211 CMR 52.01 - Applicability

Current through Register 1466, April 1, 2022

211 CMR 52.00 applies to any Carrier that offers for sale, provides or arranges for the provision of a defined set of Health Care Services to Insureds through affiliated and contracting Providers or employs Utilization Review in making decisions about whether services are Covered Benefits under a Health Benefit Plan. A Carrier that provides coverage for Limited Health Services only, that provides specified services through a workers' compensation preferred provider arrangement, or that does not provide services through a Network or through Participating Providers shall be subject to those requirements of 211 CMR 52.00 as deemed appropriate by the Commissioner in a manner consistent with a duly filed application for Accreditation as outlined in 211 CMR 52.05(2).

Certain requirements of 211 CMR 52.00, as specified, shall also apply to Dental and Vision Carriers. Such provisions are: 211 CMR 52.11(1) through (4); (11); (13); 52.13(2), (3)(a), (c) through (e), (g) through (i), (m) through (p); (4) through (10); 52.14(1)(c) and (d); (2), (3) and (7); and 52.17.

A Carrier that delegates to or contracts with another entity, including a Utilization Review Organization, for the performance of some or all of the functions governed by M.G.L. c. 176O and/or 211 CMR 52.00 shall be responsible for ensuring compliance by said entity with the provisions of M.G.L. c. 176O and 211 CMR 52.00.

Notes

211 CMR 52.01
Amended by Mass Register Issue 1345, eff. 8/11/2017.

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