(1)
Required
Benefits. A School's Student Health Insurance Program must provide
benefits that are substantially equal to the Essential Health Benefits
Benchmark Plan, in a manner consistent with the requirements and procedures of
45 CFR §
156.115.
(2)
Other
Requirements. A School's Student Health Insurance Program:
(a) may not exclude or limit coverage, except
as otherwise permitted by 956 CMR 8.04(3), of any Student who is away from
campus for any reason;
(b) must
include services delivered in accordance with the healing practices of
Christian Science;
(c) for all plan
years beginning January 1, 2014, or later must not impose an annual or lifetime
limit on the dollar amount of required benefits for any covered individual, as
established in 956 CMR 8.04(1);
(d)
must offer a prorated premium refund to any Student who paid to enroll in a
Student Health Insurance Program for an entire School Year but who is not a
Student at the beginning of a term during that School Year, provided the School
is not required to offer such a refund to a Student who disenrolls during a
term; offer a prorated premium refund to any Student who paid to enroll in a
Student Health Insurance Program for an entire School Year but who becomes
eligible for a subsidized Health Benefit Plan through the Connector or becomes
eligible for MassHealth, and who uses enrollment in such coverage to waive the
School's Student Health Insurance Program, provided the refund shall be
prorated by term and provided the Student becomes eligible prior to the
beginning of the term for which the refund is requested; offer Students the
opportunity to enroll in partial year coverage, which may be prorated by term;
and specify in writing its policy regarding premium refunds and partial year
Student enrollment;
(e) must comply
with the standards and requirements set out in
45 CFR
§
147.136 with regard to internal claims
and appeals. Carriers must provide Students with notification of the right of
appeal to the Office of Patient Protection;
(f) must designate at least one member of the
School's staff as the Student Health Insurance Program contact person to help
Students with any Student Health Insurance Program issues that may
arise;
(g) must not consider a
Student a late enrollee if a request for enrollment is made within 60 days
after termination of coverage under another health insurance plan, including
MassHealth and prorate premiums for such Student based on the month of
enrollment in the Student Health Program;
(h) must comply with the standards and
requirements set out in
45 CFR §
147.108 with regard to preexisting condition
exclusions;
(i) must comply with
the standards and requirements set out in
45 CFR §§
147.104 and
147.106
with regard to availability and renewability of coverage, except for those
exemptions applicable to Student health insurance in
45 CFR §
147.145(b);
(j) must comply with the standards and
requirements set out in
45
CFR §
147.110 with regard to
discriminating against beneficiaries;
(k) must comply with the standards and
requirements set out in
45 CFR §
147.128 with regard to rescission of
coverage;
(l) must comply with the
standards and requirements set out in
45 CFR §
147.130 with regard to cost-sharing for
preventive services; except that Student administrative health fees are
considered in the same manner as in
45 CFR §
147.145(c);
(m) must comply with the standards and
requirements set out in
45 CFR §
147.138(a) with regard to
choice of healthcare professionals;
(n) must comply with the standards and
requirements set out in
45 CFR §
147.138(b) with regard to
coverage of Emergency Services, including services received out of
network;
(o) must comply with the
standards and requirements set out in
45 CFR
148.170 with regard to benefits for mothers
and newborns; and
(p) must comply
with the standards and requirements set out in
45 CFR
148.180 with regard to discrimination based
on genetic information.
(3)
Permissible Exclusions and
Limitations. Unless otherwise prohibited by 956 CMR 8.04(1) and
(2), a School's Student Health Insurance Program may:
(a) impose reasonable exclusions and
limitations including different benefit levels for in-network and
out-of-network providers;
(b)
impose reasonable co-payments and deductibles. The School's Student Health
Insurance Program must specify the co-pay amount for in-network and
out-of-network office, clinic, and hospital visits. Cost-sharing requirements
must follow requirements outlined in
956 CMR 5.03(1)(c)
through (e).
(c) exclude charges reimbursable by any other
valid and collectible medical insurance plan, provided that any charges in
excess of the limits of such other medical insurance plan must be reimbursed as
otherwise provided in the School's Student Health Insurance Program;
and
(d) exclude hospital or medical
care resulting from participation in intercollegiate athletics provided that
such care is covered under another health insurance program with equal or
greater coverage.
(4)
Student Health Service. A School may designate its
on-campus student health service as an in-network provider for certain health
services, so long as the School's on-campus student health service is equipped
to adequately provide such services as required by law. Otherwise the program
must arrange for outside providers to act as its in-network service
provider(s).
(5)
Additional Benefits. A School's Student Health
Insurance Program may offer benefit levels that exceed the minimum
requirements. In designing Student Health Insurance Programs, Schools may take
into consideration the following factors: the type and nature of the student
body, the size of the campus, the location of the campus, the extent of
on-campus health services, the ability of individual Students to purchase
Health Benefit Plans, and the ability of the School to join with other Schools
for the purpose of securing savings through collective bidding for Student
Health Insurance Programs.
(6)
Disclosure. Schools must make available and accessible
to Students, at the same time registration materials become available but no
less than 30 days in advance of the registration deadline, information
regarding all benefits and services available to the Student under the Student
Health Insurance Program together with applicable limitations and exclusions,
provided that such information has been approved by the Division of Insurance
where the Division of Insurance requires such approval. If such information has
not been approved by the Division of Insurance within the specified timeframe,
the information must be posted within seven days of receiving approval from the
Division of Insurance. Such information, including the Student Health Insurance
Program's Evidence of Coverage and contact information for the School Student
Health Insurance Program contact person, must be made available on the School's
website or via a link on the School's website and its availability communicated
by other channels through which student health information is commonly
distributed to Students.
