reglab/statecodes huggingface dataset:
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4n - Coverage for Speech, Hearing and Language Disorders; Hearing AIDS

Section 4N. Any individual or group health maintenance contract that provides hospital expense and surgical expense insurance, delivered, issued or renewed by agreement between the insurer and the policyholder, within or without the commonwealth, shall provide benefits for residents of the commonwealth and to all group members having a principal place of employment within the commonwealth for the expenses incurred in the medically necessary diagnosis and treatment of speech, hearing and language disorders by individuals licensed as speech-language pathologists or audiologists under chapter 112, if such services are rendered within the lawful scope of practice for such speech-language pathologists or audiologists regardless of whether the services are provided in a hospital, clinic or a private office, and if such coverage shall not extend to the diagnosis or treatment of speech, hearing and language disorders in a school-based setting. The benefits provided by this section shall be subject to the same terms and conditions established for any other medical condition covered by such individual or group health maintenance contract.
An individual or group health maintenance contract, except contracts providing supplemental coverage to Medicare or other governmental programs, shall provide coverage and benefits for children 21 years of age or younger, who are insured under such contracts, for expenses incurred for the cost of 1 hearing aid per hearing impaired ear up to $2,000 for each hearing aid, as defined under section 196 of chapter 112, every 36 months upon a written statement from the child's treating physician that the hearing aids are necessary regardless of etiology. Coverage under this section shall include all related services prescribed by a licensed audiologist or hearing instrument specialist, as defined in said section 196 of said chapter 112, including the initial hearing aid evaluation, fitting and adjustments and supplies, including ear molds. The insured may choose a higher priced hearing aid and may pay the difference in cost above the $2,000 limit in this section without any financial or contractual penalty to the insured or to the provider of the hearing aid. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefits provided by the insurer. Nothing in this section shall prohibit an insurer from offering greater coverage for hearing aids than required by this section. This section shall also require coverage for such hearing aids under any non-group policy.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4nn - Coverage for Federally-Defined Preventive Services

[ Text of section added by 2023, 28, Sec. 60 effective July 1, 2023. See 2023, 28, Sec. 115.]
Section 4NN. (a) For the purposes of this section, "federally-defined preventive services'' shall mean: (i) evidence-based items or services that currently have a rating of "A'' or "B'' in the recommendations of the United States Preventive Services Task Force; (ii) immunizations with routine use in children, adolescents and adults that currently have a recommendation from the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention with respect to the individual involved; (iii) with respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the federal Health Resources and Services Administration; and (iv) with respect to women, such additional preventive care and screenings not described in clause (i) as provided for in comprehensive guidelines supported by the federal Health Resources and Services Administration; provided, however, that "federally-defined preventive services'' shall also include all other preventive services not subject to cost-sharing, as required by established federal regulatory and sub-regulatory guidance issued on or before July 1, 2023.
(b) An individual or group health maintenance contract that is issued, delivered or renewed within the commonwealth shall provide coverage for federally-defined preventive services.
(c) Coverage provided pursuant to this section shall not be subject to any cost-sharing, including, but not limited to, co-payments, co-insurance or any deductible, as required by established federal regulatory and sub-regulatory guidance issued on or before July 1, 2023.
(d) Nothing in this section shall prohibit: (i) coverage for items and services in addition to those recommended by the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention or the Health Resources and Services Administration; or (ii) denying coverage for items and services that are not recommended by the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention or the federal Health Resources and Services Administration.
(e) If a recommendation described in subsection (a) is changed during a plan year, a carrier shall not be required to make changes to the health plan during the plan year.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4p - Patient Care Services Provided Pursuant to Qualified Clinical Trials

Section 4P. Any individual or group health maintenance contract shall provide for the coverage of patient care services furnished pursuant to qualified clinical trials as defined in, and subject to the requirements and limitations of, section 110L of chapter 175.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4q - Coverage for Human Leukocyte or Histocompatibility Locus Antigen Testing

Section 4Q. Any group health maintenance contract, except contracts providing supplemental coverage to Medicare or to other government programs, delivered, issued or renewed by agreement within or without the commonwealth shall provide to a member or enrollee coverage for the cost of human leukocyte antigen testing or histocompatibility locus antigen testing that is necessary to establish the member's or enrollee's bone marrow transplant donor suitability. The coverage shall cover the costs of testing for A, B or DR antigens, or any combination thereof, consistent with rules, regulations and criteria established by the department of public health pursuant to section 218 of chapter 111.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4s - Coverage for Prosthetic Devices and Repairs

Section 4S. (a) Individual and group health maintenance contracts shall provide coverage for prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment benefit, coverage shall be provided under the same terms and conditions that apply to other durable medical equipment covered under the contracts, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone prosthetic benefit, coverage shall be consistent with the terms and conditions as described in this section.
(b) In this section, ''prosthetic device'' shall mean an artificial limb device to replace, in whole or in part, an arm or leg.
(c) A health maintenance contract shall not impose any annual or lifetime dollar maximum on coverage for prosthetic devices other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the contract.
(d) A health maintenance contract shall not apply amounts paid for prosthetic devices to any annual or lifetime dollar maximum applicable to other durable medical equipment covered under the contract other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the contract.
(e) A health maintenance contract may include a reasonable coinsurance requirement for prosthetic devices and repairs, not to exceed 20 per cent of the allowable cost of the prosthetic device or repair, unless all covered benefits applying coinsurance under the plan do so at a higher amount. If the health maintenance contract provides coverage for services from nonparticipating providers, the contract may include a reasonable coinsurance requirement for prosthetic devices and repairs, not to exceed 40 per cent of the allowable cost of the prosthetic device or repair when obtained from a nonparticipating provider, unless all covered benefits applying coinsurance under the plan do so at a higher amount.
(f) A health maintenance contract may require prior authorization as a condition of coverage for prosthetic devices.
(g) A health maintenance contract shall only be required to provide coverage for the most appropriate medically necessary model that adequately meets the medical needs of the policyholder.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4t - Coverage for Eligible Dependents Under 26 Years of Age or Dependents Mentally or Physically Incapable of Earning Their Own Living Due to Disability

Section 4T. A health maintenance contract, except certificates which provide stand-alone dental services, supplemental coverage to Medicare or other governmental programs, shall provide, as benefits to all individuals or to group members having a principal place of employment within the commonwealth, coverage to eligible dependents under 26 years of age or without regard to age, so long as the dependent, who is covered under the membership of the dependent's parent as a member of a family group, is mentally or physically incapable of earning their own living due to disability.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4u - Coverage for Medically Necessary Hypodermic Syringes or Needles

Section 4U. No individual or group health maintenance contract shall restrict or discontinue coverage for medically necessary hypodermic syringes or needles, notwithstanding section 27 of chapter 94C. The term ''medical necessity'' shall be construed in accordance with the guidelines set forth in subsection (b) of section 16 of chapter 176O.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4w - Coverage for Children Under Age 18 for Cleft Lip and Cleft Palate

Section 4W. A health maintenance contract issued or renewed within or without the commonwealth 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 176g - Health Maintenance Organizations › Section 4x - Coverage for Orally Administered Anticancer Medications

Section 4X. Any individual or group health maintenance contract that provides coverage for cancer chemotherapy treatment shall provide coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis not less favorable than intravenously administered or injected cancer medications that are covered as medical benefits. An increase in patient cost sharing for anticancer medications shall not be allowed to achieve compliance with this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4y - Coverage for Abuse Deterrent Opioid Drug Products

Section 4Y. An individual or group health maintenance contract that is issued or renewed shall provide coverage for abuse deterrent opioid drug products listed on the formulary, compiled pursuant to subsection (b) of section 13 of chapter 17, on a basis not less favorable than non-abuse deterrent opioid drug products that are covered by an individual or group health maintenance contract. An increase in patient cost sharing shall not be allowed to achieve compliance with this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 4z - Preauthorization for Substance Abuse Treatment Not to Be Required

Section 4Z. For the purposes of this section the term ''substance abuse treatment'' shall include: early intervention services for substance use disorder treatment; a substance use disorder evaluation, as defined in section 511/2 of chapter 111; outpatient services including medically assisted therapies; intensive outpatient and partial hospitalization services; residential or inpatient services, not covered under section 4AA; and medically managed intensive inpatient services, not covered under said section 4AA.
Any individual or group health maintenance contract that is issued or renewed shall not require a member to obtain a preauthorization for substance abuse treatment if the provider is certified or licensed 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 5a - Divorced or Separated Spouses; Coverage

Section 5A. (a) In the event of the granting of a judgment absolute of divorce or of separate support to which a member of a group health maintenance contract is a party, the person who was the spouse of said member prior to the issuance of such judgment shall be and remain eligible for benefits under said contract, whether or not said judgment was entered prior to the effective date of said contract, without additional premium or examination therefor, as if said judgment had not been entered; provided, however, that such eligibility shall not be required if said judgment so provides. Such eligibility shall continue through the member's participation in the contract until the remarriage of either the member or such spouse, or until such time as provided by said judgment, whichever is earlier.
(b) In the event of the remarriage of the member referred to in paragraph (a), the former spouse thereafter shall have the right, if so provided in said judgment, to continue to receive benefits as are available to the member, by means of the addition of a rider to the family contract or the issuance of an individual contract, either of which may be at additional premium rates determined by the commissioner of insurance to be just and reasonable in accordance with the additional insuring risks involved.
(c) The name, address, and policy number of a person eligible for health insurance coverage pursuant to paragraph (a) or (b), if available, shall be forwarded by such health maintenance organization to the department of public welfare within thirty days of the date when coverage of said person under said paragraph (a) or (b) is commenced.
(d) Notice of cancellation of coverage of the divorced or separated spouse of a member shall be mailed to such divorced or separated spouse at such person's last known address, together with notice of the right to reinstate coverage retroactively to the date of cancellation.
(e) Claims paid on behalf of a divorced or separated spouse or on behalf of a dependent who is not residing with the member shall be paid to the physician, hospital or other provider of covered services or to the person on whose behalf such services were performed, unless the person is a minor child. In the event the person on whose behalf such services were performed is a minor, payment shall be made to the physician, hospital or other provider of such services or to the parent or custodian with whom the child resides.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 6 - Contracts

Section 6. A health maintenance organization may enter into contractual arrangements with any other person or company for the provision, to the health maintenance organization, of health services, insurance, reinsurance and administrative, marketing, underwriting or other services on a nondiscriminatory basis. A health maintenance organization shall not refuse to contract with or compensate for covered services an otherwise eligible provider solely because such provider has in good faith communicated with one or more of his current, former or prospective patients regarding the provisions, terms or requirements of the organization's products as they relate to the needs of such provider's patients.
No contract between a participating provider of health care services and a health maintenance organization shall be issued or delivered in the commonwealth unless it contains a provision requiring that within 45 days after the receipt by the organization of completed forms for reimbursement to the provider of health care services, the health maintenance organization shall (i) make payments for such services provided, (ii) notify the provider in writing of the reason or reasons for nonpayment, or (iii) notify the provider in writing of what additional information or documentation is necessary to complete said forms for such reimbursement. If the health maintenance organization fails to comply with this paragraph for any claims related to the provision of health care services, said health maintenance organization shall pay, in addition to any reimbursement for health care services provided, interest on such benefits, which shall accrue beginning 45 days after the health maintenance organization's receipt of request for reimbursement at the rate of 1.5 per cent per month, not to exceed 18 per cent per year. The provisions of this paragraph relating to interest payments shall not apply to a claim that the health maintenance organization is investigating because of suspected fraud. No contract between a participating home health agency or a participating licensed hospice agency and a health maintenance organization shall be issued or delivered in the commonwealth that requires the participating home health agency or participating licensed hospice agency to be accredited by the Joint Commission on Accreditation of Healthcare Organizations or other national accrediting body if it is certified for participation in the Medicare program, Title XVIII of the federal Social Security Act, 42 U.S.C. Sections 1395 et seq.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 6a - Group Health Maintenance Contracts; Contribution Percentages

Section 6A. A health maintenance organization may only enter into a group health maintenance contract with an employer if the group health maintenance contract is offered by that employer to all full-time employees who live in the commonwealth; provided, however, the employer shall not make a smaller health insurance premium contribution percentage amount to an employee than the employer makes to any other employee who receives an equal or greater total hourly or annual salary for each specific or general blanket policy of insurance for all employees. Notwithstanding the foregoing, a health maintenance organization may enter into a group health maintenance contract with an employer that establishes separate contribution percentages for employees covered by collective bargaining agreements.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 6b - Retroactive Claims Denials for Behavioral Health Services

Section 6B. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise:
''Behavioral health services'', as defined in section 1 of chapter 175, or ''services''.
''Provider'', (i) a mental health clinic or substance use disorder treatment program licensed by the department of public health under chapters 17, 111, 111B or 111E; or (ii) a behavioral, substance use disorder or mental health professional who is licensed under chapter 112 and accredited or certified to provide services and who has provided services under an express or implied contract or with the expectation of receiving payment, other than co-payment, deductible or co-insurance, directly or indirectly from the commission or other entity.
''Retroactive claims denial'', as defined in section 1 of chapter 175.
(b) An insurer or other entity shall not impose a retroactive claims denial for behavioral health services on a provider unless: (i) less than 12 months have elapsed from the time of submission of the claim by the provider to the insurer or other entity; (ii) the insurer or other entity has furnished the provider with a written explanation of the reason for the retroactive claims denial and, where applicable, a description of additional documentation or any other corrective action required for payment of the claim; and (iii) where applicable, the insurer or other entity responsible for payment allows the provider 30 days to submit additional documentation or to take any other corrective action required for payment of the claim.
(c) Notwithstanding subsection (b), a retroactive claims denial may be allowed after 12 months if: (i) the claim was submitted fraudulently; (ii) the claim, or services for which the claim was submitted, is the subject of legal action; (iii) the claim payment was incorrect because the provider was paid or the insured has already paid for the services identified in the claim; or (iv) the services identified in the claim were not delivered by the provider.
(d) If a retroactive claims denial is imposed because the claim payment is subject to adjustment due to expected payment from a payer other than the insurer or other entity with which the insurer contracts to provide or manage health care services, including mental health and substance use disorder services, the insurer or other entity shall notify the provider not less than 15 days before imposing the retroactive claims denial. The provider shall have 12 months from the date of denial to determine whether the claim is subject to payment by a secondary insurer; provided, however, that if the claim is denied by the secondary insurer due to the insured's transfer or termination of coverage, the insurer shall allow for resubmission of the claim.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 8 - Public Dissemination of Deceptive or Misleading Materials

Section 8. Public dissemination of any promotional material, evidence of coverage, health maintenance contract or any other statement with respect to a health maintenance organization, which is untrue, deceptive or misleading, shall constitute an unfair and deceptive practice under the provisions of section two of chapter ninety-three A. Every health maintenance organization shall keep on file, available for inspection by the division of insurance, copies of all educational materials, displays, evidences of coverage and all materials of any promotional nature released for public dissemination. The commissioner may forbid the use of any such material if he finds that it is either untrue, deceptive, or misleading.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 9 - Trade Regulation Practices; Application of Law

Section 9. The provisions of sections 1 to 14K, inclusive, and sections 48 to 68, inclusive, of chapter ninety-three, and chapter ninety-three A shall be applicable to the ownership, organization, operation and health care services provided by a health maintenance organization as authorized by this chapter.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 11 - Contracts With Group Insurance Commission or Local Governments

Section 11. Every health maintenance organization entering into a contract with the group insurance commission under chapter thirty-two A, or a county, city, town, or district under chapter thirty-two B, shall comply with the requirements applicable to health care organizations under said chapters thirty-two A and thirty-two B except that a health maintenance organization proposing to enter into direct contract may elect to have the group insurance commission, or the appropriate county, city, town or district, as the case may be, remit applicable monthly premium costs that would otherwise be payable to a carrier, directly to the health maintenance organization.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 11a - Alternative Dental Coverage Option

Section 11A. Each employer or other organization which employs or has twenty-five or more employees or members during the full preceding calendar year and which contracts with and contributes to a health maintenance organization for the purpose of providing comprehensive dental benefits to its employees or members, shall, if the health maintenance organization restricts the covered persons in selecting the providers of dental services to a single provider or limited number of providers of dental services, offer its employees and their eligible dependents and members and members' eligible dependents at the time such a contract is offered or renewed, the option of selecting alternative coverage which permits covered persons to obtain dental services from any licensed dentist.
No employer or other organization shall be required to pay for or contribute toward the provision of alternative coverage an amount greater than the premium or cost which it pays or contributes to the health maintenance organization contract which limits the number of providers of dental services.
Notwithstanding the provisions of this section, if any of the employees of an employer required by paragraph one to offer employees the option of selecting such alternative dental coverage as described in said paragraph are represented by a certified collective bargaining representative, the offer of the option of selecting such alternative coverage as required by said paragraph one shall first be made to such collective bargaining representative. Said representative shall have the right not to accept such offer, thereby exempting the employer from the provisions of this section. If such offer is accepted by such representative, the offer of the option of selecting such alternative coverage shall then be made to each employee. Notwithstanding the provisions of this section, a union management trust created pursuant to collective bargaining shall, whenever a restricted dental benefits contract as described in paragraph one is proposed, consider offering such alternative dental coverage as described in said paragraph one, provided, however, said trust may offer the dental plan or plans of its choice.
The commissioner shall promulgate such rules and regulations as are necessary to effectuate the purpose of this section, including procedures for notice to covered persons, employers and other organizations of the provisions of this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 12 - Health Regulations Not Limited

Section 12. Nothing in this chapter shall exempt any person from any applicable provisions of chapters one hundred and eleven or one hundred and twelve, including but not limited to, provisions relating to determinations of need, licensure and regulation of hospitals and clinics and registration of health professionals.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 15 - Bond; Waiver

Section 15. Each health maintenance organization shall furnish to the commissioner evidence of a surety bond in an amount satisfactory to the commissioner or deposit with the commissioner cash or sureties acceptable to him in at least the same amount as a guarantee that the obligation to the enrollees will be performed. The commissioner may waive this requirement if a health maintenance organization has contracted with a carrier as defined in section one for the purpose of reinsurance.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 16 - Contracts, Rates, Evidence of Coverage; Disapproval of Commissioner

Section 16. The subscriber contracts, rates and evidence of coverage shall be subject to the disapproval of the commissioner. No such contracts shall be approved if the benefits provided therein are unreasonable in relation to the rate charged, nor if the rates are excessive, inadequate or unfairly discriminatory. Classifications shall be fair and reasonable.
To the extent that this chapter is inconsistent with the provisions of chapter one hundred and seventy-six K, and any regulations promulgated thereunder, medicare supplement insurance plans as defined in said chapter one hundred and seventy-six K shall be subject to the provisions of said chapter one hundred and seventy-six K.
To the extent that this section is inconsistent with the provisions of chapter one hundred and seventy-six M and any regulations promulgated thereunder, any nongroup health maintenance contract 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.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 16a - Disapproval of Certain Health Maintenance Contracts Based on High Deductibles

Section 16A. The commissioner shall not disapprove a health maintenance contract: (i) if it complies with the requirements of 42 U.S.C. Sec. 18022(e); or (ii) on the basis that it includes a deductible that is consistent with the requirements for a high deductible plan as defined in section 223 of the Internal Revenue Code and implementing regulations or guidelines; provided, however, that the maximum deductible shall not be greater than the maximum annual contribution to a health savings account permitted under said section 223 of the Internal Revenue Code; and, provided further, that a deductible equal to the maximum annual contribution to a health savings account shall only be approved for products which include a health savings account permitted under said section 223 of the Internal Revenue Code.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 16b - Disapproval of Certain Health Maintenance Contracts for Coverage of Young Adults

Section 16B. The commissioner shall not disapprove a health maintenance contract offered as coverage for young adults if the health maintenance contract complies with the minimum standards established under section 10 of chapter 176J.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 17 - Rules and Regulations; Standardized Claim Form

Section 17. The commissioner may promulgate rules and regulations as are necessary to carry out the provisions of this chapter including but not limited to the licensing of agents, who engage in solicitation of enrollment of a health care plan.
No rule or regulation shall require any health maintenance organization or contract to provide payment of, or referrals for, abortions not necessary to prevent the death of the mother.
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 176g - Health Maintenance Organizations › Section 17a - Open Enrollment for Nongroup Medicare Beneficiaries; Period, Notice of Termination

Section 17A. All health maintenance organizations governed by this chapter which enroll medicare beneficiaries shall provide open enrollment for nongroup medicare beneficiaries commencing on February first and ending March thirty-first of each year, for coverage to be effective not later than ninety days from the date of enrollment; provided, however, that nothing contained herein shall preclude additional periods of open enrollment for medicare beneficiaries.
The open enrollment period and coverage effective date for any group health maintenance organization contract covering medicare beneficiaries shall be the same as the open enrollment period of all other group health plan options offered by the employer, representative or group sponsor to the group's members who are eligible for medicare supplemental coverage.
Any such health maintenance organization whose contract with medicare is being terminated shall give each resident of the commonwealth who is covered under a medicare program offered by such health maintenance organization and each nonprofit hospital service corporation and medical service corporation in the commonwealth sixty days notice prior to such termination. Any such health maintenance organization shall cooperate fully in the prompt transfer of coverage to any organization which will assume such coverage.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 19 - Discrimination Against Abuse Victims in Terms of Health Maintenance Contract

Section 19. No health maintenance organization subject to this chapter, and no officer or agent thereof, shall cancel, refuse to issue or renew, or in any way make or permit any distinction or discrimination in the amount or payment of premiums or rates charged, in the length of coverage, or in any other of the terms and conditions of a health maintenance contract based on information that an individual has been a victim of abuse, as defined by section one of chapter two hundred and nine A. No health maintenance organization subject to this chapter, and no officer or agent thereof, shall seek information that such person has been a victim of abuse as defined by said section one of said chapter two hundred and nine A. The practices prohibited under this section shall include not only those overtly discriminatory but also practices and devices which are fair in form but discriminatory in practice. Nothing in this section shall be construed as creating a special class of insureds who have been victims of abuse as defined by said section one of said chapter two hundred and nine A. Any violation of this section shall constitute an unfair method of competition or an unfair or deceptive act or practice in violation of chapters ninety-three A and one hundred and seventy-six D.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 20 - Insolvent Health Maintenance Organization; Administrative Supervision, Rehabilitation or Liquidation; Priority of Claims

Section 20. Any administrative supervision, rehabilitation or liquidation of a health maintenance organization shall be deemed to be the administrative supervision, rehabilitation or liquidation of an insurance company and shall be instituted on the grounds contained in and conducted pursuant to sections 6, 46, 46A, 178, 179, 180 and 180A to 180L, inclusive, of chapter 175, and sections 20A and 29 of chapter 176G, except as provided in this section and may include, but not be limited to any ground identified in section 20A and in chapter 175J. Members shall have the same priority in the event of rehabilitation or liquidation as the law provides to policyholders of an insurer.
For the purpose of determining the priority of distribution of general assets, claims of members and members' beneficiaries shall have the same priority as established by section 180F of chapter 175 for policyholders, beneficiaries and insureds of insurance companies. If a member is liable to any provider for services provided pursuant to and covered by the health maintenance organization, that liability shall have the status of a member in the distribution of general assets.
Any provider who is obligated by statute or agreement to hold members harmless from liability for services provided pursuant to and covered by a health maintenance contract shall have a priority of distribution of the general assets immediately following that of members as described in this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 21 - Participating Provider; Contracts With Health Maintenance Organizations; Hold Harmless Clause; Limitation on Collection Actions

Section 21. (a) For purposes of this section, ''participating provider'' shall mean any physician, hospital or other person who, under an express or implied contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health care services to members with an expectation of receiving payment, other than co-payment, co-insurance or deductible, directly or indirectly from the health maintenance organization, its contractor or subcontractor.
(b) Every contract between a health maintenance organization and a participating provider shall be in writing and shall contain the following hold harmless provision:
The provider agrees that in no event, including but not limited to nonpayment by the health maintenance organization of amounts due the provider under this contract, insolvency of the health maintenance organization or any breach of this contract by the health maintenance organization, shall the provider or its assignees or subcontractors have a right to seek any type of payment from, bill, charge, collect a deposit from, or have any recourse against, the member, persons acting on the member's behalf, other than the health maintenance organization, the employer or the group health maintenance contract holder for services provided pursuant to this contract except for the payment of applicable co-payment, co-insurance or deductibles for services covered by the health maintenance organization. The requirements of this provision shall survive any termination of this contract for services rendered prior to the termination, regardless of the cause of such termination. The health maintenance organization's members, any persons acting on the member's behalf, other than the health maintenance organization, and the employer or group health maintenance contract-holder shall be third-party beneficiaries of this clause. This provision supercedes any oral or written agreement hereafter entered into between the provider and the member, persons acting on the member's behalf, other than the health maintenance organization, and the employer or group health maintenance contract holder.
(c) In the event that the participating provider contract has not been reduced to writing as required by subsection (b) or that the contract fails to contain the required hold harmless provision, such provision shall be deemed incorporated into such contract by operation of law.
(d) No participating provider, agent, trustee or assignee thereof, may maintain any action at law against a member to collect sums owed by the health maintenance organization.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 22 - Health Care Providers; Liability of Member of Health Maintenance Organization; Limitation on Collection of Amounts Owed

Section 22. (a) For purposes of this section, ''health care provider'' shall mean any physician, hospital or other person furnishing health services who has provided such services to members under an express or implied contract or with an expectation of receiving payment, other than co-payment, deductible or co-insurance, directly or indirectly from the health maintenance organization.
(b) In addition to the provisions of section 21, in the event of the insolvency of a health maintenance organization:
(1) a member of a health maintenance organization shall not be liable to any health care provider for any covered health services provided to the member, except as provided in subsection (c);
(2) a health care provider or any representative of a health care provider may not collect or attempt to collect from a member money owed to the health care provider by a health maintenance organization;
(3) a health care provider or any representative of a health care provider may not maintain any action against a member to collect or attempt to collect any money owed to the health care provider by a health maintenance organization.
(c) Notwithstanding any other provision of this section, a health care provider or representative of a health care provider may collect or attempt to collect from a member:
(1) a co-payment, deductible, or co-insurance amounts owed by the member to the health care provider for covered services provided by the health care provider, or
(2) a payment or charges for services not covered under the member's health maintenance contract.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 24 - Health Maintenance Contracts; Genetic Tests; Discrimination Based on Genetic Information

Section 24. For the purposes of this section the following words shall have the following meanings:—
''Genetic information'', any 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 health maintenance organization subject to this chapter, and no officer or agent thereof, shall cancel, refuse to issue or renew, or in any way make or permit any distinction or discrimination in the amount of payment of premium or rates charged, in the length of coverage or in any of the terms and conditions of a health maintenance contract based on genetic information as defined in this section. No health maintenance organization subject to the provisions of this chapter and no officer or agent thereof, shall require genetic tests or private genetic information, as defined in this section, as a condition of the issuance or renewal of a health maintenance contract. Any violation of this section shall constitute an unfair method of competition or deceptive act or practice in violation of chapters 93A and 176D.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176g - Health Maintenance Organizations › Section 26 - Deposit Maintained With Trustee Acceptable to Commissioner

Section 26. (a) Except as provided in subsections (b) and (d), each health maintenance organization shall maintain a deposit with a trustee acceptable to the commissioner through which a custodial or controlled account is utilized of cash, securities or any combination of these or other measures that are acceptable to him, which is to be used exclusively to protect the interests of policyholders, enrolled members, and the general public and which at all times shall have a value of not less than $1,000,000.
(b) Each health maintenance organization approved by the commissioner before January 1, 2004 shall provide evidence of and maintain at all times a deposit as described in subsection (a) in the amount of $500,000 not later than July 1, 2004. Not later than January 1, 2005, the health maintenance organization shall provide evidence of and maintain a deposit in the amount of an additional $500,000 to constitute the required $1,000,000 deposit.
(c) All income from the deposit shall be an asset of the health maintenance organization. A health maintenance organization that has made a securities deposit may withdraw that deposit or any part thereof after making a substitute deposit of cash, securities or any combination of these or other measures of equal amount and value. The commissioner shall approve any securities before they are deposited or substituted.
(d) The commissioner may reduce or eliminate the deposit requirement if the health maintenance organization deposits with the state treasurer, insurance commissioner or other official body of the state or jurisdiction of domicile, for the protection of policyholders, enrolled members and subscribers of such health maintenance organization and the general public, cash, acceptable securities or surety, and delivers to the commissioner a certificate to such effect, duly authenticated by the appropriate entity holding the deposit.
(e) If in the opinion of the commissioner the deposit requirement as established above would be inadequate to protect the interests of enrolled members, the deposit shall be appropriately adjusted in order to protect the interests of policyholders, enrolled members and subscribers of the health maintenance organization and the general public.
(f) The deposit shall be an admitted asset of the health maintenance organization in the determination of net worth pursuant to section 25. The commissioner may use the deposit for administrative costs directly attributable to any receivership, administrative supervision, rehabilitation or liquidation pursuant to section 20. If the health maintenance organization is ordered into receivership, administrative supervision, rehabilitation or liquidation, the deposit shall be an asset subject to the provisions of section 20.