02-031 C.M.R. ch. 360, § 5 - Procedures for review and approval of preferred provider arrangements

Current through 2022-14, April 6, 2022

A. Unless a hearing is scheduled pursuant to Section 6, the Superintendent will approve or disapprove the filing within 60 days of receipt of a complete filing.
B. Filing requirements. Applicants for preferred provider arrangements must comply with the following submission requirements:
(1) Complete an initial registration form;
(2) Provide a general statement of the health care services to be offered and the geographic area proposed to be served by the arrangement;
(3) Provide the name, address, and nature of any separate organization that administers the arrangement on behalf of the carrier or administrator;
(4) Describe the arrangement's relationship to existing health plans, specifying whether the arrangement will be offered as an alternative to coverage currently offered or as a replacement or modification of coverage currently offered, and explaining the reasons if certain classes of potential enrollees will be affected differently than others;
(5) Provide a list/directory of participating providers;
(6) Provide sample copies of provider contracts;
(7) Describe procedures, if any, for referral of enrollees to nonpreferred providers by a preferred provider, or by the carrier or administrator, including the conditions under which such referral will occur;
(8) Provide copies of contracts used involving a separate organization administering the arrangement on behalf of the carrier or administrator;
(9) Provide sample copies of contracts used with employers or other purchasers;
(10) Provide sample copies of contracts, certificates, or descriptive literature to be given to enrollees or to prospective enrollees;
(11) Describe the financial or other incentives for enrollees to use the services of a preferred provider or penalties for using nonpreferred providers;
(12) Describe provisions regarding payment for improper utilization of covered health services in situations where the enrollee has used the services of a preferred provider in compliance with the terms of the arrangement;
(13) Describe standing referral procedures regarding an enrollee with a special condition requiring ongoing care from a specialist;
(14) Describe procedures regarding coverage of the services of a nonpreferred provider if a preferred provider is not reasonably accessible;
(15) Describe utilization review procedures if review and authorization are required for health care services or for payment for those services, either by the carrier itself or by another entity contracted to perform utilization review on the carrier's behalf;
(16) Describe procedures related to the development and use of a formulary, if the carrier provides coverage for prescription drugs but limits that coverage to drugs included in a formulary;
(17) Describe procedures related to enrollees who wish to participate in clinical trials;
(18) Provide other information that the applicant may wish to submit which reasonably relates to its ability to establish, operate, maintain, or underwrite a preferred provider organization; and
(19) Provide such other information as the Superintendent may reasonably request.
C. Criteria for approval

The Superintendent will disapprove any arrangement that contains unfair, unjust, or inequitable provisions, including, but not limited to:

(1) Any arrangement in which certain classes of current or potential enrollees will be affected differently than other classes of current or potential enrollees if that effect is determined to be unfair, unjust, or inequitable;
(2) Inability to demonstrate reasonable access to providers in the arrangement's proposed geographic area;
(3) Provider contract provisions that offer any type of material inducement, bonus, or other financial incentive to a participating provider to deny, reduce, withhold, limit, or delay specifically medically necessary and appropriate health care services covered under the arrangement to an enrollee;
(4) Financial penalties to an enrollee for improper utilization of covered health services in situations where the enrollee has used the services of a preferred provider in compliance with the terms of the arrangement;
(5) Financial penalties to an enrollee for receiving emergency services from a nonpreferred provider if the care could not have been obtained from a preferred provider in a timely manner;
(6) The application of a benefit level differential for the services of a nonpreferred provider if a preferred provider is not reasonably accessible, unless the Superintendent waives the prohibition of this differential;
(7) Benefit level differentials between services rendered by preferred providers and nonpreferred providers exceeding twenty percent (20%) of the allowable charge for the service rendered, unless the Superintendent waives this requirement for a given benefit plan;
(8) Any arrangement that does not allow an enrollee with a special condition requiring ongoing care from a specialist to receive a standing referral to a specialist participating in the carrier's network for treatment of that condition or, if a specialist able to treat the enrollee's special condition does not participate in the carrier's network, does not allow the enrollee to receive a standing referral to a nonparticipating specialist;
(9) Utilization review procedures (if required for health care services or for payment for those services), either by the carrier itself or by another entity contracted to perform utilization review on the carrier's behalf that do not meet the requirements of Rule 850;
(10) The use of a formulary which does not ensure the participation of participating physicians and pharmacists in its development, or does not provide exceptions to the formulary limitation when a nonformulary alternative is medically indicated;
(11) Denial of qualified enrollee participation in approved clinical trials or denial, limitation, or imposition of additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in a clinical trial.

Notes

02-031 C.M.R. ch. 360, § 5

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