Current through Register 1531, September 27, 2024
(1) A Carrier shall provide to at least one
adult Insured in each household upon enrollment, and to a prospective Insured
upon request, the following information:
(a) a
statement that physician profiling information, so-called, may be available
from the Board of Registration in Medicine for physicians licensed to practice
in Massachusetts;
(b) a summary
description of the process by which clinical guidelines and Utilization Review
criteria are developed;
(c) the
voluntary and involuntary disenrollment rate among Insureds of the Carrier;
1. For the purposes of
211
CMR 52.14(1)(c), 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, retired or died.
2.
For the purposes of
211
CMR 52.14(1)(c), the term
"voluntary disenrollment" means that an Insured has terminated coverage with
the Carrier by nonpayment of premium.
3. For the purposes of
211
CMR 52.14(1)(c), 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)(i)2. and
3.
(d) a notice to
Insureds regarding Emergency Medical Conditions that states all of the
following:
1. 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 by dialing the emergency telephone access number 911, or its
local equivalent, whenever the Insured is confronted with an Emergency Medical
Condition which in the judgment of a prudent layperson would require
pre-hospital emergency services;
2.
that no Insured shall in any way be discouraged from using the local pre
hospital emergency medical service system, the 911 telephone number, or the
local equivalent;
3. that no
Insured will be denied coverage for medical and transportation expenses
incurred as a result of such Emergency Medical Condition; and
4. if the Carrier requires an Insured to
contact either the Carrier or its designee or the Primary Care Provider of the
Insured within 48 hours of receiving emergency services, that notification
already given to the Carrier, designee or Primary Care Provider by the
attending emergency Provider shall satisfy that requirement.
(e) a description of the Office of
Patient Protection and a statement that the information specified in
211
CMR 52.16 is available to the Insured or
prospective Insured from the Office of Patient Protection; and
(f) a statement:
1. that an Insured has the right to request
referral assistance from a Carrier if the Insured or the Insured's Primary Care
Provider has difficulty identifying Medically Necessary services within the
Carrier's Network;
2. that the
Carrier, upon request by the Insured, shall identify and confirm the
availability of these services directly; and
3. that the Carrier, if necessary, shall
obtain or arrange for Out-of-Network services if they are unavailable within
the Network.
(2) The information required of Carriers by
211
CMR 52.14(1)(a) through (f)
may be contained in the Evidence of Coverage and need not be provided in a
separate document.
(3) Every
disclosure required of Carriers and described in
211
CMR 52.14(1)(a) through (f)
must contain the effective date, date of issue and, if applicable, expiration
date.
(4) A Carrier must maintain a
toll-free telephone number and website available to Insureds to present
Provider cost information to Insureds that meets the following requirements:
(a) the Insured may request and obtain the
following, in real time:
1. the estimated or
maximum allowed amount or charge for a proposed admission, procedure or service
and
2. the estimated amount the
Insured will be responsible to pay for a proposed admission, procedure or
service that is a Medically Necessary Covered Benefit, based on the information
available to the Carrier at the time the request is made, including any
Facility fee, copayment, deductible, coinsurance or other Cost-sharing
requirements for any Covered Benefits;
(b) notwithstanding anything to the contrary
in 211 CMR
52.14(4)(a), the Insured
shall not be required to pay more than the disclosed amounts for the Covered
Benefits that were actually provided;
(c) nothing in
211
CMR 52.14(4) shall prevent
a Carrier from imposing Cost-sharing requirements disclosed in the Insured's
Evidence of Coverage for unforeseen services that a rise out of the proposed
admission, procedure or service;
(d) the Carrier must alert the Insured that
these are estimated costs, and that the actual amount the Insured will be
responsible to pay may vary due to unforeseen services that a rise out of the
proposed admission, procedure or service.
(5) To provide information to Insureds about
the disposition of Provider claims submitted to the Carrier, the Carrier shall
issue to Insureds the summary of payments form, as authorized by the
Commissioner, and the form shall be issued to the individual Insured rather
than to the subscriber, and the form may be issued in paper or through an
Internet Website, provided that a Carrier will issue the form by paper upon
request by the Insured.
(6)
Carriers shall submit Material Changes to the disclosures required by
211
CMR 52.14 to the Bureau at least 30 Days
before their effective dates.
(7)
Carriers shall submit Material Changes to the disclosures required by
211
CMR 52.14(1)(a) through (f)
to at least one adult Insured in every household residing in Massachusetts at
least once every two years.
(8) A
Carrier that provides specified services through a workers' compensation
preferred Provider arrangement shall be deemed to have met the requirements of
211
CMR 52.14 if it has met the requirements of
211 CMR
51.00: Preferred Provider Health Plans and
Workers' Compensation Preferred Provider Arrangements and
452 CMR
6.00: Utilization Review and Quality
Assessment.
(9) A Carrier,
including a Dental or Vision Carrier, shall provide to a health, Dental or
Vision Care Provider, a written reason or reasons for denying the application
of any health, Dental, or Vision Care Provider who has applied to be a
Participating Provider.
(10) A
Carrier for whom a Behavioral Health Manager is administering Behavioral Health
Services shall state the name and telephone number of the Behavioral Health
Manager on the Carrier's enrollment cards issued in the normal course of
business.
(11) A Behavioral Health
Manager shall provide the following information to at least one adult Insured
in each household covered by their services:
(a) a notice to the Insured regarding
emergency mental Health Services that states:
1. that the Insured may obtain emergency
mental Health Services, including the option of calling the local pre-hospital
emergency medical service system by dialing the 911 emergency telephone number
or its local equivalent, if the Insured has an emergency mental health
condition that would be judged by a prudent layperson to require pre-hospital
emergency services;
2. that no
Insured shall be discouraged from using the local pre-hospital emergency
medical service system, the 911 emergency telephone number or its local
equivalent;
3. that no Insured
shall be denied coverage for medical and transportation expenses incurred as a
result of such emergency mental health condition; and
4. if the Behavioral Health Manager requires
an Insured to contact either the Behavioral Health Manager, Carrier or Primary
Care Provider of the Insured within 48 hours of receiving emergency services,
notification already given to the Behavioral Health Manager, Carrier or Primary
Care Provider by the attending emergency Provider shall satisfy that
requirement;
(b) a
summary of the process by which clinical guidelines and Utilization Review
criteria are developed for Behavioral Health Services; and
(c) a statement that the Office of Patient
Protection is available to assist consumers, a description of the Grievance and
review processes available to consumers, and relevant contact information to
access the Office of Patient Protection and these processes.
(12) The information required of
Behavioral Health Managers by
211
CMR 52.14(11) may be
contained in the Carrier's Evidence of Coverage and need not be provided in a
separate document. Every disclosure described in
211
CMR 52.14(11) shall contain
the effective date, date of issue and, if applicable, expiration
date.
(13) A Behavioral Health
Manager (if applicable) or Carrier shall submit a Material Change to the
information required by
211
CMR 52.14(11) to the Bureau
at least 30 Days before its effective date and to at least one adult Insured in
every household residing in the Commonweal that least biennially.
(14) A Behavioral Health Manager that
provides specified services through a workers' compensation preferred Provider
arrangement that meets the requirements of
211 CMR
51.00: Preferred Provider Health Plans and
Workers' Compensation Preferred Provider Arrangements and
452 CMR
6.00: Utilization Review and Quality
Assessment shall be considered to comply with
211
CMR 52.14.
(15) A Carrier for whom a Behavioral Health
Manager is administering Behavioral Health Services shall be responsible for
the Behavioral Health Manager's failure to comply with the requirements of
211 CMR
52.00 in the same manner as if the Carrier failed to
comply and shall be subject to the provisions of
211
CMR 52.17.
