(1) The Commissioner shall review complete
applications to be a certified Group Purchasing Cooperative only if fewer than
six Group Purchasing Cooperatives are then so certified and if there are fewer
than 85,000 Insureds participating in such certified Group Purchasing
Cooperatives. If fewer than six Group Purchasing Cooperatives are so certified
and if there are fewer than 85,000 Insureds participating in such certified
Group Purchasing Cooperatives, then the Commissioner shall provide notice that
applications to be a certified Group Purchasing Cooperative will be reviewed,
if such applications are submitted to the Division during the time period
established by the Commissioner.
(2) If, at any time, the number of applicants
to be a certified Group Purchasing Cooperative exceeds the six Group Purchasing
Cooperatives permitted by M.G.L. c. 176J, § 12(b), the Commissioner will
consider which of the applicants better satisfies the criteria set forth in
211 CMR 151.00 and provides
access to Group Purchasing Cooperative Health Benefit Plans in a geographic
area or to a type of small business or to a type of Association not currently
served by other certified Group Purchasing Cooperatives.
(3) Upon receipt of a complete application to
be a certified Group Purchasing Cooperative, the Commissioner shall review the
submitted materials to determine whether the applicant meets the following
requirements:
(a) The applicant has a
corporate and organizational structure capable of supporting the Covered
Benefits to be offered;
(b) The
applicant has a business plan to administer the Group Purchasing Cooperative
and its Wellness Program(s) such that the Group Purchasing Cooperative's Health
Benefit Plans and Wellness Programs are available and accessible to Insureds
and ensure at all times that at least 33% of covered members are enrolled in
Wellness Programs;
(c) The
applicant has enrollment systems that:
1.
Ensure that no Qualified Associations, Eligible Association Members, Eligible
Small Businesses, Eligible Employees or Eligible Dependents are denied or
non-renewed coverage due to health condition, age, race or sex, and ensure that
Health Benefit Plans are not made available to other than Eligible Association
Members, Eligible Small Businesses, Eligible Employees and Eligible
Dependents;
2. Ensure that those
Eligible Small Businesses that purchase Health Benefit Plans through the Group
Purchasing Cooperative do not have more than 50 Eligible Employees and ensure
that those Eligible Small Businesses will be disenrolled at the end of the
current plan year if the number of Eligible Employees increases beyond 50 in
total;
3. Ensure that the Group
Purchasing Cooperative will offer Health Benefit Plans to Qualified
Associations that are new to the Group Purchasing Cooperative only on Health
Benefit Plan anniversary dates;
4.
Ensure that Qualified Associations and Qualified Association Members forfeit
annual membership fees if they choose, on dates other than Health Benefit Plan
anniversary dates, to cease being offered a Health Benefit Plan(s) through the
Group Purchasing Cooperative;
5.
Ensure that the Group Purchasing Cooperative will not offer Health Benefit
Plans to any Qualified Association or Qualified Association Member that has,
within the past three years, chosen to cease being offered a Health Benefit
Plan(s) through a Group Purchasing Cooperative; and
6. Ensure consistent application of open
enrollment rules and periods according to documented procedures for Qualified
Association Members to enter and exit Group Purchasing Cooperatives for the
purchase of Health Benefit Plans;
(d) The applicant has marketing systems that
present Group Purchasing Cooperative Health Benefit Plans to Eligible
Association Members and Qualified Association Members' Eligible Employees and
Eligible Dependents, which may include marketing through duly licensed
insurance producers;
(e) The
applicant has billing systems that ensure that no Eligible Small Business in a
Group Purchasing Cooperative is charged a rate higher than what the Carrier
would charge to a similarly situated Eligible Small Business that is not a
participant in a Group Purchasing Cooperative;
(f) The applicant has Wellness Programs
administered by the Group Purchasing Cooperative or its designees that, at a
minimum:
1. Are actuarially similar to
Wellness Programs that may be offered through the Commonwealth Health Insurance
Connector Authority and meet the standards of
211
CMR 151.15;
2. Will received an enrollment commitment
from at least 33% of all Eligible Association Members and Eligible Employees
that will be covered under Health Benefit Plans offered through the Group
Purchasing Cooperative; and
3. Have
reasonable systems, which shall comply with any applicable sections of the
Americans with Disability Act and any other federal requirements, under which
Wellness Program participants may record their participation in, and the Group
Purchasing Cooperative may monitor Wellness Program participants' participation
in available health management programs;
(g) The applicant has informational systems,
including but not limited to data redundancy and privacy controls, that ensure
the appropriate and efficient use of Covered Benefits;
(h) The applicant has operations financially
capable of coordinating the Group Purchasing Cooperative's Wellness Program
with Eligible Association Members or Eligible Small Businesses;
(i) The applicant has a written Group
Purchasing Cooperative marketing plan for attracting Eligible Association
Members and Eligible Small Businesses to obtain coverage from the Group
Purchasing Cooperative;
(j) The
applicant has adequate Wellness Programs to guarantee that all wellness
services contracted for will be accessible to Eligible Association Members,
Eligible Employees and Eligible Dependents without inappropriate delays;
and
(k) The applicant has
sufficient financial reserves or other resources to meet financial
obligations.
(4) The
Commissioner shall notify an applicant to become a certified Group Purchasing
Cooperative in writing if the reviewed application is denied, and the
Commissioner shall state the reasons for the denial of the reviewed
application.
