211 CMR 152.06 - Marketing of and Enrollment in Limited, Regional and Tiered Provider Network Plans

(1) Marketing of Limited, Regional and Tiered Provider Network Plans.

(a) Nothing in 211 CMR 152.06 shall affect a Carrier's obligation to comply with the requirements of 211 CMR 40.00.

(b) All Advertisements and Marketing Materials shall clearly identify the Health Benefit Plans being offered by the Carrier that only provide access through a Limited Provider Network, Regional Provider Network or Tiered Provider Network. Carriers shall ensure that such Advertisements and Marketing Materials specifically use the following terms as applicable to the product: "Limited Provider Network", "Regional Provider Network" or "Tiered Provider Network" so that Providers, employers and subscribers and prospective subscribers may be fully informed about the Provider Network features applicable to the offered Health Benefit Plan. In addition, Carriers shall establish auditable internal marketing procedures, methods for assuring compliance by Insurance Producers and prohibitions against high-pressure tactics.

(c) All Advertisements and Marketing Materials used in the sale, solicitation or negotiation of a Carrier's Health Benefit Plan that uses a Limited Provider Network, a Regional Provider Network or a Tiered Provider Network shall clearly disclose to prospective Insureds the type of Provider Network and the exact name of the Provider Network used for the plan. Insurance producers selling, soliciting or negotiating a Carrier's Health Benefit Plan that uses a Limited Provider Network, Regional Provider Network or Tiered Provider Network shall use only those Advertisements or Marketing Materials that contain such a disclosure.

(d) All Advertisements and Marketing Materials used in the sale, solicitation or negotiation of a Carrier's Health Benefit Plan that uses a Limited Provider Network, a Regional Provider Network or a Tiered Provider Network shall include the following disclosures:

1. The first or cover page of the Advertisements or Marketing Material, or electronic drop down menu of a web-based page, shall prominently disclose in a clear and conspicuous manner how to access a list of the Provider Network Providers and how to request a paper copy of the Health Benefit Plan's provider directory and shall provide a Provider Network description statement substantially similar to the following:

a. Limited/Regional Provider Network. This plan provides access to a network that is smaller than [Name of Carrier]'s [general provider network name] provider network. In this plan members have access to network benefits only from the providers in [name of network]. Please consult the [Limited/Regional] provider directory or visit the provider search tool at [web address] to determine which providers are included in the [name of network]."

b. Tiered Provider Network. This plan includes the Tiered Provider Network called [name of network]. In this plan members pay different levels of [copayments, coinsurance, deductibles] depending on the tier of the provider delivering a covered service or supply. This plan may make changes to a provider's benefit tier annually on [identify date]. Please consult the [name of network] provider directory or visit the provider search tool at [web address] to determine the tier of providers in [name of network]."

(e) A Carrier shall provide appropriate training to any employee or Insurance Producer selling, soliciting or negotiating its insurance products about the Carrier's Health Benefit Plans that use Limited Provider Networks, Regional Provider Networks or Tiered Provider Networks. Carriers shall maintain records of those employees and Insurance Producers who have satisfactorily completed such training and make such information available to the Commissioner upon request.

(2) Enrollment in Limited, Regional and Tiered Provider Network Plans.

(a) Within the application or related forms or electronic interface that a Carrier or Insurance Producer uses to enroll a prospective individual non-employment-based subscriber in a Health Benefit Plan that uses a Limited Provider Network, a Regional Provider Network or a Tiered Provider Network, shall be included a notice substantially similar to that in 211 CMR 152.11 and the prospective individual non-employment-based subscriber shall acknowledge that he or she understands the plan's Provider Network features. Prospective non-employment-based subscribers may signify this understanding with an alternative or electronic form of agreement and confirmation.

(b) A Health Benefit Plan that uses a Limited Provider Network, a Regional Provider Network or a Tiered Provider Network may only be effective for an individual non-employment-based subscriber to a Health Benefit Plan if the prospective individual non-employment-based subscriber receives a guide designated by the Commissioner prior to the time that the prospective individual non-employment-based subscriber is presented with an application or enrollment form or engages in any alternative or electronic enrollment process.

(3) Any Carrier or Insurance Producer that fails to comply with any provisions of 211 CMR 152.06 may be deemed to have committed an unfair or deceptive act or practice in the business of insurance in violation of M.G.L. c. 176D, § 3.

Notes

211 CMR 152.06