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2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 1 - Definitions

Section 1. In this chapter the following words shall have the following meanings:
''Commissioner'', the commissioner of insurance.
''Covered dependent'', a dependent for whose optometric care provision is made in a subscription certificate issued by an optometric service corporation to a subscriber.
''Dependent'', the spouse, child or foster child of a subscriber, or an adult relative dependent upon the subscriber for his support.
''Optometric service'', the optometric services ordinarily provided by registered optometrists in accordance with accepted practices in the community where the services are rendered.
''Optometric service corporation'', a corporation organized as provided by the provisions of this chapter for the purpose of establishing and operating a non-profit optometric service plan.
''Non-profit optometric service plan'', a plan operated by an optometric service corporation under the provisions of this chapter, whereby the cost of optometric service furnished to subscribers and covered dependents is paid by the corporation to participating optometrists and to such other optometrists as are provided for herein.
''Participating optometrist'', a registered optometrist who agrees in writing with an optometric service corporation to perform optometric service for subscribers and covered dependents and to abide by the by-laws, rules and regulations of such corporation.
''Registered optometrist'', an optometrist registered to practice optometry in the commonwealth as provided in section sixty-eight of chapter one hundred and twelve.
''Subscriber'', a person who has subscribed to a non-profit optometric service plan and to whom a subscription certificate has been issued in accordance with the provisions of section six.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 2 - Incorporators; Formation; Articles of Organization; Certification

Section 2. For the purpose of establishing, maintaining and operating a non-profit optometric service plan, seven or more persons may form an optometric service corporation. Such a corporation shall be formed in the manner prescribed in and subject to section nine of chapter one hundred and fifty-five and sections six and eight to twelve, inclusive, of chapter one hundred and fifty-six, except as follows:—
The agreement of association of a corporation having no capital stock may omit the statement of the amount of the capital stock and the par value and number of its shares. The fee to be paid to the state secretary upon the filing of the articles of organization shall be determined annually by the commissioner of administration under the provision of section three B of chapter seven.
The articles of organization specified in section ten of said chapter one hundred and fifty-six, with the records and by-laws of the corporation shall be submitted to the commissioner instead of to the commissioner of revenue, and he shall have the powers and perform the duties relative thereto specified in section eleven of said chapter one hundred and fifty-six.
The certificate issued by the state secretary under section twelve of said chapter one hundred and fifty-six shall be modified to conform to the requirements of this section.
The commissioner shall not approve the articles of organization of such a corporation until he is satisfied by such examination as he may make and such evidence as he may require, that the incorporators are of good repute and intend in good faith to operate the corporation and that an adequate initial reserve fund has been established to protect the subscribers. He shall execute a certificate of his findings, which shall be attached to the articles of organization prior to the filing thereof with the state secretary.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 3 - By-Laws; Rules and Regulations; Contracts With Governmental Agencies

Section 3. The by-laws of an optometric service corporation may contain any lawful provisions approved by the commissioner and shall provide that a majority of the directors shall at all times be persons approved in writing by an optometric society incorporated in the commonwealth not less than five years and having not less than four hundred registered optometrists as members, and that not less than one third of the directors shall be persons who are or who agree to become subscribers to the non-profit optometric service plan. The by-laws of such a corporation may define the qualifications of those persons eligible to become subscribers as provided in section five. Any such corporation may adopt such rules and regulations as may be consistent with the provisions of this chapter. Any optometric service corporation may contract with any agency of the United States of America, of the commonwealth or of any city or town within the commonwealth for the purpose of providing optometric service.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 4 - Contracts With Subscribers and Participating Optometrists

Section 4. Any optometric service corporation may enter into contracts with its subscribers and with participating optometrists for the rendering of optometric service to the subscribers. A contract with a subscriber may provide for the optometric care of any dependents of the subscriber named therein. The extent of optometric services to be provided and the form of agreement with participating optometrists shall at all times be subject to the written approval of the commissioner. The fees to be paid to participating optometrists for their services to the subscribers or to insured dependents and the rates charged by such corporation to the subscribers shall at all times be subject to a public hearing as provided by section two of chapter thirty A. Such fees shall be lower than the fees charged by participating optometrists to their non-subscriber patients. The form of subscription certificate, the rates charged by such corporation to the subscribers and the fees at which participating optometrists are compensated for their services to the subscribers or to covered dependents, shall at all times be subject to the written approval of the commissioner. Acquisition costs in connection with the solicitation of subscribers and costs of administration shall at all times be limited to such amounts as the commissioner shall approve.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 4a - Contracts With Insurance Companies

Section 4A. An optometric service corporation may enter into contracts with any company authorized to write accident and health policies in the commonwealth pursuant to sections one hundred and eight to one hundred and eleven, inclusive, of chapter one hundred and seventy-five, or with any corporation organized under chapter one hundred and seventy-six A or one hundred and seventy-six B, under which contracts such company or corporation agrees to offer optometric service, as defined in this chapter, to Massachusetts subscribers where services provided therein are to be furnished by participating optometrists holding agreements with a vision service corporation pursuant to section seven of this chapter; provided that any such contract shall be consistent with the provisions of paragraph D of subdivision 8 of section one hundred and eight of chapter one hundred and seventy-five. An optometric service corporation may contract with any person to provide administrative services necessary to the administration of any contract entered into pursuant to the authority of this paragraph or of section four of this chapter. Before any contract may be entered into under this section, it shall have the written approval of the commissioner.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 5 - Subscribers; Qualifications; Cancellation of Subscription

Section 5. Any person residing in the commonwealth shall have the right to become a subscriber of an optometric service corporation if his qualifications meet those specified in the by-laws of such corporation, provided that such a corporation may, in its discretion, refuse to issue a subscription certificate to, or upon due notice cancel the subscription certificate of, any person who has made any fraudulent claim or representation to the corporation or to a participating optometrist, or has been guilty of uncooperative or unethical dealings with the corporation, or has failed to pay premiums and assessments seasonably and promptly or for any other cause which may be approved by the commissioner.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 6 - Subscription Certificate; Issuance; Contents

Section 6. A subscription certificate shall be issued to each subscriber of an optometric service corporation. Any agreement between an optometric service corporation and a group of ten or more persons or with the employer, employers or other representatives of such group whereby the optometric service corporation undertakes to furnish benefits for optometric service to said persons and their covered dependents, if any, shall be considered a group optometric service agreement. Under a group or non-group optometric service agreement, the form of the subscription certificate, the extent of optometric services contained therein, and the premiums charged by such corporation to the subscriber shall be filed with and receive the prior approval of the commissioner. No such agreement shall be approved if he finds that the extent of optometric services offered therein are unreasonable in relation to (a) the premium charged for such services, and (b) to the economic practicality of providing for such prepaid services, or if the premium charges are excessive, inadequate or unfairly discriminatory. No subscription certificate shall be issued unless the commissioner shall have approved in writing the form of certificate nor unless it contains in substance the following provisions:—
(a) A statement of the optometric service to be paid for by the corporation, and if any optometric service is excepted, a statement of such exception.
(b) A statement of the duration of the agreement and of the terms and conditions upon which it may be extended, renewed, revised, canceled or otherwise terminated.
(c) A statement of the period of grace which will be allowed for making any payment due from the subscriber under the contract, which in any event shall not be less than ten days.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 7 - Contracts Between Corporation and Optometrist; Protection of Optometrist-Patient Relation; Rights of Subscribers; Termination of Contract

Section 7. Every registered optometrist shall have the right, on complying with such rules and regulations as the corporation may make, to enter into a written agreement with an optometric service corporation, doing business in the city or town where the said optometrist resides or has his usual place of practice, to perform optometric service. This chapter shall not change the normal relations between optometrist and patient, except as to the manner of payment and amount of fees which are to be paid by the optometric service corporation to participating optometrists on behalf of the subscriber. No officer, agent or employee of an optometric service corporation shall influence or attempt to influence a subscriber or a covered dependent in his choice of a participating optometrist. A subscriber or a covered dependent, subject to the by-laws, rules and regulations of an optometric service corporation and the terms and provisions of his subscription certificate, shall be entitled to the benefits of this chapter upon receiving optometric service from any participating optometrist or, in the discretion of the corporation, upon receiving optometric service from any non-participating optometrist in an emergency or when outside the commonwealth. A corporation may terminate its agreement with any participating optometrist at any time (a) for failure to comply with the reasonable rules and regulations of such corporation, including without limitation such rules and regulations as may be adopted governing the keeping of accounts, records and statistics, the making of reports and proof of services rendered, or (b) for presenting any fraudulent, unreasonable, or improper claim for payment or compensation.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 8 - Annual Statement

Section 8. Every optometric service corporation shall annually, on or before the first day of March, file in the office of the commissioner, a statement, verified by at least two of the principal officers of said corporation, showing its condition as of the thirty-first day of December next preceding. Such statement shall be in such form and shall contain such matters as the commissioner shall prescribe. A corporation neglecting to file its annual statement within the time herein specified shall forfeit one hundred dollars for each day during which such neglect continues, and upon notice by the commissioner to that effect, its authority to do business shall cease while such default continues.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 10 - Investment of Funds; Acquisition of Realty; Special Contingent Surplus

Section 10. The funds of an optometric service corporation shall be invested only in such securities as are permitted by chapter one hundred and seventy-five for the investment of the capital of insurance companies, or it may deposit the whole or any portion of its funds in any savings bank or savings account in a trust company organized under the laws of the commonwealth or a national banking association. It shall have the right to acquire and own real estate to be occupied by itself in the transaction of its business. The commissioner may require any such corporation after the first full calendar year of doing business to accumulate and maintain a special contingent surplus, over and above its reserves and liabilities, in such amount as the commissioner may deem proper.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 11 - Salaries, Compensation or Emoluments

Section 11. Unless each such payment is first authorized by a vote of its board of directors, no optometric service corporation shall pay any salary, compensation or emolument to any officer, trustee or director thereof, or any salary, compensation or emolument to any person amounting in any year to more than five thousand dollars. No such corporation shall make any agreement with any of its officers, trustees or employees whereby it agrees that for any services rendered or to be rendered to it, they shall receive any salary, compensation or emolument for a period of more than three years from the date of such agreement.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 12 - Disputes or Controversies; Submission to Board; Review of Board's Decision

Section 12. Any dispute or controversy arising between an optometric service corporation and any participating optometrist, or any subscriber, or any person whose subscription certificate has been canceled or to whom such corporation has refused to issue such certificate may within thirty days after such dispute or controversy arises be submitted by any person aggrieved to a board serving in the division of insurance and consisting of the commissioner or a person designated by him, the chairman of the board of registration in optometry or any person designated by him, and the attorney general or a person designated by him, for its decision with respect thereto. Such an appeal to said board shall be conducted as an adjudicatory proceeding in accordance with the provisions of section eleven of chapter thirty A. All decisions and orders of the board or of the commissioner made under any provision of this chapter may be revised as justice and equity may require upon a petition in equity filed, within ten days after the promulgation of such decision or order in the superior court within and for the county of Suffolk by any party aggrieved by such decision or order. Such proceedings in equity for judicial review shall be conducted in accordance with section fourteen of chapter thirty A.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 13 - Enjoining Transaction of Business; Grounds; Receivers

Section 13. If the commissioner is satisfied, as to any optometric service corporation, that (1) it has failed to comply with the provisions of its charter, or (2) it is being operated for profit, or (3) it is fraudulently conducted, or (4) its condition is such as to render its further transaction of business hazardous to the public or to its subscribers, or (5) its officers and agents have refused to submit to an examination under section nine, or (6) it has exceeded its powers, or (7) it has violated any provision of law, or (8) it has compromised, or is attempting to compromise, with its creditors on the ground that it is financially unable to pay its claims in full, or (9) it is insolvent, he may apply to the supreme judicial court for an injunction restraining it from further proceeding with its business. 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, moneys and other assets of the corporation, settle its affairs, and distribute its funds to those entitled thereto, subject to such rules and orders as the court may prescribe.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176f - Optometric Service Corporations › Section 14 - Status of Corporation; Immunity and Exemptions

Section 14. Every optometric service corporation is hereby declared to be a charitable corporation. No such corporation shall be liable for injuries resulting from negligence or malpractice on the part of any participating optometrist, nor shall it be liable for the cost of optometric services to which the subscriber or covered dependent may be entitled under the provisions of chapter 152. Every such corporation shall be exempt from all provisions of the insurance laws of the commonwealth, except as otherwise provided in this chapter. The property of every such corporation shall be exempt from all state and local taxes.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 2 - Application of Laws

Section 2. Except as hereinafter provided in this chapter, the provisions of chapters one hundred and seventy-five, one hundred and seventy-six A, one hundred and seventy-six B, one hundred and seventy-six C, one hundred and seventy-six E, and one hundred and seventy-six F, shall not apply to a health maintenance organization, provided, however, that in the case of any company doing business in the commonwealth and otherwise subject to the provisions of said chapters, this section shall apply only with respect to its health maintenance organization activities.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 3 - Organization; Accounting; Contracts

Section 3. A carrier or any two or more such companies, corporations, or their subsidiaries or affiliates may: (1) organize and operate a health maintenance organization as a line of business, division, department, subsidiary or affiliate under the provisions of this chapter provided that where such is organized as a line of business, division, department, subsidiary or affiliate, the operation of the health maintenance organization shall be separately accounted for, the income and expenses shall be allocated in accordance with statutory accounting practices and procedures prescribed or permitted by the commissioner, and the carrier or companies shall not utilize the income from such health maintenance organization for unrelated activities; 2) contract with a health maintenance organization to provide insurance, reinsurance, health services, reimbursement for health services or similar protection against the cost of care provided through the health maintenance organization; 3) contract with a health maintenance organization to provide coverage, health services or reimbursement for health services in the event of the failure of the health maintenance organization to meet its obligations under health maintenance contracts issued by it or a carrier; 4) contract with a health maintenance organization to provide administrative, underwriting, financing or other services relating to the provision of hospital, medical or other health services or reimbursement therefor; 5) contract with a health maintenance organization to enroll members on behalf of the health maintenance organization or to issue its own certificate of benefits for the covered health services provided by the health maintenance organization; and, 6) contract with a health maintenance organization for the joint administration of their business or for the writing and issue by the health maintenance organization, the carrier, or both jointly, of health maintenance contracts binding upon the carrier.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4 - Required Coverage for Certain Conditions and Groups

Section 4. A health maintenance contract shall provide coverage for:
(a) pregnant women, infants and children as set forth in section 47C of chapter 175;
(b) cardiac rehabilitation as set forth in section 47D of chapter 175;
(c) prenatal care, childbirth and postpartum care as set forth in section 47F of chapter 175;
(d) cytologic screening and mammographic examination as set forth in section 47G of chapter 175;
(e) diagnosis and treatment of infertility as set forth in section 47H of chapter 175; and
(f) services rendered by a certified registered nurse anesthetist or nurse practitioner as set forth in section 47Q of chapter 175, subject to the terms of a negotiated agreement between the health maintenance organization and the provider of health care services.
The dependent coverage of any such policy shall also provide coverage for medically necessary early intervention services delivered by certified early intervention specialists, as defined in the early intervention operational standards by the department of public health and in accordance with applicable certification requirements. Such medically necessary services shall be provided by early intervention specialists who are working in early intervention programs certified by the department of public health, as provided in sections 1 and 2 of chapter 111G, for children from birth until their third birthday. Reimbursement of costs for such services shall be part of a basic benefits package offered by the insurer or a third party and shall not require co-payments, coinsurance or deductibles; provided, however, that co-payments, coinsurance or deductibles shall be required if the applicable plan is governed by the Federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on co-payments, coinsurance or deductibles for these services.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4a - Employees Terminated Due to Plant Closings; Coverage

Section 4A. Any health maintenance contract shall provide coverage for employees terminated due to a plant closing or covered partial closing as required by the second paragraph of section one hundred and ten D of chapter one hundred and seventy-five and the second paragraph of section one hundred and ten G of chapter one hundred and seventy-five.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4aa - Coverage for Medically Necessary Acute Treatment and Clinical Stabilization Services

Section 4AA. For the purposes of this section the following terms shall have the following meanings, unless the context clearly requires otherwise:—
''Acute treatment services'', 24–hour medically supervised addiction treatment for adults or adolescents provided in a medically managed or medically monitored inpatient facility, as defined by the department of public health, that provides evaluation and withdrawal management and which may include biopsychosocial assessment, individual and group counseling, psychoeducational groups and discharge planning.
''Clinical stabilization services'', 24–hour clinically managed post detoxification treatment for adults or adolescents, as defined by the department of public health, usually following acute treatment services for substance abuse, which may include intensive education and counseling regarding the nature of addiction and its consequences, relapse prevention, outreach to families and significant others and aftercare planning, for individuals beginning to engage in recovery from addiction.
An individual or group health maintenance contract that is issued or renewed shall provide coverage for medically necessary acute treatment services and medically necessary clinical stabilization services for up to a total of 14 days and shall not require preauthorization prior to obtaining acute treatment services or clinical stabilization services; provided that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7; provided further, an individual or group health maintenance contract that is issued or renewed shall provide coverage for, without preauthorization, a substance use disorder evaluation ordered pursuant to section 511/2 of chapter 111.
Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient's medical record.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4cc - Coverage for Medical or Drug Treatments to Correct or Repair Disturbances of Body Composition Caused by HIV Associated Lipodystrophy Syndrome

Section 4CC. Any individual or group health maintenance contract shall provide coverage for medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome including, but not limited to, reconstructive surgery, such as suction assisted lipectomy, other restorative procedures and dermal injections or fillers for reversal of facial lipoatrophy syndrome. Coverage shall be subject to a statement from a treating provider that the treatment is necessary for correcting, repairing or ameliorating the effects of HIV associated lipodystrophy syndrome. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4d - Nonprescription Enteral Formulas for Home Use

Section 4D. A group health maintenance contract shall provide coverage for nonprescription enteral formulas for home use for which a physician has issued a written order and which are medically necessary for the treatment of malabsorption caused by Crohn's disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility, chronic intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein in an amount not to exceed $5,000 annually for any insured individual.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4dd - Filling of Remaining Portion of Prescription for Covered Drug That Is a Narcotic Substance Earlier Filled in Lesser Quantity

Section 4DD. An individual or group health maintenance contract that is issued or renewed shall provide, for any covered drug that is a narcotic substance contained in schedule II pursuant to chapter 94C and subject to cost sharing, that if a person receives a prescription filled in a lesser quantity pursuant to section 18 of said chapter 94C, said person shall not be subject to an additional payment obligation, including but not limited to co-payments, if said person fills the remaining portion of the prescription.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4e - Off-Label Drug Use; Cancer Treatment

Section 4E. A group health maintenance contract shall provide coverage for off-label uses of prescription drugs used in the treatment of cancer as set forth in sections forty-seven K and forty-seven L of chapter one hundred and seventy-five; provided, however, that neither the attending physician nor the health maintenance organization shall be liable in a suit for damages as a result of the acts or omissions of the attending physician or the health maintenance organization in connection with compliance with this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4ee - Pain Management Access Plans

Section 4EE. (a) Any individual or group health maintenance contract that is issued or renewed shall develop a plan to provide adequate coverage and access to a broad spectrum of pain management services, including, but not limited to, those that serve as alternatives to opioid prescribing, in accordance with guidelines developed by the division of insurance.
(b) The plan shall be subject to approval and shall be a component of carrier accreditation by the division of insurance pursuant to section 2 of chapter 176O. In its review, the division shall consider the adequacy of access to a broad spectrum of pain management services and any carrier policies that may create unduly preferential coverage to prescribing opioids without other pain management modalities.
(c) Carriers shall distribute educational materials to providers within their networks about the pain management access plan and make information about their plans publicly available on their websites.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4f - Group Health Maintenance Contracts; Coverage for Bone Marrow Transplants

Section 4F. Any group health maintenance contract shall provide coverage for a bone marrow transplant or transplants for persons who have been diagnosed with breast cancer that has progressed to metastatic disease; provided, however, that said person shall meet the criteria established by the department of public health. The department shall promulgate rules and regulations establishing criteria for eligibility for coverage hereunder which shall be consistent with medical research protocols reviewed and approved by the National Cancer Institute.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4ff - Coverage for Tobacco Use Cessation Counseling and Tobacco Cessation Products

Section 4FF. (a) An individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide coverage for: (i) tobacco use cessation counseling; and (ii) all generic United States Food and Drug Administration–approved tobacco cessation products without cost sharing when prescribed by a health care provider.
(b) Carriers shall be permitted to employ reasonable managed care techniques consistent with state and federal law to determine the frequency, method, treatment or setting for the recommended item or service; provided, however, that covered persons shall have access to at least 1 tobacco cessation product without prior authorization.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4g - Off-Label Use of Prescription Drugs for HIV/AIDS Treatment

Section 4G. Any individual or group health insurance maintenance contract which provides coverage for prescription drugs shall provide coverage for off-label uses of prescription drugs used in the treatment of HIV/AIDS as set forth in sections forty-seven O and forty-seven P of chapter one hundred and seventy-five.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4gg - Coverage for Treatment of Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections and Pediatric Acute-Onset Neuropsychiatric Syndrome

[Text of section applicable to contracts that take effect or are renewed on or after January 1, 2022. See 2020, 260, Sec. 74.]
Section 4GG. Any individual or group health maintenance contract shall provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome including, but not limited to, the use of intravenous immunoglobulin therapy.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4h - Items Medically Necessary for Diagnosis and Treatment of Diabetes

Section 4H. Any individual or group health maintenance contract, except contracts providing supplemental coverage to Medicare or other governmental programs, delivered, issued or renewed by agreement between the insurer and the policyholder, within or without the commonwealth, shall provide, as set forth in section 47N of chapter 175, coverage for the following items if such items are within a category of benefits or services for which coverage is otherwise afforded by the contract, have been prescribed by a health care professional legally authorized to prescribe such items and if the items are medically necessary for the diagnosis or treatment of insulin-dependent, insulin-using, gestational and non-insulin-dependent diabetes: blood glucose monitors; blood glucose monitoring strips for home use; voice-synthesizers for blood glucose monitors for use by the legally blind; visual magnifying aids for use by the legally blind; urine glucose strips; ketone strips; lancets; insulin; insulin syringes; prescribed oral diabetes medications that influence blood sugar levels; laboratory tests, including glycosylated hemoglobin, or HbAlc, tests; urinary protein/microalbumin and lipid profiles; insulin pumps and insulin pump supplies; insulin pens, so-called; therapeutic/molded shoes and shoe inserts for people who have severe diabetic foot disease when the need for therapeutic shoes and inserts has been certified by the treating doctor and prescribed by a podiatrist or other qualified doctor and furnished by a podiatrist, orthotist, prosthetist or pedorthist; supplies and equipment approved by the Federal Drug Administration for the purposes for which they have been prescribed and diabetes outpatient self-management training and education, including medical nutrition therapy, when provided by a certified diabetes health care provider participating with the health maintenance contract or affiliated with a provider participating with the health maintenance contract. As used in this section, ''certified diabetes health care provider'' shall mean a licensed health care professional with expertise in diabetes, a registered dietician or a health care provider certified by the National Certification Board of Diabetes Educators as a certified diabetes educator. Nothing in this section shall be construed to require a health maintenance organization to contract with a certified diabetes health care provider who is not already under contract with such health maintenance organization.
The benefits provided in this section shall meet all other terms and conditions within a health maintenance contract. Health maintenance contracts shall not reduce or eliminate coverage due to the requirements of this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4ii - Coverage for Prescription Eye Drops

Section 4II. An individual or group health maintenance contract that provides coverage for prescription eye drops shall provide coverage for refills of prescription eye drops in accordance with the Medicare Part D guidelines on early refills of topical ophthalmic products when: (i) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; (ii) the refill requested by the insured does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner; and (iii) the prescription eye drops prescribed by the health care practitioner are a covered benefit under the policy or contract of the insured.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4j - Scalp Hair Prostheses Necessary Due to Cancer or Leukemia Treatment

Section 4J. (a) For the purposes of this section, the following words shall have the following meanings:
''Prosthesis'', an artificial appliance used to replace a lost natural structure; provided, however, that prosthesis shall include, but not be limited to, artificial arms, legs, breasts, scalp hair or glass eyes.
''Scalp hair prosthesis'', an artificial substitute for scalp hair.
(b) A group health maintenance contract which provides coverage for any other prosthesis, shall provide coverage for expenses for scalp hair prostheses worn for hair loss suffered as a result of the treatment of any form of cancer or leukemia; provided, however, that such coverage shall be subject to a written statement by the treating physician that the scalp hair prosthesis is medically necessary; and provided, further, that such coverage shall be subject to the same limitations and guidelines as other prostheses. Scalp hair prosthesis coverage pursuant to this section shall not exceed an amount of $350 per year.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4jj - Coverage for Mental Health or Substance Use Disorder Services Delivered Through Psychiatric Collaborative Care Model

Section 4JJ. (a) For the purposes of this section, ''psychiatric collaborative care model'' shall mean the evidence-based, integrated behavioral health service delivery method in which a primary care team consisting of a primary care provider and a care manager provides structured care management to a patient, and that works in collaboration with a psychiatric consultant that provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations.
(b) Any individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide coverage for mental health or substance use disorder services that are delivered through the psychiatric collaborative care model.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4k - Newborn Hearing Screening Tests

Section 4K. A health maintenance contract shall provide coverage for a newborn hearing screening test to be performed before the newborn infant is discharged from the hospital or birthing center to the care of the parent or guardian, pursuant to regulations of the department of public health. Payment to physician, hospital or other provider for the costs of said test may be pursuant to the terms of a negotiated contract. Nothing contained in this section shall be construed to abrogate any other obligation to provide coverage for a hearing screening test or any other hearing screening test or audiological diagnostic procedure pursuant to any law of the commonwealth or of the United States or under the terms or provisions of any contract or certificate.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4kk - Coverage for Medically Necessary Mental Health Acute Treatment, Community-Based Acute Treatment and Intensive Community-Based Acute Treatment

Section 4KK. (a) For the purposes of this section, the following terms shall have the following meanings unless the context clearly requires otherwise:
''Community-based acute treatment'', 24–hour clinically managed mental health diversionary or step-down services for children and adolescents that is usually provided as an alternative to mental health acute treatment.
''Intensive community-based acute treatment'', intensive 24–hour clinically managed mental health diversionary or step-down services for children and adolescents that is usually provided as an alternative to mental health acute treatment.
''Mental health acute treatment'', 24–hour medically supervised mental health services provided in an inpatient facility, licensed by the department of mental health, that provides psychiatric evaluation, management, treatment and discharge planning in a structured treatment milieu.
(b) An individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide coverage for medically necessary mental health acute treatment, community-based acute treatment and intensive community-based acute treatment and shall not require a preauthorization before the administration of such treatment; provided, however, that the facility shall notify the carrier of the admission and the initial treatment plan within 72 hours of admission.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4l - Coverage for Hospice Services

Section 4L. Any group health maintenance contract shall provide coverage for hospice services as defined in section 57D of chapter 111 during the life of the patient, to terminally ill patients with a life expectancy of six months or less; provided, however, that such services are determined to be appropriate and authorized by the patient's primary care or treating physician and are equivalent to those services provided by a licensed hospice program regulated by the department of public health.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4ll - Benefits for Medically Necessary Emergency Services Programs

Section 4LL. An individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide benefits on a nondiscriminatory basis for medically necessary emergency services programs, as defined in section 1 of chapter 175.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4mm - Coverage for Annual Mental Health Wellness Examination

Section 4MM. (a) For the purpose of this section, the following words shall have the following meanings unless the context clearly requires otherwise:
''Licensed mental health professional,'' a licensed physician who specializes in the practice of psychiatry, a licensed psychologist, a licensed independent clinical social worker, a licensed certified social worker, a licensed mental health counselor, a licensed supervised mental health counselor, a licensed psychiatric nurse mental health clinical specialist, a licensed psychiatric mental health nurse practitioner, a licensed physician assistant who practices in the area of psychiatry, a licensed alcohol and drug counselor I, as defined in section 1 of chapter 111J, or a licensed marriage and family therapist within the lawful scope of practice for such therapist.
''Mental health wellness examination,'' a screening or assessment that seeks to identify any behavioral or mental health needs and appropriate resources for treatment. The examination may include: (i) observation, a behavioral health screening, education and consultation on healthy lifestyle changes, referrals to ongoing treatment, mental health services and other necessary supports, and discussion of potential options for medication; and (ii) age-appropriate screenings or observations to understand a covered person's mental health history, personal history and mental or cognitive state and, when appropriate, relevant adult input through screenings, interviews and questions.
''Primary care provider'', a health care professional qualified to provide general medical care for common health care problems, who (i) supervises, coordinates, prescribes or otherwise provides or proposes health care services; (ii) initiates referrals for specialist care; and (iii) maintains continuity of care within the scope of practice.
(b) An individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide coverage for an annual mental health wellness examination that is performed by a licensed mental health professional or primary care provider, which may be provided by the primary care provider as part of an annual preventive visit. The examination shall be covered with no patient cost-sharing, provided, however, that cost-sharing shall be required if the applicable plan is governed by the Federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
(c) The division of insurance, in consultation with the office of Medicaid, and the department of mental health, shall develop guidelines to implement this section.