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 152.05 - Provider Contracts in Limited, Regional and Tiered Provider Network Plans

Universal Citation: 211 MA Code of Regs 211.152

Current through Register 1531, September 27, 2024

(1) Prior to implementing a Health Benefit Plan with a Limited, Regional or Tiered Provider Network, a Carrier shall have signed contracts with those Providers that will be in that Provider Network which are in compliance with the requirements of 211 CMR 52.12.

(2) Provider contracts shall explain the waythat the Carrier will notify Providers about its Health Benefit Plans such that a Provider may clearly identify the Health Benefit Plans that use a Tiered Provider Network, a Regional Provider Network, a Limited Provider Network or another Provider Network.

(3) Provider contracts shall state that the Provider has the right to opt out of any new Health Benefit Plan that uses a Limited Provider Network or a Tiered Provider Network at least 60 days before the Health Benefit Plan is submitted to the Commissioner for approval.

(4) Provider contracts for Tiered Provider Networks shall include a statement that the Carrier shall notify the Provider, in writing, at least 60 days before the effective date of the following modifications. The Provider and the Carrier may agree, in writing, on an alternative date for notice of such modifications in the contract.

(a) Modification to the process used to classify Providers by benefit tier;

(b) Modification to the timelines that the Carrier will use to make decisions and implement any reclassification of Providers by benefit tier;

(c) Modification in the information collected from Providers to make classifications; and

(d) Modification in the criteria or methodology used to make classifications.

(3) Provider contracts for Tiered Provider Networks shall state the Provider's right to:

(a) Receive notification of the Carrier's classification of a Provider to a benefit tier;

(b) Be provided with an explanation of the information and other criteria used by the Carrier to make classification decisions; and

(c) Appeal the classification decisions to the Carrier and receive a decision on such appeal prior to the new classification being made available on the Carrier's website and in material provided to employers and individuals.

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