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 152.11 - Appendix A: Applicant Disclosure Notice for Individually Issued Coveage

APPLICANT DISCLOSURE NOTICE PROVIDER NETWORK ACCESS

[Carrier Name

Mailing Address

Customer Service Toll-Free Number]

[[Limited] [Regional]] Provider Network

This plan provides access to providers that are not the same as [name of carrier]'s [general provider network name] provider network.

Your member identification card will display the name of your provider network. The designation ["Limited" or "Regional"] will be on the top right hand side of the card that applies to the health benefit plan you have chosen.

* I understand that I may not change plans during a policy year because of changes to the provider network.

* I understand that the plan provides access to providers that may not be the same as [name of carrier]'s [general provider network name] provider network.

* I have reviewed the [name of network] provider directory or online provider search tool and understand that this plan only provides access to covered benefits from the providers in the [name of network] directory.

* I understand that it is my responsibility to ensure that a provider I voluntarily choose is enrolled in the [name of network] provider network prior to obtaining care.

* In choosing the [name of network] plan, I understand I will be required to choose a different provider for treatment if a provider I now see is not enrolled in the [name of network] provider network.

* I certify that I have received the [guide designated by the Commissioner] prior to beginning and completing the application/enrollment process.

Initials _______ Date _______ ]]

[[Tiered Provider Network]

This Plan assigns network providers to benefit tiers

Your member identification card will display the name of your provider network. The designation ["Tiered"] will be on the top right hand side of the card that applies to the health benefit plan you have chosen.

* I understand that I may not change plans during a policy year because of to the provider network.

* I understand that the plan I have chosen assigns network providers to benefit tiers.

* I understand that I will pay different [copayments, coinsurance, deductibles] based on a provider's assigned benefit tier.

* I understand that the carrier may reassign a provider's assigned benefit tier each year on [identify date].

* I understand that if a provider is reassigned to a different benefit tier, I am responsible to pay a different [copayments, coinsurance, deductibles].

* I have reviewed the [name of network] provider directory and understand that symbols displayed next to each provider identify the exact tier that the provider is assigned.

* I certify that I have received the [guide designated by the Commissioner]" prior to beginning and completing the application/enrollment process.

Initials _______ Date _______ ]]

[Assigned Form#]