reglab/statecodes huggingface dataset:
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 43 - Additional, Increased or Extra Rates of Contributions

Section 43. If the stated periodical contributions of the members of any society subject to section forty-one are insufficient to pay all reported death, disability, hospitalization and medical service claims in full, and to provide for the creation and maintenance of the funds required by its by-laws or by this chapter, additional contributions or additional, increased or extra rates of contributions shall be collected from its members to meet the deficiency, and the by-laws of the society shall so provide; and such by-laws may provide that upon the written application or consent of the member his certificate may be charged with its proportion of any deficiency disclosed by valuation, with interest not exceeding five per cent per annum.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 46 - Financial Statement, Report or Finding; Service Upon Society

Section 46. Pending, during or after an examination or investigation of a society, either domestic, foreign or alien, the commissioner shall make public no financial statement, report or finding, nor shall he permit to become public any financial statement, report or finding affecting the status, standing or rights of any society, until a copy thereof shall have been served upon the society at its principal office and the society shall have been afforded a reasonable opportunity to answer any such financial statement, report or finding and to make such showing in connection therewith as it may desire.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 47 - Misrepresentations, etc., Concerning Society or Contract

Section 47. No person shall cause or permit to be made, issued or circulated in any form—
(a) Any misrepresentation or false or misleading statement concerning the terms, benefits or advantages of any fraternal insurance contract now issued or to be issued in the commonwealth, or the financial condition of any society;
(b) Any false or misleading estimate or statement concerning the dividends or shares of surplus paid or to be paid by any society on any insurance contract; or
(c) Any incomplete comparison of an insurance contract of one society with an insurance contract of another society or insurer for the purpose of inducing the lapse, forfeiture or surrender of any insurance contract. A comparison of insurance contracts is incomplete if it does not compare in detail—
(1) The gross rates, and the gross rates less any dividend or other reduction allowed at the date of the comparison; and
(2) Any increase in cash values, and all the benefits provided by each contract for the possible duration thereof as determined by the life expectancy of the insured; or if it omits from consideration—
(3) Any benefit or value provided in the contract;
(4) Any differences as to amount or period of rates; or
(5) Any differences in limitations or conditions or provisions which directly or indirectly affect the benefits.
In any determination of the incompleteness or misleading character of any comparison or statement, it shall be presumed that the insured had no knowledge of any of the contents of the contract involved.
Any person who violates any provision of this section or knowingly receives any compensation or commission by or in consequence of such violation, shall be punished by a fine not less than one hundred dollars nor more than five hundred dollars or by imprisonment for not less than thirty days nor more than one year, or by both such fine and imprisonment; and shall, in addition, be liable in the amount of three times the sum received by such violator as compensation or commission, which may be sued for and recovered by any person or society aggrieved for his or its own use and benefit in an action of tort.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 48 - Unfair Discrimination; Inducements Not Specified in Certificate or Contract

Section 48. No society doing business in the commonwealth shall make or permit any unfair discrimination between insured members of the same class and equal expectation of life in the premiums charged for certificates of insurance, in the dividends or other benefits payable thereon, or in any other of the terms and conditions of the contracts it makes.
No society, by itself, or any other party, and no agent or solicitor, personally, or by any other party, shall offer, promise, allow, give, set off, or pay, directly or indirectly, any valuable consideration or inducement to, or for insurance, on any risk authorized to be taken by such society, which is not specified in the certificate. No member shall receive or accept, directly or indirectly, any rebate of premium, or part thereof, or agent's or solicitor's commission thereon, payable on any certificate, or receive or accept any favor or advantage or share in the dividends or other benefits to accrue on, or any valuable consideration or inducement not specified in, the contract of insurance.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 49 - Tax Exemption

Section 49. Every society organized or licensed under this chapter is hereby declared to be a charitable and benevolent institution, and all of its funds shall be exempt from all and every state, county, district, municipal and school tax other than taxes on real estate and office equipment.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 50 - Law Governing

Section 50. Societies shall be governed by this chapter, and shall be exempt from all other provisions of the insurance laws of the commonwealth except sections sixteen, one hundred and sixty A, one hundred and sixty B, one hundred and seventy-eight to one hundred and eighty, inclusive, and one hundred and eighty-five of chapter one hundred and seventy-five, not only in governmental relations with the commonwealth, but for every other purpose; and no law hereafter enacted shall apply to them unless they are expressly designated therein; provided, however, that the provisions of sections one hundred and eighty M to one hundred and eighty Q, inclusive, of chapter one hundred and seventy-five shall apply to domestic societies.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 51 - Application of Chapter

Section 51. Nothing contained in this chapter shall be so construed as to affect or apply to—
(a) Grand or subordinate lodges of societies, orders or associations doing business in the commonwealth on December thirty-first, nineteen hundred and fifty-eight, which provide benefits exclusively through local or subordinate lodges;
(b) Orders, societies or associations which admit to membership only persons engaged in one or more crafts or hazardous occupations, in the same or similar lines of business, insuring only their own members, their families and descendants of members, and the ladies' societies or ladies' auxiliaries to such orders, societies or associations;
No society which, by the provisions of this section, is exempt from the requirements of this chapter, except any society described in clause (b) of this section, shall give or allow, or promise to give or allow, to any person any compensation for procuring new members.
Every society which provides for benefits in case of death or disability resulting solely from accident, and which does not obligate itself to pay natural death or sick benefits, shall have all of the privileges and be subject to all the applicable provisions and regulations of this chapter except that the provisions thereof relating to medical examination, valuations of benefit certificates, and incontestability, shall not apply to such society.
The commissioner may require from any society or association, by examination or otherwise, such information as will enable him to determine whether such society or association is exempt from the provisions of this chapter.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 52 - Penalties

Section 52. Any person who willfully makes a false or fraudulent statement in or relating to an application for membership or for the purpose of obtaining money from or a benefit in any society, shall be punished by a fine of not less than one hundred nor more than five hundred dollars, or by imprisonment for not less than thirty days nor more than one year, or by both such fine and imprisonment.
Any person who willfully makes a false or fraudulent statement in any verified report or declaration under oath required or authorized by this chapter, or of any material fact or thing contained in a sworn statement concerning the death or disability of a member for the purpose of procuring payment of a benefit named in the certificate, shall be guilty of perjury and shall be subject to the penalties therefor prescribed by law.
Any person who solicits membership for, or in any manner assists in procuring membership in, any society not licensed to do business in this state shall be punished by a fine of not less than fifty nor more than two hundred dollars.
Any person guilty of a willful violation of, or neglect or refusal to comply with, the provisions of this chapter for which a penalty is not otherwise prescribed, shall be punished by a fine of not more than two hundred dollars.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 53 - Jurisdiction to Restrain Violations, Etc.

Section 53. The superior court shall have jurisdiction in equity, upon an information filed by the Attorney General at the relation of the commissioner, to restrain all violations of this chapter and to enforce compliance with the provisions thereof and payment of all fines, forfeitures or penalties provided thereby. The remedy herein provided shall be in addition to all other remedies otherwise provided by law or by this chapter, and not in substitution therefor.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 54 - Validity of Contracts Issued in Violation of Chapter, Charter, Articles, Constitution or By-Laws

Section 54. Any contract of insurance or any benefit certificate made, issued, issued or delivered by any society in violation of any provision of this chapter, or any provision of its charter, articles of association, constitution or by-laws, shall nevertheless be valid and binding upon it and its members, but the rights, duties and obligations of the parties thereto shall be determined by the provisions of this chapter and of the charter, articles of association, constitution and by-laws of the society.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 55 - Solicitation of Membership in Society Not Authorized to Transact Business, Etc.

Section 55. Whoever solicits membership in any society not duly authorized to transact business in the commonwealth, or, whoever, for a person other than himself, or as an agent, solicitor, organizer, officer or other representative of any such society or of any local or subordinate lodge or branch thereof, acts or aids in any manner in the issue, delivery, negotiation, continuance or renewal of any contract of insurance or benefit certificate in such society, or whoever, as such agent, solicitor, organizer, officer or other representative, acts or aids in any manner in the transaction of any business on behalf of such society or of any local or subordinate lodge or branch thereof, by the collection or transmission of dues or assessments, the calling or holding of meetings, or otherwise, shall be punished by a fine of not less than fifty nor more than five hundred dollars.
Whoever, by the means of cards, circulars, letterheads, advertisements, signs or other methods, represents or holds himself out to the public as being an agent, solicitor, organizer, officer or other representative of any such society or of any local or subordinate lodge or branch thereof shall be punished by a fine of not less than twenty nor more than one hundred dollars.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176 - Fraternal Benefit Societies › Section 56 - Payment of Pensions to Employees of Society

Section 56. Any society operating on the lodge system with a representative form of government whose rates are on a basis of mortality not lower than the national fraternal congress table as adopted by the national fraternal congress, August twenty-third, eighteen hundred and ninety-nine, if its constitution and by-laws so provide, may pay a pension to any employee who has been continuously in the service of the society for ten years or more and who has become incapacitated for further service by reason of physical or mental disability, and may pay a pension to any employee who has been continuously in the service of the society for fifteen years or more and who is retired by reason of the infirmities of age or has attained the age of sixty-five years. All moneys expended for the purposes of this section shall be paid from the expense fund of the society.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 1 - Corporations Governed by Chapter; Services Received in Nonparticipating Hospital; Substitution of Benefits in Nursing Homes

Section 1. Any corporation organized under the laws of the commonwealth for the purpose of establishing, maintaining and operating a non-profit hospital service plan whereby hospital care and reimbursement for other health services may be provided by such corporation, or by a hospital with which it has a contract for such care and which is maintained by the commonwealth or a political subdivision thereof, or maintained by a corporation organized for hospital purposes under the laws of the commonwealth, or such other hospitals as shall be approved by the commissioner of public health, to such of the public who become subscribers to said plan under a contract which entitles each subscriber or his dependents, or employees or dependents of employees of employers who contribute the subscription fees in whole or in part to certain hospital care and reimbursement for other health services, shall be governed by this chapter.
Nothing in this chapter shall prevent such a corporation from reimbursing a subscriber for services received in a non-participating hospital within or outside the commonwealth in the event of accident, illness or maternity or, upon the written direction of the subscriber, from making payment to said hospital for such services; provided, however, that the amount of such reimbursement and payment to any such hospital within the commonwealth shall conform with such method of payment and guarantee of benefits as shall have been in effect pursuant to section five of this chapter immediately prior to the expiration of the then most recent contract between said hospital and said corporation and shall be based upon the charges of the hospital in effect on such date.
Nothing in this section shall prevent any such corporation, with the approval of the commissioner of public health, from entering into contracts with a state-operated veterans' home, whereby in consideration of a contract fee, the veterans' home shall provide such care for non-service connected causes as would be provided in participating hospitals under contracts with subscribers.
Nothing in this section shall prevent any such corporation, with the approval of said commissioner, from entering into contracts with the Lemuel Shattuck Hospital whereby, in consideration of a contract fee, said hospital shall provide such hospitalization and such other care as would be provided in participating hospitals under contracts with subscribers, subject to such restrictions as to nature of disease and length of stay as may be specified from time to time in said contracts.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 1a - Right to Become Subscriber; Open Enrollment Periods

Section 1A. Any person residing in the commonwealth shall have the right to become a subscriber of a nonprofit hospital service corporation if the qualifications of such person meet those specified in the by-laws of such corporation; provided, however, that such 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 such corporation, or has been guilty of uncooperative or unethical dealings with such corporation, or has failed to pay dues and assessments seasonably and promptly, or for any other cause which may be approved by the commissioner. Any such corporation shall provide for annual open enrollment periods of not less than two months' duration. Proper notification shall be given to prospective subscribers in a form subject to approval by the commissioner.
All nonprofit hospital service corporations governed by this chapter which offer supplemental coverage to medicare, shall provide open enrollment for nongroup subscribers to medicare supplemental coverage, commencing on February first and ending March thirty-first of each year, for coverage to be effective June first of that year; provided, however, that nothing contained herein shall preclude additional periods of open enrollment for subscribers to medicare supplemental coverage.
Any person who is eligible for Medicare coverage for both hospital and physician services due to age or disability, other than end-stage renal disease, shall be eligible for supplemental coverage to Medicare ninety days before and after the month of such person's Medicare effective date or of the month of such person's loss of group or individual health coverage resulting from such person's retirement. Such supplemental coverage shall be effective no earlier than the effective date of Medicare coverage.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 1b - Medicare Supplemental Group Coverage; Medical Assistance Recipients

Section 1B. A nonprofit hospital service corporation governed by this chapter shall offer medicare supplemental group coverage to that group of medical assistance recipients designated from time to time by the department of public welfare. Such coverage shall be provided at a rate based on the projected experience of said group of recipients.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 1c - Retroactive Premium Rate Increase

Section 1C. For purposes of this section, retroactive premium rate increase shall mean any premium rate increase based upon an actual approved rate which is assessed to a subscriber after any payment has been made by said subscriber based upon an estimated premium rate for such period of coverage.
A nonprofit hospital service corporation governed by this chapter which offers medicare supplemental individual or group coverage shall, in the event of a retroactive premium rate increase for such coverage, allocate such increase among the remaining outstanding premium payments due; provided, however, that no finance charge or additional cost may be charged as a result of such allocation.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 1d - Contracts of Reinsurance

Section 1D. Any corporation subject to this chapter may make contracts of reinsurance relating to the providing of medical or other health services or reimbursement thereof, but the costs of such reinsurance shall not inure to or otherwise affect the premiums charged for any policy offered, sold, issued or delivered by the corporation pursuant to chapter 176K or for any nongroup health plan offered, sold, issued or delivered by the corporation pursuant to chapter 176M.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 2 - Incorporators; Directors; Certificate of Organization; Commissioner's Examination Report

Section 2. Persons desiring to form such a non-profit hospital service corporation shall incorporate as provided in section three of chapter one hundred and eighty.
The board of directors of each such corporation shall consist of thirty-one members, three of whom shall be officers or agents of contributing employers who are not identified with a hospital as officers, directors or employees, and two of whom shall be representatives of labor. The said directors shall be elected for terms of three years.
Every certificate of organization of a corporation subject to this chapter filed under said chapter one hundred and eighty shall have endorsed thereon or attached thereto the consent of the commissioner of insurance. The recommendations and criticisms of the latest report of each examination made by the commissioner of insurance shall be read at the next annual or special meeting of every non-profit hospital service corporation, and at the next meeting of the board of directors and thereafter a copy thereof shall be filed at the home office of the corporation and shall be made available for inspection by any member upon request.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 3 - Certificate of Compliance; Examination by Commissioner

Section 3. No non-profit hospital service corporation shall make or issue any contract to provide hospital care and reimbursement for other health services until it has obtained from the commissioner of insurance, in this section called the commissioner, a certificate, in such form as he may prescribe, stating that the corporation has complied with the conditions set forth in this chapter and all other provisions of law authorizing it to make or issue such contract. No such certificate shall be issued until the commissioner is satisfied, by such examination as he may make and such evidence as he may require, that the corporation has complied with the laws of the commonwealth, adopted a proper system of accounting, and employed either full time or on a consulting basis a competent accountant, a competent claim manager, a competent and experienced underwriter, and a competent and experienced actuary; nor, until the commissioner is satisfied, by such examination as he may make and by an affidavit filed with him, and by such evidence as he may require, that the corporation is without liabilities, except such organization expenses as the commissioner shall approve as reasonable; nor until he is satisfied that its officers and directors are of good repute and competent to manage a non-profit hospital service corporation.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 3a - Discrimination Against Abuse Victims in Terms of Hospital Service Plans

Section 3A. No corporation 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 hospital service plan 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 corporation 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 176a - Non-Profit Hospital Service Corporations › Section 3b - Medical Service Plans; Genetic Tests; Discrimination Based on Genetic Information

Section 3B. For the purposes of this section the following words shall have the following meanings:—
''Genetic information'', a written recorded individually identifiable result of a genetic test as defined by this section or explanation of such a result.
''Genetic test'', a test of human DNA, RNA, mitochondrial DNA, chromosomes or proteins for the purpose of identifying the genes, or genetic abnormalities, or the presence or absence of inherited or acquired characteristics in genetic material.
No corporation 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 premiums or rates charged, in the length of coverage, or in any other of the terms and conditions of a medical service plan based on genetic information as defined in this section. No corporation 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 hospital service plan. Any violation of this section shall constitute an unfair method of competition or unfair 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 176a - Non-Profit Hospital Service Corporations › Section 4 - Accounting System; Accountant, Claim Manager, Underwriter and Actuary

Section 4. Every non-profit hospital service corporation shall use a proper system of accounting, and employ either full time, or on a consulting basis, a competent accountant, a competent claim manager, a competent and experienced underwriter, and a competent and experienced actuary.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 6 - Approval of Nongroup Contracts

Section 6. Nongroup contracts, except contracts providing supplemental coverage to medicare subject to the provisions of chapter one hundred and seventy-six K, issued and rates charged by nonprofit hospital service corporations to its subscribers for hospital care and reimbursement for other health services shall be subject to the provisions of chapter one hundred and seventy-six M, and any regulations promulgated thereunder.
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.
The commissioner shall require every such corporation to keep its books, records, statistics, accounts and vouchers in such manner that he or his authorized representatives may readily verify its annual statements and ascertain whether the corporation has complied with the law.
At least once in three years, and whenever he determines it to be prudent, he shall personally, or by his deputy or examiner, visit each non-profit hospital service corporation and thoroughly inspect and examine its affairs to ascertain its financial condition, its ability to fulfill its obligations, whether it has complied with the law, and any other facts relating to its business methods and management, and the equity of its dealings with its subscribers.
A report of examination of any corporation made under this section shall as far as material and relevant be admitted in the discretion of the court in any judicial proceedings brought by or in behalf of the commissioner or any subscriber, non-profit hospital service corporation or other person as evidence tending to prove the facts stated in such report, but nothing in this paragraph shall be construed to require the commissioner to make an examination under this section before bringing such a proceeding.
The commissioner may investigate, in such manner and to such extent as he may deem expedient, any complaint under any subscriber's contract.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 8 1/2 - Sale of Group Non-Profit Hospital Service Contracts

Section 81/2. A corporation organized under this chapter may only contract to sell a group non-profit hospital service contract to an employer if the group non-profit hospital service 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 carrier may enter into a contract to sell a group non-profit hospital service 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 176a - Non-Profit Hospital Service Corporations › Section 8a3/4 - Retroactive Claims Denials for Behavioral Health Services

Section 8A3/4. (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) The corporation 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 corporation; (ii) the corporation 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 corporation 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 corporation or an entity with which the insurer contracts to provide or manage health care services, including mental health and substance use disorder services, the corporation 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 corporation shall allow for resubmission of the claim.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 8aa - Coverage of Prosthetic Devices and Repairs

Section 8AA. (a) A contract between a subscriber and the corporation under an individual or group hospital service plan which provides hospital expense and surgical expense insurance, 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 benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth for 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 contract, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone 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) No such contract shall 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) No such contract shall apply amounts paid for prosthetic devices to any annual or lifetime dollar maximum applicable to other durable medical equipment covered under the policy other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the contract.
(e) Any such 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 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) Any such contract may require prior authorization as a condition of coverage for prosthetic devices.
(g) Any such 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 176a - Non-Profit Hospital Service Corporations › Section 8bb - Coverage for Eligible Dependents Under 26 Years of Age or Dependents Mentally or Physically Incapable of Earning Their Own Living Due to Disability

Section 8BB. Any subscription certificate under an individual or group nonprofit hospital service agreement, except certificates which provide stand-alone dental services, supplemental coverage to Medicare or other governmental programs, that is delivered, issued or renewed in the commonwealth, shall provide, as benefits to all individuals or to all 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 their 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 176a - Non-Profit Hospital Service Corporations › Section 8cc - Coverage for Medically Necessary Hypodermic Syringes or Needles

Section 8CC. No contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed in the commonwealth shall restrict or discontinue coverage for medically necessary hypodermic syringes or needles to an individual or group subscribers within the commonwealth and to a group subscriber having a principal place of employment within the commonwealth, 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 176a - Non-Profit Hospital Service Corporations › Section 8e - Diethylstilbestrol Exposure; Discrimination

Section 8E. No contract between a subscriber and the corporation under an individual or group hospital service plan which shall be delivered or issued in the commonwealth shall be denied, cancelled or fail to be renewed, nor shall any excessive rates be charged or restrictions on the length of coverage be imposed, nor shall any other factor be altered in such a way as to constitute discrimination primarily because the insured person has had a suspected, alleged or confirmed exposure to the potential hazards and afflictions of diethylstilbestrol or compounds commonly referred to as DES. 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.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 8ee - Coverage for Children Under Age 18 for Cleft Lip and Cleft Palate

Section 8EE. A contract between a subscriber and the corporation under an individual or group hospital service plan which provides hospital expense and surgical expense insurance, 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, 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 176a - Non-Profit Hospital Service Corporations › Section 8f - Divorced or Separated Spouses; Continuation of Eligibility for Benefits

Section 8F. (a) In the event of the granting of a judgment absolute of divorce or of separate support to which a subscriber of a group nonprofit hospital service contract is a party, the person who was the spouse of said subscriber 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 subscriber's participation in the plan until the remarriage of either the subscriber or such spouse, or until such time as provided by said judgment, whichever is earlier.
(b) In the event of the remarriage of the group contract subscriber 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 subscriber, 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 nonprofit hospital service corporation 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 176a - Non-Profit Hospital Service Corporations › Section 8ff - Coverage for Orally Administered Anticancer Medications

Section 8FF. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth 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 176a - Non-Profit Hospital Service Corporations › Section 8g - Cardiac Rehabilitation Expense Benefits

Section 8G. Any contract, except contracts providing supplemental coverage to medicare or other governmental programs, between a subscriber and the corporation under an individual or group hospital service plan which shall be delivered or issued or renewed in the commonwealth shall provide, as a basic benefit to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth, for expense for cardiac rehabilitation. Cardiac rehabilitation shall mean multidisciplinary, medically necessary treatment of persons with documented cardiovascular disease, which shall be provided in either a hospital or other setting and which shall meet standards promulgated by the commissioner of public health after reviewing proposals submitted by the Massachusetts Society for Cardiac Rehabilitation, Inc. and after notice and public hearing on the proposed standards. Such standards shall include, but not be limited to, outpatient treatment which is to be initiated within twenty-six weeks after the diagnosis of such disease.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176a - Non-Profit Hospital Service Corporations › Section 8gg - Coverage for Abuse Deterrent Opioid Drug Products

Section 8GG. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth 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 the individual or group hospital service plan. 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 176a - Non-Profit Hospital Service Corporations › Section 8hh - Preauthorization for Substance Abuse Treatment Not to Be Required

Section 8HH. 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 8II; and medically managed intensive inpatient services, not covered under said section 8II.
Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth 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.