NON–PROFIT HOSPITAL SERVICE CORPORATIONS

M.G.L. pt. Part I, tit. Title XXII, ch. c. 176A

in effect

M.G.L. c. 176A, § 1 Corporations governed by chapter; services received in nonparticipating hospital; substitution of benefits in nursing homes

c. 176A, § 1. Corporations governed by chapter; services received in nonparticipating hospital; substitution of benefits in nursing homes Section 1. Any corporation organized under the laws of the commonwealth for the purpose of establishing, maintaining and operating a non-profit hospital service plan whereby hospital care and reimbursement for other health services may be provided by such corporation, or by a hospital with which it has a contract for such care and which is maintained by the commonwealth or a political subdivision thereof, or maintained by a corporation organized for hospital purposes under the laws of the commonwealth, or such other hospitals as shall be approved by the commissioner of public health, to such of the public who become subscribers to said plan under a contract which entitles each subscriber or his dependents, or employees or dependents of employees of employers who contribute the subscription fees in whole or in part to certain hospital care and reimbursement for other health services, shall be governed by this chapter. Nothing in this chapter shall prevent such a corporation from reimbursing a subscriber for services received in a non-participating hospital within or outside the commonwealth in the event of accident, illness or maternity or, upon the written direction of the subscriber, from making payment to said hospital for such services; provided, however, that the amount of such reimbursement and payment to any such hospital within the commonwealth shall conform with such method of payment and guarantee of benefits as shall have been in effect pursuant to section five of this chapter immediately prior to the expiration of the then most recent contract between said hospital and said corporation and shall be based upon the charges of the hospital in effect on such date. Nothing in this section shall prevent any such corporation, with the approval of the commissioner of public health, from entering into contracts with a state-operated veterans' home, whereby in consideration of a contract fee, the veterans' home shall provide such care for non-service connected causes as would be provided in participating hospitals under contracts with subscribers. Nothing in this section shall prevent any such corporation, with the approval of said commissioner, from entering into contracts with the Lemuel Shattuck Hospital whereby, in consideration of a contract fee, said hospital shall provide such hospitalization and such other care as would be provided in participating hospitals under contracts with subscribers, subject to such restrictions as to nature of disease and length of stay as may be specified from time to time in said contracts.

M.G.L. c. 176A, § 1A Right to become subscriber; open enrollment periods

c. 176A, § 1A. Right to become subscriber; open enrollment periods Section 1A. Any person residing in the commonwealth shall have the right to become a subscriber of a nonprofit hospital service corporation if the qualifications of such person meet those specified in the by-laws of such corporation; provided, however, that such 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 such corporation, or has been guilty of uncooperative or unethical dealings with such corporation, or has failed to pay dues and assessments seasonably and promptly, or for any other cause which may be approved by the commissioner. Any 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. All nonprofit hospital service corporations governed by this chapter which offer supplemental coverage to medicare, shall provide open enrollment for nongroup subscribers to medicare supplemental coverage, commencing on February first and ending March thirty-first of each year, for coverage to be effective June first of that year; provided, however, that nothing contained herein shall preclude additional periods of open enrollment for subscribers to medicare supplemental coverage. Any person who is eligible for Medicare coverage for both hospital and physician services 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 such person's 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. 176A, § 1B Medicare supplemental group coverage; medical assistance recipients

c. 176A, § 1B. Medicare supplemental group coverage; medical assistance recipients Section 1B. A nonprofit hospital 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. 176A, § 1C Retroactive premium rate increase

c. 176A, § 1C. Retroactive premium rate increase Section 1C. 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 nonprofit hospital 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. 176A, § 1D Contracts of reinsurance

c. 176A, § 1D. Contracts of reinsurance Section 1D. 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. 176A, § 2 Incorporators; directors; certificate of organization; commissioner's examination report

c. 176A, § 2. Incorporators; directors; certificate of organization; commissioner's examination report Section 2. Persons desiring to form such a non-profit hospital service corporation shall incorporate as provided in section three of chapter one hundred and eighty. The board of directors of each such corporation shall consist of thirty-one members, three of whom shall be officers or agents of contributing employers who are not identified with a hospital as officers, directors or employees, and two of whom shall be representatives of labor. The said directors shall be elected for terms of three years. Every certificate of organization of a corporation subject to this chapter filed under said chapter one hundred and eighty shall have endorsed thereon or attached thereto the consent of the commissioner of insurance. The recommendations and criticisms of the latest report of each examination made by the commissioner of insurance shall be read at the next annual or special meeting of every non-profit hospital service corporation, and at the next meeting of the board of directors and thereafter a copy thereof shall be filed at the home office of the corporation and shall be made available for inspection by any member upon request.

M.G.L. c. 176A, § 3 Certificate of compliance; examination by commissioner

c. 176A, § 3. Certificate of compliance; examination by commissioner Section 3. No non-profit hospital service corporation shall make or issue any contract to provide hospital care and reimbursement for other health services until it has obtained from the commissioner of insurance, in this section called the commissioner, a certificate, in such form as he may prescribe, stating that the corporation has complied with the conditions set forth in this chapter and all other provisions of law authorizing it to make or issue such contract. No such certificate shall be issued until the commissioner is satisfied, by such examination as he may make and such evidence as he may require, that the corporation has complied with the laws of the commonwealth, adopted a proper system of accounting, and employed either full time or on a consulting basis a competent accountant, a competent claim manager, a competent and experienced underwriter, and a competent and experienced actuary; nor, until the commissioner is satisfied, by such examination as he may make and by an affidavit filed with him, and by such evidence as he may require, that the corporation is without liabilities, except such organization expenses as the commissioner shall approve as reasonable; nor until he is satisfied that its officers and directors are of good repute and competent to manage a non-profit hospital service corporation.

M.G.L. c. 176A, § 3A Discrimination against abuse victims in terms of hospital service plans

c. 176A, § 3A. Discrimination against abuse victims in terms of hospital service plans Section 3A. 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 hospital 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. 176A, § 3B Medical service plans; genetic tests; discrimination based on genetic information

c. 176A, § 3B. Medical service plans; genetic tests; discrimination based on genetic information Section 3B. 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 purpose 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 or 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 hospital 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. 176A, § 4 Accounting system; accountant, claim manager, underwriter and actuary

c. 176A, § 4. Accounting system; accountant, claim manager, underwriter and actuary Section 4. Every non-profit hospital service corporation shall use a proper system of accounting, and employ either full time, or on a consulting basis, a competent accountant, a competent claim manager, a competent and experienced underwriter, and a competent and experienced actuary.

M.G.L. c. 176A, § 5 Joint administration with certain corporations

c. 176A, § 5. Joint administration with certain corporations Section 5. Any corporation subject to this chapter may contract with corporations formed under chapter one hundred and seventy-six B for the joint administration of their business and for joint and co-operative writing and issuing of certificates and may enter into reciprocal arrangements with other nonprofit hospital service corporations organized in other jurisdictions for the mutual benefit of their subscribers and may contract with any agency of the United States of America, of the commonwealth or any city or town within the commonwealth for the purpose of providing hospital service or reimbursement for other health services. Any such corporation shall contract with a corporation formed under chapter one hundred and seventy-six B for the joint administration of their business when acting as a carrier under chapter one hundred and seventy-six G. Any hospital service corporation may join with any other hospital 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 hospital services and other health services 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 non-profit hospital service corporation with which there is joint and cooperative writing and issuing of certificates shall be qualified to do business in the commonwealth. Any corporation subject to this chapter may enter into contracts for the rendering of hospital service only with hospitals referred to in section one. In providing reimbursement for health services other than hospital services, any hospital service corporation may enter into contracts for the furnishing of such health services with providers thereof. All rates of payment to providers of other health services made by such corporation, under such contracts, shall be approved in advance by the executive office of health and human services, in this section called the executive office, or a governmental unit designated by the executive office. Any such approval may be withdrawn by the commission at any time as hereinafter provided. No rates of payment under any such contract with a provider of other health services shall be approved nor their continuance be permitted by the commission, unless such rates are not excessive, not inadequate and not unfairly discriminatory in relation to other such providers who have entered into such contracts with such corporation. For the purposes of the review of rates of payment under this section, ''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. A contract between a hospital service corporation and a provider of home health services or 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. Every contract made by such corporation with a participating hospital or provider of other health services shall contain a provision whereby such hospital or provider of other health services guarantees to subscribers or their dependents or employees, or dependents of employees of employers who contribute the subscription fees in whole or in part the benefits of the subscriber's certificate in effect at the time such services are provided notwithstanding the ability of such corporation to pay therefor. Officers of the commonwealth and of counties, cities and towns within the commonwealth are authorized to execute contracts containing such provision. In negotiating a contract with a nonprofit hospital service corporation, a non-acute hospital shall have the right to designate the Massachusetts hospital association, incorporated, or any other state-wide, hospital member organization as its agent for negotiating such contract. Each individual non-acute hospital, however, shall retain the right to accept or reject all or part of such negotiated contract. When any such corporation is informed that such a negotiating agent represents one or more non-acute hospitals, such corporation shall have the right to propose to the agent, and thereafter negotiate, a non-acute hospital contract that would be applicable to some or all of the non-acute hospitals represented by the agent. Such a negotiating agent that represents more than one non-acute hospital shall have the right to propose to said corporations, and thereafter negotiate, a non-acute hospital contract which would be applicable to some or all of the non-acute hospitals represented by it. The commission shall not disapprove any contract between a non-acute hospital and said corporations on the grounds that a term or terms of the contract are similar or identical to the terms of a proposed or approved contract between any other non-acute hospital and such corporations, or that the non-acute hospital was represented by a negotiating agent which represented one or more other non-acute hospitals. All rates of payment to non-acute hospitals made by such corporation, under such contracts, shall be approved in advance by the commission. Any such approval may be withdrawn by the commission at any time as hereinafter provided. No rates of payment shall be approved, nor their continuance be permitted by the commission, unless such rates reflect reasonable costs or are based on charges made to the general public, whichever is lower. The commission in determining reasonable cost shall give consideration to services provided by the non-acute hospital and the costs of comparable non-acute hospitals, and may give consideration to depreciation, amortization, interest, occupancy, individual services which are rendered for partial or no payment and principles of reimbursement for provider costs in effect from time to time under Titles XVIII and XIX of the Social Security Act. Other requirements of this section notwithstanding, the commission may approve any rate of payment to any provider or class of providers if such rate, in the opinion of the commission, contains an incentive to achieve greater efficiency and economy in the manner of providing health care services without adversely affecting the quality of such services. A nonacute hospital shall file with the commission in accordance with regulations adopted after public hearing such data, statistics, schedules or other information as the commission may reasonably require to enable it to approve or disapprove contracts with or rates of payment to nonacute hospitals. For the purpose of approving, disapproving, or permitting the continuance of all rates of payment under such contracts, the commission may require an examination of the books of account and statistical records of each non-acute hospital and such examination shall be made under the direction and supervision of the commission. The commission may enter into an annual agreement with a nonprofit hospital service corporation for the services of such auditors or accountants as may be required in any such examination; provided, that the entire costs of such salaries of auditors or accountants and necessary expenses connected therewith, including related expenses of the commission, shall be borne by such corporation. The commission may also enter into an annual agreement with a nonprofit hospital service corporation for such health care specialists, statisticians and other personnel as may be required by the commission in performing its duties under this chapter. Expenses incurred in connection with any agreement authorized under this paragraph shall be treated as part of the cost of benefits furnished by said corporation. Within thirty days of the filing of any proposed contract or rate of payment between a nonprofit hospital service corporation and a non-acute hospital, the commission shall either (1) approve the contract or rate of payment without holding a public hearing; or (2) disapprove the contract or rate of payment without holding a public hearing, filing in its office a statement setting forth its reasons for its disapproval; or (3) hold a public hearing on all or such portion of said proposed contract or rate of payment as it shall designate in the notice of hearing which it shall file in its office. If the commission disapproves a proposed contract or rate of payment, it shall promptly notify, in writing, such corporation and each interested nonacute hospitals of its disapproval. The disapproval shall be final unless, within ten days of the filing of its statement of disapproval, such corporation or any interested hospital or provider of other health services shall file with the commission a written request for a public hearing on the disapproval. The public hearing, at which such corporation and each interested hospital and provider of other health services shall be entitled to appear, shall be held within fourteen days of the filing of the request for such hearing with the commission, and the decision thereon shall be made within twenty-eight days of the date of the filing of such request, unless the corporation and each interested non-acute hospital involved agrees, in writing, to an extension of either date. If the commission decides to hold a public hearing without prior acting on the proposed contract or rate of payment, it shall promptly notify, in writing, such corporation, each interested hospital and provider of its decision. The public hearing, at which such corporation, each interested hospital and provider of other health services shall be entitled to appear, shall be held within twenty-one days of filing of the notice thereof in its office. The decision thereon shall be made within twenty-one days of the commencement of the hearing, unless such corporation and each interested non-acute hospital involved agrees, in writing, on an extension of the date. If the commission disapproves of a previously approved contract or rate of payment, it shall file in its office a statement setting forth its reasons for its disapproval, and it shall promptly notify, in writing, such corporation and nonacute hospital of such disapproval. Such notice of disapproval shall state the effective date of the disapproval which shall not be sooner than sixty days from the date of the filing of such disapproval in its office. The disapproval shall be final on the date indicated in said notice unless, within ten days of the filing of its statement of disapproval, such corporation, any interested hospital or provider of other health services shall file with the commission a written request for a public hearing on the disapproval. The public hearing, at which such corporation, each interested non-acute hospital shall be entitled to appear, shall be held within fourteen days of the filing of the request for a hearing with the commission, and the decision thereon shall be made within twenty-eight days of the date of the filing of such request, unless the corporation and each interested non-acute hospital involved agrees, in writing, on an extension of either date. Any nonprofit hospital service corporation, non-acute hospital or provider of other health services aggrieved by an order, finding, decision or other action made or taken under this section by the commission may, within twenty days of the filing thereof by the commission in its office as a public record, appeal such order, filing, decision or other action by filing a petition with the division of administrative law appeals, established pursuant to section four H of chapter seven, if the total amount subject to appeal is less than one hundred thousand dollars or, may file in the supreme judicial court for the county of Suffolk for a review of such order, finding, decision or other action. In the event that there is an appeal from an order of the commission disapproving a rate of payment between a nonprofit hospital service corporation and a non-acute hospital or provider of other health services, any level of payment which the commission did approve shall be used pending the determination of the appeal and any difference in the rates established as a result of the appeal and the interim rate shall be adjusted, as the court may determine. Upon the filing of a petition for review under this section, an order of notice returnable not later than twenty days from the filing of such petition shall forthwith issue and be served upon the commission. Within ten days after service of a copy of the petition for review upon the commission or within such further time as the court may allow, the commission shall file in the court the original or a certified copy of the records of the proceeding under review. The review shall be governed by paragraphs (2), (3), (4) with the exception of the first sentence thereof, (5), (6), (7) and (8) of section fourteen of chapter thirty A, and review by the supreme judicial court shall be governed by section fifteen of said chapter thirty A. The commissioner of insurance shall on December thirty-first, nineteen hundred and seventy and annually thereafter require a statement from any nonprofit hospital service corporation relative to the number and type of contracts written hereunder, utilization of extended care facilities and other health services, and such other information, and in the form, as he may require.

M.G.L. c. 176A, § 6 Approval of nongroup contracts

c. 176A, § 6. Approval of nongroup contracts Section 6. Nongroup contracts, except contracts providing supplemental coverage to medicare subject to the provisions of chapter one hundred and seventy-six K, issued and rates charged by nonprofit hospital service corporations to its subscribers for hospital care and reimbursement for other health services shall be subject to the provisions of chapter one hundred and seventy-six M, and any regulations promulgated thereunder. No such contracts shall be approved if the benefits provided therein are unreasonable in relation to the rate charged, nor if the rates are excessive, inadequate or unfairly discriminatory. For the purposes of the review of rates of payment under this section, whether a contract 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. The commissioner shall require every such corporation to keep its books, records, statistics, accounts and vouchers in such manner that he or his authorized representatives may readily verify its annual statements and ascertain whether the corporation has complied with the law. At least once in three years, and whenever he determines it to be prudent, he shall personally, or by his deputy or examiner, visit each non-profit hospital service corporation and thoroughly inspect and examine its affairs to ascertain its financial condition, its ability to fulfill its obligations, whether it has complied with the law, and any other facts relating to its business methods and management, and the equity of its dealings with its subscribers. A report of examination of any corporation made under this section shall as far as material and relevant be admitted in the discretion of the court in any judicial proceedings brought by or in behalf of the commissioner or any subscriber, non-profit hospital service corporation or other person as evidence tending to prove the facts stated in such report, but nothing in this paragraph shall be construed to require the commissioner to make an examination under this section before bringing such a proceeding. The commissioner may investigate, in such manner and to such extent as he may deem expedient, any complaint under any subscriber's contract.

M.G.L. c. 176A, § 7 Information gathering authority of commissioner; confidentiality and privilege

c. 176A, § 7. Information gathering authority of commissioner; confidentiality and privilege Section 7. The commissioner of insurance, or any person authorized by him to make examinations or investigations or to conduct hearings provided for by this chapter, shall have free access to all the assets of non-profit hospital service corporations for the purpose of verification, and to all the books and papers relating to their business and to the books and papers of their representatives. Said commissioner or any person authorized by him may summon and examine under oath any person who has knowledge of the affairs, transactions or circumstances being examined or investigated; and whoever without justifiable cause neglects upon due summons to appear and testify before the commissioner of insurance or his authorized representative, and whoever obstructs said commissioner or his representative in making examinations or investigations under this chapter, shall be punished as provided herein. 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 section 6 or in the course of analysis by the commissioner of the financial condition or market conduct of a non-profit hospital 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 section 6 or assisting the commissioner in the analysis of the financial condition or market conduct of a non-profit hospital 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.

M.G.L. c. 176A, § 8 Conditions to issuance or delivery of contract

c. 176A, § 8. Conditions to issuance or delivery of contract Section 8. No contract between the subscriber and the corporation shall be issued or delivered in the commonwealth which provides full room and board benefits in an extended care facility for other than the period of hospitalization coverage provided, or which provides benefits for any service which is not medically necessary. No contract between the subscriber and the corporation shall be issued or delivered in the commonwealth unless it contains in substance the following provisions: (a) A statement of the hospital services and reimbursement for other health services to be furnished by the corporation or its participating hospitals and the period during which they will be furnished, and, if any hospital services are excluded, a statement of such exception. (b) A statement of the period of grace which will be allowed for making any payment due from the subscriber under its contract, which in any event shall not be less than ten days. (c) A provision that the subscriber or any person claiming under a subscriber's contract shall have a period of at least two years from the time the cause of action arises to bring suit thereon. (d) A provision that any child who is mentally or physically incapable of earning his own living, who is covered under the membership of his parent as a member of a family group, shall be covered under the membership of his parent as a member of such family group 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. (e) A statement that within fifteen days after the 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 contract, the corporation shall furnish the subscriber such forms as are usually furnished by it to establish a subscriber's entitlement to such benefits; and that within forty-five days after the receipt by the corporation of completed forms for such benefits, the corporation will (i) make payments for such benefits, (ii) notify the subscriber in writing of the reason or reasons for nonpayment, or (iii) notify the subscriber in writing of what additional information or documentation is necessary to establish entitlement to such benefits. If the nonprofit hospital service corporation fails to comply with the provisions of this paragraph, said corporation shall pay, in additional to any benefits which inure to such subscriber or provider, interest on such benefits which shall accrue beginning forty-five 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 nonprofit hospital service corporation is investigating because of suspected fraud. (f) 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. (g) 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. 176A, § 8A Mental illness expenses; inclusion in contracts as benefits; biologically-based mental disorders; rape-related mental disorders; non-biologically-based mental disorders for children and adolescents under age 19

c. 176A, § 8A. Mental illness expenses; inclusion in contracts as benefits; biologically-based mental disorders; rape-related mental disorders; non-biologically-based mental disorders for children and adolescents under age 19 Section 8A. (a) A contract between a subscriber and the corporation under an individual or group hospital service plan 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 and 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 contract between a subscriber and the corporation under an individual or group hospital service plan 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 and 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 contract 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 contract 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, or (3) a pattern of conduct or behavior caused by such a disorder which poses a serious danger to self or others. The nonprofit hospital 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. For the purposes of this subsection, the term ''primary care provider'' shall mean 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. (d) Any such contract shall be deemed to be providing such coverage on a non-discriminatory basis if the contract does not contain any annual or lifetime dollar or unit of service limitation on benefits 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 benefits for the diagnosis and treatment of physical conditions. (e) Any such contract 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 hospital 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 hospital service corporation. The benefits provided in any contract pursuant to this section shall meet all other terms and conditions of the contract not inconsistent with this section. (i) Nothing in this section shall be construed to require a non-profit hospital 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 hospital 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. 176A, § 8A1/2 Repealed, 2000, 80, Sec. 5

M.G.L. c. 176A, § 8A3/4 Retroactive claims denials for behavioral health services

c. 176A, § 8A3/4. Retroactive claims denials for behavioral health services Section 8A3/4. (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) The 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 insurer 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. 176A, § 8AA Coverage of prosthetic devices and repairs

c. 176A, § 8AA. Coverage of prosthetic devices and repairs Section 8AA. (a) A contract between a subscriber and the corporation under an individual or group hospital service plan which provides hospital expense and surgical expense insurance, except contracts providing 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 for 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 contract, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone 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 contract 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 contract. (d) No such contract shall apply amounts paid for prosthetic devices to any annual or lifetime dollar maximum applicable to other durable medical equipment covered under the policy other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the contract. (e) Any such contract 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 contract 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 contract 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. 176A, § 8AAA Coverage for diagnostic examinations for breast cancer; digital breast tomosynthesis screening, MRIs and ultrasounds

c. 176A, § 8AAA. 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 8AAA. (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 contract between a subscriber and a corporation under an individual or group hospital service plan which is 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. 176A, § 8B Dependent coverage for newborn infants or adoptive children; inclusion in contracts

c. 176A, § 8B. Dependent coverage for newborn infants or adoptive children; inclusion in contracts Section 8B. Any contract, which provides for dependent coverage, between a subscriber and the corporation under an individual or group hospital service plan which shall be delivered or issued for delivery or subsequently renewed in this commonwealth shall include as insured members newborn infants and newborn infants of a dependent of a contract holder immediately from the moment of birth and thereafter. Any such contract shall also include as insured members adoptive children of a contract holder immediately from the date of 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 contract holder as a foster child for whom the contract holder has been receiving foster care payments, or, in all other cases, immediately from the date of placement by a licensed placement agency of the child for purposes of adoption in the home of the contract 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 contract, as described in this section, shall provide as benefits to all subscribers and members in addition to the benefits described in the preceding paragraph the provision 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 test 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 contract 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 obligation to provide coverage for a hearing screening test or any other hearing screening test or audiological diagnostic procedure pursuant to any law or regulation of the commonwealth or of the United States or under the terms or provisions of any contract or certificate.

M.G.L. c. 176A, § 8BB Coverage for eligible dependents under 26 years of age or dependents mentally or physically incapable of earning their own living due to disability

c. 176A, § 8BB. Coverage for eligible dependents under 26 years of age or dependents mentally or physically incapable of earning their own living due to disability Section 8BB. Any subscription certificate under an individual or group nonprofit hospital service agreement, except certificates which provide stand-alone dental services, supplemental coverage to Medicare or other governmental programs, that is delivered, issued or renewed in the commonwealth, shall provide, as benefits to all individuals or 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. 176A, § 8BBB Coverage for prescribed, ordered or dispensed opioid antagonists

c. 176A, § 8BBB. 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 8BBB. (a) Any contract between a subscriber and the corporation under an individual or group hospital service plan that is 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) Such contracts 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. 176A, § 8C Refusal to contract with blind or deaf persons; prohibition

c. 176A, § 8C. Refusal to contract with blind or deaf persons; prohibition Section 8C. No corporation subject to this chapter shall refuse for the reason of blindness or deafness, to contract with a subscriber an individual hospital service plan.

M.G.L. c. 176A, § 8CC Coverage for medically necessary hypodermic syringes or needles

c. 176A, § 8CC. Coverage for medically necessary hypodermic syringes or needles Section 8CC. No contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed in the commonwealth shall restrict or discontinue coverage for medically necessary hypodermic syringes or needles to an individual or group subscribers within the commonwealth and 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. 176A, § 8CCC Coverage for the provision of services by a recovery coach

c. 176A, § 8CCC. 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 8CCC. Any contract between a subscriber and the corporation under an individual or group hospital service plan that is 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. 176A, § 8D Limited extension of benefits

c. 176A, § 8D. Limited extension of benefits Section 8D. Whenever a subscriber of a group non-profit hospital service contract, other than one authorized under the provisions of chapter thirty-two A or chapter thirty-two B, becomes ineligible for continued participation in such group contract because of involuntary lay-off or death, the coverage originally provided by such contract 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 policyholder fails to make payment to the insurer or hospital or medical service corporation with the result that coverage is terminated, the employer or policyholder 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 policyholder's receipt of the premium or subscription fee for the extended coverage from such member or his dependents 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. In addition, whenever such group non-profit hospital service contract 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 contract becomes ineligible for continued participation in such contract 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 plans. 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 requirements of this paragraph when said contractual agreement provides at least three months or ninety days continuation of such insurance. Otherwise, the requirements of this paragraph shall be deemed to be controlling.

M.G.L. c. 176A, § 8DD Coverage for diagnosis and treatment of autism spectrum disorder

c. 176A, § 8DD. Coverage for diagnosis and treatment of autism spectrum disorder Section 8DD. (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 contract 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 contract between a subscriber and the corporation under an individual or group hospital service plan 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 contract shall be in compliance with subsection (b) if the contract does not contain 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 under 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. 176A, § 8DD1/2 Coverage for treatment of Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis services

c. 176A, § 8DD1/2. 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. 4 effective January 1, 2026. See 2024, 388, Sec. 7.] Section 8DD1/2. 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. Any contract between a subscriber and the corporation under an individual or group hospital service plan that is 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. 176A, § 8DDD Coverage for identified generic and brand name drug used to treat diabetes, asthma, and certain heart conditions

c. 176A, § 8DDD. 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 8DDD. (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) Any contract between a subscriber and the corporation under an individual or group hospital service plan that is 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) Any contract between a subscriber and the corporation under an individual or group hospital service plan that is 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 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. 176A, § 8E Diethylstilbestrol exposure; discrimination

c. 176A, § 8E. Diethylstilbestrol exposure; discrimination Section 8E. No contract between a subscriber and the corporation under an individual or group hospital service plan which shall be delivered or issued in the commonwealth shall be denied, 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. 176A, § 8EE Coverage for children under age 18 for cleft lip and cleft palate

c. 176A, § 8EE. Coverage for children under age 18 for cleft lip and cleft palate Section 8EE. A contract between a subscriber and the corporation under an individual or group hospital service plan which provides hospital expense and surgical expense insurance, except contracts providing 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, 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. 176A, § 8F Divorced or separated spouses; continuation of eligibility for benefits

c. 176A, § 8F. Divorced or separated spouses; continuation of eligibility for benefits Section 8F. (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 hospital service contract 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 contract, whether or not said judgment was entered prior to the effective date of said contract, 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 contract 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 contract or the issuance of an individual contract, 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 hospital 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. 176A, § 8FF Coverage for orally administered anticancer medications

c. 176A, § 8FF. Coverage for orally administered anticancer medications Section 8FF. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is 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. 176A, § 8G Cardiac rehabilitation expense benefits

c. 176A, § 8G. Cardiac rehabilitation expense benefits Section 8G. Any contract, except contracts providing supplemental coverage to medicare or other governmental programs, between a subscriber and the corporation under an individual or group hospital service plan 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. 176A, § 8GG Coverage for abuse deterrent opioid drug products

c. 176A, § 8GG. Coverage for abuse deterrent opioid drug products Section 8GG. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is 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 the individual or group hospital service plan. An increase in patient cost sharing shall not be allowed to achieve compliance with this section.

M.G.L. c. 176A, § 8H Abortion, abortion-related care, prenatal, childbirth and postpartum care benefits; minimum coverage for in-patient care

c. 176A, § 8H. 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 8H. Any contract, except contracts providing supplemental coverage to medicare or other governmental programs, between a subscriber and the corporation under an individual or group hospital service plan 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 8W, 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. 176A, § 8HH Preauthorization for substance abuse treatment not to be required

c. 176A, § 8HH. Preauthorization for substance abuse treatment not to be required Section 8HH. 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 8II; and medically managed intensive inpatient services, not covered under said section 8II. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is 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. 176A, § 8I Home care benefits

c. 176A, § 8I. Home care benefits Section 8I. Any subscription certificate under a group nonprofit hospital service agreement, except certificates which provide supplemental coverage to medicare or other governmental programs which shall be delivered, issued or renewed in the commonwealth, shall provide, as benefits to all group members having a principal place of employment within the commonwealth, for the expense of medically necessary health care services determined to be medically necessary and provided by a participating home health agency to a member in his residence; provided, however, that such residence is neither a hospital nor an institution primarily engaged in providing skilled nursing or rehabilitation services. Said services shall include, but not be limited to, nursing and physical therapy. Additional services such as occupational therapy, speech therapy, medical social work, nutritional consultation services, the services of a home health aid and the use of durable medical equipment and supplies shall be provided to the extent such additional services are determined to be a medically necessary component of said nursing and physical therapy. Said benefits for home care services shall meet all other terms and conditions of the subscriber certificate. The provisions of this section shall not apply to group insurance plans issued pursuant to the provisions of chapter thirty-two B.

M.G.L. c. 176A, § 8II Coverage for medically necessary acute treatment or clinical stabilization services

c. 176A, § 8II. Coverage for medically necessary acute treatment or clinical stabilization services Section 8II. 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 contract between a subscriber and the corporation under an individual or group hospital service plan which is 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 contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth, shall cover, 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. 176A, § 8J Minimum requirements for cytologic screening and mammographic examination expense benefits

c. 176A, § 8J. Minimum requirements for cytologic screening and mammographic examination expense benefits Section 8J. Any contract, except contracts providing supplemental coverage to medicare or other governmental programs, between a subscriber and the corporation under an individual group hospital service plan which shall be delivered, 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 cytologic screening and mammographic examination. Said benefits shall be at least equal to the following minimum requirements: (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 a mammogram on an annual basis for women forty years of age and older.

M.G.L. c. 176A, § 8JJ Repealed, 2016, 133, Sec. 112

M.G.L. c. 176A, § 8K Infertility diagnosis and treatment benefits

c. 176A, § 8K. Infertility diagnosis and treatment benefits Section 8K. Any contract, except contracts providing supplemental coverage to medicare or other governmental programs, between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued for delivery or renewed in the commonwealth while this provision is effective and which provides pregnancy-related benefits 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, coverage for medically necessary expenses of diagnosis and treatment of infertility. Said infertility benefits shall meet all other terms and conditions of the subscriber 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. 176A, § 8KK Coverage for medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome

c. 176A, § 8KK. Coverage for medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome Section 8KK. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is 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. 176A, § 8L Nonprescription enteral formulas for home use

c. 176A, § 8L. Nonprescription enteral formulas for home use Section 8L. Any contract between a subscriber and the corporation under an individual or group hospital service plan that shall be delivered, issued or renewed in the commonwealth shall provide, as benefits to all individual subscribers and members within the commonwealth, 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. 176A, § 8LL Filling of remaining portion of prescription for covered drug that is a narcotic substance earlier filled in lesser quantity

c. 176A, § 8LL. Filling of remaining portion of prescription for covered drug that is a narcotic substance earlier filled in lesser quantity Section 8LL. Any contract between a subscriber and the corporation under an individual or group hospital service plan that is 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. 176A, § 8M Standardized claim form

c. 176A, § 8M. Standardized claim form Section 8M. 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. 176A, § 8MM Pain management access plan; non-medication and nonsurgical treatment; review; educational materials

c. 176A, § 8MM. Pain management access plan; non-medication and nonsurgical treatment; review; educational materials Section 8MM. (a) A contract between a subscriber and the corporation under an individual or group hospital service plan that is 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 contract 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 contract between a subscriber and the corporation under an individual or group hospital service plan that is 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. 176A, § 8N Off-label drug use; cancer

c. 176A, § 8N. Off-label drug use; cancer Section 8N. Any contract between a subscriber and the corporation under an individual or group hospital service plan 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 groups 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. 176A, § 8NN Coverage for tobacco use cessation counseling and tobacco cessation products

c. 176A, § 8NN. Coverage for tobacco use cessation counseling and tobacco cessation products [Text of section applicable to policies, contracts and subscription certificates delivered, issued or renewed in the commonwealth on or after January 1, 2020. See 2019, 133, Sec. 26.] Section 8NN. (a) Any contract between a subscriber and the corporation under an individual or group hospital service plan that is 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 preauthorization.

M.G.L. c. 176A, § 8O Hospital service plan benefits for bone marrow transplants

c. 176A, § 8O. Hospital service plan benefits for bone marrow transplants Section 8O. Any contract between a subscriber and the corporation under an individual or group hospital service plan that shall be delivered, issued or renewed in 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 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. 176A, § 8OO Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome

c. 176A, § 8OO. 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 8OO. Any contract between a subscriber and a corporation under an individual or group hospital service plan 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. 176A, § 8P Items medically necessary for diagnosis and treatment of diabetes

c. 176A, § 8P. Items medically necessary for diagnosis and treatment of diabetes Section 8P. A contract between a subscriber and the corporation under an individual or group hospital service plan which provides hospital expense and surgical expense insurance, except contracts providing 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 for the following items if such items are within a category of benefits or services for which coverage is otherwise afforded by the contract, 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 hospital service plan or affiliated with a provider participating with the hospital service plan. 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 nonprofit service corporation to contract with a certified diabetes health care provider who is not already under contract with such nonprofit service corporation. The benefits provided in this section shall meet all other terms and conditions within a subscription certificate. Hospital service plans shall not reduce or eliminate coverage due to the requirements of this section.

M.G.L. c. 176A, § 8PP Repealed, 2021, 29, Sec. 23

M.G.L. c. 176A, § 8Q HIV/AIDS treatment; off-label prescription drug coverage

c. 176A, § 8Q. HIV/AIDS treatment; off-label prescription drug coverage Section 8Q. Any contract between a subscriber and the corporation under an individual or group hospital service plan 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 within the commonwealth and to all group members having a 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.

M.G.L. c. 176A, § 8QQ Coverage for prescription eye drops

c. 176A, § 8QQ. Coverage for prescription eye drops Section 8QQ. A contract between a subscriber and the corporation under an individual or group hospital service plan which is 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. 176A, § 8R Coverage of hospice services for terminally ill patients

c. 176A, § 8R. Coverage of hospice services for terminally ill patients Section 8R. Any contract between a subscriber and the corporation under an individual or group hospital service plan that shall be 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, coverage for licensed hospice services for 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. 176A, § 8RR Coverage for mental health or substance use disorder services delivered through psychiatric collaborative care model

c. 176A, § 8RR. Coverage for mental health or substance use disorder services delivered through psychiatric collaborative care model Section 8RR. (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 contract between a subscriber and the corporation under an individual or group hospital service plan that is delivered, 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. 176A, § 8S Nurse anesthetist and nurse practitioner services

c. 176A, § 8S. Nurse anesthetist and nurse practitioner services Section 8S. Any contract between a subscriber and the corporation under an individual or group hospital service plan 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 certified registered nurse anesthetist or nurse practitioner by the board of registration in nursing pursuant to the provisions of section eighty B of chapter one hundred and twelve; 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. 176A, § 8SS Coverage for medically necessary mental health acute treatment, community-based acute treatment and intensive community-based acute treatment

c. 176A, § 8SS. Coverage for medically necessary mental health acute treatment, community-based acute treatment and intensive community-based acute treatment Section 8SS. (a) 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 contract between a subscriber and the corporation under an individual or group hospital service plan that is delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary mental health acute treatment, community-based acute treatment and intensive community-based acute treatment and shall not require a preauthorization before the administration of any such 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. 176A, § 8T Scalp hair prostheses necessary due to cancer or leukemia treatment

c. 176A, § 8T. Scalp hair prostheses necessary due to cancer or leukemia treatment Section 8T. (a) For the purpose 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 contracts, except contracts providing supplemental coverage to medicare or other governmental programs, between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed in the commonwealth and which provides coverage for any other prosthesis, shall provide, as a benefit 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. 176A, § 8TT Benefits for medically necessary emergency services programs

c. 176A, § 8TT. Benefits for medically necessary emergency services programs Section 8TT. A contract between a subscriber and the corporation under an individual or group hospital service plan that is delivered, issued or renewed within or without the commonwealth 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. 176A, § 8U Emergency services provided to insureds for emergency medical conditions

c. 176A, § 8U. Emergency services provided to insureds for emergency medical conditions Section 8U. (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's health 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 hospital 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. ''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. ''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), 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 the corporation or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if the 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, the 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 hospital service corporation may require an insured to contact 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 the corporation, its designee or to 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 the 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, the 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. 176A, § 8UU Coverage for annual mental health wellness examination

c. 176A, § 8UU. Coverage for annual mental health wellness examination Section 8UU. (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 supervised mental health counselor, a licensed independent clinical social worker, a licensed certified social worker, a licensed 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 of the General Laws, 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 contract between a subscriber and the corporation under an individual or group hospital service plan which is 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. 176A, § 8V Coverage for human leukocyte or histocompatibility locus antigen testing

c. 176A, § 8V. Coverage for human leukocyte or histocompatibility locus antigen testing Section 8V. Any contract between a subscriber and the corporation under an individual or group hospital service plan, except contracts providing supplemental coverage to Medicare or to other government programs, delivered, issued or renewed by agreement within or without 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 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. 176A, § 8VV Coverage for federally-defined preventive services

c. 176A, § 8VV. Coverage for federally-defined preventive services Section 8VV. (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 uses 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 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 contract between a subscriber and a corporation subject to this chapter, pursuant to an individual or group hospital service plan 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 pursuant to 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. 176A, § 8W Outpatient services; hormone replacement therapy for peri and post menopausal women; contraceptive services; approved prescription contraceptive drugs and devices; exception

c. 176A, § 8W. Outpatient services; hormone replacement therapy for peri and post menopausal women; contraceptive services; approved prescription contraceptive drugs and devices; exception Section 8W. (a) Any contract between a subscriber and the corporation under an individual or group hospital service plan 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 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 contract between a subscriber and the corporation under an individual or group hospital service plan 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 contract between a subscriber and the corporation delivered, issued or renewed pursuant to this chapter if the contract is purchased by a subscriber 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 contract between a subscriber and the corporation under an individual or group hospital service plan that is delivered, issued or renewed within or outside the commonwealth and 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 all of 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, a hospital service plan shall not be required to include all such therapeutically equivalent versions 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 hospital service plan 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, an individual or group hospital service plan 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 for: (i) not more than a 3-month period for the first time the prescription contraceptive is dispensed to the covered person; and (ii) not more than a 12-month period for any subsequent dispensing of the same prescription, which may be dispensed all at once or over the course of the 12-month period, 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 cost-sharing requirement except as provided for in subclauses (A) and (B) of clause (i) of subsection (d) or as otherwise required under federal law. Coverage offered under subsection (d) shall not impose any unreasonable restriction or delay 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 hospital service plan 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 exclude coverage for contraceptive drugs, devices, products and procedures prescribed by a provider for a reason 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 of insurance shall ensure compliance with this chapter. (i) Nothing in subsection (d) shall be construed to require a hospital service plan 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. 176A, § 8WW Coverage for standard fertility preservation services

c. 176A, § 8WW. Coverage for standard fertility preservation services Section 8WW. (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) Any contract between a subscriber and a corporation subject to this chapter, pursuant to an individual or group hospital service plan that is delivered, issued or renewed within the commonwealth shall provide coverage for standard fertility preservation services, including, but not limited to, 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. 176A, § 8X Coverage for patient care services under qualified clinical trials

c. 176A, § 8X. Coverage for patient care services under qualified clinical trials Section 8X. Any contract between a subscriber and the corporation under an individual or group hospital service plan delivered or issued or renewed within the commonwealth shall provide for 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. 176A, § 8XX Coverage for postpartum depression and major depressive disorder screenings

c. 176A, § 8XX. Coverage for postpartum depression and major depressive disorder screenings Section 8XX. Any policy, contract, agreement, plan or certificate of insurance issued, delivered 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. 176A, § 8Y Diagnosis and treatment of speech, hearing and language disorders

c. 176A, § 8Y. Diagnosis and treatment of speech, hearing and language disorders Section 8Y. Any contract between a subscriber and the corporation under an individual or group hospital service plan that 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 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 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 hospital service plan. [(f)] Any contracts, except contracts providing supplemental coverage to Medicare or other governmental programs, between a subscriber and the corporation under an individual or group hospital service plan that is delivered, issued or renewed in 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 such person's children 21 years of age or younger, who are insured under such contracts or plans, 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 a corporation 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.

M.G.L. c. 176A, § 8YY Coverage for the provision of medically necessary pasteurized donor human milk and donor human milk-derived products

c. 176A, § 8YY. Coverage for the provision of medically necessary pasteurized donor human milk and donor human milk-derived products Section 8YY. (a) Any contract between a subscriber and the corporation under an individual or group hospital service plan that is delivered, issued or renewed within the commonwealth 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 non-profit hospital 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. 176A, § 8Z Repealed, 2008, 451, Sec. 136

M.G.L. c. 176A, § 8ZZ Coverage for universal postpartum home visiting services

c. 176A, § 8ZZ. Coverage for universal postpartum home visiting services Section 8ZZ. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is 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. 176A, § 9 Repealed, 1996, 297, Sec. 11

M.G.L. c. 176A, § 10 Group hospital service plan; approval or disapproval of contracts and rates; filing

c. 176A, § 10. Group hospital service plan; approval or disapproval of contracts and rates; filing Section 10. Any plan whereby such a corporation agrees with a group of two or more persons or with the employer, employers or representatives of a group of two or more persons to furnish hospital benefits and reimbursement for other health services to said persons alone or to their dependents also and where the enrollment in such group is on a basis precluding individual selection, shall be considered a group hospital service plan. The contracts and rates under such plan shall be subject to subsequent disapproval by the commissioner if he or she finds that the basis fails to preclude individual selection. It shall not be considered a group hospital service plan if less than twenty-five per cent of those eligible in a group of fifty or more or seventy-five per cent in a group of less than fifty agree to become subscribers; provided, that, for the purposes of computing the percentage participation under this paragraph, 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 deemed to be subscribers under such a group hospital plan. If at any time the number enrolled as subscribers drops below the prescribed per cent of the total eligible members of that group the commissioner may require the corporation to cancel all contracts in that group without any liability for hospital admissions and reimbursement for other health services of any of the subscribers in that group after date of cancellation. Group contracts may be issued without written representation relative to physical condition. Group contracts shall be filed with the commissioner of insurance within thirty days after the effective date and shall be subject to his subsequent disapproval after notice and hearing if said contracts do not meet the requirements of this section. Notwithstanding the provisions of this section, group plan contracts issued and rates charged by a nonprofit hospital 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. The open enrollment period and coverage effective date for any group hospital 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. No such contracts shall be approved if the benefits provided therein are unreasonable in relation to the rate charged, nor if the rates are excessive, inadequate or unfairly discriminatory. For the purposes of the review of rates of payment under this section, whether a contract 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. Classifications shall be fair and reasonable. In determining whether any rate under this section shall be disapproved, the commissioner shall make a finding on the basis of information submitted by a nonprofit hospital service corporation, as to whether 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. Nothing in this section shall be taken to prohibit as unreasonably or unfairly discriminatory the establishment of classifications or modifications of classifications or risks based upon size, expense, management, individual expense, purpose, location or dispersion of hazard or any other reasonable considerations, or to prohibit retrospective refunds, providing such classifications, modifications and provisions for refunds apply to all risks under the same or substantially similar circumstances or conditions.

M.G.L. c. 176A, § 10A Preferred provider arrangements

c. 176A, § 10A. Preferred provider arrangements Section 10A. Other provisions of this chapter and chapter one hundred and seventy-six G notwithstanding, any nonprofit hospital service corporation, either individually or by contract with a corporation formed under chapter one hundred and seventy-six B, 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 or 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 preferred provider arrangements which have been approved by the commissioner under chapter one hundred and seventy-six I. Provided that contracts governing payment for services rendered to patients covered, by a selective product may not be tied to contracts governing payment for services rendered to other patients. The entire arrangement or contract between a medical service corporation and a hospital service corporation which involves the operation by one of those entities of a preferred provider program shall be subject to all of the requirements of chapter one hundred and seventy-six I.

M.G.L. c. 176A, § 11 Officers; duties

c. 176A, § 11. Officers; duties Section 11. The president, vice-president, if any, the secretary, assistant secretary, if any, the treasurer, and assistant treasurer, if any, shall be annually sworn and their oaths entered of record in the books of the non-profit hospital service corporation. Each director shall file with the secretary a written acceptance of the trust before he is qualified to act. The secretary, the treasurer, and each assistant secretary and each assistant treasurer, if any, of such a corporation shall, before entering upon his duties, give a bond payable to the corporation, conditioned upon the faithful performance of his duties. The bond shall be executed as surety by a surety company authorized to transact business in the commonwealth, and shall be in a form satisfactory to the commissioner of insurance and in such penal sum as the commissioner shall prescribe. If the authority of any such surety company to transact business in the commonwealth is terminated, each officer bonded as aforesaid by such surety company shall forthwith execute a new bond in compliance with this section. The secretary shall keep a record of the attendance, the votes taken and the manner in which each director votes, and of all other proceedings of all meetings of the directors and subscribers, and such other books and records as the president and directors may require. The records so kept shall be evidence of all elections and of the transactions to which they relate.

M.G.L. c. 176A, § 12 Publication of assets and liabilities

c. 176A, § 12. Publication of assets and liabilities Section 12. When any such non-profit hospital service corporation publishes its assets it shall in the same connection and with equal conspicuousness publish its liabilities, both computed on the basis allowed for its annual statements.

M.G.L. c. 176A, § 13 Hospitalization and medical service for officers and employees of corporation

c. 176A, § 13. Hospitalization and medical service for officers and employees of corporation Section 13. Any non-profit hospital service corporation may provide for the issuance to its employees of hospital service coverage, medical service coverage, and reimbursement for other health coverage. The term ''employee'' as used in this section shall include an officer.

M.G.L. c. 176A, § 14 Misrepresentation of terms of subscriber's contract

c. 176A, § 14. Misrepresentation of terms of subscriber's contract Section 14. No non-profit hospital service corporation, or any officer or agent thereof, shall make, issue, circulate or use, or cause or permit to be made, issued, circulated or used, any written or oral statement misrepresenting the terms of any subscriber's contract issued or to be issued by any non-profit hospital service corporation, or the benefits or privileges promised thereunder.

M.G.L. c. 176A, § 14A [There is no 176A:14A.]

M.G.L. c. 176A, § 14B Disclosure of information; mental or nervous conditions; exceptions

c. 176A, § 14B. Disclosure of information; mental or nervous conditions; exceptions Section 14B. No nonprofit hospital 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 nonprofit hospital 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 nonprofit hospital 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 nonprofit hospital 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 nonprofit hospital 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 nonprofit hospital 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 nonprofit hospital service corporation from disclosing patient or provider identifiers to a self-insured plan administered by said nonprofit hospital service corporation; provided, however, that such identifiers shall be used only for purposes of billing and audit; or (f) nothing contained herein shall prohibit a nonprofit hospital 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. 176A, § 15 Costs of solicitation of subscribers and administration

c. 176A, § 15. Costs of solicitation of subscribers and administration Section 15. Acquisition costs in connection with the solicitation of subscribers, and the cost of administration shall at all times be limited to such amounts as the commissioner of insurance shall approve as adequate and reasonable, but in any event, such acquisition costs shall not exceed in any one year ten per cent of the earned subscription fees during that year, except that during the first five years after the issuance of a certificate of compliance by said commissioner such corporation may disburse not more than twenty per cent of such amount in each year.

M.G.L. c. 176A, § 16 Acquisition of real estate; leases; tax exemption; limit; approval of investments, sales, loans and places of deposit

c. 176A, § 16. Acquisition of real estate; leases; tax exemption; limit; approval of investments, sales, loans and places of deposit Section 16. With the approval of the commissioner of insurance, a corporation subject to this chapter, 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 taxes on real estate granted by this chapter or granted by any provision 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 service, the real estate of which is exempt from taxation. Nothing in this paragraph shall limit the general investment powers set forth in this section. No investment, sale or loan shall be made 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.

M.G.L. c. 176A, § 17 Submission of disputes and controversies

c. 176A, § 17. Submission of disputes and controversies Section 17. Any dispute arising between a corporation subject to this chapter, and any hospital with which such corporation has a contract for hospital service as authorized by this chapter, may with the consent of both parties be submitted to the center for health information and analysis for its decision with respect thereto. Any dispute or controversy arising between a non-profit hospital service corporation and any subscriber, or any person whose subscription certificate has been cancelled, may with the consent of both parties be submitted to the commissioner of insurance for his decision with respect thereto. All decisions and findings of the center for health information and analysis and the commissioner of insurance made under this section shall be final as to the facts.

M.G.L. c. 176A, § 18 Annual statement of condition; verification, filing, form, violations; applicability of chapters 176V and 176W

c. 176A, § 18. Annual statement of condition; verification, filing, form, violations; applicability of chapters 176V and 176W Section 18. Every such corporation subject to this chapter shall annually, on or before the first day of March, file in the office of the commissioner of insurance 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. Said statement shall be in such form and shall contain such other matters as said commissioner shall prescribe. The commissioner may, for cause shown, extend the filing date of the annual statement, or of schedules or exhibits which are a part of such statement or which are required by the commissioner, for not more than sixty days beyond March first in said year. Any such corporation neglecting to make and file its annual statement in the form and within the time herein specified shall forfeit one hundred dollars for each day during which such neglect continues, and upon notice by said commissioner to that effect its authority to do new business shall cease while such default continues. Notwithstanding any general or special law to the contrary, chapter 176V shall apply to every corporation subject to this chapter. Notwithstanding any general or special law to the contrary, chapter 176W shall apply to every corporation subject to this chapter.

M.G.L. c. 176A, § 18A Financial statements; inclusion of electronic data processing equipment as asset

c. 176A, § 18A. Financial statements; inclusion of electronic data processing equipment as asset Section 18A. In an account of its financial condition, a non-profit hospital 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. 176A, § 19 Tax exemption

c. 176A, § 19. Tax exemption Section 19. Every corporation subject to this chapter is hereby declared to be a charitable and benevolent corporation and its property shall be exempt from state, city, county, district and municipal taxes.

M.G.L. c. 176A, § 20 Filing of amendment of by-laws

c. 176A, § 20. Filing of amendment of by-laws Section 20. Every non-profit hospital service corporation shall, within thirty days after the adoption of any amendment to its by-laws, file with the commissioner of insurance for his approval a copy of such amendment certified under its corporate seal by its secretary.

M.G.L. c. 176A, § 21 Submission of advertising matter to commissioner

c. 176A, § 21. Submission of advertising matter to commissioner Section 21. The commissioner of insurance may require any non-profit hospital service corporation to submit for his inspection copies of any circular or other advertising matter issued by it in the commonwealth.

M.G.L. c. 176A, § 22 Filing of riders, endorsements and applications with commissioner

c. 176A, § 22. Filing of riders, endorsements and applications with commissioner Section 22. All provisions of this chapter relative to the filing of subscriber contract forms with, and the approval of such forms by, the commissioner of insurance shall also apply to all forms of riders, endorsements and applications designed to be attached to such forms, and when so attached to constitute a part of the contract.

M.G.L. c. 176A, § 23 Grounds for enjoining transaction of business; rehabilitation proceedings; duties of receiver; distribution of assets

c. 176A, § 23. Grounds for enjoining transaction of business; rehabilitation proceedings; duties of receiver; distribution of assets Section 23. If the commissioner of insurance, in this section called the commissioner, is satisfied, as to any corporation subject to this chapter 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 six, 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 except as authorized under hospital contracts, or (9) it is insolvent, he may apply to the supreme judicial court for an injunction restraining it from further proceeding with its business. The court may 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 or the court may order that such corporation be rehabilitated as provided below in this section. The commissioner may institute a rehabilitation proceeding against any non-profit hospital service corporation for any cause specified in the preceding paragraph, by making application to the supreme judicial court for his appointment as receiver to rehabilitate such corporation and conserve its assets. The court may on such application issue a temporary injunction restraining the corporation in whole or in part from further proceeding with its business, and may appoint the commissioner as temporary receiver forthwith, and, after due notice and a full opportunity to be heard, may appoint the commissioner as permanent receiver and authorize him to take possession of all the property and effects of the corporation and to conduct its business for the purpose of rehabilitating it by taking such measures as may be proper to eliminate the causes and the conditions which caused the institution of such proceeding, subject to the order of the court, may make any other appropriate order, or may dismiss the petition. The receiver or such corporation may at any time make application to the court for the termination of a proceeding under this section and for the return to the corporation of all its property and effects, with authority to resume the conduct of its business. The court, if satisfied after due notice and a full hearing that the purposes of the proceeding have been substantially accomplished, shall grant such application. In any rehabilitation proceeding the court may authorize the receiver to employ such counsel and other assistants as may be necessary for the proper conduct of such proceeding. The compensation of such counsel and assistants and all other necessary expenses of conducting such proceeding shall be paid out of the funds or assets of the corporation in the possession of the receiver. In the event of liquidation or dissolution of a non-profit hospital service corporation the assets remaining after the payment of outstanding liabilities shall be distributed equitably to the hospitals with whom the corporation has contracts, or to the subscribers, or both, as the court may order.

M.G.L. c. 176A, § 24 Special contingent reserve fund

c. 176A, § 24. Special contingent reserve fund Section 24. Every such corporation shall set aside at the end of each calendar year out of its surplus funds, if any, but not otherwise, a special contingent reserve fund in an amount equal to, for the first year, the sum of one half of its then surplus funds, over and above its liabilities, and three per cent of its net premium written during the current calendar year, which three per cent of premium written, however, shall not exceed fifteen per cent of its incurred losses during such calendar year; thereafter, it shall at the end of each succeeding calendar year from any available surplus funds so increase such contingent reserve fund that on December thirty-first of each such year the amount of the contingent reserve fund shall exceed the required amount on the next preceding December thirty-first by an amount equal to five per cent of the net premium income of such corporation during such whole calendar year; provided, however, that the contingent reserve fund at the end of any calendar year shall not exceed forty per cent of its incurred losses during such calendar year. Such contingent reserve fund may be withdrawn or reduced below the amount required by this section with the approval of the commissioner of insurance. No other reserves except for actual liabilities shall be required.

M.G.L. c. 176A, § 25 Licensing of agents

c. 176A, § 25. Licensing of agents Section 25. Upon written notice by a non-profit hospital service corporation of its appointment of a person to act as its agent whose compensation in whole or in part is computed on a commission basis, the commissioner of insurance, in this section called the commissioner shall, if he is satisfied that the appointee is a suitable and competent person of full age and intends to hold himself out and carry on business in good faith as an agent and upon payment by the corporation of a fee to be determined annually by the commissioner of administration under the provision of section three B of chapter seven, issue to him a license which shall state in substance that the person named therein is the constituted agent of the non-profit hospital service corporation in the commonwealth. Such notice shall be upon a form furnished by the commissioner, and shall be accompanied by a statement executed on oath by the appointee which shall give his name, age, residence, present occupation, his occupation for the five years next preceding the date of the notice, and such other information as the commissioner may require upon a form furnished by him. The commissioner may, at any time, for cause shown and after a hearing, revoke the license or suspend it for a period not exceeding the unexpired term thereof, and may, for cause shown and after a hearing, revoke the license while so suspended, and shall notify both the corporation and the agent in writing of such revocation or suspension. A license issued hereunder shall expire on the thirtieth day of June next after its issue, unless sooner revoked or suspended as aforesaid, or unless the corporation, by a written notice filed with the commissioner, cancels the authority of the agent to act for it. Such license may, in the discretion of the commissioner and upon payment by the corporation of said fee, be renewed for any succeeding year by a renewal certificate without requiring anew the detailed information hereinbefore specified. Every corporation shall be bound by the acts of the person named in the license within the scope of his apparent authority as its acknowledged agent while such license remains in force. Notices of hearings required by this section shall be deemed sufficient when sent postpaid by registered mail to the last business or resident address of the licensee appearing on records of the commissioner. The affidavit of the commissioner or of any person authorized by him to send such notice that such notice has been sent in accordance with this section shall be prima facie evidence that such notice was duly given. This section shall not apply to an officer of a non-profit hospital service corporation acting for such corporation in the negotiation, continuance or renewal of any subscriber's contract which it may lawfully make.

M.G.L. c. 176A, § 26 Salaries, compensation or emoluments paid by corporation

c. 176A, § 26. Salaries, compensation or emoluments paid by corporation Section 26. No corporation subject to this chapter 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 corporation subject to this chapter 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. 176A, § 27 Payroll deductions for governmental employees

c. 176A, § 27. Payroll deductions for governmental employees Section 27. The pertinent provisions of section one hundred and thirty-eight A of chapter one hundred and seventy-five shall apply to deductions on payroll schedules from the salary of any state, county or municipal employee for the payment of the amount payable by such an employee under a contract issued to him as a subscriber by a non-profit hospital service corporation described in this chapter.

M.G.L. c. 176A, § 27A Repealed, 1955, 628, Sec. 3

M.G.L. c. 176A, § 28 Violations; penalties

c. 176A, § 28. Violations; penalties Section 28. Whoever violates any provision of this chapter for which no other penalty is provided by law, shall be punished by a fine of not more than five hundred dollars.

M.G.L. c. 176A, § 29 Application

c. 176A, § 29. Application Section 29. The provisions of this chapter shall be applicable on or after January first, nineteen hundred and fifty-one to all non-profit hospital service corporations heretofore or hereafter formed, except as otherwise herein provided and except that as to existing corporations those provisions of section two relating to the composition of the board of directors shall take effect as of the next annual meeting of any such corporation.

M.G.L. c. 176A, § 30 Savings clause

c. 176A, § 30. Savings clause Section 30. The invalidity of any section or provision of this chapter shall not invalidate any other section or provision thereof.

M.G.L. c. 176A, § 31 Contracts for administrative or other services; loans and investments

c. 176A, § 31. Contracts for administrative or other services; loans and investments Section 31. Any corporation subject to this chapter may contract with any person for the purpose of providing administrative or other services relating to the providing of hospital or other health services or reimbursement therefor. In addition, with the approval of the commissioner of insurance who shall consider the effect upon subscriber agreements and subscriber rates, a hospital 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, 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. 176A, § 32 Payment of sums owed to subscriber's estate

c. 176A, § 32. Payment of sums owed to subscriber's estate Section 32. A nonprofit hospital service corporation which, upon the death of a subscriber, owes the subscriber's estate an aggregate sum not exceeding two thousand dollars under any contract for hospital care or reimbursement for other health services, 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 contract from any executor, administrator, or special administrator of the subscriber's estate.

M.G.L. c. 176A, § 33 Insolvency of health maintenance organization; replacement coverage

c. 176A, § 33. Insolvency of health maintenance organization; replacement coverage Section 33. (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 this chapter, a nonprofit medical service corporation authorized under chapter 176B, 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. 176A, § 34 Report of individuals provided with creditable coverage

c. 176A, § 34. Report of individuals provided with creditable coverage Section 34. 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. 176A, § 35 [There is no 176A:35.]

M.G.L. c. 176A, § 36 Attribution of members to a primary care provider

c. 176A, § 36. Attribution of members to a primary care provider Section 36. To the maximum extent possible, every non-profit hospital 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. 176A, § 37 Disclosure of patient-level data and contracted prices of individual health care services by carriers to providers

c. 176A, § 37. Disclosure of patient-level data and contracted prices of individual health care services by carriers to providers Section 37. To the extent permissible under applicable state and federal privacy laws, every non-profit hospital 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 non-profit hospital 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. Non-profit hospital 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. 176A, § 38 Coverage for health care services delivered via telehealth by a contracted health care provider

c. 176A, § 38. Coverage for health care services delivered via telehealth by a contracted health care provider Section 38. (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 nonprofit hospital service corporation under an individual or group hospital service plan 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 for telehealth services 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) Coverage for telehealth services may include 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) Hospital 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.

M.G.L. c. 176A, § 81/2 Sale of group non-profit hospital service contracts

c. 176A, § 81/2. Sale of group non-profit hospital service contracts Section 81/2. A corporation organized under this chapter may only contract to sell a group non-profit hospital service contract to an employer if the group non-profit hospital service contract 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 contract to sell a group non-profit hospital service contract with an employer that establishes separate contribution percentages for employees covered by collective bargaining agreements.

Source: Massachusetts General Court (malegislature.gov)URL: https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176AFetched: 10/20/2026

NON&ndash;PROFIT HOSPITAL SERVICE CORPORATIONS