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 152.11 - Appendix A: Applicant Disclosure Notice for Individually Issued Coveage

Current through Register 1525, July 5, 2024
APPLICANT DISCLOSURE NOTICE PROVIDER NETWORK
				ACCESS
[Carrier Name
Mailing Address
Customer Service Toll-Free Number]
[[Limited] [Regional]] Provider Network
This plan provides access to providers that are not the
				same as [name of carrier]'s [general provider network name] provider
				network.
Your member identification card will display the name of your
				provider network. The designation ["Limited" or "Regional"] will be on the top
				right hand side of the card that applies to the health benefit plan you have
				chosen.
* I understand that I may not change plans during a policy year
				because of changes to the provider network.
* I understand that the plan provides access to providers that
				may not be the same as [name of carrier]'s [general provider network name]
				provider network.
* I have reviewed the [name of network] provider directory or
				online provider search tool and understand that this plan only provides access
				to covered benefits from the providers in the [name of network]
				directory.
* I understand that it is my responsibility to ensure that a
				provider I voluntarily choose is enrolled in the [name of network] provider
				network prior to obtaining care.
* In choosing the [name of network] plan, I understand I will
				be required to choose a different provider for treatment if a provider I now
				see is not enrolled in the [name of network] provider network.
* I certify that I have received the [guide designated by the
				Commissioner] prior to beginning and completing the application/enrollment
				process.
Initials _______ Date _______ ]]
[[
Tiered Provider Network]
This Plan assigns network providers to benefit
				tiers
Your member identification card will display the name of your
				provider network. The designation ["Tiered"] will be on the top right hand side
				of the card that applies to the health benefit plan you have chosen.
* I understand that I may not change plans during a policy year
				because of to the provider network.
* I understand that the plan I have chosen assigns network
				providers to benefit tiers.
* I understand that I will pay different [copayments,
				coinsurance, deductibles] based on a provider's assigned benefit tier.
* I understand that the carrier may reassign a provider's
				assigned benefit tier each year on [identify date].
* I understand that if a provider is reassigned to a different
				benefit tier, I am responsible to pay a different [copayments, coinsurance,
				deductibles].
* I have reviewed the [name of network] provider directory and
				understand that symbols displayed next to each provider identify the exact tier
				that the provider is assigned.
* I certify that I have received the [guide designated by the
				Commissioner]" prior to beginning and completing the application/enrollment
				process.
Initials _______ Date _______ ]]
[Assigned Form#]