reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 44.00 - Confidentiality Of Bids Submitted For Restricted Pharmacy Network Contracts - To Facilitate The Implementation Of M.g.l. C.176d, Section 3b › Section 44.05 - Request for Ruling

Current through Register 1525, July 5, 2024
Whenever an Eligible Bidder or Carrier believes that certain
				data or information contained in a bid which is not listed as being proprietary
				under
				211 CMR
				44.04(2)(a) or (b) is of a
				proprietary nature, the Eligible Bidder or Carrier may make a written request
				to the Commissioner that such information be deemed proprietary for the
				purposes of M.G.L. c. 176D, §3B. Written requests should specifically
				identify the information sought to be deemed proprietary and state in detail
				the reasons for requesting that the information be deemed proprietary. The
				information will be treated as proprietary until the Commissioner renders a
				decision.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 44.00 - Confidentiality Of Bids Submitted For Restricted Pharmacy Network Contracts - To Facilitate The Implementation Of M.g.l. C.176d, Section 3b › Section 44.06 - Notice that a Bid is Public

Current through Register 1525, July 5, 2024
A Carrier that solicits bids for a Restricted Network Pharmacy
				contract shall open all bids at a previously specified time, which shall not be
				more than 30 days after the bid submission deadline in a public manner pursuant
				to M.G.L. c. 176D, § 3B and subject to the restrictions set forth in
				211 CMR
				44.04(2)(a) and (b). A
				Carrier shall notify the Commissioner in writing that the bids have been opened
				no later than three days after the opening of the bids. The notification shall
				specify the date the bids were opened.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 44.00 - Confidentiality Of Bids Submitted For Restricted Pharmacy Network Contracts - To Facilitate The Implementation Of M.g.l. C.176d, Section 3b › Section 44.07 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 44.00, or the
				applicability thereof to any person or circumstance is held invalid by any
				court of competent jurisdiction, the remainder of
				211 CMR 44.00, or the
				applicability thereof to other persons or circumstances, shall not be affected
				thereby.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 45.00 - Establishment Of Service Fee To Insurance Producers Assisting Employer S In Obtaining Workers' Compensation Insurance › Section 45.01 - Authority

Current through Register 1525, July 5, 2024
211 CMR 45.00 is made
				pursuant to the authority vested in The Commissioner of Insurance by M.G.L. c.
				152, § 65O (inserted by St. 1974, c. 761).
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 45.00 - Establishment Of Service Fee To Insurance Producers Assisting Employer S In Obtaining Workers' Compensation Insurance › Section 45.02 - Purpose

Current through Register 1525, July 5, 2024
The purpose of
				211 CMR 45.00 is to set a
				service fee as required by M.G.L. c. 152, § 65O at a percentage rate of
				the average commission rate customarily paid by those workers' compensation
				insurers that compensate insurance producers by commissions which will be
				sufficiently attractive to encourage insurance producers to assist employers in
				obtaining coverage while, at the same time, leaving a further incentive to
				insurance producers to place such insurance coverage through their customary
				markets when that is practicable.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 45.00 - Establishment Of Service Fee To Insurance Producers Assisting Employer S In Obtaining Workers' Compensation Insurance › Section 45.03 - Eligibility to Receive Service Fee

Current through Register 1525, July 5, 2024
In order to be eligible to receive the service fee established
				under
				211 CMR 45.00 a licensed
				insurance producer must be designated, in writing, as producer of record by the
				employer to assist the employer in dealing with the Massachusetts Workers'
				Compensation Reinsurance Pool and the insurer to which he is assigned and must
				show to the satisfaction of the Plan that he has a relationship with an insurer
				writing workers' compensation insurance but is unable to place the employer so
				designating him with that insurer. The designation of an insurance producer as
				producer of record will remain in effect until revoked, in writing, by the
				employer or until a new producer of record is designated by the employer. No
				more than one insurance producer shall be designated as producer of record for
				an employer at any time.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 45.00 - Establishment Of Service Fee To Insurance Producers Assisting Employer S In Obtaining Workers' Compensation Insurance › Section 45.04 - Amount of Service Fee

Current through Register 1525, July 5, 2024
The service fee shall be based on Massachusetts standard
				premium and paid in accordance with the following schedule:
On 1st $1,000 in premium
- 9%
On next 4,000 " "
- 5%
On next 95,000 " "
- 4%
Over 100,000 " "
- 3%
The service fee schedule shall be used from the effective date
				of
				211 CMR 45.00 until such time
				as
				211 CMR 45.00 is further
				amended or changed by the Commissioner of Insurance.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 50.00 - Continuing Education For Insurance Producers › Section 50.01 - Purpose

Current through Register 1525, July 5, 2024
The purpose of
				211 CMR 50.00 is to assure
				the professional competence of licensed insurance producers by requiring
				satisfactory completion of approved continuing education
				courses.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 50.00 - Continuing Education For Insurance Producers › Section 50.02 - Definitions

Current through Register 1525, July 5, 2024
Commissioner
. The Commissioner of
				Insurance, appointed under the provisions of M.G.L. c. 26, § 6, or his or
				her designee
Committee
. The review committee
				established pursuant to M.G.L. c. 175, § 177E, subsection J.
Continuing Education Administrator or
				Administrator
. A third party selected by the Commissioner to
				review continuing education courses and to maintain records of course
				completion.
Insurance Producers
. All persons
				required to be licensed under the laws of the Commonwealth to sell, solicit or
				negotiate insurance.
Person
. An individual or a business
				entity.
Satisfactory Completion
. Completion in
				accordance with course credit rules established by the Committee.
Sponsor
. Any business entity, trade
				association or other group which develops a course of study, monitors insurance
				producer participation in a course of study, or otherwise administers a course
				of study approved for continuing education credits pursuant to
				211 CMR 50.00.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 50.00 - Continuing Education For Insurance Producers › Section 50.03 - Applicability

Current through Register 1525, July 5, 2024
(1) The provisions of
			 211 CMR 50.00 shall apply to
			 resident and non-resident persons licensed in Massachusetts to engage in the
			 sale of the following lines of insurance:
(a)
			 life and annuity contracts;
(b)
			 variable annuity and variable life insurance contracts;
(c) accident and health or
			 sickness;
(d) all lines of property
			 and casualty.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 50.00 - Continuing Education For Insurance Producers › Section 50.04 - Hours of Study

Current through Register 1525, July 5, 2024
Any insurance producer licensed to sell one or more lines of
				insurance listed in
				211 CMR 50.03(1)
				 shall satisfactorily complete 60 hours of
				approved instruction prior to the renewal date of his or her initial insurance
				license. Following the initial renewal, any person licensed to sell one or more
				lines of insurance shall satisfactorily complete, for each 36 month period
				prior to the renewal date of his or her license, 45 hours or equivalent of
				approved instruction. Said instruction shall include a program of instruction
				or seminar on Massachusetts Approved Ethics (MAE) equivalent to three classroom
				hours of instruction. The requirements of 211 CMR 50.04 may be met by the
				licensee in any of the lines of insurance for which he or she is licensed.
				Licensees are encouraged to take at least one credit hour of approved
				instruction in each line for which they are licensed.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 50.00 - Continuing Education For Insurance Producers › Section 50.05 - Forms of Submission

Current through Register 1525, July 5, 2024
Each licensed resident insurance producer, who is required to
				complete continuing education pursuant to
				211 CMR 50.03,
				shall be responsible for the completion of a form prescribed by the
				Commissioner which certifies that said person has met the continuing education
				requirements of M.G.L. c. 175, § 177E and
				211 CMR 50.04.
				Each Sponsor shall be responsible for providing the form to all course
				participants. Each form shall be certified by the Sponsor as to the
				participant's satisfactory completion of the approved course. Sponsors shall
				keep records verifying the participation of licensees for at least six
				years.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 50.00 - Continuing Education For Insurance Producers › Section 50.06 - Application for Program Credit

Current through Register 1525, July 5, 2024
Each course Sponsor shall submit to the Continuing Education
				Administrator on a form approved by the Commissioner any request for approval
				of credits for continuing education courses. Each such request shall be
				reviewed by the Administrator and submitted to the Committee, for approval by
				the Commissioner. The Administrator will notify the Sponsor if the Commissioner
				disapproves the course of study or if the Commissioner requires that the amount
				of credit hours be adjusted. Each course Sponsor must certify the hours of
				study and requirements necessary for successful completion of the course of
				study. The Committee shall recommend and the Commissioner shall approve the
				amount of credit hours to be assigned each approved course. The Administrator
				shall make available for public inspection a list of all approved courses of
				instruction.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 50.00 - Continuing Education For Insurance Producers › Section 50.07 - Failure to Comply

Current through Register 1525, July 5, 2024
The failure of an insurance producer to complete the required
				number of continuing education credits by their producer license renewal date
				may result in the non-renewal or suspension of their insurance producer
				license. In addition to, or in lieu of, a license suspension, an insurance
				producer, after a hearing, which hearing may be waived by said insurance
				producer, may be subject to a civil fine of not less than $20.00 nor more than
				$100.00 for each hour of instruction by which they fail to meet the
				requirements imposed by M.G.L. c. 175, § 177E and
				211 CMR 50.00. For good cause
				shown, however, the Commissioner may grant an extension of time during which
				the continuing education requirements may be satisfied by any such insurance
				producer.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 51.00 - Preferred Provider Health Plans And Workers' Compensation Preferred Provider Arrangements › Section 51.01 - Authority

Current through Register 1525, July 5, 2024
211 CMR 51.00 is promulgated
				in accordance with the authority granted to the Commissioner of Insurance by
				M.G.L.c. 152, §25A, M.G.L.c. 1761, § 8(a) and M.G.L.c. 1760,
				§17.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 51.00 - Preferred Provider Health Plans And Workers' Compensation Preferred Provider Arrangements › Section 51.03 - Applicability

Current through Register 1525, July 5, 2024
No Preferred Provider Health Plan or Workers' Compensation
				Preferred Provider Arrangement may be offered without meeting the filing and
				other requirements set forth in M.G.L. c. 152 and 1761, and until it is
				approved by the Commissioner in accordance with the provisions of
				211 CMR
				51.00.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 51.00 - Preferred Provider Health Plans And Workers' Compensation Preferred Provider Arrangements › Section 51.04 - Approval of Preferred Provider Health Plans and Workers' Compensation Preferred Provider Arrangements

Current through Register 1525, July 5, 2024
(1)
Application
. No Preferred Provider Health Plan or
			 Workers' Compensation Preferred Provider Arrangement may be approved without
			 first submitting an application in a format specified by the Commissioner that
			 includes at least the following:
(a) A
			 description of the geographical area in which the Preferred Providers are
			 located, including a map of the distribution of the Preferred
			 Providers;
(b) A description of the
			 manner in which covered Health Care Services and other benefits may be obtained
			 by persons using the Preferred Providers, including a description of the
			 grievance system available to Covered Persons, including procedures for the
			 registration and resolution of grievance and any requirement within a Preferred
			 Provider Health Plan that Covered Persons select a gatekeeper
			 provider;
(c) Provider contracts
			 and contracting criteria, including:
1. A
			 narrative description of the financial arrangements between the Organization
			 and contracting Health Care Providers, identifying any assumption by the
			 providers of financial risk through arrangements such as
per diems,
diagnosis-related groups, capitation or percentage withholding of
			 fees;
2. A copy of every standard
			 form contract with preferred physicians and other Health Care Providers,
			 including providers joining the Preferred Provider Arrangement via leasing,
			 subcontracting, or other arrangements whereby the Organization does not
			 contract directly with the providers (do not include rates of payment to
			 providers);
3. A copy of every
			 standard form contract for all Preferred Provider Arrangements including
			 administrative service agreements;
4. A copy of the terms and conditions that
			 must be met or agreed to by Health Care Providers desiring to enter into the
			 Preferred Provider Arrangement(s) (do not include rates of payments to Health
			 Care Providers); and
5. A
			 description of the criteria and method used to select Preferred
			 Providers.
(d) A
			 detailed description of the utilization review program;
(e) A detailed description of the quality
			 assurance program;
(f) Preferred
			 Provider directory, which shall include:
1. A
			 copy of the Preferred Provider directory distributed to Covered Persons;
			 and
2. A description of the process
			 for distributing the directory to Covered Persons.
(g) Filing fee for initial applications as
			 determined by the Executive Office for Administration and Finance as set forth
			 in
			 801 CMR
			 4.02:
Fees for Licenses, Permits, and
			 Services to be Charged by State Agencies.
(h) Evidence of compliance with M.G.L. c.
			 1760 and
			 211 CMR 52.00:
Managed Care Consumer Protections and Accreditation of
			 Carriers.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 51.00 - Preferred Provider Health Plans And Workers' Compensation Preferred Provider Arrangements › Section 51.05 - Evidence of Coverage for Insured Preferred Provider Health Plan Coverage Only

Current through Register 1525, July 5, 2024
The Evidence of Coverage, including all amendments and material
				changes, must be submitted to the Commissioner for approval.
(1) The Evidence of Coverage must meet the
			 requirements of M.G.L.c. 1761, M.G.L. c. 1760,
			 211 CMR 51.00 and
			 52.00:
Managed Care
			 Consumer Protections and Accreditation of Carriers.
(2) The Evidence of Coverage must also
			 include the following in clear and understandable language:
(a) a complete description of the benefit
			 differential between services offered by Preferred Providers and non-preferred
			 providers;
(b) Provisions that if a
			 Covered Person receives Emergency Care and cannot reasonably reach a Preferred
			 Provider, payment for such care will be made at the same level and in the same
			 manner as if the Covered Person had been treated by a Preferred
			 Provider;
(c) Benefit levels for
			 covered Health Care Services rendered by non-preferred providers must be at
			 least 80% of the Benefit Levels for the same covered Health Care Services
			 rendered by Preferred Providers.
1. Payments
			 made to non-preferred providers shall be a percentage of the provider's fee, up
			 to a Usual and Customary Charge, and not a percentage of the amount paid to
			 Preferred Providers.
2. The 80%
			 requirement shall be met if the coinsurance percentage for Health Care Services
			 rendered by a non-preferred provider is no more than 20 percentage points
			 greater than the highest coinsurance percentage for the same Health Care
			 Services rendered by a Preferred Provider, excluding reasonable deductibles and
			 copayments.
(d) A
			 description of all benefits required to be provided by law in accordance with
			 all of the provisions of the Organization's enabling or licensing
			 statutes.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 51.00 - Preferred Provider Health Plans And Workers' Compensation Preferred Provider Arrangements › Section 51.06 - Reporting

Current through Register 1525, July 5, 2024
(1)
Material
			 Changes
. Each Organization with a Preferred Provider Health Plan
			 or Workers' Compensation Preferred Provider Arrangement shall file with the
			 Commissioner any material changes or additions to the material previously
			 submitted on or before their effective date, including amendments to an
			 Evidence of Coverage and significant changes to the lists of Preferred
			 Providers.
(2)
Annual
			 Reports
. The Division of Insurance will collect annual report
			 information for each Organization with a Preferred Provider Health Plan or a
			 Workers' Compensation Preferred Provider Arrangement on April
			 30th of each year covering the prior fiscal year.
			 The annual report shall include at least the following information in a format
			 specified by the Commissioner:
(a) A summary
			 of the number of Covered Persons;
(b) A summary of the utilization experience
			 of Covered Persons; and
(c) A list
			 of preferred providers.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 51.00 - Preferred Provider Health Plans And Workers' Compensation Preferred Provider Arrangements › Section 51.07 - Severability

Current through Register 1525, July 5, 2024
If any provision of
				211 CMR 51.00 or the
				applicability thereof to any person, entity or circumstance is held invalid by
				a court, the remainder of
				211 CMR 51.00 or the
				applicability of such provision to other persons, entities or circumstances
				shall not be affected thereby.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.01 - Applicability

Current through Register 1525, July 5, 2024
211 CMR
				52.00 applies to any Carrier that offers for sale,
				provides or arranges for the provision of a defined set of Health Care Services
				to Insureds through affiliated and contracting Providers or employs Utilization
				Review in making decisions about whether services are Covered Benefits under a
				Health Benefit Plan. A Carrier that provides coverage for Limited Health
				Services only, that provides specified services through a workers' compensation
				preferred Provider arrangement, or that does not provide services through a
				Network or through Participating Providers shall be subject to those
				requirements of
				211 CMR
				52.00 as deemed appropriate by the Commissioner in a
				manner consistent with a duly filed application for Accreditation as outlined
				in 211 CMR
				52.05(2).
Certain requirements of
				211 CMR
				52.00, as specified, shall also apply to Dental and
				Vision Carriers. Such provisions are:
				211
				CMR 52.11(1) through (4);
				(11); (13); 52.13(2), (3)(a), (c) through (e), (g), (h), (l) through (o); (4)
				through (10); 52.14(1)(c) and (d); (2), (3) and (7); and
				211
				CMR 52.17.
A Carrier that delegates to or contracts with another entity,
				including a Utilization Review Organization, for the performance of some or all
				of the functions governed by M.G.L. c. 176O and/or
				211 CMR
				52.00 shall be responsible for ensuring compliance by
				said entity with the provisions of M.G.L. c. 176O and
				211 CMR
				52.00.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.03 - Accreditation of Carriers

Current through Register 1525, July 5, 2024
(1) A Carrier must
			 be accredited according to the requirements set forth in
			 211 CMR
			 52.00 in order to offer for sale, provide, or arrange
			 for the provision of a defined set of Health Care Services to Insureds through
			 affiliated and contracting Providers or employ Utilization Review in making
			 decisions about whether services are Covered Benefits under a Health Benefit
			 Plan.
(2) Accreditation granted to
			 Carriers pursuant to
			 211 CMR
			 52.00 shall remain in effect for up to 24 months until
			 the end of the respective biennial Accreditation period, unless revoked or
			 suspended by the Commissioner.
(3)
			 A Carrier shall be exempt from
			 211 CMR
			 52.00 if in the written opinion of the Attorney
			 General, the Commissioner, and the Commissioner of Public Health, the health
			 and safety of health care consumers would be materially jeopardized by
			 requiring Accreditation of the Carrier.
(a)
			 Before publishing a written exemption pursuant to
			 211
			 CMR 52.03(3), the Attorney
			 General, the Commissioner, and the Commissioner of Public Health shall jointly
			 hold at least one public hearing at which testimony from interested parties on
			 the subject of the exemption shall be solicited.
(b) A Carrier granted an exemption pursuant
			 to 211 CMR 52.03(3)
			  shall be provisionally accredited and,
			 during such provisional Accreditation, shall be subject to review not less than
			 every four months and shall be subject to those requirements of M.G.L. c. 176O
			 and 211 CMR
			 52.00 as deemed appropriate by the
			 Commissioner.
(c) Before the end of
			 each four-month period specified in
			 211
			 CMR 52.03(3)(b)  the
			 Commissioner shall review the Carrier's exemption.
1. If the Bureau determines that the Carrier
			 has met the requirements of
			 211 CMR
			 52.00, then the Carrier shall be accredited and the
			 exemption shall expire upon Accreditation.
2. If the Commissioner determines that the
			 Carrier's exemption should be continued, the Commissioner shall communicate
			 that determination in writing to the Attorney General and the Commissioner of
			 Public Health. Continuation of the exemption shall be granted only upon a
			 written decision by the Commissioner, the Attorney General and the Commissioner
			 of Public Health.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.04 - Deemed Accreditation

Current through Register 1525, July 5, 2024
(1) A Carrier may
			 apply for deemed Accreditation. A Carrier that applies for deemed Accreditation
			 may be deemed to be in compliance with the standards set forth in
			 211
			 CMR 52.00a nd may be so accredited by the
			 Bureau if it meets the following requirements:
(a) It must be accredited by JCAHO, NCQA or
			 URAC;
(b) It must meet all the
			 requirements set forth in M.G.L. c. 176O,
			 211 CMR
			 52.00 and
			 958 CMR
			 3.000:
Health Insurance Consumer
			 Protection
; and
(c) It
			 must have received the ratings specified in
			 211
			 CMR 52.05(5)(c) and
			 (d).
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.05 - Application for Accreditation

Current through Register 1525, July 5, 2024
(1)
Timing of Application
.
(a) Carriers must submit biennial renewal
			 applications by July 1st for renewals to be
			 effective on November 1st.
(b) A Carrier seeking initial Accreditation
			 must submit an application at least 90 Days prior to the date on which it
			 intends to offer Health Benefit Plans.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.06 - Review of Application for Accreditation

Current through Register 1525, July 5, 2024
(1) Carriers shall comply with the standards
			 set forth in M.G.L. c. 176O,
			 211 CMR
			 52.00;958 CMR
			 3.000:
Health Insurance Consumer
			 Protection
;
			 211 CMR
			 152.00:
Health Benefit Plans Using Limited,
			 Regional or Tiered Provider Networks
, if applicable; and all other
			 applicable state and federal law.
(a) For all
			 products, a Carrier shall not be accredited unless the Carrier scores 65% or
			 higher of an aggregate of the applicable elements in the NCQA Standards,
			 effective July 1, 2017, or any edition of such standards determined by the
			 Commissioner to be functionally equivalent or appropriate, for the
			 Accreditation of Health Benefit Plans, including health maintenance
			 organizations, gatekeeper preferred Provider plans, and Nongatekeeper Preferred
			 Provider Plans, in the categories of utilization management, quality management
			 and improvement, and credentialing and recredentialing.
(b) The NCQA Standards, effective July 1,
			 2017, or any edition of such standards determined by the Commissioner to be
			 functionally equivalent or appropriate, are incorporated by reference into
			 211 CMR
			 52.00 to the extent that the NCQA Standards do not
			 conflict with other laws of this Commonwealth. The NCQA Standards can be
			 obtained from the NCQA.
(c) In
			 reviewing the Carrier's application for Accreditation under
			 211
			 CMR 52.06, the Carrier may be given credit
			 toward the relevant score for any Accreditation that it received, or which the
			 Carrier's subcontracting organization, with which the Carrier has a written
			 agreement delegating certain services, received, from a National Accreditation
			 Organization for the standards described in
			 211
			 CMR 52.07,
			 52.08 or
			 52.09.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.07 - Utilization Review

Current through Register 1525, July 5, 2024
(1)
Standards
. A Carrier's application will be reviewed
			 for compliance with the applicable NCQA Standards for utilization management.
			 In addition, Carriers shall meet the requirements identified in
			 211
			 CMR 52.07(2) through (10).
			 In cases where the standards in
			 211
			 CMR 52.07(2) through (10)
			 differ from those in the NCQA Standards, the standards in
			 211
			 CMR 52.07(2) through (10)
			 shall apply.
(2)
Written Plan
. Utilization Review conducted by a
			 Carrier or a Utilization Review Organization shall be conducted pursuant to a
			 written plan, under the supervision of a physician and staffed by appropriately
			 trained and qualified personnel, and shall include a documented process to:
(a) review and evaluate its
			 effectiveness;
(b) ensure the
			 consistent application of Utilization Review criteria; and
(c) ensure the timeliness of Utilization
			 Review determinations.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.08 - Quality Management and Improvement

Current through Register 1525, July 5, 2024
(1)
Standards
. A Carrier's application will be reviewed
			 for compliance with the applicable NCQA Standards for quality management and
			 improvement.
(2)
Workers' Compensation Preferred Provider Arrangements
.
			 A Carrier that provides specified services through a workers' compensation
			 preferred Provider arrangement shall be deemed to have met the requirements of
			 211
			 CMR 52.08 if it has met the requirements of
			 452 CMR
			 6.00:
Utilization Review and Quality
			 Assessment
.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.09 - Credentialing

Current through Register 1525, July 5, 2024
(1) A Carrier will credential all Health Care
			 Providers according to the NCQA Standards for credentialing and
			 recredentialing, and the Bureau of Managed Care will review a Carrier's
			 credentialing and recredentialing processes that are set forth in the Carrier's
			 application for Accreditation for compliance with the applicable NCQA Standards
			 for credentialing and recredentialing if the Carrier does not have Deemed
			 Accreditation with respect to credentialing and recredentialing.
(2)
Credentialing of Health Care
			 Professionals
.
(a) A Carrier
			 shall accept, in both electronic and paper form, a Health Care Professional
			 credentialing application that is submitted in an application format specified
			 by the Commissioner. For purposes of
			 211
			 CMR 52.09(2), acceptance in
			 electronic form shall mean that a Carrier, at minimum, shall accept a Health
			 Care Professional credentialing application by means of facsimile and
			 electronic mail and may implement an online process for the purpose of
			 processing credentialing applications. For purposes of
			 211
			 CMR 52.09(2),Carriers may
			 charge Health Care Professionals a reasonable administrative charge associated
			 with the costs of processing submissions in electronic or paper form that
			 differs from the form used by the majority of Health Care
			 Professionals
(b) Unless there are
			 otherwise binding arrangements between a Carrier and specific Providers holding
			 Carriers to a shorter time standard, a Carrier shall notify a Health Care
			 Professional that a submitted credentialing application is incomplete no later
			 than 20 business days after the Carrier receives the credentialing
			 application.
(c) All Carriers shall
			 complete credentialing of 95% of Health Care Professionals' initial Clean and
			 Complete Credentialing Applications within 60 Days of receipt of the Health
			 Care Professional's Clean and Complete Credentialing Application, and all
			 Carriers shall complete credentialing of 95% of Health Care Professionals'
			 Clean and Complete re-Credentialing Applications within 120 Days of receipt of
			 the Health Care Professional's Clean and Complete re-Credentialing Application,
			 and Carriers shall inform a Health Care Professional within 75 Days of receipt
			 of an initial Clean and Complete Credentialing Application of the status of the
			 application, including, if applicable, the reasons for any delay in the
			 completion of credentialing and a timeline of the expected resolution of the
			 application and, if a Health Care Professional is not credentialed, the reasons
			 that the Health Care Professional is not credentialed.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.10 - Preventive Health Services

Current through Register 1525, July 5, 2024
(1) A Carrier's
			 application will be reviewed for compliance with preventive services man dated
			 by applicable law. A Carrier that is not an HMO shall be required to comply
			 with 211 CMR 52.10 only to the
			 extent of those Preventive Health Services mandated by its licensing or
			 enabling statute or by any other applicable state or federal law.
(2) A Carrier that provides specified
			 services through a workers' compensation preferred Provider arrangement shall
			 not be required to meet the requirements of
			 211
			 CMR 52.10.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.11 - Provider Contracts

Current through Register 1525, July 5, 2024
(1) Contracts
			 between Carriers and Providers shall state that a Carrier shall not refuse to
			 contract with or compensate for covered services an otherwise eligible Health
			 Care Provider solely because such Provider has in good faith:
(a) communicated with or advocated on behalf
			 of one or more of his or her prospective, current or former patients regarding
			 the provisions, terms or requirements of the Carrier's Health Benefit Plans as
			 they relate to the needs of such Provider's patients; or
(b) communicated with one or more of his or
			 her 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.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.13 - Evidences of Coverage

Current through Register 1525, July 5, 2024
(1)
Evidences of Coverage as to a Carrier
. It shall
			 constitute delivery of an Evidence of Coverage if a Carrier chooses to, upon or
			 after enrollment, require the Insured to designate whether the Insured wants to
			 receive an Evidence of Coverage electronically or in writing. If no option is
			 designated, the Evidence of Coverage shall be provided electronically. If the
			 Insured designates written notice, a Carrier shall issue and deliver to at
			 least one adult Insured in the household an Evidence of Coverage. If the
			 Insured designates electronic notice, a Carrier shall refer the Insured to a
			 resource where the information described in such Evidence of Coverage can be
			 accessed including, but not limited to, an Internet Website. In such instance,
			 the Evidence of Coverage must meet the requirements of
			 211
			 CMR 52.13(4).
An electronic copy of the Evidence of Coverage shall always be
				delivered to the group representative in the case of a group policy.
(2)
Evidences of
			 Coverage as to Dental and Vision Carriers
. Dental and Vision
			 Carriers shall issue and deliver to at least one adult Insured in each
			 household residing in Massachusetts, upon enrollment:
(a) an Evidence of Coverage;
(b) a summary of the information contained in
			 the Evidence of Coverage; or
(c)
			 refer the Insured to resources where the information described in such Evidence
			 of Coverage can be accessed, including, but not limited to, an Internet
			 Website.
Dental and Vision Carriers shall be exempt from the provisions
				of 211 CMR 52.13(3)(b), (h) through (j), (q)
				through (x), (z) and (aa).
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.15 - Provider Directories

Current through Register 1525, July 5, 2024
All Provider directory requirements set forth in
				211
				CMR 52.15 shall be in addition to any
				applicable Provider directory requirements under
				211
				CMR 152.08 for insured Health Benefit Plans
				that use limited, regional or tiered Provider Networks:
(1) Carriers shall establish appropriate
			 systems to collect, store, and maintain detailed information about each Health
			 Care Provider within their Provider Network systems. The systems are to be
			 developed in a manner that facilitates a Health Care Provider's ability to
			 update personal and practice information to the maximum extent feasible.
			 Carriers shall ensure that Provider directories educate persons covered by
			 plans providing services through Networks of Providers about how they may
			 obtain in-Network care from an out-of-Network Provider when an in-Network
			 Provider is not available.
(2) The
			 detailed information that the Carrier is required to collect, store and
			 maintain about Health Care Providers who are a part of the Carrier's Network,
			 shall include at least the following information for each Health Care Provider:
(a) Health Care Provider's primary Specialty,
			 secondary Specialty (if applicable), tertiary Specialty (if applicable),
			 Behavioral Health sub-Specialty (if applicable)
1. The reporting of a Specialty or
			 sub-Specialty should be based on the Provider's actual training and experience
			 in treatment of this Specialty or sub-Specialty in the past 24
			 months.;
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.16 - Access to Covered Services through Telehealth

Current through Register 1525, July 5, 2024
(1) A Carrier shall provide coverage for
			 Health Care Services delivered via Telehealth by a contracted Network Provider
			 if:
(a) the Health Care Services are covered
			 by way of in-person consultation or delivery; and
(b) the Health Care Services may be
			 appropriately provided through the use of Telehealth.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.17 - Material to Be Provided to the Office of Patient Protection

Current through Register 1525, July 5, 2024
(1) A Carrier shall provide the following to
			 the Office of Patient Protection at the same time the Carrier provides such
			 material to the Bureau of Managed Care:
(a) A
			 copy of every Evidence of Coverage and amendments thereto offered by the
			 Carrier.
(b) A copy of the Provider
			 directory described in
			 211
			 CMR 52.15.
(c) A copy of the materials specified in
			 211
			 CMR 52.14.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.18 - Noncompliance with 211 CMR 52.00

Current through Register 1525, July 5, 2024
(1)
Reporting
. If the Commissioner issues a Finding of
			 Neglect on the part of a Carrier, the Commissioner shall notify the Carrier in
			 writing that the Carrier has failed to make and file the materials required by
			 M.G.L. c. 176O or
			 211 CMR
			 52.00 in the form and within the time required. The
			 notice shall identify all deficiencies and the manner in which the neglect must
			 be remedied. Following the written notice, the Commissioner shall fine the
			 Carrier $5000 for each Day during which the neglect continues.
Following notice and hearing, the Commissioner shall suspend
				the Carrier's authority to do new business until all required reports or
				materials are received in a form satisfactory to the Commissioner and the
				Commissioner has determined that the Finding of Neglect can be removed.
(2)
Noncompliance with
			 211 CMR
			 52.00
.
(a)
Investigation
.
			 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 under
			 211 CMR
			 52.00.
(b)
Notice
. The Bureau shall notify a Carrier when, in the
			 opinion of the Bureau, Complaints made against a Carrier or any entity with
			 which it contracts indicate a pattern of noncompliance with a particular
			 requirement. The notice shall detail the alleged noncompliance and establish a
			 hearing date for the matter.
(c)
Hearing Held Pursuant to
			 211
			 CMR
			 52.17(2)(b)
.
1. The hearing shall be held no later than 21
			 Days following the date of the notice specified in
			 211
			 CMR 52.17(2)(b).
2. The hearing shall be conducted pursuant to
			 M.G.L. c. 30A.
3. The hearing shall
			 provide the Carrier with an opportunity to respond to the alleged
			 noncompliance.
(d)
Penalties
. Following the hearing specified in
			 211
			 CMR 52.17(2)(c), the Bureau
			 may issue a finding against the Carrier including, but not limited to:
1. An order requesting a corrective action
			 plan and timeframe to achieve compliance.
2. A reprimand or censure of the
			 Carrier.
3. A penalty not to exceed
			 $10,000 for each classification of violation.
4. The suspension or revocation of the
			 Carrier's Accreditation.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.19 - Severability

Current through Register 1525, July 5, 2024
If any provision of
				211 CMR
				52.00 or the applicability thereof to any person,
				entity or circumstance is held invalid by a court, the remainder of
				211 CMR
				52.00 or the applicability of such provision to other
				persons, entities or circumstances shall not be affected.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 54.00 - Procedure For Surrender And Non-renewal Of Licenses By Insurers Authorized To Write Motor Vehicle Insurance › Section 54.01 - Purpose and Scope

Current through Register 1525, July 5, 2024
(1)
Purpose and Scope
. The procedures established by
			 211 CMR 54.00 shall govern
			 the administrative process by which an insurer or group of insurers authorized
			 to write motor vehicle insurance may initiate the process of surrendering or
			 non-renewing any or all licenses to engage in the business of insurance in the
			 Commonwealth.
(2)
								211 CMR 54.00 shall apply
			 only when one or more of the licenses to be surrendered or non-renewed is a
			 license to write motor vehicle insurance.
(3) The purpose for codifying
			 211 CMR 54.00 is to prevent
			 or limit massive market disturbance and to preserve the rights of existing
			 policyholders and others affected, while permitting insurers to phase out their
			 business in an orderly fashion and consistently with the satisfaction of their
			 obligations under applicable laws.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 54.00 - Procedure For Surrender And Non-renewal Of Licenses By Insurers Authorized To Write Motor Vehicle Insurance › Section 54.02 - Applicability

Current through Register 1525, July 5, 2024
No applicant may effectuate a surrender or non-renewal of any
				of its licenses without complying with the requirements of
				211 CMR 54.00.
No applicant may attempt to implement a withdrawal plan until
				that plan is reviewed and approved by the Commissioner in accordance with the
				provisions of
				211 CMR
				54.05.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 54.00 - Procedure For Surrender And Non-renewal Of Licenses By Insurers Authorized To Write Motor Vehicle Insurance › Section 54.03 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 54.00, the following
				terms shall mean:
Affiliate
. Any parent, subsidiary or
				other corporation which is either controlled by the applicant, or by a
				corporation which controls the applicant, or one which controls the applicant,
				with
Control
defined as in M.G.L. c. 175, §
				193L.
Applicant
. An insurer or group of
				insurers, including all affiliates, any of which are authorized to write motor
				vehicle insurance, (referred to herein collectively as the "applicant")
				intending to surrender or non-renew any or all of its licenses to engage in the
				business of insurance in the Commonwealth as of a certain date, and seeking
				review and approval of a withdrawal plan to implement that process.
Assigned Risk Company
. An insurer that
				has been appointed pursuant to the CAR Plan and Rules of Operation to issue
				motor vehicle policies in accordance with M.G.L. c. 175, § 113H.
Commissioner
. The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Commonwealth Automobile Reinsurers
				(CAR)
. The plan established by M.G.L. c. 175, § 113H, serving
				as the residual market mechanism for motor vehicle insurance.
Division
. The Division of Insurance
				created pursuant to M. G. L. c. 26, § 1.
Insurer
. A company authorized to write
				insurance of any kind under M.G.L. c. 175.
License
. Any license, certificate of
				authority, or other formal approval granted or issued by the Division
				authorizing an insurer to engage in the business of insurance in the
				Commonwealth.
Massachusetts Resident
. A person who
				is domiciled in Massachusetts or a corporate entity doing business or having
				any employees in Massachusetts.
Motor Vehicle Insurance
. Motor vehicle
				policies or bonds as defined in M.G.L. c. 90, §§ 34A, 340 and c. 175,
				§§ 113A, 113C, 113E, and 1130.
Policy
. Any policy of insurance,
				annuity, rider, endorsement or other contract covering any Massachusetts
				resident.
Producer
. An insurance producer
				licensed in accordance with M.G.L. c. 175, § 1621.
Servicing Carrier
. An insurer that has
				been appointed pursuant to the CAR Plan and Rules of Operation to issue
				commercial motor vehicle policies in accordance with M.G.L. c. 175, §
				113H.
Withdrawal Plan
. A plan submitted by
				an applicant in accordance with the provisions of
				211 CMR 54.00 which describes
				in detail how the applicant intends to fulfill its responsibilities in
				connection with the surrender or non-renewal of its
				license(s).