Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 153.00 - Continuity Of Care Access To Comprehensive Cancer Centers, Pediatric Hospitals, And Pediatric Specialty Units For Small Group Health Benefit Plans That Utilize Limited, Regional Or Tiered Provider Networks
Section 153.02 - Definitions
As used in 211 CMR 153.00, the following words mean:
Active Course of Medical Treatment: treatment that is:
(a) delivered following an inpatient stay or outpatient procedure and designed to assure recovery/rehabilitation; or
(b) continuing care for a Serious Disease that requires periodic diagnostic studies or adjustment of medications or treatments at least every six months.
An Active Course of Medical Treatment does not include services considered preventive in nature, or services provided for the monitoring or surveillance of the patient's condition following the completion of the treatment protocol for the Serious Disease, nor does it include clinical trials, experimental treatments, off-label use for products, or products not approved by the Food and Drug Administration, except insofar as coverage is mandated as set forth in M.G.L. c. 175, § 110L, c. 176A, § 8X, c. 176B, § 4X and c. 176G, § 4P.
Adverse Determination: a determination, based upon a review of information provided, by a Carrier or its designated utilization review organization, to deny, reduce, modify, or terminate an admission, continued inpatient stay, or the availability of any other Health Care Services, for failure to meet the requirements for coverage based on medical necessity, appropriateness of health care setting and level of care, or effectiveness.
Carrier: an insurer licensed or otherwise authorized to transact accident and health insurance under M.G.L. c. 175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a non-profit medical service corporation organized under M.G.L. c. 176B; or a health maintenance organization organized under M.G.L. c. 176G.
Commissioner: the Commissioner of Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her designee.
Comprehensive Cancer Center the term Comprehensive Cancer Center shall have the same meaning as that term is defined in M.G.L. c. 118G, §1, but shall be limited in 211 CMR 153.00 to only those entities in Massachusetts.
Commonwealth: the Commonwealth of Massachusetts.
Eligible Individual: an individual who is a resident of the Commonwealth and who is not seeking individual coverage to replace an employment-based Health Benefit Plan for which the individual or individual's dependent is eligible and which provides coverage that is at least actuarially equivalent to minimum creditable coverage as defined by 956 CMR 5.00: Minimum Creditable Coverage, provided, however, that any person enrolled in an individual Health Benefit Plan before September 30, 2010 shall be considered an Eligible Individual so long as such person continues to be a resident of the Commonwealth and maintains enrollment in an individual Health Benefit Plan.
Eligible Small Business or Group: any sole proprietorship, firm, corporation, partnership or association actively engaged in business who, on at least 50% of its working days during the preceding year, employed from among one to not more than 50 eligible employees, the majority of whom worked in Massachusetts; provided, however, that the sole proprietorship, firm, corporation, partnership or association need not have been in existence during the preceding year in order to qualify as an Eligible Small Business or Group. A business shall be considered to be one eligible small business or group if:
(a) it is eligible to file a combined tax return for purpose of state taxation; or
(b) its companies are affiliated companies through the same corporate parent.
Except as otherwise specifically provided, provisions of 211 CMR 153.00 which apply to an eligible small business will continue to apply through the end of the rating period in which an eligible small business no longer meets the requirements of Eligible Small Business or Group. An eligible small business that exists within a Multiple Employer Welfare Arrangement (MEWA) shall be subject to 211 CMR 153.00.
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.
General Provider Network: the most comprehensive provider network offered by a Carrier in its Massachusetts Service Area.
Health Benefit Plan: the term Health Benefit Plan shall have the same meaning as that term is defined in M.G.L. c. 176J, § 1.
Health Care Services: services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease.
Insured: any policyholder, certificate holder, subscriber, member or other person on whose behalf the Carrier is obligated to pay for and/or provide Health Care Services.
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.
Pediatric Hospital: the term Pediatric Hospital shall have the same meaning as that term is defined in M.G.L. c. 118G, § 1, but shall be limited in 211 CMR 153.00 to only those entities in Massachusetts.
Pediatric Specialty Unit: the term Pediatric Secialty Unit shall have the same meaning as that term is defined in M.G.L. c. 118G, § 1, but shall be limited in 211 CMR 153.00 to only those entities in Massachusetts.
Plan Year: the 12-month period beginning on a newly enrolled subscriber's initial effective date of coverage for health insurance coverage under a Health Benefit Plan with a Limited, Tiered, or Regional Provider Network.
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 Health Benefit 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, but shall include network providers that are subject to M.G.L. c. 176I.
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 Health Benefit Plan in a limited geographic area within the Commonwealth. A Regional Provider Network may be a geographic subset of the Carrier's General Provider Network.
Serious Disease: a condition that is life threatening or is likely to lead to serious or permanent disability if left untreated.
Service Area: the geographical area, 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.
Undue Hardship: circumstances that:
(a) could endanger life, cause suffering or pain, or cause physical deformity or malfunction; or
(b) require the Insured to undertake a substantial change in recommended treatment for covered Health Care Services; or
(c) require the Insured to receive covered Health Care Services from multiple providers/ facilities in an uncoordinated manner which will significantly worsen the Insured's Serious Disease.
