PREFERRED PROVIDER ARRANGEMENTS

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

in effect

M.G.L. c. 176I, § 1 Definitions

c. 176I, § 1. Definitions Section 1. The following words as used in this chapter shall have the meanings given to them in this section unless the context clearly requires otherwise: ''Commissioner'', the commissioner of insurance. ''Covered person'', any policy holder or other person on whose behalf the organization is obligated to pay for or provide health care services. ''Covered services'', health care services which the organization is obligated to pay for or provide under the health benefit plan. ''Emergency care'', services provided in or by a hospital emergency facility to a covered person after the development of a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity 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 covered person's 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). ''Health benefit plan'', the health insurance policy, subscriber agreement, or contract between the covered person and an organization which defines the covered services and benefit levels available. ''Health care provider'', a provider of health care services licensed or registered pursuant to chapter one hundred and eleven or chapter one hundred and twelve. ''Health care services'', services rendered or products sold by a health care provider within the scope of the provider's license. The term includes, but is not limited to, hospital, medical, surgical, dental, vision, and pharmaceutical services or products. ''Organization'', an insurer authorized to write accident and health insurance under chapter one hundred and seventy-five, a nonprofit hospital service corporation authorized under chapter one hundred and seventy-six A, a nonprofit medical service corporation authorized under chapter one hundred and seventy-six B, a dental service corporation authorized under chapter one hundred and seventy-six E, an optometric service corporation authorized under chapter one hundred and seventy-six F, a health maintenance organization authorized under chapter one hundred and seventy-six G, an insurer as defined in paragraph (7) of section one of chapter one hundred and fifty-two, or any other entity approved by the commissioner under this chapter. ''Preferred provider'', a health care provider or group of health care providers who have contracted to provide specified covered services. ''Preferred provider arrangement'', a contract between or on behalf of an organization and a preferred provider which complies with all the requirements of this chapter.

M.G.L. c. 176I, § 2 Proposed preferred provider arrangements; requirements upon receipt of completed forms for reimbursement

c. 176I, § 2. Proposed preferred provider arrangements; requirements upon receipt of completed forms for reimbursement Section 2. An organization may enter into a preferred provider arrangement with one or more health care providers upon a determination by the commissioner that the organization and the arrangement comply with the requirements of this chapter and the regulations hereunder. An organization shall not condition its willingness to allow any health care provider to participate in a preferred provider arrangement on such health care provider's agreeing to enter into other contracts or arrangements with the organization that are not part of or related to such preferred provider arrangements. An organization shall not refuse to contract with or compensate for covered services an otherwise eligible participating or nonparticipating provider solely because such provider has in good faith communicated with one or more of his current, former or prospective patients regarding the provisions, terms or requirements of the organization's products as they relate to the needs of such provider's patients. A preferred provider arrangement entered into between an organization and a home health agency or licensed hospice agency shall not require the participating home health agency 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. An organization shall submit information concerning any proposed preferred provider arrangements to the commissioner for approval in accordance with regulations promulgated by the commissioner. Said regulations shall comply with the applicable provisions of chapter thirty A of the General Laws. Said information shall include at least the following: (a) a description of the health services and any other benefits to which the covered person is entitled; (b) a description of the locations where and the manner in which health services and other benefits may be obtained; (c) a copy of the evidence of coverage; (d) copies of any contracts with preferred providers; (e) a description of the rating methodology and rates. The arrangement shall meet the following standards: (a) Standards for maintaining quality health care, including satisfying any quality assurance regulations promulgated by any state agency; (b) Standards for controlling health care costs; (c) Standards for assuring reasonable levels of access of health care services and an adequate number and geographical distribution of preferred providers to render those services; (d) Standards for assuring appropriate utilization of health care service; and (e) Other standards deemed appropriate by the commissioner. No organization may enter into a preferred provider arrangement with one or more health care providers unless said written arrangement contains a provision requiring that within 45 days after the receipt by the organization of completed forms for reimbursement to the health care provider, the organization shall (i) make payments for the provision of such services, (ii) notify the provider in writing of the reason or reasons for nonpayment, or (iii) notify the provider in writing of what additional information or documentation is necessary to complete said forms for such reimbursement. If the organization fails to comply with the provisions of this paragraph for any claims related to the provision of health care services, said organization shall pay, in addition to any reimbursement for health care services provided, interest on such benefits, which shall accrue beginning 45 days after the organization's receipt of request for reimbursement at the rate of 1.5 per cent per month, not to exceed 18 per cent per year. The provisions of this paragraph relating to interest payments shall not apply to a claim that the organization is investigating because of suspected fraud.

M.G.L. c. 176I, § 3 Health benefit plans; minimum requirements

c. 176I, § 3. Health benefit plans; minimum requirements Section 3. Organizations, but not an insurer as defined in paragraph (7) of section one of chapter one hundred and fifty-two, may offer health benefit plans which provide for incentives for covered persons to use the health care services of preferred providers. Such health benefit policies or plans shall meet at least the following minimum requirements: (a) Benefit levels for health care services rendered by nonpreferred providers shall be at least eighty per cent of the benefit levels for services rendered by preferred providers. (b) If a covered person receives emergency care and cannot reasonably reach a preferred provider, payment for care related to the emergency shall be made at the same level and in the same manner as if the covered person had been treated by a preferred provider; provided, however, that every brochure, contract, policy manual and all printed materials shall clearly state that covered persons 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 a covered person is confronted with a need for emergency care, and no covered person 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 use of emergency care; (c) A procedure shall be specified for resolving consumer complaints and grievances; and (d) A procedure shall be specified for the disclosure to covered persons of the names of current preferred providers by specialty and geographic area.

M.G.L. c. 176I, § 3A Workers' compensation medical services organizations; minimum requirements

c. 176I, § 3A. Workers' compensation medical services organizations; minimum requirements Section 3A. The requirement of subsections (b) (c) and (d) of section three shall apply to organizations that furnish workers' compensation medical services through a preferred provider arrangement.

M.G.L. c. 176I, § 4 Discriminatory refusal of provider

c. 176I, § 4. Discriminatory refusal of provider Section 4. An organization shall not refuse to enter into a preferred provider arrangement with a health care provider on the basis of religion, race, color, national origin, age, sex, marital status, sexual orientation, or such provider's relationships with any other organization. The selection of preferred providers shall be based primarily on cost, availability and quality of covered services. The terms and conditions offered by an organization that must be met or agreed to by physicians and other professional providers of health care services desiring to enter into a preferred provider arrangement shall be subject to the disapproval of the commissioner if said terms and conditions are not consistent with the purposes, policies and provisions of this chapter.

M.G.L. c. 176I, § 4A Health benefit plans; genetic tests; discrimination based on genetic information

c. 176I, § 4A. Health benefit plans; genetic tests; discrimination based on genetic information Section 4A. 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 organization and no preferred provider 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 of the terms and conditions of a health benefit plan based on genetic information as defined in this section. No organization and no preferred provider shall require genetic tests or private genetic information, as defined in this section, as a condition of the issuance or renewal of a health benefit plan.

M.G.L. c. 176I, § 5 Financial and utilization records

c. 176I, § 5. Financial and utilization records Section 5. An organization shall maintain financial and utilization records for its preferred provider arrangements and activities in a form separate or separable from the financial and utilization records of other operations and activities carried on by the organization.

M.G.L. c. 176I, § 6 Surety bond, reinsurance or other financial resources

c. 176I, § 6. Surety bond, reinsurance or other financial resources Section 6. An organization shall furnish to the commissioner evidence of a surety bond, reinsurance or other financial resources in an amount satisfactory to the commissioner as a guarantee that obligations to covered persons will be performed.

M.G.L. c. 176I, § 7 Report

c. 176I, § 7. Report Section 7. An organization which enters into a preferred provider arrangement shall file annually with the commissioner, within one hundred and twenty days of the close of its fiscal year, a report covering its prior fiscal year. The report shall include: (a) the number of covered persons under health benefit plans and workers' compensation insurance or self-insured workers' compensation plans, which include preferred provider arrangements; (b) financial and utilization date of health benefit plans and workers' compensation insurance or self-insured workers' compensation plans, which include preferred provider arrangements; (c) a list of preferred providers; and (d) such other information as the commissioner may reasonably require.

M.G.L. c. 176I, § 8 Powers of commissioner; standardized claim form

c. 176I, § 8. Powers of commissioner; standardized claim form Section 8. In addition to other powers specified in this chapter, the commissioner may, after due hearing: (a) promulgate appropriate rules and regulations necessary to the administration and enforcement of this chapter; (b) issue an order requiring any person or organization to cease and desist from violating any provision of this chapter or any rules, regulations, or order hereunder; (c) require any person or organization found to have violated any provision of this chapter or any rule, regulation or order hereunder to forfeit an amount not to exceed ten thousand dollars for any single violation; and (d) institute a rehabilitation or liquidation proceeding in accordance with the provisions of section one hundred and eighty A through one hundred and eighty L of chapter one hundred and seventy-five. 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. 176I, § 9 Application of laws

c. 176I, § 9. Application of laws Section 9. An organization which offers or administers a health benefit plan or furnishes workers' compensation, under a preferred provider arrangement shall be subject to all of the provisions of its enabling or licensing statute and of any other provisions of the general laws applicable thereto, including but not limited to, the provisions of chapter 176O and any benefits required to be provided by law. To the extent that this section is inconsistent with the provisions of one hundred and seventy-six M and any regulations promulgated thereunder, any nongroup health plan under a preferred provider arrangement that is within the definition of a guaranteed issue health plan in said chapter one hundred and seventy-six M shall be governed by the provisions of said chapter one hundred and seventy-six M and any regulations promulgated thereunder. In connection with any preferred provider arrangement and activities, an organization shall be considered to be an insurance company for the purposes of sections one hundred and ninety-three C, one hundred and ninety-three D, one hundred and ninety-three L, one hundred and ninety-three M and one hundred and ninety-three N of chapter one hundred and seventy-five.

M.G.L. c. 176I, § 10 Applications

c. 176I, § 10. Applications Section 10. Any organization which has entered into preferred provider arrangements prior to the effective date of this chapter shall file an application within ninety days of the effective date of this chapter, and may continue to operate until such time as its application may be denied.

M.G.L. c. 176I, § 11 Annual assessment

c. 176I, § 11. Annual assessment Section 11. (a) Every organization other than a workers' compensation insurer, operating a preferred provider arrangement shall annually pay an assessment equal to two and twenty-eight hundredths per cent of the gross premiums received during the preceding calendar year for coverage of covered persons residing in this commonwealth; provided, however, that no assessment shall be imposed on premiums for medicare supplemental coverage. In calculating said gross premiums, there shall be deducted any amounts eligible for deduction pursuant to section twenty-four of chapter sixty-three and any amounts that are subject to the assessment imposed by section one hundred and ten L of chapter one hundred and seventy-five or by section ten A of chapter one hundred and seventy-six G. All said assessments, including interest thereon or penalties, shall be deposited in the general fund. (b) The assessment imposed by this section shall be collected and administered by the commissioner of revenue. Every organization operating a preferred provider arrangement shall annually, on or before March fifteenth, make a return to said commissioner giving such information as said commissioner may deem necessary for the determination of the assessment for the preceding calendar year. The payment and collection of the assessments imposed by this section shall, to the extent consistent with this section, be governed by the provisions of chapters sixty-two C and sixty-three B. This provision shall take effect for premiums received after December thirty-first, nineteen hundred and eighty-eight.

M.G.L. c. 176I, § 12 Coverage for children under age 18 for cleft lip and cleft palate

c. 176I, § 12. Coverage for children under age 18 for cleft lip and cleft palate Section 12. An organization entering into a preferred provider contract 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. 176I, § 13 Coverage for health care services delivered via telehealth by a contracted health care provider

c. 176I, § 13. Coverage for health care services delivered via telehealth by a contracted health care provider Section 13. (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 preferred provider contract between a covered person and an organization 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) An organization may undertake 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. An organization shall not be required to reimburse a health care provider for a health care service that is not a covered benefit under the plan or reimburse a health care provider not contracted under the plan except as provided for under subclause (i) of clause (4) of the second sentence of subsection (a) of section 6 of chapter 176O. (d) A health care provider shall not be required to document a barrier to an in-person visit nor shall the type of setting where telehealth services are provided be limited for health care services provided via telehealth; provided, however, that a patient may decline receiving services via telehealth in order to receive in-person services. (e) A preferred provider contract that provides coverage for telehealth services may contain a provision for a deductible, copayment or coinsurance requirement for a health care service provided via telehealth as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to an in-person consultation or in-person delivery of services. The rate of payment for telehealth services provided via interactive audio-video technology may be greater than the rate of payment for the same service delivered by other telehealth modalities. (f) Coverage that reimburses a provider with a global payment, as defined in section 1 of chapter 6D, shall account for the provision of telehealth services to set the global payment amount. (g) Organizations shall ensure that the rate of payment for in-network providers of behavioral health services delivered via interactive audio-video technology and audio-only telephone shall be no less than the rate of payment for the same behavioral health service delivered via in-person methods; provided, that this subsection shall apply to providers of behavioral health services covered as required under subclause (i) of clause (4) of the second sentence of subsection (a) of section 6 of chapter 176O. (h) Health care services provided via telehealth shall conform to the standards of care applicable to the telehealth provider's profession and specialty. Such services shall also conform to applicable federal and state health information privacy and security standards as well as standards for informed consent.

Source: Massachusetts General Court (malegislature.gov)URL: https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176IFetched: 10/20/2026