reglab/statecodes huggingface dataset:
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176j - Small Group Health Insurance › Section 17 - Disclosure of Patient-Level Data and Contracted Prices of Individual Health Care Services by Carriers to Providers

Section 17. To the extent permissible under applicable state and federal privacy laws, every carrier shall disclose patient-level data to providers in their network solely for the purpose of carrying out treatment, coordinating care among providers and managing the care of their own patient panel; provided, that an individual provider shall only receive patient-level data related to patients treated by said provider. Patient-level data shall include, but not be limited to, health care service utilization, medical expenses, and demographics.
The division of insurance shall develop procedures and a standard format for disclosing such patient-level information. The division may require carriers to disclose such information through the all-payer claims database established under section 12 of chapter 12C if the division and the center for health information and analysis determine that the all-payer claims database is an efficient means to provide such information.
Carriers shall make available to any provider with whom they have entered into an alternative payment contract, the contracted prices of individual health care services within such payer's network for the purpose of referrals.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176k - Medicare Supplement Insurance Plans › Section 2 - Compliance; Withdrawal From Market

Section 2. (a) Notwithstanding the provisions of any other law to the contrary, and subject to the provisions of OBRA 90 and Section 1882 of the federal Social Security Act (42 U.S.C. Section 1395 et seq.), any policy for medicare supplement insurance or medicare select insurance or policy issued pursuant to a risk or cost contract offered, sold, issued, delivered, or otherwise made effective or renewed by a carrier in the commonwealth after July first, nineteen hundred and ninety-four shall comply with the provisions of this chapter.
(b) A carrier that participated in the market on or after a date set by the commissioner by regulation may not withdraw from the market until all insureds of such carrier have had the opportunity to join a policy for medicare supplement insurance or medicare select insurance or a policy issued pursuant to a risk or cost contract offered by another carrier during the next annual open enrollment period or other enrollment period required in section three.
(c) A carrier that withdraws from the market on or after the effective date of this chapter may not participate in the market in the commonwealth for five years from the date of withdrawal, unless the commissioner finds that such re-entry shall be permitted earlier than said five years due to a compelling public interest.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176k - Medicare Supplement Insurance Plans › Section 5 - Right to Coverage; Conversion of Policies; Renewability; Cancellation

Section 5. Any eligible person who applies on or after a date set by the commissioner pursuant to regulation for a policy for medicare supplement insurance or medicare select insurance or a policy issued pursuant to a risk or cost contract from any carrier participating in the market in the commonwealth, during the six month period beginning at the time the person became initially eligible for coverage shall have the right to any of the policies for medicare supplement insurance or medicare select insurance authorized in the commissioner's regulations from any carrier that provides policies issued pursuant to a medicare supplement insurance or medicare select insurance contract, and shall have the right to the policy issued pursuant to a risk or cost contract authorized in the commissioner's regulations from any carrier that provides a policy issued pursuant to a risk or cost contract. The commissioner may require every carrier that participates in the market for medicare supplement insurance to offer more than a single type of benefit plan to an eligible person.
Notwithstanding any provision of this chapter concerning guaranteed renewability, the commissioner may by regulation establish a process for the conversion of every carrier's business in force as of a date established in such regulations into the policy for medicare supplement insurance or medicare select insurance or policy issued pursuant to a risk or cost contract authorized by section four. The commissioner may by regulation require that this conversion process be completed by the end of the third calendar quarter of nineteen hundred and ninety-four and implemented through a required special open enrollment period prior to July first, nineteen hundred and ninety-four, during which period eligible persons may enroll without a surcharge for late enrollment and upgrading.
Every policy for medicare supplement insurance or medicare select insurance or policy issued pursuant to a risk or cost contract authorized to be offered, sold, issued, delivered, or otherwise made effective, or renewed on or after a date established by the commissioner pursuant to this chapter shall be a guaranteed renewable plan with respect to an eligible person at the option of the eligible person. A carrier that participated in the market may, however, in its discretion and to the extent permitted by OBRA 90, refuse to offer, sell, issue, deliver, or otherwise make effective, or renew a medicare supplement insurance policy, medicare select insurance policy, or a policy issued pursuant to a risk or cost contract to, or upon reasonable notice, cancel such a plan of any person due to non-payment of premium or material misrepresentation, or because the person does not live in or has moved out of the health maintenance organization service area, or has not resided in the commonwealth for the past six months, or for any other cause which may be approved by the commissioner.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176k - Medicare Supplement Insurance Plans › Section 8 - Employers' or Labor Organizations

Section 8. This chapter shall not apply to a policy or contract of one or more employers' or labor organizations, or of the trustees of a fund established by one or more employers' or labor organizations, or a combination thereof, covering employees or former employees, or a combination thereof, or covering members or former members of labor organizations, or a combination thereof.
All policies issued by a carrier to which section two hundred and five of chapter one hundred and seventy-five applies shall be subject to this chapter.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176l - Risk Retention and Risk Purchasing Groups › Section 2 - Charter and License; Application; Plan of Operation or Feasibility Study

Section 2. (A) A risk retention group shall be chartered and licensed under the laws of the commonwealth to write only liability insurance pursuant to the provisions of this chapter and, except as provided elsewhere in this chapter, must comply with (1) all of the laws, rules, regulations and requirements applicable to such insurers chartered and licensed in the commonwealth and with (2) section three to the extent such requirements of said section three are not a limitation on laws, rules, regulations or requirements of the commonwealth.
(B) Before it may offer insurance in any state, a risk retention group shall submit to the commissioner for approval a plan of operation or a feasibility study. In the event of any subsequent material change in any item of the plan of operation or feasibility study, the risk retention group shall submit an appropriate revision or amendment to the commissioner for approval at least ten working days prior to the requested effective date of any such change. The group shall not offer any additional kinds of liability insurance, in the commonwealth or in any other state, until the commissioner approves a revision or amendment of such plan or study.
(C) At the time of filing its application for charter, the risk retention group shall provide to the commissioner in summary form the following information:
(1) the identity of the initial members of the group;
(2) the identity of the persons who organized the group or who will provide administrative services or otherwise influence or control the activities of the group;
(3) the amount and nature of initial capitalization;
(4) the coverages to be afforded; and
(5) the states in which the group intends to operate.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176l - Risk Retention and Risk Purchasing Groups › Section 4 - Insurance Insolvency Guaranty Fund

Section 4. (A) No risk retention group shall be required or permitted to join or contribute financially to any insurance insolvency guaranty fund, or similar mechanism, in the commonwealth, nor shall any risk retention group, or its insureds or claimants against its insurers, receive any benefit from any such fund for claims arising under the insurance policies issued by such risk retention group.
(B) When a purchasing group obtains insurance covering its members' risks from an insurer which is not required to participate in the Massachusetts Insurers Insolvency Fund established under chapter one hundred and seventy-five D, or a risk retention group, no such risks, wherever resident or located, shall be covered by any insurance guaranty fund or similar mechanism in the commonwealth.
(C) When a purchasing group obtains insurance covering its members' risks from an admitted or licensed insurer, only risks resident or located in the commonwealth shall be covered by an insurance guaranty fund or similar mechanism in the commonwealth.
(D) Notwithstanding the provisions of any general or special law to the contrary, the commissioner may require or exempt a risk retention group from participation in any joint underwriting association or other mechanism established or authorized under the laws of the commonwealth for the equitable apportionment among insurers of liability insurance losses and expenses incurred on policies written through such association or mechanism, and such risk retention group shall submit sufficient information to the commissioner to enable the commissioner to apportion on a nondiscriminatory basis the risk retention group's proportionate share of such losses and expenses.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176l - Risk Retention and Risk Purchasing Groups › Section 6 - Purchasing Groups; Exemptions

Section 6. A purchasing group and its insurer or insurers shall be subject to all applicable laws of the commonwealth except that a purchasing group and its insurer or insurers shall be exempt, in regard to liability insurance for the purchasing group, from any law that would:
(A) prohibit the establishment of a purchasing group;
(B) make it unlawful for an insurer to provide or offer to provide insurance to a purchasing group or its members allowing advantages with respect to rates, policy forms, coverages or other matters, based on their loss and expense experience, which are not afforded to other persons;
(C) prohibit a purchasing group or its members from purchasing insurance described in clause (B) on a group basis;
(D) prohibit a purchasing group or its members from purchasing a group basis because the group has not been in existence for a minimum period of time or because any member has not belonged to the group for a minimum period of time;
(E) require that a purchasing group must have a minimum number of members, common ownership or affiliation, or certain legal form;
(F) require that a certain percentage of a purchasing group must obtain insurance on a group basis;
(G) otherwise discriminate against a purchasing group or any of its members; or
(H) require that any insurance policy issued to a purchasing group or any of its members be countersigned by an insurance agent or broker residing in the commonwealth.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176l - Risk Retention and Risk Purchasing Groups › Section 8 - Purchases of Insurance by Purchasing Groups; Agents or Brokers; Notice to Members

Section 8. (A) A purchasing group may not purchase insurance from a risk retention group that is not chartered in a state or from an insurer not admitted in the state in which the purchasing group is located, unless the purchase is effected through a licensed agent or broker acting pursuant to the surplus lines laws and regulations of such state. For purposes of this chapter, the purchasing group shall be deemed to be located in any state in which its members are resident or conducting business which is to be insured through the risk purchasing group.
(B) A purchasing group which obtains liability insurance from an insurer not admitted in the commonwealth or a risk retention group shall inform each of the members of such purchasing group which are resident in or have a risk located in the commonwealth that such risk is not protected by an insurance insolvency guaranty fund in the commonwealth, and that such risk retention group or such insurer may not be subject to all General Laws and regulations of the commonwealth.
(C) No purchasing group may purchase insurance providing for a deductible or self-insured retention applicable to the group as a whole, however, coverage may provide for a deductible or self-insured retention applicable to individual members.
(D) Purchases of insurance by purchasing groups are subject to the same standards regarding aggregate limits which are applicable to all purchases of group insurance.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176l - Risk Retention and Risk Purchasing Groups › Section 9 - Premium Taxes

Section 9. Premium taxes and taxes on premiums paid for coverage of residents or risks located in the commonwealth by a purchasing group or any members of a purchasing group shall be:
(A) imposed at the same rate and subject to the same interest, fines and penalties as are applicable to premium taxes and taxes on premiums paid for similar coverage from a similar insurance source by other insureds; and
(B) paid first by such insurance source, and if not by such source by the agent or broker for the purchasing group, and if not by such agent or broker then by the purchasing group, and if not by such purchasing group then by each of its members.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176l - Risk Retention and Risk Purchasing Groups › Section 11 - Enforcement by Commissioner

Section 11. The commissioner is authorized to make use of any of the powers established under the laws governing insurance to enforce those laws not specifically preempted by the Risk Retention Act of 1986 including the commissioner's administrative authority to investigate, issue subpoenas, conduct depositions and hearings, issue orders, impose penalties and seek injunctive relief.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176l - Risk Retention and Risk Purchasing Groups › Section 12 - License Requirement

Section 12. (A) No person, firm, association or corporation shall act or aid in any manner in soliciting, negotiating or procuring liability insurance in the commonwealth from a risk retention group unless such person, firm, association or corporation is licensed in accordance with the applicable provisions of chapter one hundred and seventy-five.
(B)(1) No person, firm, association or corporation shall act or aid in any manner in soliciting, negotiating or procuring liability insurance in the commonwealth for a purchasing group from an authorized insurer or a risk retention group chartered in a state unless such person, firm, association or corporation is licensed in accordance with the applicable provisions of chapter one hundred and seventy-five.
(2) No person, firm, association or corporation shall act or aid in any manner in soliciting, negotiating or procuring liability insurance coverage in the commonwealth for any member of a purchasing group under a purchasing group's policy unless such person, firm, association or corporation is licensed in accordance with the applicable provisions of chapter one hundred and seventy-five.
(C) For purposes of acting as an agent or broker for a risk retention group or purchasing group pursuant to subsections (A) and (B), any requirement of residence in the commonwealth shall not apply.
(D) Every person, firm, association or corporation licensed pursuant to the provisions of chapter one hundred and seventy-five, on business placed with risk retention groups or written through a purchasing group, shall inform each prospective insured of the provisions of the notice required by subsection (G) of section three in the case of a purchasing group and subsection (B) of section eight in the case of a purchasing group.
(2) Each licensee who has placed business with or on behalf of a risk retention group not chartered in the commonwealth shall report to the commissioner the premiums for direct business on residents or risk located within the commonwealth.
(3) Each licensee who places business with a risk retention group shall keep a complete and separate record of all policies procured from each such risk retention group, which record shall be open to examination by the commissioner, as provided in section five of chapter one hundred and seventy-six D. These records shall, for each policy and each kind of insurance provided thereunder, include the following:
(a) the limit of liability; (b) the time period covered; (c) the effective date; (d) the name of the risk retention group which issued the policy; (e) the gross premium charged; and (f) the amount of return premiums, if any.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176l - Risk Retention and Risk Purchasing Groups › Section 13 - Enforcement of Court Orders

Section 13. An order issued by any district court of the United States enjoining a risk retention group from soliciting or selling insurance, or operating in any state, or in all states or in any territory or possession of the United States, upon a finding that such a group is in hazardous financial or financially impaired condition shall be enforceable in the courts of the commonwealth.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176n - Portability of Health Insurance › Section 2 - Exclusion From Coverage; Compliance With Other Provisions of Law

Section 2. (a) No health plan shall:
(i) exclude any eligible insured on the basis of age, occupation, actual or expected health condition, claims experience, duration of coverage or medical condition of such person; and
(ii) exclude late enrollees from coverage for more than 12 months from the date of the application for coverage of any late enrollee.
(b) In any circumstance in which more extensive coverage than that provided by clauses (i) and (ii) of subsection (a) is required by any other state or federal law, the health benefit plan shall satisfy such other provision insofar as it requires more extensive coverage.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 3 - Complaints Against Carriers; Notice; Hearing

Section 3. (a) The bureau shall investigate all complaints made against a carrier or any entity with which it contracts for allegations of noncompliance with the accreditation requirements established by section 2. The bureau shall notify a carrier when, in the opinion of the bureau, the complaints made against such a carrier indicate a pattern of noncompliance with a particular accreditation requirement. The notice shall detail the alleged noncompliance and establish a hearing date for the matter, which shall be held no later than 21 days after the date of the notice. The hearing shall be conducted pursuant to chapter 30A. The hearing shall provide such a carrier with the opportunity to respond to the alleged noncompliance.
(b) The bureau may, after said hearing, suspend or revoke the accreditation of such a carrier, or reprimand, censure or impose a civil administrative penalty not to exceed $10,000 for each classification of violation.
(c) If, after said hearing, the bureau determines that such a pattern of noncompliance has been substantiated, the bureau may issue an order requesting a corrective action plan and timeframe to achieve compliance.
(d) If a national accreditation organization takes any action to revoke the accreditation or otherwise limit or negatively affect the accreditation status of a carrier, or any entity with which it contracts for services regulated under this chapter, such carrier shall promptly notify the bureau. If a national accreditation entity revokes such accreditation, the carrier shall not be eligible for deemed accreditation status, and the bureau shall initiate proceedings pursuant to chapter 30A to revoke or suspend the carrier's accreditation.
(e) Nothing in this section shall be construed to prohibit the bureau and a carrier from resolving compliance issues through informal means.
(f) Accreditation granted to carriers pursuant to this section shall be renewed every 2 years. The fee for the renewal shall be in an amount determined by the commissioner, but shall not be less than $1,000.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 4 - Refusal of Carriers to Contract With Eligible Health, Dental or Vision Care Providers Solely Because Providers Have Practiced Good Faith Advocacy on Behalf of Patients

Section 4. A carrier, including a dental or vision carrier, shall not refuse to contract with or compensate for covered services an otherwise eligible health, dental or vision care provider solely because such provider has in good faith communicated with or advocated on behalf of one or more of his prospective, current or former patients regarding the provisions, terms or requirements of the carrier's health, dental or vision benefit plans as they relate to the needs of such provider's patients, or communicated with 1 or more of his prospective, current or former patients with respect to the method by which such provider is compensated by the carrier for services provided to the patient. Nothing in this section shall preclude a carrier, including a dental or vision carrier, from requiring a health, dental or vision care provider to hold confidential specific compensation terms.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 5 - Contracts; Liability

Section 5. No contract between a carrier, including a dental or vision carrier, and a health, dental or vision care provider for the provision of services to insureds may require the provider to indemnify the carrier for any expenses and liabilities, including, without limitation, judgments, settlements, attorneys' fees, court costs and any associated charges, incurred in connection with any claim or action brought against the carrier based on the carrier's management decisions, utilization review provisions or other policies, guidelines or actions.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 5a - Acceptance and Recognition of Information Submitted Pursuant to Current Coding Standards and Guidelines Required; Use of Standardized Claim Formats

Section 5A. (a) Subject to subsection (c), for the purposes of processing claims for health care services submitted by a health care provider and to provide uniformity and consistency in the reporting of patient diagnostic information, patient care service and procedure information as it relates to the submission and processing of health care claims, a carrier and its subcontractors shall, without local customization, accept and recognize patient diagnostic information and patient care service and procedure information submitted pursuant to, and consistent with the current Health Insurance Portability and Accountability Act compliant code sets: the International Classification of Diseases; the American Medical Association's Current Procedural Terminology codes, reporting guidelines and conventions; and the Centers for Medicare and Medicaid Services Healthcare Common Procedure Coding System. A carrier and its subcontractors shall adopt the aforementioned coding standards and guidelines, and all changes thereto, in their entirety, which shall be effective on the same date as the national implementation date established by the entity implementing the coding standards.
(b) Subject to subsection (c), a carrier and its subcontractors shall, without local customization, use the standardized claim formats for processing health care claims as adopted by the National Uniform Claim Committee and the National Uniform Billing Committee and implemented pursuant to the Health Insurance Portability and Accountability Act. A carrier and its subcontractors shall, without local customization, adopt and routinely process all changes to such formats which shall be effective on the same date as the implementation date established by the entity implementing the formats.
(c) Except for the requirements for consistency and uniformity in coding patient diagnostic information and patient care service and procedure information, this section shall not modify or supersede a carrier's or its subcontractor's payment policy, utilization review policy or benefits under a health benefit plan. Nothing in this section shall further preclude a carrier or a subcontractor thereof from adjudicating a claim pursuant to its billing guidelines, payment policies, provider contracts or health benefit plans.
(d) Carriers and their subcontractors shall accept and recognize all claims submitted by health care providers pursuant to this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 5b - Policies and Procedures to Enforce Sec. 5a

Section 5B. To ensure uniformity and consistency in the submission and processing of claims for health care services pursuant to section 5A, the bureau of managed care within the division of insurance, after consultation with a statewide advisory committee including, but not limited to, representatives of the Massachusetts Hospital Association, the Massachusetts Medical Society, the Massachusetts Association of Health Plans, the Blue Cross and Blue Shield of Massachusetts, the Massachusetts Health Information Management Association, the Massachusetts Health Data Consortium, a representative of America's Health Insurance Plans, a representative of a MassHealth contracted managed care organization, the executive office of health and human services, the center for health information and analysis, the house of representatives and the senate, shall adopt policies and procedures to enforce said section 5A. The policies and procedures shall include a system for reporting inconsistencies related to a carrier's compliance with said section 5A. The bureau shall work jointly with the executive office of health and human services to resolve reports of noncompliance with the requirements of section 61 of chapter 118E. The bureau shall convene the advisory committee annually to review and discuss issues reported by health care providers pursuant to this section and to discuss further recommendations to improve the uniformity and consistency of the reporting of patient diagnostic information and patient care service and procedure information as it relates to the submission and processing of health care claims.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 5c - Failure of Carrier to Comply With Coding Standards and Guidelines; Notice; Penalty

Section 5C. If the commissioner determines that a carrier is neglecting to comply with the coding standards and guidelines under this chapter in the form and within the time required the commissioner shall notify the carrier of such neglect. If the carrier does not come into compliance within a period determined by the commissioner, the carrier shall be fined up to $5000 for each day during which such neglect continues.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 5d - Establishment of Base Fee Schedule for Evaluation and Management Services for Behavioral Health Providers

[Text of section added by 2022, 177, Sec. 63 effective November 8, 2023.]
Section 5D. For the purposes of this section, the term ''base fee schedule'' shall mean the minimum rates, typically set forth in fee schedules, paid by the carrier to an in-network health care provider who is not paid under an alternative payment arrangement for covered health care services; provided, however, that final rates may be subject to negotiations or adjustments that may result in payments to in-network providers that are different from the base fee schedule.
A carrier, directly or through any entity that manages or administers mental health or substance use disorder benefits for the carrier, shall establish a base fee schedule for evaluation and management services for behavioral health providers that is not less than the base fee schedule used for evaluation and management services for primary care providers of the same or similar licensure type and in the same geographic region; provided, however, that a carrier shall not lower its base fee schedule for primary care providers to comply with this section.
The division shall promulgate regulations to implement this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 8 - Failure by Carrier to File Annual Statement; Fine

Section 8. A carrier neglecting to make and file its annual statement or the materials required by the commissioner to be filed with the division under this chapter or under chapter 176G in the form and within the time required thereby shall be fined $5,000 for each day during which such neglect continues after being notified by said commissioner of such neglect, and, after notice and a hearing by the commissioner to that effect, its authority to do new business shall cease while such neglect continues.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 9a - Agreements or Contracts Between Carrier and Health Care Provider Prohibited if Containing Certain Provisions

Section 9A. A carrier shall not enter into an agreement or contract with a health care provider if the agreement or contract contains a provision that:
(a)(i) limits the ability of the carrier to introduce or modify a select network plan or tiered network plan by granting the health care provider a guaranteed right of participation; (ii) requires the carrier to place all members of a provider group, whether local practice groups or facilities, in the same tier of a tiered network plan; (iii) requires the carrier to include all members of a provider group, whether local practice groups or facilities, in a select network plan on an all-or-nothing basis; or (iv) requires a provider to participate in a new select network or tiered network plan that the carrier introduces without granting the provider the right to opt-out of the new plan at least 60 days before the new plan is submitted to the commissioner for approval; or
(b) requires or permits the carrier or the health care provider to alter or terminate a contract or agreement, in whole or in part, to affect parity with an agreement or contract with other carriers or health care providers or based on a decision to introduce or modify a select network plan or tiered network plan; or
(c) requires or permits the carrier to make any form of supplemental payment unless each supplemental payment is publicly disclosed to the commissioner as a condition of accreditation, including the amount and purpose of each payment and whether or not each payment is included within the provider's reported relative prices and health status adjusted total medical expenses under section 10 of chapter 12C; and
(d) limits the ability of either the carrier or the health care provider from disclosing the allowed amount and fees of services to an insured or insured's treating health care provider.
(e) limits the ability of either the carrier or the health care provider from disclosing out-of-pocket costs to an insured.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 10 - Contractual Financial Incentive Plans

Section 10. (a) No contract between a carrier, including a dental or vision carrier, and a licensed health, dental or vision care provider group shall contain any incentive plan that includes a specific payment made to a health, dental or vision care professional as an inducement to reduce, delay or limit specific, necessary services covered by the health, dental or vision care contract. Health, dental or vision care professionals shall not profit from provision of covered services that are not necessary and appropriate. Carriers, including a dental or vision carrier, shall not profit from denial or withholding of covered services that are necessary and appropriate. Nothing in this section shall prohibit contracts that contain incentive plans that involve general payments such as capitation payments or shared risk agreements that are made with respect to health, dental or vision providers or which are made with respect to groups of insureds if such contracts, which impose risk on such health, dental or vision providers for the costs of care, services and equipment provided or authorized by another health, dental or vision care provider, comply with subsection (b).
(b) In order that patient care decisions are based on need and not on financial incentives, no carrier, including a dental or vision carrier, shall enter into a new contract, revise the risk arrangements in an existing contract or, after July 1, 2001, revise the fee schedule in an existing contract with a health, dental or vision care provider which imposes financial risk on such provider for the costs of care, services or equipment provided or authorized by another provider unless such contract includes specific provisions with respect to the following: (1) stop loss protection, (2) minimum patient population size for the provider group, and (3) identification of the health, dental or vision care services for which the provider is at risk.
(c) A carrier or utilization review organization shall conduct an annual survey of insureds to assess satisfaction with access to specialist services, ancillary services, hospitalization services, durable medical equipment and other covered services. Said survey shall compare the actual satisfaction of insureds with projected measures of their satisfaction. Carriers that utilize incentive plans shall establish mechanisms for monitoring the satisfaction, quality of care and actual utilization compared with projected utilization of health care services of insureds.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 11 - Rights of Health Benefit Plans to Include as Providers Religious Non-Medical Providers

Section 11. Nothing in this chapter shall be construed to restrict or limit the rights of health benefit plans to include as providers religious non-medical providers, require such health benefit plans to utilize medically based eligibility standards or criteria in deciding provider status for religious non-medical providers, use medical professionals or criteria to decide insured access to religious non-medical providers, utilize medical professionals or criteria in making decisions in internal appeals from decisions denying or limiting coverage or care by religious non-medical providers, compel an insured to undergo a medical examination or test as a condition of receiving coverage for treatment by a religious non-medical provider, or require such health benefit plans to exclude religious non-medical providers because they do not provide medical or other data otherwise required, if such data is inconsistent with the religious non-medical treatment or nursing care provided by the provider.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 12b - Commission on Step Therapy Protocol; Responsibilities; Annual Report

Section 12B. (a) There shall be a commission on step therapy protocols within the division. The commission shall consist of: the commissioner of insurance or a designee, who shall serve as chair; the executive director of the health policy commission or a designee; the assistant secretary for MassHealth or a designee; the executive director of the center for health information and analysis or a designee; and 7 members appointed by the governor, 1 of whom shall represent the Massachusetts Public Health Association, 1 of whom shall represent Blue Cross and Blue Shield of Massachusetts, Inc., 1 of whom shall represent the Massachusetts Association of Health Plans, Inc., 1 of whom shall represent a patient advocacy organization, 1 of whom shall represent an employer organization, 1 of whom shall be currently practicing as a licensed physician in the commonwealth and 1 of whom shall be currently practicing as a licensed clinician, other than a physician, who has prescribing authority under the scope of their licensure. The commission shall meet as needed to satisfy the reporting requirements of this section.
(b) The commission shall study and assess the implementation of step therapy process reforms established in section 51A of chapter 118E and section 12A. The commission shall: (i) analyze the impact of step therapy protocols on total medical expenses, health care quality outcomes, premium cost and out-of-pocket costs to the consumer and the health care cost benchmark; and (ii) assess the efficacy of the step therapy exception process in ensuring that consumers diagnosed with medical conditions that rely on stability or have achieved a positive clinical response on a medication are able to maintain that course of treatment including, but not limited to, a form of multiple sclerosis. The commission shall also examine any available empirical data on the impact of step therapy protocols on health disparities related to outcomes, access and medication adherence.
(c) Not later than October 1 of each even-numbered year, the commission shall submit a report that includes findings from the commission's review and recommendations, including any draft legislation necessary to implement the recommendations, to the secretary of health and human services and the joint committee on health care financing.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 18 - Responsibility of Carrier for Behavioral Health Services Compliance

Section 18. A carrier for whom a behavioral health manager is administering behavioral health services shall be responsible for the behavioral health manager's failure to comply with the requirements of this chapter in the same manner as if the carrier failed to comply.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 19 - Display of Name and Telephone Number of Health Service Manager on Enrollment Cards of Carrier

Section 19. A carrier for whom a behavioral health manager is administering behavioral health services shall state on its new enrollment cards issued in the normal course of business, within one year, the name and telephone number of the behavioral health manager.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 20 - Information Provided to Insured Adults by Behavioral Health Manager; Submission of Material Changes; Workers' Compensation; Preferred Provider Arrangements

Section 20. (a) A behavioral health manager shall provide the following information to at least 1 adult insured in each household covered by their services:
(1) a notice to the insured regarding emergency mental health services that states:
(i) that the insured may obtain emergency mental health services, including the option of calling the local pre-hospital emergency medical service system by dialing the 911 emergency telephone number or its local equivalent, if the insured has an emergency mental health condition that would be judged by a prudent layperson to require pre-hospital emergency services;
(ii) that no insured shall be discouraged from using the local pre-hospital emergency medical service system, the 911 emergency telephone number or its local equivalent;
(iii) that no insured shall be denied coverage for medical and transportation expenses incurred as a result of such emergency mental health condition; and
(iv) if the behavioral health manager requires an insured to contact either the behavioral health manager, carrier or the primary care provider of the insured within 48 hours of receiving emergency services, notification already given to the behavioral health manager, carrier or primary care provider by the attending emergency physician shall satisfy that requirement;
(2) a summary of the process by which clinical guidelines and utilization review criteria are developed for behavioral health services; and
(3) a statement that the office of patient protection, established by section 16 of chapter 6D or, if applicable, the designated state consumer assistance program is available to assist consumers, a description of the grievance and review processes available to consumers under chapter 176O, and relevant contact information to access the office and these processes.
(b) The information required by subsection (a) may be contained in the carrier's evidence of coverage and need not be provided in a separate document. Every disclosure described in this section shall contain the effective date, date of issue and, if applicable, expiration date.
(c) A behavioral health manager shall submit material changes to the information required by subsection (a) to the bureau of managed care, established by section 2 of chapter 176O, at least 30 days before their effective dates and to at least 1 adult insured in every household residing in the commonwealth at least biennially.
(d) A behavioral health manager that provides specified services through a workers' compensation preferred provider arrangement that meets the requirements of 211 CMR 112.00 and 452 CMR 6.00 shall be considered to comply with this section.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 22 - Participation in Medical Assistance Program as Condition for Participation in Carrier's Provider Network

Section 22. Notwithstanding any other general or special law to the contrary, each carrier shall require, as a condition of participation in the carrier's provider network by a physician, dentist, optometrist, podiatrist, nurse practicing in an advance practice nursing role, intern, resident, physician assistant, pharmacist with a collaborative practice agreement, psychologist and licensed independent clinical social worker, that such provider also apply to participate in the medical assistance program administered by the secretary of health and human services in accordance with chapter 118E and Title XIX of the Social Security Act and any federal demonstration or waiver relating to such medical assistance program for the limited purposes of ordering and referring services covered under such program, provided that regulations governing such limited participation are promulgated under said chapter 118E. Any such provider who chooses to participate in such medical assistance program as a provider of services shall be deemed to have fulfilled this requirement.
2023 Massachusetts General Laws › Part I - Administration of the Government › Title XXII - Corporations › Chapter 176o - Health Insurance Consumer Protections › Section 23 - Disclosure by Carrier Upon Request for Network Status of Health Care Provider and Estimated or Maximum Allowed Amount or Charge for a Proposed Admission, Procedure or Service and Amount Insured Responsible to Pay; Establishment of Toll-Free Telephone Number and Website

Section 23. All carriers shall establish a toll-free telephone number and website that enables consumers to request and obtain from the carrier, in real time, the network status of an identified health care provider, the estimated or maximum allowed amount or charge for a proposed admission, procedure or service and the estimated amount the insured, will be responsible to pay for a proposed admission, procedure or service that is a medically necessary covered benefit, based on the information available to the carrier at the time the request is made, including any facility fee, copayment, deductible, coinsurance or other out of pocket amount for any covered health care benefits; provided, that the insured shall not be required to pay more than the disclosed amounts for the covered health care benefits that were actually provided; provided, however, that nothing in this section shall prevent carriers from imposing cost sharing requirements disclosed in the insured's evidence of coverage for unforeseen services that arise out of the proposed admission, procedure or service; and provided further, that the carrier shall alert the insured that these are estimated costs, and that the actual amount the insured will be responsible to pay may vary due to unforeseen services that arise out of the proposed admission, procedure or service.