Code of Massachusetts Regulations
801 CMR - EXECUTIVE OFFICE FOR ADMINISTRATION AND FINANCE
Title 801 CMR 52.00 - Municipal Health Insurance
Section 52.06 - Health Insurance Review Panel Review Process

1. Within ten calendar days of receiving proposed changes under M.G.L. c. 32B, §§ 22 or 23, the panel shall determine whether the proposed increased dollar amounts for co-payments, deductibles, and other cost-sharing plan design features for the non-Medicare plan under M.G.L. c. 32B, § 22 exceed the dollar amounts of the plan design features for the same or most similar benefits offered by the commission for the non-Medicare plan under M.G.L. c. 32A, § 4 with the largest subscriber enrollment. If such increased amounts do not exceed the dollar amounts of the plan design features for the same or most similar benefits offered by the commission for the non-Medicare plan under M.G.L. c. 32A, § 4 with the largest subscriber enrollment, the panel shall approve the appropriate public authority's immediate implementation of the proposed changes under M.G.L. c. 32b, § 22, subject to 801 CMR 52.07. Where the political subdivision is not proposing a tiered provider network, the determination shall be made by comparing the savings that would result if the dollar amounts of the co-pays, deductibles and other cost-sharing plan design features in the political subdivision's plan equaled the dollar amounts of the co-pays, deductibles and other cost-sharing plan design features under tier 2 of the commission's most-subscribed plan. Where the political subdivision currently is proposing a tiered provider network that is tiered differently from the tiering in the commission's most-subscribed plan, the determination shall be made by assuming the co-pays, deductibles and cost-sharing plan design features in each tier of the political subdivision's plan are equal to those in the same tier of the commission's most-subscribed plan, beginning with a comparison of the highest tier. If the political subdivision's plan has fewer tiers than the commission's plan, the political subdivision's highest tier shall be compared to the commission's tier 3, and the second highest tier to the commission's tier 3.

2. Within ten calendar days of receiving proposed changes under M.G.L. c. 32B, §§ 22 or 23, the panel shall determine whether the proposed increased dollar amounts for co-payments and deductibles proposed for a Medicare-extension plan under M.G.L. c. 32B, § 22 exceed the dollar amounts of the plan design features for the same or most similar benefits offered by the commission for the Medicare-extension plan under M.G.L. c. 32A, §§ 10C and 14 with the largest subscriber enrollment. If such increased amounts do not exceed the dollar amounts of the plan design features for the same or most similar benefits offered by the commission for the Medicare-extension plan under M.G.L. c. 32A, § 4 with the largest subscriber enrollment, the panel shall approve the appropriate public authority's immediate implementation of the proposed changes under M.G.L. c. 32B, § 22, subject to 801 CMR 52.07.

3. Where the political subdivision is not proposing a tiered provider network, the determination shall be made by comparing the savings that would result if the dollar amounts of the co-pays, deductibles and other cost-sharing plan design features in the political subdivision's plan equaled the dollar amounts of the co-pays, deductibles and other cost-sharing plan design features under tier 2 of the commission's most-subscribed plan. Where the political subdivision currently is proposing a tiered provider network that is tiered differently from the tiering in the commission's most-subscribed plan, the determination shall be made by assuming the co-pays, deductibles and cost-sharing plan design features in each tier of the political subdivision's plan are equal to those in the same tier of the commission's most-subscribed plan, beginning with a comparison of the highest tier. If the political subdivision's plan has fewer tiers than the commission's plan, the political subdivision's highest tier shall be compared to the commission's tier 3, and the second highest tier to the commission's tier 2.

4. If the panel does not approve implementation because the appropriate public authority's proposal fails to meet the criteria detailed in 801 CMR 52.06(4)(a)1. and 2., the appropriate public authority may submit a new proposal to the public employee committee and restart the process from that point pursuant to 801 CMR 52.03.

1. Within ten calendar days of receiving proposed changes under M.G.L. c. 32B, § 22 or 23, the panel shall confirm, the appropriate public authority's estimated monetary savings due to proposed changes under M.G.L. c. 32B, § 22 or 23.

2. If the proposal is to transfer subscribers to the Commission, the panel shall determine if the anticipated savings by doing so would be at least five percent greater than the maximum possible savings amount that would be attained by plan design changes authorized under M.G.L. c. 32B, § 22. If the panel confirms these savings, the panel shall approve the appropriate public authority's immediate implementation of the proposed changes under M.G.L. c. 32B, § 23, subject to procedures adopted by the commission for transfer of subscribers.

3. The appropriate public authority's estimate of savings due to the proposed changes shall be confirmed by the panel after consultation with the actuary selected by the Commission.

4. If the panel finds that the savings estimate is unsubstantiated, it may require the public authority to provide additional information or submit a new savings estimate for the panel's review and confirmation. It may also require the public employee committee to submit a response to the new estimate.

5. A certified copy of the vote confirming the savings estimate and, if the proposal is to transfer subscribers to the Commission, approval or rejection of the proposal, and explanation of the basis for any such change or disapproval shall be sent to the parties and the Secretary.

1. Within ten calendar days of receiving proposed changes under M.G.L. c. 32B, § 22 or 23, the panel shall review the proposal to mitigate, moderate or cap the impact of these changes for subscribers, including retirees, low-income subscribers and subscribers with high out-of-pocket health care costs, who would otherwise be disproportionately affected.

2. The municipal health insurance review panel may approve the mitigation proposal, or it may determine the proposal to be insufficient and may require additional savings to be shared with subscribers in the form of health reimbursement arrangements, wellness programs, health care trust funds for emergency medical care or inpatient hospital care, out-of-pocket caps, Medicare Part B reimbursements or reimbursements for other qualified medical expenses, as determined by the panel. Premium reductions for subscribers that result from the plan design changes shall not be credited against the total amount determined to be required to fund the mitigation proposal. Any health reimbursement arrangements created under a mitigation proposal shall be administered by the appropriate public authority and shall not be the responsibility of the Commission.

3. In no case shall the municipal health insurance review panel designate more than 25% of the estimated savings to subscribers.

4. All obligations on behalf of the appropriate public authority related to the mitigation proposal shall expire after the initial amount of estimated savings designated by the panel to be distributed to subscribers has been expended.

5. In reaching a decision on the proposal under this subsection, the municipal health insurance review panel may consider:

6. The panel's decision shall incorporate any agreements made by the parties, and shall constitute the written agreement between the public employee committee and the appropriate public authority. The agreement shall be binding on all subscribers and their representatives.