Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers
Section 52.01 - Applicability

211 CMR 52.00 applies to any Carrier that offers for sale, provides or arranges for the provision of a defined set of Health Care Services to Insureds through affiliated and contracting Providers or employs Utilization Review in making decisions about whether services are Covered Benefits under a Health Benefit Plan. A Carrier that provides coverage for Limited Health Services only, that provides specified services through a workers' compensation preferred Provider arrangement, or that does not provide services through a Network or through Participating Providers shall be subject to those requirements of 211 CMR 52.00 as deemed appropriate by the Commissioner in a manner consistent with a duly filed application for Accreditation as outlined in 211 CMR 52.05(2).

Certain requirements of 211 CMR 52.00, as specified, shall also apply to Dental and Vision Carriers. Such provisions are: 211 CMR 52.11(1) through (4); (11); (13); 52.13(2), (3)(a), (c) through (e), (g), (h), (l) through (o); (4) through (10); 52.14(1)(c) and (d); (2), (3) and (7); and 211 CMR 52.17.

A Carrier that delegates to or contracts with another entity, including a Utilization Review Organization, for the performance of some or all of the functions governed by M.G.L. c. 176O and/or 211 CMR 52.00 shall be responsible for ensuring compliance by said entity with the provisions of M.G.L. c. 176O and 211 CMR 52.00.