reglab/statecodes huggingface dataset:
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 30 - Statement for Individuals Provided With Creditable Coverage; Reporting

Section 30. Pursuant to section 8B of chapter 62C, carriers shall provide written statements to residents of the commonwealth for whom creditable coverage is provided and shall provide a separate report verifying those statements to the commissioner of revenue.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 32 - Disclosure of Patient-Level Data and Contracted Prices of Individual Health Care Services by Carriers to Providers

Section 32. To the extent permissible under applicable state and federal privacy laws, every health maintenance organization shall disclose patient-level data to providers in their network solely for the purpose of carrying out treatment, coordinating care among providers and managing the care of their own patient panel; provided, that an individual provider shall only receive patient-level data related to patients treated by said provider. Patient-level data shall include, but not be limited to, health care service utilization, medical expenses, and demographics.
The division of insurance shall develop procedures and a standard format for disclosing such patient-level information. The division may require every health maintenance organization to disclose such information through the all-payer claims database established under section 12 of chapter 12C if the division and the center for health information and analysis determine that the all-payer claims database is an efficient means to provide such information.
Health maintenance organizations shall make available to any provider with whom they have entered into an alternative payment contract, the contracted prices of individual health care services within such payer's network for the purpose of referrals.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 1 - Definitions

Section 1. In this chapter the following words shall have the following meanings:—
''Attorney'', an attorney at law who is a member of the bar of the commonwealth or any other state.
''Commissioner'', the commissioner of insurance.
''Covered dependents'', dependents of an insured for whom benefits for covered legal services are provided under an insured legal services plan, or dependents of a member for whom covered legal services are provided under a membership legal services plan.
''Covered legal services'', legal services for which benefits are provided under an insured legal services plan or which are provided under a membership legal services plan.
''Insurance certificate'', a contract entered into between an insurer and an insured under an insured legal services plan, or a statement of legal services provided by an insurer to an insured under a group insurance policy.
''Insured'', a person to whom an insurance certificate has been issued.
''Insured legal services plan'', a plan whereby benefits for legal services are provided to insureds and their covered dependents in accordance with the provisions of this chapter.
''Insurer'', a corporation which underwrites a legal services plan.
''Member'', a person to whom a membership certificate has been issued.
''Membership certificate'', a contract entered into between a sponsor and a member under a membership legal services plan.
''Membership legal services plan'', a plan whereby legal services are provided to members and their covered dependents in accordance with the provisions of this chapter.
''Participating attorney'', an attorney who agrees in writing with an insurer to provide legal services to an insured or insureds in accordance with the provisions of an insurance certificate under an insured legal services plan, or an attorney who agrees in writing with a sponsor to provide legal services to a member or members in accordance with the provisions of a membership certificate under a membership legal services plan.
''Sponsor'', any person, group of persons, or entity which establishes and operates a legal services plan in accordance with the provisions of this chapter.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 2 - Establishment and Operation of Insured Legal Services Plan; Types of Plans

Section 2. Any sponsor may establish and operate an insured legal services plan underwritten in whole or in part by an insurer subject to the provisions of this chapter. An insured legal services plan may be either an indemnity plan or a service plan, or a combination of both. Under an indemnity plan, benefits for covered legal services shall be paid to the insured for the legal services of an attorney of the insured's choice. Under a service plan, benefits for covered legal services shall be paid to a participating attorney for the legal services of a participating attorney of the insured's choice, provided, however, that such benefits shall be paid to an attorney for his legal services, whether or not such attorney is a participating attorney, if the insured chooses such attorney and notifies the insurer in writing before such legal services are rendered.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 3 - Insurer of Insured Legal Services Plans

Section 3. Insurance corporations may be insurers of insured legal services plans, and such companies shall be subject to the insurance laws of the commonwealth except insofar as any provision of the insurance laws may be in conflict with applicable provisions of this chapter. An insurer may also be a sponsor of an insured legal services plan.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 4 - Insurance Certificates; Issuance; Required Provisions

Section 4. An insurance certificate shall be issued to each insured under an insured legal services plan. No insurance certificate shall be issued unless it contains the following provisions:—
(a) A statement of covered legal services and the basis for payment for such legal services;
(b) A statement of the duration of the legal services provided and of the terms and conditions upon which such services may be extended, renewed, amended, canceled or otherwise terminated; and
(c) A statement of the period of grace which will be allowed for making any payment due to the insurer which in any event shall not be less than thirty days.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 5 - Group Insurance Policy or Insurance Certificate Contract; Filing Copies; Approval; Hearing

Section 5. No insurer shall issue a group insurance policy providing benefits for legal services or an insurance certificate which is a contract, or any amendment to such group policy provisions or insurance certificate previously approved and issued without prior approval of the commissioner, and prior to such approval the insurer shall file a copy of the group insurance policy or the insured legal services plan and insurance certificate contract to be issued thereunder with the commissioner and shall provide copies thereof to the advisory committee on prepaid legal services. The advisory committee on prepaid legal services shall review the group insurance policy or the insured legal services plan and insurance certificate contract and advise the commissioner in writing whether such group policy provisions or plan and certificate are in conformity with rules of the supreme judicial court governing the practice of law.
After the filing of any such plan, certificate, or group insurance policy provisions the commissioner shall either approve the plan in writing or hold a public hearing upon such plan, upon not less than fifteen days written notice to all interested parties, otherwise, after thirty days after such filing, the plan, certificate, or group insurance policy shall be deemed approved. The advisory committee on prepaid legal services shall be a party with respect to any plan, certificate or group policy filed under this section, shall have the right to participate in any hearing held hereunder, and shall receive notice of the approval by the commissioner of any plan, certificate or group policy under the provisions of this section. Any such plan, certificate or group policy shall be approved unless the commissioner finds that the plan, certificate or group policy contains a provision which is unfair, inequitable, misleading, or deceptive, or that the plan, certificate or group policy does not comply with the provisions of this chapter or any other applicable provision of law, or rule of the supreme judicial court.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 6 - Rates Under Insured Legal Services Plan

Section 6. The rates to be charged by an insurer for an insurance certificate contract under an insured legal services plan approved under the provisions of this chapter shall be filed and determined in accordance with the provisions of sections one to five, inclusive, and six to twenty, inclusive, of chapter one hundred and seventy-five A. The rates to be charged by an insurer under a group insurance policy for legal services benefits shall be filed and determined in accordance with such provisions of chapter one hundred and seventy-five A; provided, however, that such filing and determination procedure shall not apply to any insurer which maintains at all times an unassigned surplus of not less than twenty million dollars.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 7 - Membership Legal Services Plan

Section 7. Any corporation formed under the provisions of chapter one hundred and eighty, any corporation formed under general or special law for any of the purposes set forth in section four of chapter one hundred and eighty, or any labor organization is authorized to establish and operate a membership legal services plan. Only such corporations or labor organizations may be sponsors of membership legal services plans. Under a membership legal services plan sponsored by a corporation whose primary purpose is other than the establishment and operation of a membership legal services plan, legal services may be provided only to bona fide members of the corporation and the dependents of such members; and any such member may elect not to participate in such plan. A sponsor of a membership legal services plan may contract on behalf of its members with a participating attorney or participating attorneys, including, at the option of the sponsor, an attorney or attorneys chosen by a member or members, to provide covered legal services to such members and dependents.
A membership legal services plan shall not include any plan or legal services provided by a legal aid office or public defender office, a military legal assistance office, a lawyer referral service operated, sponsored or approved by a bar association representative of the general bar of the geographical area in which the association exists, or of any other nonprofit organization that recommends, furnishes or pays for legal services to its members or beneficiaries in a manner incidental and reasonably related to a primary purpose of such organization to promote a public interest, including, without limitation, defense of human and civil rights, elimination of prejudice and discrimination as to race, religion, sex and national origin, lessening neighborhood tensions, preservation of scenic beauty, combatting or preventing pollution, preservation of natural resources, protection of consumer interest, promotion of cultural, historical or other educational activities, and prevention of cruelty to animals.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 8 - Membership Certificate; Required Provisions

Section 8. A membership certificate shall be issued by a sponsor to each participating member under a membership legal services plan. No membership certificate shall be issued unless it contains the following provisions:—
(a) A statement of covered legal services under the certificate and the basis for payment for such legal services;
(b) A statement of the duration of the certificate and of the terms and conditions upon which it may be extended, renewed, amended, canceled or otherwise terminated;
(c) A statement of the period of grace which will be allowed for making any payment due from the participant member under the certificate, which in any event shall not be less than thirty days; and
(d) A description of the membership legal services plan's method for resolving member complaints.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 9 - Issuance of Membership Certificates; Filing of Copy of Plan and Certificate for Commissioner's Approval; Hearing

Section 9. No sponsor shall issue a membership certificate or any amendment to a membership certificate previously approved and issued without prior approval of the commissioner, and prior to such approval the sponsor shall file a copy of the membership legal services plan and membership certificate to be issued thereunder with the commissioner and copies thereof to the advisory committee on prepaid legal services. The advisory committee on prepaid legal services shall review the membership legal services plan and membership certificate and advise the commissioner in writing whether such plan and certificate are in conformity with rules of the supreme judicial court governing the practice of law.
Within thirty days after the filing of any such plan or certificate the commissioner shall either approve the plan in writing or hold a public hearing on such plan, after not less than fifteen days written notice to all interested parties. The advisory committee on prepaid legal services shall be a party with respect to any plan or certificate filed under this section, shall have the right to participate in any hearing held hereunder, and shall receive notice of the approval by the commissioner of any plan or certificate under this section. Any such plan and certificate shall be approved unless the commissioner finds that the plan or certificate contains any provision which is unfair, inequitable, misleading or deceptive, or that the plan or certificate does not comply with the provisions of this chapter or any other applicable provision of law or rule of the supreme judicial court, or that the sponsor has failed to establish its ability to provide covered legal services to its members in accordance with the terms of the membership certificate. The commissioner may approve any such plan subject to such conditions as may be appropriate to assure the continuing ability of the sponsor to provide covered legal services to its members in accordance with the terms of the membership certificate.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 11 - Hearing; Determination to Modify Provisions or Rescind Prior Approval

Section 11. The commissioner may, upon not less than fifteen days' written notice to all interested parties, hold a public hearing upon an insured legal services plan or a membership legal services plan previously approved by him under section five or section nine of this chapter to determine whether modification of any provisions of such a plan or rescission of his prior approval may be necessary in order to protect the interests of the insureds, members or covered dependents of such a plan. The advisory committee on prepaid legal services shall be a party with respect to any plan which is the subject of a hearing under this section, shall have the right to participate in any hearing held hereunder, and shall receive notice of any order or decision of the commissioner issued thereon. After hearing, upon his finding that it is necessary in order to protect the interests of the insureds, members or covered dependents of a plan, the commissioner may modify any provisions of a plan or rescind his prior approval thereof.
No insured legal services plan or membership legal services plan may be the subject of a hearing under this section except after three years from the date of approval of the plan by the commissioner under section five or section nine of this chapter or except after three years from the date of any order or decision of the commissioner after a hearing upon such a plan under this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 12 - Hearing; Orders or Decisions Made Without Hearing; Request; Decisions to Be in Writing

Section 12. Any insurer or sponsor or other interested party aggrieved by any order or decision of the commissioner made without a hearing, or the advisory committee on prepaid legal services may, within fifteen days after written notice of the order or decision, make written request to the commissioner for a hearing thereon. The commissioner or his designee shall hear such party or parties within thirty days after receipt of such request and shall give not less than fifteen days' written notice of the time and place of the hearing. Such hearing shall be an adjudicatory hearing as defined in chapter thirty A. Within thirty days after such hearing, the commissioner or his designee shall affirm, reverse or modify his previous order or decision specifying his reasons therefor in writing. Pending such hearing and decision thereon, the commissioner may suspend or postpone the effective date of his previous order or decision.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 13 - Examination of Books, Records, Papers, Officers and Employees; Costs and Expenses; Confidential Matters Exempt

Section 13. The commissioner, or any deputy examiner or any other person designated by the commissioner, shall, at least once in three years, and at other times the commissioner deems prudent, visit any sponsor, other than an employer or employee organization subject to the Employee Retirement Income Security Act of 1974, P.L. 93–406, and examine into its affairs. The commissioner shall have free access to all of the books, records and papers of the sponsor and may summon and examine under oath its officers, agents, employees and other persons in relation to its affairs and condition. The commissioner shall require every such sponsor to keep its books, records, accounts and vouchers in such manner that he or his authorized representatives may readily determine whether the sponsor has complied with the law. Said sponsor shall be liable for all costs incurred in such examinations, including expenses of the commissioner, deputy examiner, or any designee employed in such examinations.
Files or records containing confidential matters of an insured, a member, or covered dependents, or attorney's client files and records shall be exempt from this section, except as otherwise may be ordered by court upon a complaint brought in the superior court by the commissioner.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 14 - Disputes or Controversies; Hearings

Section 14. Any dispute or controversy arising between an insurer or sponsor and any attorney, insured, or member, or any person whose insurance certificate contract or membership certificate has been canceled or to whom an insurer or sponsor has refused to issue an insurance certificate contract or membership certificate or between any attorney and an insured or member may within thirty days after such dispute or controversy arises make written request to the commissioner for a hearing thereon. The commissioner or his designee shall hear such party or parties within thirty days after receipt of such request and shall give not less than fifteen days written notice of the time and place of the hearing. Such hearing shall be an adjudicatory hearing as defined in chapter thirty A. Within thirty days after such hearing the commissioner or his designee shall issue a decision thereon.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 15 - Injunction

Section 15. Upon application to the superior court by the commissioner, injunctive relief may be granted if any sponsor of an insured legal services plan or a membership legal services plan has failed to comply with the provisions of this chapter; is operating fraudulently; is operating so as to render further operations contrary to the public interest; has exceeded its powers; has violated any provision of law; is financially unable to pay its claims in full; or is insolvent. The court may forthwith issue a temporary injunction restraining the transaction of any business, and it may, after a full hearing make the injunction permanent, and appoint one or more receivers to take possession of the books, papers, monies and other assets of the sponsor to settle its affairs, and distribute its funds to those entitled thereto, subject to such rules and orders as the court may prescribe, or may make such other order as it may deem appropriate.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 16 - Sale of Legal Services Plan

Section 16. It shall be unlawful for any person, group of persons, or entity except an insurer or sponsor of an insured legal services plan or a membership legal services plan, to establish, underwrite, operate or offer to sell a legal services plan, except in conformity with the provisions of this chapter; provided, however, that the provisions of this chapter shall not apply to a labor organization providing legal services to its members and their dependents nor to legal fee reimbursement services provided by an automobile club in conformity with the provisions of chapter one hundred and seventy-four B.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176h - Legal Services Plans › Section 17 - Rules and Regulations

Section 17. The commissioner may, after public hearing, promulgate appropriate rules and regulations for the execution of his duties under this chapter. The rules and regulations may include such provisions as the commissioner deems necessary to assure that legal services plans operate in the public interest, to enable insureds, members and their covered dependents to receive legal services at reasonable cost, and to restrain any inflation in the cost of legal services attributable to the operation of legal services plans.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176i - Preferred Provider Arrangements › Section 1 - Definitions

Section 1. The following words as used in this chapter shall have the meanings given to them in this section unless the context clearly requires otherwise:
''Commissioner'', the commissioner of insurance.
''Covered person'', any policy holder or other person on whose behalf the organization is obligated to pay for or provide health care services.
''Covered services'', health care services which the organization is obligated to pay for or provide under the health benefit plan.
''Emergency care'', services provided in or by a hospital emergency facility to a covered person after the development of a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the covered person's or another person's health in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).
''Health benefit plan'', the health insurance policy, subscriber agreement, or contract between the covered person and an organization which defines the covered services and benefit levels available.
''Health care provider'', a provider of health care services licensed or registered pursuant to chapter one hundred and eleven or chapter one hundred and twelve.
''Health care services'', services rendered or products sold by a health care provider within the scope of the provider's license. The term includes, but is not limited to, hospital, medical, surgical, dental, vision, and pharmaceutical services or products.
''Organization'', an insurer authorized to write accident and health insurance under chapter one hundred and seventy-five, a nonprofit hospital service corporation authorized under chapter one hundred and seventy-six A, a nonprofit medical service corporation authorized under chapter one hundred and seventy-six B, a dental service corporation authorized under chapter one hundred and seventy-six E, an optometric service corporation authorized under chapter one hundred and seventy-six F, a health maintenance organization authorized under chapter one hundred and seventy-six G, an insurer as defined in paragraph (7) of section one of chapter one hundred and fifty-two, or any other entity approved by the commissioner under this chapter.
''Preferred provider'', a health care provider or group of health care providers who have contracted to provide specified covered services.
''Preferred provider arrangement'', a contract between or on behalf of an organization and a preferred provider which complies with all the requirements of this chapter.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176i - Preferred Provider Arrangements › Section 3 - Health Benefit Plans; Minimum Requirements

Section 3. Organizations, but not an insurer as defined in paragraph (7) of section one of chapter one hundred and fifty-two, may offer health benefit plans which provide for incentives for covered persons to use the health care services of preferred providers. Such health benefit policies or plans shall meet at least the following minimum requirements:
(a) Benefit levels for health care services rendered by nonpreferred providers shall be at least eighty per cent of the benefit levels for services rendered by preferred providers.
(b) If a covered person receives emergency care and cannot reasonably reach a preferred provider, payment for care related to the emergency shall be made at the same level and in the same manner as if the covered person had been treated by a preferred provider; provided, however, that every brochure, contract, policy manual and all printed materials shall clearly state that covered persons shall have 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 a covered person is confronted with a need for emergency care, and no covered person shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of such use of emergency care;
(c) A procedure shall be specified for resolving consumer complaints and grievances; and
(d) A procedure shall be specified for the disclosure to covered persons of the names of current preferred providers by specialty and geographic area.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176i - Preferred Provider Arrangements › Section 4 - Discriminatory Refusal of Provider

Section 4. An organization shall not refuse to enter into a preferred provider arrangement with a health care provider on the basis of religion, race, color, national origin, age, sex, marital status, sexual orientation, or such provider's relationships with any other organization. The selection of preferred providers shall be based primarily on cost, availability and quality of covered services. The terms and conditions offered by an organization that must be met or agreed to by physicians and other professional providers of health care services desiring to enter into a preferred provider arrangement shall be subject to the disapproval of the commissioner if said terms and conditions are not consistent with the purposes, policies and provisions of this chapter.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176i - Preferred Provider Arrangements › Section 4a - Health Benefit Plans; Genetic Tests; Discrimination Based on Genetic Information

Section 4A. For the purposes of this section the following words shall have the following meanings:—
''Genetic information'', a written recorded individually identifiable result of a genetic test as defined by this section or explanation of such a result.
''Genetic test'', a test of human DNA, RNA, mitochondrial DNA, chromosomes or proteins for the purpose of identifying the genes, or genetic abnormalities, or the presence or absence of inherited or acquired characteristics in genetic material.
No organization and no preferred provider shall cancel, refuse to issue or renew, or in any way make or permit any distinction or discrimination in the amount of payment of premiums or rates charged, in the length of coverage or in any of the terms and conditions of a health benefit plan based on genetic information as defined in this section. No organization and no preferred provider shall require genetic tests or private genetic information, as defined in this section, as a condition of the issuance or renewal of a health benefit plan.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176i - Preferred Provider Arrangements › Section 7 - Report

Section 7. An organization which enters into a preferred provider arrangement shall file annually with the commissioner, within one hundred and twenty days of the close of its fiscal year, a report covering its prior fiscal year. The report shall include:
(a) the number of covered persons under health benefit plans and workers' compensation insurance or self-insured workers' compensation plans, which include preferred provider arrangements;
(b) financial and utilization date of health benefit plans and workers' compensation insurance or self-insured workers' compensation plans, which include preferred provider arrangements;
(c) a list of preferred providers; and
(d) such other information as the commissioner may reasonably require.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176i - Preferred Provider Arrangements › Section 8 - Powers of Commissioner; Standardized Claim Form

Section 8. In addition to other powers specified in this chapter, the commissioner may, after due hearing:
(a) promulgate appropriate rules and regulations necessary to the administration and enforcement of this chapter;
(b) issue an order requiring any person or organization to cease and desist from violating any provision of this chapter or any rules, regulations, or order hereunder;
(c) require any person or organization found to have violated any provision of this chapter or any rule, regulation or order hereunder to forfeit an amount not to exceed ten thousand dollars for any single violation; and
(d) institute a rehabilitation or liquidation proceeding in accordance with the provisions of section one hundred and eighty A through one hundred and eighty L of chapter one hundred and seventy-five.
The commissioner of insurance is hereby directed to produce a standardized claim form to be utilized by all health insurance companies licensed to do business in the commonwealth for billing purposes.
Said form shall be made available to said companies no later than July first, nineteen hundred and ninety-three.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176i - Preferred Provider Arrangements › Section 9 - Application of Laws

Section 9. An organization which offers or administers a health benefit plan or furnishes workers' compensation, under a preferred provider arrangement shall be subject to all of the provisions of its enabling or licensing statute and of any other provisions of the general laws applicable thereto, including but not limited to, the provisions of chapter 176O and any benefits required to be provided by law. To the extent that this section is inconsistent with the provisions of one hundred and seventy-six M and any regulations promulgated thereunder, any nongroup health plan under a preferred provider arrangement that is within the definition of a guaranteed issue health plan in said chapter one hundred and seventy-six M shall be governed by the provisions of said chapter one hundred and seventy-six M and any regulations promulgated thereunder. In connection with any preferred provider arrangement and activities, an organization shall be considered to be an insurance company for the purposes of sections one hundred and ninety-three C, one hundred and ninety-three D, one hundred and ninety-three L, one hundred and ninety-three M and one hundred and ninety-three N of chapter one hundred and seventy-five.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176i - Preferred Provider Arrangements › Section 11 - Annual Assessment

Section 11. (a) Every organization other than a workers' compensation insurer, operating a preferred provider arrangement shall annually pay an assessment equal to two and twenty-eight hundredths per cent of the gross premiums received during the preceding calendar year for coverage of covered persons residing in this commonwealth; provided, however, that no assessment shall be imposed on premiums for medicare supplemental coverage. In calculating said gross premiums, there shall be deducted any amounts eligible for deduction pursuant to section twenty-four of chapter sixty-three and any amounts that are subject to the assessment imposed by section one hundred and ten L of chapter one hundred and seventy-five or by section ten A of chapter one hundred and seventy-six G. All said assessments, including interest thereon or penalties, shall be deposited in the general fund.
(b) The assessment imposed by this section shall be collected and administered by the commissioner of revenue. Every organization operating a preferred provider arrangement shall annually, on or before March fifteenth, make a return to said commissioner giving such information as said commissioner may deem necessary for the determination of the assessment for the preceding calendar year. The payment and collection of the assessments imposed by this section shall, to the extent consistent with this section, be governed by the provisions of chapters sixty-two C and sixty-three B. This provision shall take effect for premiums received after December thirty-first, nineteen hundred and eighty-eight.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176i - Preferred Provider Arrangements › Section 12 - Coverage for Children Under Age 18 for Cleft Lip and Cleft Palate

Section 12. An organization entering into a preferred provider contract that covers a child under the age of 18 shall provide coverage for the cost of treating cleft lip and cleft palate for the child. The coverage shall include benefits for medical, dental, oral and facial surgery, surgical management and follow-up care by oral and plastic surgeons, orthodontic treatment and management, preventative and restorative dentistry to ensure good health and adequate dental structures for orthodontic treatment or prosthetic management therapy, speech therapy, audiology and nutrition services, if such services are prescribed by the treating physician or surgeon and such physician or surgeon certifies that such services are medically necessary and consequent to the treatment of the cleft lip, cleft palate or both. The coverage required by this section shall be subject to the terms and conditions applicable to other benefits. Payment for dental or orthodontic treatment not related to the management of the congenital conditions of cleft lip and cleft palate shall not be covered under this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176j - Small Group Health Insurance › Section 2 - Application of Chapter

Section 2. Except as otherwise provided, this chapter applies to all health benefit plans issued, made effective, delivered or renewed to any eligible small business after April 1, 1992, and all health benefit plans issued, made effective, delivered or renewed to any eligible individual on or after July 1, 2007, whether issued directly by a carrier, through the connector, or through an intermediary. Nothing in this chapter shall be construed to require a carrier that does not issue health benefit plans subject to the chapter to issue health benefit plans subject to this chapter.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176j - Small Group Health Insurance › Section 7 - Disclosure by Carriers

Section 7. (a) Every carrier shall make reasonable disclosure to prospective small business insureds, as part of its solicitation and sales material of:—
(1) the surcharge, if any, which shall be applied to a group's premium if one or more members are covered in the plan set forth in section 8; and
(2) the participation requirements or participation rate adjustments of the carrier for each health benefit plan.
(b) Every carrier, as a condition of doing business under the jurisdiction of this chapter on and after January 1, 2007, shall electronically file with the commissioner an annual actuarial opinion that the carrier's rating methodologies and rates to be applied in the upcoming calendar year comply with the requirements of this chapter and any regulations promulgated under the authority of this chapter. In addition, every carrier shall file electronically an annual statement of the number of eligible individuals, eligible employees and eligible dependents, as of the close of the preceding calendar year, enrolled in a health benefit plan offered by the carrier. A carrier that may require eligible individuals or eligible small groups with 5 or fewer eligible employees to obtain coverage through an intermediary or the connector shall file a list of those intermediaries, with associated contact information, before requiring those small groups to go through an intermediary to obtain small group health coverage. Every carrier shall maintain at its principal place of business a complete and detailed description of its rating practices including information and documentation which demonstrates that its rating methods and practices are based upon commonly accepted actuarial assumptions, are under sound actuarial principles, and comply with this chapter. Such information shall be made available to the commissioner upon request, but shall remain confidential.
(c) Every carrier shall notify the commissioner regarding any material changes or additions to the actuarial methodology at least 30 days before the effective date of the change or addition, including amendments to rate basis types, rating factors, intermediary relationships, distribution networks and products offered within this market. If the commissioner determines that a carrier is not complying with this chapter, the commissioner may disapprove the rating methodologies and the rates which the carrier uses.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176j - Small Group Health Insurance › Section 8 - Transitional Reinsurance Program

Section 8. The commissioner may study the implementation of, establish, if warranted, and supervise a transitional reinsurance program pursuant to section 1341 of the federal Affordable Care Act or, if the commissioner believes that such program is not appropriate for the commonwealth, to apply for any appropriate waiver from the requirement to implement such program. The commissioner may promulgate regulations to enforce this section; provided, however, that before a waiver is sought or a transitional reinsurance program is to be implemented, the commissioner shall provide a report on the decision and the details of any proposed program to the clerks of the senate and house of representatives and the senate and house committee on ways and means.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176j - Small Group Health Insurance › Section 10 - Young Adult Health Benefit Plans; Coverage Requirements; Premiums

Section 10. The division of insurance, with the advice and consent of the director of the connector, shall issue regulations to define coverage for young adult health benefit plans, and to implement this section. Eligibility for enrollment in a qualifying young adult health insurance program will be restricted to individuals between the ages of 18 and 26, inclusive, who do not otherwise have access to health insurance coverage subsidized by an employer. Coverage for young adults shall provide reasonably comprehensive coverage of inpatient and outpatient hospital services and physician services for physical and mental illness and shall provide all services which a carrier is required to include under applicable division of insurance statutes and regulations, including, but not limited to, mental health services, emergency services, and any health service or category of health service provider which a carrier is required by its licensing or other statute to include in its health benefit plans. Any carrier offering young adult health plans must offer at least 1 product that includes coverage for outpatient prescription drugs. Coverage for young adults may impose reasonable copayments, coinsurance and deductibles and may use cost control techniques commonly used in the health insurance industry, including tiered provider networks and selective provider contracting.
Such plans shall only be offered by a carrier that, as of the close of any preceding calendar year, has a combined total of 5,000 or more eligible individuals, eligible employees and eligible dependents, who are enrolled in health plans sold, issued, delivered, made effective or renewed to qualified small businesses or eligible individuals pursuant to its license under chapter 175, chapter 176A, chapter 176B or chapter 176G. Further, such plans shall only be offered through the commonwealth health insurance connector as defined in chapter 176Q. Premium rates for young adult plans shall be consistent with section 3.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176j - Small Group Health Insurance › Section 11a - Continuing Coverage for Active Course of Treatment for Serious Disease Begun Prior to Enrollment in Reduced or Selective Network Plan or Tiered Network Plan

Section 11A. (a) For an insured member who (1) is receiving an active course of medical treatment from a health care provider for a serious disease, including but not limited to cancer or cystic fibrosis, that if disrupted in the course of medical treatment would pose an undue hardship to the patient and (2)(i) began this active course of treatment before being enrolled in a reduced or selective network plan where the provider is not part of the reduced or selective network or (ii) began this active course of treatment before being enrolled in a tiered network plan where the provider is in the highest cost-sharing tier, the carrier shall provide coverage for those medically necessary and covered services that are part of that active course of treatment provided by that health care provider, to the extent required by subsection (b).
(b) A carrier to which subsection (a) applies shall cover the health care provider's services for the duration of the active course of treatment during the plan year, if (1) the insured's employer offers the insured only a choice of reduced or selective network plans in which the health care provider is not part of any of the offered reduced or selective networks, or a choice of tiered network plans in which the health care provider is in the highest cost-sharing tier; (2) that health care provider is a comprehensive cancer center, pediatric hospital or pediatric specialty unit as defined in section 1 of chapter 118G; and (3) that health care provider is providing the insured with an active course of medical treatment that is not available from another provider in the network of the insured's plan.
(c) For services provided under this section from a provider that is not in the network of the insured's plan, patient cost-sharing shall be at the lowest cost-sharing level applicable to those services in the plan, and reimbursement shall be based on median in-network rates of the specific health care provider in that carrier's private plans in a manner consistent with data filed by that carrier with the division of health care finance and policy; provided, however, that if the specific health care provider does not participate in any other plan of the carrier, then based on negotiated rates. For services provided under this section by a provider in the highest cost-sharing tier of a tiered network plan, patient cost-sharing shall be based on the second-highest cost-sharing tier in that plan.
(d) The commissioner shall adopt regulations to carry out this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176j - Small Group Health Insurance › Section 14 - Coverage of Medically Necessary and Covered Services Otherwise Unavailable Within Carrier's Provider Network

Section 14. If a medically necessary and covered service is not available to a member within the carrier's provider network, the carrier shall cover the services out-of-network, for as long as the service is unavailable in-network.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176j - Small Group Health Insurance › Section 15 - Display by Insurer Offering Tiered Network Plan of Cost-Sharing Differences for Enrollees in Various Tiers in Promotional and Agreement Material

Section 15. An insurer offering a tiered network plan shall clearly and conspicuously indicate, in all promotional and agreement materials, the cost-sharing differences for enrollees in the various tiers. The commissioner shall adopt regulations to carry out this section.