211 CMR 52.13 - Evidences of Coverage
Current through Register 1466, April 1, 2022
(1)
Evidences of Coverage as to a Carrier. It shall
constitute delivery of an Evidence of Coverage if a carrier chooses to, upon or
after enrollment, require the Insured to designate whether the Insured wants to
receive an Evidence of Coverage electronically or in writing. If no option is
designated, the Evidence of Coverage shall be provided electronically. If the
insured designates written notice, a carrier shall issue and deliver to at
least one adult Insured in the household an Evidence of Coverage. If the
Insured designates electronic notice, a carrier shall refer the insured to a
resource where the information described in such Evidence of Coverage can be
accessed, including, but not limited to, an Internet Website. In such instance,
the Evidence of Coverage must meet the requirements of 211 CMR 52.13(4).
An electronic copy of the Evidence of Coverage shall always be delivered to the group representative in the case of a group policy.
(2)
Evidences of
Coverage as to Dental and Vision Carriers. Dental and Vision
Carriers shall issue and deliver to at least one adult Insured in each
household residing in Massachusetts, upon enrollment:
(a) an Evidence of Coverage;
(b) a summary of the information contained in
the Evidence of Coverage; or
(c)
refer the Insured to resources where the information described in such Evidence
of Coverage can be accessed, including, but not limited to, an Internet
Website.
Dental and Vision Carriers shall be exempt from the provisions of 211 CMR 52.13(3)(b), (f), (j) through (l) and (q) through (aa).
(3)
Evidence
of Coverage Requirements. An Evidence of Coverage shall contain a
clear, concise and complete statement of all of the information described at
211 CMR 52.13(3)(a) through (aa). In addition, for Limited, Regional and Tiered
Network Plans, an Evidence of Coverage shall also contain any information as
required by
211 CMR 152.00:
Health Benefit Plans Using Limited, Regional or Tiered Provider
Networks.
(a) The health, Dental or
Vision Care Services and any other Benefits to which the Insured is entitled on
a nondiscriminatory basis, including Benefits mandated by state or federal
law;
(b) The prepaid fee which must
be paid by or on behalf of the Insured and an explanation of any grace period
for the payment of any Health Benefit Plan premium;
(c) The toll-free telephone number and
website established by the Carrier to present Provider cost information and an
explanation of the information that a Insured may obtain through such toll-free
number and website.
(d) The
limitations on the scope of:
1. Health Care
Services and any other Benefits to be provided, including:
a. an explanation of any Facility fee,
allowed amount, coinsurance, copayment, deductible or other amount that the
Insured may be responsible to pay to obtain Covered Benefits from Network or
Out-of-network Providers; and
b. an
explanation of the information that an Insured may obtain through the toll-free
number and website established by the Carrier under
211
CMR 52.14(4).
2. Dental or Vision Care Services
and any other Benefits to be provided, including an explanation of any
deductible or copayment feature.
(e) All restrictions relating to preexisting
condition limitations or exclusions, or a statement that there are no
preexisting condition limitations or exclusions if there are none under the
Health, Dental or Vision Benefit Plan;
(f) A description of the locations where, and
the manner in which, Health, Dental or Vision Care Services and other Benefits
may be obtained, and, additionally, for Health Care Services:
1. the method to locate Provider directory
information on a Carrier's website and the method to obtain a paper Provider
directory;
2. an explanation that
whenever a proposed admission, procedure or covered service that is Medically
Necessary is not available to an Insured within the Carrier's Network, the
Carrier will cover the out-of-Network admission, procedure or service, and the
Insured will not be responsible for paying more than the amount which would be
required for a similar admission, procedure or service offered within the
Carrier's Network; and
3. an
explanation that whenever a location where Health Care Services are provided is
part of a Carrier's Network, the Carrier will cover Medically Necessary covered
Benefits delivered at that location, and an explanation that the Insured will
not be responsible for paying more than the amount required for Network
services delivered at that location even if part of the Medically Necessary
Covered Benefits are performed by out-of-Network Provider(s), unless the
Insured has a reasonable opportunity to choose to have the service performed by
a Network Provider.
(g) A
description of eligibility of coverage for dependents, including a summary
description of the procedure by which dependents may be added to the
plan;
(h) The criteria by which an
Insured may be disenrolled or denied enrollment. 211 CMR 52.13(3)(h) shall
apply to Carriers, including Dental and Vision Carriers.
(i) The involuntary disenrollment rate among
Insureds of the Carrier. 211 CMR 52.13(3)(i) shall apply to Carriers, including
Dental and Vision Carriers.
1. For the
purposes of 211 CMR 52.13(3)(i), Carriers shall exclude all Administrative
Disenrollments, Insureds who are disenrolled because they have moved out of a
health plan's Service Area, Insureds whose continuation of coverage periods
have expired, former dependents who no longer qualify as dependents, or
Insureds who lose coverage under an employer-sponsored plan because they have
ceased employment or because their employer group has cancelled coverage under
the plan, reduced the numbers of hours worked, become disabled, retired or
died.
(j) The requirement that an Insured's
coverage may be canceled, or its renewal refused may arise only in the
circumstances listed in 211 CMR 52.13(3)(j)1. through 5. 211 CMR 52.13(3)(j)
shall apply to Carriers, including Dental and Vision Carriers.
1. failure by the insured or other
responsible party to make payments required under the contract;
2. misrepresentation or fraud on the part of
the Insured;
3. commission of acts
of physical or verbal abuse by the Insured which pose a threat to Providers or
other Insureds of the Carrier and which are unrelated to the physical or mental
condition of the Insured; provided, that the Commissioner prescribes or
approves the procedures for the implementation of the provisions of 211 CMR
52.13(3)(i)3.;
4. relocation of the
Insured outside the service area of the carrier; or
5. non-renewal or cancellation of the group
contract through which the Insured receives coverage;
(k) A description of the Carrier's, including
a Dental or Vision Carrier's, method for resolving Insured Inquiries and
Complaints. For a Health Benefit Plan, this description shall include a
description of the internal Grievance process and the external review process
consistent with
958 CMR 3.000: Health
Insurance Consumer Protection, including a internal and external
reviews pursuant to
958 CMR 3.000;
(l) A statement telling Insureds how to
obtain the report regarding Grievances pursuant to
958 CMR 3.600(1)(d)
from the Office of Patient
Protection;
(m) A description of
the Office of Patient Protection, including its toll-free telephone number,
facsimile number, and Internet Website;
(n) A summary description of the procedure,
if any, for out-of-Network referrals and any additional charge for utilizing
out-of-network Providers. 211 CMR 52.13(3)(n) shall apply to Carriers,
including Dental and Vision Carriers;
(o) A summary description of the Utilization
Review procedures and quality assurance programs used by the Carrier, including
a Dental or Vision Carrier, including the toll-free telephone number to be
established by the Carrier that enables consumers to determine the status or
outcome of Utilization Review decisions;
(p) A statement detailing what translator and
interpretation services are available to assist Insureds, including that the
Carrier will provide, upon request, interpreter and translation services
related to administrative procedures. The statement must appear in at least the
languages identified by the Centers for Medicare & Medicaid Services as the
top non-English languages in Massachusetts, 211 CMR 52.13(3)(p) shall apply to
Carriers, including Dental and Vision Carriers.
(q) A list of prescription drugs excluded
from any closed or restricted formulary available to Insureds under the Health
Benefit Plan; provided, that the Carrier shall annually disclose any changes in
such a formulary, and shall provide a toll-free telephone number to enable
consumers to determine whether a particular drug is included in the closed or
restricted formulary. A Carrier will be deemed to have met the requirements of
211 CMR 52.13(3)(q) if the Carrier does all of the following:
1. provides a complete list of prescription
drugs that are included in any closed or restricted formulary;
2. clearly states that all other prescription
drugs are excluded;
3. provides a
toll-free number that is updated within 48 hours of any change in the closed or
restricted formulary to enable Insureds to determine whether a particular drug
is included in or excluded from the closed or restricted formulary;
4. provides an Internet Website that is
updated as soon as practicable relative to any change in the closed or
restricted formulary to enable Insureds to determine whether a particular drug
is included in or excluded from the closed or restricted formulary;
and
5. clearly states that there
shall be no financial penalty for a patient's choice to receive a lesser
quantity of any opioid contained in schedule II or III of M.G.L. c. 94C, §
3, and lists each of such schedule II or III drugs.
(r) A summary description of the procedures
followed by the Carrier in making decisions about the experimental or
investigational nature of individual drugs, medical devices or treatments in
clinical trials;
(s) Requirements
for continuation of coverage mandated by state and federal law;
(t) A description of coordination of Benefits
consistent with
211 CMR 38.00:
Coordination
of Benefits (COB);
(u) A description of coverage for emergency
care and 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;
(v) If the Carrier offers services through a
Network or through Participating Providers, the following statements regarding
continued treatment:
1. If the Carrier allows
or requires the designation of a Primary Care Provider, a statement that the
Carrier will notify an Insured at least 30 Days before the disenrollment of
such Insured's Primary Care Provider and shall permit such Insured to continue
to be covered for Health Services, consistent with the terms of the Evidence of
Coverage, by such Primary Care Provider for at least 30 Days after said
Provider is disenrolled, other than disenrollment for quality related reasons
or for fraud. The statement shall also include a description of the procedure
for choosing an alternative Primary Care Provider.
2. A statement that the Carrier will allow
any female Insured who is in her second or third trimester of pregnancy and
whose Provider in connection with her pregnancy is involuntarily disenrolled,
other than disenrollment for quality-related reasons or for fraud, to continue
treatment with said Provider, consistent with the terms of the Evidence of
Coverage, for the period up to and including the Insured's first postpartum
visit.
3. A statement that the
Carrier will allow any Insured who is Terminally Ill and whose Provider in
connection with said illness is involuntarily disenrolled, other than
disenrollment for quality related reasons or for fraud, to continue treatment
with said Provider, consistent with the terms of the Evidence of Coverage,
until the Insured's death.
4. A
statement that the Carrier will provide coverage for Health Services for up to
30 Days from the effective date of coverage to a new Insured by a Provider who
is not a Participating Provider in the Carrier's Network if:
a. the Insured's employer only offers the
Insured a choice of Carriers in which said Provider is not a Participating
Provider; and
b. said Provider is
providing the Insured with an ongoing course of treatment or is the Insured's
Primary Care Provider; and
5. A Carrier may condition
coverage of continued treatment by a Provider under 211 CMR 52.13(3)(v)1.
through 4. upon the Provider's agreeing as follows:
a. to accept reimbursement from the Carrier
at the rates applicable prior to notice of disenrollment as payment in full and
not to impose Cost Sharing with respect to the Insured in an amount that would
exceed the Cost Sharing that could have been imposed if the Provider had not
been disenrolled;
b. to adhere to
the quality assurance standards of the Carrier and to provide the Carrier with
necessary medical information related to the care provided; and
c. to adhere to the Carrier's policies and
procedures, including procedures regarding referrals, obtaining prior
authorization and providing services pursuant to a treatment plan, if any,
approved by the Carrier;
6. Nothing in 211 CMR 52.13(3)(v) shall be
construed to require the coverage of Benefits that would not have been covered
if the Provider involved remained a Participating Provider;
(w) If a Carrier requires an
Insured to designate a Primary Care Provider, a statement that the Carrier will
allow the Primary Care Provider to authorize a standing referral for specialty
health care provided by a Health Care Provider participating in the Carrier's
Network when:
1. the Primary Care Provider
determines that such referrals are appropriate;
2. the Provider of specialty health care
agrees to a treatment plan for the Insured and provides the Primary Care
Provider with all necessary clinical and administrative information on a
regular basis; and
3. the Health
Care Services to be provided are consistent with the terms of the Evidence of
Coverage.
Nothing in 211 CMR 52.13(3)(w) shall be construed to permit a Provider of specialty health care who is the subject of a referral to authorize any further referral of an Insured to any other Provider without the approval of the Insured's Carrier;
(x) If a Carrier requires an Insured to
obtain referrals or prior authorization from a Primary Care Provider for
specialty care, a statement that the Carrier will not require an Insured to
obtain a referral or prior authorization from a Primary Care Provider for the
following specialty care provided by an obstetrician, gynecologist, certified
nurse midwife or family practitioner participating in such Carrier's Health
Care Provider Network and that the Carrier will not require higher copayments,
coinsurance, deductibles or additional Cost-Sharing features for such services
provided to such Insureds in the absence of a referral from a Primary Care
Provider:
1. annual preventive gynecologic
health examinations, including any subsequent obstetric or gynecological
services determined by such obstetrician, gynecologist, certified nurse midwife
or family practitioner to be Medically Necessary as a result of such
examination;
2. maternity care;
and
3. medically necessary
evaluations and resultant Health Care Services for acute or emergency
gynecological conditions.
Carriers may establish reasonable requirements for participating obstetricians, gynecologists, certified nurse midwives or family practitioners to communicate with an Insured's Primary Care Provider regarding the Insured's condition, treatment, and need for follow-up care; and nothing in 211 CMR 52.13(3)(x) shall be construed to permit an obstetrician, gynecologist, certified nurse midwife or family practitioner to authorize any further referral of an Insured to any other Provider without the approval of the Insured's Carrier;
(y) A statement that the Carrier will provide
coverage of pediatric specialty care, including, for the purposes of 211 CMR
52.13(3)(y), mental health care, by persons with recognized expertise in
specialty pediatrics to Insureds requiring such services.
(z) If a Carrier allows or requires an
Insured to designate a Primary Care Provider, a statement that the Carrier
shall provide the Insured with an opportunity to select a Participating
Provider Nurse Practitioner or a Participating Provider Physician Assistant as
a Primary Care Provider or to change his or her Primary Care Provider to a
Participating Provider Nurse Practitioner or a Participating Provider Physician
Assistant at any time during the Insured's coverage period.
(aa) Evidence that the Carrier will provide
coverage on a nondiscriminatory basis for covered services when delivered or
arranged for by a Participating Provider Nurse Practitioner or a Participating
Provider Physician Assistant. For the purposes of 211 CMR 52.13(3)(aa),
nondiscriminatory basis shall mean that a Carrier's plan does not contain any
annual or lifetime dollar or unit of service limitation imposed on coverage for
the care provided by a Participating Provider Nurse Practitioner or
Participating Provider Physician Assistant which is less than any annual or
lifetime dollar or unit of service limitation imposed on coverage for the same
services by other Participating Providers, in accordance with M.G.L. c. 176R,
§ 16(1) and c. 176S, § 1;
(bb) A statement that the Carrier shall be
required to pay for Health Care Services ordered by a treating physician or a
Primary Care Provider if the Health Services are a Covered Benefit under the
Insured's Health Benefit Plan and the Health Services are Medically
Necessary.
(4)
Internet Websites. If the Carrier, including any
Dental or Vision Carrier, refers the Insured to resources where the information
described in the Evidence of Coverage can be accessed, including, but not
limited to, an Internet Website, such Carrier must be able to demonstrate
compliance with applicable law, and with the following with respect to the
Internet Website:
(a) The Carrier has issued
and delivered written notice to the Insured that includes:
1. All necessary information and a clear
explanation of the manner by which Insureds can access their specific Evidence
of Coverage and any amendments thereto through such Internet Website;
2. A list of the specific information to be
furnished by the Carrier through an Internet Website;
3. The significance of such information to
the Insured;
4. The Insured's right
to receive, free of charge, a paper copy of evidences of coverage and any
amendments thereto at any time;
5.
The manner by which the Insured can exercise the right to receive a paper copy
at no cost to the Insured; and
6. A
toll-free number for the Insured to call with any questions or
requests.
(b) The Carrier
has taken reasonable measures to ensure that the information and documents
furnished in an Internet Website is substantially the same as that contained in
its paper documents. All notice and time requirements applicable to Evidences
of Coverage shall apply to information and documents furnished by an Internet
Website.
(c) The Carrier has taken
reasonable measures to ensure that it furnishes, upon request of the Insured, a
paper copy of the Evidence of Coverage and any amendments
thereto.
(5)
Group Plans. A Carrier, including a Dental and Vision
Carrier, shall always deliver at least one Evidence of Coverage to the group
representative of a group plan, notwithstanding the provisions of 211 CMR
52.13,
52.14
or
52.15.
(6)
General Notice of Material
Changes. A Carrier, including a Dental and Vision Carrier, shall
provide to at least one adult Insured in each household residing in
Massachusetts, or in the case of a group policy, to the group representative,
notice of all Material Changes to the Evidence of Coverage.
(7)
Advance Notice of Material
Modifications. A Carrier, including a Dental or Vision Carrier,
shall issue and deliver to at least one adult Insured in each household
residing in Massachusetts, or in the case of a group policy, to the group
representative, prior notice of material modifications in covered services
under the health, Dental or Vision Plan, at least 60 Days before the effective
date of the modifications. Such notices shall include the following:
(a) any changes in Clinical Review Criteria;
and
(b) a statement of the effect
of such changes on the personal liability of the Insured for the cost of any
such changes.
(8)
Advance Filing of Evidence of Coverage. A Carrier,
including a Dental or Vision Carrier, shall submit all Evidences of Coverage to
the Bureau at least 30 Days prior to their effective dates.
(9)
Dates Required.
Every Evidence of Coverage described in 211 CMR 52.13 must contain the
effective date, date of issue and, if applicable, expiration date.
(10)
Workers'
Compensation. A Carrier that provides specified services through a
workers' compensation preferred provider arrangement shall be deemed to have
met the requirements of 211 CMR 52.13 if it has met the requirements of
211 CMR 51.00:
Preferred Provider Health Plans and Workers' Compensation Preferred
Provider Arrangements and
452 CMR 6.00:
Utilization Review and Quality Assessment.
Notes
The following state regulations pages link to this page.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.