211 CMR 52.14 - Required Disclosures for Carriers and Behavioral Health Managers

Current through Register 1466, April 1, 2022

(1) A Carrier shall provide to at least one adult Insured in each household upon enrollment, and to a prospective Insured upon request, the following information:
(a) a statement that physician profiling information, so-called, may be available from the Board of Registration in Medicine for physicians licensed to practice in Massachusetts;
(b) a summary description of the process by which clinical guidelines and Utilization Review criteria are developed;
(c) the voluntary and involuntary disenrollment rate among Insureds of the Carrier;
1. For the purposes of 211 CMR 52.14(1)(c), 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, retired or died.
2. For the purposes of 211 CMR 52.14(1)(c), the term "voluntary disenrollment" means that an Insured has terminated coverage with the Carrier by nonpayment of premium.
3. For the purposes of 211 CMR 52.14(1)(c), the term "involuntary disenrollment" means that a Carrier has terminated the coverage of the Insured due to any of the reasons contained in 211 CMR 52.13(3)(j)2. and 3.
(d) a notice to Insureds regarding Emergency Medical Conditions that states all of the following:
1. 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 by dialing the emergency telephone access number 911, or its local equivalent, whenever the Insured is confronted with an Emergency Medical Condition which in the judgment of a prudent layperson would require pre-hospital emergency services;
2. that no Insured shall in any way be discouraged from using the local pre hospital emergency medical service system, the 911 telephone number, or the local equivalent;
3. that no Insured will be denied coverage for medical and transportation expenses incurred as a result of such Emergency Medical Condition; and
4. if the Carrier requires an Insured to contact either the Carrier or its designee or the Primary Care Provider of the Insured within 48 hours of receiving emergency services, that notification already given to the Carrier, designee or Primary Care Provider by the attending emergency Provider shall satisfy that requirement.
(e) a description of the Office of Patient Protection and a statement that the information specified in 211 CMR 52.16 is available to the Insured or prospective Insured from the Office of Patient Protection; and
(f) a statement:
1. that an Insured has the right to request referral assistance from a Carrier if the Insured or the Insured's Primary Care Provider has difficulty identifying Medically Necessary services within the Carrier's Network;
2. that the Carrier, upon request by the Insured, shall identify and confirm the availability of these services directly; and
3. that the Carrier, if necessary, shall obtain or arrange for Out-of-network services if they are unavailable within the Network.
(2) The information required of Carriers by 211 CMR 52.14(1)(a) through (f) may be contained in the Evidence of Coverage and need not be provided in a separate document.
(3) Every disclosure required of Carriers and described in 211 CMR 52.14(1)(a) through (f) must contain the effective date, date of issue and, if applicable, expiration date.
(4) A Carrier must maintain a toll-free telephone number and website available to Insureds to present Provider cost information to Insureds that meets the following requirements:
(a) the Insured may request and obtain the following, in real time:
1. the estimated or maximum allowed amount or charge for a proposed admission, procedure or service and
2. the estimated amount the Insured will be responsible to pay for a proposed admission, procedure or service that is a Medically Necessary Covered Benefit, based on the information available to the Carrier at the time the request is made, including any facility fee, copayment, deductible, coinsurance or other Cost-sharing requirements for any Covered Benefits;
(b) notwithstanding anything to the contrary in 211 CMR 52.14(4)(a), the Insured shall not be required to pay more than the disclosed amounts for the Covered Benefits that were actually provided;
(c) nothing in 211 CMR 52.14(4) shall prevent a Carrier from imposing Cost-sharing requirements disclosed in the Insured's Evidence of Coverage for unforeseen services that arise out of the proposed admission, procedure or service;
(d) the Carrier must alert the Insured that these are estimated costs, and that the actual amount the Insured will be responsible to pay may vary due to unforeseen services that arise out of the proposed admission, procedure or service.
(5) To provide information to Insureds about the disposition of Provider claims submitted to the Carrier, the Carrier shall issue to Insureds the summary of payments form, as authorized by the Commissioner, and the form shall be issued to the individual Insured rather than to the subscriber, and the form may be issued in paper or through an Internet Website, provided that a Carrier will issue the form by paper upon request by the Insured.
(6) Carriers shall submit Material Changes to the disclosures required by 211 CMR 52.14 to the Bureau at least 30 Days before their effective dates.
(7) Carriers shall submit Material Changes to the disclosures required by 211 CMR 52.14(1)(a) through (f) to at least one adult Insured in every household residing in Massachusetts at least once every two years.
(8) A Carrier that provides specified services through a workers' compensation preferred provider arrangement shall be deemed to have met the requirements of 211 CMR 52.14 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.
(9) A Carrier, including a Dental or Vision Carrier, shall provide to a health, Dental or Vision Care Provider, a written reason or reasons for denying the application of any health, Dental, or Vision Care Provider who has applied to be a Participating Provider.
(10) A Carrier for whom a Behavioral Health Manager is administering behavioral Health Services shall state on its new enrollment cards issued in the normal course of business, within one year, the name and telephone number of the Behavioral Health Manager.
(11) A Behavioral Health Manager shall provide the following information to at least one adult Insured in each household covered by their services:
(a) a notice to the Insured regarding emergency mental Health Services that states:
1. that the Insured may obtain emergency mental Health Services, including the option of calling the local pre-hospital emergency medical service system by dialing the 911 emergency telephone number or its local equivalent, if the Insured has an emergency mental health condition that would be judged by a prudent layperson to require pre-hospital emergency services;
2. that no Insured shall be discouraged from using the local pre-hospital emergency medical service system, the 911 emergency telephone number or its local equivalent;
3. that no Insured shall be denied coverage for medical and transportation expenses incurred as a result of such emergency mental health condition; and
4. if the Behavioral Health Manager requires an Insured to contact either the Behavioral Health Manager, Carrier or Primary Care Provider of the Insured within 48 hours of receiving emergency services, notification already given to the Behavioral Health Manager, Carrier or Primary Care Provider by the attending emergency Provider shall satisfy that requirement;
(b) a summary of the process by which clinical guidelines and Utilization Review criteria are developed for behavioral Health Services; and
(c) a statement that the Office of Patient Protection is available to assist consumers, a description of the Grievance and review processes available to consumers, and relevant contact information to access the Office of Patient Protection and these processes.
(12) The information required of Behavioral Health Managers by 211 CMR 52.14(11) may be contained in the Carrier's Evidence of Coverage and need not be provided in a separate document. Every disclosure described in 211 CMR 52.14(11) shall contain the effective date, date of issue and, if applicable, expiration date.
(13) A Behavioral Health Manager shall submit a Material Change to the information required by 211 CMR 52.14(11) to the Bureau at least 30 Days before its effective date and to at least one adult Insured in every household residing in the Commonwealth at least biennially.
(14) A Behavioral Health Manager that provides specified services through a workers' compensation preferred provider arrangement that meets 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 shall be considered to comply with 211 CMR 52.14.
(15) A Carrier for whom a Behavioral Health Manager is administering behavioral Health Services shall be responsible for the Behavioral Health Manager's failure to comply with the requirements of 211 CMR 52.00 in the same manner as if the Carrier failed to comply and shall be subject to the provisions of 211 CMR 52.17.

Notes

211 CMR 52.14
Amended by Mass Register Issue 1345, eff. 8/11/2017.

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