Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers › Section 52.14 - Required Disclosures for Carriers and Behavioral Health Managers

Current through Register 1525, July 5, 2024
(1) A Carrier shall provide to at least one
			 adult Insured in each household upon enrollment, and to a prospective Insured
			 upon request, the following information:
(a) a
			 statement that physician profiling information, so-called, may be available
			 from the Board of Registration in Medicine for physicians licensed to practice
			 in Massachusetts;
(b) a summary
			 description of the process by which clinical guidelines and Utilization Review
			 criteria are developed;
(c) the
			 voluntary and involuntary disenrollment rate among Insureds of the Carrier;
1. For the purposes of
			 211
			 CMR 52.14(1)(c), Carriers
			 shall exclude all Administrative Disenrollments, Insureds who are disenrolled
			 because they have moved out of a health plan's Service Area, Insureds whose
			 continuation of coverage periods have expired, former dependents who no longer
			 qualify as dependents, or Insureds who lose coverage under an
			 employer-sponsored plan because they have ceased employment or because their
			 employer group has cancelled coverage under the plan, reduced the numbers of
			 hours worked, retired or died.
2.
			 For the purposes of
			 211
			 CMR 52.14(1)(c), the term
			 "voluntary disenrollment" means that an Insured has terminated coverage with
			 the Carrier by nonpayment of premium.
3. For the purposes of
			 211
			 CMR 52.14(1)(c), the term
			 "involuntary disenrollment" means that a Carrier has terminated the coverage of
			 the Insured due to any of the reasons contained in
			 211
			 CMR 52.13(3)(i)2. and
			 3.
(d) a notice to
			 Insureds regarding Emergency Medical Conditions that states all of the
			 following:
1. that Insureds have the
			 opportunity to obtain Health Care Services for an Emergency Medical Condition,
			 including the option of calling the local pre-hospital emergency medical
			 service system by dialing the emergency telephone access number 911, or its
			 local equivalent, whenever the Insured is confronted with an Emergency Medical
			 Condition which in the judgment of a prudent layperson would require
			 pre-hospital emergency services;
2.
			 that no Insured shall in any way be discouraged from using the local pre
			 hospital emergency medical service system, the 911 telephone number, or the
			 local equivalent;
3. that no
			 Insured will be denied coverage for medical and transportation expenses
			 incurred as a result of such Emergency Medical Condition; and
4. if the Carrier requires an Insured to
			 contact either the Carrier or its designee or the Primary Care Provider of the
			 Insured within 48 hours of receiving emergency services, that notification
			 already given to the Carrier, designee or Primary Care Provider by the
			 attending emergency Provider shall satisfy that requirement.
(e) a description of the Office of
			 Patient Protection and a statement that the information specified in
			 211
			 CMR 52.16 is available to the Insured or
			 prospective Insured from the Office of Patient Protection; and
(f) a statement:
1. that an Insured has the right to request
			 referral assistance from a Carrier if the Insured or the Insured's Primary Care
			 Provider has difficulty identifying Medically Necessary services within the
			 Carrier's Network;
2. that the
			 Carrier, upon request by the Insured, shall identify and confirm the
			 availability of these services directly; and
3. that the Carrier, if necessary, shall
			 obtain or arrange for Out-of-Network services if they are unavailable within
			 the Network.