(3)(s), evidences of coverage shall contain a clear, concise and complete

statement of the requirements for continuation of coverage mandated by state and federal law as

follows:

Insured Leaves Group. [This provision applies to dental and vision insurance - *§110D states "Every

policy of insurance" under chapter 110.]

According to M.G.L. c. 175 §110D, “[e]very policy of insurance issued after January first, nineteen hundred

and sixty-eight under the provisions of section one hundred and ten shall contain a provision that, in the event

that the insured person leaves the group covered by such insurance, said person shall remain insured under

such policy for a period of thirty-one days thereafter unless, during such period, he shall otherwise be entitled

to similar benefits. The provisions of this paragraph shall apply to any policy issued or renewed within or

without the commonwealth and which covers residents of the commonwealth.

Please identify the section and page number of the evidence of coverage that completely describes the

above-noted statute.

__________________________________________________________________________________________

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 17

Divorce or of Separate Support. [*M.G.L. c. 175 §110I states "group hospital, surgical, medical, or dental

insurance”]

According to M.G.L. c. 175 §110I(a), “[i]n the event of the granting of a judgment absolute of divorce or of

separate support to which a member of a group hospital, surgical, medical, or dental insurance plan provided for

in section one hundred and ten 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 plan,

 whether or not said judgment was entered prior to the effective date of said plan,

 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 plan until the remarriage of

either the member or such spouse

 or until such time as provided by said judgment, whichever is earlier.

 The provision of this section shall apply to any policy issued or renewed within or without the

commonwealth and which covers residents of the commonwealth.

According to M.G.L. c. 175 §110I(b), “[i]n the event of the remarriage of the group plan member referred to in

subsection (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 plan or the

issuance of an individual plan, 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.

Please identify the section and page number of the evidence of coverage that completely describes the

above-noted statute.________________________________________________________________________

Divorce or of Separate Support. [(M.G.L. c. 176A §8F and c. 176B §6B)]

(a) In the event of the granting of a judgment absolute of divorce or of separate support to which a subscriber of

a group nonprofit hospital service contract [medical service plan] is a party, the person who was the spouse of

said subscriber 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

subscriber’s participation in the plan until the remarriage of either the subscriber or such spouse, or until such

time as provided by said judgment, whichever is earlier.

(b) In the event of the remarriage of the group contract subscriber 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 subscriber, 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.

Please identify the section and page number of the evidence of coverage that completely describes the

above-noted statute. ________________________________________________________________________

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 18

GROUP HEALTH CARE INSURERS, TERMINATION OF COVERAGE

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 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.

As defined in 940 CMR 9.04, the term “Group Health Insurance Plan” means “[a] contract, arrangement or

policy between a Group Health Care Insurer and a Sponsor under which the Group Health Care Insurer agrees to

pay for or provide medical, chiropractic, optometric, dental or other health care services.”

Please identify the section(s) and page number of the evidence of coverage that clearly identify the above-

noted regulatory provision.

__________________________________________________________________________________________

APPLICATION FORMS [211 CMR 40.00]:

_______

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.

6. At the completion of the above required statements of disclosure space shall be made for the

applicant's signature acknowledging understanding of such disclosures.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 19

INDIVIDUAL REQUIREMENTS

FOR PRODUCTS MARKETED AND SOLD IN MASSACHUSETTS

INDIVIDUAL REQUIREMENTS – POLICY:

_______

General Requirements for all individual dental insurance filings:

 Policy or Evidence of Coverage

 Provider Contracts

 Disclosure Statement (Outline of Coverage)

 Application

 Notice of Information Practices

 Replacement form

 Flesch Score Document

INDIVIDUAL REQUIREMENTS – COVER PAGE:

_______

Company name, address and telephone number are listed.

All pre-existing conditions must appear as a separate paragraph on the cover page. 211 CMR

42.05(1)(b)

All policies must include at least a 10-day right of examination from date of delivery and such

right must be explained in the policy. 211 CMR 42.05(1)(e)

INDIVIDUAL REQUIREMENTS – DEFINITIONS:

_______

Definitions should be in alphabetical order for ease of disclosure of policy provisions and

comparison with other policies. If used, must conform with the following:

Accident, Accidental Injury, Accidental Means - “must be defined to employ “result”

language and may not include words which establish an accidental means test or use words such

as “external, violent, visible wounds” or similar words of description or characterization. The

definition may not be modified or an exception or limitation may be included to provide that

injuries shall not include injuries for which benefits are provided under any workmen’s

compensation, occupational disease, employer’s liability or similar law.” 211 CMR 42.04

Class “underwriting/rating classifications used when policy originally issued.” 211 CMR 42.04

Medicare - “program established under Title XVIII of federal Social Security Act, “Health

Insurance for the Aged Act”, 42 UCSC § 1396 et seq., as amended.” 211 CMR 42.04

Policy - “any policy, plan, certificate, contract, agreement, statement of coverage, rider or

endorsement which provides insurance benefits whether as a service or on an indemnity

reimbursement or prepaid basis.” 211 CMR 42.04

Pre-existing condition - “medical condition for which an insured persons received medical

advice or treatment during a period to be determined by the carrier prior to the effective date of

coverage or because of which an individual had symptoms which would have led an ordinarily

prudent person to seek medical advice or treatment for that medical condition, or a pregnancy

existing on the effective date of coverage.” 211 CMR 42.04

Sickness - “must be defined to be no more restrictive that a sickness or disease of an insured

that first manifests itself after the effective date of insurance and while the insurance is in force.

This definition may be modified to exclude sickness or disease for which benefits are provided

under any workmen’s compensation, occupational disease, employer’s liability or similar law.”

211 CMR 42.04

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 20

INDIVIDUAL REQUIREMENTS – DISCLOSURE:

_______

A policy paying benefits based on standards described as “usual and customary,”

“reasonable and customary,” or words of similar import must define and explain the terms

in its outline of coverage. 211 CMR 42.05(1)(a)

No misleading policy names may be used and no policy may be marketed or advertised as a

group policy unless it qualifies as such. 211 CMR 42.09(1)(a)

A carrier’s policy name may not misrepresent the extent of benefits actually provided nor

may a name be used which conflicts with the prescribed category name or which is similar

to the prescribed name of a different category. 211 CMR 42.09(1)(a)

If age is to be used as a determining factor for reducing benefits made available in the

policy as originally issued, such fact must be prominently set forth in the policy. 211 CMR

42.09(1)(b)

All insurance policies must contain a renewability provision on the first page of the policy

in a highlighted section. 211 CMR 42.09(1)(c)

In the event that the policy is issued on a basis other than that applied for, the outline of

coverage must contain the following statement, in no less than 12-point type, immediately

above the company name:

“NOTICE: Read this outline carefully. The coverage you originally applied for has not been

issued. This policy is therefore not identical to the coverage you requested - it differs in the

following respects: [list]” 211 CMR 42.09(1)(d)

Policies providing conversion privileges must specify the benefits to be provided or shall

state that the converted coverage shall be on the policy form then being issued by the

company for this purpose. 211 CMR 42.09(1)(f)

INDIVIDUAL REQUIREMENTS – LIMITATIONS & EXCLUSIONS:

_______

Limitations on benefits should where possible be so labeled in a separate section of the

policy or placed with the benefit provisions to which they apply, rather than or in addition to

included in other sections of the policy.

Termination of the policy should be without prejudice to any continuous loss which

commenced while the policy was in force, but the extension of benefits beyond the period

while the policy was in force may be predicated upon the continuous total disability of the

insured or limited to the extent of the benefit period.

Pre-existing limitations must appear as a separate paragraph of the policy and be labeled as

"Pre-existing Condition Limitations." 211 CMR 42.05(1)(b)

The policy must clearly explain all limitations and elimination periods, including

elimination periods affecting different levels of benefits. 211 CMR 42.05(2)(g)

The following exclusions are common and permitted:

1. Pre-existing

2. War or act of war, declared or undeclared.

3. Participation in a felony, riot or insurrection.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 21

_______

4. Service in armed forces or auxiliary units.

5. Intentionally self-inflicted injury or attempted suicide.

6. Aviation (non-fare paying passengers).

7. Alcohol or drug detoxification or rehabilitation

8. Government facility, non-Medicaid government program including Medicare, any state or

workers' compensation, employer's liability or occupational disease law, or any motor

vehicle no-fault law; services provided by a member of the insured's immediate family and

services for which no charge is made in the absence of insurance.

INDIVIDUAL REQUIREMENTS – UNIFORM PROVISIONS:

M.G.L. c. 175, §108 3.(b)

_______

(1) Entire Contract; Changes. — This policy, including the endorsements and the

attached papers, if any, constitutes the entire contract of insurance. No change in this

policy shall be valid until approved by an executive officer of the insurer and unless such

approval be endorsed hereon or attached hereto. No agent has authority to change this

policy or to waive any of its provisions.

_______

(2) Time Limit on Certain Defenses. — After two years from the date of issue of this

policy no misstatements, except fraudulent misstatements, made by the applicant in the

application for such policy shall be used to void the policy or to deny a claim for loss

incurred or disability as defined in the policy commencing after the expiration of such

two-year period.

_______

The foregoing policy provision shall not be so construed as to affect any legal

requirement for avoidance of a policy or denial of a claim during such initial two-year

period, nor to limit the application of provisions (1) to (5), inclusive, of paragraph (b) of

this subdivision, in the event of misstatement with respect to age or occupation or other

insurance.

_______

A policy which the insured has the right to continue in force subject to its terms by the

timely payment of premium until at least age fifty, or, in the case of a policy issued after

age forty-four, for at least five years from its date of issue, may contain in lieu of the

foregoing provision the following provision from which the clause in parentheses may be

omitted at the insurer’s option, under the caption “INCONTESTABLE”:—

_______

After this policy has been in force for a period of two years during the lifetime of the

insured (excluding any period during which the insured is disabled), it shall become

incontestable as to the statements contained in the application.

_______

No claim for loss incurred or disability (as defined in the policy) commencing after two

years from the date of issue of this policy shall be reduced or denied on the ground that a

disease or physical condition not excluded from coverage by name or specific description

effective on the date of loss had existed prior to the effective date of coverage of this

policy.

_______

(3) Grace Period. — A grace period of [insert a number not less than “7” for weekly

premium policies, “10” for monthly premium policies and “31” for all other policies] days

will be granted for the payment of each premium falling due after the first premium

during which grace period the policy shall continue in force.

_______

A policy in which the insurer reserves the right to refuse renewal shall have, at the

beginning of the above provision:— Unless not less than thirty days prior to the premium

due date the insurer has delivered to the insured or has mailed to his last address as shown

by the records of the insurer written notice of its intention not to renew this policy beyond

the period for which the premium has been accepted.

_______

(4) Reinstatement. — If any renewal premium be not paid within the time granted the

insured for payment, a subsequent acceptance of premium by the insurer or by any agent

duly authorized by the insurer to accept such premium, without requiring in connection

therewith an application for reinstatement, shall reinstate the policy; provided, however,

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 22

that if the insurer or such agent requires an application for reinstatement and issues a

conditional receipt for the premium tendered, the policy will be reinstated upon approval

of such application by the insurer or, lacking such approval, upon the forty-fifth day

following the date of such conditional receipt unless the insurer has previously notified

the insured in writing of its disapproval of such application. The reinstated policy shall

cover only loss resulting from such accidental injury as may be sustained after the date of

reinstatement and loss due to such sickness as may begin more than ten days after such

date. In all other respects the insured and insurer shall have the same rights thereunder as

they had under the policy immediately before the due date of the defaulted premium,

subject to any provisions endorsed hereon or attached hereto in connection with the

reinstatement. Any premium accepted in connection with a reinstatement shall be applied

to a period for which premium has not been previously paid, but not to any period more

than sixty days prior to the date of reinstatement.

_______

The last sentence of the above provision may be omitted from any policy which the

insured has the right to continue in force subject to its terms by the timely payment of

premiums until at least age fifty, or, in the case of a policy issued after age forty-four, for

at least five years from its date of issue.

_______

(5) Notice of Claim. — Written notice of claim must be given to the insurer within twenty

days after the occurrence or commencement of any loss covered by the policy, or as soon

thereafter as is reasonably possible. Notice given by or on behalf of the insured or the

beneficiary to the insurer at [insert the location of such office as the insurer may designate

for the purpose] or to any authorized agent of the insurer, with information sufficient to

identify the insured, shall be deemed notice to the insurer.

_______

In a policy providing a loss-of-time benefit which may be payable for at least two years,

an insurer may at its option insert after the first sentence of provision (5) the following

three sentences:—

_______

Subject to the qualifications set forth below, if the insured suffers loss of time on account

of disability for which indemnity may be payable for at least two years, he shall, at least

once in every six months after having given notice of claim, give to the insurer notice of

continuance of said disability, except in the event of legal incapacity. The period of six

months following any filing of proof by the insured or any payment by the insurer on

account of such claim or any denial of liability in whole or in part by the insurer shall be

excluded in applying this provision. Delay in the giving of such notice shall not impair the

insured’s right to any indemnity which would otherwise have accrued during the period of

six months preceding the date on which such notice is actually given.

_______

(6) Claim Forms. — The insurer, upon receipt of a notice of claim, will furnish to the

claimant such forms as are usually furnished by it for filing proofs of loss. If such forms

are not furnished within fifteen days after the giving of such notice the claimant shall be

deemed to have complied with the requirements of this policy as to proof of loss upon

submitting, within the time fixed in the policy for filing proofs of loss, written proof

covering the occurrence, the character and the extent of the loss for which claim is made.

_______

(7) Proof of Loss. — Written proof of loss must be furnished to the insurer at its said

office in case of claim for loss for which this policy provides any periodic payment

contingent upon continuing loss within ninety days after the termination of the period for

which the insurer is liable and in case of claim for any other loss within ninety days after

the date of such loss. Failure to furnish such proof within the time required shall not

invalidate nor reduce any claim if it was not reasonably possible to give proof within such

time, provided such proof is furnished as soon as reasonably possible and in no event,

except in the absence of legal capacity, later than one year from the time proof is

otherwise required.

_______

(8) Time of Payment of Claims. — Indemnities payable under this policy for any loss

other than loss for which this policy provides any periodic payment will be paid

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 23

immediately upon receipt of due written proof of such loss. Subject to due written proof

of loss, all accrued indemnities for loss for which this policy provides periodic payment

will be paid [insert period for payment which must not be less frequently than monthly]

and any balance remaining unpaid upon the termination of liability will be paid

immediately upon receipt of due written proof.

_______

(9) Payment of Claims. — Indemnity for loss of life will be payable in accordance with

the beneficiary designation and the provisions respecting such payment which may be

prescribed herein and effective at the time of payment. If no such designation or provision

is then effective, such indemnity shall be payable to the estate of the insured. Any other

accrued indemnities unpaid at the insured’s death may, at the option of the insurer, be

paid either to such beneficiary or to such estate. All other indemnities will be payable to

the insured.

_______

The following two paragraphs, or either of them, may be added to provision (9) at the

option of the insurer:—

_______

If any indemnity of this policy shall be payable to the estate of the insured, or to an

insured or beneficiary who is a minor or otherwise not competent to give a valid release,

the insurer may pay such indemnity, up to an amount not exceeding [insert an amount

which shall not exceed $1,000], to any relative by blood or connection by marriage of the

insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any

payment made by the insurer in good faith pursuant to this provision shall fully discharge

the insurer to the extent of such payment.

_______

Subject to any written direction of the insured in the application or otherwise all or a

portion of any indemnities provided by this policy on account of hospital, nursing,

medical, or surgical services may, at the insurer’s option and unless the insured requests

otherwise in writing not later than the time of filing proofs of such loss, be paid directly to

the hospital or person rendering such services; but it is not required that the service be

rendered by a particular hospital or person.

_______

(10) Physical Examinations. — The insurer at its own expense shall have the right and

opportunity to examine the person of the insured when and as often as it may reasonably

require during the pendency of a claim hereunder.

_______

(11) Legal Actions. — No action at law or in equity shall be brought to recover on this

policy prior to the expiration of sixty days after written proof of loss has been furnished in

accordance with the requirements of this policy. No such action shall be brought after the

expiration of three years after the time written proof of loss is required to be furnished.

_______

(12) Change of Beneficiary. — Unless the insured makes an irrevocable designation of

beneficiary, the right to change of beneficiary is reserved to the insured and the consent of

the beneficiary or beneficiaries shall not be requisite to surrender or assignment of this

policy or to any change of beneficiary or beneficiaries, or to any other changes in this

policy

INDIVIDUAL REQUIREMENTS – OPTIONAL PROVISIONS:

M.G.L. c. 175, §108 3.(b)

_______

(1) Change of Occupation. — If the insured be injured or contract sickness after having

changed his occupation to one classified by the insurer as more hazardous than that stated in

this policy or while doing for compensation anything pertaining to an occupation so

classified, the insurer will pay only such portion of the indemnities provided in this policy as

the premium paid would have purchased at the rates and within the limits fixed by the

insurer for such more hazardous occupation. If the insured changes his occupation to one

classified by the insurer as less hazardous than that stated in this policy, the insurer, upon

receipt of proof of such change of occupation, will reduce the premium rate accordingly, and

will return the excess pro-rata unearned premium from the date of change of occupation or

from the policy anniversary date immediately preceding receipt of such proof, whichever is

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 24

the more recent. In applying this provision, the classification of occupational risk and the

premium rates shall be such as have been last filed by the insurer prior to the occurrence of

the loss for which the insurer is liable or prior to date of proof of change in occupation with

the state official having supervision of insurance in the state where the insured resided at the

time this policy was issued; but if such filing was not required, then the classification of

occupational risk and the premium rates shall be those last made effective by the insurer in

such state prior to the occurrence of the loss or prior to the date of proof of change in

occupation.

_______

(2) Misstatement of Age. — If the age of the insured has been misstated, all amounts

payable under this policy shall be such as the premium paid would have purchased at the

correct age.

_______

(3) Other Insurance in This Insurer. — If an accident or sickness or accident and sickness

policy or policies previously issued by the insurer to the insured be in force concurrently

herewith, making the aggregate indemnity for [insert type of coverage or coverages] in

excess of [insert maximum limit of indemnity or indemnities] the excess insurance shall be

void and all premiums paid for such excess shall be returned to the insured or to his estate.

or, in lieu thereof:—

_______

Insurance effective at any one time on the insured under a like policy or policies in this

insurer is limited to the one such policy elected by the insured, his beneficiary or his estate,

as the case may be, and the insurer will return all premiums paid for all other such policies.

_______

(4) Insurance with Other Insurers. — If there be other valid coverage, not with this insurer,

providing benefits for the same loss on a provision of service basis or on an expense incurred

basis and of which this insurer has not been given written notice prior to the occurrence or

commencement of loss, the only liability under any expense incurred coverage of this policy

shall be for such proportion of the loss as the amount which would otherwise have been

payable hereunder plus the total of the like amounts under all such other valid coverages for

the same loss of which this insurer had notice bears to the total like amounts under all valid

coverages for such loss, and for the return of such portion of the premiums paid as shall

exceed the pro-rata portion for the amount so determined. For the purpose of applying this

provision when other coverage is on a provision of service basis, the like amount of such

other coverage shall be taken as the amount which the services rendered would have cost in

the absence of such coverage.

_______

If the above policy provision (4) is included in a policy which also contains the next

following policy provision there shall be added to the caption of said provision (4) the phrase

C EXPENSE INCURRED BENEFITS. The insurer may, at its option, include in this

provision a definition of other valid coverage, approved as to form by the commissioner,

which definition shall be limited in subject matter to coverage provided by organizations

subject to regulation by insurance law or by insurance authorities of this or any other state of

the United States or any province of Canada, and by hospital or medical service

organizations, and to any other coverage the inclusion of which may be approved by the

commissioner. In the absence of such definition such term shall not include group insurance,

automobile medical payments insurance, or coverage provided by hospital or medical service

organizations or by union welfare plans or employer or employee benefit organizations. For

the purpose of applying policy provision (4) with respect to any insured, any amount of

benefit provided for such insured pursuant to any compulsory benefit statute including any

workers’ compensation or employer’s liability statute whether provided by a governmental

agency or otherwise shall in all cases be deemed to be other valid coverage of which the

insurer has had notice. In applying said policy provision (4) no third party liability coverage

shall be included as other valid coverage.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 25

_______

(5) Insurance with Other Insurers. — If there be other valid coverage, not with this insurer,

providing benefits for the same loss on other than an expense incurred basis and of which

this insurer has not been given written notice prior to the occurrence or commencement of

loss, the only liability for such benefits under this policy shall be for such proportion of the

indemnities otherwise provided hereunder for such loss as the like indemnities of which the

insurer had notice (including the indemnities under this policy) bear to the total amount of all

like indemnities for such loss, and for the return of such portion of the premium paid as shall

exceed the pro-rata portion for the indemnities thus determined.

_______

If policy provision (5) is included in a policy which also contains policy provision (4) there

shall be added to the caption of said provision (5) the phrase C OTHER BENEFITS. The

insurer may, at its option, include in this provision a definition of other valid coverage,

approved as to form by the commissioner, which definition shall be limited in subject matter

to coverage provided by organizations subject to regulation by insurance law or by insurance

authorities of this or any other state of the United States or any province of Canada, and to

any other coverage the inclusion of which may be approved by the commissioner. In the

absence of such definition such term shall not include group insurance, or benefits provided

by union welfare plans or by employer or employee benefit organizations. For the purpose of

applying said policy provisions (5) with respect to any insured, any amount of benefit

provided for such insured pursuant to any compulsory benefit statute including any workers’

compensation or employer’s liability statute whether provided by a governmental agency or

otherwise shall in all cases be deemed to be other valid coverage of which the insurer has

had notice. In applying the said policy provision (5) no third party liability coverage shall be

included as other valid coverage.

_______

(6) Overinsurance. — see statutory citation

_______

(7) Unpaid Premium. — Upon the payment of a claim under this policy, any premium then

due and unpaid or covered by any note or written order may be deducted therefrom.

_______

(9) Conformity with State Statutes. — Any provision of this policy which, on its effective

date, is in conflict with the statutes of the state in which the insured resides on such date is

hereby amended to conform to the minimum requirements of such statutes.

_______

(10) Illegal Occupation. — The insurer shall not be liable for any loss to which a

contributing cause was the insured’s commission of or attempt to commit a felony or to

which a contributing cause was the insured’s being engaged in an illegal occupation.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 26

INDIVIDUAL REQUIREMENTS – OUTLINE OF COVERAGE / POLICY

SUMMARY / DISCLOSURE FORM:

_______

No individual accident and sickness insurance policy or contract may be delivered or issued

for delivery in Massachusetts unless the disclosure form is delivered with the policy, or is

delivered to the applicant at the time application is made. 211 CMR 42.09(3)(a)

The summary must be a part of the policy and must be plainly printed in light-faced type of

a style in general use, size of which shall be uniform and not less than 10-point with lower-

case unspaced alphabet length not less than 12-point. 211 CMR 42.09(3)(a)

If the policy is issued on a changed basis from what was originally requested, a revised

summary must be affixed to the policy. 211 CMR 42.09(3)(b)

Except as otherwise provided, disclosure forms must provide the following information

when it is applicable to the form: 211 CMR 42.09(3)(c)

1. Name of the carrier, description of the policy type, the policy number.

2. Description of benefits in a manner that does not misrepresent the actual coverage

provided in the policy.

3. Any deductibles, coinsurance, and benefit maximums.

4. Whether the policy is renewable to eligibility to Medicare.

5. Whether there are any age limitations.

6. Whether the policy is subject to premium increases.

7. Any pre-existing condition limitations

8. Any waiting periods.

9. Whether mental illness is covered and the extent of benefits.

10. Whether pregnancy is covered.

11. Free look provisions and the procedure for returning the policy for a refund.

12. The following statement or similar language as approved by the Commissioner:

“Read your policy carefully. This disclosure statement is a very brief summary of

your policy. The policy itself sets forth the rights and obligations of both you and

the insurance company. It is, therefore, important that you READ YOUR POLICY

CAREFULLY.”

13. Exclusions, limitations and reductions listed in a manner that does not misrepresent

the actual coverage provided.

14. The following statement or similar language as approved by the Commissioner

“COMPLAINTS: If you have a complaint, call us at [ ] or your agent. If you are

not satisfied, you may call the Massachusetts Division of Insurance.”

INDIVIDUAL REQUIREMENTS – APPLICATION FORM:

_______

Applications to be attached to policy forms upon issue should be attached to such forms

upon submission. If such an application was previously filed and approved or deemed

approved, the approximate date of such approval must be noted, if possible.

The application forms must contain a question to elicit information as to whether the

insurance to be issued is to replace any other accident and sickness insurance currently in

force. A supplementary application or other form to be signed by the applicant containing

such a question may be used. 211 CMR 42.08(1)

Any rider, amendment or endorsement used to reduce or eliminate coverages at date of

policy issue shall be ineffective without the signed acceptance by the insured policyholder.

211 CMR 42.09(2)

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 27

_______

Riders or endorsements that provide a benefit for which a specific premium is charged shall

show the premium on the application, rider or elsewhere in the policy. 211 CMR 42.09(2)

When the Medical Information Bureau is used by the insurer, the policy application or

another appropriate notice shall indicate the possible use of this service as it relates to

medical information concerning the insured. 211 CMR 42.09(2)

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.

7. 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.]

8. 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.

9. The application must disclose for all health policies whether or not and to what extent

benefits are or are not contingent upon hospital confinement.

10. The application must disclose the premium rate for the policy being solicited.

11. The application must disclose clearly and unambiguously the terms of renewability and

premium guarantee, if any.

12. At the completion of the above required statements of disclosure space shall be made for

the applicant's signature acknowledging understanding of such disclosures.

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 28

INDIVIDUAL REQUIREMENTS – CONFIDENTIALITY OF INFORMATION:

_______

Application form must conform to requirements of M.G.L. c. 175I:

A notice of information practices must be provided to all applicants no later than at the

time the application for insurance is made. The notice must be in writing and must contain

EITHER:

whether personal information may be collected from persons other than the individual

proposed for coverage; M.G.L. c. 175I § 4(b)(1)

the type of personal information that may be collected and the type of source and

investigative technique that may be used to collect such information;

M.G.L. c. 175I § 4(b)(2)

the type of disclosure permitted by chapter 175I and the circumstances under which such

disclosure may be made without prior authorization: provided, however, that only such

circumstances need be described which occur with such frequency as to indicate a general

business practice; M.G.L. c. 175I § 4(b)(3)

a description of the rights established under sections eight, nine and ten and the manner in

which such rights may be exercised: M.G.L. c. 175I § 4(b)(4)

§ 8 describes the right of an individual to obtain any personal information collected or

maintained by the insurer upon written request, including any persons to whom the

insurer has disclosed the information, and procedures by which such information may

be corrected, amended, or deleted.

§ 9 describes the right of an individual to have factual errors corrected and any

misrepresentation or misleading information amended or deleted upon written request.

§ 10 describes the right of an individual to receive the specific reason for an adverse

underwriting decision in writing.

that information obtained from a report prepared by an insurance-support organization may

be retained by the insurance-support organization and disclosed to other persons. M.G.L. c.

175I § 4(b)(5)

OR:

an abbreviated notice may be used that informs the applicant that:

personal information may be collected from a person other than the individual proposed

for coverage; M.G.L. c. 175I § 4(c)(1)

such information as well as other personal or privileged information subsequently collected

by the insurance institution or insurance representative may in certain circumstances be

disclosed to a third party without authorization; M.G.L. c. 175I § 4(c)(2)

a right of access and correction exists with respect to all personal information collected;

M.G.L. c. 175I § 4(c)(3)

the more detailed notices described above will be furnished to the applicant upon request.

M.G.L. c. 175I § (4)(c)(4)

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 29

_______

AND:

Disclosure authorization form must meet requirements of M.G.L. c. 175I § 6:

1. is written in plain language

2. is dated

3. specifies the types of persons authorized to disclose information about the individual

4. specifies the nature of the information to be disclosed

5. names the insurance company and identifies by generic reference the person to

whom the applicant is authorizing information to be disclosed.

6. specifies the purposes for which the information is collected.

7. specifies that the authorization shall be valid for no longer than thirty months from

the time it is signed

8. advises the applicant that s/he is entitled to receive a copy of the authorization form.

INDIVIDUAL REQUIREMENTS – REPLACEMENT FORM (211 CMR 42.08(2))

_______

An agent or carrier soliciting the sale, upon determining that the sale would involve

replacement must furnish to the applicant, at the time of taking the application, or before

the policy is issued, the below noted notice. A copy of the notice must be left with or

retained by the applicant and a signed copy must be retained by the carrier. 211 CMR

42.08(2)

NOTICE TO APPLICANT

REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS INSURANCE

According to (your application)/(the information furnished by you), you intend to lapse or

otherwise terminate your present policy and replace it with a policy to be issued by

_______Insurance Company. For your own information and protection, certain facts

should be pointed out to you which could affect your rights to coverage under the new

policy.

1. Health conditions which you may presently have, may not be covered under the new

policy. This could result in a claim for benefits being denied which may been

payable under your present policy.

2. Even though some of your present health conditions may be covered under the new

policy, these conditions may be subject to certain waiting periods under the new

policy before coverage is effective.

3. Questions in the application for the new policy must be answered truthfully and

completely; otherwise, the validity of the policy and the payment of any benefits

thereunder may be voided.

4. It May be to your advantage to secure the advice of your present carrier or its agent

regarding the proposed replacement of your present policy. This is your right, under

the policy you have chosen.

The above “Notice to Applicant” was delivered to me on __________

_________________________________________________________Applicant

Managed Care: INDIVIDUAL Stand-Alone Dental and Vision (Rev. 010518) Page 30

INDIVIDUAL REQUIREMENTS – RATE FILING:

A rate filing must be enclosed with each policy, rider, or endorsement that affects the premium rate

to be charged. 211 CMR 42.06(2)

All rate filings shall at least explain formulas used to derive rates, expected claim costs, assumptions

regarding mortality, morbidity and lapse rates, and the detailed commission schedule and anticipated

administrative expenses associated with the policy. In order to substantiate rate revision filings,

filings must maintain experience for that policy form, may combine experience for different policy

forms whether the coverage is substantially the same, and must demonstrate that the carrier is using

fund accounting for guaranteed renewable policies to reflect premiums, investment income, losses,

expenses, and provisions for reserves specific to that policy form. 211 CMR 42.06(2)

Any rates filed, whether initial or revised, will be disapproved unless the aggregate anticipated loss

ratio for the entire period for which rates are computed to provide coverage meets the minimum loss

ratio standard for the policy. 211 CMR 42.06(2).

For hospital and medical expense policies (including indemnity policies) and for similar policies:

[Check (√) type of policy filed]

[ ] No less than 60% for policies sold as optionally renewable policies 211 CMR 42.06(2)(b)1

[ ] No less than 55% for policies sold as conditionally renewable policies 211 CMR 42.06(2)(b)2

[ ] No less than 55% for policies sold as guaranteed renewable policies 211 CMR 42.06(2)(b)2

[ ] No less than 50% for policies sold as guaranteed rate policies 211 CMR 42.06(2)(b)3

Every carrier must maintain on file with the Division an up-to-date rate manual for all individual

accident and health policies, riders, and endorsements currently available for sale in Massachusetts,

that must include:

(a) name of carrier on each page,

(b) table of contents or index, and

CMR 42.06(4)

Provide statement to confirm:

A rate filing and/or rate manual & actuarial memorandum needs to be forwarded to actuary for

review. 211 CMR 42.06(3)(a)

Provide statement to confirm:

All rate filings are subject to review by an actuary specified by the Commissioner whose costs will

be paid by the company submitting the filing. Filing is to include certification from company’s Chief

Financial Officer that all actuarial costs associated with reviewing the filing will be borne by the

company as part of the filing. 211 CMR 42.06(3)(a)

Provide statement to confirm appropriate documents are attached to submission.

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Managed Care Group Stand-Alone Vision & Dental Products Pursuant to the Requirements of M.G.L. c. 176I & c. 176O and Regulations 211 CMR 52.00

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