Current through Register 1531, September 27, 2024
(1) A Carrier
proposing to offer a Health Benefit Plan that uses a Tiered Provider Network
with variations on cost-sharing between Provider tiers, shall submit to the
Division materials demonstrating that:
(a)
The Carrier has notified each Provider of its right to opt out of a new Health
Benefit Plan with a Tiered Provider Network at least 60 days before the Carrier
submits the new plan to the Commissioner.
(b) The Carrier maintains up to date
enrollment systems, Marketing Materials and Evidences of Coverage that identify
for all Providers, employers and Insureds the Providers in the Provider Network
specifying each Network Provider's designated tier in each Health Benefit
Plan.
(c) The Carrier has a clearly
articulated system in place for Providers to appeal to the Carrier the tier in
which each is placed. Descriptions of criteria such as data sources and
methodologies for placing Providers in specific tiers shall be made available
to a Provider prior to the appeal process.
(d) Variations on cost-sharing between
Provider tiers are reasonable in relation to the premium charged:
1. Carriers may offer more than two benefit
level tiers of Providers within the Tiered Provider Network; and
2. Variations among each of the benefit level
tiers must be reasonable in relation to the premium charged.
(2) A Carrier must use
defined criteria and evaluation systems that are coordinated by appropriate
Carrier staff and overseen by the Carrier's medical director to classify
Providers by benefit level tier.
(3) A Carrier shall provide detailed
information on its website and available in paper form, on request, about its
Tiered Network Plan(s), including, but not limited to:
(a) The Providers participating in the Tiered
Network Plan;
(b) The selection
criteria used to select the Providers;
(c) The potential for Providers to move from
one tier to another at any time; and
(d) The tier, if any, in which each Provider
is classified.
(4) A
Carrier may reclassify Providers within Health Benefit Plans using a Tiered
Provider Network among the tiers as follows:
(a) A provider may be reclassified from a
lower cost sharing tier to a higher cost sharing tier only on the Carrier's
Reclassification Date.
(b) A
Carrier that is reclassifying a Provider from a lower cost-sharing tier to a
higher cost-sharing tier shall submit the following information to the
Division:
1. At least five months prior to
the effective date of the change in tier, the Carrier shall submit to the
Division a copy of the material the Carrier will use to notify all Providers
within the Tiered Provider Network who are expected to be reclassified to a
higher cost-sharing tier, which shall explain:
a. The tier in which the Provider is being
classified;
b. The process and the
Health Benefit Plan-specific data used by the Carrier to make the
reclassification decision;
c. The
process by which the Provider may obtain additional information regarding the
Carrier's reclassification decision;
d. Notification of the Provider's right to
appeal to the Carrier the reclassification decision within 30 days after
receiving notice of such decision from the Carrier; and
e. The process by which the Provider may
appeal the reclassification decision to the Carrier, which shall be completed
by the Carrier within 40 days after the Provider received notice of such
decision from the Carrier;
2. A copy of Provider directories and
internet-based list of the Providers in Health Benefit Plans using the Tiered
Provider Network, which shall be updated and submitted to the Division at least
90 days before the Reclassification Date with a list of the tier in which each
Provider will be classified; and
3.
At least 90 days before the Reclassification Date, a Carrier shall provide to
the Division a copy of any material changes to Marketing Material that will be
used in employer and individual open enrollment documents for coverage
effective on or after the Reclassification Date to notify all prospective
subscribers and renewing subscribers of the new tiering
classifications.
4. At least 90
days before the Reclassification Date, the Carrier shall submit a copy of all
information that shall be provided to subscribers pursuant to 211 CMR
152.04(5).
(5) For any Health Benefit Plans that will be
in effect on the Reclassification Date, the Carrier shall make a reasonable
effort to provide, by mail or electronically, certain information to
subscribers at least 30 days before the Reclassification Date. This information
shall include, but not be limited to the following notices:
(a) If the Carrier allows or requires the
designation of a PCP, a statement provided to all subscribers whose PCP has
been reclassified to a higher cost-sharing tier which shall describe the
process used to reclassify Providers, explain how to access a list of the
reclassified Providers and describe the procedure for choosing an alternative
PCP to obtain treatment at the same cost-sharing level.
(b) If a subscriber is in her second or third
trimester of pregnancy and a Provider in connection with her pregnancy is
reclassified to a higher cost-sharing level, the statement provided to such a
subscriber shall identify the process used to reclassify the Provider, the new
benefit tier for the Provider and the new cost-sharing level for continued
treatment by that Provider. The statement also shall include a description of
the procedure for choosing an alternative Provider to continue treatment
associated with the pregnancy.
(c)
If a Carrier is aware that a subscriber is terminally ill and a Provider
providing treatment in connection with such illness is reclassified to a higher
cost-sharing level, a statement shall be provided to such subscriber
identifying the process used to reclassify the Provider, the new benefit tier
for the Provider treating the illness and the new cost-sharing level for
continued treatment by that Provider and a description of the procedure for
choosing an alternative Provider to continue treatment associated with the
illness.