reglab/housing_qa huggingface dataset:
MA Gen L ch 176o § 9a (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 9a - Agreements or Contracts Between Carrier and Health Care Provider Prohibited if Containing Certain Provisions

Section 9A. A carrier shall not enter into an agreement or contract with a health care provider if the agreement or contract contains a provision that:  (a)(i) limits the ability of the carrier to introduce or modify a select network plan or tiered network plan by granting the health care provider a guaranteed right of participation; (ii) requires the carrier to place all members of a provider group, whether local practice groups or facilities, in the same tier of a tiered network plan; (iii) requires the carrier to include all members of a provider group, whether local practice groups or facilities, in a select network plan on an all-or-nothing basis; or (iv) requires a provider to participate in a new select network or tiered network plan that the carrier introduces without granting the provider the right to opt-out of the new plan at least 60 days before the new plan is submitted to the commissioner for approval; or  (b) requires or permits the carrier or the health care provider to alter or terminate a contract or agreement, in whole or in part, to affect parity with an agreement or contract with other carriers or health care providers or based on a decision to introduce or modify a select network plan or tiered network plan; or  (c) requires or permits the carrier to make any form of supplemental payment unless each supplemental payment is publicly disclosed to the commissioner as a condition of accreditation, including the amount and purpose of each payment and whether or not each payment is included within the provider's reported relative prices and health status adjusted total medical expenses under section 10 of chapter 12C; and  (d) limits the ability of either the carrier or the health care provider from disclosing the allowed amount and fees of services to an insured or insured's treating health care provider.  (e) limits the ability of either the carrier or the health care provider from disclosing out-of-pocket costs to an insured.
MA Gen L ch 176o § 9b (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 9b - Alternate Payment Arrangements Involving Downside Risk Prohibited Without Risk Certificate

Section 9B. Carriers shall not be permitted to enter into or continue alternate payment arrangements involving downside risk with provider organizations that have not received a risk certificate under chapter 176U.
MA Gen L ch 176o § 10 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 10 - Contractual Financial Incentive Plans

Section 10. (a) No contract between a carrier, including a dental or vision carrier, and a licensed health, dental or vision care provider group shall contain any incentive plan that includes a specific payment made to a health, dental or vision care professional as an inducement to reduce, delay or limit specific, necessary services covered by the health, dental or vision care contract. Health, dental or vision care professionals shall not profit from provision of covered services that are not necessary and appropriate. Carriers, including a dental or vision carrier, shall not profit from denial or withholding of covered services that are necessary and appropriate. Nothing in this section shall prohibit contracts that contain incentive plans that involve general payments such as capitation payments or shared risk agreements that are made with respect to health, dental or vision providers or which are made with respect to groups of insureds if such contracts, which impose risk on such health, dental or vision providers for the costs of care, services and equipment provided or authorized by another health, dental or vision care provider, comply with subsection (b).  (b) In order that patient care decisions are based on need and not on financial incentives, no carrier, including a dental or vision carrier, shall enter into a new contract, revise the risk arrangements in an existing contract or, after July 1, 2001, revise the fee schedule in an existing contract with a health, dental or vision care provider which imposes financial risk on such provider for the costs of care, services or equipment provided or authorized by another provider unless such contract includes specific provisions with respect to the following: (1) stop loss protection, (2) minimum patient population size for the provider group, and (3) identification of the health, dental or vision care services for which the provider is at risk.  (c) A carrier or utilization review organization shall conduct an annual survey of insureds to assess satisfaction with access to specialist services, ancillary services, hospitalization services, durable medical equipment and other covered services. Said survey shall compare the actual satisfaction of insureds with projected measures of their satisfaction. Carriers that utilize incentive plans shall establish mechanisms for monitoring the satisfaction, quality of care and actual utilization compared with projected utilization of health care services of insureds.
MA Gen L ch 176o § 11 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 11 - Rights of Health Benefit Plans to Include as Providers Religious Non-Medical Providers

Section 11. Nothing in this chapter shall be construed to restrict or limit the rights of health benefit plans to include as providers religious non-medical providers, require such health benefit plans to utilize medically based eligibility standards or criteria in deciding provider status for religious non-medical providers, use medical professionals or criteria to decide insured access to religious non-medical providers, utilize medical professionals or criteria in making decisions in internal appeals from decisions denying or limiting coverage or care by religious non-medical providers, compel an insured to undergo a medical examination or test as a condition of receiving coverage for treatment by a religious non-medical provider, or require such health benefit plans to exclude religious non-medical providers because they do not provide medical or other data otherwise required, if such data is inconsistent with the religious non-medical treatment or nursing care provided by the provider.
MA Gen L ch 176o § 16 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 16 - Clinical Decisions Regarding Medical Treatment Made by Treating Physicians; Payment for Health Care Services Ordered by Treating Physician or Primary Care Provider

Section 16. (a) The physician treating an insured, shall, consistent with generally accepted principles of professional medical practice and in consultation with the insured, make all clinical decisions regarding medical treatment to be provided to the insured, including the provision of durable medical equipment and hospital lengths of stay. Nothing in this section shall be construed as altering, affecting or modifying either the obligations of any third party or the terms and conditions of any agreement or contract between either the treating physician or the insured and any third party.  (b) A carrier shall be required to pay for health care services ordered by a treating physician or a primary care provider if: (1) the services are a covered benefit under the insured's health benefit plan; and (2) the services are medically necessary. A carrier may develop guidelines to be used in applying the standard of medical necessity, as defined in this subsection. Any such medical necessity guidelines utilized by a carrier in making coverage determinations shall be: (i) developed with input from practicing physicians and participating providers in the carrier's or utilization review organization's service area; (ii) developed under the standards adopted by national accreditation organizations; (iii) updated at least biennially or more often as new treatments, applications and technologies are adopted as generally accepted professional medical practice; and (iv) evidence-based, if practicable. In applying such guidelines, a carrier shall consider the individual health care needs of the insured. Any such medical necessity guidelines criteria shall be applied consistently by a carrier or a utilization review organization and made easily accessible and up-to-date on a carrier or utilization review organization's website to insureds, prospective insureds and health care providers consistent with subsection (a) of section 12. If a carrier or utilization review organization intends either to implement a new medical necessity guideline or amend an existing requirement or restriction, the carrier or utilization review organization shall ensure that the new or amended requirement or restriction shall not be implemented unless the carrier's or utilization review organization's website has been updated to reflect the new or amended requirement or restriction.  (c) With respect to an insured enrolled in a health benefit plan under which the carrier or utilization review organization only provides administrative services, the obligations of a carrier or utilization review organization created by this section and related to payment shall be limited to recommending to the third party payor that coverage should be authorized.
MA Gen L ch 176o § 17 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 17 - Regulations; Promulgation

Section 17. The commissioner shall promulgate regulations to enforce sections 2 to 12, inclusive. The health policy commission shall promulgate regulations to enforce sections 13, 14, 15 and 16.
MA Gen L ch 176o § 18 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 18 - Responsibility of Carrier for Behavioral Health Services Compliance

Section 18. 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 this chapter in the same manner as if the carrier failed to comply.
MA Gen L ch 176o § 19 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 19 - Display of Name and Telephone Number of Health Service Manager on Enrollment Cards of Carrier

Section 19. A carrier for whom a behavioral health manager is administering behavioral health services shall state on its new enrollment cards issued in the normal course of business, within one year, the name and telephone number of the behavioral health manager.
MA Gen L ch 176o § 20 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 20 - Information Provided to Insured Adults by Behavioral Health Manager; Submission of Material Changes; Workers' Compensation; Preferred Provider Arrangements

Section 20. (a) A behavioral health manager shall provide the following information to at least 1 adult insured in each household covered by their services:  (1) a notice to the insured regarding emergency mental health services that states:  (i) 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;  (ii) 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;  (iii) that no insured shall be denied coverage for medical and transportation expenses incurred as a result of such emergency mental health condition; and  (iv) if the behavioral health manager requires an insured to contact either the behavioral health manager, carrier or the 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 physician shall satisfy that requirement;  (2) a summary of the process by which clinical guidelines and utilization review criteria are developed for behavioral health services; and  (3) a statement that the office of patient protection, established by section 16 of chapter 6D or, if applicable, the designated state consumer assistance program is available to assist consumers, a description of the grievance and review processes available to consumers under chapter 176O, and relevant contact information to access the office and these processes.  (b) The information required by subsection (a) may be contained in the carrier's evidence of coverage and need not be provided in a separate document. Every disclosure described in this section shall contain the effective date, date of issue and, if applicable, expiration date.  (c) A behavioral health manager shall submit material changes to the information required by subsection (a) to the bureau of managed care, established by section 2 of chapter 176O, at least 30 days before their effective dates and to at least 1 adult insured in every household residing in the commonwealth at least biennially.  (d) A behavioral health manager that provides specified services through a workers' compensation preferred provider arrangement that meets the requirements of 211 CMR 112.00 and 452 CMR 6.00 shall be considered to comply with this section.
MA Gen L ch 176o § 22 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 22 - Participation in Medical Assistance Program as Condition for Participation in Carrier's Provider Network

Section 22. Notwithstanding any other general or special law to the contrary, each carrier shall require, as a condition of participation in the carrier's provider network by a physician, dentist, optometrist, podiatrist, nurse practicing in an advance practice nursing role, intern, resident, physician assistant, pharmacist with a collaborative practice agreement, psychologist and licensed independent clinical social worker, that such provider also apply to participate in the medical assistance program administered by the secretary of health and human services in accordance with chapter 118E and Title XIX of the Social Security Act and any federal demonstration or waiver relating to such medical assistance program for the limited purposes of ordering and referring services covered under such program, provided that regulations governing such limited participation are promulgated under said chapter 118E. Any such provider who chooses to participate in such medical assistance program as a provider of services shall be deemed to have fulfilled this requirement.
MA Gen L ch 176o § 23 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 23 - Disclosure by Carrier Upon Request for Network Status of Health Care Provider and Estimated or Maximum Allowed Amount or Charge for a Proposed Admission, Procedure or Service and Amount Insured Responsible to Pay; Establishment of Toll-Free Telephone Number and Website

Section 23. All carriers shall establish a toll-free telephone number and website that enables consumers to request and obtain from the carrier, in real time, the network status of an identified health care provider, the estimated or maximum allowed amount or charge for a proposed admission, procedure or service and 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 out of pocket amount for any covered health care benefits; provided, that the insured shall not be required to pay more than the disclosed amounts for the covered health care benefits that were actually provided; provided, however, that nothing in this section shall prevent carriers from imposing cost sharing requirements disclosed in the insured's evidence of coverage for unforeseen services that arise out of the proposed admission, procedure or service; and provided further, that the carrier shall 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 arise out of the proposed admission, procedure or service.
MA Gen L ch 176o § 24 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 24 - Internal Appeals Processes for Risk-Bearing Provider Organizations; Patient's Right to Third-Party Advocate; External Review Process

Section 24. (a) All risk-bearing provider organizations certified under chapter 176U shall create internal appeals processes. The appeals processes shall be available to the public in written format and, by request, in electronic format.  (b) The internal appeals processes in subsection (a) shall be completed in a period not longer than 14 days; provided, however, that an expedited internal appeal shall be completed in a period not longer that 3 days for a patient with an urgent medical need including, but not limited to, terminal illness or emergency situations, as defined through regulations by the office of patient protection. During the appeals process, the risk-bearing provider organization shall not: (i) prevent a patient from seeking medical opinions outside of that organization; or (ii) terminate any medical services being provided to the patient, including medical services which began prior to the appeal and are the subject of such appeal. The decision on the appeal shall be in writing and shall notify the patient of the right to file a further external appeal. The decision on the appeal shall prominently provide information on the patient's right to appeal the decision to the office of patient protection including, but not limited to: (i) contact information for the office of patient protection,; (ii) a notice of a patient's right to file a grievance with the office of patient protection; and (iii) information on how to file a grievance with the office of patient protection.  (c) Risk-bearing provider organizations shall inform any patient of the right to designate a third party to advocate on the patient's behalf during the appeals process including, but not limited to, a spouse or other family member, an attorney of record or a legal guardian. If the patient does not elect a person to serve as his or her advocate such provider organization shall offer to contact the office of patient protection and the office of patient protection may designate an ombudsman to advocate on the patient's behalf.  (d) The office of patient protection shall establish by regulation an external review process for the review of grievances submitted by or on behalf of patients of risk-bearing provider organizations. The process shall specify the maximum amount of time for the completion of a determination and review after a grievance is submitted and shall include the right to have benefits continued pending appeal. The office of patient protection shall establish expedited review procedures applicable to emergency and urgent care situations  (e) The office of patient protection shall promulgate regulations necessary to implement this section.
MA Gen L ch 176o § 25 (2021)
2021 Massachusetts General Laws|Part I - Administration of the Government|Title XXII - Corporations|Chapter 176o - Health Insurance Consumer Protections|Section 25 - Use and Acceptance of Specifically Designated Prior Authorization Forms

Section 25. (a) A payer or any entity acting for a payer under contract, when requiring prior authorization for a health care service or benefit, shall use and accept only the prior authorization forms designated for the specific types of services and benefits developed under subsection (c).  (b) If a payer or any entity acting for a payer under contract fails to use or accept the required prior authorization form, or fails to respond within 2 business days after receiving a completed prior authorization request from a provider, pursuant to the submission of the prior authorization form developed as described in subsection (c), the prior authorization request shall be deemed to have been granted.  (c) The division shall develop and implement uniform prior authorization forms for different health care services and benefits. The forms shall cover such health care services and benefits including, but not limited to, provider office visits, prescription drug benefits, imaging and other diagnostic testing, laboratory testing and any other health care services. The division shall develop forms for different kinds of services as it deems necessary or appropriate; provided that, all payers and any entities acting for a payer under contract shall use the uniform form designated by the division for the specific type of service. Six months after the full set of forms has been developed, every provider shall use the appropriate uniform prior authorization form to request prior authorization for coverage of the health care service or benefit and every payer or any entity acting for a payer under contract shall accept the form as sufficient to request prior authorization for the health care service or benefit.  Nothing in this section shall prohibit a payer or any entity acting for a payer under contract from using a prior authorization methodology that utilizes an internet webpage, internet webpage portal, or similar electronic, internet, and web-based system in lieu of a paper form, provided that it is consistent with the paper form, developed pursuant to subsection (c).  (d) The prior authorization forms developed under subsection (c) shall:  (1) not exceed 2 pages;  (2) be made electronically available; and  (3) be capable of being electronically accepted by the payer after being completed.  (e) The division, in developing the forms, shall:  (1) seek input from interested stakeholders and shall seek to use forms that have been mutually agreed upon by payers and providers;  (2) ensure that the forms are consistent with existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services; and  (3) consider other national standards pertaining to electronic prior authorization.  (f) Nothing in this section shall limit a health plan from requiring prior authorization for services.