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Form a Business

MEDICAL SERVICE CORPORATIONS

M.G.L. pt. Part I, tit. Title XXII, ch. c. 176B
in effect

M.G.L. c. 176B, § 1 Definitions

c. 176B, § 1. Definitions Section 1. In this chapter the following words shall have the following meanings: ''Certified nurse midwife'', a nurse midwife authorized to practice midwifery in the commonwealth by the board of registration in nursing pursuant to section eighty B of chapter one hundred and twelve. ''Commissioner'', the commissioner of insurance. ''Covered dependent'', a dependent for whose medical or chiropractic care provision is made in a subscription certificate issued by a medical service corporation to a subscriber. ''Dependent'', the spouse, child or foster child of a subscriber, or an adult relative dependent upon the subscriber for his support. ''Medical service'', the medical services ordinarily provided by registered physicians in accordance with accepted practices in the community where the services are rendered. ''Chiropractic service'', the chiropractic services ordinarily provided by registered chiropractors in accordance with accepted practices in the community where the services are rendered. ''Visual service'', the optometric services ordinarily provided by registered optometrists and physicians in accordance with accepted practices in the community where the services are rendered. ''Medical service corporation'', a corporation organized as provided by this chapter for the purpose of establishing and operating a non-profit medical service plan. ''Nonparticipating provider'', a registered physician under the provisions of chapter one hundred and twelve or other provider of health care services licensed under the laws of the commonwealth who is not party to an agreement in writing with a medical service corporation to perform medical services for subscribers and covered dependents who are covered under a preferred provider arrangement approved by the commissioner under chapter one hundred and seventy-six I. ''Nonprofit medical service plan'', a plan operated by a medical service corporation under the provisions of this chapter, whereby the cost of medical and chiropractic services and other health services furnished to subscribers and covered dependents is paid by the corporation, to participating physicians, to participating chiropractors, to nonparticipating providers if the subscriber is covered by a Preferred Provider Organization, and to such other physicians as are provided for herein, and to providers of other health services. ''Participating nurse midwife'', a certified nurse midwife who agrees in writing with a medical service corporation to perform midwifery service for subscribers and covered dependents and to abide by the by-laws, rules and regulations of such corporation. ''Participating physician'', a registered physician under the provisions of chapter one hundred and twelve who agrees in writing with a medical service corporation to perform medical service for subscribers and covered dependents and to abide by the by-laws, rules and regulations of such corporation. ''Participating chiropractor'', a registered chiropractor under the provisions of chapter one hundred and twelve who agrees in writing with a medical service corporation to perform chiropractic service for subscribers and covered dependents and to abide by the by-laws, rules and regulations of such corporation. ''Participating optometrist'', a registered optometrist who agrees in writing with a medical service corporation to perform visual service for subscribers and covered dependents and to abide by the by-laws, rules and regulation of such corporation. ''Primary care provider'', a health care professional qualified to provide general medical care for common health care problems who; (1) supervises, coordinates, prescribes, or otherwise provides or proposes health care services; (2) initiates referrals for specialist care; and (3) maintains continuity of care within the scope of practice. ''Registered physician'', a physician registered to practice medicine in the commonwealth as provided in section two of chapter one hundred and twelve. ''Registered chiropractor'', a chiropractor registered to practice chiropractic in the commonwealth as provided in section eighty-nine of chapter one hundred and twelve. ''Subscriber'', a person who has subscribed to a non-profit medical service plan and to whom a subscription certificate has been issued in accordance with the provisions of section six.

M.G.L. c. 176B, § 2 Incorporators; formation; articles of organization; certification

c. 176B, § 2. Incorporators; formation; articles of organization; certification Section 2. For the purpose of establishing, maintaining and operating a non-profit medical service plan, seven or more persons may form a medical service corporation. Such a corporation shall be formed in the manner prescribed in and subject to section nine of chapter one hundred and fifty-five and sections six and eight to twelve, inclusive, of chapter one hundred and fifty-six, except as follows: The agreement of association of a corporation having no capital stock may omit the statement of the amount of the capital stock and the par value and number of its shares. The fee to be paid to the state secretary upon the filing of the articles of organization shall be determined annually by the commissioner of administration under the provision of section three B of chapter seven. The articles of organization specified in section ten of said chapter one hundred and fifty-six, with the records and by-laws of the corporation, shall be submitted to the commissioner instead of to the commissioner of revenue, and he shall have the powers and perform the duties relative thereto specified in section eleven of said chapter one hundred and fifty-six. The certificate issued by the state secretary under section twelve of said chapter one hundred and fifty-six shall be modified to conform to the requirements of this section. The commissioner shall not approve the articles of organization of such a corporation until he is satisfied by such examination as he may make and such evidence as he may require, that the incorporators are of good repute and intend in good faith to operate the corporation. He shall execute a certificate of his findings, which shall be attached to the articles of organization prior to the filing thereof with the state secretary.

M.G.L. c. 176B, § 3 By-laws; joint service contracts; preferred provider arrangements

c. 176B, § 3. By-laws; joint service contracts; preferred provider arrangements Section 3. The by-laws of a medical service corporation may contain any lawful provisions approved by the commissioner, and shall provide that a majority of the incorporators or members of the corporation and a majority of the directors shall at all times be persons who are not providers of health services licensed under the laws of the commonwealth and that a majority of the directors shall at all times be persons who are or agree to become subscribers to the nonprofit medical service plan. The by-laws of such a corporation may define the qualifications of those persons eligible to become subscribers as provided in section five. Any such corporation may adopt such rules and regulations as may be consistent with the provisions of this chapter. Such rules and regulations and any changes or amendments thereto shall be filed with the commissioner thirty days before their effective dates and shall be subject to subsequent disapproval by the commissioner. Any medical service corporation may contract with a corporation formed under chapter one hundred and seventy-six A for the joint or co-operative administration of their affairs and for the joint or co-operative writing and issuing of subscription certificates, and shall contract with a corporation formed under chapter one hundred and seventy-six A for the joint or cooperative administration of their affairs when acting as a carrier under chapter one hundred and seventy-six G. Any medical service corporation may join with any other medical service corporation organized either under the laws of the commonwealth or of any other state for the purpose of establishing or maintaining an agency or corporation designed to facilitate the provision of medical service for residents of the commonwealth employed by firms having employees located in more than one state and may enter into contracts with such an agency or corporation or with a corporation owned by such an agency or corporation for the joint administration of their business and for the joint and cooperative writing and issuing of certificates, provided that any corporation or agency which is not a nonprofit medical service corporation with which there is joint and cooperative writing and issuing of certificates shall be qualified to do business in the commonwealth. Any medical service corporation may contract with any agency of the United States of America, of the commonwealth or of any city or town within the commonwealth or with any corporation organized under general or special laws for any of the purposes mentioned in chapter one hundred and eighty for the purpose of providing medical service or other health services or reimbursement for such medical service or other health services. Any medical service corporation which contracts with any agency of the United States of America to provide benefits under Title XVIII of the Social Security Act shall require that a practitioner who participates in said program shall post, in a conspicuous place, his policy regarding the acceptance of medicare assignment, and also require that said practitioner shall inform all eligible persons of his policy regarding medicare assignment prior to the delivery of care and services. Other provisions of this chapter and chapter one hundred and seventy-six G notwithstanding, any medical service corporation, either individually or by contract with a corporation formed under chapter one hundred and seventy-six A, one or more hospitals licensed under chapter one hundred and eleven, one or more health maintenance organizations under chapter one hundred and seventy-six G, physicians registered under chapter one hundred and twelve and other providers of health care licensed or registered pursuant to chapter one hundred and eleven and chapter one hundred and twelve or one or more insurance companies licensed under chapter one hundred and seventy-five, may establish, maintain, operate, own or offer plans, programs or arrangements which have been approved by the commissioner under said chapter one hundred and seventy-six I. A medical service corporation shall not condition its willingness to allow any physician or other provider of health services to participate in a preferred provider arrangement on such physician's or provider's agreeing to enter into other contracts or arrangements with the medical service corporation or any other persons that are not part of or related to such preferred provider arrangement. The terms and conditions offered by a medical service corporation that must be met or agreed to by physicians and other providers of health services desiring to enter into a preferred provider arrangement or plan shall be fair and reasonable. No physician or other provider of health services willing to meet the reasonable terms and conditions proposed or offered in connection with such preferred arrangements shall be denied the opportunity to offer to enter into an agreement with such medical service corporation. The terms and conditions offered by a medical service corporation that must be met or agreed to by physicians and other providers of health services desiring to enter into such agreements shall be subject to the disapproval of the commissioner.

M.G.L. c. 176B, § 3A Contracts of reinsurance

c. 176B, § 3A. Contracts of reinsurance Section 3A. Any corporation subject to this chapter may make contracts of reinsurance relating to the providing of medical or other health services or reimbursement thereof, but the costs of such reinsurance shall not inure to or otherwise affect the premiums charged for any policy offered, sold, issued or delivered by the corporation pursuant to chapter 176K or for any nongroup health plan offered, sold, issued or delivered by the corporation pursuant to chapter 176M.

M.G.L. c. 176B, § 3B Group medical service agreements; contribution percentages

c. 176B, § 3B. Group medical service agreements; contribution percentages Section 3B. A medical service corporation organized under this chapter may only enter into a group medical service agreement with an employer if the group medical service agreement is offered by that employer to all full-time employees who live in the commonwealth; provided, however, the employer shall not make a smaller health insurance premium contribution percentage amount to an employee than the employer makes to any other employee who receives an equal or greater total hourly or annual salary for each specific or general blanket policy of insurance for all employees. Notwithstanding the foregoing, a carrier may enter into a group medical service agreement with an employer that establishes separate contribution percentages for employees covered by collective bargaining agreements.

M.G.L. c. 176B, § 4 Contracts for medical, chiropractic, visual, surgical, and other health services; approval, subscription certificates; classification of risks

c. 176B, § 4. Contracts for medical, chiropractic, visual, surgical, and other health services; approval, subscription certificates; classification of risks Section 4. Any medical service corporation may enter into contracts with its subscribers, and with participating physicians, chiropractors, nurse midwives, optometrists, dentists, podiatrists, psychologists, licensed independent clinical social workers, certified clinical specialist in psychiatric and mental health nursing and other providers of health services licensed under the laws of the commonwealth for such medical, chiropractic, visual, surgical, midwifery, mental health and other health services as may lawfully be rendered by them to subscribers and their dependents and shall make payment for such services either, or directly to participating providers or to nonparticipating providers if the subscriber is covered by a Preferred Provider Organization, as provided for in this chapter. The form of any and all agreements with such participating physicians, chiropractors, nurse midwives, optometrists, dentists, podiatrists, psychologists, licensed independent clinical social workers, certified clinical specialist in psychiatric and mental health nursing and other providers of health services shall at all times be subject to the written approval of the commissioner, but no participating provider shall be denied the right to enter into any agreement with any medical service corporation by reason of any unfair or arbitrary discrimination. The methods of compensating such physicians, chiropractors, nurse midwives, optometrists, dentists, podiatrists, psychologists, licensed independent clinical social workers, certified clinical specialist in psychiatric and mental health nursing and other providers of health services for their services to subscribers, or covered dependents shall at all times be subject to the written approval of the commissioner. A contract between a medical service corporation and a provider of home health services or a licensed hospice agency shall not require the participating home health provider or participating licensed hospice agency to be accredited by the Joint Commission on Accreditation of Healthcare Organizations or other national accrediting body if the agency is certified for participation in the Medicare program, Title XVIII of the federal Social Security Act, 42 U.S.C. Sections 1395 et seq. Any agreement between a medical service corporation and a person whereby such corporation undertakes to furnish benefits for medical service to said person and his covered dependents, if any, shall be considered a non-group medical service agreement. No such agreement shall be approved if he finds that the benefits provided therein are unreasonable in relation to the rate charged, nor if the rates charged are excessive, inadequate or unfairly discriminatory. For the purposes of the review of rates of payment under this section, whether an agreement is not excessive shall include considerations of affordability for consumers and purchasers of health insurance products; provided, however, that such review shall adhere to principles of solvency and actuarial soundness. Nongroup agreements, except contracts providing supplemental coverage to medicare or other governmental programs that are subject to the provisions of chapter one hundred and seventy-six K, shall be subject to the provisions of chapter one hundred and seventy-six M and any regulations promulgated thereunder. Any such corporation shall make available each type of medicare supplemental coverage allowed by the commissioner of insurance to any resident of the commonwealth whose coverage under a medicare program offered by a health maintenance organization licensed under chapter one hundred and seventy-six G has been cancelled because the health maintenance organization's contract with medicare has been terminated. Such coverage shall be offered without any waiting periods or exclusions for pre-existing conditions and shall become effective on the date that the coverage is cancelled. Any agreement between a medical service corporation and a group of two or more persons or with the employer, employers or other representatives of such group whereby the medical service corporation undertakes to furnish benefits for medical service to said persons and to their covered dependents, if any, shall be considered a group medical service agreement; provided, however, that eligible persons in a group who are enrollees under a group health maintenance contract, as defined in section one of chapter one hundred and seventy-six G, shall be included for purposes of determining the number of persons within a group having a medical service agreement. Under such a group medical service agreement, subscription certificates and the rates charged by the corporation to the subscribers shall be filed with the commissioner within thirty days after their effective date, and shall be subject to subsequent disapproval by the commissioner if he finds that the benefits provided therein are unreasonable in relation to the rate charged, or that the rates charged are excessive, inadequate or unfairly discriminatory; and provided that group plan contracts issued and rates charged by a nonprofit medical service corporation to its subscribers providing supplemental coverage to medicare shall be subject to the provisions of chapter one hundred and seventy-six K if the subscribers, and not their employer, employers or representatives, are billed directly for such contracts. No classification of risk may be established on the basis of age. In disapproving any rate under this section, the commissioner shall make a finding on the basis of information submitted by a medical service corporation, that such corporation employs a utilization review program and other techniques acceptable to him which have had or are expected to have a demonstrated impact on the prevention of reimbursement by such corporation for services which are not medically necessary. The commissioner may make and, at any time, alter or amend, reasonable rules or regulations to facilitate the operation and enforcement of this section and to govern hearings and investigations thereunder. He may issue such orders as he finds proper, expedient or necessary to enforce and administer the provisions of this section and to secure compliance with any rules and regulations made thereunder. The open enrollment period and coverage effective date for any group medical service plan contract providing supplemental coverage to medicare shall be the same as the open enrollment period of all other group health plan options offered by the employer, representative or group sponsor to the group's members who are eligible for medicare supplemental coverage. Nothing in this section shall be construed to prohibit as unreasonable or unfairly discriminatory the establishment of classifications or modifications of classifications of risks based upon size, expense, management, individual experience, purpose, location or dispersion of hazard or any other reasonable considerations, or to prohibit retrospective refunds. Acquisition costs in connection with the solicitation of subscribers and costs of administration shall at all times be limited to such amounts as the commissioner shall approve. To the extent that this section is inconsistent with the provisions of chapter one hundred and seventy-six K, and any regulations promulgated thereunder, medicare supplement insurance and medicare select insurance plans as defined in said chapter one hundred and seventy-six K shall be subject to the provisions of said chapter one hundred and seventy-six K. To the extent that this section is inconsistent with the provisions of chapter one hundred and seventy-six M and any regulations promulgated thereunder, any nongroup plan that is within the definition of a guaranteed issue health plan in said chapter one hundred and seventy-six M shall be subject to the provisions of said chapter one hundred and seventy-six M and any regulations promulgated thereunder.

M.G.L. c. 176B, § 4A Mental illness expenses; inclusion as benefits; biologically-based mental disorders; rape-related mental disorders; non-biologically-based mental disorders of children and adolescents under age 19

c. 176B, § 4A. Mental illness expenses; inclusion as benefits; biologically-based mental disorders; rape-related mental disorders; non-biologically-based mental disorders of children and adolescents under age 19 Section 4A. (a) A subscription certificate under an individual or group medical service agreement which is issued or renewed within or without the commonwealth shall provide mental health benefits on a nondiscriminatory basis to residents of the commonwealth and to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment in the commonwealth for the diagnosis and treatment of the following biologically-based mental disorders, as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, referred to in this section as the DSM: (1) schizophrenia; (2) schizoaffective disorder; (3) major depressive disorder; (4) bipolar disorder; (5) paranoia and other psychotic disorders; (6) obsessive-compulsive disorder; (7) panic disorder; (8) delirium and dementia; (9) affective disorders; (10) eating disorders; (11) post traumatic stress disorder; (12) substance abuse disorders; and (13) autism. A subscription certificate under an individual or group medical service agreement which is issued or renewed within or without the commonwealth shall provide mental health benefits on a nondiscriminatory basis to residents of the commonwealth and to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment in the commonwealth for the diagnosis and medically necessary and active treatment of any mental disorder, as described in the most recent edition of the DSM, that is approved by the commissioner of mental health. (b) In addition to the mental health benefits established pursuant to this section, any such subscription certificate shall also provide benefits on a non-discriminatory basis for the diagnosis and treatment of rape-related mental or emotional disorders to victims of a rape or victims of an assault with intent to commit rape, as defined by sections 22 and 24 of chapter 265, whenever the costs of such diagnosis and treatment exceed the maximum compensation awarded to such victims pursuant to subparagraph (C) of paragraph (2) of subsection (b) of section 3 of chapter 258C. (c) In addition to the mental health benefits established pursuant to this section, any such subscription certificate shall also provide benefits on a non-discriminatory basis for children and adolescents under the age of 19 for the diagnosis and treatment of non-biologically-based mental, behavioral or emotional disorders, as described in the most recent edition of the DSM, which substantially interfere with or substantially limit the functioning and social interactions of such a child or adolescent; provided, that said interference or limitation is documented by and the referral for said diagnosis and treatment is made by the primary care provider, primary pediatrician or a licensed mental health professional of such a child or adolescent or is evidenced by conduct, including, but not limited to: (1) an inability to attend school as a result of such a disorder, (2) the need to hospitalize the child or adolescent as a result of such a disorder, (3) a pattern of conduct or behavior caused by such a disorder which poses a serious danger to self or others. The nonprofit medical service corporation shall continue to provide such benefits to any adolescent who is engaged in an ongoing course of treatment beyond the adolescent's nineteenth birthday until said course of treatment, as specified in said adolescent's treatment plan, is completed and while the benefit contract under which such benefits first became available remains in effect, or subject to a subsequent benefits contract which is in effect. (d) Any such subscription certificate shall be deemed to be providing such coverage on a nondiscriminatory basis if the subscription certificate does not contain any annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of said mental disorders which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions. (e) Any such subscription certificate shall also provide medically necessary benefits for the diagnosis and treatment of all other mental disorders not otherwise provided for in this section and which are described in the most recent edition of the DSM during each 12 month period for a minimum of 60 days of inpatient treatment and for a minimum of 24 outpatient visits. [There is no subsection (f).] (g) Benefits authorized pursuant to this section shall consist of a range of inpatient, intermediate, and outpatient services that shall permit medically necessary and active and noncustodial treatment for said mental disorders to take place in the least restrictive clinically appropriate setting. For purposes of this section, inpatient services may be provided in a general hospital licensed to provide such services, in a facility under the direction and supervision of the department of mental health, in a private mental hospital licensed by the department of mental health, or in a substance abuse facility licensed by the department of public health. Intermediate services shall include, but not be limited to, Level III community-based detoxification, acute residential treatment, partial hospitalization, day treatment and crisis stabilization licensed or approved by the department of public health or the department of mental health. Outpatient services may be provided in a licensed hospital, a mental health or substance abuse clinic licensed by the department of public health, a public community mental health center, a professional office, or home-based services, provided, however, services delivered in such offices or settings are rendered by a licensed mental health professional acting within the scope of his license. (h) A nonprofit medical service corporation may, as a condition of providing coverage pursuant to this section, require consent to the disclosure of information regarding services for mental disorders only to the same or similar extent in which it requires consent for the disclosure of information for other medical conditions. Only licensed mental health professionals shall be allowed to deny services mandated by this section. The provisions of this subsection shall not be construed as applying to denials of service resulting from an insured's lack of insurance coverage or the use of a facility or professional which, if applicable under the insured's benefits contract, has not entered into a negotiated agreement with said medical service corporation. The benefits provided in any subscription certificate pursuant to this section shall meet all other terms and conditions of the subscription certificate not inconsistent with this section. (i) Nothing in this section shall be construed to require a non-profit medical service corporation to pay for mental health benefits or services: which are provided to a person who has third party insurance and who is presently incarcerated, confined or committed to a jail, house of correction or prison, or custodial facility in the department of youth services within the commonwealth or one of its political subdivisions; which constitute educational services required to be provided by a school committee pursuant to section 5 of chapter 71B; or which constitute services provided by the department of mental health. For the purposes of this section, ''licensed mental health professional'' shall mean a licensed physician who specializes in the practice of psychiatry, a licensed psychologist, a licensed independent clinical social worker, a licensed mental health counselor, a licensed nurse mental health clinical specialist, a clinician practicing under the supervision of a licensed professional and working towards licensure in a clinic licensed under chapter 111, a licensed alcohol and drug counselor I, as defined in section 1 of chapter 111J, or a licensed marriage and family therapist within the lawful scope of practice for such therapist. For the purposes of this section, psychopharmacological services and neuropsychological assessment services shall be treated as a medical benefit and shall be covered in a manner identical to all other medical services. (j) A nonprofit medical service corporation may not deny coverage for any behavioral health services or any evaluation and management office visit solely because the behavioral health services and the evaluation and management office visit were delivered on the same day in the same practice or facility, unless the behavioral health services and the evaluation and management office visit were delivered by the same provider or by providers of the same specialty. The division of insurance shall provide guidance relative to implementation of this subsection.

M.G.L. c. 176B, § 4AA Coverage for prosthetic devices and repairs

c. 176B, § 4AA. Coverage for prosthetic devices and repairs Section 4AA. (a) Any subscription certificate under an individual or group medical service agreement, except certificates which provide supplemental coverage to Medicare or other governmental programs that shall be delivered, issued or renewed within the commonwealth shall provide, as benefits to all individual subscribers or members within the commonwealth and to all group members having a principal place of employment within the commonwealth, coverage for prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment benefit, coverage shall be provided under the same terms and conditions that apply to other durable medical equipment covered under the policy, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone prosthetic benefit, coverage shall be consistent with the terms and conditions as described in this section. (b) In this section, ''prosthetic device'' shall mean an artificial limb device to replace, in whole or in part, an arm or leg. (c) No such certificate shall impose any annual or lifetime dollar maximum on coverage for prosthetic devices other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the certificate. (d) No such certificate shall apply amounts paid for prosthetic devices to any annual or lifetime dollar maximum applicable to other durable medical equipment covered under the certificate other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the certificate. (e) Any such certificate may include a reasonable coinsurance requirement for prosthetic devices and repairs, not to exceed 20 per cent of the allowable cost of the prosthetic device or repair, unless all covered benefits applying coinsurance under the plan do so at a higher amount. If the certificate provides coverage for services from nonparticipating providers, the contract may include a reasonable coinsurance requirement for prosthetic devices and repairs, not to exceed 40 per cent of the allowable cost of the prosthetic device or repair when obtained from a nonparticipating provider, unless all covered benefits applying coinsurance under the plan do so at a higher amount. (f) Any such certificate may require prior authorization as a condition of coverage for prosthetic devices. (g) Any such contract shall only be required to provide coverage for the most appropriate medically necessary model that adequately meets the medical needs of the policyholder.

M.G.L. c. 176B, § 4AAA Coverage for diagnostic examinations for breast cancer; digital breast tomosynthesis screening, MRIs and ultrasounds

c. 176B, § 4AAA. Coverage for diagnostic examinations for breast cancer; digital breast tomosynthesis screening, MRIs and ultrasounds [Text of section effective for contracts entered into, renewed or amended on or after January 1, 2026. See 2024, 231, Sec. 7.] Section 4AAA. (a) As used in this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:— ''Cost sharing'', a deductible, coinsurance, copayment and any maximum limitation on the application of such a deductible, coinsurance, copayment or similar out-of-pocket expense. ''Diagnostic examinations for breast cancer'', a medically necessary and appropriate examination for breast cancer to evaluate an abnormality in the breast that is seen or suspected from a screening examination for breast cancer, detected by another means of examination or suspected based on the medical history or family medical history of the individual. ''Examination for breast cancer'', an examination used to evaluate an abnormality in a breast using diagnostic mammography, digital breast tomosynthesis, breast magnetic resonance imaging or breast ultrasound. ''HSA-qualified health insurance policy'', a policy of individual or group health insurance coverage that satisfies the criteria for a high-deductible health plan under 26 U.S.C. 223, as implemented and interpreted by the United States Department of the Treasury in the regulations and guidance in effect at the time the policy is issued. (b) Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth that provides coverage for screening mammograms shall provide coverage for diagnostic examinations for breast cancer, digital breast tomosynthesis screening and medically necessary and appropriate screening with breast magnetic resonance imaging or screening breast ultrasound on a basis not less favorable than screening mammograms that are covered as medical benefits. There shall be no increase in patient cost sharing for: (i) screening mammograms; (ii) digital breast tomosynthesis; (iii) screening breast magnetic resonance imaging; (iv) screening breast ultrasound; or (v) diagnostic examinations for breast cancer. (c)(1) Except as provided in paragraph (2), an HSA-qualified health insurance policy shall be exempt from any prohibition on cost-sharing requirements for a covered benefit required under any general or special law to the extent that the exemption is necessary to allow the policy to be an HSA-qualified health insurance policy. (2) The exemption provided in paragraph (1) shall not apply to any coverage required under any general or special law pertaining to preventive care, as described in 26 U.S.C. 223, with respect to any HSA-qualified health insurance policy issued, delivered, amended or renewed while such regulation or guidance is effective.

M.G.L. c. 176B, § 4BB Coverage for eligible dependents under 26 years of age or dependents mentally or physically incapable of earning their own living due to disability

c. 176B, § 4BB. Coverage for eligible dependents under 26 years of age or dependents mentally or physically incapable of earning their own living due to disability Section 4BB. Any subscription certificate under an individual or group medical service agreement, except certificates that provide stand-alone dental services, supplemental coverage to Medicare or other governmental programs, that is delivered or issued or renewed in the commonwealth, shall provide, as benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth, coverage to eligible dependents under 26 years of age or without regard to age, so long as the dependent, who is covered under the membership of their parent as a member of a family group, is mentally or physically incapable of earning their own living due to disability.

M.G.L. c. 176B, § 4BBB Coverage for prescribed, ordered or dispensed opioid antagonists

c. 176B, § 4BBB. Coverage for prescribed, ordered or dispensed opioid antagonists [Text of section applicable to all contracts entered into, renewed or amended on or after July 1, 2025. See 2024, 285, Sec. 45.] Section 4BBB. (a) A subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth, shall provide coverage for prescribed, ordered or dispensed opioid antagonists, as defined in section 19B of chapter 94C and used in the reversal of overdoses caused by opioids; provided, however, that the coverage for such prescribed, ordered or dispensed opioid antagonists shall not require prior authorization; and provided further, that a prescription from a health care practitioner shall not be required for coverage or reimbursement of opioid antagonists under this section. An opioid antagonist used in the reversal of overdoses caused by opioids shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service. (b) The policy, contract, agreement, plan or certificate of insurance shall provide coverage and reimbursement for an opioid antagonist used in the reversal of overdoses caused by opioids as a medical benefit when dispensed by the health care facility in which the opioid antagonist was prescribed or ordered and shall provide coverage as a pharmacy benefit for an opioid antagonist used in the reversal of overdoses caused by opioids dispensed by a pharmacist, including an opioid antagonist dispensed pursuant to section 19B of chapter 94C; provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the carrier's average in-network pharmacy benefit rate and the health care facility shall not balance bill the patient.

M.G.L. c. 176B, § 4C Dependent coverage for newborn infants or adoptive children; inclusion of medical expenses as benefits

c. 176B, § 4C. Dependent coverage for newborn infants or adoptive children; inclusion of medical expenses as benefits Section 4C. Any subscription certificate, which provides for dependent coverage, under an individual or group medical service agreement which shall be delivered or issued for delivery or subsequently renewed in the commonwealth shall include as insured members, newborn infants and newborn infants of a dependent of a subscription certificate holder immediately from the moment of birth and thereafter and shall also include as insured members adoptive children of a subscription certificate holder immediately from the date of the filing of a petition to adopt under chapter two hundred and ten and thereafter if the child has been residing in the home of the subscription certificate holder as a foster child for whom the holder has been receiving foster care payments, or, in all other cases, immediately from the date of placement by a licensed placement agency of a child for purposes of adoption in the home of the subscription certificate holder and thereafter. Such insurance shall provide benefits for expense arising from illness, injury, congenital malformation, or premature birth. Such coverage shall include also those special medical formulas which are approved by the commissioner of the department of public health, prescribed by a physician, and are medically necessary for treatment of phenylketonuria, tyrosinemia, homocystinuria, maple syrup urine disease, propionic acidemia, or methylmalonic acidemia in infants and children or medically necessary to protect the unborn fetuses of pregnant women with phenylketonuria. Such coverage shall also include screening for lead poisoning as required by the regulations promulgated pursuant to section one hundred and ninety-three of chapter one hundred and eleven. If payment of a subscription fee is required to provide coverage for a child, the policy or contract may require that notification of birth of a newly born child or of filing of a petition to adopt a foster child or of placement of a child for purposes of adoption and payment of the required fees must be furnished to the non-profit service corporation. For the purposes of this section, ''notification'' may mean submission of a claim. Any subscriptions certificate, as described in this section, shall provide as benefits to all subscribers and members in addition to those benefits described in the preceding paragraph the provisions of preventive and primary care services for children. For the purposes of this paragraph preventive and primary care services shall mean services rendered to a dependent child or a subscriber or member from the date of birth through the attainment of six years of age and shall include physical examination, history, measurements, sensory screening, neuropsychiatric evaluation and development screening, and assessment at the following intervals: six times during the child's first year after birth, three times during the year annually until age six. Such services shall also include hereditary and metabolic screening at birth, appropriate immunizations, and tuberculin tests, hematocrit, hemoglobin or other appropriate blood tests and urinalysis as recommended by the physician. The dependent coverage of any such policy shall also provide coverage for medically necessary early intervention services delivered by certified early intervention specialists, as defined in the early intervention operational standards by the department of public health and in accordance with applicable certification requirements. Such medically necessary services shall be provided by early intervention specialists who are working in early intervention programs certified by the department of public health, as provided in sections 1 and 2 of chapter 111G, for children from birth until their third birthday. Reimbursement of costs for such services shall be part of a basic benefits package offered by the insurer or a third party and shall not require co-payments, coinsurance or deductibles; provided, however, that co-payments, coinsurance or deductibles shall be required if the applicable plan is governed by the Federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on co-payments, coinsurance or deductibles for these services. In addition to such benefits, any subscription certificate, as described in this section, shall provide coverage for the cost of a newborn hearing screening test to be performed before the newborn infant is discharged from the hospital or birthing center to the care of the parent or guardian or as provided by regulations of the department of public health. Nothing contained in this paragraph shall be construed to abrogate any other obligation to provide coverage for a hearing screening test or any other hearing screening test or audiological diagnostic procedure pursuant to any law of the commonwealth or of the United States or under the terms or provisions of any contract or certificate.

M.G.L. c. 176B, § 4CC Coverage for medically necessary hypodermic syringes or needles

c. 176B, § 4CC. Coverage for medically necessary hypodermic syringes or needles Section 4CC. No subscription certificate under an individual or group medical service agreement, delivered, issued or renewed in the commonwealth shall restrict or discontinue coverage for medically necessary hypodermic syringes or needles to an individual or group subscriber within the commonwealth or to a group subscriber having a principal place of employment within the commonwealth, notwithstanding section 27 of chapter 94C. The term ''medical necessity'' shall be construed in accordance with the guidelines set forth in subsection (b) of section 16 of chapter 176O.

M.G.L. c. 176B, § 4CCC Coverage for the provision of services by a recovery coach

c. 176B, § 4CCC. Coverage for the provision of services by a recovery coach [Text of section applicable to all contracts entered into, renewed or amended on or after January 1, 2026. See 2024, 285, Sec. 46.] Section 4CCC. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for the provision of services by a recovery coach licensed or otherwise authorized to practice under chapter 111J, regardless of the setting in which these services are provided; provided, however, that such services shall be within the lawful scope of practice of a recovery coach. The contractual rate for these services shall be not less than the prevailing MassHealth rate for recovery coach services. The benefits in this section shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service. Recovery coach services shall not require prior authorization.

M.G.L. c. 176B, § 4D Refusal to contract with blind or deaf persons; prohibition

c. 176B, § 4D. Refusal to contract with blind or deaf persons; prohibition Section 4D. No corporation subject to this chapter shall refuse for the reason of blindness or deafness, to contract with a subscriber a subscription certificate under an individual medical service agreement.

M.G.L. c. 176B, § 4DD Coverage for diagnosis and treatment of autism spectrum disorder

c. 176B, § 4DD. Coverage for diagnosis and treatment of autism spectrum disorder Section 4DD. (a) As used in this section the following words shall, unless the context clearly requires otherwise, have the following meanings:— ''Actuary'', a person who is a member of American Academy of Actuaries and meets the academy's professional qualification standards for rendering an actuarial opinion related to health insurance rate making. ''Applied behavior analysis'', the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior. ''Autism services provider'', a person, entity or group that provides treatment of autism spectrum disorders. ''Autism spectrum disorders'', any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, Asperger's disorder and pervasive developmental disorders not otherwise specified. ''Board certified behavior analyst'', a behavior analyst credentialed by the behavior analyst certification board as a board certified behavior analyst. ''Diagnosis of autism spectrum disorders'', medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has 1 of the autism spectrum disorders. ''Habilitative or rehabilitative care'', professional, counseling and guidance services and treatment programs, including, but not limited to, applied behavior analysis supervised by a board certified behavior analyst, that are necessary to develop, maintain and restore, to the maximum extent practicable, the functioning of an individual. ''Pharmacy care'', medications prescribed by a licensed physician and health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the certificate for other medical conditions. ''Psychiatric care'', direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices. ''Psychological care'', direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices. ''Therapeutic care'', services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers. ''Treatment of autism spectrum disorders'', includes the following care prescribed, provided or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary: habilitative or rehabilitative care; pharmacy care; psychiatric care; psychological care; and therapeutic care. (b) A subscription certificate under an individual or group medical service agreement which is issued or renewed within or without the commonwealth shall provide benefits on a nondiscriminatory basis to residents of the commonwealth and to all policyholders having a principal place of employment in the commonwealth for the diagnosis and treatment of autism spectrum disorder in individuals. (c) Such certificate shall be in compliance with subsection (b) if the certificate does not contain any annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of autism spectrum disorders which is less than annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions. (d) This section shall not limit benefits that are otherwise available to an individual under a health insurance policy. (e) Coverage under this section shall not be subject to a limit on the number of visits an individual may make to an autism services provider. (f) This section shall not affect an obligation to provide services to an individual under an individualized family service plan, an individualized education program or an individualized service plan. Services related to autism spectrum disorder provided by school personnel pursuant to an individualized education program are not subject to reimbursement under this section. (g) An insurer, corporation or health maintenance organization shall be exempt for a period of 3 years from the requirement to provide coverage for habilitative or rehabilitative care required under this section and not covered by the insurer, corporation or health maintenance organization as of December 31, 2010, if: (1) an actuary, affiliated with the insurer, corporation or health maintenance organization certifies in writing to the commissioner of insurance that: (i) based on an analysis to be completed not more than once annually by each insurer, corporation or health maintenance organization for the most recent experience period of at least 1 year's duration, the annual costs associated with coverage of habilitative or rehabilitative care required under this section and not covered as of December 31, 2010, exceeded 1 per cent of the premiums charged over the experience period by the insurer, corporation or health maintenance organization; (ii) those costs solely would lead to an increase in average premiums charged of more than 1 per cent for all insurance policies, subscription contracts or health care plans commencing on inception or the next renewal date, based on the premium rating methodology and practices the insurer, corporation or health maintenance organization employs; and (iii) the commissioner of insurance approves the certification of the actuary. (2) An exemption allowed under paragraph (1) shall apply for a 3 year coverage period following inception or next renewal date of all insurance policies, subscription contracts or health care plans issued or renewed during the 1–year period following the date of the exemption, after which the insurer, corporation or health maintenance organization shall again provide coverage for habilitative or rehabilitative care required under this section. (3) Notwithstanding the exemption allowed under paragraph (1), an insurer, corporation or health maintenance organization may elect to continue to provide coverage for habilitative or rehabilitative care required under this section.

M.G.L. c. 176B, § 4DD1/2 Coverage for treatment of Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis services

c. 176B, § 4DD1/2. Coverage for treatment of Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis services [Text of section added by 2024, 388, Sec. 5 effective January 1, 2026. See 2024, 388, Sec. 7.] Section 4DD1/2. For purposes of this section, ''Down syndrome'' shall mean a chromosomal condition caused by an error in cell division that results in the presence of an extra whole or partial copy of chromosome 21. A subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for the treatment of Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis services.

M.G.L. c. 176B, § 4DDD Coverage for identified generic and brand name drug used to treat diabetes, asthma, and certain heart conditions

c. 176B, § 4DDD. Coverage for identified generic and brand name drug used to treat diabetes, asthma, and certain heart conditions [Text of section applicable to all contracts entered into, renewed or amended on or after July 1, 2025. See 2024, 342, Sec. 39.] Section 4DDD. (a) As used in this section, the following words shall have the following meanings unless the context clearly requires otherwise: ''Brand name drug'', a drug that is: (i) produced or distributed pursuant to an original new drug application approved under 21 U.S.C. 355(c) except for: (A) any drug approved through an application submitted under section 505(b)(2) of the Federal Food, Drug, and Cosmetic Act that is pharmaceutically equivalent, as that term is defined by the United States Food and Drug Administration, to a drug approved under 21 U.S.C. 355(c); (B) an abbreviated new drug application that was approved by the United States Secretary of Health and Human Services under section 505(c) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. 355(c), before the date of the enactment of the Drug Price Competition and Patent Term Restoration Act of 1984, Public Law 98–417, 98 Stat. 1585; or (C) an authorized generic drug as defined in 42 C.F.R. 447.502; (ii) produced or distributed pursuant to a biologics license application approved under 42 U.S.C. 262(a)(2)(C); or (iii) identified by the health benefit plan as a brand name drug based on available data resources, including Medi–Span. ''Generic drug'', a retail drug that is: (i) marketed or distributed pursuant to an abbreviated new drug application approved under 21 U.S.C. 355(j); (ii) an authorized generic drug as defined in 42 C.F.R. 447.502; (iii) a drug that entered the market before January 1, 1962 and was not originally marketed under a new drug application; or (iv) identified by the health benefit plan as a generic drug based on available data resources, including Medi–Span. (b) A subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall identify 1 generic drug and 1 brand name drug used to treat each of the following chronic conditions: (i) diabetes; (ii) asthma; and (iii) the 2 most prevalent heart conditions among its enrollees. (c) The carrier shall identify insulin as the drug used to treat diabetes. In determining the 1 generic drug and 1 brand name drug used to treat each chronic condition, the carrier shall consider whether the drug is: (i) of clear benefit and strongly supported by clinical evidence; (ii) likely to: (A) reduce hospitalizations or emergency department visits; (B) reduce future exacerbations of illness progression; or (C) improve quality of life; (iii) cost effective for the carrier and its enrollees; (iv) at low risk for overutilization, abuse, addiction, diversion or fraud; and (v) one of the most widely utilized as a treatment for the chronic condition. (d) A subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for the brand name drugs and generic drugs identified pursuant to subsection (b). Coverage for the identified generic drugs shall not be subject to any cost-sharing, including co-payments and co-insurance and shall not be subject to any deductible; provided, however, that cost-sharing shall be required if the applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing under this section. Coverage for identified brand name drugs shall not be subject to any deductible or co-insurance and any co-payment shall not exceed $25 per 30–day supply. Coverage for 1 brand name insulin drug per dosage and type, including rapid-acting, short-acting, intermediate-acting, long-acting, ultra long-acting and premixed under this section shall not be subject to any deductible or co-insurance and any co-payment shall not exceed $25 per 30–day supply. (e) The carrier shall implement a continuity of coverage policy to apply to enrollees that are new to the plan and that provides coverage for a 30–day fill of a United States Food and Drug Administration-approved drug reimbursed through a pharmacy benefit that the enrollee has already been prescribed and on which the enrollee is stable, upon documentation by the enrollee's prescriber; provided, however, that a carrier shall not apply any greater deductible, coinsurance, copayments or out-of-pocket limits than would otherwise apply to other drugs covered by the plan. (f) The carrier may make changes in its selection of drugs pursuant to this section not more than annually. (g) The carrier shall make public the drugs selected pursuant to subsection (b).

M.G.L. c. 176B, § 4E Diethylstilbestrol exposure; discrimination

c. 176B, § 4E. Diethylstilbestrol exposure; discrimination Section 4E. No subscription certificate under an individual or group medical service agreement which shall be delivered or issued or renewed in the commonwealth shall be denied or cancelled or fail to be renewed, nor shall any excessive rates be charged or restrictions on the length of coverage be imposed, nor shall any other factor be altered in such a way as to constitute discrimination primarily because the insured person has had a suspected, alleged or confirmed exposure to the potential hazards and afflictions of diethylstilbestrol or compounds commonly referred to as DES. The practices prohibited under this section shall include not only those overtly discriminatory but also practices and devices which are fair in form but discriminatory in practice.

M.G.L. c. 176B, § 4EE Coverage for children 21 years of age or younger for hearing aids and related services

c. 176B, § 4EE. Coverage for children 21 years of age or younger for hearing aids and related services [Text of section added by 2012, 233, Sec. 4. See also, Section 4EE added by 2012, 234, Sec. 5, below.] Section 4EE. Any subscription certificate under an individual or group medical service agreement, except certificates which provide supplemental coverage to Medicare or other governmental programs, that shall be delivered, issued or renewed within the commonwealth shall provide as benefits to all individual subscribers or members within the commonwealth and to all group members having a principal place of employment in the commonwealth, coverage for such person's children 21 years of age or younger, who are insured under such certificates or agreements, for the cost of 1 hearing aid per hearing impaired ear up to $2,000 for each hearing aid, as defined under section 196 of chapter 112, every 36 months upon a written statement from the child's treating physician that the hearing aids are necessary regardless of etiology. Coverage under this section shall include all related services prescribed by a licensed audiologist or hearing instrument specialist, as defined in said section 196 of said chapter 112, including the initial hearing aid evaluation, fitting and adjustments and supplies, including ear molds. The insured may choose a higher priced hearing aid and may pay the difference in cost above the $2,000 limit in this section without any financial or contractual penalty to the insured or to the provider of the hearing aid. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefits provided by the insurer. Nothing in this section shall prohibit an insurer from offering greater coverage for hearing aids than required by this section. This section shall also require coverage for such hearing aids under any non-group policy. Chapter 176B: Section 4EE. Coverage for children under age 18 for cleft lip and cleft palate [Text of section added by 2012, 234, Sec. 5. See also, Section 4EE added by 2012, 233, Sec. 4, above.] Section 4EE. Any subscription certificate under an individual or group medical service agreement, except certificates that provide supplemental coverage to Medicare or other governmental programs, issued, delivered or renewed within or without the commonwealth, that covers a child under the age of 18 shall provide coverage for the cost of treating cleft lip and cleft palate for the child. The coverage shall include benefits for medical, dental, oral and facial surgery, surgical management and follow-up care by oral and plastic surgeons, orthodontic treatment and management, preventative and restorative dentistry to ensure good health and adequate dental structures for orthodontic treatment or prosthetic management therapy, speech therapy, audiology and nutrition services, if such services are prescribed by the treating physician or surgeon and such physician or surgeon certifies that such services are medically necessary and consequent to the treatment of the cleft lip, cleft palate or both. The coverage required by this section shall be subject to the terms and conditions applicable to other benefits. Payment for dental or orthodontic treatment not related to the management of the congenital conditions of cleft lip and cleft palate shall not be covered under this section.

M.G.L. c. 176B, § 4F Cardiac rehabilitation expense benefits

c. 176B, § 4F. Cardiac rehabilitation expense benefits Section 4F. Any subscription certificate under an individual or group medical service agreement, except certificates which provide supplemental coverage to medicare or other governmental programs, which shall be delivered or issued or renewed in the commonwealth shall provide, as a basic benefit to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth for expense for cardiac rehabilitation. Cardiac rehabilitation shall mean multidisciplinary, medically necessary treatment of persons with documented cardiovascular disease which shall be provided in either a hospital or other setting and which shall meet standards promulgated by the commissioner of public health after reviewing proposals submitted by the Massachusetts Society for Cardiac Rehabilitation, Inc. and after notice and public hearing on the proposed standards. Such standards shall include, but not be limited to, outpatient treatment which is to be initiated within twenty-six weeks after the diagnosis of such disease.

M.G.L. c. 176B, § 4FF Coverage for orally administered anticancer medications

c. 176B, § 4FF. Coverage for orally administered anticancer medications Section 4FF. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth that provides coverage for cancer chemotherapy treatment shall provide coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis not less favorable than intravenously administered or injected cancer medications that are covered as medical benefits. An increase in patient cost sharing for anticancer medications shall not be allowed to achieve compliance with this section.

M.G.L. c. 176B, § 4G Certified nurse midwife services benefits

c. 176B, § 4G. Certified nurse midwife services benefits Section 4G. Any subscription certificate under an individual or group medical service agreement which shall be delivered or issued or renewed in this commonwealth shall provide as benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth, for expense for services of a certified nurse midwife; provided, however, that such services are reimbursed when rendered by any other duly licensed practitioner; and provided, further, that such services are within the lawful scope of practice for a certified nurse midwife.

M.G.L. c. 176B, § 4GG Coverage for abuse deterrent opioid drug products

c. 176B, § 4GG. Coverage for abuse deterrent opioid drug products Section 4GG. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for abuse deterrent opioid drug products listed on the formulary, compiled pursuant to subsection (b) of section 13 of chapter 17, on a basis not less favorable than non-abuse deterrent opioid drug products that are covered by an individual or group medical service agreement. An increase in patient cost sharing shall not be allowed to achieve compliance with this section.

M.G.L. c. 176B, § 4H Abortion, abortion-related care, prenatal, childbirth and postpartum care benefits; minimum coverage for in-patient care

c. 176B, § 4H. Abortion, abortion-related care, prenatal, childbirth and postpartum care benefits; minimum coverage for in-patient care [First paragraph applicable as provided by 2022, 127, Sec. 44.] Section 4H. Any subscription certificate under an individual or group medical service agreement, except certificates which provide supplemental coverage to medicare or other governmental programs, which shall be delivered or issued or renewed in the commonwealth shall provide, as a basic benefit to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth for expense for abortion, as defined in section 12K of chapter 112, abortion-related care, prenatal care, childbirth and post partum care. In addition to such benefits, such policy or plan shall provide coverage of a minimum of forty-eight hours of in-patient care following a vaginal delivery and a minimum of ninety-six hours of in-patient care following a caesarean section for a mother and her newly born child. Any decision to shorten these minimum coverages shall be made by the attending physician in consultation with the mother. Any such decision shall be made in accordance with rules and regulations promulgated by the department of public health. Said regulations shall be relative to early discharge, defined as less than forty-eight hours for a vaginal delivery and ninety-six hours for a caesarean delivery, and post-delivery care and shall include, but not be limited to, home visits, parent education, assistance and training in breast or bottle feeding and the performance of any necessary and appropriate clinical tests; provided, however, that the first home visit shall be conducted by a registered nurse, physician, or certified nurse midwife; and provided, further, that any subsequent home visit determined to be clinically necessary shall be provided by a licensed health care provider. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician, or certified nurse midwife attending the mother and newly born child. [Fourth through sixth paragraphs applicable as provided by 2022, 127, Sec. 44.] Coverage provided under this section for abortion or abortion-related care shall not be subject to any deductible, coinsurance, copayment or any other cost-sharing requirement; provided, however, that deductibles, coinsurance or copayments shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on deductibles, coinsurance or copayments for these services. Coverage offered under this section for abortion or abortion-related care shall not impose unreasonable restrictions or delays in the coverage. Benefits for an enrollee under this section shall be the same for the enrollee's covered spouse and covered dependents. A policy of accident and sickness insurance that is purchased by an employer that is a church or qualified church-controlled organization, as those terms are defined in subsection (j) of section 4W, shall be exempt from covering abortion or abortion-related care at the request of the employer. An employer that invokes the exemption under this subsection shall provide written notice to prospective enrollees prior to enrollment with the plan and such notice shall list the health care methods and services for which the employer will not provide coverage for religious reasons. Any subscriber or member who is aggrieved by a denial of benefits to be provided under this section may appeal said denial in accordance with regulations of the department of public health.

M.G.L. c. 176B, § 4HH Preauthorization for substance abuse treatment not to be required

c. 176B, § 4HH. Preauthorization for substance abuse treatment not to be required Section 4HH. For the purposes of this section the term ''substance abuse treatment'' shall include: early intervention services for substance use disorder treatment; a substance use disorder evaluation, as defined in section 511/2 of chapter 111; outpatient services including medically assisted therapies; intensive outpatient and partial hospitalization services; residential or inpatient services, not covered under section 4II; and medically managed intensive inpatient services, not covered under said section 4II. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall not require a member to obtain a preauthorization for substance abuse treatment if the provider is certified or licensed by the department of public health.

M.G.L. c. 176B, § 4I Cytologic screening and mammographic examination benefits

c. 176B, § 4I. Cytologic screening and mammographic examination benefits Section 4I. Any subscription certificate under an individual or group medical service agreement, except certificates which provide supplemental coverage to Medicare or other governmental programs, which shall be delivered or issued or renewed in the commonwealth shall provide as benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth for expense of cytologic screening and mammographic examination. Said benefits shall be at least equal to the following minimum requirement; (a) in the case of benefits for cytologic screening, said benefits shall provide for an annual cytologic screening for women eighteen years of age and older; and (b), in the case of benefits for mammographic examination said benefits shall provide for a baseline mammogram for women between the ages of thirty-five and forty and for mammogram on an annual basis for women forty years of age and older.

M.G.L. c. 176B, § 4II Coverage for medically necessary acute treatment or clinical stabilization services

c. 176B, § 4II. Coverage for medically necessary acute treatment or clinical stabilization services Section 4II. For the purposes of this section the following terms shall, unless the context clearly requires otherwise, have the following meanings:— ''Acute treatment services'', 24–hour medically supervised addiction treatment for adults or adolescents provided in a medically managed or medically monitored inpatient facility, as defined by the department of public health, that provides evaluation and withdrawal management and which may include biopsychosocial assessment, individual and group counseling, psychoeducational groups and discharge planning. ''Clinical stabilization services'', 24–hour clinically managed post detoxification treatment for adults or adolescents, as defined by the department of public health, usually following acute treatment services for substance abuse, which may include intensive education and counseling regarding the nature of addiction and its consequences, relapse prevention, outreach to families and significant others and aftercare planning, for individuals beginning to engage in recovery from addiction. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary acute treatment services and medically necessary clinical stabilization services for up to a total of 14 days and shall not require preauthorization prior to obtaining acute treatment services or clinical stabilization services; provided that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7; provided further, any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for, without preauthorization, a substance use disorder evaluation ordered pursuant to section 511/2 of chapter 111. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient's medical record.

M.G.L. c. 176B, § 4J Infertility diagnosis and treatment benefits

c. 176B, § 4J. Infertility diagnosis and treatment benefits Section 4J. Any subscription certificate under an individual or group medical service agreement, except certificates which provide supplemental coverage to medicare or other governmental programs, which is delivered, issued for delivery or renewed in the commonwealth while this section is effective shall provide as a benefit for all individual subscribers or members within the commonwealth and all group members having a principal place of employment within the commonwealth, to the same extent that benefits are provided for other pregnancy-related procedures and subject to the other terms and conditions of the subscription certificate, coverage for medically necessary expenses of diagnosis and treatment of infertility. Said infertility benefits shall meet all other terms and conditions of the subscription certificate. For purposes of this section, ''infertility' shall mean the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35. For purposes of meeting the criteria for infertility in this section, if a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the 1 year or 6 month period, as applicable.

M.G.L. c. 176B, § 4K Nonprescription enteral formulas for home use

c. 176B, § 4K. Nonprescription enteral formulas for home use Section 4K. Any subscription certificate under an individual or group medical service agreement that shall be delivered, issued or renewed in the commonwealth shall provide, as benefits to all individual subscribers and members within the commonwealth, all group members having a principal place of employment within the commonwealth and all persons included in section four C, coverage for nonprescription enteral formulas for home use for which a physician has issued a written order and which are medically necessary for the treatment of malabsorption caused by Crohn's disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility, chronic intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein in an amount not to exceed $5,000 annually for any insured individual.

M.G.L. c. 176B, § 4KK Coverage for medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome

c. 176B, § 4KK. Coverage for medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome Section 4KK. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome including, but not limited to, reconstructive surgery, such as suction assisted lipectomy, other restorative procedures and dermal injections or fillers for reversal of facial lipoatrophy syndrome. Coverage shall be subject to a statement from a treating provider that the treatment is necessary for correcting, repairing or ameliorating the effects of HIV associated lipodystrophy syndrome. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

M.G.L. c. 176B, § 4L Chiropractic services benefits

c. 176B, § 4L. Chiropractic services benefits Section 4L. Any subscription certificate under an individual or group medical service agreement which shall be delivered or issued or renewed in the commonwealth shall provide as benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth for expense for chiropractic service.

M.G.L. c. 176B, § 4LL Filling of remaining portion of prescription for covered drug that is a narcotic substance earlier filled in lesser quantity

c. 176B, § 4LL. Filling of remaining portion of prescription for covered drug that is a narcotic substance earlier filled in lesser quantity Section 4LL. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide, for any covered drug that is a narcotic substance contained in schedule II pursuant to chapter 94C and subject to cost sharing, that if a person receives a prescription filled in a lesser quantity pursuant to section 18 of said chapter 94C, said person shall not be subject to an additional payment obligation, including but not limited to co-payments, if said person fills the remaining portion of the prescription.

M.G.L. c. 176B, § 4M Standardized claim form

c. 176B, § 4M. Standardized claim form Section 4M. The commissioner of insurance is hereby directed to produce a standardized claim form to be utilized by all health insurance companies licensed to do business in the commonwealth for billing purposes. Said form shall be made available to said companies no later than July first, nineteen hundred and ninety-three.

M.G.L. c. 176B, § 4MM Pain management access plan; non-medication and nonsurgical treatment; review; educational materials

c. 176B, § 4MM. Pain management access plan; non-medication and nonsurgical treatment; review; educational materials [Text of section applicable to all contracts entered into, renewed or amended on or after July 1, 2025. See 2024, 285, Sec. 47.] Section 4MM. (a) A subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall develop a plan to provide adequate coverage and access to a broad spectrum of pain management services, including, but not limited to, non-medication, nonsurgical treatment modalities and non-opioid medication treatment options that serve as alternatives to opioid prescribing, in accordance with guidelines developed by the division of insurance. (b) No such subscription certificate shall, relative to pain management services identified by the carrier pursuant to subsection (a), require a member to obtain prior authorization for non-medication, nonsurgical treatment modalities that include restorative therapies, behavioral health approaches or integrative health therapies, including acupuncture, chiropractic treatments, massage and movement therapies. (c)(1) The plan developed pursuant to subsection (a) shall be subject to approval by the division of insurance and shall be a component of carrier accreditation by the division pursuant to section 2 of chapter 176O. In its review, the division shall consider the adequacy of access to a broad spectrum of pain management services and any carrier policies that may create unduly preferential coverage to prescribing opioids without other pain management modalities. (2) No subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall establish utilization controls, including prior authorization or step therapy requirements, for clinically appropriate non-opioid drugs approved by the United States Food and Drug Administration for the treatment or management of pain, that are more restrictive or extensive than the least restrictive or extensive utilization controls applicable to any clinically appropriate opioid drug. (d) Carriers shall annually distribute educational materials to providers within their networks and to members about the pain management access plans developed pursuant to subsection (a) and shall make information about the plans publicly available on their websites.

M.G.L. c. 176B, § 4N Off-label drug use; cancer

c. 176B, § 4N. Off-label drug use; cancer Section 4N. Any subscription certificate under an individual or group medical service agreement that shall be delivered, issued or renewed in the commonwealth which provides coverage for prescription drugs, shall provide as benefits to all individual subscribers and members and to all group members having a principal place of employment within the commonwealth, coverage for off-label uses of prescription drugs used in the treatment of cancer as defined in, and subject to the restrictions of, sections forty-seven K and forty-seven L of chapter one hundred and seventy-five.

M.G.L. c. 176B, § 4NN Coverage for tobacco use cessation counseling and tobacco cessation products

c. 176B, § 4NN. Coverage for tobacco use cessation counseling and tobacco cessation products Section 4NN. (a) Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for: (i) tobacco use cessation counseling; and (ii) all generic United States Food and Drug Administration-approved tobacco cessation products without cost sharing when prescribed by a health care provider. (b) Carriers shall be permitted to employ reasonable managed care techniques consistent with state and federal law to determine the frequency, method, treatment or setting for the recommended item or service; provided, however, that covered persons shall have access to at least 1 tobacco cessation product without prior authorization.

M.G.L. c. 176B, § 4O Medical service agreement coverage for bone marrow transplants

c. 176B, § 4O. Medical service agreement coverage for bone marrow transplants Section 4O. Any subscription certificate under an individual or group medical service agreement that shall be delivered, issued or renewed in the commonwealth shall provide as a benefit for all individual subscribers or members within the commonwealth and all group members having a principal place of employment within the commonwealth, coverage for a bone marrow transplant or transplants for persons who have been diagnosed with breast cancer that has progressed to metastatic disease; provided, however, that said person shall meet the criteria established by the department of public health. The department of public health shall promulgate rules and regulations establishing criteria for eligibility for coverage hereunder which shall be consistent with medical research protocols reviewed and approved by the National Cancer Institute.

M.G.L. c. 176B, § 4OO Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome

c. 176B, § 4OO. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome [Text of section applicable to contracts that take effect or are renewed on or after January 1, 2022. See 2020, 260, Sec. 74.] Section 4OO. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome including, but not limited to, the use of intravenous immunoglobulin therapy.

M.G.L. c. 176B, § 4P Off-label use of prescription drugs for HIV/AIDS treatment

c. 176B, § 4P. Off-label use of prescription drugs for HIV/AIDS treatment Section 4P. Any subscription certificate under individual or group medical service agreement that shall be delivered, issued or renewed in the commonwealth which provides coverage for prescription drugs shall provide coverage for off-label uses of prescription drugs used in the treatment of HIV/AIDS as set forth in sections forty-seven O and forty-seven P of chapter one hundred and seventy-five as benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth.

M.G.L. c. 176B, § 4Q Coverage for licensed hospice services

c. 176B, § 4Q. Coverage for licensed hospice services Section 4Q. Any subscription certificate under an individual or group medical service agreement that shall be delivered, issued or renewed in the commonwealth shall provide as a benefit for all individual subscribers or members within the commonwealth and all group members having a principal place of employment within the commonwealth, coverage for licensed hospice services to terminally ill patients with a life expectancy of six months or less, as set forth and regulated by the provisions of section fifty-seven D of chapter one hundred and eleven and as authorized by a duly licensed physician.

M.G.L. c. 176B, § 4QQ Coverage for prescription eye drops

c. 176B, § 4QQ. Coverage for prescription eye drops Section 4QQ. A subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth that provides coverage for prescription eye drops shall provide coverage for refills of prescription eye drops in accordance with the Medicare Part D guidelines on early refills of topical ophthalmic products when: (i) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; (ii) the refill requested by the insured does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner; and (iii) the prescription eye drops prescribed by the health care practitioner are a covered benefit under the policy or contract of the insured.

M.G.L. c. 176B, § 4R Scalp hair prostheses necessary due to cancer or leukemia treatment

c. 176B, § 4R. Scalp hair prostheses necessary due to cancer or leukemia treatment Section 4R. (a) For the purposes of this section, the following words shall have the following meanings: ''Prosthesis'', an artificial appliance used to replace a lost natural structure; provided, however, that prosthesis shall include, but not be limited to, artificial arms, legs, breasts, scalp hair or glass eyes. ''Scalp hair prosthesis'', an artificial substitute for scalp hair. (b) Any subscription certificate under an individual or group medical service agreement, except certificates which provide supplemental coverage to medicare or other governmental programs, that shall be delivered, issued or renewed within the commonwealth, and which provides coverage for any other prosthesis, shall provide, as benefits to all individual subscribers or members within the commonwealth and to all group members having a principal place of employment within the commonwealth, coverage for expenses for scalp hair prostheses worn for hair loss suffered as a result of the treatment of any form of cancer or leukemia; provided, however, that such coverage shall be subject to a written statement by the treating physician that the scalp hair prosthesis is medically necessary; and provided, further, that such coverage shall be subject to the same limitations and guidelines as other prostheses. Scalp hair prosthesis coverage pursuant to this section shall not exceed an amount of $350 per year.

M.G.L. c. 176B, § 4RR Coverage for mental health or substance use disorder services delivered through psychiatric collaborative care model

c. 176B, § 4RR. Coverage for mental health or substance use disorder services delivered through psychiatric collaborative care model Section 4RR. (a) For the purposes of this section, ''psychiatric collaborative care model'' shall mean the evidence-based, integrated behavioral health service delivery method in which a primary care team consisting of a primary care provider and a care manager provides structured care management to a patient, and that works in collaboration with a psychiatric consultant that provides regular consultations to the primary care team to review the clinical status and care of patients and to make recommendations. (b) A subscription certificate under an individual or group medical service agreement that is issued or renewed within or without the commonwealth shall provide coverage for mental health or substance use disorder services that are delivered through the psychiatric collaborative care model.

M.G.L. c. 176B, § 4S Items medically necessary for diagnosis and treatment of diabetes

c. 176B, § 4S. Items medically necessary for diagnosis and treatment of diabetes Section 4S. A subscription certificate under an individual or group medical service agreement which provides hospital expense and surgical expense insurance, except certificates which provide supplemental coverage to Medicare or other governmental programs, delivered, issued or renewed by agreement between the insurer and the policyholder, within or without the commonwealth, shall provide benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth coverage for the following items if such items are within a category of benefits or services for which coverage is otherwise afforded by the medical service agreement, have been prescribed by a health care professional legally authorized to prescribe such items and if the items are medically necessary for the diagnosis or treatment of insulin-dependent, insulin-using, gestational and non-insulin-dependent diabetes: blood glucose monitors; blood glucose monitoring strips for home use; voice-synthesizers for blood glucose monitors for use by the legally blind; visual magnifying aids for use by the legally blind; urine glucose strips; ketone strips; lancets; insulin; insulin syringes; prescribed oral diabetes medications that influence blood sugar levels; laboratory tests, including glycosylated hemoglobin, or HbAlc, tests; urinary protein/microalbumin and lipid profiles; insulin pumps and insulin pump supplies; insulin pens, so-called; therapeutic/molded shoes and shoe inserts for people who have severe diabetic foot disease when the need for therapeutic shoes and inserts has been certified by the treating doctor and prescribed by a podiatrist or other qualified doctor and furnished by a podiatrist, orthotist, prosthetist or pedorthist; supplies and equipment approved by the Federal Drug Administration for the purposes for which they have been prescribed and diabetes outpatient self-management training and education, including medical nutrition therapy, when provided by a certified diabetes health care provider participating with the medical service agreement or affiliated with a provider participating with the medical service agreement. As used in this section, ''certified diabetes health care provider'' shall mean a licensed health care professional with expertise in diabetes, a registered dietician or a health care provider certified by the National Certification Board of Diabetes Educators as a certified diabetes educator. Nothing in this section shall be construed to require a medical service corporation to contract with a certified diabetes health care provider who is not already under contract with such medical service corporation. The benefits provided in this section shall meet all other terms and conditions within a subscription certificate. Medical service agreements shall not reduce or eliminate coverage due to the requirements of this section.

M.G.L. c. 176B, § 4SS Coverage for medically necessary mental health acute treatment, community-based acute treatment, intensive community-based acute treatment

c. 176B, § 4SS. Coverage for medically necessary mental health acute treatment, community-based acute treatment, intensive community-based acute treatment Section 4SS. For the purposes of this section, the following terms shall have the following meanings unless the context clearly requires otherwise: ''Community-based acute treatment'', 24–hour clinically managed mental health diversionary or step-down services for children and adolescents that is usually provided as an alternative to mental health acute treatment. ''Intensive community-based acute treatment'', intensive 24–hour clinically managed mental health diversionary or step-down services for children and adolescents that is usually provided as an alternative to mental health acute treatment. ''Mental health acute treatment'', 24–hour medically supervised mental health services provided in an inpatient facility, licensed by the department of mental health, that provides psychiatric evaluation, management, treatment and discharge planning in a structured treatment milieu. (b) A subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary mental health acute treatment, community-based acute treatment, intensive community-based acute treatment and shall not require a preauthorization before obtaining treatment; provided, however, that the facility shall notify the carrier of the admission and the initial treatment plan within 72 hours of admission.

M.G.L. c. 176B, § 4T Subscription certificate benefits for services rendered by a nurse anesthetist or nurse practitioner

c. 176B, § 4T. Subscription certificate benefits for services rendered by a nurse anesthetist or nurse practitioner Section 4T. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed in the commonwealth shall provide as benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth for services rendered by a certified registered nurse anesthetist or nurse practitioner designated as such a certified registered nurse anesthetist or nurse practitioner by the board of registration in nursing pursuant to the provisions of section 80B of chapter 112; provided, however, that the following conditions are met: (1) the service rendered is within the scope of the certified registered nurse anesthetist's license or nurse practitioner's authorization to practice by the board of registration in nursing; and (2) the policy or contract currently provides benefits for identical services rendered by a provider of health care licensed by the commonwealth.

M.G.L. c. 176B, § 4TT Benefits for medically necessary emergency services programs

c. 176B, § 4TT. Benefits for medically necessary emergency services programs Section 4TT. A subscription certificate under an individual or group medical service agreement that is issued or renewed shall provide benefits on a nondiscriminatory basis for medically necessary emergency services programs, as defined in section 1 of chapter 175.

M.G.L. c. 176B, § 4U Emergency services provided to insureds for emergency medical conditions

c. 176B, § 4U. Emergency services provided to insureds for emergency medical conditions Section 4U. (a) As used in this section, the following words shall have the following meanings:- ''Attending physician'', the emergency physician or consultant physician who actively treats the emergency medical condition of an insured at an emergency facility. ''Emergency medical condition'', a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of an insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B). ''Insured'', a member or subscriber of a medical service corporation who is treated in an emergency facility for an emergency medical condition, regardless of whether the member's or subscriber's contract with the corporation is delivered, issued or renewed on a group or individual basis. ''Stabilization for discharge'', an emergency medical condition shall be deemed to be stabilized for purposes of discharging an insured, other than for the purpose of transfer from one facility to another facility, when the attending physician has determined that, within reasonable clinical confidence, the insured has reached the point where further care, including diagnostic work-up or treatment, or both, could be reasonably performed on an outpatient basis or a later scheduled inpatient basis if the insured is given a reasonable plan for appropriate follow-up care and discharge instructions, or as further defined in section 1867(e)(3)(A) of the Social Security Act, 42 U.S.C. section 1395dd(e)(3)(A). Stabilization for discharge does not require final resolution of the emergency medical condition. ''Stabilization for transfer'', an emergency medical condition shall be deemed to be stabilized for transfer if an insured can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the insured is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4) of the Social Security Act, 42 U.S.C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition. (b) Any contract or subscription certificate between an insured and the corporation shall provide as benefits coverage for emergency services provided to an insured for emergency medical conditions. After an insured has been stabilized for discharge or transfer, the corporation or its designee may require a hospital emergency department to contact the physician on call designated by the corporation or its designee for authorization of post-stabilization services to be provided. The hospital emergency department shall take all reasonable steps to initiate contact with said corporation or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if said corporation or its designee has not responded to said call within 30 minutes. Notwithstanding the foregoing provision, in the event the attending physician and said on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician shall prevail and such treatment shall be considered appropriate treatment for an emergency medical condition provided that such treatment is consistent with generally accepted principles of professional medical practice and is a covered benefit under the contract or subscription certificate of an insured with the corporation. Consistent with the foregoing, said corporation or its designee may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services. (c) Any contract or subscription certificate between an insured and the medical service corporation may require an insured to contact either the corporation or its designee or the primary care provider of the insured within 48 hours of receiving such emergency services, but notification already given to said corporation, designee or said primary care provider by the attending physician shall satisfy the requirements of this paragraph. (d) Nothing in this section shall be construed to limit retrospective utilization review activities by said corporation or its designee with respect to screening, stabilization and post-stabilization services for the purposes of assessing quality, utilization patterns and coding and billing practices, but such activities shall not result in retroactive changes to treatment or reimbursement decisions previously made in accordance with this section. In conducting said utilization review activities, said corporation or its designee shall be in compliance with section 12 of chapter 176O and all applicable state and federal confidentiality provisions. (e) The corporation or its designee shall clearly state in its brochures, contracts, policy manuals and all printed materials that insureds shall have 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 an insured is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. 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, or be denied coverage for medical and transportation expenses incurred as a result of such emergency medical condition.

M.G.L. c. 176B, § 4UU Coverage for annual mental health wellness examination

c. 176B, § 4UU. Coverage for annual mental health wellness examination Section 4UU. (a) For the purpose of this section, the following words shall have the following meanings: ''Licensed mental health professional,'' a licensed physician who specializes in the practice of psychiatry, a licensed psychologist, a licensed independent clinical social worker, a licensed certified social worker, a licensed mental health counselor, a licensed supervised mental health counselor, a licensed psychiatric nurse mental health clinical specialist, a licensed psychiatric mental health nurse practitioner, a licensed physician assistant who practices in the area of psychiatry, a licensed alcohol and drug counselor I, as defined in section 1 of chapter 111J, or a licensed marriage and family therapist within the lawful scope of practice for such therapist. ''Mental health wellness examination,'' a screening or assessment that seeks to identify any behavioral or mental health needs and appropriate resources for treatment. The examination may include: (i) observation, a behavioral health screening, education and consultation on healthy lifestyle changes, referrals to ongoing treatment, mental health services and other necessary supports, and discussion of potential options for medication; and (ii) age-appropriate screenings or observations to understand a covered person's mental health history, personal history and mental or cognitive state and, when appropriate, relevant adult input through screenings, interviews, and questions. ''Primary care provider'', a health care professional qualified to provide general medical care for common health care problems, who: (i) supervises, coordinates, prescribes or otherwise provides or proposes health care services; (ii) initiates referrals for specialist care; and (iii) maintains continuity of care within the scope of practice. (b) A subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for an annual mental health wellness examination that is performed by a licensed mental health professional or primary care provider, which may be provided by the primary care provider as part of an annual preventive visit. The examination shall be covered with no patient cost-sharing, provided, however, that cost-sharing shall be required if the applicable plan is governed by the Federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service. (c) The division of insurance, in consultation with the office of Medicaid, and the department of mental health, shall develop guidelines to implement this section.

M.G.L. c. 176B, § 4V Coverage for human leukocyte or histocompatibility locus antigen testing

c. 176B, § 4V. Coverage for human leukocyte or histocompatibility locus antigen testing Section 4V. Any subscription certificate under an individual or group medical service agreement, except certificates providing supplemental coverage to Medicare or to other government programs, delivered, issued or renewed by agreement within or without the commonwealth shall provide, as a benefit for all individual subscribers or members within the commonwealth and all group members having a principal place of employment within the commonwealth, coverage for the cost of human leukocyte antigen testing or histocompatibility locus antigen testing that is necessary to establish bone marrow transplant donor suitability. The coverage shall cover the costs of testing for A, B or DR antigens, or any combination thereof, consistent with rules, regulations and criteria established by the department of public health pursuant to section 218 of chapter 111.

M.G.L. c. 176B, § 4VV Coverage for federally-defined preventive services

c. 176B, § 4VV. Coverage for federally-defined preventive services Section 4VV. (a) For the purposes of this section, ''federally-defined preventive services'' shall mean: (i) evidence-based items or services that currently have a rating of ''A'' or ''B'' in the recommendations of the United States Preventive Services Task Force; (ii) immunizations with routine use in children, adolescents and adults that currently have a recommendation from the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention with respect to the individual involved; (iii) with respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the federal Health Resources and Services Administration; and (iv) with respect to women, such additional preventive care and screenings not described in clause (i) as provided for in comprehensive guidelines supported by the federal Health Resources and Services Administration; provided, however, that ''federally-defined preventive services'' shall also include all other preventive services not subject to cost-sharing, as required by established federal regulatory and sub-regulatory guidance issued on or before July 1, 2023. (b) Any subscription certificate under an individual or group medical service agreement that is delivered, issued or renewed within the commonwealth shall provide coverage for federally-defined preventive services. (c) Coverage provided pursuant to this section shall not be subject to any cost-sharing, including, but not limited to, co-payments, co-insurance or any deductible, as required by established federal regulatory and sub-regulatory guidance issued on or before July 1, 2023. (d) Nothing in this section shall prohibit: (i) coverage for items and services in addition to those recommended by the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention or the federal Health Resources and Services Administration; or (ii) denying coverage for items and services that are not recommended by the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention or the federal Health Resources and Services Administration. (e) If a recommendation described in subsection (a) is changed during a plan year, a carrier shall not be required to make changes to the health plan during the plan year.

M.G.L. c. 176B, § 4W Outpatient services; hormone replacement therapy for peri and post menopausal women; contraceptive services; approved prescription contraceptive drugs or devises; exception

c. 176B, § 4W. Outpatient services; hormone replacement therapy for peri and post menopausal women; contraceptive services; approved prescription contraceptive drugs or devises; exception Section 4W. (a) Any subscription certificate under an individual or group medical service agreement that is delivered, issued or renewed within or without the commonwealth and that provides benefits for outpatient services shall provide to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth benefits for hormone replacement therapy services for peri and post menopausal women and outpatient contraceptive services under the same terms and conditions as for such other outpatient services. Outpatient contraceptive services shall mean consultations, examinations, procedures and medical services provided on an outpatient basis and related to the use of all contraceptive methods to prevent pregnancy that have been approved by the United States Food and Drug Administration. (b) Any subscription certificate under an individual or group medical service agreement that is delivered, issued or renewed within or without the commonwealth and that provides benefits for outpatient prescription drugs or devices shall provide to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth benefits for hormone replacement therapy for peri and post menopausal women and for outpatient prescription contraceptive drugs or devices which have been approved by the United States Food and Drug Administration under the same terms and conditions as for such other prescription drugs or devices, provided that in covering all FDA approved prescription contraceptive methods, nothing in this section precludes the use of closed or restricted formulary. (c) This section shall not apply to a subscription certificate under an individual or group medical service agreement delivered, issued or renewed under this chapter if that subscription certificate is purchased by an employer that is a church or qualified church-controlled organization, as those terms are defined in 26 U.S.C. section 3121(w)(3)(A) and (B). (d) A subscription certificate under an individual or group medical service agreement that is delivered, issued or renewed within or outside the commonwealth and that provides benefits for outpatient services shall provide to all individual subscribers and members in the commonwealth and to all group members having a principal place of employment in the commonwealth coverage for the following services and contraceptive methods: (i) Food and Drug Administration, FDA, approved contraceptive drugs, devices and other products; provided, however, that coverage shall not be required for male condoms or FDA-approved oral contraceptive drugs that do not have a therapeutic equivalent; and provided further, that: (A) if the FDA has approved 1 or more therapeutic equivalents of a contraceptive drug, device or product, an individual or group medical service agreement shall not be required to include all such therapeutically equivalent version in its formulary as long as at least 1 is included and covered without cost-sharing and in accordance with this subsection; (B) if there is a therapeutic equivalent of a drug, device or other product for an FDA-approved contraceptive method, a medical service agreement may provide coverage for more than 1 drug, device or other product and may impose cost-sharing requirements as long as at least 1 drug, device or other product for that method is available without cost-sharing; provided, however, that if an individual's attending provider recommends a particular FDA-approved contraceptive based on a medical determination with respect to that individual, regardless of whether the contraceptive has a therapeutic equivalent, a medical service agreement shall provide coverage, subject to a plan's utilization management procedures, for the prescribed contraceptive drug, device or product without cost-sharing; and (C) appeals of an adverse determination of a request for coverage of an alternative FDA-approved contraceptive drug, device or other product without cost sharing shall be subject to the expedited grievance process under section 13 of chapter 176O; (ii) FDA-approved emergency contraception available over-the-counter, whether with a prescription or dispensed consistent with the requirements of section 19A of chapter 94C; (iii) prescription contraceptives intended to last: (A) for not more than a 3-month period for the first time the prescription contraceptive is dispensed to the covered person; and (B) for not more than a 12-month period for any subsequent dispensing of the same prescription, which may be furnished or dispensed all at once or over the course of the 12 months, regardless of whether the covered person was enrolled in the policy, contract or plan at the time the prescription contraceptive was first dispensed; provided, however, that a corporation shall not be required to provide coverage for more than one 12-month prescription in a single dispensing per plan year; (iv) voluntary female sterilization procedures; (v) patient education and counseling on contraception; and (vi) follow-up services related to the drugs, devices, products and procedures covered under this subsection including, but not limited to, management of side effects, counseling for continued adherence and device insertion and removal. (e) (1) Coverage provided under subsection (d) shall not be subject to any deductible, coinsurance, copayment or any other cost-sharing requirement except as provided for in subclauses (A) and (B) of clause (i) of subsection (d) or otherwise as required under federal law. Coverage offered under said subsection (d) shall not impose unreasonable restrictions or delays in the coverage, in accordance with the requirements of chapter 176O; provided, however, that reasonable medical management techniques may be applied to coverage within a method category, as defined by the FDA, but not across types of methods. (2) Benefits for an enrollee under subsection (d) shall be the same for the enrollee's covered spouse and covered dependents. (f) A medical service agreement that is delivered, issued or renewed within or outside the commonwealth that is purchased by an employer that is a church or qualified church-controlled organization shall be exempt from subsection (d) at the request of the employer. An employer that invokes the exemption under this subsection shall provide written notice to prospective enrollees prior to enrollment with the plan and such notice shall list the contraceptive health care methods and services for which the employer will not provide coverage for religious reasons. (g) Nothing in subsection (d) shall be construed to exclude coverage for contraceptive drugs, devices, products and procedures prescribed by a provider for reasons other than contraceptive purposes, including, but not limited to, decreasing the risk of ovarian cancer, eliminating symptoms of menopause or providing contraception that is necessary to preserve the life or health of an enrollee or the enrollee's covered spouse or covered dependents. (h) The commissioner shall ensure compliance with this chapter. (i) Nothing in subsection (d) shall be construed to require a medical service agreement to cover experimental or investigational treatments. (j) For purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: ''Church'', a church, a convention or association of churches or an elementary or secondary school that is controlled, operated or principally supported by a church or by a convention or association of churches. ''Provider'', an individual or facility licensed, certified or otherwise authorized or permitted by law to administer health care in the ordinary course of business or professional practice, acting within the scope of their license. ''Qualified church-controlled organization'', an organization described in section 501(c)(3) of the federal Internal Revenue Code, other than an organization that: (i) offers goods, services or facilities for sale, other than on an incidental basis, to the general public, other than goods, services or facilities that are sold at a nominal charge that is substantially less than the cost of providing such goods, services or facilities; and (ii) normally receives more than 25 per cent of its support from: (A) governmental sources; (B) receipts from admissions, sales of merchandise, performance of services or furnishing of facilities in activities that are not unrelated trades or businesses; or (C) both clauses (A) and (B). ''Therapeutic equivalent'', a contraceptive drug, device or product that is: (i) approved as safe and effective; (ii) pharmaceutically equivalent to another contraceptive drug, device or product in that it contains an identical amount of the same active drug ingredient in the same dosage form and route of administration and meets compendial or other applicable standards of strength, quality, purity and identity; and (iii) assigned the same therapeutic equivalence code as another contraceptive drug, device or product by the FDA.

M.G.L. c. 176B, § 4WW Coverage for standard fertility preservation services

c. 176B, § 4WW. Coverage for standard fertility preservation services Section 4WW. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: ''Directly or indirectly cause impairment of fertility'', to cause circumstances where a disease or the necessary treatment for a disease has a likely side effect of infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology or other reputable professional organizations. ''Standard fertility preservation services'', procedures or treatments to preserve fertility as recommended by a board-certified obstetrician gynecologist, reproductive endocrinologist or other physician; provided, however, that the recommendation shall be made in accordance with current medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology or other reputable professional organizations. (b) A subscription certificate under an individual or group medical service agreement that is delivered, issued or renewed within the commonwealth shall provide coverage for standard fertility preservation services, including, but not limited to, the coverage for procurement, cryopreservation and storage of gametes, embryos or other reproductive tissue, when the enrollee has a diagnosed medical or genetic condition that may directly or indirectly cause impairment of fertility by affecting reproductive organs or processes. Coverage shall be provided to the same extent that coverage is provided for other pregnancy-related procedures.

M.G.L. c. 176B, § 4X Coverage for patient care services provided under qualified clinical trials

c. 176B, § 4X. Coverage for patient care services provided under qualified clinical trials Section 4X. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide for the coverage of patient care services furnished pursuant to qualified clinical trials as defined in, and subject to the requirements and limitations of, section 110L of chapter 175.

M.G.L. c. 176B, § 4XX Coverage for postpartum depression and major depressive disorder screenings

c. 176B, § 4XX. Coverage for postpartum depression and major depressive disorder screenings Section 4XX. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth, which is considered creditable coverage under section 1 of chapter 111M, shall provide coverage for postpartum depression and major depressive disorder screenings conducted pursuant to section 247 of chapter 111.

M.G.L. c. 176B, § 4Y Coverage for speech, hearing and language disorders

c. 176B, § 4Y. Coverage for speech, hearing and language disorders Section 4Y. Any subscription certificate under an individual or group medical service agreement which provides hospital expense and surgical expense insurance, delivered, issued or renewed by agreement between the insurer and the policyholder, within or without the commonwealth, shall provide benefits for residents of the commonwealth and to all group members having a principal place of employment within the commonwealth for the expenses incurred in the medically necessary diagnosis and treatment of speech, hearing and language disorders by individuals licensed as speech–language pathologists or audiologists under chapter 112, if such services are rendered within the lawful scope of practice for such speech–language pathologists or audiologists regardless of whether the services are provided in a hospital, clinic or private office; provided, however, that such coverage shall not extend to the diagnosis or treatment of speech, hearing and language disorders in a school–based setting. The benefits provided by this section shall be subject to the same terms and conditions established for any other medical condition covered by such individual or group medical service agreement.

M.G.L. c. 176B, § 4YY Coverage for the provision of medically necessary pasteurized donor human milk and donor human milk-derived products

c. 176B, § 4YY. Coverage for the provision of medically necessary pasteurized donor human milk and donor human milk-derived products Section 4YY. (a) Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth, which is considered creditable coverage under section 1 of chapter 111M, shall provide coverage for the provision of medically necessary pasteurized donor human milk and donor human milk-derived products; provided, however, that: (i) the milk is obtained from a human milk bank that meets quality guidelines established by the department of public health; (ii) a licensed medical practitioner has issued a written order for the provision of such human breast milk or donor human milk-derived products for the covered infant; and (iii) the covered infant is: (1) under the age of 6 months; (2) undergoing treatment in an inpatient setting for a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis or a congenital or acquired condition that may benefit from the use of such human breast milk as determined by the department of public health; and (3) medically or physically unable to receive maternal breast milk or participate in breastfeeding or whose mother is medically or physically unable, despite receiving lactation support, to produce maternal breast milk in sufficient quantities or caloric density. (b) If an inpatient stay is reimbursed through a diagnosis related group or other bundled payment arrangement, the medical service corporation shall include the cost of reimbursement provided under subsection (a) for donor human milk and donor human milk-derived products in the development of the reimbursement rate for such diagnosis related group or bundled payment.

M.G.L. c. 176B, § 4ZZ Coverage for universal postpartum home visiting services

c. 176B, § 4ZZ. Coverage for universal postpartum home visiting services Section 4ZZ. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for universal postpartum home visiting services, in accordance with operational standards set by the department of public health pursuant to section 248 of chapter 111. Such coverage shall not be subject to any cost-sharing, including co-payments and co-insurance, and shall not be subject to any deductible; provided, however, that co-payments, coinsurance or deductibles shall be required if the applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status due to the prohibition on co-payments, coinsurance or deductibles for these services.

M.G.L. c. 176B, § 5 Subscribers; qualifications, misrepresentation; open enrollment periods

c. 176B, § 5. Subscribers; qualifications, misrepresentation; open enrollment periods Section 5. Any person residing in the commonwealth shall have the right to become a subscriber of a medical service corporation if his qualifications meet those specified in the by-laws of such corporation, provided that such a corporation may, in its discretion, refuse to issue a subscription certificate to, or upon due notice cancel the subscription certificate of, any person who has made any fraudulent claim or representation to the corporation or to a participating physician, participating chiropractor or to any other participating provider of health services licensed under the laws of the commonwealth, or has been guilty of uncooperative or unethical dealings with the corporation, or has failed to pay dues and assessments seasonably and promptly or for any other cause which may be approved by the commissioner. Such corporation shall provide for annual open enrollment periods of not less than two months' duration. Proper notification shall be given to prospective subscribers in a form subject to approval by the commissioner.

M.G.L. c. 176B, § 5A Discrimination against abuse victims in terms of medical service plans

c. 176B, § 5A. Discrimination against abuse victims in terms of medical service plans Section 5A. No corporation subject to this chapter, and no officer or agent thereof, shall cancel, refuse to issue or renew, or in any way make or permit any distinction or discrimination in the amount or payment of premiums or rates charged, in the length of coverage, or in any other of the terms and conditions of a medical service plan based on information that an individual has been a victim of abuse, as defined by section one of chapter two hundred and nine A. No corporation subject to this chapter, and no officer or agent thereof, shall seek information that such person has been a victim of abuse as defined by said section one of said chapter two hundred and nine A. The practices prohibited under this section shall include not only those overtly discriminatory but also practices and devices which are fair in form but discriminatory in practice. Nothing in this section shall be construed as creating a special class of insureds who have been victims of abuse as defined by said section one of said chapter two hundred and nine A. Any violation of this section shall constitute an unfair method of competition or an unfair or deceptive act or practice in violation of chapters ninety-three A and one hundred and seventy-six D.

M.G.L. c. 176B, § 5B Medical service plans; genetic tests; discrimination based on genetic information

c. 176B, § 5B. Medical service plans; genetic tests; discrimination based on genetic information Section 5B. For the purposes of this section the following words shall have the following meanings:— ''Genetic information'', a written recorded individually identifiable result of a genetic test as defined by this section or explanation of such a result. ''Genetic test'', a test of human DNA, RNA, mitochondrial DNA, chromosomes or proteins for the purposes of identifying the genes, or genetic abnormalities, or the presence or absence of inherited or acquired characteristics in genetic material. No corporation subject to this chapter and no officer or agent thereof, shall cancel, refuse to issue or renew, or in any way make or permit any distinction or discrimination in the amount of payment of premiums as rates charged, in the length of coverage, or in any other of the terms and conditions of a medical service plan based on genetic information as defined in this section. No corporation subject to the provisions of this chapter and no officer or agent thereof, shall require genetic tests or private genetic information, as defined in this section, as a condition of the issuance or renewal of a medical service plan. Any violation of this section shall constitute an unfair method of competition or unfair or deceptive act or practice in violation of chapters 93A and 176D.

M.G.L. c. 176B, § 6 Subscription certificate; issuance; content

c. 176B, § 6. Subscription certificate; issuance; content Section 6. No subscription certificate shall be issued unless it contains in substance the following provisions: (a) A statement of the medical service to be paid for by the corporation, and if any medical service is excepted, a statement of such exception. (b) A statement of the duration of the agreement and of the terms and conditions upon which it may be extended, renewed, revised, canceled or otherwise terminated. (c) A statement that any child who is mentally or physically incapable of earning his own living who is eligible for services by membership of his parent under a family contract shall be eligible under the membership of his parent as a member of such family contract so long as he continues to be mentally or physically incapable of earning his own living, without any limitation as to age, subject, however, to such rules and regulations, premiums or additional premiums as the commissioner of insurance may approve. (d) A statement that within fifteen days after receipt by the corporation of notice by a subscriber, or someone acting on his behalf, that such subscriber or a covered dependent of such subscriber has received services for which the subscriber is entitled to direct payment of benefits under a subscription certificate, the corporation shall furnish the subscriber such forms as are usually furnished by it to establish a subscriber entitlement to such benefits; and that within forty-five days after the receipt by the corporation of completed forms for such benefits, the corporation shall (i) make payment for such benefits, (ii) notify the subscriber in writing of the reason or reasons for nonpayment, or (iii) notify the subscriber in writing what additional information or documentation is necessary to establish entitlement to such benefits. (e) A statement, in the case of any subscription certificates providing supplemental coverage to Medicare or other governmental programs, that no participating physician or other participating provider of health services shall charge to, or collect from, a subscriber of a covered dependent any amount in excess of the maximum allowable compensation determined by the governmental agency administering such program as the basis for the government's payment thereunder to such participating physician or other participating provider of health services. To the extent that this section is inconsistent with the provisions of chapter one hundred and seventy-six K and any regulations promulgated thereunder, medicare supplement insurance and medicare select insurance plans as defined in said chapter one hundred and seventy-six K shall be subject to the provisions of said chapter one hundred and seventy-six K and any regulations promulgated thereunder. To the extent that this section is inconsistent with the provisions of chapter one hundred and seventy-six M and any regulations promulgated thereunder, any nongroup plan that is within the definition of a guaranteed issue health plan in said chapter one hundred and seventy-six M shall be subject to the provisions of said chapter one hundred and seventy-six M and any regulations promulgated thereunder.

M.G.L. c. 176B, § 6A Limited extension of benefits

c. 176B, § 6A. Limited extension of benefits Section 6A. Whenever a subscriber of a group non-profit medical service plan, other than the one authorized under the provisions of chapter thirty-two A or chapter thirty-two B, becomes ineligible for continued participation in such group plan because of involuntary lay-off or death, the coverage originally provided by such plan for the subscriber and his dependents shall be continued as provided herein for a period of thirty-nine weeks from the date of such ineligibility or until such subscriber and his dependents become eligible for benefits under another group plan, whichever occurs first but in no event shall such continuation period exceed the period during which the member was most recently covered under such group plan. The employer or policyholder shall notify the involuntary laid-off member, surviving spouse of a deceased member and dependents of their eligibility to participate in such plans. The involuntary laid-off member, surviving spouse of a deceased member and dependents may elect to continue participation in such plan by giving at least thirty days written notice thereof to the employer or policyholder. Such member or surviving spouse or dependents, as the case may be, shall be responsible for the payment of the whole premium due for such coverage, including any and all amounts normally paid by the employer as employee's benefits, to the employer or policyholder throughout the extension period. After timely receipt of the premium payment from the responsible individual, if the employer or certificate holder fails to make payment to the insurer or hospital or medical service corporation with the result that coverage is terminated, the employer or certificate holder shall be liable for benefits to the same extent as the insurer or hospital or medical service corporation would have been liable if coverage had not been terminated. Timely receipt of premium payment shall mean the employer's or certificate holder's receipt of the premium or subscription fee for the extended coverage for such member or dependents within the dates or by the date indicated by the employer at the time of the election of extended coverage. Failure to give such notice or to make premium payments as hereinabove provided shall constitute a waiver of the option to have such extended coverage. In addition, whenever such group nonprofit hospital service plan is issued or subsequently renewed by agreement between the insurer and the policyholder within or without the commonwealth, during the period this provision is effective, such plan shall include coverage such that when a subscriber of such group plan becomes ineligible for continued participation in such plan because he is an employee whose employment is terminated due to a plant closing or covered partial closing, as those terms are defined in section seventy-one A of chapter one hundred and fifty-one A, the coverage originally provided by such contract for the subscriber and his dependents shall continue as provided herein, for a period of ninety days from the date of ineligibility or until such subscriber and his dependents become eligible for benefits under another group plan, whichever comes first. Such subscriber and such employer or policyholder shall be responsible for the payment of their respective shares of the premium due as provided in said group plan. In the event that said employer or policyholder closed under the provisions of the Federal Bankruptcy Act, 11 USC sec. 101 et seq. except for employers or policyholders in reorganization proceedings, such employer's or policyholder's share of the premium shall be paid from the health insurance benefits fund established pursuant to section seventy-one E of said chapter one hundred and fifty-one A. The employer or policyholder shall notify the terminated member of their eligibility to participate in such plan. The terminated member may elect to continue participation in such plan by giving written notice thereof to the employer or policyholder. The member whose employment has been terminated shall be responsible for the payment of whatever part of the premium, if any, normally paid by such terminated employee as originally provided in such plan, throughout the ninety day period. If applicable, after timely receipt of the premium payment from the individual, if the employer or policyholder fails to make payment to the insurer or hospital or medical service corporation with the result that the coverage is terminated, the employer or policyholder shall be liable for the benefits to the same extent as the insurer or hospital or medical service corporation would have been liable if coverage had not been terminated. Timely receipt of payment shall mean the employer's or policyholder's receipt of the premium or subscription fee for extended coverage from such member within the dates or by the date indicated by the employer or policyholder at the time of the election of extended coverage. Failure to give notice or to make premium payments as hereinabove provided shall constitute a waiver of the option to have such extended coverage. Notwithstanding the provisions of this paragraph, any contractual agreement arrived at by a collective bargaining process that contains provisions requiring an employer to pay for the continuation of such insurance for employees whose employment is terminated by a plant closing or covered partial closing shall supercede the requirement of this paragraph when said contractual agreement provides at least three months or ninety days continuation of such insurance. Otherwise, the provisions of this paragraph shall be deemed to be controlling.

M.G.L. c. 176B, § 6B Divorced or separated spouses; continuation of eligibility for benefits

c. 176B, § 6B. Divorced or separated spouses; continuation of eligibility for benefits Section 6B. (a) In the event of the granting of a judgment absolute of divorce or of separate support to which a subscriber of a group nonprofit medical service plan is a party, the person who was the spouse of said subscriber prior to the issuance of such judgment shall be and remain eligible for benefits under said plan, whether or not said judgment was entered prior to the effective date of said plan, without additional premium or examination therefor, as if said judgment had not been entered; provided, however, that such eligibility shall not be required if said judgment so provides. Such eligibility shall continue through the subscriber's participation in the plan until the remarriage of either the subscriber or such spouse, or until such time as provided by said judgment, whichever is earlier. (b) In the event of the remarriage of the group plan subscriber referred to in paragraph (a), the former spouse thereafter shall have the right, if so provided in said judgment, to continue to receive benefits as are available to the subscriber, by means of the addition of a rider to the family plan or the issuance of an individual plan, either of which may be at additional premium rates determined by the commissioner of insurance to be just and reasonable in accordance with the additional insuring risks involved. (c) The name, address, and policy number of a person eligible for health insurance coverage pursuant to paragraph (a) or (b), if available, shall be forwarded by such nonprofit medical service corporation to the department of public welfare within thirty days of the date when coverage of said person under said paragraph (a) or (b) is commenced. (d) Notice of cancellation of coverage of the divorced or separated spouse of a member shall be mailed to such divorced or separated spouse at such person's last known address, together with notice of the right to reinstate coverage retroactively to the date of cancellation. (e) Claims paid on behalf of a divorced or separated spouse or on behalf of a dependent who is not residing with the member shall be paid to the physician, hospital or other provider of covered services or to the person on whose behalf such services were performed, unless the person is a minor child. In the event the person on whose behalf such services were performed is a minor, payment shall be made to the physician, hospital or other provider of such services or to the parent or custodian with whom the child resides.

M.G.L. c. 176B, § 7 Contracts between corporation and care providers

c. 176B, § 7. Contracts between corporation and care providers Section 7. Every registered physician, chiropractor and nurse midwife shall have the right, on complying with such rules and regulations as the corporation may make, to enter into a written agreement with a medical service corporation, doing business in the city or town where the said physician, chiropractor or nurse midwife resides or has a usual place of business, to perform medical, chiropractic, or midwifery services. A medical service corporation shall not refuse to contract with or compensate for covered services an otherwise eligible provider solely because such provider has in good faith communicated with one or more of his current, former or prospective patients regarding the provisions, terms or requirements of the medical service corporation's products as they relate to the needs of such provider's patients. No participating physician or other participating provider of health services shall charge to or collect from a subscriber or covered dependent any amount in excess of the amount of compensation determined and allowed by a medical service corporation pursuant to the applicable method of compensation approved by the commissioner, except when such subscriber or covered dependent (a) is eligible for benefits under a subscription certificate containing a provision permitting such charge or collection when the subscriber or covered dependent (i) is entitled to receive reimbursement or compensation from a third party for the cost of the same or similar services or (ii) receives money or its equivalent as a result of a claim against a third party for loss or damages for personal injuries, and only in the circumstances and to the extent so permitted, or (b) is eligible for benefits under a subscription certificate which provides for compensation to a participating physician or other participating provider of health services under a nonprofit medical service plan previously approved by the commissioner, the so-called ''Plan B'', and has an annual income in excess of seven thousand five hundred dollars, or (c) is eligible for benefits under a subscription certificate under a group medical service agreement containing a provision describing the specific circumstances under which and the extent to which additional amounts may be charged or collected; provided, however, that such provision has first been approved in writing by the commissioner and has been requested by the employer, employers or other representatives of the group to which it applies, and only in the circumstances and to the extent so described. This chapter shall not change the relations between physician, chiropractor, or nurse midwife and patient. No restriction shall be placed by any such corporation upon its participating physicians, chiropractors, or nurse midwives as to methods of diagnosis or treatment. No officer, agent, or employee of a medical service corporation shall influence or attempt to influence a subscriber or a covered dependent in the choice of a participating physician, chiropractor, or nurse midwife. A subscriber or a covered dependent, subject to the by-laws, rules and regulations of a medical service corporation and the terms and provisions of the subscription certificate, shall be entitled to the benefits of this chapter upon receiving medical, chiropractic, or midwifery service from any participating physician, chiropractor, or nurse midwife or, in the discretion of the corporation, upon receiving medical, chiropractic or midwifery service from any non-participating physician, chiropractor, or nurse midwife in an emergency or when outside the commonwealth. A corporation may terminate its agreement with any participating physician, chiropractor, nurse midwife or any other participating provider of health services licensed under the laws of the commonwealth at any time (a) for failure to comply with the reasonable rules and regulations of such corporation, including without limitation, such rules and regulations governing the keeping of accounts, records and statistics, the making of reports and proof of services rendered, or (b) for presenting any fraudulent, unreasonable, or improper claim for payment, or compensation. No such agreement may be terminated by a medical service corporation unless such corporation shall first have given the participating physician or other provider of health services a written statement of the charges against him or her, an opportunity for hearing, reasonable notice of the time and place of hearing, and a written decision accompanied by a statement of the reasons for the decision. A participating physician or other provider of health services shall also have (a) the right, within 45 days after receipt by a medical service corporation from a provider of a completed claim form for covered services, to receive (i) payment, (ii) notice of the reasons for any nonpayment or (iii) notice of additional information or documentation necessary to establish entitlement to payment; (b) the right, upon request following denial of entitlement to payment for covered service because such services were determined by a medical service corporation to be unnecessary for the medical or other health care of a subscriber or covered dependent to a formal peer review process; (c) the right to inspect a listing of his or her usual charges maintained by a medical service corporation; (d) the right to inspect a listing of customary charges maintained by a medical service corporation which are applicable to his or her services; and (e) the right to a copy of the bylaws of a medical service corporation and rules and regulations adopted by the board of directors of such a corporation. If the medical service corporation fails to comply with the provisions of this paragraph, said corporation shall pay, in addition to any benefits which inure to such subscriber or provider, interest on such benefits, which shall accrue beginning 45 days after the corporation's receipt of notice of claim at the rate of one and one-half percent per month, not to exceed eighteen percent per year. The provisions of this paragraph relating to interest payments shall not apply to a claim which a medical service corporation is investigating because of suspected fraud. A participating physician or other professional provider of health services may terminate his or her agreement with a medical service corporation at any time upon giving not less than one year notice in writing to the medical service corporation and each of his patients to terminate as of a date specified in such notice; provided however, that any physician or provider giving such notice shall not terminate any physician-patient relationship after the one-year notice period with any subscriber or covered dependent unless and until arrangements have been made for appropriate referrals, continuation, and follow-up care. Until such time as a patient or subscriber has been referred to and has established a physician-patient relationship with another participating physician, the medical services corporation shall continue to provide compensation to the terminating physician or provider at the rate allowed for such services prior to termination and said terminating physician or provider shall not be allowed to charge the patient any additional amount for such services. Nothing in this section shall limit or derogate from the rights of beneficiaries of health insurance under Title XVIII of the federal Social Security Act to the benefits of chapter four hundred and seventy-five of the acts of nineteen hundred and eighty-five. Every participating provider shall receive from a medical service corporation not less than annually a handbook, written in plain English and subject to the commissioner's approval, that explains said corporation's methods of payment, including but not limited to, all requirements for the submission of charges, all restrictions on payments, an explanation of the usual and customary charge system and methods of updating a provider's charge profile. Said handbook shall be made available to participating providers at least six months prior to any annual update of charge profiles. A subscriber who is eligible for benefits supplemental to Part B of Title XVIII of the Social Security Act, as amended, under a nongroup medical service agreement, or a subscription certificate issued thereunder, or under a group medical service agreement shall be entitled to the benefits provided therein, including payments for the services of a participating or nonparticipating physician to be made by a medical service corporation to the subscriber or to the physician as such payments are made for the services under Part B of Title XVIII of the Social Security Act, as amended. Nothing in this section shall be construed to allow a physician, who receives payment under a supplemental program of coverage to medicare, or other governmental programs, to charge to, or collect from, a subscriber or covered dependent any amount in excess of the maximum allowable compensation determined by the governmental agency administering such program as the basis for the government's payment thereunder to such physician. Nothing in section four or in this section shall be construed to prohibit any medical service corporation from entering into written agreements with its subscribers and with participating chiropractors to furnish chiropractic services to subscribers and covered dependents or from including chiropractic services in its nonprofit medical service plan, nor shall any medical service corporation discriminate in any way against participating chiropractors in the furnishing of chiropractic service to its subscribers and covered dependents. Nothing in section four or in this section shall be construed to prohibit any medical service corporation from entering into written agreements with its subscribers and with participating nurse midwives to furnish midwifery services to subscribers and covered dependents or from including midwifery services in its non-profit medical service plan, nor shall any medical service corporation discriminate in any way against participating nurse midwives in the furnishing of midwifery service to its subscribers and covered dependents.

M.G.L. c. 176B, § 7A Medicare supplemental group coverage; eligibility due to age or disability

c. 176B, § 7A. Medicare supplemental group coverage; eligibility due to age or disability Section 7A. Any person who is eligible for Medicare coverage for both hospital and physician service due to age or disability, other than end-stage renal disease, shall be eligible for supplemental coverage to Medicare ninety days before and after the month of such person's Medicare effective date or of the month of loss of group or individual health coverage resulting from such person's retirement. Such supplemental coverage shall be effective no earlier than the effective date of Medicare coverage.

M.G.L. c. 176B, § 7B Medicare supplemental group coverage; medical assistance recipients

c. 176B, § 7B. Medicare supplemental group coverage; medical assistance recipients Section 7B. A medical service corporation governed by this chapter shall offer medicare supplemental group coverage to that group of medical assistance recipients designated from time to time by the department of public welfare. Such coverage shall be provided at a rate based on the projected experience of said group of recipients.

M.G.L. c. 176B, § 7C Retroactive premium rate increase

c. 176B, § 7C. Retroactive premium rate increase Section 7C. For purposes of this section, retroactive premium rate increase shall mean any premium rate increase based upon an actual approved rate which is assessed to a subscriber after any payment has been made by said subscriber based upon an estimated premium rate for such period of coverage. A medical service corporation governed by this chapter which offers medicare supplemental individual or group coverage shall, in the event of a retroactive premium rate increase for such coverage, allocate such increase among the remaining outstanding premium payments due; provided, however, that no finance charge or additional cost may be charged as a result of such allocation.

M.G.L. c. 176B, § 7D Retroactive claims denial for behavioral health services

c. 176B, § 7D. Retroactive claims denial for behavioral health services Section 7D. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: ''Behavioral health services'', as defined in section 1 of chapter 175, or ''services''. ''Provider'', (i) a mental health clinic or substance use disorder treatment program licensed by the department of public health under chapters 17, 111, 111B or 111E; or (ii) a behavioral, substance use disorder or mental health professional who is licensed under chapter 112 and accredited or certified to provide services and who has provided services under an express or implied contract or with the expectation of receiving payment, other than co-payment, deductible or co-insurance, directly or indirectly from the commission or other entity. ''Retroactive claims denial'', as defined in section 1 of chapter 175. (b) A corporation shall not impose a retroactive claims denial for behavioral health services on a provider unless: (i) less than 12 months have elapsed from the time of submission of the claim by the provider to the corporation; (ii) the corporation has furnished the provider with a written explanation of the reason for the retroactive claims denial and, where applicable, a description of additional documentation or any other corrective action required for payment of the claim; and (iii) where applicable, the corporation allows the provider 30 days to submit additional documentation or to take any other corrective action required for payment of the claim. (c) Notwithstanding subsection (b), a retroactive claims denial may be allowed after 12 months if: (i) the claim was submitted fraudulently; (ii) the claim, or services for which the claim was submitted, is the subject of legal action; (iii) the claim payment was incorrect because the provider was paid or the insured has already paid for the services identified in the claim; or (iv) the services identified in the claim were not delivered by the provider. (d) If a retroactive claims denial is imposed because the claim payment is subject to adjustment due to expected payment from a payer other than the corporation or an entity with which the corporation contracts to provide or manage health care services, including mental health and substance use disorder services, the corporation shall notify the provider not less than 15 days before imposing the retroactive claims denial. The provider shall have 12 months from the date of denial to determine whether the claim is subject to payment by a secondary insurer; provided, however, that if the claim is denied by the secondary insurer due to the insured's transfer or termination of coverage, the corporation shall allow for resubmission of the claim.

M.G.L. c. 176B, § 8 Annual statement; verification, form, violations

c. 176B, § 8. Annual statement; verification, form, violations Section 8. Every medical service corporation shall annually, on or before the first day of March, file in the office of the commissioner a statement, verified by at least two of the principal officers of said corporation, showing its condition as of the thirty-first day of December next preceding. Such statement shall be in such form and shall contain such matters as the commissioner shall prescribe. A corporation neglecting to file its annual statement within the time herein specified shall forfeit one hundred dollars for each day during which such neglect continues, and upon notice by the commissioner to that effect, its authority to do business shall cease while such default continues.

M.G.L. c. 176B, § 8A Financial statements; inclusion of electronic data processing equipment as asset

c. 176B, § 8A. Financial statements; inclusion of electronic data processing equipment as asset Section 8A. In an account of its financial condition, a medical service corporation may include as an asset available for the payment of losses electronic data processing equipment, provided that the cost of such equipment at the time of acquisition is at least one hundred thousand dollars and that said cost is to be amortized in full over a period not to exceed ten years.

M.G.L. c. 176B, § 8B Applicability of chapter 176V to medical service corporations governed by this chapter

c. 176B, § 8B. Applicability of chapter 176V to medical service corporations governed by this chapter Section 8B. Notwithstanding any general or special law to the contrary, chapter 176V shall apply to a medical service corporation governed by this chapter.

M.G.L. c. 176B, § 8C Applicability of chapter 176W to medical service corporations governed by this chapter

c. 176B, § 8C. Applicability of chapter 176W to medical service corporations governed by this chapter Section 8C. Notwithstanding any general or special law to the contrary, chapter 176W shall apply to a medical service corporation governed by this chapter.

M.G.L. c. 176B, § 9 Inspection and examination of affairs of corporation; confidentiality and privilege; inability to pay providers; pro rata payments; termination of contract

c. 176B, § 9. Inspection and examination of affairs of corporation; confidentiality and privilege; inability to pay providers; pro rata payments; termination of contract Section 9. The commissioner, or any deputy examiner or any other person designated by the commissioner, shall, at least once in three years, and whenever the commissioner deems it prudent, visit any medical service corporation and examine into its affairs. The commissioner shall have free access to all of the books, records and papers of the corporation, and may summon and examine under oath its officers, agents, employees and other persons in relation to its affairs and condition. The commissioner shall require every such corporation to keep its books, records, accounts and vouchers in such manner that he or his authorized representatives may readily verify its annual statements and determine whether the corporation has complied with the law. Notwithstanding any other provision of the General Laws, including clause Twenty-sixth of section 7 of chapter 4 and chapter 66, documents, materials or other information, including but not limited to, all working papers and copies thereof created, produced or obtained by or disclosed to the commissioner or any other person in the course of an examination made pursuant to this section or in the course of analysis by the commissioner of the financial condition or market conduct of a medical service corporation shall be confidential by law and privileged, shall not be a public record under said clause Twenty-sixth, shall not be subject to subpoena and shall not be subject to discovery or admissible in evidence in any private civil action. The commissioner may use the documents, materials or other information in the furtherance of any regulatory or legal action brought as part of the commissioner's official duties. Documents, materials or other information, including but not limited to, all working papers and copies thereof in the possession or control of the National Association of Insurance Commissioners and its affiliates and subsidiaries shall be confidential by law and privileged, shall not be subject to subpoena and shall not be subject to discovery or admissible in evidence in any private civil action if they are: (i) created, produced, obtained by or disclosed to the National Association of Insurance Commissioners and its affiliates and subsidiaries in the course of the National Association of Insurance Commissioners and its affiliates and subsidiaries assisting an examination made pursuant to this section or assisting the commissioner in the analysis of the financial condition or market conduct of a medical service corporation; or (ii) disclosed to the National Association of Insurance Commissioners and its affiliates and subsidiaries pursuant to this section by any member of the National Association of Insurance Commissioners. Neither the commissioner nor any person who received the documents, material or other information while acting under the authority of the commissioner, including the National Association of Insurance Commissioners and its affiliates and subsidiaries, shall be permitted to testify in any private civil action concerning any confidential documents, materials or information subject to this section. In order to assist in the performance of the commissioner's duties, the commissioner: (i) may share documents, materials or other information, including the confidential and privileged documents, materials or information subject to this section, with other state, federal and international regulatory agencies, the National Association of Insurance Commissioners and its affiliates and subsidiaries and state, federal and international law enforcement authorities provided that the recipient agrees to maintain the confidentiality and privileged status of the document, material, communication or other information; (ii) may receive documents, materials, communications or information, including otherwise confidential and privileged documents, materials or information, from the National Association of Insurance Commissioners and its affiliates and subsidiaries and regulatory and law enforcement officials of other foreign or domestic jurisdictions and shall maintain as confidential or privileged any document, material or information received with notice or the understanding that it is confidential or privileged under the laws of the jurisdiction that is the source of the document, material or information; and (iii) may enter into agreements governing sharing and use of information consistent with this section. No waiver of any applicable privilege or claim of confidentiality in the documents, materials or information shall occur as a result of disclosure to the commissioner under this section or as a result of sharing as authorized in this section. A privilege established under the law of any state or jurisdiction that is substantially similar to the privilege established under this section shall be available and enforced in any proceeding in and in any court of the commonwealth. If, at any time, the commissioner determines the corporation is unable to pay a participating physician or other participating professional provider of health services, the participating physician or other participating professional provider of health services shall accept payment on a pro rata basis as determined by the commissioner and shall not be allowed to charge the patient any additional amount for such services. In such case, and notwithstanding the provisions of the third paragraph of section seven, the participating physician or other participating professional provider of health services may give written notice of intent to terminate the provider agreement. Termination under this paragraph shall be effective on the ninety-first day after written notice of intent to terminate is given to the corporation and the commissioner. The corporation may not invoke the so-called ''unit system'' unless the commissioner has first made the determinations required under this paragraph.

M.G.L. c. 176B, § 10 Investments, sales, loans and places of deposit; approval; acquisition of real estate; leases; tax exemption; limit; special contingent surplus

c. 176B, § 10. Investments, sales, loans and places of deposit; approval; acquisition of real estate; leases; tax exemption; limit; special contingent surplus Section 10. No investment, sale or loan shall be made by a medical service corporation which has not first been authorized by the board of directors, or by a committee thereof charged with the duty of investing or loaning the funds of the corporation; nor shall any deposit be made in a bank or banking institution unless such bank or banking institution has first been approved as a bank of deposit by the board of directors or said committee thereof, and unless the vote authorizing such investment, sale or loan or approval of the place of deposit has been duly recorded in the books of the corporation. With the approval of the commissioner, a medical service corporation, alone or with one or more nonprofit corporations, the real estate of which is exempt from taxation, may acquire real estate it reasonably expects to use in whole or in part for conducting the business of such corporation or corporations. Real estate so acquired may be leased to other occupants, and when so leased, the exemption from taxation on real estate granted by this chapter or granted by any provisions of the general laws to a co-owner shall not apply to that portion of the real estate which is so leased unless such other occupant occupies the leased premises for its purposes and is (a) a charitable organization, as defined in section five of chapter fifty-nine, or (b) a nonprofit corporation organized under the laws of the commonwealth to provide any kind of health services, the real estate of which is exempt from taxation. Nothing in this paragraph shall limit the general investment powers set forth in this section. The commissioner may require any such corporation after the first full year of doing business to accumulate and maintain a special contingent surplus, over and above its reserves and liabilities, in such amount as the commissioner may deem proper. A medical service corporation may invest in, acquire and hold the capital stock of any corporation as a subsidiary which is an insurance company authorized to transact the business of providing health insurance to persons residing outside the commonwealth, and which is duly licensed by the commissioner of insurance, provided that the medical service corporation shall notify the commissioner at least thirty days prior to entering into any agreement or contract to make such investment or acquisition.

M.G.L. c. 176B, § 11 Salaries, compensation or emoluments

c. 176B, § 11. Salaries, compensation or emoluments Section 11. No medical service corporation shall pay any salary, compensation or emolument to any officer, trustee or director thereof, nor any salary, compensation or emolument amounting in any year to more than twenty thousand dollars to any person, unless such payment be first authorized by a vote of its board of directors; provided, however, that the amount of such salaries, compensation or emoluments may be adjusted by the corporation to exceed such amount to reflect any decrease or increase in the cost of living since January first, nineteen hundred and sixty-nine, as measured by the Consumer Price Index for Urban Wage Earners and Clerical Workers, United States City Average, published by the Bureau of Labor Statistics of the United States Department of Labor. No such corporation shall make any agreement with any of its officers, trustees or employees whereby it agrees that for any services rendered or to be rendered he shall receive any salary, compensation or emolument for a period of more than three years from the date of such agreement; provided, however, that the payment of an amount not in excess of twelve and one half per cent of such annual salary, compensation or emolument, or a larger percentage if approved by the commissioner, may be deferred beyond such period.

M.G.L. c. 176B, § 12 Submission of disputes or controversies to board; privacy of patient information

c. 176B, § 12. Submission of disputes or controversies to board; privacy of patient information Section 12. Any dispute or controversy arising between a medical service corporation and any participating physician, participating chiropractor, or any other participating provider of health services licensed under the laws of the commonwealth, or any subscriber, or any person whose subscription certificate has been canceled or to whom such corporation has refused to issue such certificate may within thirty days after such dispute or controversy arises be submitted by any person aggrieved to a board serving in the division of insurance and consisting of the commissioner or a person designated by him, the chairman of the board of registration and discipline in medicine or any person designated by him, and the attorney general or a person designated by him, for its decision with respect thereto. All decisions and orders of the board or of the commissioner made under any provision of this chapter may be revised as justice and equity may require upon a petition in equity filed, within ten days after the promulgation of such decision or order in the superior court within and for the county of Suffolk by any party aggrieved by such decision or order. If the board fails to resolve a dispute or controversy not involving a medical service corporation's methods of compensating such participating physician or provider within one year, any such participating physician or other participating provider of health services and any such subscriber or person may commence an action against such medical service corporation with respect to such dispute or controversy by filing a complaint in the superior court for the county in which he resides, which action may be maintained as a class action, subject to the provisions of rule twenty-three of the Massachusetts rules of civil procedure and shall be assigned by the court for a speedy completion of the pleadings, pretrial discovery, and hearing on the merits. Any dispute or controversy arising between a medical service corporation and any participating psychiatrist, psychologist or social worker licensed under the laws of the commonwealth, or any subscriber, which is submitted by any aggrieved person to a board established pursuant to the provisions of this section shall be heard by such board in such a manner as to protect the privacy of all patient information which is the subject of such dispute or controversy or which comes to the attention of the board in its review. In furtherance of the protection of such privacy a board may and is hereby authorized to exclude the public during its hearing and deliberation of such cases.

M.G.L. c. 176B, § 13 Grounds for enjoining transaction of business; receivers

c. 176B, § 13. Grounds for enjoining transaction of business; receivers Section 13. If the commissioner is satisfied, as to any medical service corporation, that (1) it has failed to comply with the provisions of its charter, or (2) it is being operated for profit, or (3) it is fraudulently conducted, or (4) its condition is such as to render its further transaction of business hazardous to the public or to its subscribers, or (5) its officers and agents have refused to submit to an examination under section nine, or (6) it has exceeded its powers, or (7) it has violated any provision of law, or (8) it has compromised, or is attempting to compromise, with its creditors on the ground that it is financially unable to pay its claims in full, or (9) it is insolvent, he may apply to the supreme judicial court for an injunction restraining it from further proceeding with its business. If the right of any person or group of persons to become a participating physician, chiropractor, or nurse midwife, as defined in section one, is denied because of arbitrary or unfair discrimination, any such person or group of persons so aggrieved may apply to the supreme judicial court for an injunction restraining such corporation from further proceeding with its business. The court may, after application by the commissioner or any person or group of persons aggrieved as aforesaid, forthwith issue a temporary injunction restraining the transaction of any business, and it may, after a full hearing, make the injunction permanent, and appoint one or more receivers to take possession of the books, papers, moneys and other assets of the corporation, settle its affairs, and distribute its funds to those entitled thereto, subject to such rules and orders as the court may prescribe.

M.G.L. c. 176B, § 14 Liability of corporation; exemption from insurance laws; tax exemption

c. 176B, § 14. Liability of corporation; exemption from insurance laws; tax exemption Section 14. Every medical service corporation is hereby declared to be a charitable corporation. No such corporation shall be liable for injuries resulting from negligence or malpractice on the part of any participating physician, participating chiropractor or any other participating provider of health services under the laws of the commonwealth or of any of its employees, nor shall it be liable for the cost of medical services, chiropractic services or other health services under the laws of the commonwealth to which the subscriber or covered dependent may be entitled under the provisions of chapter 152. Every such corporation shall be exempt from all provisions of the insurance laws of the commonwealth, except as otherwise provided in this chapter. The property of every such corporation shall, except as hereinafter provided, be exempt from all state and local taxes.

M.G.L. c. 176B, § 16 Operators of medical service plan

c. 176B, § 16. Operators of medical service plan Section 16. It shall be unlawful for any person, firm, corporation or association, except a medical service corporation, to establish, maintain or operate a non-profit medical service plan; provided, however, that this chapter shall not render unlawful or affect any operation or activity of any company organized under the provisions of chapter one hundred and seventy-five, of any society or fraternal benefit society organized under the provisions of chapter one hundred and seventy-six or subject to any of the provisions thereof, of any non-profit hospital service or medical service corporation organized under the provisions of chapter one hundred and seventy-six A or one hundred and seventy-six C, or of any corporation organized or to be organized under chapter one hundred and eighty, the existence, purposes, activities and operations of which were lawful or would be lawful notwithstanding the provisions of this chapter.

M.G.L. c. 176B, § 16A Payroll deductions of governmental employees

c. 176B, § 16A. Payroll deductions of governmental employees Section 16A. The pertinent provisions of section one hundred and thirty-eight A of chapter one hundred and seventy-five shall apply to deductions on pay-roll schedules from the salary of any state, county or municipal employee for the payment of the amount payable by such an employee under a subscription certificate issued to him as a subscriber by a medical service corporation.

M.G.L. c. 176B, § 17 Enforcement

c. 176B, § 17. Enforcement Section 17. The provisions of this chapter may be enforced by a bill in equity brought in the supreme judicial court by the commissioner, the attorney general, any district attorney or any aggrieved party.

M.G.L. c. 176B, § 18 Contracts for administrative or other services; loans and investments

c. 176B, § 18. Contracts for administrative or other services; loans and investments Section 18. Any medical service corporation may contract with any person for the purpose of providing administrative or other services relating to the providing of medical or other health services or reimbursement therefor. In addition, with the approval of the commissioner who shall consider the effect upon subscriber agreements and subscriber rates, a medical service corporation may, after being authorized by its board of directors, or by a committee thereof, charged with the duty of authorizing transactions under this section, make loans to, guarantee loans of and make investments in hospitals and providers of other health services for the purpose of improving efficiency, reducing costs, or increasing benefits in the delivery of health services to subscribers and others.

M.G.L. c. 176B, § 19 Payment of sums owed subscriber's estate

c. 176B, § 19. Payment of sums owed subscriber's estate Section 19. A medical service corporation which, upon the death of a subscriber, owes the subscriber's estate an aggregate sum not exceeding two thousand dollars under any medical service agreement, may, at any time not less than sixty days after the subscriber's death, pay such sum to the husband, wife and next of kin of the subscriber and any such payment made in good faith shall fully discharge the corporation to the extent thereof; provided, however, that this section shall not apply if, prior to the time of such payment, the corporation has received a written claim under the subscriber's medical service agreement from any executor, administrator, or special administrator of the subscriber's estate.

M.G.L. c. 176B, § 20 Disclosure of information; mental or nervous condition

c. 176B, § 20. Disclosure of information; mental or nervous condition Section 20. No medical service corporation may, without the express and informed written consent of its subscriber or a covered family member of its subscriber, disclose any information it may have acquired from or about any such subscriber or covered family member pertaining to the administration of benefits provided for expenses arising from the out-patient diagnosis or treatment, or both, of mental or nervous conditions; provided, however, that: (a) no such written consent from such subscriber or covered family member shall be made a condition of the receipt of such benefits or any other benefits for which the insured subscribes; (b) nothing contained herein shall prohibit the disclosure of any information held by such medical service corporation which is not privileged pursuant to section one hundred and thirty-five of chapter one hundred and twelve or section twenty B of chapter two hundred and thirty-three; (c) a medical service corporation shall not be prohibited from disclosing aggregate patient data if such data contains no information personally identifying any insured or family member of the insured; (d) a medical service corporation shall not be prohibited from disclosing patient utilization data to a law enforcement authority, a state board of registration, or a court of competent jurisdiction if the medical service corporation, a law enforcement authority, or a state board of registration has reason to believe (i) a patient is committing or has committed fraud, or (ii) a provider is committing or has committed fraud or professional misconduct related to the provision of such diagnosis or treatment; (e) nothing contained herein shall prohibit a medical service corporation from using or disclosing patient information for coordination of benefits, subrogation, peer review or utilization review. For the purposes of this clause the term ''coordination of benefits'' shall mean the determination of primary and secondary responsibility for the payment of a claim between or among two or more insurers providing the same or similar coverage to an insured. Nothing contained herein shall prohibit a medical service corporation from disclosing patient or provider identifiers to a self-insured plan administered by said medical service corporation; provided, however, that such identifiers shall be used only for purposes of billing and audit; or (f) that nothing contained herein shall prohibit a medical service corporation from disclosing patient information to an account which is self-insured in whole or in part, and administered by such corporation for research to be conducted by the account; provided, however, that no patient shall be the subject of such research without having first been notified by the account in writing of the scope and purpose of the research. Such written notice shall clearly state that the patient will not be a participant in any such research and will not be penalized in any way if the patient elects in writing to be excluded. Any research conducted by an account under this clause shall maintain the confidentiality of all identifiable patient information.

M.G.L. c. 176B, § 21 Insolvency of health maintenance organization; replacement coverage

c. 176B, § 21. Insolvency of health maintenance organization; replacement coverage Section 21. (a) For purposes of this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:- ''Carrier'', a health maintenance organization authorized under chapter 176G, an insurance company authorized to provide accident and health insurance under chapter 175, a nonprofit hospital service corporation authorized under chapter 176A, a nonprofit medical service corporation authorized under this chapter, or any other entity responsible for the payment of benefits or provision of services under a group contract. ''Replacement'', the benefits provided by a succeeding carrier. ''Discontinuance'', the termination of the contract between the group contract holder and a health maintenance organization authorized under chapter 176G due to the insolvency of the health maintenance organization. The word ''discontinuance'' does not refer to the termination of any agreement between any individual enrollee and the health maintenance organization. (b) (1) In the event of an insolvency of a health maintenance organization authorized under chapter 176G, upon order of the commissioner, all other carriers that participated in the enrollment process with the insolvent health maintenance organization at a group's last regular enrollment period shall offer such group's enrollees of the insolvent health maintenance organization a 30 day enrollment period commencing upon the date of insolvency. Each carrier shall offer such enrollees of the insolvent health maintenance organization the same coverages and rates that it had offered to the enrollees of the group at its last regular enrollment period. (2) If no other carrier had been offered to some groups whose members were enrolled in the insolvent health maintenance organization, or if the commissioner determines that the other carriers lack sufficient health care delivery resources to assure that health care services will be available and accessible to all of the group's enrollees of the insolvent health maintenance organization, then the commissioner shall allocate equitably the insolvent health maintenance organization's group contracts for such groups among all health maintenance organizations that operate within a portion of the insolvent health maintenance organization's service area as provided in paragraph (2) of subsection (b) of section 23 of chapter 176G. (c) (1) Any carrier providing replacement coverage with respect to group hospital, medical or surgical expense or service benefits within 60 days from the date of discontinuance of a prior health maintenance organization contract or policy providing such hospital, medical or surgical expense or service benefits shall immediately cover all enrollees who were validly covered under the previous health maintenance organization contract or policy at the date of discontinuance and who would otherwise be eligible for coverage under the succeeding carrier's contract, regardless of any provisions of the contract relating to active employment or hospital confinement or pregnancy. (2) Except to the extent benefits for the condition would have been reduced or excluded under the prior carrier's contract or policy, no provision in a succeeding carrier's contract of replacement coverage that would operate to reduce or exclude benefits on the basis that the condition giving rise to benefits preexisted the effective date of the succeeding carrier's contract shall be applied with respect to those enrollees validly covered under the prior carrier's contract or policy on the date of discontinuance.

M.G.L. c. 176B, § 22 Statement provided to individuals provided with creditable coverage; report

c. 176B, § 22. Statement provided to individuals provided with creditable coverage; report Section 22. Pursuant to section 8B of chapter 62C, any corporation subject to this chapter shall provide written statements to residents of the commonwealth for whom creditable coverage is provided and shall provide a separate report verifying those statements to the commissioner of revenue.

M.G.L. c. 176B, § 23 Attribution of members to a primary care provider

c. 176B, § 23. Attribution of members to a primary care provider Section 23. To the maximum extent possible, every medical service corporation shall attribute every member to a primary care provider. Members may change their primary care provider, provided that the member gives notice to the carrier.

M.G.L. c. 176B, § 24 Disclosure of patient-level data and contracted prices of individual health care services by carriers to providers

c. 176B, § 24. Disclosure of patient-level data and contracted prices of individual health care services by carriers to providers Section 24. To the extent permissible under applicable state and federal privacy laws, every medical service corporation shall disclose patient-level data to providers in their network solely for the purpose of carrying out treatment, coordinating care among providers and managing the care of their own patient panel; provided, that an individual provider shall only receive patient-level data related to patients treated by said provider. Patient-level data shall include, but not be limited to, health care service utilization, medical expenses, and demographics. The division of insurance shall develop procedures and a standard format for disclosing such patient-level information. The division may require every medical service corporation to disclose such information through the all-payer claims database established under section 12 of chapter 12C if the division and the center for health information and analysis determine that the all-payer claims database is an efficient means to provide such information. Medical service corporations shall make available to any provider with whom they have entered into an alternative payment contract, the contracted prices of individual health care services within such payer's network for the purpose of referrals.

M.G.L. c. 176B, § 25 Coverage for health care services delivered via telehealth by a contracted health care provider

c. 176B, § 25. Coverage for health care services delivered via telehealth by a contracted health care provider Section 25. (a) For the purposes of this section, the following words shall, unless the context clearly requires otherwise, have the following meanings: ''Behavioral health services'', care and services for the evaluation, diagnosis, treatment or management of patients with mental health, developmental or substance use disorders. ''Telehealth'', the use of synchronous or asynchronous audio, video, electronic media or other telecommunications technology, including, but not limited to: (i) interactive audio-video technology; (ii) remote patient monitoring devices; (iii) audio-only telephone; and (iv) online adaptive interviews, for the purpose of evaluating, diagnosing, consulting, prescribing, treating or monitoring of a patient's physical health, oral health, mental health or substance use disorder condition. (b) A contract between a subscriber and a medical service corporation shall provide coverage for health care services delivered via telehealth by a contracted health care provider if: (i) the health care services are covered by way of in-person consultation or delivery; and (ii) the health care services may be appropriately provided through the use of telehealth; provided, however, that an insurer shall not meet network adequacy through significant reliance on telehealth providers and shall not be considered to have an adequate network if patients are not able to access appropriate in-person services in a timely manner upon request. Coverage shall not be limited to services delivered by third-party providers. (c) Coverage may include utilization review, including preauthorization, to determine the appropriateness of telehealth as a means of delivering a health care service; provided, however, that the determination shall be made in the same manner as if the service was delivered in person. A carrier shall not be required to reimburse a health care provider for a health care service that is not a covered benefit under the plan or reimburse a health care provider not contracted under the plan except as provided for under subclause (i) of clause (4) of the second sentence of subsection (a) of section 6 of chapter 176O. (d) A health care provider shall not be required to document a barrier to an in-person visit nor shall the type of setting where telehealth services are provided be limited for health care services provided via telehealth; provided, however, that a patient may decline receiving services via telehealth in order to receive in-person services. (e) A contract that provides coverage for telehealth services may contain a provision for a deductible, copayment or coinsurance requirement for a health care service provided via telehealth as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to an in-person consultation or in-person delivery of services. The rate of payment for telehealth services provided via interactive audio-video technology may be greater than the rate of payment for the same service delivered by other telehealth modalities. (f) Coverage that reimburses a provider with a global payment, as defined in section 1 of chapter 6D, shall account for the provision of telehealth services to set the global payment amount. (g) Medical service corporations shall ensure that the rate of payment for in-network providers of behavioral health services delivered via interactive audio-video technology and audio-only telephone shall be no less than the rate of payment for the same behavioral health service delivered via in-person methods; provided, that this subsection shall apply to providers of behavioral health services covered as required under subclause (i) of clause (4) of the second sentence of subsection (a) of section 6 of chapter 176O. (h) Health care services provided via telehealth shall conform to the standards of care applicable to the telehealth provider's profession and specialty. Such services shall also conform to applicable federal and state health information privacy and security standards as well as standards for informed consent.
Source: Massachusetts General Court (malegislature.gov)URL: https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176BFetched: 10/20/2026

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