Current through Register 1531, September 27, 2024
(1)
Timing of Application.
(a) Carriers must submit biennial renewal
applications by July 1st for renewals to be
effective on November 1st.
(b) A Carrier seeking initial Accreditation
must submit an application at least 90 Days prior to the date on which it
intends to offer Health Benefit Plans.
(2)
Inapplicability of
Accreditation Requirements.
(a) A
Carrier that provides coverage for Limited Health Services only, that does not
provide services through a Network or through Participating Providers or for
which other requirements set forth in
211
CMR 52.05 are otherwise inapplicable may
indicate within its application which of those items are inapplicable to its
Health Benefit Plan and provide an explanation of why the Carrier is exempt
from each particular requirement.
(b) A Carrier that provides coverage for
specified services through a workers' compensation preferred Provider
arrangement may provide evidence of compliance with
211 CMR
51.00:Preferred Provider Health Plans and
Workers' Compensation Preferred Provider Arrangements and
452 CMR
6.00: Utilization Review and Quality
Assessment to satisfy the materials required by
211
CMR 52.05(3)(b), (e), (g), (h), (i), (j), (l), and
(n). A Carrier that provides coverage for
specified services through a workers' compensation preferred Provider
arrangement may provide evidence of compliance with
211 CMR
51.00 and
452
CMR 6.00 to satisfy the materials required by
211
CMR 52.05(4)(d) and
(g).
(3)
Initial
Application. Any Carrier seeking initial Accreditation under
M.G.L. c. 176O must submit an application that contains at least the materials
applicable for Massachusetts described in
211
CMR 52.05(3)(a) through (s)
in a format specified by the Commissioner. Any Carrier that contracts with
another organization to perform any of the functions specified in
211
CMR 52.00 is responsible for collecting and
submitting all of such materials from the contracting organization.
(a) A filing fee of $1,000 made payable to
the Commonwealth of Massachusetts;
(b) A complete description of the Carrier's
Utilization Review policies and procedures;
(c) A written attestation by a company
officer to the Commissioner that the Utilization Review program of the Carrier
or its designee complies with all applicable state and federal laws concerning
confidentiality and reporting requirements;
(d) A copy of the most recent existing survey
described in
211
CMR 52.07(10);
(e) A complete description of the Carrier's
internal Grievance procedures consistent with958 CMR 3.000: Health
Insurance Consumer Protection and a complete description of the
external review process consistent with
958 CMR
3.000: Health Insurance Consumer
Protection;
(f) A complete
description of the Carrier's process to establish guidelines for Medical
Necessity consistent with
958 CMR
3.000: Health Insurance Consumer
Protection;
(g) A complete
description of the Carrier's quality management and improvement policies and
procedures;
(h) A complete
description of the Carrier's credentialing policies and procedures for all
Participating Providers;
(i) A
complete description of the Carrier's policies and procedures for providing or
arranging for the provision of Preventive Health Services;
(j) A sample of every Provider contract used
by the Carrier or the organization with which the Carrier contracts, unless the
Commissioner has requested the Provider contract under 52.05(3)(k);
(k) All contracts the Carrier has with a
subcontracting organization and/or delegated vendor that performs Utilization
Review, member services, or pharmacy benefit management on behalf of the
Carrier, as well as any Provider contracts requested by the
Commissioner;
(l) A statement that
advises the Bureau whether the Carrier has contracts with Providers that places
the Provider into a Limited, Regional, or Tiered Network Plan subject to
211 CMR
152.00: Health Benefit Plans Using Limited,
Regional or Tiered Provider Networks. If the Carrier has any such
contract, the Carrier shall identify the contracts in which such arrangements
exist and identify the sections of the contracts that comply with
211
CMR 152.05: Provider Contracts in
Limited, Regional and Tiered Provider Network Plans;
(m) A statement that advises the Bureau
whether the Carrier has contracts with Providers that places the Provider into
a Limited, Regional, or Tiered Network Plan subject to
211 CMR
152.00: Health Benefit Plans Using Limited,
Regional or Tiered Provider Networks. If the Carrier has any such
contract, the Carrier shall identify the contracts in which such arrangements
exist and identify the sections of the contracts that comply with
211
CMR 152.05: Provider Contracts in
Limited, Regional and Tiered Provider Network Plans;
(n) A complete description of the Carrier's
Network adequacy standards, along with an access analysis meeting the
requirements of
211
CMR 52.12(2);
(o) A copy of every Provider directory used
by the Carrier, including a summary description of the insured's Telehealth
coverage and access to Telehealth services including, but not limited to,
Behavioral Health Services, Chronic Disease Management, and Primary Care
Services via Telehealth, as well as the telecommunications
technology platforms that are available for insureds to use to access
Telehealth services;
(p) Evidence
satisfactory to the Commissioner that the Carrier is providing adequate access
within its Network to pain management services, including non-opioid and
non-pharmaceutical service options;
(q) Evidence satisfactory to the Commissioner
that the Carrier is providing adequate access within its Network to Behavioral
Health Services, Chronic Disease Management, and Primary Care Services via
Telehealth, including the following:
1.
Communications for use with Providers that specify the Providers' service and
documentation standards necessary in order for Telehealth services to be
covered by the Carrier;
2. A
statement that restricts covered Telehealth visits to those that are compatible
with state/federal privacy standards;
3. A list of the services that will not be
covered when provided to a covered person viaTelehealth, and
an explanation for why these services are not covered;
4. An explanation of how and when
cost-sharing (copayments, coinsurance, and deductibles) will apply for
Telehealth services, and if cost-sharing is waived, a description of the exact
circumstances under which the cost-sharing will be waived with a company
officer stating how the Carrier intends to reimburse Providers for Telehealth
services, including an identification of the billing codes, location codes or
other codes that the Carrier intends to use to reimburse Providers for
Telehealth services, and the following information for Telehealth
services.
5. A statement of how the
Carrier intends to reimburse Providers for the following Telehealth services:
a. Behavioral Health Services;
b. Primary Care Services;
c. Chronic Disease Management
Services;
d. Physical exams,
including those that have both Telehealth and in-person components;
and
6. When Telehealth
may be used for follow-up care, including but not limited to follow-up care
provided by Asynchronous Telehealth that may be considered less than a Visit, a
description of how the Carrier intends to reimburse Providers for these
follow-up Telehealth services;
(r) The Evidence of Coverage for every
product offered by the Carrier;
(s)
A copy of each disclosure described in
211
CMR 52.14, if applicable;
(t) A written attestation by a company
officer that the Carrier has complied with
211
CMR 52.16;
(u) An explanation of how the Carrier,
directly or through any entity that manages or administers mental health or
substance use disorder benefits for the Carrier, utilizes a base fee schedule
for evaluation and management services for Behavioral Health Providers that is
not less than the base fee schedule used for evaluation and management services
for Primary Care Providers of the same or similar licensure type and in the
same geographic region, and an explanation how the Carrier has established such
a base fee schedule for Behavioral Health Providers while not lowering its base
fee schedule for Primary Care Providers; and
(v) Any additional information as deemed
necessary by the Commissioner.
(4)
Renewal
Application. Any Carrier seeking renewal of Accreditation under
M.G.L. c. 176O must submit an application that contains at least the materials
for Massachusetts described in211 CMR 52.05(4)(a) through
(m) in a format specified by the
Commissioner. Any Carrier that contracts with another organization to perform
any of the functions specified in
211
CMR 52.00 is responsible for collecting and
submitting all of such materials from the contracting organization.
(a) A filing fee of $1,000 made payable to
the Commonwealth of Massachusetts;
(b) A written attestation by a company
officer to the Commissioner that the Utilization Review Program of the Carrier
or its designee complies with all applicable state and federal laws concerning
confidentiality and reporting requirements;
(c) A copy of the most recent survey
described in
211
CMR 52.07(10);
(d) A sample of every Provider contract used
by the Carrier or the organization with which the Carrier contracts since the
Carrier's most recent Accreditation, unless the Commissioner has requested the
Provider contract under 52.05(4)(e);
(e) All contracts the Carrier has with a
subcontracting organization or delegated vendor that performs Utilization
Review, medical management, member services, or pharmacy benefits management on
behalf of the Carrier, as well as any Provider contracts requested by the
Commissioner;
(f) A statement that
advises the Bureau whether the Carrier has issued new contracts or revised
existing contracts with Providers that places the Provider into a limited,
regional, or tiered network subject to
211 CMR
152.00: Health Benefit Plans Using Limited,
Regional or Tiered Provider Networks. If the Carrier has made any of
the specified changes, the Carrier shall identify the contracts in which such
changes were made and identify the sections of the contracts that comply with
211
CMR 152.05: Provider Contracts in
Limited, Regional and Tiered Provider Network Plans;
(g) A statement that advises the Bureau
whether the Carrier has issued new contracts or revised existing contracts with
Providers that places the Provider into a limited, regional, or tiered Network
subject to
211 CMR
152.00: Health Benefit Plans Using Limited,
Regional or Tiered Provider Networks. If the Carrier has made any of
the specified changes, the Carrier shall identify the contracts in which such
changes were made and identify the sections of the contracts that comply with
211
CMR 152.05: Provider Contracts in
Limited, Regional and Tiered Provider Network Plans;
(h) Any Material Change made to the Carrier's
Network adequacy standards, along with an access analysis meeting the
requirements of
211
CMR 52.11(2);
(i) The Evidence of Coverage for every
product offered by the Carrier, and for every product that has Insureds but is
no longer offered, which was revised since the Carrier's most recent
Accreditation;
(j) A copy of each
Provider directory used by the Carrier, including a summary description of the
insured's Telehealth coverage and access to Telehealth services including, but
not limited to, Behavioral Health Services, Chronic Disease Management, and
Primary Care Services via Telehealth, as well as the telecommunications
technology platforms that are available for insureds to use to access
Telehealth services;
(k) Material
Changes to any of the information contained in
211
CMR 52.05(3)(b), (e), (f), (g), (h), (i), and
(s);
(l) Evidence satisfactory to the Commissioner
that the Carrier is providing adequate access within its Network to pain
management services, including non-opioid and non-pharmaceutical service
options;
(m) Evidence satisfactory
to the Commissioner that the Carrier is providing adequate access within its
Network to Behavioral Health Services, Chronic Disease Management, and Primary
Care Services via Telehealth, including the following;
1. The communications for use with Providers
that specify the Providers' service and documentation standards necessary in
order for Telehealth services to be covered by the Carrier;
2. A statement that restricts covered
Telehealth visits to those that are compatible with state/federal privacy
standards;
3. A list of the
services that will not be covered when provided to a covered person via
Telehealth, and an explanation for why these services are not
covered;
4. An explanation of how
and when cost-sharing (copayments, coinsurance, and deductibles) will apply for
Telehealth services, and if cost-sharing is waived, a description of the exact
circumstances under which the cost-sharing will be waived, with a company
officer stating how the Carrier intends to reimburse Providers for Telehealth
services, including an identification of the billing codes, location codes or
other codes that the Carrier intends to use to reimburse Providers for
Telehealth services;
5. A statement
of how the Carrier intends to reimburse Providers for the following Telehealth
services:
(a) Behavioral Health
Services;
(b) Primary Care
Services;
(c) Chronic Disease
Management Services; and
(n) Evidence that the Carrier, directly or
through any entity that manages or administers mental health or substance use
disorder benefits for the Carrier, utilizes a base fee schedule for evaluation
and management services for Behavioral Health Providers that is not less than
the base fee schedule used for evaluation and management services for Primary
Care Providers of the same or similar licensure type and in the same geographic
region, and an explanation how the Carrier has established such a base fee
schedule for Behavioral Health Providers while not lowering its base fee
schedule for Primary Care Providers;
(o) A written attestation by a company
officer that the Carrier has complied with
211
CMR 52.16; and
(p) Any additional information as deemed
necessary by the Commissioner.
(5)
Application for Deemed
Accreditation. A Carrier seeking deemed Accreditation pursuant to
211
CMR 52.04 shall submit an application that
contains the materials described in
211
CMR 52.05(5)(a) through (d).
(a) For initial applicants, the information
required by
211
CMR 52.05(3).
(b) For renewal applicants, the information
required by
211
CMR 52.05(4).
(c) Proof in a form satisfactory to the
Commissioner that the Carrier has attained:
1.
a score equal to or above 80% of the standard in effect at the time of the most
recent review by NCQA for the Accreditation of Managed Care Organizations, in
the categories of utilization management, quality management and improvement,
and members' rights and responsibilities;
2. a score equal to or above the rating of
"accredited" in the categories of utilization management, Network management,
quality management and member protections for the most recent review of health
plan standards by URAC; or
3. for
Non-gatekeeper Preferred Provider Plans, a score equal to or above 80% of the
standard in effect at the time of the most recent review by NCQA for the
Accreditation of preferred Provider organizations, in the categories of
utilization management, quality management and improvement, and enrollees'
rights and responsibilities.
4. for
Non-gatekeeper Preferred Provider Plans, a score equal to or above the rating
of "accredited" in the most recent review of health utilization management
standards by URAC and a score equal or above the rating of "accredited" in the
categories of Network management, quality management and member protections for
the most recent review of health Network standards by URAC.
(d) Proof in a form satisfactory
to the Commissioner that the Carrier has attained:
1. a score equal to or above 80% of the
standard in effect at the time of the most recent review by NCQA for the
Accreditation of Managed Care Organizations, in the category of credentialing
and recredentialing;
2. a score
equal to or above the rating of "accredited" in the category of Provider
credentialing for the most recent review of health plan standards by URAC;
or
3. for Non-gatekeeper Preferred
Provider plans, a score equal to or above 80% of the standard in effect at the
time of the most recent review by NCQA for the Accreditation of preferred
Provider organizations in the category of credentialing and
recredentialing.
4. for
Non-gatekeeper Preferred Provider Plans, a score equal to or above the rating
of "accredited" in the category of Provider credentialing for the most recent
review of health Network standards by URAC.
(6)
Application to be Reviewed as
a Non-gatekeeper Preferred Provider Plan. A Carrier shall submit a
statement signed by a corporate officer certifying that none of the Carrier's
insured plans require the Insured to designate a Primary Care Provider to
coordinate the delivery of care or receive referrals from the Carrier or any
Network Provider as a condition of receiving Benefits at the preferred benefit
level.
(7)
Material
Changes. Carriers shall submit to the Bureau any Material Changes
to any of the items under
211
CMR 52.05(3) and (4) at
least 30 Days before the effective date of the changes.