Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 156.00 - Dental Insurance
Section 156.04 - Coverage Standards
Universal Citation: 211 MA Code of Regs 211.156
Current through Register 1531, September 27, 2024
(1) Evidences of Coverage. Carriers are to file all insured Dental Benefit Plans offered under 211 CMR 156.00 with the Division.
(a) All such Plans are to be reviewed for
compliance with M.G.L. c. 175, § 2B.
(b) Individually issued Dental Benefit Plans
are to comply with the requirements of 211 CMR 42.00: Health
Maintenance Organizations (HMOs).
(c) Plans that provide or arrange for the
delivery of dental benefits through a network of Dental Providers or use
utilization management in the review of the necessity of certain Dental
Services are to comply with the requirements of 211 CMR 52.00: Managed
Care Consumer Protections and Accreditation of Carriers, as noted in
211 CMR 52.01: Applicability.
(d) Plans that provide or arrange for the
delivery of dental benefits through a network of Dental Providers and include
dental networks that differ from those of a Dental Benefit Plan's overall
network should prominently display on all Plan documents, including provider
directory materials, a provider network name that distinguishes the network of
the Plan from the other networks offered by the Carrier.
(e) Plans that permit both an in-network and
an out-of-network level of dental benefits are to comply with the requirements
of 211 CMR 51.00: Preferred Provider Health Plans and Workers'
Compensation Preferred Provider Arrangements.
(2) Issuing Coverage.
(a)
1. No Carrier may exclude any Individual,
Eligible Employee, or Eligible Dependent from a Dental Benefit Plan on the
basis of any impermissible factors, including but not limited to race, color,
religious creed, national origin, sex, gender identity, sexual orientation,
genetic information, pregnancy, ancestry, or status as a veteran.
2. No Carrier may modify the coverage of an
Individual, Eligible Employee, or Eligible Dependent through riders or
endorsements, or otherwise restrict or exclude coverage for certain diseases or
conditions otherwise covered by the Dental Benefit Plan, except as permitted
under 211 CMR 156.00.
3. Every
Carrier must make appropriate disclosures in plain language and provide access
to information assistance to prospective group Insureds and prospective
individual Insureds, as part of its solicitation and sales material, of:
a. renewal provisions;
b. rating limitations according to
211
CMR 156.05; and
c. availability of Dental Benefit Plans,
including, but not limited to, situations where a plan has a dental provider
network that is limited to a particular service area or to employees that live
in the service area.
(b) Carriers are permitted to underwrite
Dental Benefit Plans that are issued to Individuals, provided that the
applicant completes a dental coverage application and the Carrier uses the
information from the application to determine whether to issue coverage based
on its policy for underwriting individual dental policies. Carriers may apply
waiting periods, deductibles, benefit limitations, or exclusions as a condition
of issuing coverage, provided that the applicant is made aware of and is
provided with complete written information regarding all conditions that differ
from the coverage originally applied for. When issuing Individual Dental
Benefit Plans, Carriers are required to prominently and clearly identify the
renewal conditions of the policy on the cover page of the Individual policy, in
a manner that is consistent with the requirements set forth in 211 CMR 42.00:
Health Maintenance Organizations (HMOs).
(c) Carriers are permitted to underwrite
Dental Benefit Plans to be issued to Group Associations and may underwrite
coverage issued to Individuals through Group Associations, provided that the
applicant completes a dental coverage application and the Carrier uses the
information from the application to determine whether to issue coverage based
on its individual coverage policy. Carriers may apply waiting periods,
deductibles, benefit limitations, or exclusions as a condition of issuing
coverage, provided that the applicant is made aware of and is provided with
complete written information regarding all conditions that differ from the
coverage originally applied for. When issuing certificates of coverage for
Group Association Dental Benefit Plans, Carriers are required to prominently
and clearly identify the renewal conditions on the cover page of the
certificate of coverage.
(d)
Carriers are permitted to underwrite the issuance of group dental coverage to
Employer Groups, but are not permitted to underwrite coverage issued to
Eligible Employees and their eligible dependents. Carriers may apply waiting
periods, deductibles, benefit limitations, or exclusions as a condition of
issuing coverage to an Employer Group, provided that the applicant is made
aware of and is provided with complete written information regarding all
conditions that differ from the coverage originally applied for. When issuing
certificates of coverage to Employer Groups for Dental Benefit Plans, Carriers
are required to prominently and clearly identify within the certificates all
continuation of coverage provisions, including, but not limited, to those
required under federal COBRA protections, in the event employment-based
coverage is lost due to a qualifying event.
Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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