reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 147.00 - Methodology For Calculating And Reporting Medical Lass Ratios (mlrs) Of Health Benefit Plans › Section 147.01 - Purpose and Scope

Current through Register 1525, July 5, 2024
211 CMR 147.00 establishes a
				uniform methodology for calculating and reporting by Carriers for the Medical
				Loss Ratios (MLRs) of Health Benefit Plans under M.G.L. c. 176J, § 6 and
				M.G.L. c. 176O, § 21.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 147.00 - Methodology For Calculating And Reporting Medical Lass Ratios (mlrs) Of Health Benefit Plans › Section 147.02 - Definitions

Current through Register 1525, July 5, 2024
For purposes of
				211 CMR 147.00, the
				following words shall mean:
Carrier
. An insurer 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. Unless otherwise noted,
Carrier
shall not
				include any entity to the extent it offers a policy, certificate or contract
				that is not a health benefit plan, as defined in M.G.L. c. 176J, §
				1.
Commissioner
. The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Commonwealth
. The Commonwealth of
				Massachusetts.
Health Benefit Plan
. A policy,
				contract, certificate or agreement entered into, offered or issued by a Carrier
				to provide, deliver, arrange for, pay for, or reimburse any of the costs of
				health care services.
Health Care Services
. Services for the
				diagnosis, prevention, treatment, care or relief of a health condition,
				illness, injury or disease.
MLR
. Medical Loss Ratio, which is the
				ratio of the incurred loss (or incurred claims) plus the loss adjustment
				expense (or change in contract reserves) to earned premiums, according to
				current NAIC methodology and with reference to federal guidance, or as
				otherwise determined by the Commissioner.
NAIC
. The National Association of
				Insurance Commissioners.
Third-party Administrator
. A person
				who, on behalf of a health insurer or purchaser of health benefits, receives or
				collects charges, contributions or premiums for, or adjusts or settles claims
				on or for residents of the Commonwealth.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 147.00 - Methodology For Calculating And Reporting Medical Lass Ratios (mlrs) Of Health Benefit Plans › Section 147.03 - Methodology for Calculating and Reporting MLR

Current through Register 1525, July 5, 2024
Unless otherwise determined by the Commissioner, for the
				purposes of M.G.L. c. 176J, § 6 and M.G.L. c. 176O, § 21, the MLR of
				a Health Benefit Plan shall be calculated and reported in accordance with the
				current NAIC methodology for calculating and reporting MLR and with reference
				to federal guidance. When calculating MLR, a Third-party Administrator,
				pharmacy benefit manager or other similar entity shall perform its calculations
				utilizing data from the Health Benefit Plans it administers in the
				Commonwealth, and, if applicable, aggregate such data.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 147.00 - Methodology For Calculating And Reporting Medical Lass Ratios (mlrs) Of Health Benefit Plans › Section 147.04 - Administrative Cost Expenditure

Current through Register 1525, July 5, 2024
Unless otherwise determined by the Commissioner, the following
				items shall be deemed to be an Administrative Cost Expenditure for the purposes
				of calculating and reporting the MLR of Health Benefit Plans for M.G.L. c.
				176J, § 6 and M.G.L. c. 176O, § 21:
(a) Financial administration
			 expenses;
(b) Marketing and sales
			 expenses;
(c) Distribution
			 expenses;
(d) Claims operations
			 expenses;
(e) Medical
			 administration expenses, such as disease management, care management,
			 utilization review and medical management activities;
(f) Network operations expenses;
(g) Charitable expenses;
(h) Board, bureau or association
			 fees;
(i) State and federal tax
			 expenses, including assessments; and
(j) Payroll expenses.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 147.00 - Methodology For Calculating And Reporting Medical Lass Ratios (mlrs) Of Health Benefit Plans › Section 147.05 - Medical Claims Expenditure

Current through Register 1525, July 5, 2024
Unless otherwise determined by the Commissioner, only those
				items treated as a Medical Claims Expenditures by the current NAIC methodology
				or federal guidance for calculating and reporting MLR shall be deemed to be a
				Medical Claims Expenditure for the purposes of calculating and reporting the
				MLR of Health Benefit Plans for M.G.L. c. 176J, § 6 and M.G.L. c. 176O,
				§ 21.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 147.00 - Methodology For Calculating And Reporting Medical Lass Ratios (mlrs) Of Health Benefit Plans › Section 147.06 - Reporting MLR

Current through Register 1525, July 5, 2024
Carriers shall report MLRs of Health Benefit Plans to the
				Division in accordance with M.G.L. c. 176J, § 6 and M.G.L. c. 176O, §
				21 and by any other method designated by the Commissioner.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 147.00 - Methodology For Calculating And Reporting Medical Lass Ratios (mlrs) Of Health Benefit Plans › Section 147.07 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 147.00, or the
				applicability thereof to any person or circumstance is held invalid by any
				court of competent jurisdiction, the remainder of
				211 CMR 147.00, or the
				applicability thereof to other persons or circumstances, will not be affected
				thereby.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 148.00 - Registration And Reporting Requirements For Third-party Administrators › Section 148.01 - Purpose and Scope

Current through Register 1525, July 5, 2024
211 CMR 148.00 governs the
				registration and reporting requirements applicable to Third-party
				Administrators, including pharmacy benefit managers and other entities with
				claims data, eligibility data, provider files and other information relating to
				health care provided to residents of the Commonwealth and health care provided
				by health care providers in the Commonwealth.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 148.00 - Registration And Reporting Requirements For Third-party Administrators › Section 148.03 - Initial Registration and Annual Renewal of Registration

Current through Register 1525, July 5, 2024
(1) No Third-party Administrator shall do
			 business in the Commonwealth prior to registering with the Division. Such
			 registration shall be renewed on an annual basis no later than April
			 1st of each year and shall require the submission of
			 the annual report described in
			 211 CMR
			 148.04.
(2) All Third-party Administrators shall
			 register and renew registration with the Division in a form and method
			 prescribed by the Commissioner. All registration and renewal of registration
			 forms shall be completed in their entirety in order to be considered by the
			 Division. Incomplete forms may not be considered and may be returned to the
			 Third-party Administrator seeking to register in accordance with
			 211 CMR 148.00.
(3) All registration forms and renewal of
			 registration forms shall include, but may not be limited to, the following
			 information certified by an officer of the Third-party Administrator: A
			 narrative description of the Third-party Administrator and its activities,
			 including the identity of the state(s) in which it has been formed,
			 headquartered and in which its operates, as well as a designated contact person
			 for the Third-party Administrator, including said person's phone number, email
			 and mailing address.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 148.00 - Registration And Reporting Requirements For Third-party Administrators › Section 148.05 - Grounds for Suspension or Revocation of Registration and Imposition of Fines

Current through Register 1525, July 5, 2024
(1) The Commissioner
			 may, after a hearing, suspend or revoke the registration of any Third-party
			 Administrator if the Commissioner finds that:
(a) The Third-party Administrator has failed
			 to submit to the Division required annual reporting information as set forth in
			 211 CMR
			 148.04;
(b) The Third-party Administrator has its
			 license or registration to do business suspended or revoked by any state,
			 including its home state;
(c) The
			 Third-party Administrator is insolvent or impaired;
(d) A proceeding for receivership,
			 conservatorship, rehabilitation or other delinquency proceeding regarding the
			 Third-party Administrator has been commenced in any state; or
(e) The financial condition or business
			 practices of the Third-party Administrator otherwise pose an imminent threat to
			 the public health, safety or welfare of the residents of the
			 Commonwealth.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 148.00 - Registration And Reporting Requirements For Third-party Administrators › Section 148.06 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 148.00, or the
				applicability thereof to any person or circumstance is held invalid by any
				Court of competent jurisdiction, the remainder of
				211 CMR 148.00, 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 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.01 - Authority

Current through Register 1525, July 5, 2024
211 CMR 149.00 is
				promulgated in accordance with the Commissioner of Insurance's authority
				pursuant to St. 2010, c. 288 and M.G. L. c. 176O, § 21.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.02 - Purpose

Current through Register 1525, July 5, 2024
211 CMR 149.00 governs the
				form and content of Annual Comprehensive Financial Statements and appendices
				thereto submitted pursuant to M.G.L. c. 176O, § 21, and any and all public
				hearings commenced in connection therewith.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.03 - Applicability

Current through Register 1525, July 5, 2024
(1) Every Carrier shall be subject to the
			 requirements of
			 211 CMR 149.00.
(2)
								211 CMR 149.00 shall not
			 prohibit, preclude or in any way limit the Commissioner from ordering, or
			 conducting or performing insurance examinations of Carriers under the
			 Commissioner's jurisdiction as to practices, procedures, financial condition,
			 market conduct and other aspects of insurance operations of such
			 Carriers.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.04 - Definitions

Current through Register 1525, July 5, 2024
For purposes of
				211 CMR 149.00, the
				following words shall mean:
Accumulated Surplus
: Unassigned Funds
				(Surplus), defined as the undistributed and unappropriated amounts of surplus,
				in Statement ofStatutory Accounting Principle No. 72 of the NAIC Accounting
				Practices and Procedure Manual of March 2011.
Carrier
: An insurer 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. Unless otherwise noted, the term Carrier shall not include any entity
				to the extent it offers a policy, certificate or contract that provides
				coverage solely for dental care services or vision care services. The term
				Carrier also shall not include any entity to the extent it offers a policy,
				certificate or contract that does not qualify as creditable coverage as defined
				in M.G.L. c. 111M, § 1.
Commissioner
: The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6.
Commonwealth
: The Commonwealth of
				Massachusetts.
Direct Claims Incurred
: Paid claims
				during the year, plus net change in the direct claim liability, plus the change
				in direct claim reserves, plus the change in direct contract reserves, plus
				incurred medical incentive pools, plus change in net healthcare receivables and
				net reinsurance recoverables, as calculated in the Supplemental Health Care
				Exhibit as adopted by the NAIC on August 17, 2010.
Direct Premium Earned
: Direct written
				premium plus the change in unearned premium reserves and the change in reserve
				for rate credits, minus the Regulatory authority licenses and fees, less
				write-offs, as calculated in the Supplemental Health Care Exhibit as adopted by
				the NAIC on August 17, 2010.
Division
: The Massachusetts Division
				of Insurance established pursuant to M.G.L. c. 26, § 1.
Medical Loss Ratio (MLR)
: The ratio of
				the incurred loss (or Incurred Claims) plus the loss adjustment expense (or
				change in contract reserves) to earned premiums, according to current NAIC
				methodology, or as otherwise determined by the Commissioner. The MLR shall be
				calculated and submitted to the Division pursuant to St. 2010, c. 288 and
				211 CMR 147.00.
NAIC
: The National Association of
				Insurance Commissioners.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.05 - General Requirements Related to Filing of Annual Comprehensive Financial Statement

Current through Register 1525, July 5, 2024
All Carriers shall file with the Division an Annual
				Comprehensive Financial Statement on or before April
				1st for the year ended December
				31st immediately preceding. The Annual Comprehensive
				Financial Statement shall be submitted electronically in a form approved by the
				Commissioner.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.06 - Form and Content of Annual Comprehensive Financial Statement

Current through Register 1525, July 5, 2024
The Annual Comprehensive Financial Statement shall provide a
				detailed report on a form approved by the Commissioner of the costs incurred by
				the Carrier as of December 31st of the most recent
				calendar year.
(1) The Annual
			 Comprehensive Financial Statement shall be itemized, where applicable, by:
(a) Market group size, including:
1. Individual;
2. Small groups of one to five, six to ten,
			 11 to 25 and 26 to 50; and
3. 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 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.08 - Audit of Annual Comprehensive Financial Statement and Appendix to 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, or the appendix to 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, or
			 the appendix to its Annual Comprehensive Financial Statement, shall be borne by
			 the subject Carrier.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.09 - 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%, 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 health benefit plans or health care
			 quality improvement, patient safety or health cost containment activities not
			 conducted in previous years.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.10 - Notice of Public Hearing

Current through Register 1525, July 5, 2024
(1) The
			 Commissioner shall issue written notice of the public hearing to the subject
			 Carrier no less than 30 days prior to the public hearing.
(2) 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.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.11 - Pre-hearing Filing by Carrier

Current through Register 1525, July 5, 2024
(1) 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 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.12 - Conduct of Public Hearing

Current through Register 1525, July 5, 2024
(1)
Duties of the Presiding Officer
. The Presiding Officer
			 shall conduct the public hearing and take appropriate action to ensure the
			 orderly conduct of the public hearing. Testimony may be taken under oath or
			 affirmation, at the discretion of the Presiding Officer.
(2)
Transcript
. The
			 Carrier shall arrange that any public hearing be officially recorded by a
			 stenographer. The full cost of the stenographer's fees, along with the cost of
			 providing two copies of the written transcript of the public hearing to the
			 Division, shall be paid by the Carrier.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.13 - Commissioner's Report on Public Hearing

Current through Register 1525, July 5, 2024
The Commissioner shall review the testimony from the public
				hearing and issue a final report on the public hearing.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 149.00 - Annual Comprehensive Financial Statements Pursuant To M.g.l. C. 1760, Section 21 › Section 149.14 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 149.00, or the
				applicability thereof to any person or circumstance is held invalid by any
				court of competent jurisdiction, the remainder of
				211 CMR 149.00, or the
				applicability thereof to other persons or circumstances, will not be affected
				thereby.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 150.00 - Standards And Commissioner's Authority For Placing Companies Deemed To Be In Hazardous Financial Condition Under Administrative Supervision › Section 150.01 - Authority

Current through Register 1525, July 5, 2024
211 CMR 150.00 is
				promulgated in accordance with the authority granted to the Commissioner of
				Insurance by M.G.L. c. 175J, § 9 and M.G.L. c. 176G, §
				20A.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 150.00 - Standards And Commissioner's Authority For Placing Companies Deemed To Be In Hazardous Financial Condition Under Administrative Supervision › Section 150.02 - Purpose

Current through Register 1525, July 5, 2024
The purpose of
				211 CMR 150.00 is to set
				forth the standards which the Commissioner may use for identifying insurers
				found to be in such condition as to render the continuance of their business
				hazardous to their policyholders or the general public.
211 CMR 150.00 shall not be
				interpreted to limit the powers granted the Commissioner by any laws or parts
				of laws of this state, nor shall
				211 CMR 150.00 be
				interpreted to supersede any laws or parts of laws of this
				state.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 150.00 - Standards And Commissioner's Authority For Placing Companies Deemed To Be In Hazardous Financial Condition Under Administrative Supervision › Section 150.04 - Commissioner's Authority

Current through Register 1525, July 5, 2024
(1) For the
			 purposes of making a determination of an insurer's financial condition under
			 211 CMR 150.00, the
			 Commissioner may:
(a) disregard any credit or
			 amount receivable resulting from transactions with a reinsurer that is
			 insolvent, impaired or otherwise subject to a delinquency proceeding;
(b) make appropriate adjustments including
			 disallowance to asset values attributable to investments in or transactions
			 with parents, subsidiaries or affiliates consistent with the NAIC Accounting
			 Policies And Procedures Manual, state laws and regulations;
(c) refuse to recognize the stated value of
			 accounts receivable if the ability to collect receivables is highly speculative
			 in view of the age of the account or the financial condition of the debtor;
			 and
(d) increase the insurer's
			 liability in an amount equal to any contingent liability, pledge, or guarantee
			 not otherwise included if there is a substantial risk that the insurer will be
			 called upon to meet the obligation undertaken within the next 12 month
			 period.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 150.00 - Standards And Commissioner's Authority For Placing Companies Deemed To Be In Hazardous Financial Condition Under Administrative Supervision › Section 150.05 - Judicial Review

Current through Register 1525, July 5, 2024
Any order or decision of the Commissioner shall be subject to
				review by the supreme judicial court for Suffolk County in accordance with
				M.G.L. c. 175J, § 7.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 150.00 - Standards And Commissioner's Authority For Placing Companies Deemed To Be In Hazardous Financial Condition Under Administrative Supervision › Section 150.06 - Severability

Current through Register 1525, July 5, 2024
If any provision of
				211 CMR 150.00 or
				application thereof to any regulation is held invalid, such invalidity shall
				not affect other provisions of
				211 CMR 150.00 and, to that
				end, the provisions of
				211 CMR 150.00 are
				severable.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.01 - Authority

Current through Register 1525, July 5, 2024
211 CMR 151.00 is
				promulgated in accordance with the authority granted to the Commissioner of
				Insurance by St. 2010, c. 288, §§ 21, 22, 23 and 34 and M.G.L. c.
				176J, §§ 12 and 13.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.02 - Applicability and Purpose

Current through Register 1525, July 5, 2024
211 CMR 151.00 applies to
				Small Business Group Purchasing Cooperatives and any Carrier that offers for
				sale, provides or arranges for insured Health Benefit Plans to be offered
				through Small Business Group Purchasing Cooperatives in the Commonwealth. The
				purpose of
				211 CMR 151.00 is to
				implement the provisions of St. 2010, c. 288 and M.G.L. c. 176J, §§
				12 and 13.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.04 - Approval as a Qualified Association

Current through Register 1525, July 5, 2024
(1) An
			 Association must be approved by the Commissioner as a Qualified Association
			 according to the requirements set forth in
			 211 CMR 151.00 in order for
			 its Eligible Association Members or its Qualified Association Members' Eligible
			 Employees and Eligible Dependents to be offered Health Benefit Plans through a
			 certified Group Purchasing Cooperative.
(2) Approval as a Qualified Association
			 pursuant to
			 211 CMR 151.00 shall remain
			 in effect for 12 months, unless sooner suspended or revoked by the
			 Commissioner. A Qualified Association's approval will expire after twelve
			 months if the Qualified Association does not timely file its annual
			 filing.
(3) A Qualified Association
			 may file an application to be a certified Group Purchasing Cooperative or
			 participate in a Massachusetts nonprofit or a not-for-profit corporation that
			 files an application to be a certified Group Purchasing Cooperative.
(4) If the Commissioner determines that a
			 Qualified Association has become ineligible to be a Qualified Association, he
			 or she shall notify the Association of such determination, in writing, stating
			 the reason(s) for such determination. The Commissioner shall also provide
			 notice of this determination to any certified Group Purchasing Cooperative that
			 has contracted with that Association to offer coverage to members of that
			 Association.
(5) In the event that
			 a Qualified Association becomes ineligible to be a Qualified Association, the
			 Group Purchasing Cooperative will notify contracting Carriers not to accept any
			 new applications for Group Purchasing Cooperative coverage from the in eligible
			 Association's Eligible Employers or Eligible Association Members following the
			 date of date of such notification. The Carriers who have contracted with the
			 certified Group Purchasing Cooperative shall continue the coverage obtained by
			 members of the Association through but not beyond the next renewal date of the
			 Health Benefit Plan unless the Eligible Employer becomes a member of another
			 Qualified Association and thereby retains eligibility for the Health Benefit
			 Plan.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.05 - Application to be Approved as a Qualified Association

Current through Register 1525, July 5, 2024
(1) An Association may file an application
			 with the Commissioner to be approved as a Qualified Association. The
			 application shall contain at least the following information, certified by an
			 officer of the Association. The Commissioner may at any time specify an
			 application format:
(a) A narrative
			 description of the Association, including the state in which the Association
			 has been formed and headquartered;
(b) A copy of the basic organizational
			 documents of the Association, such as the articles of incorporation,
			 partnership agreement, or similar documentation and any amendments
			 thereto;
(c) A copy of the bylaws,
			 rules, regulations or other similar documents regulating the conduct of the
			 affairs of the Association;
(d) A
			 statement of the purpose of the Association that demonstrates that the
			 Association was formed for the purpose of advancing the occupational,
			 professional, trade, or industry interests of association members, other than
			 that of obtaining health insurance;
(e) The number of Eligible Association
			 Members and Eligible Small Businesses that are members of the
			 Association;
(f) A listing of the
			 services, other than health insurance, which the Association offers to its
			 members;
(g) The fees paid by
			 members of the Association to join or maintain membership in the Association,
			 including, but not limited to, membership dues, ancillary service fees, program
			 fees and charges, fees or dues related to associate membership or any
			 subcategory of membership,
etc
.;
(h) A statement, certified by an officer of
			 the Association, indicating that the Association does not condition membership
			 in the Association or the offer of any Association benefits on health status,
			 claims experience, or duration of coverage since issue, and that the
			 Association does not discriminate based on age, sex, race, creed, ethnicity,
			 racial background, religious preference or any criteria that is not related to
			 the occupational, professional, trade or industry interests of association
			 members;
(i) A statement affirming
			 that the Association was not formed for the purposes of obtaining insurance;
			 and
(j) Any other information
			 required by the Commissioner.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.06 - Annual Filing by Qualified Association

Current through Register 1525, July 5, 2024
(1)
			 Every Qualified Association must submit to the Division, on or before April
			 1st of each year, an annual filing that contains at
			 least the following information. The Commissioner may at any time specify an
			 application format:
(a) The number of
			 Massachusetts members in the Qualified Association as of the preceding December
			 31st and the number of Massachusetts Eligible Small
			 Business and Massachusetts Eligible Association Members in the Qualified
			 Association as of the preceding December
			 31st;
(b) A description of the services, other than
			 the offering of the purchase of health insurance, which the Qualified
			 Association offers to its members;
(c) The fees paid by members to join and
			 maintain membership in the Qualified Association, including, but not limited
			 to, membership dues, ancillary service fees, program fees and charges, fees or
			 dues related to associate membership or any sub category of membership,
etc
.;
(d) The
			 number of Qualified Association Members' Eligible Employees and Eligible
			 Dependents as of the preceding December
			 31st;
(e) The number of Eligible Association
			 Members, Eligible Employees and Eligible Dependents who are covered by Health
			 Benefit Plans offered by a certified Group Purchasing Cooperative as of the
			 preceding December 31st;
(f) A statement, certified by an officer of
			 the Qualified Association, indicating that the Qualified Association does not
			 condition membership in the association or the offer of any association
			 benefits on health status, claims experience, or duration of coverage since
			 issue, and that the Qualified Association does not discriminate based on age,
			 sex, race, creed, ethnicity, racial background, religious preference or any
			 criteria that is not related to the occupational, professional, trade or
			 industry interests of Qualified Association members;
(g) A statement affirming that the Qualified
			 Association was not formed for the purposes of obtaining insurance;
(h) If the Qualified Association is a
			 participant in a Massachusetts nonprofit or a Massachusetts not-for-profit
			 corporation that has applied for or been certified as a Group Purchasing
			 Cooperative, then the Association shall identify said Massachusetts nonprofit
			 or Massachusetts not-for-profit corporation; and
(i) Any other information required by the
			 Commissioner.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.07 - Certification as Group Purchasing Cooperative

Current through Register 1525, July 5, 2024
(1) A Group Purchasing Cooperative must be
			 certified by the Commissioner according to the requirements set forth in
			 211 CMR 151.00 in order to
			 procure Health Benefit Plans for Eligible Association Members or Qualified
			 Association Members' Eligible Employees and Eligible Dependents.
(2) Certification as a Group Purchasing
			 Cooperative pursuant to
			 211 CMR 151.00 shall remain
			 in effect for 12 months, unless sooner suspended or revoked by the
			 Commissioner.
(3) There shall be no
			 more than six certified Group Purchasing Cooperatives operating in the
			 Commonwealth at the same time.
(4)
			 Certified Group Purchasing Cooperatives may offer Health Benefit Plans only to
			 Eligible Association Members and Qualified Association Members' Eligible
			 Employees and Eligible Dependents. However, nothing in
			 211 CMR 151.00 shall prevent
			 a certified Group Purchasing Cooperative from offering other products or
			 insurance to Eligible Association Members and Qualified Association Members'
			 Eligible Employees and Eligible Dependents.
(5) The Commissioner shall have the
			 discretion to limit the number of Insureds to whom a certified Group Purchasing
			 Cooperative may offer a Health Benefit Plan.
(6) A Massachusetts nonprofit or a
			 Massachusetts not-for-profit corporation or approved Qualified Association may
			 submit an application to be a certified Group Purchasing Cooperative only
			 during time periods as established by the Commissioner, and applications will
			 only be considered if there are fewer than six certified Group Purchasing
			 Cooperatives in existence on the date of receipt of such application by the
			 Division and if there are fewer than 85,000 Insureds participating in certified
			 Group Purchasing Cooperatives.
(7)
			 An application to be a certified Group Purchasing Cooperative must be submitted
			 to the Division at least 90 days prior to the date upon which the applicant, if
			 so certified, intends to offer Health Benefit Plans in the
			 Commonwealth.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.08 - Application to be Certified Group Purchasing Cooperative

Current through Register 1525, July 5, 2024
(1) Any Qualified Association, or any
			 Massachusetts nonprofit, or Massachusetts not-for-profit corporation that seeks
			 certification as a Group Purchasing Cooperative pursuant to M.G.L. c. 176J,
			 § 12 shall submit to the Division an application that contains at least
			 the following, and any other information required by the Commissioner. The
			 Commissioner may at any time specify an application format.
(a)
Internal Operations
			 Plan.
1. A copy of basic
			 organizational documents, such as articles of incorporation, articles of
			 association, partnership agreement, trust agreement or any other applicable
			 documents establishing the applicant and all amendments thereto;
2. A list of the Board of Directors or
			 similar policy-making body of the applicant, including the name, principal
			 occupation and employer of each person;
3. A copy of the bylaws, rules and
			 regulations, or other similar document regulating the conduct of the
			 applicant's internal affairs;
4. A
			 copy of the organizational chart of the applicant, including titles in the
			 areas of marketing, administration, enrollment, grievance procedures, contract
			 negotiation and financial matters;
5. A narrative of the facilities and
			 personnel of the applicant, including but not limited to the organizational
			 structure of the applicant;
6. A
			 description and map of the Service Area in which the applicant would propose to
			 offer Health Benefit Plans and Wellness Programs to Eligible Association
			 Members and Qualified Association Members' Eligible Employees and Eligible
			 Dependents;
7. A power of attorney
			 authorizing the Commissioner to accept service of process for any legal actions
			 commenced against the applicant, if the applicant is not domiciled in the
			 Commonwealth;
8. A plan for the
			 Group Purchasing Cooperative to arrange for information about Health Benefit
			 Plan options to be published and distributed to contracting Qualified
			 Associations on an annual basis;
9.
			 A statement of the Group Purchasing Cooperative's procedures used to maintain
			 member confidentiality including, but not limited to, any health information or
			 other personal information protected under laws or regulations of the
			 Commonwealth or under the Health Insurance Portability and Accountability Act
			 of 1996, as it is amended, or by regulations promulgated under that
			 act;
10. Procedures the Group
			 Purchasing Cooperative plans to undertake to study and improve its processes;
			 and
11. A detailed description of
			 the Group Purchasing Cooperative's formal internal grievance systems, including
			 procedures for the registration of grievances other than grievances related to
			 claims and benefit administration.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.11 - Material Changes to Certified Group Purchasing Cooperative

Current through Register 1525, July 5, 2024
Certified Group Purchasing Cooperatives shall submit material
				changes to their initial or renewal Group Purchasing Cooperative certification
				application at least 30 days before the effective date of such
				changes.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.12 - Audit of Certified Group Purchasing Cooperative

Current through Register 1525, July 5, 2024
The Commissioner may at any time authorize an audit of any
				certified Group Purchasing Cooperative in order to verify compliance with the
				provisions of
				211 CMR 151.00. All costs
				associated with such audit shall be borne by the subject certified Group
				Purchasing Cooperative.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.13 - Non-renewal of Certification of Group Purchasing Cooperative

Current through Register 1525, July 5, 2024
(1) If a renewal application for
			 certification as a Group Purchasing Cooperative is denied, the Commissioner
			 shall notify the Group Purchasing Cooperative, in writing, stating the
			 reason(s) for such denial.
(2) A
			 certified Group Purchasing Cooperative whose renewal application has been
			 denied shall cease offering new Health Benefit Plans in the
			 Commonwealth.
(3) A certified Group
			 Purchasing Cooperative whose renewal application has been denied may request a
			 hearing on such denial within 30 days of the date of the denial.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.14 - Suspension or Revocation of Certification of Group Purchasing Cooperative

Current through Register 1525, July 5, 2024
If any certified Group Purchasing Cooperative is in a
				financially unsound condition, or if it substantively fails to comply with any
				of the requirements of M.G.L. c. 176J,
				211 CMR 151.00, or any other
				provision of law or regulation, the Commissioner may, after a hearing, suspend
				or revoke the certification of such Group Purchasing Cooperative. Upon
				suspension or revocation of the certification of a Group Purchasing
				Cooperative, the Commissioner shall take steps, if necessary, to manage
				transfer of coverage of Eligible Association Members and Qualified Association
				Members' Eligible Employees and Eligible Dependents that are covered under
				Health Benefit Plans offered by said Group Purchasing
				Cooperative.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.15 - Standards for Certified Group Purchasing Cooperative Wellness Programs

Current through Register 1525, July 5, 2024
(1) The Wellness Program shall be
			 administered by the certified Group Purchasing Cooperative or by an entity that
			 has contracted with the certified Group Purchasing Cooperative. The certified
			 Group Purchasing Cooperative shall be responsible for all the features of the
			 Wellness Program(s) , which shall be conducted pursuant to a written plan,
			 under the supervision of a properly trained health practitioner and staffed by
			 appropriately trained and qualified personnel, and shall include a documented
			 process to:
(a) Conduct health risk
			 assessments, at least annually, of all Insureds participating in the Wellness
			 Program(s), according to a tool that has been accredited by the National
			 Committee on Quality Assurance;
(b)
			 Develop reasonable health maintenance or improvement goals with each Wellness
			 Program participant based upon factors derived from the participant's health
			 risk assessment;
(c) Record each
			 participant's activities designed to address wellness goals and, as
			 appropriate, provide workplace or other geographically convenient wellness
			 monitoring locations;
(d) Monitor
			 participants' progress toward meeting wellness goals and assign trained and
			 qualified lifestyle coaches to assist participants to keep on track with goals
			 and develop ways to encourage continued activities to achieve desired goals
			 including through financial or other incentives, periodic reminders and/or
			 motivational interviewing;
(e)
			 Measure, at least annually, the Wellness Program's effectiveness at developing
			 goals that improve participants' health status, promoting adherence to planned
			 goals and changing overall trends in health status, and redesigning the program
			 to address new or persistent health issues;
(f) Maintain the confidentiality of each
			 participant's health risk assessment and progress toward reaching the
			 participant's individualized health goals; and
(g) Maintain Wellness Programs consistent
			 with state and federal statutes, regulations and guidelines, including required
			 accommodations made for those with physical or other disabilities that could
			 prevent participation in standard programs.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 151.00 - Certified Group Purchasing Cooperatives › Section 151.16 - Health Benefit Plans Offered By Carriers through Certified Group Purchasing Cooperatives

Current through Register 1525, July 5, 2024
(1) As a condition
			 of continued offer of small group insured Health Benefit Plans, a Carrier that,
			 as of the close of the preceding calendar year, has a combined total of at
			 least 5,000 Eligible Individuals, Eligible Employees and Eligible Dependents
			 who are enrolled in Health Benefit Plans sold, issued, delivered, made
			 effective or renewed shall be required to annually file a Health Benefit Plan
			 and accompanying rates according to the Health Benefit Plan specifications
			 developed by a certified Group Purchasing Cooperative for the Group Purchasing
			 Cooperative's consideration, if said certified Group Purchasing Cooperative
			 requests such Health Benefit Plan proposals for its next plan year.
(2) Acceptable Health Benefit Plan features
			 shall include, but not be limited to, the following:
(a) All Health Benefit Plans offered by a
			 Carrier through each certified Group Purchasing Cooperative are to include
			 Mandated Benefits and comply with all additional relevant statutory and
			 regulatory requirements for insured Health Benefit Plans.
(b) For Eligible Small Businesses or
			 Qualified Associations of five or fewer Eligible Employees or Eligible
			 Association Members, a Carrier may require a Participation Rate not to exceed
			 100%. For Eligible Small Businesses or Qualified Associations of six or more
			 Eligible Employees or Eligible Association Members, a Carrier may require a
			 Participation Rate not to exceed 75%.
(c) Pre-existing condition limitations and
			 Waiting Periods are to be applied by a Carrier within Health Benefit Plans
			 offered through each certified Group Purchasing Cooperative in the same manner
			 that they are applied to individuals and small employer groups enrolling in
			 coverage outside the certified Group Purchasing Cooperative.
(d) Continuation of coverage provisions are
			 to be applied by a Carrier within Health Benefit Plans offered through each
			 certified Group Purchasing Cooperative in the same manner that they are applied
			 to individuals and small employer groups enrolling in coverage outside the
			 certified Group Purchasing Cooperative.
(e) Managed care practices, including
			 utilization review, quality assurance, credentialing of health plan providers,
			 and dissemination of required consumer materials are to be applied by a Carrier
			 within a Health Benefit Plan offered through each certified Group Purchasing
			 Cooperative in the same manner that they are applied to individuals and small
			 employer groups enrolling in coverage outside the certified Group Purchasing
			 Cooperative.