211 CMR 52.11 - Provider Contracts

Current through Register 1466, April 1, 2022

(1) Contracts between Carriers and Providers shall state that a Carrier shall not refuse to contract with or compensate for covered services an otherwise eligible Health Care Provider solely because such Provider has in good faith:
(a) communicated with or advocated on behalf of one or more of his or her prospective, current or former patients regarding the provisions, terms or requirements of the Carrier's Health Benefit Plans as they relate to the needs of such Provider's patients; or
(b) communicated with one or more of his or her prospective, current or former patients with respect to the method by which such Provider is compensated by the Carrier for services provided to the patient.
(2) Contracts between Carriers and Providers shall state that the Provider is not required to indemnify the Carrier for any expenses and liabilities, including, without limitation, judgments, settlements, attorneys' fees, court costs and any associated charges, incurred in connection with any claim or action brought against the Carrier based on the Carrier's management decisions, Utilization Review provisions or other policies, guidelines or actions.
(3) No contract between a Carrier and a Licensed Health Care Provider Group may contain any Incentive Plan that includes a specific payment made to a Health Care Professional as an inducement to reduce, delay or limit specific, Medically Necessary services covered by the health care contract.
(a) Health Care Professionals shall not profit from provision of covered services that are not Medically Necessary or medically appropriate.
(b) Carriers shall not profit from denial or withholding of covered services that are Medically Necessary or medically appropriate.
(c) Nothing in 211 CMR 52.11(3) shall be construed to prohibit contracts that contain Incentive Plans that involve general payments such as Capitation payments or shared risk agreements between Carriers and Providers, so long as such contracts, which impose risk on such Providers for the costs of care, services and equipment provided or authorized by another Health Care Provider, comply with 211 CMR 52.11(4) and 155.00: Risk-bearing Provider Organizations.
(d) In the event that a Provider with which a Carrier has a contract makes any decisions about coverage of requested care, then the Carrier remains responsible to ensure compliance with all applicable utilization review processes, including but not limited to adverse determination notices that describe rights to appeal medical necessity denials.
(4) No Carrier may enter into a new contract, revise the risk arrangements in an existing contract, or revise the fee schedule in an existing contract with a Health Care Provider which imposes financial risk on such Provider for the costs of care, services or equipment provided or authorized by another Provider unless such contract includes specific provisions with respect to the following:
(a) stop loss protection;
(b) minimum patient population size for the Provider group; and
(c) identification of the Health Care Services for which the Provider is at risk.
(5) No Carrier shall enter into an agreement or contract with a Health Care Provider if the agreement or contract contains a provision that:
(a)
1. limits the ability of the Carrier to introduce or modify a Limited, Regional or Tiered Network Plan by granting the Health Care Provider a guaranteed right of participation;
2. requires the Carrier to place all members of a Provider group, whether local practice groups or facilities, in the same tier of a Tiered Network Plan;
3. requires the Carrier to include all members of a Provider group, whether local practice groups or facilities, in a Limited Network Plan on an all-or-nothing basis; or
4. requires a Provider to participate in a new plan subject to 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks that the Carrier introduces without granting the Provider the right to opt-out of the new plan at least 60 Days before the new plan is submitted to the Commissioner for approval; or
(b) requires or permits the Carrier or the Health Care Provider to alter or terminate a contract or agreement, in whole or in part, to affect parity with an agreement or contract with other Carriers or Health Care Providers or based on a decision to introduce or modify a select Network plan or Tiered Network Plan;
(c) requires or permits the Carrier to make any form of supplemental payment unless each supplemental payment is publicly disclosed to the Commissioner as a condition of Accreditation, including the amount and purpose of each payment and whether or not each payment is included within the Provider's reported relative prices and health status adjusted total medical expenses under M.G.L. c. 12C, ยง 10;
(d) limits the ability of either the Carrier or the Health Care Provider to disclose the allowed amount and fees of services to an Insured's treating Health Care Provider; or
(e) limits the ability of either the Carrier or the Health Care Provider to disclose out-of- pocket costs to an Insured.
(6) Contracts between Carriers and Health Care Providers shall state that neither the Carrier nor the Provider has the right to terminate the contract without cause.
(7) Contracts between Carriers and Health Care Providers shall state that a Carrier shall provide a written statement to a Provider of the reason or reasons for such Provider's involuntary disenrollment.
(8) Contracts between Carriers and Health Care Providers shall state that the Carrier shall notify Providers, either by mail or electronically, of modifications in payments, modifications in covered services or modifications in a Carrier's procedures, documents or requirements, including those associated with Utilization Review, quality management and improvement, credentialing and Preventive Health Services, that have a substantial impact on the rights or responsibilities of the Providers, and the effective date of the modifications. The notice shall be provided 60 Days before the effective date of such modification unless such other date for notice is mutually agreed upon between the Carrier and the Provider.
(9) Contracts between Carriers and Health Care Providers shall state that Providers shall not bill patients for charges for covered services other than for deductibles, copayments, or coinsurance.
(10) Contracts between Carriers and Health Care Providers shall prohibit Health Care Providers from billing patients for nonpayment by the Carrier of amounts owed under the contract due to the insolvency of the Carrier. Contracts shall further state that this requirement shall survive the termination of the contract for services rendered prior to the termination of the contract, regardless of the cause of the termination.
(11) Contracts between Carriers and Health Care Providers shall require Providers to comply with the Carrier's requirements for Utilization Review, quality management and improvement, credentialing and the delivery of Preventive Health Services.
(12) Nothing in 211 CMR 52.11: Provider Contracts shall be construed to preclude a Carrier from requiring a Health Care Provider to hold confidential specific compensation terms.
(13) Nothing in 211 CMR 52.11: Provider Contracts shall be construed to restrict or limit the rights of Health Benefit Plans to include as Providers Religious Non-medical Providers or to utilize medically based eligibility standards or criteria in deciding Provider status for Religious Non-medical Providers.
(14) For Dental and Vision Benefit Plans, the following provisions regarding the standards for Provider contracts found at 211 CMR 51.11: Provider Contracts, shall apply for Dental and Vision Benefits: 211 CMR 52.11(1) through (4) and (11).
(15) Contracts between Carriers and Health Care Providers shall recognize Nurse Practitioners and Physician Assistants as Participating Providers and shall treat services provided by Participating Provider Nurse Practitioners and Physician Assistants to their Insureds in a nondiscriminatory manner for care provided for the purposes of health maintenance, diagnosis and treatment. Such nondiscriminatory treatment shall include, but not be limited to, coverage of Benefits for primary care, intermediate care and inpatient care, including care provided in a hospital, clinic, professional office, home care setting, long-term care setting, mental health or substance abuse program, or any other setting when rendered by a Nurse Practitioner or Physician Assistant who is a Participating Provider and is practicing within the scope of his or her professional license to the extent that such policy or contract currently provides Benefits for identical services rendered by a Provider of healthcare licensed by the Commonwealth.

Notes

211 CMR 52.11
Amended by Mass Register Issue 1345, eff. 8/11/2017.

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