(3)
Evidence of
Coverage Requirements. An Evidence of Coverage shall contain a
clear, concise and complete statement of all of the information described at
211
CMR 52.13(3)(a) through
(aa). In addition, for Limited, Regional and
Tiered Network Plans, an Evidence of Coverage shall also contain any
information as required by
211 CMR
152.00: Health Benefit Plans Using Limited,
Regional or Tiered Provider Networks.
(a) The health, Dental or Vision Care
Services and any other Benefits to which the Insured is entitled on a
nondiscriminatory basis, including Benefits mandated by state or federal
law;
(b) The prepaid fee which must
be paid by or on behalf of the Insured and an explanation of any grace period
for the payment of any Health Benefit Plan premium;
(c) The toll-free telephone number and
website established by the Carrier to identify the Network status of an
identified health care Provider and present Provider cost and location
information and an explanation of the information that an Insured may obtain
through such toll-free number and website.
(d) The limitations on the scope of:
1. Health Care Services and any other
Benefits to be provided, including:
a. an
explanation of any Facility fee, allowed amount, coinsurance, copayment,
deductible or other amount that the Insured may be responsible to pay to obtain
Covered Benefits from Network or Out-of-Network Providers; and
b. an explanation of the information that an
Insured may obtain through the toll-free number and website established by the
Carrier under
211
CMR 52.14(4).
2. Dental or Vision Care Services
and any other Benefits to be provided, including an explanation of any
deductible or copayment feature.
(e) All restrictions relating to preexisting
condition limitations or exclusions, or a statement that there are no
preexisting condition limitations or exclusions if there are none under the
Health, Dental or Vision Benefit Plan;
(f) A description of the locations where, and
the manner in which, Health, Dental or Vision Care Services and other Benefits
may be obtained, and, additionally, for Health Care Services:
1. the method to locate Provider directory
information on a Carrier's website and the method to obtain a paper Provider
directory;
2. an explanation that
whenever a proposed admission, procedure or covered service that is Medically
Necessary is not available to an Insured within the Carrier's Network, the
Carrier will cover the out-of-Network admission, procedure or service, and the
Insured will not be responsible for paying more than the amount which would be
required for a similar admission, procedure or service offered within the
Carrier's Network; and
3. an
explanation that whenever a location where Health Care Services are provided is
part of a Carrier's Network, the Carrier will cover Medically Necessary covered
Benefits delivered at that location, and an explanation that the Insured will
not be responsible for paying more than the amount required for Network
services delivered at that location even if part of the Medically Necessary
Covered Benefits are performed by out-of-Network Provider(s), unless the
Insured has a reasonable opportunity to choose to have the service performed by
a Network Provider.
(g) A
description of eligibility of coverage for dependents, including a summary
description of the procedure by which dependents may be added to the
plan;
(h) The criteria by which an
Insured may be disenrolled or denied enrollment.
211
CMR 52.13(3)(h) shall apply
to Carriers, including Dental and Vision Carriers.
(i) The involuntary disenrollment rate among
Insureds of the Carrier.
211
CMR 52.13(3)(i) shall apply
to Carriers, including Dental and Vision Carriers.
1. For the purposes of
211
CMR 52.13(3)(i), Carriers
shall exclude all Administrative Disenrollments, Insureds who are disenrolled
because they have moved out of a health plan's Service Area, Insureds whose
continuation of coverage periods have expired, former dependents who no longer
qualify as dependents, or Insureds who lose coverage under an employer
sponsored plan because they have ceased employment or because their employer
group has cancelled coverage under the plan, reduced the numbers of hours
worked, become disabled, retired or died.
2. For the purposes of
211
CMR 52.13(3)(i), the term
"involuntary disenrollment" means that a Carrier has terminated the coverage of
the Insured due to any of the reasons contained in
211
CMR 52.13(3)(j)2. and
3.
(j) The requirement
that an Insured's coverage may be canceled, or its renewal refused may a rise
only in the circumstances listed in
211
CMR 52.13(3)(j)1. through 5.
211
CMR 52.13(3)(j) shall apply
to Carriers, including Dental and Vision Carriers.
1. failure by the Insured or other
responsible party to make payments required under thecontract;
2. misrepresentation or fraud on the part of
the Insured;
3. commission of acts
of physical or verbal abuse by the Insured which pose a threat to Providers or
other Insureds of the Carrier and which are unrelated to the physical or mental
condition of the Insured; provided, that the Commissioner prescribes or
approves the procedures for the implementation of the provisions of
211
CMR 52.13(3)(i)3.;
4. relocation of the Insured outside the
Service Area of the Carrier; or
5.
non-renewal or cancellation of the group contract through which the Insured
receives coverage;
(k) A
description of the Carrier's, including a Dental or Vision Carrier's, method
for resolving Insured Inquiries and Complaints. For a Health Benefit Plan, this
description shall include a description of the internal Grievance process and
the external review process consistent with
958 CMR
3.000: Health Insurance Consumer
Protection, including a description of the process for seeking
expedited internal review and concurrent expedited internal and external
reviews pursuant to
958 CMR
3.000;
(l)
A statement telling Insureds how to obtain the report regarding Grievances
pursuant to
958
CMR 3.600(1)(d) from the
Office of Patient Protection;
(m) A
description of the Office of Patient Protection, including its toll-free
telephone number, facsimile number, and Internet Website;
(n) A summary description of the procedure,
if any, for out-of-Network referrals and any additional charge for utilizing
out-of-network Providers.
211
CMR 52.13(3)(n) shall apply
to Carriers, including Dental and Vision Carriers;
(o) A summary description of the Utilization
Review procedures and quality assurance programs used by the Carrier, including
a Dental or Vision Carrier, including the toll-free telephone number to be
established by the Carrier that enables consumers to determine the status or
outcome of Utilization Review decisions;
(p) A statement regarding all products/plans
detailing what translator and interpretation services are available to assist
Insureds, including that the Carrier will provide, upon request, interpreter
and translation services related to administrative procedures. The statement
must appear in at least the languages identified by the Centers for Medicare
& Medicaid Services as the top non-English languages in Massachusetts,
211
CMR 52.13(3)(p) shall apply
to Carriers, including Dental and Vision Carriers.
(q) A list of prescription drugs excluded
from any closed or restricted formulary available to Insureds under the Health
Benefit Plan; provided, that the Carrier shall annually disclose any changes in
such a formulary, and shall provide a toll-free telephone number to enable
consumers to determine whether a particular drug is included in the closed or
restricted formulary. A Carrier will be deemed to have met the requirements of
211
CMR 52.13(3)(q) if the
Carrier does all of the following:
1. provides
a complete list of prescription drugs that are included in any closed or
restricted formulary;
2. clearly
states that all other prescription drugs are excluded;
3. provides a toll-free number that is
updated within 48 hours of any change in the closed or restricted formulary to
enable Insureds to determine whether a particular drug is included in or
excluded from the closed or restricted formulary;
4. provides an Internet Website that is
updated as soon as practicable relative to anychange in the closed or
restricted formulary to enable Insureds to determine whether a particular drug
is included in or excluded from the closed or restricted formulary;
and
5. clearly states that there
shall be no financial penalty for a patient's choice to receive a lesser
quantity of any opioid contained in schedule II or III of M.G.L. c. 94C, §
3, and lists each of such schedule II or III drugs.
(r) A summary description of the procedures
followed by the Carrier in making decisions about the experimental or
investigational nature of individual drugs, medical devices or treatments in
clinical trials;
(s) Requirements
for continuation of coverage mandated by state and federal law;
(t) A description of coordination of Benefits
consistent with
211 CMR
38.00: Coordination of Benefits
(COB);
(u) A description
of coverage for emergency care and a statement that Insureds have the
opportunity to obtain Health Care Services for an Emergency Medical Condition,
including the option of calling the local pre-hospital emergency medical
service system, whenever the Insured is confronted with an Emergency Medical
Condition which in the judgment of a prudent layperson would require
pre-hospital emergency services;
(v) If the Carrier offers services through a
Network or through Participating Providers, the following statements regarding
continued treatment:
1. If the Carrier allows
or requires the designation of a Primary Care Provider, a statement that the
Carrier will notify an Insured at least 30 Days before the disenrollment of
such Insured's Primary Care Provider and shall permit such Insured to continue
to be covered for Health Services, consistent with the terms of the Evidence of
Coverage, by such Primary Care Provider for at least 30 Days after said
Provider is disenrolled, other than disenrollment for quality related reasons
or for fraud. The statement shall also include a description of the procedure
for choosing an alternative Primary Care Provider.
2. A statement that the Carrier will allow
any female Insured who is in her second or third trimester of pregnancy and
whose Provider in connection with her pregnancy is involuntarily disenrolled,
other than disenrollment for quality-related reasons or for fraud, to continue
treatment with said Provider, consistent with the terms of the Evidence of
Coverage, for the period up to and including the Insured's first postpartum
Visit.
3. A statement that the
Carrier will allow any Insured who is Terminally Ill and whose Provider in
connection with said illness is involuntarily disenrolled, other than
disenrollment for quality related reasons or for fraud, to continue treatment
with said Provider, consistent with the terms of the Evidence of Coverage,
until the Insured's death.
4. A
statement that the Carrier will provide coverage for Health Services for up to
30 Days from the effective date of coverage to a new Insured by a Provider who
is not a Participating Provider in the Carrier's Network if:
a. the Insured's employer only offers the
Insured a choice of Carriers in which said Provider is not a Participating
Provider; and
b. said Provider is
providing the Insured with an ongoing course of treatment or is the Insured's
Primary Care Provider; and
c. With
respect to an Insured in her second or third trimester of
pregnancy,211 CMR
52.13(3)(v)4. shall apply to
services rendered through the first postpartum Visit. With respect to an
Insured with a Terminal Illness,
211
CMR 52.13(3)(v)4.shall apply
to services rendered until death;
5. A Carrier may condition coverage of
continued treatment by a Provider under211 CMR
52.13(3)(v)1. through 4.
upon the Provider's agreeing as follows:
a. to
accept reimbursement from the Carrier at the rates applicable prior to notice
of disenrollment as payment in full and not to impose Cost Sharing with respect
to the Insured in an amount that would exceed the Cost Sharing that could have
been imposed if the Provider had not been disenrolled;
b. to adhere to the quality assurance
standards of the Carrier and to provide the Carrier with necessary medical
information related to the care provided; and
c. to adhere to the Carrier's policies and
procedures, including procedures regarding referrals, obtaining prior
authorization and providing services pursuant to a treatment plan, if any,
approved by the Carrier;
6. Nothing in
211
CMR 52.13(3)(v) shall be
construed to require the coverage of Benefits that would not have been covered
if the Provider involved remained a Participating Provider;
(w) If a Carrier requires an
Insured to designate a Primary Care Provider, a statement that the Carrier will
allow the Primary Care Provider to authorize a standing referral for Specialty
health Care provided by a Health Care Provider participating in the Carrier's
Network when:
1. the Primary Care Provider
determines that such referrals are appropriate;
2. the Provider of Specialty Care agrees to a
treatment plan for the Insured and provides the Primary Care Provider with all
necessary clinical and administrative information on a regular basis;
and
3. the Health Care Services to
be provided are consistent with the terms of the Evidence of Coverage.
Nothing in
211
CMR 52.13(3)(v) shall be
construed to permit a Provider of Specialty health Care who is the subject of a
referral to authorize any further referral of an Insured to any other Provider
without the approval of the Insured's Carrier;
(x) If a Carrier requires an Insured to
obtain referrals or prior authorization from a Primary Care Provider for
Specialty Care, a statement that the Carrier will not require an Insured to
obtain a referral or prior authorization from a Primary Care Provider for the
following Specialty Care provided by an obstetrician, gynecologist, certified
nurse midwife or family practitioner participating in such Carrier's Health
Care Provider Network and that the Carrier will not require higher copayments,
coinsurance, deductibles or additional Cost-Sharing features for such services
provided to such Insureds in the absence of a referral from a Primary Care
Provider:
1. annual preventive gynecologic
health examinations, including any subsequent obstetric or gynecological
services determined by such obstetrician, gynecologist, certified nurse midwife
or family practitioner to be Medically Necessary as a result of such
examination;
2. maternity care;
and
3. medically necessary
evaluations and resultant Health Care Services for acute or emergency
gynecological conditions.
Carriers may establish reasonable requirements for
participating obstetricians, gynecologists, certified nurse midwives or family
practitioners to communicate with an Insured's Primary Care Provider regarding
the Insured's condition, treatment, and need for follow-up care; and nothing in
211
CMR 52.13(3)(x) shall be
construed to permit an obstetrician, gynecologist, certified nurse midwife or
family practitioner to authorize any further referral of an Insured to any
other Provider without the approval of the Insured's Carrier;
(y) If a Carrier offers a Site of
Service Plan, the Carrier must prominently and clearly specify on the cover of
the Evidence of Coverage and related promotional materials that care delivered
by certain Network Providers or at certain Network locations may only be
available when deemed medically necessary for the patient's condition. In
addition, prior to offering Site of Service Plans, the Carrier is to provide
notice to covered members and to Network Providers prior to the Site of Service
Plan being issued or renewed.
(z) A
statement that the Carrier will provide coverage of pediatric Specialty Care,
including, for the purposes of
211
CMR 52.13(3)(x), mental
health care, by persons with recognized expertise in Specialty pediatrics to
Insureds requiring such services.
(aa) If a Carrier allows or requires an
Insured to designate a Primary Care Provider, a statement that the Carrier
shall provide the Insured with an opportunity to select a Participating
Provider Nurse Practitioner or a Participating Provider Physician Assistant as
a Primary Care Provider or to change his or her Primary Care Provider to a
Participating Provider Nurse Practitioner or a Participating Provider Physician
Assistant at any time during the Insured's coverage period.
(bb) Evidence that the Carrier will provide
coverage on a nondiscriminatory basis for covered services when delivered or
arranged for by a Participating Provider Nurse Practitioner or a Participating
Provider Physician Assistant. For the purposes of
211
CMR 52.13(3)(bb),
nondiscriminatory basis shall mean that a Carrier's plan does not contain any
annual or lifetime dollar or unit of service limitation imposed on coverage for
the care provided by a Participating Provider Nurse Practitioner or
Participating Provider Physician Assistant which is less than any annual or
lifetime dollar or unit of service limitation imposed on coverage for the same
services by other Participating Providers, in accordance with M.G.L. c. 176R,
§ 16(1) and c. 176S, § 1;
(cc) A statement that the Carrier shall be
required to pay for Health Care Services ordered by a treating physician or a
Primary Care Provider if the Health Services are a Covered Benefit under the
Insured's Health Benefit Plan and the Health Services are Medically
Necessary.
(4)
Internet Websites. If the Carrier, including any
Dental or Vision Carrier, refers the Insured to resources where the information
described in the Evidence of Coverage can be accessed including, but not
limited to, an Internet Website, such Carrier must be able to demonstrate
compliance with applicable law, and with the following with respect to the
Internet Website:
(a) The Carrier has issued
and delivered written notice to the Insured that includes:
1. All necessary information and a clear
explanation of the manner by which Insured scan access their specific Evidence
of Coverage and any amendments thereto through such Internet Website;
2. A list of the specific information to be
furnished by the Carrier through an Internet Website;
3. The significance of such information to
the Insured;
4. The Insured's right
to receive, free of charge, a paper copy of Evidences of Coverage and any
amendments thereto at any time;
5.
The manner by which the Insured can exercise the right to receive a paper copy
at no cost to the Insured; and
6. A
toll free number for the Insured to call with any questions or requests
including, but not limited to, a request for the Carrier to provide assistance
for the Insured with finding a Provider.
(b) The Carrier has taken reasonable measures
to ensure that the information and documents furnished in an Internet Website
is substantially the same as that contained in its paper documents. All notice
and time requirements applicable to Evidences of Coverage shall apply to
information and documents furnished by an Internet Website.
(c) The Carrier has taken reasonable measures
to ensure that it furnishes, upon request of the Insured, a paper copy of the
Evidence of Coverage and any amendments thereto.
