Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 51.00 - Preferred Provider Health Plans And Workers' Compensation Preferred Provider Arrangements
Section 51.05 - Evidence of Coverage for Insured Preferred Provider Health Plan Coverage Only
Universal Citation: 211 MA Code of Regs 211.51
Current through Register 1531, September 27, 2024
The Evidence of Coverage, including all amendments and material changes, must be submitted to the Commissioner for approval.
(1) The Evidence of Coverage must meet the requirements of M.G.L.c. 1761, M.G.L. c. 1760, 211 CMR 51.00 and 52.00: Managed Care Consumer Protections and Accreditation of Carriers.
(2) The Evidence of Coverage must also include the following in clear and understandable language:
(a) a complete description of the benefit
differential between services offered by Preferred Providers and non-preferred
providers;
(b) Provisions that if a
Covered Person receives Emergency Care and cannot reasonably reach a Preferred
Provider, payment for such care will be made at the same level and in the same
manner as if the Covered Person had been treated by a Preferred
Provider;
(c) Benefit levels for
covered Health Care Services rendered by non-preferred providers must be at
least 80% of the Benefit Levels for the same covered Health Care Services
rendered by Preferred Providers.
1. Payments
made to non-preferred providers shall be a percentage of the provider's fee, up
to a Usual and Customary Charge, and not a percentage of the amount paid to
Preferred Providers.
2. The 80%
requirement shall be met if the coinsurance percentage for Health Care Services
rendered by a non-preferred provider is no more than 20 percentage points
greater than the highest coinsurance percentage for the same Health Care
Services rendered by a Preferred Provider, excluding reasonable deductibles and
copayments.
(d) A
description of all benefits required to be provided by law in accordance with
all of the provisions of the Organization's enabling or licensing
statutes.
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