Current through Register 1531, September 27, 2024
(1) For an
Insured who:
(a) is receiving an Active
Course of Medical Treatment from a health care provider for a Serious Disease,
including but not limited to cancer or cystic fibrosis, that if disrupted in
the course of such medical treatment would pose an Undue Hardship to the
Insured; and
(b)
1. began this Active Course of Medical
Treatment before being enrolled in a Limited, Regional or Tiered Provider
Network plan where the provider is not part of the Limited, Regional or Tiered
Provider Network; or
2. began this
Active Course of Medical Treatment before being enrolled in a Tiered Provider
Network plan where the provider is in the highest cost-sharing tier; the
Carrier shall provide coverage for those medically necessary and covered Health
Care Services that are part of that Active Course of Medical Treatment provided
by that health care provider, to the extent required by 211 CMR
153.04(2).
(2) A Carrier to which 211 CMR 153.04(1)
applies shall provide coverage for the health care provider's covered Health
Care Services for the duration of the Active Course of Medical Treatment during
the Plan Year if:
(a) the Insured's employer
offers the Insured only a choice of Limited, Regional or Tiered Provider
Network plans in which the health care provider is not part of any of the
offered Limited, Regional or Tiered Provider Networks or a choice of Tiered
Provider Network plans in which the health care provider is in the highest
cost-sharing tier; and
(b) that
health care provider is a Comprehensive Cancer Center, Pediatric Hospital or
Pediatric Specialty Unit; and
(c)
that health care provider is providing the Insured with an Active Course of
Medical Treatment that is not available from another provider in the Provider
Network of the Insured's Health Benefit Plan.
(3) For covered Health Care Services provided
under 211 CMR 153.04 from a provider that is not in the Provider Network of the
Insured's Health Benefit Plan, patient cost-sharing shall be at the lowest
cost-sharing level applicable to those covered Health Care Services in the
Health Benefit Plan, and reimbursement shall be based on median in-network
rates of the specific health care provider in that Carrier's private Health
Benefit Plans in a manner consistent with data filed by that Carrier with the
Division of Health Care Finance and Policy; provided, however, that if the
specific health care provider does not participate in any other Health Benefit
Plan of the Carrier, then based on negotiated rates. For covered Health Care
Services provided under 211 CMR 153.04 by a provider in the highest
cost-sharing tier of a Tiered Provider Network plan, patient cost-sharing shall
be based on the second-highest cost-sharing tier in that plan.
(4) Notwithstanding 211 CMR 153.04(2), for an
Insured who, before May 2, 2012:
(a) began an
Active Course of Medical Treatment from a health care provider that is a
Comprehensive Cancer Center, Pediatric Hospital or Pediatric Specialty Unit for
a Serious Disease, including but not limited to, cancer or cystic fibrosis,
that if disrupted in the course of medical treatment would pose an Undue
Hardship to the patient; and
(b)
1. began this Active Course of Medical
Treatment before being enrolled in a Limited, Regional or Tiered Provider
Network plan where the provider is not part of the Limited, Regional or Tiered
Provider Network; or
2. began this
Active Course of Medical Treatment before being enrolled in a Tiered Provider
Network plan where the provider is in the highest cost-sharing tier; the
Carrier shall provide coverage for those medically necessary and covered Health
Care Services that are part of that Active Course of Medical Treatment provided
by that health care provider until April 30,2013 at the patient cost-sharing
levels and reimbursement rates required by 211 CMR 153.04(3).
