Current through Register 1531, September 27, 2024
(1)
Application. No Preferred Provider Health Plan or
Workers' Compensation Preferred Provider Arrangement may be approved without
first submitting an application in a format specified by the Commissioner that
includes at least the following:
(a) A
description of the geographical area in which the Preferred Providers are
located, including a map of the distribution of the Preferred
Providers;
(b) A description of the
manner in which covered Health Care Services and other benefits may be obtained
by persons using the Preferred Providers, including a description of the
grievance system available to Covered Persons, including procedures for the
registration and resolution of grievance and any requirement within a Preferred
Provider Health Plan that Covered Persons select a gatekeeper
provider;
(c) Provider contracts
and contracting criteria, including:
1. A
narrative description of the financial arrangements between the Organization
and contracting Health Care Providers, identifying any assumption by the
providers of financial risk through arrangements such as per diems,
diagnosis-related groups, capitation or percentage withholding of
fees;
2. A copy of every standard
form contract with preferred physicians and other Health Care Providers,
including providers joining the Preferred Provider Arrangement via leasing,
subcontracting, or other arrangements whereby the Organization does not
contract directly with the providers (do not include rates of payment to
providers);
3. A copy of every
standard form contract for all Preferred Provider Arrangements including
administrative service agreements;
4. A copy of the terms and conditions that
must be met or agreed to by Health Care Providers desiring to enter into the
Preferred Provider Arrangement(s) (do not include rates of payments to Health
Care Providers); and
5. A
description of the criteria and method used to select Preferred
Providers.
(d) A
detailed description of the utilization review program;
(e) A detailed description of the quality
assurance program;
(f) Preferred
Provider directory, which shall include:
1. A
copy of the Preferred Provider directory distributed to Covered Persons;
and
2. A description of the process
for distributing the directory to Covered Persons.
(g) Filing fee for initial applications as
determined by the Executive Office for Administration and Finance as set forth
in
801 CMR
4.02: Fees for Licenses, Permits, and
Services to be Charged by State Agencies.
(h) Evidence of compliance with M.G.L. c.
1760 and
211 CMR 52.00:
Managed Care Consumer Protections and Accreditation of
Carriers.
(2)
Application Materials to be Submitted by Preferred Provider Health
Plans Only. In addition to the application required by 211 CMR
51.04(1), Preferred Provider Health Plans must submit:
(a) A narrative description of the Preferred
Provider Health Plan to be offered, including a description of whether the plan
will be available to small employers eligible under M.G.L. c. 176J;
(b)
Benefits and
Services.
1. A copy of every
standard form contract between the Organization and Health Care Purchasers for
the Preferred Provider Health Plan;
2. A copy of every standard form Evidence of
Coverage for every Preferred Provider Health Plan;
3. A description of any provision for Covered
Services to be payable at the preferred level until an adequate network has
been established for a particular service or provider type;
4. A description of all mandated benefits and
provider types available at the preferred and non-preferred level;
5. A description of the incentives for
Covered Persons to use the services of Preferred Providers;
6. A description of any provisions that allow
Covered Persons to obtain covered Health Care Services from a non-preferred
provider at the Benefit Level for the same covered health care service rendered
by a Preferred Provider; and
7. A
description of any provisions within the Preferred Provider Health Plan for
holding Covered Persons financially harmless for payment denials by, or on
behalf of, the Organization for improper utilization of covered Health Care
Services caused by Preferred Providers.
(c)
Financial
Resources.
1. A description of
the arrangements to be used by the Organization to protect covered members from
financial liability in the event of financial impairment or insolvency of any
Preferred Provider that assumes financial risk; and
2. Evidence of a surety bond, reinsurance, or
other financial resources adequate to guarantee that the Organization's
obligations to Covered Persons will be performed.
(d)
Rates.
1. A description of the Organization's
methodology for establishing premium rates; and
2. A copy of the average rates for
community-rated accounts, non-credible accounts, or their equivalent in the
rating structure used by the Organization.
(3)
Application Materials to be
Submitted by Workers' Compensation Preferred Provider Arrangements
Only. In addition to the application required by 211 CMR 51.04(1),
Workers' Compensation Preferred Provider Arrangements must submit:
(a) a list of each type of Health Care
Provider and medical specialty involved in the proposed Preferred Provider
Arrangement and the number of individuals representing each such type of
practice and specialty;
(b) a list
of each Organization with which the Health Care Provider has previously entered
into a Preferred Provider Arrangement, and of each Organization with which the
applicant has a pending application for a Preferred Provider
Arrangement;
(c) copy of the letter
from the Department of Industrial Accidents approving the applicant's
utilization review and quality assessment program;
(d) a written agreement to abide by, and a
description of the procedure to incorporate, any treatment guidelines or
protocols promulgated by the Department of Industrial Accidents pursuant to
M.G.L. c. 152, §§ 13 and 30;
(e) a procedure to guarantee cooperation by
Preferred Providers with the utilization review and quality assurance program
which allow for the removal of noncomplying providers from the
arrangement;
(f) a procedure for
referring Covered Persons to Health Care Services outside the Preferred
Provider Plan when indicated by diagnosis, excessive travel time, and presence
of any preexisting medical condition which would make treatment substantially
more difficult;
(g) a position
statement indicating how the applicant intends to facilitate the return to work
of injured employees in a rapid, cost-effective and safe manner;
(h) a copy from the Organization, if a
self-insurer or self-insurance group, of the Organization's current
authorization to act as a self-insurer or self-insurance group; and
(i) a copy of the information distributed
annually to employees which shall include clear reference to the following:
1. that an employee is required to obtain
treatment within the Preferred Provider Health Plan for the first scheduled
appointment or incur the responsibility to pay for such appointment, provided
that such person may seek Health Care Services for a compensable injury outside
the Preferred Provider Arrangement for the initial scheduled appointment
without incurring any financial obligation when such appointment is with a
licensed or registered Health Care Provider of a type or specialty not
represented within the Preferred Provider Arrangement;
2. that an employee may seek Health Care
Services for a compensable injury outside the Preferred Provider Arrangement
after the initial scheduled appointment without incurring any obligation to pay
for such subsequent visit(s) according to the provisions of M.G.L. c. 152,
§ 30;
3. that no copayments or
deductibles may be charged employees with compensable injuries who utilize the
Preferred Provider Arrangement or any other Health Care Provider under the
provisions of M.G.L. c. 152, §§ 13 and 30;
4. that each Covered Person has the right to
file complaints regarding the provision of Health Care Services with the Health
Care Services Board within the Division of Industrial Accidents;
5. the names of all current Preferred
Providers within the geographic region of such Covered Person or of all current
Preferred Providers arranged geographically, to be distributed to Covered
Persons upon initial approval of the Preferred Provider Arrangement; which
shall also be posted in a convenient and prominent place in workplaces where
covered workers are employed, and be re-distributed to Covered Persons after
any alleged workplace injury or upon request; and
6. a clear description of all other rights of
Covered Persons and the obligations of applicants as well as information
regarding any restrictions or requirements imposed upon Covered Persons by the
Preferred Provider Arrangement's utilization review or quality assurance
programs.
(4)
Review of Application. Upon receipt of a complete
application, the Commissioner will review the submitted material to determine
whether applicable requirements set forth in M.G.L. c. 152, and c. 1761 and
211 CMR 51.00 have been met,
including the following:
(a) Corporate and
organizational structure capable of supporting the benefits offered;
(b) Contractual agreements that adequately
protect the interests of members;
(c) Utilization systems ensuring the
appropriate and efficient use of Health Care Services;
(d) Quality assurance system monitoring the
quality of care provided to members;
(e) Clear and logical plan for marketing of a
Preferred Provider Health Plan;
(f)
Adequate Preferred Provider networks to guarantee that all services contracted
for will be accessible to members on a preferred basis and in all cases without
delays detrimental to the health of Covered Persons;
(g) Operations capable of administering the
Preferred Provider Health Plan or Workers' Compensation Preferred Provider
Arrangement and to maintain financial and utilization data for the Preferred
Provider Health Plan or Preferred Provider Arrangement in a form separate or
separable from other activities of the Organization;
(h) Sufficient financial reserves to support
introduction of a Preferred Provider Health Plan; and
(i) Submission of all documentation and other
materials required by
211 CMR 51.00.
(5)
Approval of
Application. Each Preferred Provider Health Plan or Workers'
Compensation Preferred Provider Arrangement, approved under M.G.L. c. 1761 and
211 CMR 51.00, may continue
to be marketed unless such approval is subsequently revoked by the
Commissioner. Following approval of any Workers' Compensation Preferred
Provider Arrangement, a copy of the approved application must then be forwarded
to the Office of Health Policy at the Department of Industrial
Accidents.
(6)
Denial
of Application. If an application is denied or a Preferred
Provider Health Plan or Workers' Compensation Preferred Provider Arrangement is
disapproved, the Commissioner shall notify the Organization in writing, stating
the reason(s) for the denial. The Organization shall have the right to a
hearing within 45 days of its receipt of such notice by filing a written
request for hearing within 15 days of its receipt of such notice. Within 30
days after the conclusion of the hearing, the Commissioner shall either grant
approval or shall notify the applicant in writing of the denial, stating the
reason(s) for the denial. The Organization shall have the right to judicial
review of the Commissioner's decision in accordance with the provisions of
M.G.L. c. 30A, § 14.
(7)
Licensure. If it is determined during the review of
any material submitted that any entity is bearing insurance risk, engaging or
proposing to engage in the business of insurance as defined in M.G.L. c. 175;
or the business of a nonprofit hospital service corporation as defined in
M.G.L. c. 176A; or the business of a medical service corporation as defined in
M.G.L. c. 176B; or the business of a dental service corporation as defined in
M.G.L. c. 176E; or the business of an optometric service corporation as defined
in M.G.L. c. 176F; or the business of a health maintenance organization as
defined in M.G.L. c. 176G without proper licensure, the Commissioner will so
inform the filer and require the relevant entity to seek licensure under the
appropriate statute. The Commissioner may require the filer to submit any
information necessary to make this determination.
