reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.17 - Carrier Filing and Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
			 On or before April 1st of each year, every Carrier
			 doing business in the Commonwealth through a certified Group Purchasing
			 Cooperative must file with the Commissioner a report verified by at least two
			 principal officers of the Carrier and covering its preceding calendar year. The
			 Commissioner may at any time specify a report format.
(2) The report must contain the following
			 information, and any other information requested by the Commissioner:
(a) The number of Health Benefit Plans
			 offered by the Carrier through a certified Group Purchasing Cooperative during
			 the preceding calendar year;
(b)
			 The number of Eligible Association Members, Eligible Employees and Eligible
			 Dependents covered by a Health Benefit Plan from the Carrier through each
			 certified Group Purchasing Cooperative, as of the close of the preceding
			 calendar year; and
(c) The number
			 of total lives covered by a Health Benefit Plan from the Carrier through each
			 certified Group Purchasing Cooperative, as of the close of the preceding
			 calendar year.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.18 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 151.00, or the
				applicability thereof to any person or circumstance is held invalid by any
				court of competent jurisdiction, the remainder of
				211 CMR 151.00, 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 152.00 - Health Benefit Plans Using Limited, Regional Or Tiered Provider Networks › Section 152.01 - Purpose, Scope and Authority

Current through Register 1525, July 5, 2024
211 CMR 152.00 applies to
				the design and Marketing of Insured Health Benefit Plans that make use
				of:
(a) a Limited Provider Network
			 that differs from the Carrier's General Provider Network;
(b) a Regional Provider Network; or
(c) a Tiered Provider Network in which the
			 Health Benefit Plan copayments, coinsurance or deductibles are tied to the
			 Health Care Provider's assigned benefit level tier.
			 211 CMR 152.00 also governs
			 the offering by Carriers of at least one Health Benefit Plan with a Limited or
			 Tiered network to Eligible Small Businesses or Eligible Individuals as defined
			 in M.G.L. c. 176J.
			 211 CMR 152.00 is
			 promulgated pursuant to the Commissioner's authority under St. 2010, c. 288,
			 § 32A, c. 359, § 103, M.G.L. chs. 176D, § 11, c. 176J, § 11
			 and c. 176O, §§ 2 and 17.
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 152.03 - Limited and Regional Provider Network Plans

Current through Register 1525, July 5, 2024
(1) A Carrier proposing to offer a Health
			 Benefit Plan that uses a Limited Provider Network or a Regional Provider
			 Network shall submit to the Division materials demonstrating that:
(a) The Carrier has notified each Provider of
			 its right to opt out of a new Health Benefit Plan with a Limited Provider
			 Network or a Regional Provider Network at least 60 days before the Carrier
			 submits the new plan to the Commissioner; and
(b) The Carrier maintains up to date
			 enrollment systems, Marketing Materials and Evidences of Coverage that identify
			 for all Providers, employers and Insureds the Provider Network available
			 through the Insured's Health Benefit Plan.
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 152.04 - Tiered Provider Network Plans

Current through Register 1525, July 5, 2024
(1) A Carrier
			 proposing to offer a Health Benefit Plan that uses a Tiered Provider Network
			 with variations on cost-sharing between Provider tiers, shall submit to the
			 Division materials demonstrating that:
(a)
			 The Carrier has notified each Provider of its right to opt out of a new Health
			 Benefit Plan with a Tiered Provider Network at least 60 days before the Carrier
			 submits the new plan to the Commissioner.
(b) The Carrier maintains up to date
			 enrollment systems, Marketing Materials and Evidences of Coverage that identify
			 for all Providers, employers and Insureds the Providers in the Provider Network
			 specifying each Network Provider's designated tier in each Health Benefit
			 Plan.
(c) The Carrier has a clearly
			 articulated system in place for Providers to appeal to the Carrier the tier in
			 which each is placed. Descriptions of criteria such as data sources and
			 methodologies for placing Providers in specific tiers shall be made available
			 to a Provider prior to the appeal process.
(d) Variations on cost-sharing between
			 Provider tiers are reasonable in relation to the premium charged:
1. Carriers may offer more than two benefit
			 level tiers of Providers within the Tiered Provider Network; and
2. Variations among each of the benefit level
			 tiers must be reasonable in relation to the premium charged.
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 152.05 - Provider Contracts in Limited, Regional and Tiered Provider Network Plans

Current through Register 1525, July 5, 2024
(1) Prior to
			 implementing a Health Benefit Plan with a Limited, Regional or Tiered Provider
			 Network, a Carrier shall have signed contracts with those Providers that will
			 be in that Provider Network which are in compliance with the requirements of
			 211 CMR
			 52.12.
(2) Provider contracts shall explain the
			 waythat the Carrier will notify Providers about its Health Benefit Plans such
			 that a Provider may clearly identify the Health Benefit Plans that use a Tiered
			 Provider Network, a Regional Provider Network, a Limited Provider Network or
			 another Provider Network.
(3)
			 Provider contracts shall state that the Provider has the right to opt out of
			 any new Health Benefit Plan that uses a Limited Provider Network or a Tiered
			 Provider Network at least 60 days before the Health Benefit Plan is submitted
			 to the Commissioner for approval.
(4) Provider contracts for Tiered Provider
			 Networks shall include a statement that the Carrier shall notify the Provider,
			 in writing, at least 60 days before the effective date of the following
			 modifications. The Provider and the Carrier may agree, in writing, on an
			 alternative date for notice of such modifications in the contract.
(a) Modification to the process used to
			 classify Providers by benefit tier;
(b) Modification to the timelines that the
			 Carrier will use to make decisions and implement any reclassification of
			 Providers by benefit tier;
(c)
			 Modification in the information collected from Providers to make
			 classifications; and
(d)
			 Modification in the criteria or methodology used to make
			 classifications.
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 152.07 - Evidences of Coverage for Limited, Regional and Tiered Provider Network Plans

Current through Register 1525, July 5, 2024
(1) In addition to
			 containing the information required under
			 211 CMR
			 52.13, the first or cover page of the
			 Evidence of Coverage for a Health Benefit Plan that uses a Limited Provider
			 Network, a Regional Provider Network of a Tiered Provider Network shall
			 disclose prominently and in a clear and conspicuous manner language
			 substantially similar to the following:
(a) A
			 statement of applicable Provider Network:
1.
Limited/Regional Provider Network
. This plan provides
			 access to a network that is smaller than [name of carrier]'s [general provider
			 network name] provider network. In this plan, members have access to network
			 benefits only from the providers in [name of network]. Please consult the
			 [Limited/Regional] provider directory or visit the provider search tool at [web
			 address] to determine which providers are included in the [name of
			 network].
2.
Tiered
			 Provider Network
. This plan includes the tiered provider network
			 called [name of network]. In this plan, members pay different levels of
			 [copayments, coinsurance, deductibles] depending on the tier of the provider
			 delivering a covered service or supply. This plan may make changes to a
			 provider's benefit tier annually on [identify date]. Please consult the [name
			 of network] provider directory or visit the provider search tool at [web
			 address] to determine the tier of providers in [name of network].
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 152.08 - Provider Directories for Limited, Regional and Tiered Provider Network Plans

Current through Register 1525, July 5, 2024
(1) In addition to
			 containing the information required under
			 211 CMR
			 52.15, the first or cover page of a printed
			 provider directory or the first screen of an internet-based provider search
			 tool for a Health Benefit Plan that uses a Limited Provider Network, a Regional
			 Provider Network or a Tiered Provider Network shall include a statement
			 prominently displayed in a clear and conspicuous manner that is substantially
			 similar to the following:
(a)
Limited/Regional Provider Network
. This plan provides
			 access to a network that is smaller than [name of carrier]'s [general provider
			 network name] provider network. In this plan, members have access to network
			 benefits only from the providers in [name of network]. Please consult the
			 [Limited/Regional] provider directory or visit the provider search tool at [web
			 address] to determine which providers are included in the [name of
			 network]."
(b)
Tiered
			 Provider Network
. This plan includes the tiered provider network
			 called [name of network]. In this plan, members pay different levels of
			 [copayments, coinsurance, deductibles] depending on the tier of the provider
			 delivering a covered service or supply. This plan may make changes to a
			 provider's benefit tier annually on [identify date]. Please consult the [name
			 of network] provider directory or visit the provider search tool at [web
			 address] to determine the tier of providers in [name of network].
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 152.09 - Plan Reporting for Limited, Regional and Tiered Provider Network Plans

Current through Register 1525, July 5, 2024
Carriers shall submit to the Division by April
				30th of each year information identifying the prior
				year's utilization trends of employers and individuals enrolled in the
				Carrier's Limited Provider Network plans and Tiered Provider Network plans. The
				information shall be submitted in a format and according to specifications
				identified by the Commissioner, which shall include, but shall not be limited
				to:
(a) The number of Insureds
			 enrolled by plan type;
(b)
			 Aggregate demographic and geographic information on all Insureds;
(c) Direct premium claims incurred as defined
			 in M.G.L. c. 176J, § 6 for the Carrier's Limited Provider Network plans
			 and Tiered Provider Network plans as compared to direct premium claims incurred
			 for the Carrier's non-tiered and non-Limited plans;
(d) Utilization by tier during the plan year;
			 and
(e) Requests by Insureds
			 enrolled in Limited Provider Network plans for out-of-network coverage within
			 the plan year.
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 152.10 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 152.00, or the
				applicability thereof to any person or circumstance is held invalid by any
				Court of competent jurisdiction, the remainder of
				211 CMR 152.00, 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 153.00 - Continuity Of Care Access To Comprehensive Cancer Centers, Pediatric Hospitals, And Pediatric Specialty Units For Small Group Health Benefit Plans That Utilize Limited, Regional Or Tiered Provider Networks › Section 153.01 - Purpose, Scope and Authority

Current through Register 1525, July 5, 2024
211 CMR 153.00 provides
				guidance and definitions for terms set forth in St. 2012, c. 61, which amends
				M.G.L. c. 176J. The guidance and definitions are for continuity of care access
				to Comprehensive Cancer Centers, Pediatric Hospitals, and Pediatric Specialty
				Units for Health Benefit Plans offered to Eligible Small Businesses or Eligible
				Individuals that utilize Limited, Regional and Tiered Provider Networks.
				211 CMR 153.00 is
				promulgated pursuant to the Commissioner's authority under St. 2012, c. 61 and
				M.G.L. c. 176J, § 11A.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 153.00 - Continuity Of Care Access To Comprehensive Cancer Centers, Pediatric Hospitals, And Pediatric Specialty Units For Small Group Health Benefit Plans That Utilize Limited, Regional Or Tiered Provider Networks › Section 153.03 - Notice to Insureds in Limited, Regional and Tiered Provider Network Plans Offered to Eligible Small Businesses or Eligible Individuals

Current through Register 1525, July 5, 2024
A Carrier with a Health Benefit Plan offered to Eligible Small
				Businesses or Eligible Individuals that utilizes a Limited, Regional or Tiered
				Provider Network shall issue and deliver a notice relating to access to
				continuity of care, separate from the evidence of coverage for said plan. The
				Carrier shall post said notice prominently on its website and shall issue and
				deliver said notice to each member household on or before June 15, 2012, and,
				thereafter, to all newly Insured member households prior to the effective date
				of coverage. Such notice shall describe:
(1) the Insured's rights to continuity of
			 care access under
			 211 CMR
			 153.04;
(2) the process by which the Insured and the
			 Insured's provider may pursue access to continuity of care at a Comprehensive
			 Cancer Center, a Pediatric Hospital, or a Pediatric Specialty Unit under
			 211 CMR
			 153.04;
(3) the importance of the Insured or the
			 Insured's provider informing the Carrier that continuity of care access is
			 being sought prior to the Insured's receipt of any covered Health Care Services
			 that are subject to a continuity of care access determination under
			 211 CMR
			 153.04; and
(4) the Insured's possible liability for
			 charges if continuity of care is accessed in violation of
			 211 CMR
			 153.04.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 153.00 - Continuity Of Care Access To Comprehensive Cancer Centers, Pediatric Hospitals, And Pediatric Specialty Units For Small Group Health Benefit Plans That Utilize Limited, Regional Or Tiered Provider Networks › Section 153.04 - Access to Continuity of Care

Current through Register 1525, July 5, 2024
(1) For an
			 Insured who:
(a) is receiving an Active
			 Course of Medical Treatment from a health care provider for a Serious Disease,
			 including but not limited to cancer or cystic fibrosis, that if disrupted in
			 the course of such medical treatment would pose an Undue Hardship to the
			 Insured; and
(b)
1. began this Active Course of Medical
			 Treatment before being enrolled in a Limited, Regional or Tiered Provider
			 Network plan where the provider is not part of the Limited, Regional or Tiered
			 Provider Network; or
2. began this
			 Active Course of Medical Treatment before being enrolled in a Tiered Provider
			 Network plan where the provider is in the highest cost-sharing tier; the
			 Carrier shall provide coverage for those medically necessary and covered Health
			 Care Services that are part of that Active Course of Medical Treatment provided
			 by that health care provider, to the extent required by 211 CMR
			 153.04(2).
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 153.00 - Continuity Of Care Access To Comprehensive Cancer Centers, Pediatric Hospitals, And Pediatric Specialty Units For Small Group Health Benefit Plans That Utilize Limited, Regional Or Tiered Provider Networks › Section 153.05 - Denial of Access to Continuity of Care

Current through Register 1525, July 5, 2024
A Carrier's Adverse Determination of an Insured's access to
				continuity of care under
				211 CMR
				153.04 is subject to the review procedures
				set forth in M.G.L. c. 176O.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 153.00 - Continuity Of Care Access To Comprehensive Cancer Centers, Pediatric Hospitals, And Pediatric Specialty Units For Small Group Health Benefit Plans That Utilize Limited, Regional Or Tiered Provider Networks › Section 153.06 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 153.00, or the
				applicability ther of to any person or circumstance is held invalid by any
				court competent jurisdiction, the remainder of
				211 CMR 153.00, 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 154.00 - Enforcement Of Mental Health Parity › Section 154.01 - Purpose, Scope and Authority

Current through Register 1525, July 5, 2024
211 CMR 154.00 provides
				guidance and definitions for provisions set forth in St. 2012, c. 224, which
				amends M.G.L. c. 26.
				211 CMR 154.00 guidance and
				definitions provide for the Commissioner of Insurance's implementation and
				enforcement power over federal and state mental health parity and substance use
				disorder laws.
				211 CMR 154.00 is
				promulgated pursuant to the Commissioner's authority under St. 2012, c. 224 and
				M.G.L. c. 26, § 8K.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 154.00 - Enforcement Of Mental Health Parity › Section 154.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 154.00, the
				following words mean:
Carrier
: an insurer that is subject to
				State Mental Health Parity Laws or Federal Mental Health Parity Law, and which
				is licensed or otherwise authorized to transact accident or 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 organized under M.G.L. c. 176G; and
				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.
Commissioner
: the Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Commonwealth
: the Commonwealth of
				Massachusetts.
Examination
: an examination of the
				affairs of a Carrier as called by the Commissioner or one of the Commissioner's
				deputies, according to the relevant licensing statute of the carrier.
Federal Mental Health Parity Law
: Paul
				Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of
				2008.
Federal Mental Health Parity Law
				Agencies
: the United States Department of Health and Human
				Services, the United States Department of Labor, the United States Department
				of the Treasury, and/or any succeeding federal agency or organization that is
				responsible for development of rules, regulations, guidances and/or policies
				associated with Federal Mental Health Parity Law.
State Mental Health Parity Laws
:
				M.G.L. c. 32A, §22; M.G.L. c. 175, § 47B; M.G.L. c. 176A, § 8A;
				M.G.L. c. 176B, § 4A; and M.G.L. c. 176G, §§ 4, 4B, and 4M; in
				regard to any carrier licensed under M.G.L. chs. 175, 176A, 176B and
				176G.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 154.00 - Enforcement Of Mental Health Parity › Section 154.03 - Certification of Compliance with State and Federal Mental Health Parity Requirements

Current through Register 1525, July 5, 2024
(1)
Initial Certification Materials to be Submitted by no Later than
			 October 1, 2013
.
(a) Carriers
			 must review their administrative and other practices, including those delegated
			 to subcontracting organizations, for compliance with the relevant provisions of
			 State Mental Health Parity Laws and Federal Mental Health Parity Law, and any
			 interim or final regulations, guidelines, sub-regulatory guidances, or related
			 instructions that have been issued or promulgated by the federal Center for
			 Medicaid and Medicare Services or other federal organization in its exercise of
			 appropriate authority over the Federal Mental Health Parity Law.
(b) Carriers must submit a certification to
			 the Division of Insurance and the Office of the Attorney General signed by the
			 Carrier's chief executive officer and chief medical officer that states that
			 the Carrier has completed a comprehensive review of the administrative
			 practices of the Carrier for the 2012 calendar year for compliance with the
			 provisions of State Mental Health Parity Laws and the Federal Mental Health
			 Parity Law.
1. If the Carrier determines that
			 all administrative and other practices were in compliance with State Mental
			 Health Parity Laws and Federal Mental Health Parity Law during calendar year
			 2012, the certification will affirmatively state, that all relevant
			 administrative and other practices were in compliance with State Mental Health
			 Parity Laws and Federal Mental Health Parity Law.
2. If the Carrier determines that any
			 administrative or other practices were not in compliance with State Mental
			 Health Parity Laws or Federal Mental Health Parity Law during calendar year
			 2012, the certification will state that not all practices were in compliance
			 with State Mental Health Partiy Laws and Federal Mental Health Parity Law and
			 will include a list of the practices not in compliance and the steps the
			 Carrier has taken to bring these practices into compliance.
(c) In support of its
			 certification, every Carrier shall submit such information as determined by the
			 Commissioner that demonstrates the Carrier's compliance with State Mental
			 Health Parity Laws and Federal Mental Health Parity Law, including but not
			 limited to information regarding financial and treatment limitations, medical
			 necessity criteria, and authorization processes.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 154.00 - Enforcement Of Mental Health Parity › Section 154.04 - Complaints, Disclosures, Investigations and Examinations

Current through Register 1525, July 5, 2024
(1)
Complaints
.
			 alleging a Carrier's noncompliance with State Mental Health Parity Laws and/or
			 Federal Mental Health Parity Law may be submitted verbally or in writing to the
			 Division of Insurance for its review.
(2)
Disclosures
.
			 Carriers shall provide each subscriber household with a written notice in a
			 form approved by the Commissioner which sets forth in clear language covered
			 persons' rights under State Mental Health Parity Laws and Federal Mental Health
			 Parity Law.
(3)
Investigation
. The Commissioner shall review all
			 complaints made against a Carrier or any subcontracting entity to which the
			 Carrier has delegated administrative or other functions alleging noncompliance
			 with State Mental Health Parity Laws and Federal Mental Health Parity Law and
			 may at any time initiate an investigation into the practices of a
			 Carrier.
(4)
Examination
. The Commissioner may initiate an
			 Examination at any time to review the operations of any Carrier when, in the
			 opinion of the Commissioner, a carrier or any subcontracting entity to which
			 the Carrier has delegated administrative or other functions may be engaging in
			 or has engaged in a pattern of noncompliance with State Mental Health Parity
			 Laws or Federal Mental Health Parity Law. The Examination shall be conducted
			 pursuant to the Commissioner's examination authority under M.G.L. c. 175,
			 § 4; M.G.L. c. 176G, § 10; and any other applicable law.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 154.00 - Enforcement Of Mental Health Parity › Section 154.05 - Penalties

Current through Register 1525, July 5, 2024
The Commissioner may order the following penalties if he or she
				finds, after hearing held pursuant to M.G.L. c. 30A, that a violation of M.G.L.
				c. 26, §8K or
				211 CMR 154.00 has
				occurred:
(1) A corrective action plan
			 and a timeframe to achieve compliance;
(2) A civil fine not to exceed $10,000 for
			 each violation;
(3) Suspension or
			 revocation of a Carrier's accreditation; and/or
(4) Suspension or revocation of a Carrier's
			 license or certificate of authority.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 154.00 - Enforcement Of Mental Health Parity › Section 154.06 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 154.00, or the
				applicability therof to any person or circumstance is held invalid by any court
				competent jurisdiction, the remainder of
				211 CMR 154.00, 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 155.00 - Risk-bearing Provider Organizations › Section 155.01 - Purpose and Scope

Current through Register 1525, July 5, 2024
211 CMR 155.00 governs the
				certification of Risk-bearing Provider Organizations.
				211 CMR 155.00 applies to
				any Provider Organization that manages the treatment of a group of patients and
				that bears the Downside Risk of the cost of treating those patients according
				to the terms of an Alternative Payment Contract.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 155.00 - Risk-bearing Provider Organizations › Section 155.03 - Applicability

Current through Register 1525, July 5, 2024
(1)
								211 CMR 155.00 applies to a
			 Provider Organization that negotiates, represents, or otherwise acts on behalf
			 of one or more Providers or Provider Organizations, which may include itself,
			 in establishing Alternate Payment Contracts in which:
(a) The Provider Organization bears Downside
			 Risk; or
(b) One or more Providers
			 or Provider Organizations with which the Provider Organization has a
			 Contracting Affiliation bear Downside Risk.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 155.00 - Risk-bearing Provider Organizations › Section 155.04 - Risk Certificate Waivers

Current through Register 1525, July 5, 2024
(1) A
			 Risk-bearing Provider Organization may apply for an annual Risk Certificate
			 Waiver if it wishes to demonstrate that its Alternative Payment Contracts do
			 not contain significant downside risk.
(a) A
			 Risk-bearing Provider Organization may apply for a new Risk Certificate Waiver
			 at any time as specified by the Division.
(b) All Risk Certificate Waivers will be
			 valid beginning no earlier than March 1st, for up to
			 one year through the last calendar day of February.
Each Risk-bearing Provider Organization may apply to renew a
				current Risk Certificate Waiver for an additional annual term, provided that it
				submits materials in a form approved by the Commissioner by no later than
				August 31st in the year prior to the expiration date
				of the Risk Certificate Waiver.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 155.00 - Risk-bearing Provider Organizations › Section 155.06 - Actuarial Certifications

Current through Register 1525, July 5, 2024
A Risk-bearing Provider Organization shall provide the
				following Actuarial Certification in a form acceptable to the
				Commissioner:
(a) For a Provider
			 Organization that is seeking to enter into an arrangement to manage the
			 treatment of a group of patients and bears Downside Risk according to the terms
			 of an Alternative Payment Contract, certification by an actuary that the
			 prospective terms within the contract or in anticipation of the contract are
			 such that the contract is not expected to threaten the financial solvency of
			 the Provider Organization or any entity with which it has a Contracting
			 Affiliation that involves Downside Risk or any entity with which it has a
			 Contracting Affiliation that involves Downside Risk; or
(b) For a Risk-bearing Provider Organization
			 that already has entered into an arrangement to manage the treatment of a group
			 of patients and bears Downside Risk according to the terms of an Alternative
			 Payment Contract, certification by an actuary that the terms of the contract
			 are not expected to threaten the financial solvency of the Risk-bearing
			 Provider Organization during the period that the Risk Certificate is in
			 effect.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 155.00 - Risk-bearing Provider Organizations › Section 155.07 - Examinations of Risk-bearing Provider Organizations

Current through Register 1525, July 5, 2024
(1) The Commissioner may examine the affairs
			 of a Risk-bearing Provider Organization regarding its arrangement to manage the
			 treatment of a group of patients and bear Downside Risk according to the terms
			 of an Alternative Payment Contract when the Commissioner deems prudent, but not
			 less frequently than once every three years for those with Risk
			 Certificates.
(2) The charge for
			 each examination shall be borne by the Risk-bearing Provider Organization as
			 set forth in M.G.L. c. 175, § 4.
(3) The examination shall be conducted in
			 accordance with the procedures set forth in M.G.L. c. 175, § 4 and c.
			 176T, § 4.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 155.00 - Risk-bearing Provider Organizations › Section 155.08 - Noncompliance with 211 CMR 155.00

Current through Register 1525, July 5, 2024
(1) If the
			 Commissioner determines that a Provider Organization qualifies as a
			 Risk-bearing Provider Organization and is subject to
			 211 CMR 155.00, but has
			 failed to submit an application for an initial Risk Certificate, or an initial
			 Risk Certificate Waiver, as applicable, the Division shall provide written
			 notice to the Provider Organization, as well as to the Commission and the
			 Center. If a Risk-bearing Provider Organization fails to submit the annual
			 renewal application for either a Risk Certificate or a Risk Certificate Waiver
			 to the Division in the form and within the time provided, the Division shall
			 provide written notice to the Commission and the Center.
(2) If the Commissioner determines that a
			 Risk-bearing Provider Organization has entered into an arrangement to manage
			 the treatment of a group of patients and bear Downside Risk according to the
			 terms of an Alternative Payment Contract directly with any Employers or
			 individuals, the Commissioner will contact the Risk-bearing Provider
			 Organization or Provider Organization in writing and may require the
			 Risk-bearing Provider Organization or Provider Organization to be otherwise
			 licensed pursuant to the criteria set forth in M.G.L. c. 176T, §
			 2.
(3) If the Commissioner
			 determines that a Risk-bearing Provider Organization's existing or proposed
			 arrangement to manage the treatment of a group of patients and bear Downside
			 Risk according to the terms of an Alternative Payment Contract is likely to
			 threaten the financial solvency of the Risk-bearing Provider Organization, the
			 Commissioner shall provide written notice to the Risk-bearing Provider
			 Organization. A copy of such notice shall be provided to the Commission and the
			 Center.
(4) The Commissioner shall
			 not suspend or cancel a Risk Certificate unless the Commissioner has first
			 afforded the Risk-bearing Provider Organization an opportunity for a hearing
			 pursuant to M.G.L. c. 30A. After hearing, the Commissioner may suspend or
			 cancel a Risk-bearing Provider Organization's Risk Certificate upon a
			 determination that:
(a) the Risk-bearing
			 Provider Organization has not cured a threat to its financial
			 solvency;
(b) the Risk-bearing
			 Provider Organization's application for a Risk Certificate contained false,
			 misleading or fraudulent information;
(c) the Actuarial Certification that was part
			 of the Risk Certificate application is withdrawn; or
(d) the Risk-bearing Provider Organization
			 has otherwise failed to comply with the requirements of M.G.L. c. 176T or
			 211 CMR 155.00.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 155.00 - Risk-bearing Provider Organizations › Section 155.09 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 155.00, or the
				applicability therof to any person or circumstance is held invalid by any court
				of competent jurisdiction, the remainder of
				211 CMR 155.00, 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 156.00 - Dental Insurance › Section 156.02 - Applicability and Scope

Current through Register 1525, July 5, 2024
211 CMR 156.00 applies to all Dental Benefit Plans offered,
				made effective, issued or renewed in Massachusetts to any Individual, Group
				Association, or Employer Group, whether issued directly by a Carrier, through
				the Connector, or through a Group Association.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 156.00 - Dental Insurance › Section 156.04 - Coverage Standards

Current through Register 1525, July 5, 2024
(1)
Evidences of Coverage
. Carriers are to file all
			 insured Dental Benefit Plans offered under 211 CMR 156.00 with the Division.
(a) All such Plans are to be reviewed for
			 compliance with M.G.L. c. 175, § 2B.
(b) Individually issued Dental Benefit Plans
			 are to comply with the requirements of 211 CMR 42.00:
Health
			 Maintenance Organizations (HMOs)
.
(c) Plans that provide or arrange for the
			 delivery of dental benefits through a network of Dental Providers or use
			 utilization management in the review of the necessity of certain Dental
			 Services are to comply with the requirements of 211 CMR 52.00:
Managed
			 Care Consumer Protections and Accreditation of Carriers
, as noted in
			 211 CMR 52.01:
Applicability
.
(d) Plans that provide or arrange for the
			 delivery of dental benefits through a network of Dental Providers and include
			 dental networks that differ from those of a Dental Benefit Plan's overall
			 network should prominently display on all Plan documents, including provider
			 directory materials, a provider network name that distinguishes the network of
			 the Plan from the other networks offered by the Carrier.
(e) Plans that permit both an in-network and
			 an out-of-network level of dental benefits are to comply with the requirements
			 of 211 CMR 51.00:
Preferred Provider Health Plans and Workers'
			 Compensation Preferred Provider Arrangements
.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 156.00 - Dental Insurance › Section 156.05 - Restrictions Relating to Premium Rates

Current through Register 1525, July 5, 2024
Carriers may develop Base Rates that are based on the
				collective experience of all Individuals, Group Associations, Small Groups, and
				Large Groups to which the Dental Benefit Plans are marketed, or Carriers may
				develop Base Rates for any single or combination of Individual, Group
				Association, Small Group, or Large Group Markets in which they offer Dental
				Benefit Plans. Premiums charged must satisfy the following requirements:
Premium Calculations
(1) In calculating the premium to be charged,
			 a Carrier shall develop a Base Rate and may develop and use one or more Rating
			 Adjustment Factors, provided that such Rating Adjustment Factors are used in
			 connection with all products offered to those eligible within a Market.
(a) Carriers may develop one Base Rate and
			 set of Rating Adjustment Factors that apply to all Markets; or
(b) Carriers may develop separate Base Rates
			 and Rating Adjustment Factors for each or combination of each of the Markets in
			 which it offers Dental Benefit Plans.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 156.00 - Dental Insurance › Section 156.07 - Annual Comprehensive Financial Statement

Current through Register 1525, July 5, 2024
On or before March 31st, the
				Division will collect reports that contain at least the following information
				about a Carrier's insured dental business in a format specified by the
				Commissioner. Each Carrier shall submit a detailed report on a form approved by
				the Commissioner of the insured dental business costs incurred by the Carrier
				as of December 31st of the prior calendar
				year.
(1) Market group size, including:
(a) Individual;
(b) Small Groups of one to five, six to ten,
			 11 to 25, and 26 to 50; and
(c)
			 Large Groups of 51 to 100, 101 to 500, 501 to 1000, and greater than
			 1000.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 156.00 - Dental Insurance › Section 156.08 - Audit of Annual Comprehensive Financial Statement

Current through Register 1525, July 5, 2024
(1) The Commissioner may, in his or her
			 discretion, require that a Carrier make available the underlying data used in
			 its calculations for its Annual Comprehensive Financial Statement, if
			 applicable, for audit by Division staff or outside consultants or Advisors of
			 the Division.
(2) Any and all fees
			 and costs for the Division's audit of the Carrier's Annual Comprehensive
			 Financial Statement shall be borne by the subject Carrier.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 156.00 - Dental Insurance › Section 156.09 - Public Hearing on Carrier's Financial Condition

Current through Register 1525, July 5, 2024
(1)
			 If, in any year, a Carrier reports in its Annual Comprehensive Financial
			 Statement that its Risk-based Capital ratio on a combined entity basis exceeds
			 700%, then the Commissioner, or a designated Presiding Officer, shall hold a
			 public hearing to examine the Carrier's overall financial condition and the
			 Carrier's continued need for additional surplus.
(2) The public hearing shall be held within
			 60 days of the date of the Carrier's filing of its fully completed Annual
			 Comprehensive Financial Statement.
(3) At the public hearing, the Carrier shall
			 submit testimony on its overall financial condition and its continued need for
			 additional surplus. The Carrier shall also submit testimony on how, and in what
			 proportion to the total surplus accumulated, the Carrier will dedicate any
			 additional surplus to reducing the cost of Dental Benefit Plans, or on dental
			 Quality Improvement Activities, patient safety, or dental cost-containment
			 activities not conducted in previous years.
(4) The Commissioner shall issue written
			 notice of the public hearing to the subject Carrier no less than 30 days prior
			 to the public hearing.
(5) The
			 Carrier shall arrange for newspaper publication of the written notice of the
			 public hearing in a newspaper or newspapers designated by the Commissioner.
			 Such notice shall be published no less than 21 days prior to the public
			 hearing.
(6) No later than 15 days
			 prior to the public hearing, the Carrier shall submit a filing to the Division
			 containing:
(a) The title and docket number of
			 the proceeding and the complete name and address of the Carrier submitting the
			 filing;
(b) A summary containing a
			 description of the contents of the filing;
(c) A list of the names and occupations of
			 all persons who will present oral testimony, statements, or comments on behalf
			 of the Carrier at the public hearing; and
(d) Any other information required by the
			 Commissioner or the Presiding Officer.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 156.00 - Dental Insurance › Section 156.10 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of 211 CMR 156.00, or
				the applicability thereof to any person or circumstance is held invalid by any
				court of competent jurisdiction, the remainder of 211 CMR 156.00, or the
				applicability thereof to other persons or circumstances, shall not be affected
				thereby.
Code of Massachusetts Regulations › 212 CMR - THE APPRAISAL AND REPAIR OF DAMAGED MOTOR VEHICLES › Title 212 CMR 2.00 - The Appraisal And Repair Of Damaged Motor Vehicles › Section 2.01 - Scope of Regulations

Current through Register 1525, July 5, 2024
(1)
Purpose and Applicability
. The purpose of 212 CMR 2.00 is to promote the public welfare and safety by improving the quality and economy of the appraisal and repair of damaged motor vehicles. Any licensed appraiser
,
individual or corporate entity who employs licensed appraisers shall be bound by 212 CMR 2.00.
212 CMR 2.00 is intended to be read in conjunction with 211 CMR 133.00,
Standards for the Repair of Damaged Motor Vehicles.
(2)
Authority
. 212 CMR 2.00 is promulgated under the authority granted to the Auto Damage Appraiser Licensing Board by M.G.L. c. 26, § 8G, as added by St. 1981, c. 775, § 1.
(3) The Board may from time to time issue Advisory Rulings and shall do so in compliance with M.G.L. c. 30A, § 8.
(4)
Definitions.
Appraisal
- a written motor vehicle damage report as defined in M.G.L. c. 26, § 8G and in compliance with the provisions of M.G.L. c. 93A, c. 100A, c. 90, § 34R, and c. 26, 8G.
Appraiser
- means any person licensed by the Auto Damage Appraiser Licensing Board to evaluate motor vehicle damage and determine the cost of parts and labor required to repair the motor vehicle damage.
Claimant
- means any person making a claim for damage to a motor vehicle for either first or third party damages.
Independent appraiser
- means any appraiser other than a staff appraiser who makes appraisals under an assignment by an insurer or repair shop and shall include the owner or employee of a repair shop who makes appraisals under a contract with an insurer.
Intensified appraisal
- means the combination of the appraisal of a motor vehicle before its repair and the reinspection of the vehicle subsequent to its repair.
Staff appraiser
- means an appraiser who is an employee of an insurer and whose job duties include the making of appraisals for his or her employer.
Supervisory appraisal
- means an appraisal conducted by an insurance company or appraisal company supervisor solely for the purpose of evaluating the appraisal ability of one of his or her appraiser employees or for the purpose of providing on-the-job training of an appraiser employee.
Code of Massachusetts Regulations › 212 CMR - THE APPRAISAL AND REPAIR OF DAMAGED MOTOR VEHICLES › Title 212 CMR 2.00 - The Appraisal And Repair Of Damaged Motor Vehicles › Section 2.03 - Duties of Insurers and Repairers

Current through Register 1525, July 5, 2024
(1)
Responsibilities for Actions of Appraisers
. An insurer or repair shop shall be responsible for the actions of all of its appraisers whether staff or independent, and shall be subject to the applicable penalties under law for any violation of 212 CMR 2.00 by its appraiser.
The Board may assess penalties against either the appraiser, the insurer, the repair shop or all three. In the event of default by the appraiser, the insurer or the repair shop may be responsible for penalties.
(2)
Records and Analysis of Appraisals
. Every insurer or repair shop appraiser shall retain for at least two years, copies of all records related to appraisals and inspection. Every insurer shall retain copies of all records including photographs in accordance with state law.
Code of Massachusetts Regulations › 212 CMR - THE APPRAISAL AND REPAIR OF DAMAGED MOTOR VEHICLES › Title 212 CMR 2.00 - The Appraisal And Repair Of Damaged Motor Vehicles › Section 2.05 - Penalties

Current through Register 1525, July 5, 2024
(1) Violations of M.G.L. c. 26, § 8G, and 212 CMR 2.00 may result in penalties including administrative costs, revocation or suspension of license or both. All administrative costs are subject to the discretion of the Board. The administrative costs may be assessed against the appraiser, the appraiser's employer, the insurer, or the repair shop.
An alleged violation of 212 CMR 2.00 by a licensed appraiser at the direction of an insurer may be reported to the Division of Insurance which may impose applicable penalties against such an insurer.
Code of Massachusetts Regulations › 212 CMR - THE APPRAISAL AND REPAIR OF DAMAGED MOTOR VEHICLES › Title 212 CMR 2.00 - The Appraisal And Repair Of Damaged Motor Vehicles › Section 2.06 - Severability

Current through Register 1525, July 5, 2024
If any provision of 212 CMR 2.00 or its application to any person or circumstances is held invalid, such invalidity shall not affect the validity of other provisions or applications of 212 CMR 2.00