Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.600 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1) Carriers shall
			 provide the following information to the Office of Patient Protection no later
			 than April 1st of each year, with the exception of
			 the materials required under
			 958
			 CMR 3.600(l)(e), which shall
			 be submitted concurrent with their submission to the Division of Insurance for
			 parity certification under M.G.L. c. 26, § 8K, and
			 958
			 CMR 3.600(l)(f), which shall
			 be submitted concurrent with their submission to the Division of Insurance.
			 Such information shall be submitted in a manner specified by the Office of
			 Patient Protection or using a template or form developed by the Office of
			 Patient Protection. Unless concurrent submission is required, where the carrier
			 is also providing the requested information or materials to the Division of
			 Insurance within the same calendar year, the related element of the reporting
			 requirement to the Office of Patient Protection may be satisfied by providing a
			 written statement to the Office of Patient Protection describing which
			 information or materials are being provided to the Division and on what date
			 the carriers will provide the information or materials to the Division.
(a) a list of sources of independently
			 published information assessing insureds' satisfaction and evaluating the
			 quality of health care services offered by the carrier;
(b) the percentage of physicians and nurse
			 practitioners who voluntarily and involuntarily terminated participation
			 contracts with the carrier during the previous calendar year for which such
			 data has been compiled and the three most common reasons for voluntary and
			 involuntary provider disenrollment;
(c) the medical loss ratio, which is
			 percentage of premium revenue expended by the carrier for health care services
			 provided to insureds for the most recent year for which information is
			 available;
(d) a report detailing,
			 for the previous calendar year:
1. the total
			 number of filed grievances, the type of medical or behavioral health treatment
			 at issue where applicable, the number of grievances that were approved
			 internally, the number of grievances that were denied internally, and the
			 number of grievances that were withdrawn before resolution;
2. the number of grievances which resulted
			 from an adverse determination, the type of medical or behavioral health
			 treatment at issue, and the outcomes of those grievances; or if this
			 information is also being reported to the Commissioner of Insurance on or prior
			 to July 1st, a statement to that effect;
3. the percentage of insureds who filed
			 internal grievances with the carrier;
4. the total number of internal grievances
			 that were reconsidered pursuant to
			 958
			 CMR 3.308, the number of reconsidered
			 grievances that were approved internally, the number of reconsidered grievances
			 that were denied internally, and the number of reconsidered grievances that
			 were withdrawn before resolution;
5. the total number of external reviews
			 pursued after exhausting the internal grievance process, and the resolution of
			 all such external reviews.
The report shall identify, for each such category, to the
				extent such information is available, the demographics of such insureds, which
				shall include, but need not be limited to, race, gender and age.
				958
				CMR 3.600(l)(d)2. through 4.
				shall take effect for reports due to the Office of Patient Protection on and
				after April 1, 2015.
(e) a report detailing the information
			 required to be reported pursuant to M.G.L. c. 1760, § 7(b)(5), in a manner
			 and form to be specified by the Office of Patient Protection.
			 958
			 CMR 3.600 (1)(e) shall take effect for
			 reports due to the Office of Patient Protection in 2018.
(f) An electronic copy of the following,
			 which are required to be provided upon enrollment to at least one adult insured
			 in each household residing in Massachusetts pursuant to M.G.L. c.1760,
			 §§ 6 and 7(a):
1. Evidence of
			 coverage and any amendments thereto;
2. A list of health care providers in the
			 carrier's network, organized by specialty and by location and summarizing for
			 each such provider the method used to compensate or reimburse such provider,
			 provided, however, that disclosure of the specific details of any financial
			 arrangements between a carrier and a provider is not required;
3. A statement that physician profiling
			 information, so-called, may be available from the board of registration in
			 medicine;
4. A summary description
			 of the process by which clinical guidelines and utilization review criteria are
			 developed;
5. The voluntary and
			 involuntary disenrollment rate among insureds of the carrier;
6. A statement 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, whenever the insured is confronted with an emergency medical
			 condition which in the judgment of a prudent layperson would require
			 pre-hospital emergency services; and
7. A statement that the information specified
			 in 958 CMR 3.600(l)(a) through
			 (d) is available to the insured or
			 prospective insured from the Office of Patient Protection.