Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 152.00 - Health Benefit Plans Using Limited, Regional Or Tiered Provider Networks › Section 152.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 152.00, the
				following words mean:
Advertisemen
t: Advertisement shall
				include:
(a) Printed and published material, audio-visual material and
				descriptive literature used by a Carrier in direct mail, newspapers, magazines,
				internet websites, radio scripts, television scripts, billboards and similar
				displays;
(b) Descriptive literature and sales aids of all kinds issued
				by a Carrier, Insurance Producer or other entity for presentation to the
				insurance-buying public including, but not limited to, circulars, leaflets,
				booklets, internet websites, depictions, illustrations, and form letters;
				and
(c) Prepared sales talks, presentations and material for use by
				providers and Insurance Producers.
Carrier
: An insurer licensed or
				otherwise authorized to transact health insurance under M.G.L. c. 175; a
				nonprofit hospital service corporation organized under M.G.L. c. 176A; a
				nonprofit medical service corporation organized under M.G.L. c. 176B; a health
				maintenance organization licensed under M.G.L. c. 176G; an organization
				entering into a preferred provider arrangement under M.G.L. c. 176I, but not
				including an employer purchasing coverage or acting on behalf of its employees
				or the employees of one or more subsidiaries or affiliated corporations of the
				employer. Carrier shall not include any entity to the extent it offers a
				policy, certificate or contract that provides coverage solely for dental care
				services or vision care services.
Commissioner
: The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6.
Covered Benefits
: Those Health Care
				Services to which an Insured is entitled under the terms of the Health Benefit
				Plan.
Division
: The Division of Insurance
				established pursuant to M.G.L. c. 26, § 1.
Emergency Services
: Services to treat
				a medical condition, whether physical or mental, manifesting itself by symptoms
				of sufficient severity, including severe pain, that the absence of prompt
				medical attention could reasonably be expected by a prudent layperson who
				possesses an average knowledge of health and medicine, to result in placing the
				health of an Insured or another person in serious jeopardy, serious impairment
				to body function, or serious dysfunction of any body organ or part, or, with
				respect to a pregnant woman, as further defined in § 1867(e)(1)(B) of the
				Social Security Act,
				42
				U.S.C.
				1395dd(e)(1)(B).
Evidence of Coverage
: Any certificate,
				contract or agreement of health insurance including riders, amendments,
				endorsements and any other supplementary inserts or a summary plan description
				pursuant to § 104(b)(1) of the Employee Retirement Income Security Act of
				1974, 29 U.S.C. § 1024(b), issued to an Insured specifying the benefits to
				which the Insured is entitled.
Facility
: A licensed institution
				providing Health Care Services or a health care setting, including, but not
				limited to, hospitals and other licensed inpatient centers, ambulatory surgical
				or treatment centers, skilled nursing centers, residential treatment centers,
				diagnostic, laboratory and imaging centers, and rehabilitation and other
				therapeutic health settings.
General Provider Network
: The most
				comprehensive provider network offered by a Carrier in its Massachusetts
				Service Area.
Health Benefit Plan
: A policy,
				contract, certificate or agreement entered into, offered, or issued by a
				Carrier to provide, deliver, arrange for, pay for or reimburse any of the costs
				of covered Health Care Services.
Health Care Professional
: A physician
				or other health care practitioner licensed, accredited or certified by the
				Commonwealth of Massachusetts or other entity authorized to perform or supply
				specified Health Care Services.
Health Care Provider or Provider
: A
				Health Care Professional or a Facility.
Health Care Services
: Services for the
				diagnosis, prevention, treatment, cure or relief of a health condition,
				illness, injury or disease.
Insurance Producer:
A person required
				to be licensed under the laws of the Commonwealth M.G.L. c. 175 § 162I, to
				sell, solicit or negotiate insurance.
Insured
: An enrollee, covered person,
				member, policyholder or subscriber of a Carrier.
Limited Provider Network
: A reduced or
				selective Provider Network, not a Regional Provider Network, which is smaller
				than a Carrier's General Provider Network and from which the Carrier may choose
				to exclude from participation other Providers who participate in the Carrier's
				Regional Provider Network or General Provider Network.
Marketing or Marketing Material
: Any
				of the following including, but not limited to, Advertisements, when they are
				used byany person with the intent of soliciting an offer to contract for a
				Health Benefit Plan:
(a) Printed, published or web based material, audio-visual
				material and descriptive literature used in direct mail, newspapers, magazines,
				radio or TV scripts, billboards, computer or electronic transmissions and
				similar displays;
(b) Descriptive literature and sales aids of all kinds issued
				for presentation to members of the insurance-buying public, including but not
				limited to circulars, leaflets, booklets, depictions, illustrations, internet
				websites and form letters;
(c) Prepared sales talks, presentations and material;
				and
(d) All oral and written solicitations and
				presentations.
(e) Social media sites including networking sites, blog
				postings and smartphone applications created by or for a Carrier, Insurance
				Producer or other entity for presentation to or use by the insurance buying
				public.
Network Adequacy
: Sufficient access to
				Covered Benefits with a Provider Network within the Health Benefit Plan's
				Service Area to guarantee that all Covered Benefits are accessible to Insureds
				without delays detrimental to the Insureds' health.
Network Provider
: A person or entity
				under contract with a Carrier or with its subcontractor to provide covered
				Health Care Services to Insureds.
PCP
: A Provider that is a primary care
				Provider designated by the Insured.
Provider Network
: A group of Health
				Care Providers contracted with a Carrier or affiliate to provide Health Care
				Services to Insureds covered by any or all of the Carrier's or affiliate's
				plans, policies, contracts or other arrangements. Provider network shall not
				mean those participating Providers that provide services to subscribers of a
				nonprofit hospital service corporation organized under M.G.L. c. 176A, or a
				nonprofit medical service corporation organized under M.G.L. c. 176B.
Reclassification Date
: The effective
				date specified bythe Carrier on which the Carrier reclassifies Providers among
				the benefit tiers of a tiered Provider Network and, thereafter, the date on
				which any future reclassifications would take effect, unless the Carrier
				submits a written request to the Commissioner at least 90 days in advance of
				the proposed date.
Regional Provider Network
: A Provider
				Network for a defined geographic area within Massachusetts that is smaller than
				the Carrier's Service Area and includes only those Providers that have agreed
				to participate in the Carrier's plan in a limited geographic area within the
				Commonwealth of Massachusetts. A Regional Provider Network may be a geographic
				subset of the Carrier's General Provider Network.
Service Area
: The geographicalarea, as
				approved bythe Commissioner, within which the Carrier has developed a Provider
				Network to afford adequate access to Insureds for Covered Benefits.
Tiered Provider Network
: A Provider
				Network in which a Carrier assigns Providers to different benefit tiers based
				on the Carrier's assessment of a Provider's relative cost and, where available,
				quality and in which Insureds pay the cost-sharing (copayment, coinsurance or
				deductible) associated with a Provider's assigned benefit
				tiers.