reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.14 - Intervention

Current through Register 1525, July 5, 2024
(1) At any time after the filing of the
			 Hearing Request, but no more than four days after publication of the hearing
			 notice in accordance with
			 211 CMR
			 41.13(8), a Statutory
			 Intervenor intending to participate in the Proceeding shall file and serve on
			 the Carrier, the State Rating Bureau, and any other Statutory Intervenors, a
			 notice of intent to participate.
(2) No more than ten days after publication
			 of the hearing notice in accordance with
			 211 CMR
			 41.13(8), a person who
			 wishes to intervene in the Proceeding, other than the State Rating Bureau,
			 Statutory Intervenors, or the Carrier, shall simultaneously file, and serve
			 upon the Carrier, the State Rating Bureau and all Statutory Intervenors and
			 already permitted Intervenors, a petition for leave to participate as an
			 Intervenor. The petition must state the name and address of the petitioner; its
			 grounds for seeking leave to intervene, including the manner in which it is
			 affected by or interested in the proceeding; the contentions of, and relief
			 sought by, the petitioner; the statutory or other authority in support of the
			 petition; a description of the extent of the petitioner's proposed
			 intervention, including the nature, if any, of the evidence the petitioner
			 seeks to present if the petition is granted; and a statement explaining why the
			 petitioner's interests would not be adequately represented by the Carrier or
			 Intervenors already participating and how the petitioner will avoid
			 introduction of repetitive testimony and not unduly delay the
			 Hearing.
(3) A Party opposing a
			 petition to intervene shall file a written objection, setting forth the grounds
			 for its objection, no later than two days after service of the
			 petition.
(4) The Presiding Officer
			 may schedule a hearing on the petition. The Presiding Officer shall determine
			 whether the petitioner will be allowed to intervene in the Proceeding. The
			 Presiding Officer may order two or more Intervenors to consolidate their
			 appearances or presentations if consolidation will facilitate and expedite the
			 Proceeding.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.15 - Responsive Filings

Current through Register 1525, July 5, 2024
(1)
Purpose
. Each Intervenor in a Proceeding shall submit
			 a Responsive Filing which identifies the grounds upon which the Intervenor
			 supports or contests the issues raised by the Carrier in its Hearing Request.
			 The Responsive Filing constitutes the direct case of an Intervenor.
(2)
Timing
. Each
			 Intervenor, other than the State Rating Bureau, shall file a Responsive Filing
			 no later than ten days after the conclusion of the examination of the Carrier's
			 witnesses, unless the Presiding Officer orders another time period. The State
			 Rating Bureau shall file a Responsive Filing two days after the other
			 Intervenors' Responsive Filings are due, unless the Presiding Officer orders
			 another time period.
(3)
Contents
. Every Responsive Filing must consist of
			 sequentially numbered pages, must use any format previously prescribed by the
			 Presiding Officer and, subject to limits on intervention set pursuant to
			 211 CMR 41.14, must
			 contain:
(a) A title stating the nature of
			 the Proceeding, and the complete name and address of the Intervenor submitting
			 the filing;
(b) The name and
			 address of counsel, or other representative, if the Intervenor is represented,
			 as prescribed in
			 211 CMR
			 41.13(7);
(c) A statement of the issues the Intervenor
			 intends to present for consideration in the Proceeding;
(d) A statement in short and plain terms of
			 the specific components of the Hearing Request which the Intervenor intends to
			 address;
(e) A statement in short
			 and plain terms of the legal grounds pursuant to which the Intervenor intends
			 to support or oppose the proposed rate, in whole or in part;
(f) At the Intervenor's option, any
			 recommended alternative rate adjustment or methodology, which the Intervenor
			 contends is supported in the record;
(g) Identification of each witness who
			 submits testimony as part of the Responsive Filing and identification of the
			 subject matter of the witness' testimony, with sufficient clarity to enable the
			 Presiding Officer to determine which witness is testifying about each component
			 of the Responsive Filing, and his or her qualifications to testify on that
			 subject matter;
(h) Sworn written
			 testimony of all witnesses including all information and commentary submitted
			 in support of any recommendations;
(i) All information, including data,
			 statistics, schedules, and exhibits, submitted in support of any
			 recommendations; and
(j) Other
			 information as prescribed from time to time by the Commissioner or the
			 Presiding Officer by order, decision or bulletin.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.16 - Scheduling of Proceeding

Current through Register 1525, July 5, 2024
(1)
Timing of Hearing and Order of Presentation
. The
			 Hearing will begin within 30 days after the submission of a complete Hearing
			 Request. The Proceeding will be conducted in the following order, and in
			 accordance with orders issued by the Presiding Officer:
(2)
Hearing on the Carrier's
			 Evidence
. Intervenors are permitted to cross-examine the Carrier's
			 witnesses, subject to any limits on intervention pursuant to
			 211 CMR 41.14. The
			 Presiding Officer may limit examination by Parties. The Presiding Officer may
			 ask questions of the Carrier's witnesses, regardless of whether a Party has
			 intervened.
(3)
Hearing
			 on the Intervenors' Evidence
. Cross-examination, redirect and
			 recross-examination of an Intervenors' witnesses will begin within six days
			 after the submission of that Intervenor's Responsive Filing, unless the
			 Presiding Officer orders another time period. If the Presiding Officer orders
			 or permits an Intervenor to present oral direct evidence, examination of the
			 Intervenors' witnesses will begin within six days of the completion of direct
			 testimony. The Presiding Officer may limit examination by Parties.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.17 - Discovery

Current through Register 1525, July 5, 2024
(1)
Information
			 Requests.
(a) Subject to any
			 limits on intervention imposed pursuant to
			 211 CMR 41.14, a
			 Party may serve upon another Party that has submitted a Rate Filing or
			 Responsive Filing, within five days of the filing of that Party's filing,
			 written Information Requests to produce or make available documents or tangible
			 things, not privileged, and not previously supplied, that are in the custody or
			 control of the Party upon whom the request is served. An Information Request
			 must set forth, with reasonable particularity, the items to be provided. With
			 the permission of the Presiding Officer, a Party may serve interrogatories on
			 another Party. The Presiding Officer, in his or her discretion, may permit
			 Information Requests to be served on a Party after the start of the examination
			 of that Party's witnesses and before the conclusion of the Hearing. Discovery
			 must be conducted expeditiously and, except for good cause, will not be grounds
			 to delay the Hearing.
(b) All
			 Information Requests must be filed and served on all Parties. A Party
			 requesting documents from the Division or the State Rating Bureau shall pay the
			 Division the fee per page for copies as determined from time to time by the
			 Executive Office for Administration and Finance, unless the Presiding Officer
			 waives the fee.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.18 - Pre-hearing Motions and Conferences

Current through Register 1525, July 5, 2024
(1)
Pre-hearing Motions
. Pre-hearing motions must be filed
			 in accordance with the following schedule:
(a) No later than 14 days following the date
			 the hearing notice is issued, an Intervenor may move to dismiss the Hearing
			 Request or for a decision on any or all issues raised by the Hearing Request on
			 the ground that the Hearing Request contains insufficient evidence to
			 substantiate claims it makes, or otherwise fails to comply with the filing
			 requirements established in
			 211 CMR 41.00.
(b) No later than five days following the
			 filing of a Responsive Filing, a Party may move to dismiss the Responsive
			 Filing or for a decision on any or all issues raised by that filing on the
			 ground that it contains insufficient description of the basis on which an
			 Intervenor supports or contests the Rate Filing.
(c) The Presiding Officer may permit a Party
			 to amend its Hearing Request or Responsive Filing in order to address the
			 issues raised by pre-hearing motions, including motions to dismiss, or to add
			 or revise data.
(d) All other
			 pre-hearing motions not specifically addressed in
			 211 CMR 41.00 must be filed
			 at least three days before the date of Hearing.
(e) The filing of any pre-hearing motion will
			 not affect any of the time periods set in
			 211 CMR 41.00 unless so
			 ordered by the Presiding Officer.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.20 - Briefs

Current through Register 1525, July 5, 2024
(1) Parties shall file briefs within a period
			 set by the Presiding Officer. Parties shall file five copies of briefs and
			 serve one copy on each Party, unless the Presiding Officer directs that a
			 different number of copies be provided. The Presiding Officer may set a page
			 limit for briefs and may require Parties to file a copy of briefs by electronic
			 means in a format determined by the Presiding Officer. Each brief shall
			 include:
(a) A concise statement of the
			 case;
(b) A clear and specific
			 identification of all evidence relied upon by the filing Party, with references
			 to the pages in the record where the evidence appears;
(c) Arguments and supporting
			 authorities;
(d) A statement of the
			 specific relief requested on each contested issue; and
(e) Any other information required by the
			 Presiding Officer.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.21 - Decision and Order on Closed Guaranteed Issue Health Plan Rate Filing

Current through Register 1525, July 5, 2024
(1) The Presiding Officer's Decision and
			 Order on a Closed Guaranteed Issue Health Plan Rate Filing shall be in writing
			 or stated on the record no more than 30 days following the Parties' final oral
			 or written submissions or arguments in the Proceeding.
(2) The Decision and Order shall be
			 accompanied by a statement of reasons therefore, including a determination of
			 each material issue of fact or law necessary to the decision.
(3) Rates that are approved by the Decision
			 and Order will be effective no earlier than 30 days after the issuance of the
			 Decision and Order.
(4) If a
			 Carrier's Closed Guaranteed Issue Health Plan Rate Filing is disapproved by the
			 Decision and Order, the Presiding Officer may indicate an alternative rate or
			 rate component, if any, that the Presiding Officer, based on the evidence in
			 the record, would find to be reasonable. If a Carrier's Rate Filing is
			 disapproved, the Carrier may, within a time period specified in the Decision
			 and Order disapproving the Rate Filing, file a Revised Rate Filing in the same
			 Proceeding.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.22 - Revised Rate Filings

Current through Register 1525, July 5, 2024
(1)
Contents
. A Carrier shall file any Revised Rate Filing
			 within the time period specified in the Presiding Officer's Decision and Order.
			 The Revised Rate Filing must meet the requirements set forth in the Decision
			 and Order, must contain all information required by the Decision and Order, and
			 must comply with the format, filing and service requirements of
			 211
			 CMR 41.12, but need not otherwise comply with
			 211
			 CMR 41.12.
(2)
Hearing on Revised Rate
			 Filing
. No later than ten days after a Revised Rate Filing is
			 submitted, the Presiding Officer may hold a Hearing at which the Presiding
			 Officer may hear argument and receive evidence regarding compliance of the
			 Revised Rate Filing with the Decision and Order. The Presiding Officer may
			 permit the Carrier to further revise the Revised Rate Filing to meet the
			 requirements of the Decision and Order. If the Presiding Officer determines
			 that the Revised Rate Filing complies with the Decision and Order, he or she
			 shall approve it.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.23 - Appeals

Current through Register 1525, July 5, 2024
(1) A Carrier aggrieved by a Decision and
			 Order on a Rate Filing or a Revised Rate Filing issued in a Proceeding
			 conducted by a Presiding Officer designated by the Commissioner, which the
			 Commissioner has no t affirmed, may appeal t he decision to the Commissioner
			 pursuant t o M. G. L. c. 26, § 7.
(2) A Carrier aggrieved by a Decision and
			 Order on a Rate Filing or a Revised Rate Filing, which the Commissioner has
			 affirmed, may, within 20 days of the decision, file a petition in the Supreme
			 Judicial Court for Suffolk County for a review of such decision. The Supreme
			 Judicial Court's review on the merits shall be limited to he record of the
			 proceedings before the Commissioner and shall be based upon the standards set
			 forth in M.G.L. c. 30A, § 14(7).
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.24 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 41.00, or the
				applicability thereof to any person or circumstance is held invalid by any
				court of competent jurisdiction, the remainder of
				211 CMR 41.00, 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 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.98 - Appendix A: Adjusted Composite Rate Worksheet

Current through Register 1525, July 5, 2024
Worksheet for Calculating the Composite Rate and Adjusted
				Composite Rate
Click to view
				image
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				view image
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				to view image
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Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 41.00 - Nongroup Health Insurance Rate And Policy Form Filings, Review, And Hearing Procedures Under M.g.l. C.176m › Section 41.99 - Appendix B: Adjusted Composite Rate Worksheet Examples

Current through Register 1525, July 5, 2024
(1)
Benefits Factor
.
			 The following example addresses the derivation of the factor. It assumes that
			 the plan includes an eyeglasses benefit that is not part of the Standard
			 Benefits Plan and that the benefit will be used equally by members regardless
			 of age, premium payment mode, rate basis type, or geographic rating region, and
			 that the proposed premiums reflect this assumption.
The Carrier assumes that the eyeglasses benefit represents
				0.5% of each of the proposed premiums and, therefore, 0.5% of the composite
				rate. The Benefits Factor equals 0.9550 (which is 1 - 0.0050).
(2)
Geographic
			 Differences Factor
. Examples 1 and 2 below address the derivation
			 of the Geographic Differences Factor assuming that there are only two
			 geographic rating regions ­ eastern and western Massachusetts, and that
			 both Company X and Y offer standard benefits plans with only one rate basis
			 type and one premium payment mode (annual).
Example 1
: Company X markets
				throughout Massachusetts, but proposes that its annual premium rate be $1,800
				in western Massachusetts and $2,400 in eastern Massachusetts. Company X
				projects that 100 eligible individuals will enroll in Company X from western
				Massachusetts and 200 eligible individuals will enroll in Company X from
				eastern Massachusetts.
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Example 2
: Company Y markets a closed
				network plan in eastern Massachusetts and proposes that its annual premium rate
				be $2,500 in eastern Massachusetts. Company Y projects that 200 eligible
				individuals will enroll in Company Y from eastern Massachusetts.
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				here to view image
(3)
Common-age
			 Factor
. The following example addresses the derivation of the
			 factor. It assumes that there are only two age bands -- 40 and under, and over
			 40 -- and that the Carrier offers a standard benefits plan with the same rates
			 statewide with one rate basis type and one premium payment mode (annual).
Example
: Company Z proposes that its
				annual premium rate is $1,800 for contractholders age 40 and under and $2,100
				for contractholders over 40 years old. Company Z projects that 100 eligible
				individuals 40 and under will enroll in Company Z and 200 eligible individuals
				over 40 years old will enroll in Company Z.
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				here to view image
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance › Section 42.01 - Purpose

Current through Register 1525, July 5, 2024
The purpose of
				211 CMR 42.00 is to provide
				reasonable simplification of terms and coverage of individual accident and
				sickness insurance policies in order to facilitate public understanding and
				comparison, to encourage flexibility and responsible innovation in the
				development of individual policies, and to eliminate provisions which may be
				misleading, confusing or contrary to the needs of the public
				.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance › Section 42.02 - Applicability

Current through Register 1525, July 5, 2024
211 CMR 42.00 applies to all
				individual accident and sickness insurance policies, including basic hospital
				expense, basic hospital-surgical expense, hospital confinement indemnity, major
				medical expense, specified accident, specified disease, accident only,
				disability income, and restricted benefit insurance policies on and after
				December 31, 1996. The requirements contained in
				211 CMR 42.00 are in addition
				to any other applicable statutory provisions or lawful
				regulations.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance › Section 42.03 - Authority

Current through Register 1525, July 5, 2024
211 CMR 42.00 is issued under
				the authority granted to the Commissioner under M.G.L. c. 175, §§ 108
				and 110E, c. 176, c. 176A, c. 176B, and c. 176D.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance › Section 42.05 - Policy Types

Current through Register 1525, July 5, 2024
(1)
General Standards.
(a) A policy paying benefits based on
			 standards described as "usual and customary," "reasonable and customary" or
			 words of similar import must define and explain the terms in its outline of
			 coverage;
(b) All pre-existing
			 condition provisions must be labeled as "Pre-existing Condition Provision" and
			 appear as a separate paragraph on the first page of the policy;
(c) In the event of cancellation or refusal
			 to renew by the carrier, policies providing pregnancy benefits must provide
			 benefits for pregnancy commencing while the policy is in force.
(d) A policy provision relating to recurrent
			 confinements or recurrent disabilities will be considered to be in compliance
			 with the provisions of M.G.L. c. 176D if does not specify that such
			 confinements or such disabilities be separated by a period greater than six
			 months.
(e) A policy's "free-look"
			 section or right of examination will be considered to be in compliance with the
			 provisions of M.G.L. c. 176D if it is for at least a ten-day period from the
			 date of policy delivery.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance › Section 42.08 - Requirements for Replacement

Current through Register 1525, July 5, 2024
(1) Application
			 forms must contain a question to elicit information as to whether the insurance
			 to be issued is to replace any other accident and sickness insurance currently
			 in force. A supplementary application or other form to be signed by the
			 applicant containing such a question may be used.
(2) An agent or carrier soliciting the sale,
			 upon determining that the sale would involve replacement, must furnish to the
			 applicant, at the time of taking the application, or before the policy is
			 issued, the notice described in 211 CMR 42.99. A copy of the notice must be
			 left with or retained by the applicant and a signed copy must be retained by
			 the carrier.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance › Section 42.09 - Requirements for Disclosure

Current through Register 1525, July 5, 2024
(1)
General Rules.
(a)
			 No misleading policy names may be used and no policy may be marketed or
			 advertised as a group policy unless it qualifies as such. A carrier's policy
			 name may not misrepresent the extent of benefits actually provided nor may a
			 name be used which conflicts with the prescribed category name or which is
			 similar to the prescribed name of a different category.
(b) If age is to be used as a determining
			 factor for reducing the benefits made available in the policy as originally
			 issued, such fact must be prominently set forth in the policy.
(c) All insurance policies must contain a
			 renewability provision on the first page of the policy in highlighted
			 section.
(d) In the event that the
			 policy is issued on a basis other than that applied for, a disclosure statement
			 properly describing the policy must accompany the policy when it is delivered
			 and contain the following statement, in no less than 12-point type, immediately
			 above the company name: "NOTICE: Read this disclosure statement carefully. The
			 coverage you originally applied for has not been issued. This policy is
			 therefore not identical to the coverage you requested - it differs in the
			 following respects: [ list ]."
(e)
			 Any Non-Medicare-Supplement policy summary delivered to a person eligible for
			 Medicare must conspicuously display on its first page the following statement
			 unless the policy does not cover hospital, medical or surgical expenses: "This
			 policy IS NOT A MEDICARE SUPPLEMENT POLICY." The statement may be printed or
			 affixed by sticker.
(f) Policies
			 providing conversion privileges must specify the benefits to be provided or
			 must state that the converted coverage shall be on the policy form then being
			 issued by the company for this purpose.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance › Section 42.10 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of
				211 CMR 42.00, or the
				applicability thereof to any person or circumstance is held invalid by any
				Court of competent jurisdiction, the remainder of
				211 CMR 42.00, 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 42.00 - The Form And Contents Of Individual Accident And Sickness Insurance › Section 42.11 - Required Notice for Policy Replacement

Current through Register 1525, July 5, 2024
The notice required by
				211 CMR
				42.08 shall be provided, in substantially the
				following form:
NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND
				SICKNESS INSURANCE
Accordingto(yourapplication)/(the information furnished by
				you), you intend to lapse or otherwise terminate your present policy and
				replace it with a policy to be issued by ___ Insurance Company. For your own
				information and protection, certain facts should be pointed out to you which
				could affect your rights to coverage under the new policy.
1. Health conditions which you may presently
			 have, may not be covered under the new policy. This could result in a claim for
			 benefits being denied which may have been payable under your present
			 policy.
2. Even though some of your
			 present health conditions may be covered under the new policy, these conditions
			 may be subject to certain waiting periods under the new policy before coverage
			 is effective.
3. Questions in the
			 application for the new policy must be answered truthfully and completely;
			 otherwise, the validity of the policy and the payment of any benefits
			 thereunder may be voided.
4. It may
			 be to your advantage to secure the advice of your present carrier or its agent
			 regarding the proposed replacement of your present policy. This is your right,
			 under the policy you have chosen.
The above "Notice to Applicant" was delivered to me on
				(date).
____________________________________________________________
				Applicant
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.01 - Applicability

Current through Register 1525, July 5, 2024
(1) No organization may provide or arrange
			 for health services to enrolled members who are Massachusetts residents in
			 exchange primarily for a prepaid per capita or aggregate fixed sum without
			 being licensed in accordance with the provisions of
			 211 CMR 43.00.
(2) A university or college health service or
			 plan shall not be required to obtain a license under M.G.L. c. 176G or
			 211 CMR 43.00 where
			 membership in such service or plan is limited solely to enrolled students,
			 faculty, employees, and affiliates, and their dependents.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.03 - Licensing

Current through Register 1525, July 5, 2024
(1)
Application for Initial
			 License
. Any organization seeking licensure as an HMO under M.G.L.
			 c. 176G must submit an application that contains at least the following
			 information in a format specified by the Commissioner.
(a)
Internal Operations
			 Plan
.
1. A copy of the basic
			 organizational documents, such as articles of incorporation, articles of
			 association, partnership agreement, trust agreement or any other applicable
			 document establishing the HMO and all amendments thereto;
2. A list of the Board of Directors or
			 similar policy-making body, including the name, principal occupation and
			 employer of each person;
3. A copy
			 of the by-laws, rules and regulations, or other similar document regulating the
			 conduct of the applicant's internal affairs;
4. A copy of the organizational chart with
			 titles in the areas of marketing, administration, enrollment, grievance
			 procedures, quality assurance, contract negotiation and financial
			 matters;
5. A narrative of the
			 health care plan, facilities and personnel including, but not limited to, the
			 organizational structure, a description of the service area and provider
			 network, the roles, functions, responsibilities of, and interrelationships
			 among providers and the methods of provider reimbursement and risk-sharing
			 arrangements;
6. An inventory of
			 owned, operated, contracted and participating provider facilities including,
			 but not limited to, hospitals, skilled nursing facilities, home health care and
			 medical care services;
7. For HMOs
			 who manage their own health care facilities only, a legal opinion from the
			 General Counsel of the Department of Public Health indicating whether the
			 applicant has complied with the requirements of M.G.L. c. 111;
8. A power of attorney authorizing the
			 Commissioner to accept service of process for any legal actions commenced
			 against an HMO not domiciled in the Commonwealth of Massachusetts;
			 and
9. For staff model HMOs only,
			 an inventory of full-time equivalents of providers by specialty with physician
			 to population ratios.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.05 - Deposit Requirements

Current through Register 1525, July 5, 2024
(1) Except as
			 provided in 211 CMR 43.05(2) and (3), each HMO shall maintain a deposit with a
			 trustee acceptable to the Commissioner through which a custodial or controlled
			 account is utilized of cash, securities or any combination of these or other
			 measures that are acceptable to him or her, which is to be used exclusively to
			 protect the interests of policyholders, enrolled members, and the general
			 public and which at all times shall have a value of not less than
			 $1,000,000.
(2) All income from the
			 deposit shall be an asset of the HMO. A HMO that has made a securities deposit
			 may withdraw that deposit or any part thereof after making a substitute deposit
			 of cash, securities or any combination of these or other measures of equal
			 amount and value. The Commissioner shall approve any securities before they are
			 deposited or substituted.
(3) The
			 Commissioner may reduce or eliminate the deposit requirement if the HMO
			 deposits with the state treasurer, insurance Commissioner or other official
			 body of the state or jurisdiction of domicile, for the protection of
			 policyholders, enrolled members and subscribers of such HMO and the general
			 public, cash, acceptable securities or surety, and delivers to the Commissioner
			 a certificate to such effect, duly authenticated by the appropriate entity
			 holding the deposit.
(4) If in the
			 opinion of the Commissioner the deposit requirement as established above would
			 be inadequate to protect the interests of enrolled members, the deposit shall
			 be appropriately adjusted in order to protect the interests of policyholders,
			 enrolled members and subscribers of the HMO and the general public.
(5) The deposit shall be an admitted asset of
			 the HMO in the determination of net worth pursuant to M.G.L. c. 176G, §
			 25. The Commissioner may use the deposit for administrative costs directly
			 attributable to any receivership, administrative supervision, rehabilitation or
			 liquidation pursuant to M.G.L. c. 176G, § 20. If the HMO is ordered into
			 receivership, administrative supervision, rehabilitation or liquidation, the
			 deposit shall be an asset subject to the provisions of M.G.L. c. 176G, §
			 20.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.06 - Net Worth Requirements

Current through Register 1525, July 5, 2024
(1)
Initial Net Worth
. The Commissioner shall require upon
			 issuance of an initial license under this chapter that a HMO shall have an
			 initial adjusted net worth of $1,500,000.
(2)
Ongoing Net
			 Worth
. Except as provided by 211 CMR 43.06(3), the adjusted net
			 worth of a HMO shall be maintained subsequent to initial licensure in an amount
			 equal to the greater of the following amounts:
(a) $1,000,000;
(b) 2% of annual premium revenues as reported
			 on the most recent annual financial statement filed with the Commissioner on
			 the first $150,000,000 of premium and 1% of annual premium on the premium in
			 excess of $150,000,000;
(c) An
			 amount equal to the sum of three months uncovered expenditures as reported on
			 the most recent financial statement filed with the Commissioner;
(d) An amount equal to the sum of:
1. 8% of annual health care expenditures
			 except those paid on a capitated basis or managed hospital payment basis as
			 reported on the most recent financial statement filed with the Commissioner;
			 and
2. 4% of annual hospital
			 expenditures paid on a managed hospital payment basis as reported on the most
			 recent financial statement filed with the Commissioner.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.07 - Premium Rates

Current through Register 1525, July 5, 2024
(1) All base rates
			 are subject to the Commissioner's disapproval if they do not meet the
			 requirements of M.G.L. c. 176G, § 16.
(2)
Small Group Base
			 Rates
. Small group and individual base rates shall be submitted in
			 accordance with M.G.L. c. 176J and
			 211
			 CMR 66.00:
Small Group Health
			 Insurance
.
(3)
Large Group Base Rates
. Each HMO shall submit proposed
			 large group base rates for each product at least 90 days prior to their
			 effective date(s).
(4) The
			 Commissioner shall notify the HMO if he or she determines that the HMO's
			 submission is not complete and he or she shall identify the manner in which the
			 submission is not complete. A submission shall not be deemed complete unless it
			 contains: an actuarial opinion stating that the rates are neither excessive,
			 inadequate, nor unfairly discriminatory, and that they are reasonable in
			 comparison to the benefits offered; and any other information required by the
			 Commissioner. As used in 211 CMR 43.07, "actuarial opinion" means a signed
			 written statement by a member of the American Academy of Actuaries based upon
			 the person's review of the appropriate records and of the actuarial assumptions
			 and methods utilized by the HMO in establishing premium rates for applicable
			 health benefit plans. The actuarial opinion also shall explain the method in
			 which the submitted base rates were derived.
(5) An HMO's submission shall contain the
			 following documentation:
(a) Three years of
			 historic claims payment experience, including member months, shown separately
			 for each year and differentiating among:
1.
			 Inpatient hospital care;
2.
			 Outpatient hospital care, with separate experience for:
a. Radiological/laboratory/pathology costs;
			 and
b. All other outpatient
			 costs;
3. Health care
			 provider charges for:
a. Medical and
			 osteopathic physicians;
b. Mental
			 health providers; and
c. All other
			 health care practitioners.
4. Supplies; and
5. Outpatient prescription drugs.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.08 - Evidence of Coverage

Current through Register 1525, July 5, 2024
The evidence of coverage for each product offered by the HMO
				must be submitted to the Commissioner, and is subject to the disapproval of the
				Commissioner if it does not meet the requirements of M.G.L. c. 176G, M.G.L. c.
				176O,
				211 CMR 43.00 and
				52.13:
Evidences of Coverage
.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.09 - Agents

Current through Register 1525, July 5, 2024
(1) All agents of licensed HMOs must be duly
			 licensed to sell accident and health insurance products pursuant to M.G.L. c.
			 175, § 162I.
(2) Nothing in
			 211 CMR 43.07(1)
			  shall require an HMO to appoint
			 agents.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.10 - Books and Records

Current through Register 1525, July 5, 2024
Every HMO shall keep and maintain its books of account and
				other records on a current basis and within Massachusetts. In addition, every
				HMO shall make, or cause to be made, and retain books and records which
				accurately reflect:
(1) The names and
			 last known addresses of all current subscribers to the HMO;
(2) All contracts required to be submitted to
			 the Commissioner and all other contracts entered into by the HMO;
(3) All requests made to the HMO for payment
			 of monies for health care services, the date of such requests, and the
			 dispositions thereof;
(4) The names
			 and last known addresses of persons who solicit or obtain members for an HMO,
			 including but not limited to employees, insurance producers and
			 agents;
(5) The amount of any
			 commissions paid to persons who obtained members for the HMO and the manner in
			 which said commissions are determined; and
(6) the total number and disposition of
			 malpractice claims and other claims relating to the service or care rendered by
			 the HMO made by, or on behalf of, members of the HMO that were settled or
			 resulted in a judgment during the year by the HMO.
Every HMO shall preserve for a period of not less than five
				years, the last two years of which shall be in an easily accessible place at
				the main offices of the HMO, the books of account and other records required
				under the provisions of, and for the purposes of
				211 CMR 43.00. After such
				books and records have been preserved for two years, they may be stored subject
				to their availability to the Commissioner not more than five days after he or
				she may request them
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.11 - Penalties

Current through Register 1525, July 5, 2024
(1) If the Commissioner issues a finding of
			 neglect on the part of an HMO, the Commissioner shall notify the HMO in writing
			 that the HMO has failed to make and file the materials required by M.G.L. c.
			 176G, M.G.L. c. 176O,
			 211 CMR 43.00 or
			 52.00:
Managed Care
			 Consumer Protections and Accreditation of Carriers
in the form and
			 within the time required. The notice shall identify all deficiencies and the
			 manner in which the neglect must be remedied. Following the written notice, the
			 Commissioner shall fine the HMO $5000 for each day during which the neglect
			 continues.
(2) Following notice and
			 hearing, the Commissioner shall suspend the HMO's authority to do new business
			 until all required reports or materials are received in a form satisfactory to
			 the Commissioner and the Commissioner has determined that the finding of
			 neglect can be removed.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.12 - Health Maintenance Organization Holding Company System Requirements

Current through Register 1525, July 5, 2024
(1) All HMOs shall meet the requirements of
			 M.G.L. c. 176G, §§ 27 through 29.
(2) HMOs shall comply with the provisions of
			 211 CMR 7.00:
Massachusetts Insurance Holding Company System
where
			 consistent with M.G.L. c. 176G. References to terms such as
Foreign
			 Insurer
,
Insurer
,
Policyholders
,
Shareholders
,
			 and M.G.L. c. 175, §§ 206 through 206D in
			 211 CMR 7.00 shall correspond
			 to terms
Foreign HMO
,
HMO
,
Members
and
Enrolled Members
,
			 and M.G.L. c. 176G, §§ 25 through 29.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 43.00 - Health Maintenance Organizations (HMOs) › Section 43.13 - Severability

Current through Register 1525, July 5, 2024
If any provision of
				211 CMR 43.00 or application
				thereof to any regulatee is held invalid, such invalidity shall not affect
				other provisions of
				211 CMR 43.00 and, to that
				end, the provisions of
				211 CMR 43.00 are
				severable.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 44.00 - Confidentiality Of Bids Submitted For Restricted Pharmacy Network Contracts - To Facilitate The Implementation Of M.g.l. C.176d, Section 3b › Section 44.01 - Purpose

Current through Register 1525, July 5, 2024
The purpose of
				211 CMR 44.00
et
				seq
. is to provide for the implementation of M.G.L. c. 176D, § 3B
				and to set forth the proprietary data and information that a Carrier shall
				withhold from public disclosure in the opening of Restricted Pharmacy Network
				contract bids.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 44.00 - Confidentiality Of Bids Submitted For Restricted Pharmacy Network Contracts - To Facilitate The Implementation Of M.g.l. C.176d, Section 3b › Section 44.02 - Applicability, Scope and Effective Date

Current through Register 1525, July 5, 2024
(1)
								211 CMR 44.00
et
			 seq
. shall apply to the Restrictive Pharmacy Network contract bidding
			 process between Carriers and Eligible Bidders after December 31,
			 1994.
(2)
								211 CMR 44.00
et
			 seq
. shall not apply to arrangements for the provision of
			 pharmaceutical drug benefits to Insureds between a Carrier and a mail order
			 pharmacy, a hospital-based pharmacy which is not a retail pharmacy, a pharmacy
			 maintained by a physician group practice or clinic which is not a retail
			 pharmacy or a pharmacy wholly-owned by a Carrier or to the establishment of any
			 Restricted Pharmacy Network in a geographical area, approved by the
			 Commissioner, which is served solely by a single provider of pharmaceutical
			 services.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 44.00 - Confidentiality Of Bids Submitted For Restricted Pharmacy Network Contracts - To Facilitate The Implementation Of M.g.l. C.176d, Section 3b › Section 44.03 - Definitions

Current through Register 1525, July 5, 2024
Carrier
:an insurer operating pursuant
				to the provisions of M.G.L. c. 175, a hospital service corporation operating
				pursuant to the provisions of M.G.L. c. 176A, a medical service corporation
				operating pursuant to the provisions of M.G.L. c. 176B, a health maintenance
				organization operating pursuant to the provisions of M.G.L. c. 176G, and a
				preferred provider arrangement operating pursuant to the provisions of M.G.L.
				c. 176I, or a wholly-owned subsidiary or affiliate under common ownership
				thereof.
Commissioner
: the Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Eligible Bidder
: a retail pharmacy,
				community pharmacy or pharmacy department registered pursuant to M.G.L. c. 112,
				§§ 38 and 39, or an association of such pharmacies, irrespective of
				corporate structure or number of locations at which it conducts business,
				located within the Geographical Service Area of a Carrier and willing to bid
				for participation in a Restricted Pharmacy Network contract.
Geographical Service Area
: that area
				defined in the terms of a Carrier's certificate, contract or agreement of
				insurance or coverage. If the Carrier's certificate, contract or agreement of
				insurance does not define a specific geographic area, then it shall be deemed
				to be the entire State.
Insured
: a person whose health care
				services and benefits are provided by, or indemnified by or otherwise covered
				by a Carrier's group or individual insurance policy, or certificate, agreement
				or contract and shall include subscribers, enrollees or members.
Restricted Pharmacy Network
: an
				arrangement for the provision of pharmaceutical drug benefits to Insureds which
				under the terms of a Carrier's policy, certificate, contract or agreement of
				insurance or coverage requires an Insured, or creates a financial incentive for
				an Insured, to obtain prescription drug benefits from one or more participating
				pharmacies that have entered into a specific contractual relationship with the
				Carrier pursuant to a competitive bidding process.
Willing Pharmacy Provider
: a retail
				pharmacy registered pursuant to M.G.L. c. 112, §§ 38 and 39, or an
				association of such pharmacies whose purpose is to promote participation in
				Restricted Pharmacy Networks, irrespective of corporate structure or number of
				locations at which it conducts business, located within the Geographical
				Service Area of a Carrier and which are not offered or are not participating in
				a Carrier's Restricted Pharmacy Network contract but are willing to provide
				drug benefits to the Carrier's Insureds in accordance with M.G.L. c. 176D,
				§ 3B.
Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 44.00 - Confidentiality Of Bids Submitted For Restricted Pharmacy Network Contracts - To Facilitate The Implementation Of M.g.l. C.176d, Section 3b › Section 44.04 - Bid Disclosure and Confidentiality Requirements

Current through Register 1525, July 5, 2024
(1)
Bid Disclosure
:
			 A Carrier shall open all Restricted Pharmacy Network contract bids in a public
			 manner in accordance with the requirements of M.G.L. c. 176D, § 3B subject
			 to the restrictions set forth in 211 CMR 44.04(2)(a) and (b).
(2)
(a)
Proprietary Data and Information
: Except as provided
			 for in 211 CMR 44.04(2)(b), a Carrier shall withhold proprietary data and
			 information contained in the Restricted Pharmacy Network contact bids as
			 confidential from public view. Proprietary data and information shall include :
1. a Carrier's or an Eligible Bidder's
			 marketing strategy;
2. a
			 description of a Carrier's or an Eligible Bidder's information system, computer
			 programs or other on-line service;
3. a Carrier's projected utilization
			 information;
4. rebates, refunds,
			 discount amounts or formulas, volume discounts, any class of trade discounts or
			 any estimated unit and dollar volume discounts provided to an Eligible Bidder
			 by drug manufacturers or pharmaceutical companies;
5. proposed discounts from the average
			 wholesale price, dispensing fees, capitation or other risk-sharing methodology,
			 or ingredient costs;
6. a Carrier's
			 closed formulary;
7. descriptions
			 of unique, plan-specific programs or techniques including cost containment
			 efforts, drug utilization review, formulary compliance assistance, disease
			 management, outcomes management, patient compliance, generic utilization,
			 generic and therapeutic substitution programs; and
8. lists of pharmacies included in the
			 network of an Eligible Bidder which is not chosen in the bidding process by a
			 Carrier to participate in the Carrier's Restricted Pharmacy Network.