Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 152.00 - Health Benefit Plans Using Limited, Regional Or Tiered Provider Networks
Section 152.02 - Definitions
As used in 211 CMR 152.00, the following words mean:
Advertisemen t: Advertisement shall include:
(a) Printed and published material, audio-visual material and descriptive literature used by a Carrier in direct mail, newspapers, magazines, internet websites, radio scripts, television scripts, billboards and similar displays;
(b) Descriptive literature and sales aids of all kinds issued by a Carrier, Insurance Producer or other entity for presentation to the insurance-buying public including, but not limited to, circulars, leaflets, booklets, internet websites, depictions, illustrations, and form letters; and
(c) Prepared sales talks, presentations and material for use by providers and Insurance Producers.
Carrier: An insurer licensed or otherwise authorized to transact 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 licensed under M.G.L. c. 176G; 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. Carrier shall not include any entity to the extent it offers a policy, certificate or contract that provides coverage solely for dental care services or vision care services.
Commissioner: The Commissioner of Insurance appointed pursuant to M.G.L. c. 26, § 6.
Covered Benefits: Those Health Care Services to which an Insured is entitled under the terms of the Health Benefit Plan.
Division: The Division of Insurance established pursuant to M.G.L. c. 26, § 1.
Emergency Services: Services to treat a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of an Insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in § 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. 1395dd(e)(1)(B).
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.
Facility: A licensed institution providing Health Care Services or a health care setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.
General Provider Network: The most comprehensive provider network offered by a Carrier in its Massachusetts Service Area.
Health Benefit Plan: A policy, contract, certificate or agreement entered into, offered, or issued by a Carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of covered Health Care Services.
Health Care Professional: A physician or other health care practitioner licensed, accredited or certified by the Commonwealth of Massachusetts or other entity authorized to perform or supply specified Health Care Services.
Health Care Provider or Provider: A Health Care Professional or a Facility.
Health Care Services: Services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
Insurance Producer: A person required to be licensed under the laws of the Commonwealth M.G.L. c. 175 § 162I, to sell, solicit or negotiate insurance.
Insured: An enrollee, covered person, member, policyholder or subscriber of a Carrier.
Limited Provider Network: A reduced or selective Provider Network, not a Regional Provider Network, which is smaller than a Carrier's General Provider Network and from which the Carrier may choose to exclude from participation other Providers who participate in the Carrier's Regional Provider Network or General Provider Network.
Marketing or Marketing Material: Any of the following including, but not limited to, Advertisements, when they are used byany person with the intent of soliciting an offer to contract for a Health Benefit Plan:
(a) Printed, published or web based material, audio-visual material and descriptive literature used in direct mail, newspapers, magazines, radio or TV scripts, billboards, computer or electronic transmissions and similar displays;
(b) Descriptive literature and sales aids of all kinds issued for presentation to members of the insurance-buying public, including but not limited to circulars, leaflets, booklets, depictions, illustrations, internet websites and form letters;
(c) Prepared sales talks, presentations and material; and
(d) All oral and written solicitations and presentations.
(e) Social media sites including networking sites, blog postings and smartphone applications created by or for a Carrier, Insurance Producer or other entity for presentation to or use by the insurance buying public.
Network Adequacy: Sufficient access to Covered Benefits with a Provider Network within the Health Benefit Plan's Service Area to guarantee that all Covered Benefits are accessible to Insureds without delays detrimental to the Insureds' health.
Network Provider: A person or entity under contract with a Carrier or with its subcontractor to provide covered Health Care Services to Insureds.
PCP: A Provider that is a primary care Provider designated by the Insured.
Provider Network: A group of Health Care Providers contracted with a Carrier or affiliate to provide Health Care Services to Insureds covered by any or all of the Carrier's or affiliate's plans, policies, contracts or other arrangements. Provider network shall not mean those participating Providers that 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.
Reclassification Date: The effective date specified bythe Carrier on which the Carrier reclassifies Providers among the benefit tiers of a tiered Provider Network and, thereafter, the date on which any future reclassifications would take effect, unless the Carrier submits a written request to the Commissioner at least 90 days in advance of the proposed date.
Regional Provider Network: A Provider Network for a defined geographic area within Massachusetts that is smaller than the Carrier's Service Area and includes only those Providers that have agreed to participate in the Carrier's plan in a limited geographic area within the Commonwealth of Massachusetts. A Regional Provider Network may be a geographic subset of the Carrier's General Provider Network.
Service Area: The geographicalarea, as approved bythe Commissioner, within which the Carrier has developed a Provider Network to afford adequate access to Insureds for Covered Benefits.
Tiered Provider Network: A Provider Network in which a Carrier assigns Providers to different benefit tiers based on the Carrier's assessment of a Provider's relative cost and, where available, quality and in which Insureds pay the cost-sharing (copayment, coinsurance or deductible) associated with a Provider's assigned benefit tiers.
