HEALTH MAINTENANCE ORGANIZATIONS

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

in effect

M.G.L. c. 176G, § 1 Definitions

c. 176G, § 1. Definitions Section 1. The following words as used in this chapter shall, unless the context clearly requires otherwise, have the following meanings: ''Affiliate'', an affiliate of, or person affiliated with, a specific person, is a person that directly, or indirectly through 1 or more intermediaries, controls, or is controlled by, or is under common control with, the person specified. ''Carrier'', an insurance company authorized to provide 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, or a nonprofit medical service corporation authorized under chapter one hundred and seventy-six B. ''Commissioner'', the commissioner of insurance. ''Company'', a corporation, a partnership, a business trust, an association, an organized group of persons whether incorporated or not, or any line of business division, department, subsidiary or affiliate of any thereof and any receiver, trustee or other liquidating agent of any of the foregoing while acting in such capacity. ''Control'', including controlling, controlled by and under common control with, the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or non-management services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds with the power to vote, or holds proxies representing, 10 per cent or more of the voting securities of any other person. In the case of a person subject to chapter 180, control shall be presumed to exist if any other person shall, directly or indirectly, own, control or hold, more than 10 per cent of the aggregate rights in any membership class or shall, directly or indirectly, have the right to appoint or elect more than 10 per cent of the directors serving on the person's board of directors. Any of these aforementioned presumptions may be rebutted by a showing made in the manner provided with respect to insurers under subsection (k) of section 206C of chapter 175 that control does not exist in fact. The commissioner may determine, after furnishing all persons in interest notice and opportunity to be heard and making specific findings of fact to support such determination, that such control exists in fact, notwithstanding the absence of a presumption to that effect. ''Evidence of coverage'', any certificate, contract or agreement issued to a member stating the health services and any other benefits to which the member is entitled. ''Foreign health maintenance organization'', a health maintenance organization formed by authority of any state or government other than the commonwealth and qualified to conduct business in the commonwealth. ''Group health maintenance contract'', any health maintenance contract with any group of five or more persons, or the employer or representative of a group of five or more persons; provided, that twenty-five per cent or more of those eligible in a group of fifty or more persons and seventy-five per cent or more of those eligible in a group of less than fifty persons, are group contract enrollees; provided further, that, for the purposes of computing the percentage of group contract enrollment under this definition, persons in a group who are subscribers to a general or blanket policy of insurance issued pursuant to section one hundred and ten of chapter one hundred and seventy-five, or to a group hospital service plan issued pursuant to section ten of chapter one hundred and seventy-six A, or to a group medical service plan issued pursuant to chapter one hundred and seventy-six B, shall be considered to be group contract enrollees. ''Health maintenance contract'', any contract entered into by a health maintenance organization or a carrier, or both with a member or group of members whereby the health maintenance organization agrees to provide health services on a nondiscriminatory basis. ''Health maintenance organization'', a company organized under the laws of the commonwealth, or organized under the laws of another state and qualified to do business in the commonwealth, which: (1) provides or arranges for the provision of health services to voluntarily enrolled members in exchange primarily for a prepaid per capita or aggregate fixed sum. (2) demonstrates to the satisfaction of the commissioner proof of its capability to provide its members protection against loss of prepaid fees or unavailability of covered health services resulting from its insolvency or bankruptcy or from other financial impairment of its obligations to its members. ''Health maintenance organization holding company system'', a health maintenance organization holding company system consists of 2 or more affiliates, 1 or more of which is a health maintenance organization. ''Health services'', at least reasonably comprehensive physician services, on a nondiscriminatory basis, inpatient and outpatient services, emergency health services, and may include chiropractic services, optometric services and podiatric services. ''Managed hospital payment basis'', agreements wherein the financial risk is primarily related to the degree of utilization rather than to the cost of the services. ''Member'', any individual who has entered into a health maintenance contract, or on whose behalf such an arrangement has been made, with a health maintenance organization or carrier or both for health services and any dependent of such individual who is covered by the same contract; provided that in sections 25 to 29, inclusive. ''Enrolled member'' shall mean any such individual, and ''Member'' shall have the same meaning as set forth in chapter 180. ''Net worth'', the excess of total admitted assets over total liabilities, but the liabilities shall not include fully subordinated debt pursuant to subsection (d) of section 24. ''Nondiscriminatory'', any individual who has entered into a group health maintenance contract that provides for any podiatric medical or surgical service which is within the lawful scope of practice of a licensed podiatrist, shall be entitled to such services whether the service is performed by a physician or licensed podiatrist, including authorized referral services on a nondiscriminatory basis. ''Person'', shall have the meaning set forth in section 206 of chapter 175. ''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. ''Subsidiary'', shall have the meaning set forth in section 206 of chapter 175. ''Uncovered expenditures'', the cost to a health maintenance organization for health care services that are the obligation of such a health maintenance organization, for which an enrollee may also be liable in the event of the health maintenance organizations' insolvency and for which no alternative arrangements have been made to cover such costs that are acceptable to the commissioner. ''Voting security'', shall have the meaning set forth in section 206 of chapter 175.

M.G.L. c. 176G, § 2 Application of laws

c. 176G, § 2. Application of laws Section 2. Except as hereinafter provided in this chapter, the provisions of chapters one hundred and seventy-five, one hundred and seventy-six A, one hundred and seventy-six B, one hundred and seventy-six C, one hundred and seventy-six E, and one hundred and seventy-six F, shall not apply to a health maintenance organization, provided, however, that in the case of any company doing business in the commonwealth and otherwise subject to the provisions of said chapters, this section shall apply only with respect to its health maintenance organization activities.

M.G.L. c. 176G, § 3 Organization; accounting; contracts

c. 176G, § 3. Organization; accounting; contracts Section 3. A carrier or any two or more such companies, corporations, or their subsidiaries or affiliates may: (1) organize and operate a health maintenance organization as a line of business, division, department, subsidiary or affiliate under the provisions of this chapter provided that where such is organized as a line of business, division, department, subsidiary or affiliate, the operation of the health maintenance organization shall be separately accounted for, the income and expenses shall be allocated in accordance with statutory accounting practices and procedures prescribed or permitted by the commissioner, and the carrier or companies shall not utilize the income from such health maintenance organization for unrelated activities; 2) contract with a health maintenance organization to provide insurance, reinsurance, health services, reimbursement for health services or similar protection against the cost of care provided through the health maintenance organization; 3) contract with a health maintenance organization to provide coverage, health services or reimbursement for health services in the event of the failure of the health maintenance organization to meet its obligations under health maintenance contracts issued by it or a carrier; 4) contract with a health maintenance organization to provide administrative, underwriting, financing or other services relating to the provision of hospital, medical or other health services or reimbursement therefor; 5) contract with a health maintenance organization to enroll members on behalf of the health maintenance organization or to issue its own certificate of benefits for the covered health services provided by the health maintenance organization; and, 6) contract with a health maintenance organization for the joint administration of their business or for the writing and issue by the health maintenance organization, the carrier, or both jointly, of health maintenance contracts binding upon the carrier.

M.G.L. c. 176G, § 4 Required coverage for certain conditions and groups

c. 176G, § 4. Required coverage for certain conditions and groups Section 4. A health maintenance contract shall provide coverage for: (a) pregnant women, infants and children as set forth in section 47C of chapter 175; (b) cardiac rehabilitation as set forth in section 47D of chapter 175; (c) prenatal care, childbirth and postpartum care as set forth in section 47F of chapter 175; (d) cytologic screening and mammographic examination as set forth in section 47G of chapter 175; (e) diagnosis and treatment of infertility as set forth in section 47H of chapter 175; and (f) services rendered by a certified registered nurse anesthetist or nurse practitioner as set forth in section 47Q of chapter 175, subject to the terms of a negotiated agreement between the health maintenance organization and the provider of health care services. 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.

M.G.L. c. 176G, § 4A Employees terminated due to plant closings; coverage

c. 176G, § 4A. Employees terminated due to plant closings; coverage Section 4A. Any health maintenance contract shall provide coverage for employees terminated due to a plant closing or covered partial closing as required by the second paragraph of section one hundred and ten D of chapter one hundred and seventy-five and the second paragraph of section one hundred and ten G of chapter one hundred and seventy-five.

M.G.L. c. 176G, § 4AA Coverage for medically necessary acute treatment and clinical stabilization services

c. 176G, § 4AA. Coverage for medically necessary acute treatment and clinical stabilization services Section 4AA. For the purposes of this section the following terms shall have the following meanings, unless the context clearly requires otherwise:— ''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. An individual or group health maintenance contract that is issued or renewed 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, an individual or group health maintenance contract that is issued or renewed shall provide coverage for, without preauthorization, a substance use disorder evaluation ordered pursuant to section 511/2 of chapter 111. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient's medical record.

M.G.L. c. 176G, § 4B Confidentiality of information; mental or nervous condition; exceptions

c. 176G, § 4B. Confidentiality of information; mental or nervous condition; exceptions Section 4B. No health maintenance organization shall require as a condition to receiving benefits pursuant to this chapter consent to the disclosure of information regarding services for mental disorders under different terms and conditions than consent is required for the disclosure of information for other medical conditions; provided, however, that: (a) no such written consent shall be made a condition of the receipt of such benefits or any other benefits for which the member is otherwise covered; (b) nothing contained herein shall prohibit the disclosure of any information held by such health maintenance organization 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 health maintenance organization shall not be prohibited from disclosing aggregate patient data if such data contains no information personally identifying any member; (d) a health maintenance organization 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 health maintenance organization, 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 health maintenance organization 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 health maintenance organization from disclosing patient or provider identifiers to a self-insured plan administered by said health maintenance organization; provided, however, that such identifiers shall be used only for purposes of billing and audit; or (f) nothing contained herein shall prohibit a health maintenance organization from disclosing patient information to an account which is self-insured in whole or in part, and administered by such organization 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. 176G, § 4BB Repealed, 2016, 133, Sec. 116

M.G.L. c. 176G, § 4C Home care benefits

c. 176G, § 4C. Home care benefits Section 4C. Any group health maintenance contract shall provide coverage for home care services as set forth in clause (k) of section one hundred and ten of chapter one hundred and seventy-five.

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

c. 176G, § 4CC. Coverage for medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome Section 4CC. Any individual or group health maintenance contract 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. 176G, § 4D Nonprescription enteral formulas for home use

c. 176G, § 4D. Nonprescription enteral formulas for home use Section 4D. A group health maintenance contract shall provide 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. 176G, § 4DD Filling of remaining portion of prescription for covered drug that is a narcotic substance earlier filled in lesser quantity

c. 176G, § 4DD. Filling of remaining portion of prescription for covered drug that is a narcotic substance earlier filled in lesser quantity Section 4DD. An individual or group health maintenance contract that is issued or renewed 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. 176G, § 4E Off-label drug use; cancer treatment

c. 176G, § 4E. Off-label drug use; cancer treatment Section 4E. A group health maintenance contract shall provide coverage for off-label uses of prescription drugs used in the treatment of cancer as set forth in sections forty-seven K and forty-seven L of chapter one hundred and seventy-five; provided, however, that neither the attending physician nor the health maintenance organization shall be liable in a suit for damages as a result of the acts or omissions of the attending physician or the health maintenance organization in connection with compliance with this section.

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

c. 176G, § 4EE. Pain management access plan; non-medication and nonsurgical treatment; review; educational materials [Text of section applicable to all contracts entered into, renewed or amended on or after July 1, 2025. See 2024, 285, Sec. 47.] Section 4EE. (a) Any individual or group health maintenance contract that is issued or renewed within or without 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 individual or group health maintenance contract that is issued or renewed within or without 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. 176G, § 4F Group health maintenance contracts; coverage for bone marrow transplants

c. 176G, § 4F. Group health maintenance contracts; coverage for bone marrow transplants Section 4F. Any group health maintenance contract shall provide 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 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. 176G, § 4FF Coverage for tobacco use cessation counseling and tobacco cessation products

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

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

c. 176G, § 4G. Off-label use of prescription drugs for HIV/AIDS treatment Section 4G. Any individual or group health insurance maintenance contract which provides coverage for prescription drugs shall provide coverage for off-label uses of prescription drugs used in the treatment of HIV/AIDS as set forth in sections forty-seven O and forty-seven P of chapter one hundred and seventy-five.

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

c. 176G, § 4GG. 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 4GG. Any individual or group health maintenance contract 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. 176G, § 4H Items medically necessary for diagnosis and treatment of diabetes

c. 176G, § 4H. Items medically necessary for diagnosis and treatment of diabetes Section 4H. Any individual or group health maintenance contract, 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, as set forth in section 47N of chapter 175, coverage 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 health maintenance contract or affiliated with a provider participating with the health maintenance contract. 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 health maintenance organization to contract with a certified diabetes health care provider who is not already under contract with such health maintenance organization. The benefits provided in this section shall meet all other terms and conditions within a health maintenance contract. Health maintenance contracts shall not reduce or eliminate coverage due to the requirements of this section.

M.G.L. c. 176G, § 4HH Repealed, 2021, 29, Sec. 27

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

c. 176G, § 4I. Abortion, abortion-related care, prenatal care, childbirth and postpartum care benefits; minimum coverage for in-patient care; exemptions [ Text of section applicable as provided by 2022, 127, Sec. 44.] Section 4I. Any health maintenance contract shall provide coverage for abortion, as defined in section 12K of chapter 112, abortion-related care, prenatal care, childbirth and postpartum care in accordance with section four of chapter one hundred and seventy-six G. In addition to such benefits, such health maintenance contract 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. [Third through fifth 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 health maintenance contract 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 4O, 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. 176G, § 4II Coverage for prescription eye drops

c. 176G, § 4II. Coverage for prescription eye drops Section 4II. An individual or group health maintenance contract 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. 176G, § 4J Scalp hair prostheses necessary due to cancer or leukemia treatment

c. 176G, § 4J. Scalp hair prostheses necessary due to cancer or leukemia treatment Section 4J. (a) For the purposes of this section, the following words shall have the following meanings: ''Prosthesis'', an artificial appliance used to replace a lost natural structure; provided, however, that prosthesis shall include, but not be limited to, artificial arms, legs, breasts, scalp hair or glass eyes. ''Scalp hair prosthesis'', an artificial substitute for scalp hair. (b) A group health maintenance contract which provides coverage for any other prosthesis, shall provide 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. 176G, § 4JJ Coverage for mental health or substance use disorder services delivered through psychiatric collaborative care model

c. 176G, § 4JJ. Coverage for mental health or substance use disorder services delivered through psychiatric collaborative care model Section 4JJ. (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) Any individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide coverage for mental health or substance use disorder services that are delivered through the psychiatric collaborative care model.

M.G.L. c. 176G, § 4K Newborn hearing screening tests

c. 176G, § 4K. Newborn hearing screening tests Section 4K. A health maintenance contract shall provide coverage for 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, pursuant to regulations of the department of public health. Payment to physician, hospital or other provider for the costs of said test may be pursuant to the terms of a negotiated contract. Nothing contained in this section shall be construed to abrogate any other obligation to provide coverage for a hearing screening test or any other hearing screening test or audiological diagnostic procedure pursuant to any law of the commonwealth or of the United States or under the terms or provisions of any contract or certificate.

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

c. 176G, § 4KK. Coverage for medically necessary mental health acute treatment, community-based acute treatment and intensive community-based acute treatment Section 4KK. (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) An individual or group health maintenance contract that is issued or renewed within or without 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 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. 176G, § 4L Coverage for hospice services

c. 176G, § 4L. Coverage for hospice services Section 4L. Any group health maintenance contract shall provide coverage for hospice services as defined in section 57D of chapter 111 during the life of the patient, to terminally ill patients with a life expectancy of six months or less; provided, however, that such services are determined to be appropriate and authorized by the patient's primary care or treating physician and are equivalent to those services provided by a licensed hospice program regulated by the department of public health.

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

c. 176G, § 4LL. Benefits for medically necessary emergency services programs Section 4LL. An individual or group health maintenance contract that is 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. 176G, § 4M Mental health benefits; biologically-based mental disorders; rape-related mental disorders; non-biologically-based mental disorders of children and adolescents under age 19

c. 176G, § 4M. Mental health benefits; biologically-based mental disorders; rape-related mental disorders; non-biologically-based mental disorders of children and adolescents under age 19 Section 4M. (a) A health maintenance contract 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 members or enrollees 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 health maintenance contract 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 members or enrollees 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 health maintenance 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 said mental health benefits established pursuant to this section, any such health maintenance contract shall also provide benefits on a non-discriminatory basis to children and adolescents under the age of 19 for the diagnosis and treatment of non-biologically-based mental, behavioral or emotional disorders, as described in the most recent edition of the DSM, which substantially interfere with or substantially limit the functioning and social interactions of such a child or adolescent; provided, that said interference or limitation is documented by and the referral for said diagnosis and treatment is made by the primary care provider, primary pediatrician or a licensed mental health professional of such a child or adolescent or is evidenced by conduct, including, but not limited to: (1) an inability to attend school as a result of such a disorder, (2) the need to hospitalize the child or adolescent as a result of such a disorder, (3) a pattern of conduct or behavior caused by such a disorder which poses a serious danger to self or others. The health maintenance organization shall continue to provide such benefits to any adolescent who is engaged in an ongoing course of treatment beyond the adolescent's nineteenth birthday until said course of treatment, as specified in said adolescent's treatment plan, is completed and while the benefit contract under which such benefits first became available remains in effect, or subject to a subsequent benefits contract which is in effect. (d) Any such health maintenance contract shall be deemed to be providing such coverage on a non-discriminatory basis if the health maintenance contract does not contain any annual or lifetime dollar or unit of service limitation on coverage for the diagnosis and treatment of said mental disorders which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions. (e) Any such health maintenance contract shall also provide 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) No health maintenance organization shall require as a condition to receiving benefits mandated by this section consent to the disclosure of information regarding services for mental disorders under different terms and conditions than consent is required for disclosure of information for other medical conditions. A determination by a health maintenance organization that services authorized pursuant to this section are not medically necessary shall only be made by a licensed mental health professional; provided, that this provision shall not be construed as applying to denials of service resulting from an insured's lack of insurance coverage or use of a facility or professional which has not entered into a negotiated agreement with the health maintenance organization. The benefits provided in any health maintenance contract pursuant to this section shall meet all other terms and conditions of the health maintenance contract not inconsistent with this section. (i) Nothing in this section shall be construed to require a health maintenance organization 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 health maintenance organization 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. 176G, § 4MM Coverage for annual mental health wellness examination

c. 176G, § 4MM. Coverage for annual mental health wellness examination Section 4MM. (a) For the purpose of this section, the following words shall have the following meanings unless the context clearly requires otherwise: ''Licensed mental health professional,'' a licensed physician who specializes in the practice of psychiatry, a licensed psychologist, a licensed independent clinical social worker, a licensed certified social worker, a licensed mental health counselor, a licensed supervised mental health counselor, a licensed psychiatric nurse mental health clinical specialist, a licensed psychiatric mental health nurse practitioner, a licensed physician assistant who practices in the area of psychiatry, a licensed alcohol and drug counselor I, as defined in section 1 of chapter 111J, or a licensed marriage and family therapist within the lawful scope of practice for such therapist. ''Mental health wellness examination,'' a screening or assessment that seeks to identify any behavioral or mental health needs and appropriate resources for treatment. The examination may include: (i) observation, a behavioral health screening, education and consultation on healthy lifestyle changes, referrals to ongoing treatment, mental health services and other necessary supports, and discussion of potential options for medication; and (ii) age-appropriate screenings or observations to understand a covered person's mental health history, personal history and mental or cognitive state and, when appropriate, relevant adult input through screenings, interviews and questions. ''Primary care provider'', a health care professional qualified to provide general medical care for common health care problems, who (i) supervises, coordinates, prescribes or otherwise provides or proposes health care services; (ii) initiates referrals for specialist care; and (iii) maintains continuity of care within the scope of practice. (b) An individual or group health maintenance contract that is issued or renewed within or without 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. 176G, § 4N Coverage for speech, hearing and language disorders; hearing aids

c. 176G, § 4N. Coverage for speech, hearing and language disorders; hearing aids Section 4N. Any individual or group health maintenance contract 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 to all group members having a principal place of employment within the commonwealth for the expenses incurred in the medically necessary diagnosis and treatment of speech, hearing and language disorders by individuals licensed as speech-language pathologists or audiologists under chapter 112, if such services are rendered within the lawful scope of practice for such speech-language pathologists or audiologists regardless of whether the services are provided in a hospital, clinic or a private office, and if 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 health maintenance contract. An individual or group health maintenance contract, except contracts providing supplemental coverage to Medicare or other governmental programs, shall provide coverage and benefits for children 21 years of age or younger, who are insured under such contracts, for expenses incurred for the cost of 1 hearing aid per hearing impaired ear up to $2,000 for each hearing aid, as defined under section 196 of chapter 112, every 36 months upon a written statement from the child's treating physician that the hearing aids are necessary regardless of etiology. Coverage under this section shall include all related services prescribed by a licensed audiologist or hearing instrument specialist, as defined in said section 196 of said chapter 112, including the initial hearing aid evaluation, fitting and adjustments and supplies, including ear molds. The insured may choose a higher priced hearing aid and may pay the difference in cost above the $2,000 limit in this section without any financial or contractual penalty to the insured or to the provider of the hearing aid. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefits provided by the insurer. Nothing in this section shall prohibit an insurer from offering greater coverage for hearing aids than required by this section. This section shall also require coverage for such hearing aids under any non-group policy.

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

c. 176G, § 4NN. Coverage for federally-defined preventive services Section 4NN. (a) For the purposes of this section, ''federally-defined preventive services'' shall mean: (i) evidence-based items or services that currently have a rating of ''A'' or ''B'' in the recommendations of the United States Preventive Services Task Force; (ii) immunizations with routine use in children, adolescents and adults that currently have a recommendation from the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention with respect to the individual involved; (iii) with respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the federal Health Resources and Services Administration; and (iv) with respect to women, such additional preventive care and screenings not described in clause (i) as provided for in comprehensive guidelines supported by the federal Health Resources and Services Administration; provided, however, that ''federally-defined preventive services'' shall also include all other preventive services not subject to cost-sharing, as required by established federal regulatory and sub-regulatory guidance issued on or before July 1, 2023. (b) An individual or group health maintenance contract that is issued, delivered 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 Health Resources and Services Administration; or (ii) denying coverage for items and services that are not recommended by the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices of the federal Centers for Disease Control and Prevention or the federal Health Resources and Services Administration. (e) If a recommendation described in subsection (a) is changed during a plan year, a carrier shall not be required to make changes to the health plan during the plan year.

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

c. 176G, § 4O. Outpatient services; hormone replacement therapy for peri and post menopausal women; contraceptive services; approved prescription contraceptive drugs or devices; exception Section 4O. (a) Any individual or group health maintenance contract that is issued, renewed or delivered within or without the commonwealth and that provides benefits for outpatient services shall provide to residents of the commonwealth and to persons having a principal place of employment within the commonwealth benefits for hormone replacement therapy services for peri and post menopausal women and outpatient contraceptive services under the same terms and conditions as for such other outpatient services. Outpatient contraceptive services shall mean consultations, examinations, procedures and medical services provided on an outpatient basis and related to the use of all contraceptive methods to prevent pregnancy that have been approved by the United States Food and Drug Administration. (b) Any individual or group health maintenance contract that is issued, renewed or delivered within or without the commonwealth and that provides benefits for outpatient prescription drugs or devices shall provide to residents of the commonwealth and to persons 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 that 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) The requirements of this section shall not apply to a health maintenance contract delivered, issued or renewed pursuant to this chapter if that contract is purchased by an employer that is a church or qualified church-controlled organization, as those terms are defined in 26 U.S.C. section 3121(w)(3)(A) and (B). (d) An individual or group health maintenance contract that is issued, renewed or delivered within or outside the commonwealth and that provides benefits for outpatient prescription drugs or devices shall provide to residents of the commonwealth and to persons having a principal place of employment in the commonwealth coverage for the following services and contraceptive methods: (i) Food and Drug Administration, FDA, approved contraceptive drugs, devices and other products; provided, however, that coverage shall not be required for male condoms or FDA-approved oral contraceptive drugs that do not have a therapeutic equivalent; provided further, that: (A) if the FDA has approved 1 or more therapeutic equivalents of a contraceptive drug, device or product, a health maintenance contract 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 health maintenance contract may provide coverage for more than 1 drug, device or other product for that method 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, the health maintenance contract shall provide coverage, subject to the plan's utilization management procedures, for the prescribed contraceptive drug, device or product without cost-sharing; and (C) appeals of an adverse determination of a request for coverage of an alternative FDA-approved contraceptive drug, device or other product without cost-sharing shall be subject to the expedited grievance process under section 13 of chapter 176O; (ii) FDA-approved emergency contraception available over-the-counter, whether with a prescription or dispensed consistent with the requirements of section 19A of chapter 94C; (iii) prescription contraceptives intended to last: (A) for not more than a 3-month period for the first time the prescription contraceptive is dispensed to the covered person; and (B) for not more than a 12-month period for any subsequent dispensing of the same prescription, which may be dispensed all at once or over the course of the 12-month period, regardless of whether the covered person was enrolled in the plan at the time the prescription contraceptive was first dispensed; provided, however, that a corporation shall not be required to provide coverage for more than one 12-month prescription in a single dispensing per plan year; (iv) voluntary female sterilization procedures; (v) patient education and counseling on contraception; and (vi) follow-up services related to the drugs, devices, products and procedures covered under this subsection including, but not limited to, management of side effects, counseling for continued adherence and device insertion and removal. (e) (1) Coverage provided under subsection (d) shall not be subject to any deductible, coinsurance, copayment or any other cost-sharing requirement except as provided for in subclauses (A) and (B) of clause (i) of subsection (d) or as otherwise required under federal law. Coverage offered under said subsection (d) shall not impose unreasonable restrictions or delays in the coverage, in accordance with the requirements of chapter 176O; provided, however, that reasonable medical management techniques may be applied to coverage within a method category, as defined by the FDA, but not across types of methods. (2) Benefits for an enrollee under subsection (d) shall be the same for the enrollee's covered spouse and covered dependents. (f) A health maintenance contract that is purchased by an employer that is a church or qualified church-controlled organization shall be exempt from subsection (d) at the request of the employer. An employer that invokes the exemption under this subsection shall provide written notice to prospective enrollees prior to enrollment with the plan and such notice shall list the contraceptive health care methods and services for which the employer will not provide coverage for religious reasons. (g) Nothing in subsection (d) shall be construed to exclude coverage for contraceptive drugs, devices, products and procedures as prescribed by a provider for reasons other than contraceptive purposes, including, but not limited to, decreasing the risk of ovarian cancer, eliminating symptoms of menopause or providing contraception that is necessary to preserve the life or health of an enrollee or the enrollee's covered spouse or covered dependents. (h) The commissioner shall ensure compliance with this chapter. (i) Nothing in subsection (d) shall be construed to require a health maintenance contract 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; or (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. 176G, § 4OO Coverage for standard fertility preservation services

c. 176G, § 4OO. Coverage for standard fertility preservation services Section 4OO. (a) For the purposes of this section, the following words shall have the following meaning 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) An individual or group health maintenance contract that is issued, delivered 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. 176G, § 4P Patient care services provided pursuant to qualified clinical trials

c. 176G, § 4P. Patient care services provided pursuant to qualified clinical trials Section 4P. Any individual or group health maintenance contract shall provide for the coverage of patient care services furnished pursuant to qualified clinical trials as defined in, and subject to the requirements and limitations of, section 110L of chapter 175.

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

c. 176G, § 4PP. Coverage for postpartum depression and major depressive disorder screenings Section 4PP. An individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide coverage for postpartum depression and major depressive disorder screenings conducted pursuant to section 247 of chapter 111.

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

c. 176G, § 4Q. Coverage for human leukocyte or histocompatibility locus antigen testing Section 4Q. Any group health maintenance contract, 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 to a member or enrollee coverage for the cost of human leukocyte antigen testing or histocompatibility locus antigen testing that is necessary to establish the member's or enrollee's 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. 176G, § 4QQ Coverage for the provision of medically necessary pasteurized donor human milk and donor human milk-derived products

c. 176G, § 4QQ. Coverage for the provision of medically necessary pasteurized donor human milk and donor human milk-derived products Section 4QQ. (a) An individual or group health maintenance contract that is issued or renewed within or without 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 health maintenance organization 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. 176G, § 4R Repealed, 2008, 451, Sec. 140

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

c. 176G, § 4RR. Coverage for universal postpartum home visiting services Section 4RR. Any individual or group health maintenance contract that is issued or renewed within or without 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. 176G, § 4S Coverage for prosthetic devices and repairs

c. 176G, § 4S. Coverage for prosthetic devices and repairs Section 4S. (a) Individual and group health maintenance contracts shall provide 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 contracts, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone prosthetic benefit, coverage shall be consistent with the terms and conditions as described in this section. (b) In this section, ''prosthetic device'' shall mean an artificial limb device to replace, in whole or in part, an arm or leg. (c) A health maintenance contract shall not 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) A health maintenance contract shall not apply amounts paid for prosthetic devices to any annual or lifetime dollar maximum applicable to other durable medical equipment covered under the contract other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the contract. (e) A health maintenance 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 health maintenance 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) A health maintenance contract may require prior authorization as a condition of coverage for prosthetic devices. (g) A health maintenance 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. 176G, § 4SS Coverage for diagnostic examinations for breast cancer; digital breast tomosynthesis screening, MRIs and ultrasounds

c. 176G, § 4SS. 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 4SS. (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 individual or group health maintenance contract 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. 176G, § 4T Coverage for eligible dependents under 26 years of age or dependents mentally or physically incapable of earning their own living due to disability

c. 176G, § 4T. Coverage for eligible dependents under 26 years of age or dependents mentally or physically incapable of earning their own living due to disability Section 4T. A health maintenance contract, except certificates which provide stand-alone dental services, supplemental coverage to Medicare or other governmental programs, shall provide, as benefits to all individuals or to 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 the dependent's 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. 176G, § 4TT Coverage for prescribed, ordered or dispensed opioid antagonists

c. 176G, § 4TT. 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 4TT. (a) An individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide coverage for prescribed, ordered or dispensed opioid antagonists, as defined in section 19B of chapter 94C and used in the reversal of overdoses caused by opioids; provided, however, that the coverage for such prescribed, ordered or dispensed opioid antagonists shall not require prior authorization; and provided further, that a prescription from a health care practitioner shall not be required for coverage or reimbursement of opioid antagonists under this section. An opioid antagonist used in the reversal of overdoses caused by opioids shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service. (b) The individual or group health maintenance contract 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. 176G, § 4U Coverage for medically necessary hypodermic syringes or needles

c. 176G, § 4U. Coverage for medically necessary hypodermic syringes or needles Section 4U. No individual or group health maintenance contract shall restrict or discontinue coverage for medically necessary hypodermic syringes or needles, 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. 176G, § 4UU Coverage for the provision of services by a recovery coach

c. 176G, § 4UU. 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 4UU. An individual or group health maintenance contract that is issued or renewed within or without 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. 176G, § 4V Coverage for diagnosis and treatment of autism spectrum disorder

c. 176G, § 4V. Coverage for diagnosis and treatment of autism spectrum disorder Section 4V. (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 health maintenance contract 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) A health maintenance 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. 176G, § 4V1/2 Coverage for the treatment of Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis services

c. 176G, § 4V1/2. Coverage for the treatment of Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis services [Text of section added by 2024, 388, Sec. 6 effective January 1, 2026. See 2024, 388, Sec. 7.] Section 4V1/2. 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. An individual or group health maintenance contract that is 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. 176G, § 4VV Coverage for identified generic and brand name drug used to treat diabetes, asthma, and certain heart conditions

c. 176G, § 4VV. 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 4VV. (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) An individual group health maintenance contract that is issued or renewed within or without 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 to be cost-effective; (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) An individual group health maintenance contract that is issued or renewed within or without 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. 176G, § 4W Coverage for children under age 18 for cleft lip and cleft palate

c. 176G, § 4W. Coverage for children under age 18 for cleft lip and cleft palate Section 4W. A health maintenance contract issued or renewed within or without the commonwealth that covers a child under the age of 18 shall provide coverage for the cost of treating cleft lip and cleft palate for the child. The coverage shall include benefits for medical, dental, oral and facial surgery, surgical management and follow-up care by oral and plastic surgeons, orthodontic treatment and management, preventative and restorative dentistry to ensure good health and adequate dental structures for orthodontic treatment or prosthetic management therapy, speech therapy, audiology and nutrition services, if such services are prescribed by the treating physician or surgeon and such physician or surgeon certifies that such services are medically necessary and consequent to the treatment of the cleft lip, cleft palate or both. The coverage required by this section shall be subject to the terms and conditions applicable to other benefits. Payment for dental or orthodontic treatment not related to the management of the congenital conditions of cleft lip and cleft palate shall not be covered under this section.

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

c. 176G, § 4X. Coverage for orally administered anticancer medications Section 4X. Any individual or group health maintenance contract 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. 176G, § 4Y Coverage for abuse deterrent opioid drug products

c. 176G, § 4Y. Coverage for abuse deterrent opioid drug products Section 4Y. An individual or group health maintenance contract that is issued or renewed shall provide coverage for abuse deterrent opioid drug products listed on the formulary, compiled pursuant to subsection (b) of section 13 of chapter 17, on a basis not less favorable than non-abuse deterrent opioid drug products that are covered by an individual or group health maintenance contract. An increase in patient cost sharing shall not be allowed to achieve compliance with this section.

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

c. 176G, § 4Z. Preauthorization for substance abuse treatment not to be required Section 4Z. 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 4AA; and medically managed intensive inpatient services, not covered under said section 4AA. Any individual or group health maintenance contract that is issued or renewed 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. 176G, § 5 Emergency services provided to members for emergency medical conditions

c. 176G, § 5. Emergency services provided to members for emergency medical conditions Section 5. (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 a member 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 a member or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B). ''Stabilization for discharge'', an emergency medical condition shall be deemed to be stabilized for purposes of discharging a member, 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 member 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 member 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 a member can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the member is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4) of the Social Security Act, 42 U.S.C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition. (b) A health maintenance organization shall cover emergency services provided to members for emergency medical conditions. After the member has been stabilized for discharge or transfer, the health maintenance organization or its designee may require a hospital emergency department to contact the physician on-call designated by the health maintenance organization 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 health maintenance organization or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if the health maintenance organization 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 a covered benefit under the member's evidence of coverage. Consistent with the foregoing, a health maintenance organization may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services. (c) A health maintenance organization may require a member to contact either the health maintenance organization or its designee or the primary care provider of the member within 48 hours of receiving such emergency services, but notification already given to the health maintenance organization 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 a health maintenance organization 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 health maintenance organization shall be in compliance with section 12 of chapter 176O and all applicable state and federal confidentiality provisions. (e) A health maintenance organization shall clearly state in its brochures, contracts, policy manuals and printed materials that members 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 enrollee is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. No member 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 an emergency medical condition. (f) A health maintenance organization shall provide or arrange for indemnity payments to a member or provider for a reasonable amount charged for the cost of emergency medical services by a provider who is not normally affiliated with the health maintenance organization when the member requires services for an emergency medical condition. Said indemnity payment under this section shall not be subject to the insurance laws of the commonwealth. No contract between a participating provider of health care services and a health maintenance organization shall be issued or delivered in the commonwealth unless it contains a provision requiring that within 45 days after the receipt by the organization of completed forms for reimbursement to the provider of health care services, the health maintenance organization shall (i) make payments for such services provided, (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 health maintenance organization fails to comply with this paragraph for any claims related to the provision of health care services, said health maintenance 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 health maintenance 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 health maintenance organization is investigating because of suspected fraud.

M.G.L. c. 176G, § 5A Divorced or separated spouses; coverage

c. 176G, § 5A. Divorced or separated spouses; coverage Section 5A. (a) In the event of the granting of a judgment absolute of divorce or of separate support to which a member of a group health maintenance contract is a party, the person who was the spouse of said member 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 member's participation in the contract until the remarriage of either the member or such spouse, or until such time as provided by said judgment, whichever is earlier. (b) In the event of the remarriage of the member 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 member, 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 health maintenance organization 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. 176G, § 6 Contracts

c. 176G, § 6. Contracts Section 6. A health maintenance organization may enter into contractual arrangements with any other person or company for the provision, to the health maintenance organization, of health services, insurance, reinsurance and administrative, marketing, underwriting or other services on a nondiscriminatory basis. A health maintenance organization shall not refuse to contract with or compensate for covered services an otherwise eligible provider solely because such provider has in good faith communicated with one or more of his current, former or prospective patients regarding the provisions, terms or requirements of the organization's products as they relate to the needs of such provider's patients. No contract between a participating provider of health care services and a health maintenance organization shall be issued or delivered in the commonwealth unless it contains a provision requiring that within 45 days after the receipt by the organization of completed forms for reimbursement to the provider of health care services, the health maintenance organization shall (i) make payments for such services provided, (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 health maintenance organization fails to comply with this paragraph for any claims related to the provision of health care services, said health maintenance 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 health maintenance 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 health maintenance organization is investigating because of suspected fraud. No contract between a participating home health agency or a participating licensed hospice agency and a health maintenance organization shall be issued or delivered in the commonwealth that requires 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 it is certified for participation in the Medicare program, Title XVIII of the federal Social Security Act, 42 U.S.C. Sections 1395 et seq.

M.G.L. c. 176G, § 6A Group health maintenance contracts; contribution percentages

c. 176G, § 6A. Group health maintenance contracts; contribution percentages Section 6A. A health maintenance organization may only enter into a group health maintenance contract with an employer if the group health maintenance 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 health maintenance organization may enter into a group health maintenance contract with an employer that establishes separate contribution percentages for employees covered by collective bargaining agreements.

M.G.L. c. 176G, § 6B Retroactive claims denials for behavioral health services

c. 176G, § 6B. Retroactive claims denials for behavioral health services Section 6B. (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) An insurer or other entity 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 insurer or other entity; (ii) the insurer or other entity 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 insurer or other entity responsible for payment 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 insurer or other entity with which the insurer contracts to provide or manage health care services, including mental health and substance use disorder services, the insurer or other entity 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 insurer shall allow for resubmission of the claim.

M.G.L. c. 176G, § 7 Repealed, 2000, 141, Sec. 21

M.G.L. c. 176G, § 8 Public dissemination of deceptive or misleading materials

c. 176G, § 8. Public dissemination of deceptive or misleading materials Section 8. Public dissemination of any promotional material, evidence of coverage, health maintenance contract or any other statement with respect to a health maintenance organization, which is untrue, deceptive or misleading, shall constitute an unfair and deceptive practice under the provisions of section two of chapter ninety-three A. Every health maintenance organization shall keep on file, available for inspection by the division of insurance, copies of all educational materials, displays, evidences of coverage and all materials of any promotional nature released for public dissemination. The commissioner may forbid the use of any such material if he finds that it is either untrue, deceptive, or misleading.

M.G.L. c. 176G, § 9 Trade regulation practices; application of law

c. 176G, § 9. Trade regulation practices; application of law Section 9. The provisions of sections 1 to 14K, inclusive, and sections 48 to 68, inclusive, of chapter ninety-three, and chapter ninety-three A shall be applicable to the ownership, organization, operation and health care services provided by a health maintenance organization as authorized by this chapter.

M.G.L. c. 176G, § 10 Reports; audits, examinations or inspections; confidentiality and privilege

c. 176G, § 10. Reports; audits, examinations or inspections; confidentiality and privilege Section 10. Every health maintenance organization shall annually file with the commissioner, within 60 days of the close of its fiscal year, a report verified by at least 2 principal officers and covering its preceding fiscal year; provided that, if the commissioner determines that a threat of insolvency exists with respect to a health maintenance organization, he may require that such report be made available prior to the expiration of said 60 days. The report shall include:— (1) financial statements of the health maintenance organization on the latest applicable form of annual statement approved by the National Association of Insurance Commissioners for health maintenance organizations, with any additional information the commissioner may require for the purpose of eliciting a complete and accurate exhibit of the condition and transactions of the health maintenance organization; (2) statistics relating to the cost of operations and the pattern of utilization of services in the previous fiscal year; and (3) such other information as the commissioner may reasonably require relating to the past performance of the organization. All financial information reflected in the annual report shall be maintained and prepared in accordance with statutory accounting practices and procedures prescribed or permitted by the commissioner. The commissioner shall require that the annual report be maintained and prepared in accordance with the Annual Statement Instructions and Accounting Practices and Procedures Manual adopted by the National Association of Insurance Commissioners unless further modified by the commissioner as deemed appropriate. The commissioner may make an examination of the affairs of a health maintenance organization when the commissioner deems prudent but, in any event, not less frequently than once every 5 years. Health maintenance organizations shall be examined in all respects as companies subject to and pursuant to section 4 of chapter 175. Notwithstanding any other provision of the General Laws, including clause Twenty-sixth of section 7 of chapter 4 and chapter 66, documents, materials or other information, including but not limited to, all working papers and copies thereof created, produced or obtained by or disclosed to the commissioner or any other person in the course of an examination made pursuant to this subsection or in the course of analysis by the commissioner of the financial condition or market conduct of a health maintenance organization 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. (a) Documents, materials or other information, including but not limited to, all working papers and copies thereof in the possession or control of the National Association of Insurance Commissioners and its affiliates and subsidiaries shall be confidential by law and privileged, shall not be subject to subpoena and shall not be subject to discovery or admissible in evidence in any private civil action if they are: (i) created, produced, obtained by or disclosed to the National Association of Insurance Commissioners and its affiliates and subsidiaries in the course of the National Association of Insurance Commissioners and its affiliates and subsidiaries assisting an examination made pursuant to this section or assisting the commissioner in the analysis of the financial condition or market conduct of a health maintenance organization; or (ii) disclosed to the National Association of Insurance Commissioners and its affiliates and subsidiaries pursuant to subsection (c) by any member of the National Association of Insurance Commissioners. (b) 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. (c) 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 subsection 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 paragraph. (d) 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 paragraph or as a result of sharing as authorized in this subsection. (e) A privilege established under the law of any state or jurisdiction that is substantially similar to the privilege established under this paragraph shall be available and enforced in any proceeding in and in any court of the commonwealth. The final report of any such audit, examination or other inspection by or on behalf of the division shall be a public record.

M.G.L. c. 176G, § 10A Applicability of chapter 176V to health maintenance organizations governed by this chapter

c. 176G, § 10A. Applicability of chapter 176V to health maintenance organizations governed by this chapter Section 10A. Notwithstanding any general or special law to the contrary, chapter 176V shall apply to a health maintenance organization governed by this chapter.

M.G.L. c. 176G, § 10B Applicability of chapter 176W to health maintenance organizations governed by this chapter

c. 176G, § 10B. Applicability of chapter 176W to health maintenance organizations governed by this chapter Section 10B. Notwithstanding any general or special law to the contrary, chapter 176W shall apply to a health maintenance organization governed by this chapter.

M.G.L. c. 176G, § 11 Contracts with group insurance commission or local governments

c. 176G, § 11. Contracts with group insurance commission or local governments Section 11. Every health maintenance organization entering into a contract with the group insurance commission under chapter thirty-two A, or a county, city, town, or district under chapter thirty-two B, shall comply with the requirements applicable to health care organizations under said chapters thirty-two A and thirty-two B except that a health maintenance organization proposing to enter into direct contract may elect to have the group insurance commission, or the appropriate county, city, town or district, as the case may be, remit applicable monthly premium costs that would otherwise be payable to a carrier, directly to the health maintenance organization.

M.G.L. c. 176G, § 11A Alternative dental coverage option

c. 176G, § 11A. Alternative dental coverage option Section 11A. Each employer or other organization which employs or has twenty-five or more employees or members during the full preceding calendar year and which contracts with and contributes to a health maintenance organization for the purpose of providing comprehensive dental benefits to its employees or members, shall, if the health maintenance organization restricts the covered persons in selecting the providers of dental services to a single provider or limited number of providers of dental services, offer its employees and their eligible dependents and members and members' eligible dependents at the time such a contract is offered or renewed, the option of selecting alternative coverage which permits covered persons to obtain dental services from any licensed dentist. No employer or other organization shall be required to pay for or contribute toward the provision of alternative coverage an amount greater than the premium or cost which it pays or contributes to the health maintenance organization contract which limits the number of providers of dental services. Notwithstanding the provisions of this section, if any of the employees of an employer required by paragraph one to offer employees the option of selecting such alternative dental coverage as described in said paragraph are represented by a certified collective bargaining representative, the offer of the option of selecting such alternative coverage as required by said paragraph one shall first be made to such collective bargaining representative. Said representative shall have the right not to accept such offer, thereby exempting the employer from the provisions of this section. If such offer is accepted by such representative, the offer of the option of selecting such alternative coverage shall then be made to each employee. Notwithstanding the provisions of this section, a union management trust created pursuant to collective bargaining shall, whenever a restricted dental benefits contract as described in paragraph one is proposed, consider offering such alternative dental coverage as described in said paragraph one, provided, however, said trust may offer the dental plan or plans of its choice. The commissioner shall promulgate such rules and regulations as are necessary to effectuate the purpose of this section, including procedures for notice to covered persons, employers and other organizations of the provisions of this section.

M.G.L. c. 176G, § 12 Health regulations not limited

c. 176G, § 12. Health regulations not limited Section 12. Nothing in this chapter shall exempt any person from any applicable provisions of chapters one hundred and eleven or one hundred and twelve, including but not limited to, provisions relating to determinations of need, licensure and regulation of hospitals and clinics and registration of health professionals.

M.G.L. c. 176G, § 13 Name restriction

c. 176G, § 13. Name restriction Section 13. No company, person, entity or health care plan not meeting the definition of health maintenance organization specified under this chapter shall use in its name, contract, or literature the term ''health maintenance organization'' or the initials ''HMO''.

M.G.L. c. 176G, § 14 Licensure applicants; documents required; approval by commissioner

c. 176G, § 14. Licensure applicants; documents required; approval by commissioner Section 14. Each applicant for a health maintenance organization license shall upon initial application submit to the commissioner for his approval such materials as the commissioner shall by regulation require, in a form approved by the commissioner. A health maintenance organization shall annually notify the commissioner of any material change to the information submitted, in a form and at a time approved by the commissioner. Said materials shall include, but not be limited to: (1) a copy of the basic organization document such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents establishing the health maintenance organization; (2) a copy of the by-laws, rules and regulations, or similar document, regulating the conduct of the internal affairs of the applicant; (3) a statement generally describing the health maintenance organization, its health care plan or plans, facilities and personnel; (4) an internal operations plan, including an organizational chart, description of organizational structure, a description of the service area and provider network, the roles, functions, responsibilities of and interrelationships among providers, and the methods of provider reimbursement and risk-sharing arrangements; (5) a provider inventory, including a listing of providers by specialty, a calculation of physician to population ratios, and an inventory of owned, operated, contracting and participating provider facilities, including, but not limited to, hospitals, skilled nursing facilities, home health care and medical care services; (6) a copy of every contract form made or to be made between the applicant and any providers of health services, copies of administrative contracts, and a statement of written procedures and standards for the prior review and approval by the applicant of provider subcontracts; (7) a copy of the form of evidence of coverage to be issued to the members; (8) a copy of the form of group contract, if any, which is to be issued to employers, unions, trustees, or other organizations; (9) financial statements showing the applicant's assets, liabilities, and sources of working capital and other sources of financial support and projections of the results of operations for the succeeding three years; (10) a financial plan, including a statement indicating when the applicant estimates that income from operations will equal expenses, a statement of the applicant's plan to establish and maintain sufficient reserves to cover projected risks, copies of reinsurance or other agreements to provide for provision of contracted health services in the event the applicant is unable to provide such services for any reason, and a detailed description of mechanisms to monitor the financial solvency of any organization contraction with the applicant that assumes substantial financial risk for the provision of health services; (11) a plan for compliance with section 15, including copies of any contract or agreement with a carrier for reinsurance; (12) an enrollment and marketing plan describing the marketing methods, anticipated enrollment, the service area population and utilization rates projected for health services delivered in the organization's service area; (13) a utilization plan describing inpatient and outpatient utilization review measures and a statement of actuarial review and certification of actuarial assumptions made regarding utilization as applied to projected financial statements; (14) premium rates for all products offered; (15) a member services plan, including a statement of procedures to be used to maintain member confidentiality of medical records, grievances, and quality assurance study responses; (16) a detailed description of the quality assurance system; (17) a detailed description of the formal internal grievance system including procedures for the registration and resolution of member grievances, and, for renewal applications only, the total number and disposition of malpractice claims and other claims relating to the service or care rendered by the health maintenance organization made by, or on behalf of, members of the organization that were settled or resulted in a judgment during the year by the health maintenance organization; and (18) evidence of compliance with chapter 176O. Any applicant accredited by the managed care bureau established under section 2 of said chapter 176O shall be deemed to meet the requirements of this chapter with respect to requirements with any utilization review standards. A license granted to a health maintenance organization pursuant to this section shall be renewed every 2 years. The fee for such renewal, in an amount determined by the commissioner, shall be not less than $1,000.

M.G.L. c. 176G, § 15 Bond; waiver

c. 176G, § 15. Bond; waiver Section 15. Each health maintenance organization shall furnish to the commissioner evidence of a surety bond in an amount satisfactory to the commissioner or deposit with the commissioner cash or sureties acceptable to him in at least the same amount as a guarantee that the obligation to the enrollees will be performed. The commissioner may waive this requirement if a health maintenance organization has contracted with a carrier as defined in section one for the purpose of reinsurance.

M.G.L. c. 176G, § 16 Contracts, rates, evidence of coverage; disapproval of commissioner

c. 176G, § 16. Contracts, rates, evidence of coverage; disapproval of commissioner Section 16. The subscriber contracts, rates and evidence of coverage shall be subject to the disapproval of the commissioner. 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. To the extent that this chapter is inconsistent with the provisions of chapter one hundred and seventy-six K, and any regulations promulgated thereunder, medicare supplement insurance plans as defined in said chapter one hundred and seventy-six K shall be subject to the provisions of said chapter one hundred and seventy-six K. To the extent that this section is inconsistent with the provisions of chapter one hundred and seventy-six M and any regulations promulgated thereunder, any nongroup health maintenance contract 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.

M.G.L. c. 176G, § 16A Disapproval of certain health maintenance contracts based on high deductibles

c. 176G, § 16A. Disapproval of certain health maintenance contracts based on high deductibles Section 16A. The commissioner shall not disapprove a health maintenance contract: (i) if it complies with the requirements of 42 U.S.C. Sec. 18022(e); or (ii) on the basis that it includes a deductible that is consistent with the requirements for a high deductible plan as defined in section 223 of the Internal Revenue Code and implementing regulations or guidelines; provided, however, that the maximum deductible shall not be greater than the maximum annual contribution to a health savings account permitted under said section 223 of the Internal Revenue Code; and, provided further, that a deductible equal to the maximum annual contribution to a health savings account shall only be approved for products which include a health savings account permitted under said section 223 of the Internal Revenue Code.

M.G.L. c. 176G, § 16B Disapproval of certain health maintenance contracts for coverage of young adults

c. 176G, § 16B. Disapproval of certain health maintenance contracts for coverage of young adults Section 16B. The commissioner shall not disapprove a health maintenance contract offered as coverage for young adults if the health maintenance contract complies with the minimum standards established under section 10 of chapter 176J.

M.G.L. c. 176G, § 17 Rules and regulations; standardized claim form

c. 176G, § 17. Rules and regulations; standardized claim form Section 17. The commissioner may promulgate rules and regulations as are necessary to carry out the provisions of this chapter including but not limited to the licensing of agents, who engage in solicitation of enrollment of a health care plan. No rule or regulation shall require any health maintenance organization or contract to provide payment of, or referrals for, abortions not necessary to prevent the death of the mother. 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. 176G, § 17A Open enrollment for nongroup medicare beneficiaries; period, notice of termination

c. 176G, § 17A. Open enrollment for nongroup medicare beneficiaries; period, notice of termination Section 17A. All health maintenance organizations governed by this chapter which enroll medicare beneficiaries shall provide open enrollment for nongroup medicare beneficiaries commencing on February first and ending March thirty-first of each year, for coverage to be effective not later than ninety days from the date of enrollment; provided, however, that nothing contained herein shall preclude additional periods of open enrollment for medicare beneficiaries. The open enrollment period and coverage effective date for any group health maintenance organization contract covering medicare beneficiaries 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. Any such health maintenance organization whose contract with medicare is being terminated shall give each resident of the commonwealth who is covered under a medicare program offered by such health maintenance organization and each nonprofit hospital service corporation and medical service corporation in the commonwealth sixty days notice prior to such termination. Any such health maintenance organization shall cooperate fully in the prompt transfer of coverage to any organization which will assume such coverage.

M.G.L. c. 176G, § 18 Repealed, 1993, 110, Sec. 214

M.G.L. c. 176G, § 19 Discrimination against abuse victims in terms of health maintenance contract

c. 176G, § 19. Discrimination against abuse victims in terms of health maintenance contract Section 19. No health maintenance organization 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 health maintenance contract 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 health maintenance organization 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. 176G, § 20 Insolvent health maintenance organization; administrative supervision, rehabilitation or liquidation; priority of claims

c. 176G, § 20. Insolvent health maintenance organization; administrative supervision, rehabilitation or liquidation; priority of claims Section 20. Any administrative supervision, rehabilitation or liquidation of a health maintenance organization shall be deemed to be the administrative supervision, rehabilitation or liquidation of an insurance company and shall be instituted on the grounds contained in and conducted pursuant to sections 6, 46, 46A, 178, 179, 180 and 180A to 180L3/4, inclusive, of chapter 175, and sections 20A and 29 of chapter 176G, except as provided in this section and may include, but not be limited to any ground identified in section 20A and in chapter 175J. Members shall have the same priority in the event of rehabilitation or liquidation as the law provides to policyholders of an insurer. For the purpose of determining the priority of distribution of general assets, claims of members and members' beneficiaries shall have the same priority as established by section 180F of chapter 175 for policyholders, beneficiaries and insureds of insurance companies. If a member is liable to any provider for services provided pursuant to and covered by the health maintenance organization, that liability shall have the status of a member in the distribution of general assets. Any provider who is obligated by statute or agreement to hold members harmless from liability for services provided pursuant to and covered by a health maintenance contract shall have a priority of distribution of the general assets immediately following that of members as described in this section.

M.G.L. c. 176G, § 20A Administrative supervision, rehabilitation or liquidation of health maintenance organizations; revocation or suspension of license

c. 176G, § 20A. Administrative supervision, rehabilitation or liquidation of health maintenance organizations; revocation or suspension of license Section 20A. If the commissioner is satisfied, upon examination or other evidence submitted to him, that (1) any health maintenance organization is insolvent or is in an unsound financial condition, (2) its business policies or methods are unsound or improper, (3) its condition or management is such as to render its further transaction of business hazardous to the public or its members or creditors, (4) it is transacting business fraudulently, (5) the health maintenance organization or its officers or agents have refused to submit to an examination under section 10 or to perform any legal obligation relative thereto, (6) the amount of its funds, net cash or contingent assets is deficient, (7) the health maintenance organization has attempted or is attempting to compromise with its creditors on the ground that it is financially unable to pay its claims in full, or (8) the health maintenance organization has inadequately reserved for unearned premiums, he may seek administrative supervision, rehabilitation or liquidation pursuant to section 20 or revoke or suspend the license issued to the health maintenance organization under section 14 for a period not exceeding the unexpired terms thereof. In the case of revocation or suspension, the commissioner shall give written notice to the company specifying the date on which such revocation or suspension shall be effective, the term of any such suspension and the ground for such revocation or suspension; provided, that if the ground for revocation or suspension is that the health maintenance organization has violated any provision of law or has failed to comply with its charter, the effective date of such revocation or suspension shall be not less than 10 days from the date of issue of the notice, and the particulars of such violation or failure to comply with its charter shall be specified in said notice. Such notice may be served by registered mail, sent postage prepaid, addressed to the health maintenance organization at its last home office address or to the last known address of the resident agent. An affidavit of the commissioner, in such form as he may prescribe, or of anyone authorized by him to give such notice, appended to a copy thereof, that such notice has been mailed as aforesaid shall be prima facie evidence that such notice has been duly given. He shall also cause notice of such revocation or suspension to be published in such manner as he may deem necessary for the protection of the public. A health maintenance organization aggrieved by a revocation or suspension of its license under this section, may within 10 days from the effective date of such revocation or suspension file a petition in the supreme judicial court for the county of Suffolk for a review of such action of the commissioner. The court shall summarily hear and determine the question whether the ground for revocation or suspension specified in the notice of the commissioner exists and may make any appropriate order or decree. If the order or decree is adverse to the petitioning health maintenance organization it may within 10 days therefrom appeal to the full court and in case of such an appeal the revocation or suspension of the license of the health maintenance organization shall continue in full force until the final determination of the question by the full court, unless vacated by the commissioner during the pendency of such appeal.

M.G.L. c. 176G, § 21 Participating provider; contracts with health maintenance organizations; hold harmless clause; limitation on collection actions

c. 176G, § 21. Participating provider; contracts with health maintenance organizations; hold harmless clause; limitation on collection actions Section 21. (a) For purposes of this section, ''participating provider'' shall mean any physician, hospital or other person who, under an express or implied contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health care services to members with an expectation of receiving payment, other than co-payment, co-insurance or deductible, directly or indirectly from the health maintenance organization, its contractor or subcontractor. (b) Every contract between a health maintenance organization and a participating provider shall be in writing and shall contain the following hold harmless provision: The provider agrees that in no event, including but not limited to nonpayment by the health maintenance organization of amounts due the provider under this contract, insolvency of the health maintenance organization or any breach of this contract by the health maintenance organization, shall the provider or its assignees or subcontractors have a right to seek any type of payment from, bill, charge, collect a deposit from, or have any recourse against, the member, persons acting on the member's behalf, other than the health maintenance organization, the employer or the group health maintenance contract holder for services provided pursuant to this contract except for the payment of applicable co-payment, co-insurance or deductibles for services covered by the health maintenance organization. The requirements of this provision shall survive any termination of this contract for services rendered prior to the termination, regardless of the cause of such termination. The health maintenance organization's members, any persons acting on the member's behalf, other than the health maintenance organization, and the employer or group health maintenance contract-holder shall be third-party beneficiaries of this clause. This provision supercedes any oral or written agreement hereafter entered into between the provider and the member, persons acting on the member's behalf, other than the health maintenance organization, and the employer or group health maintenance contract holder. (c) In the event that the participating provider contract has not been reduced to writing as required by subsection (b) or that the contract fails to contain the required hold harmless provision, such provision shall be deemed incorporated into such contract by operation of law. (d) No participating provider, agent, trustee or assignee thereof, may maintain any action at law against a member to collect sums owed by the health maintenance organization.

M.G.L. c. 176G, § 22 Health care providers; liability of member of health maintenance organization; limitation on collection of amounts owed

c. 176G, § 22. Health care providers; liability of member of health maintenance organization; limitation on collection of amounts owed Section 22. (a) For purposes of this section, ''health care provider'' shall mean any physician, hospital or other person furnishing health services who has provided such services to members under an express or implied contract or with an expectation of receiving payment, other than co-payment, deductible or co-insurance, directly or indirectly from the health maintenance organization. (b) In addition to the provisions of section 21, in the event of the insolvency of a health maintenance organization: (1) a member of a health maintenance organization shall not be liable to any health care provider for any covered health services provided to the member, except as provided in subsection (c); (2) a health care provider or any representative of a health care provider may not collect or attempt to collect from a member money owed to the health care provider by a health maintenance organization; (3) a health care provider or any representative of a health care provider may not maintain any action against a member to collect or attempt to collect any money owed to the health care provider by a health maintenance organization. (c) Notwithstanding any other provision of this section, a health care provider or representative of a health care provider may collect or attempt to collect from a member: (1) a co-payment, deductible, or co-insurance amounts owed by the member to the health care provider for covered services provided by the health care provider, or (2) a payment or charges for services not covered under the member's health maintenance contract.

M.G.L. c. 176G, § 23 Insolvency of health maintenance organization; replacement coverage

c. 176G, § 23. Insolvency of health maintenance organization; replacement coverage Section 23. (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 this chapter, an insurance company authorized to provide accident and health insurance under chapter 175, a nonprofit hospital service corporation authorized under chapter 176A, a nonprofit medical service corporation authorized under 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 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, 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. Nothing in this section shall prevent an employer from making alternative arrangements with any carrier to provide coverage to its employees who were members of the insolvent health maintenance organization. (2) If no other carrier had been offered to some groups whose members were enrolled in the insolvent health maintenance organization, or if the employer does not arrange for alternative coverage, 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, taking into consideration the health care delivery resources of each health maintenance organization. Each health maintenance organization to which a group or groups are so allocated shall offer such group or groups the health maintenance organization's existing coverage which is most similar to each group's coverage with the insolvent health maintenance organization at rates determined in accordance with the succeeding health maintenance organization's existing rating methodology. (3) The commissioner shall also allocate equitably the insolvent health maintenance organization's nongroup enrollees who are unable to obtain other comparable coverage among all health maintenance organizations that operate within a portion of the insolvent health maintenance organization's service area, taking into consideration the health care delivery resources of each such health maintenance organization. Each health maintenance organization to which nongroup enrollees are allocated shall offer such nongroup enrollees the health maintenance organization's existing coverage for individual or conversion coverage as determined by his type of coverage in the insolvent health maintenance organization at rates determined in accordance with the succeeding health maintenance organization's existing rating methodology. Succeeding health maintenance organizations that do not offer direct nongroup enrollment may aggregate all of the allocated nongroup enrollees into one group for rating and coverage purposes. (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. 176G, § 24 Health maintenance contracts; genetic tests; discrimination based on genetic information

c. 176G, § 24. Health maintenance contracts; genetic tests; discrimination based on genetic information Section 24. For the purposes of this section the following words shall have the following meanings:— ''Genetic information'', any 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 health maintenance organization 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 premium or rates charged, in the length of coverage or in any of the terms and conditions of a health maintenance contract based on genetic information as defined in this section. No health maintenance organization 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 health maintenance contract. Any violation of this section shall constitute an unfair method of competition or deceptive act or practice in violation of chapters 93A and 176D.

M.G.L. c. 176G, § 25 Net worth of health maintenance organization

c. 176G, § 25. Net worth of health maintenance organization Section 25. (a) The commissioner shall require upon issuance of an initial license under this chapter that a health maintenance organization shall have an initial adjusted net worth of $1,500,000. (b) Except as provided by subsection (c) or (d), the commissioner shall require that the adjusted net worth of a health maintenance organization be maintained subsequent to initial licensure in an amount equal to the greater of the following amounts: (1) $1,000,000; or (2) 2 per cent of annual premium revenues as reported on the most recent annual financial statement filed with the commissioner on the first $150,000,000 of premium and 1 per cent of annual premium on the premium in excess of $150,000,000; or (3) An amount equal to the sum of 3 months uncovered health care expenditures as reported on the most recent financial statement filed with the commissioner; or (4) An amount equal to the sum of: (i) 8 per cent of annual health care expenditures except those paid on a capitated basis or managed hospital payment basis as reported on the most recent financial statement filed with the commissioner; and (ii) 4 per cent of annual hospital expenditures paid on a managed hospital payment basis as reported on the most recent financial statement filed with the commissioner. (c) A health maintenance organization licensed before January 1, 2004 must maintain a minimum adjusted net worth of: (1) 10 per cent of the amount required by subsection (b) by December 31, 2004; (2) 25 per cent of the amount required by subsection (b) by December 31, 2005; (3) 40 per cent of the amount required by subsection (b) by December 31, 2006; (4) 55 per cent of the amount required by subsection (b) by December 31, 2007; (5) 70 per cent of the amount required by subsection (b) by December 31, 2008; (6) 85 per cent of the amount required by subsection (b) by December 31, 2009; and (7) 100 per cent of the amount required by subsection (b) by December 31, 2010. (d) In determining adjusted net worth, no debt shall be considered fully subordinated unless the subordination clause is in a form acceptable to the commissioner, which shall at a minimum meet the following requirements: (1) The effective date, amount, interest and parties involved in such debt are clearly set forth; (2) The principal sum and any interest accrued thereon are subject to and subordinate to all other liabilities of the health maintenance organization, and upon dissolution or liquidation, no payment of any kind shall be made until all other liabilities of the health maintenance organization have been paid; (3) The instrument states that the parties agree that the health maintenance organization must obtain written approval from the commissioner prior to any payment of interest or repayment of principal; and (4) The debt is deemed fully subordinated by the commissioner in his discretion. (e) Any debt incurred by a note meeting the requirements of subsection (d) shall not be considered a liability and shall be recorded as equity. (f) The commissioner may adopt rules, regulations and guidelines, from time to time, requiring any health maintenance organization incorporated, licensed, approved or authorized to engage in business pursuant to this chapter to possess and constantly maintain capital and surplus levels in excess of the statutory levels required by this chapter based upon any of the following factors: (1) the nature and type of health maintenance contracts that a health maintenance organization provides, arranges for or otherwise participates in, the nature and type of such contracts in effect in the overall health maintenance organization market in the commonwealth, and the capability of the health maintenance organization to provide protection against loss of prepaid fees or other revenues or unavailability of covered health services or from other financial impairment of its obligations to its members; (2) the volume of contract premiums or fees relative to health maintenance contracts that a health maintenance organization provides, arranges for or otherwise participates in; (3) the composition, quality, duration or liquidity of a health maintenance organization's investment portfolio; (4) fluctuations in the market value of securities or other assets a health maintenance organization holds; (5) the adequacy of a health maintenance organization's reserves; or (6) the size of a health maintenance organization's asset valuation reserves and interest maintenance reserves. The rules, regulations or guidelines adopted under this section shall be designed to assure the financial solvency of health maintenance organizations for the protection of policyholders, enrolled members, shareholders and the general public. The commissioner may establish, by rule, regulation or guideline, a procedure that shall require a health maintenance organization to increase its capital and surplus amounts over a specified period of time until the required statutory minimums established by this chapter, or higher levels as ordered by the commissioner, are met.

M.G.L. c. 176G, § 26 Deposit maintained with trustee acceptable to commissioner

c. 176G, § 26. Deposit maintained with trustee acceptable to commissioner Section 26. (a) Except as provided in subsections (b) and (d), each health maintenance organization shall maintain a deposit with a trustee acceptable to the commissioner through which a custodial or controlled account is utilized of cash, securities or any combination of these or other measures that are acceptable to him, which is to be used exclusively to protect the interests of policyholders, enrolled members, and the general public and which at all times shall have a value of not less than $1,000,000. (b) Each health maintenance organization approved by the commissioner before January 1, 2004 shall provide evidence of and maintain at all times a deposit as described in subsection (a) in the amount of $500,000 not later than July 1, 2004. Not later than January 1, 2005, the health maintenance organization shall provide evidence of and maintain a deposit in the amount of an additional $500,000 to constitute the required $1,000,000 deposit. (c) All income from the deposit shall be an asset of the health maintenance organization. A health maintenance organization that has made a securities deposit may withdraw that deposit or any part thereof after making a substitute deposit of cash, securities or any combination of these or other measures of equal amount and value. The commissioner shall approve any securities before they are deposited or substituted. (d) The commissioner may reduce or eliminate the deposit requirement if the health maintenance organization deposits with the state treasurer, insurance commissioner or other official body of the state or jurisdiction of domicile, for the protection of policyholders, enrolled members and subscribers of such health maintenance organization and the general public, cash, acceptable securities or surety, and delivers to the commissioner a certificate to such effect, duly authenticated by the appropriate entity holding the deposit. (e) If in the opinion of the commissioner the deposit requirement as established above would be inadequate to protect the interests of enrolled members, the deposit shall be appropriately adjusted in order to protect the interests of policyholders, enrolled members and subscribers of the health maintenance organization and the general public. (f) The deposit shall be an admitted asset of the health maintenance organization in the determination of net worth pursuant to section 25. The commissioner may use the deposit for administrative costs directly attributable to any receivership, administrative supervision, rehabilitation or liquidation pursuant to section 20. If the health maintenance organization is ordered into receivership, administrative supervision, rehabilitation or liquidation, the deposit shall be an asset subject to the provisions of section 20.

M.G.L. c. 176G, § 27 Merger or acquisition of control

c. 176G, § 27. Merger or acquisition of control Section 27. (a) No person other than the health maintenance organization shall make a tender offer for or a request or invitation for tenders of, or enter into any agreement to exchange securities, or seek to acquire, or acquire, in the open market or otherwise, any voting security of, any membership rights in, or any right to appoint or elect members of the board of directors of a domestic health maintenance organization if, after the consummation thereof, such person would, directly or indirectly, or by conversion or by exercise of any right to acquire, be in control of such health maintenance organization. A person shall not enter into an agreement to merge with or otherwise to acquire control of a domestic health maintenance organization or any person controlling a domestic health maintenance organization unless, at the time any such offer, request or invitation is made or any such agreement is entered into, or prior to the acquisition of such securities, membership rights, or board of directors appointment or election rights, if no offer or agreement is involved, such person has filed with the commissioner and has sent to such health maintenance organization, a statement containing the information required by this section, and such offer, request, invitation, agreement or acquisition has been approved by the commissioner in the manner hereinafter described. For purposes of this section a domestic health maintenance organization shall include any person controlling a domestic health maintenance organization. For the purposes of this section, a person shall not include any securities broker holding, in the usual and customary broker's function, less than 10 per cent of the voting securities, membership rights, or board of directors appointment or election rights, of a domestic health maintenance organization or of any person which controls a domestic health maintenance organization. (b) The statement to be filed with the commissioner pursuant to subsection (a) shall be made under oath or affirmation and shall contain the following information: (1) The name and address of each person by whom or on whose behalf the merger or other acquisition of control referred to in subsection (a) is to be effected, hereinafter called the acquiring party, and (i) if such person is an individual, his principal occupation and all offices and positions held during the past 5 years, and any convictions of crimes other than minor traffic violations during the past 10 years; (ii) if such person is not an individual, a report of the nature of its business operations during the past 5 years or for such lesser period as such person and any predecessors thereof shall have been in existence; an informative description of the business intended to be done by such person and such person's subsidiaries; and a list of all individuals who are or who have been selected to become directors or executive officers of such person, or who perform or will perform functions appropriate to such positions. Such list shall include for each such individual the information required by this subparagraph. (2) The source, nature and amount of the consideration used or to be used in effecting the merger or other acquisition of control, a description of any transaction wherein funds were or are to be obtained for any such purpose, including any pledge of the health maintenance organization's stock or assets, or the stock or assets of any of its subsidiaries, or controlling affiliates, and the identity of persons furnishing such consideration; provided, however, that where the source of such consideration is a loan made in the lender's ordinary course of business, the identity of the lender shall remain confidential, if the person filing such statement so requests. (3) Fully audited financial information as to the earnings and financial condition of each acquiring party for the preceding 5 fiscal years of each such acquiring party or for such lesser period as such acquiring party and any predecessors thereof shall have been in existence, and similar unaudited information as of a date not earlier than 90 days prior to the filing of the statement. (4) Any plans or proposals which each acquiring party may have to liquidate such health maintenance organization, to sell its assets or merge or consolidate it with any person, or to make any other material change in its business or corporate structure or management. A person who omits from the statement filed hereunder any plans or proposals that should have been included pursuant to this subsection, and shall be granted approval for a change of control without the disclosure of the plans or proposals, shall be prohibited for a period of 2 years from the date of the approval from engaging in or taking any steps preparatory to engaging in any transaction described or referenced in or contemplated by the plans or proposals except with the specific approval of the commissioner. (5) The number of any shares of any security, or the extent of any membership rights, or board of directors appointment or election rights, as the case may be, referred to in subsection (a) which each acquiring party proposes to acquire, and the terms of the offer, request, invitation, agreement or acquisition referred to in said subsection (a), and a statement as to the method by which the fairness of the proposal was arrived at. (6) The amount of each class of any security, membership right, board of directors appointment or election rights referred to in said subsection (a), as the case may be, which is beneficially owned or concerning which there is a right to acquire beneficial ownership by each acquiring party. (7) A full description of any contracts, arrangements or understandings with respect to any security, membership right, board of directors appointment or election rights, as the case may be, referred to in said subsection (a) in which any acquiring party is involved, including but not limited to transfer of any of the securities, joint ventures, loan or option arrangements, put or calls, guarantees of loans, guarantees against loss or guarantees of profits, division of losses or profits or the giving or withholding of proxies. The description shall identify the persons with whom such contracts, arrangements or understandings have been entered into. (8) A description of the purchase of any security, membership right, board of directors appointment or election rights, as the case may be, referred to in said subsection (a) during the 12 calendar months preceding the filing of the statement, by the acquiring party, including the dates of purchase, names of the purchasers and consideration paid or agreed to be paid therefore. (9) A description of any recommendations to purchase any security, membership right, board of directors appointment or election rights, as the case may be, referred to in said subsection (a) made during the 12 calendar months preceding the filing of the statement, by any acquiring party, or by anyone based on interviews or at the suggestion of such acquiring party. (10) Copies of all tender offers for, requests, or invitations for tenders of, exchange offers for, and agreements to acquire or exchange any securities, membership rights, board of directors appointment or election rights, as the case may be, referred to in said subsection (a), and, if distributed, of additional soliciting material relating thereto. (11) The term of any agreement, contract or understanding made with or proposed to be made with any broker-dealer as to solicitation of securities, membership rights, board of directors appointment or election rights, as the case may be, referred to in said subsection (a) for tender or the like, and the amount of any fees, commissions or other compensation to be paid to broker-dealers with regard thereto. (12) Such additional information as the commissioner may by rule or regulation prescribe as necessary or appropriate for the protection of enrolled members, policyholders, stockholders and members of the health maintenance organization or in the public interest. If the person required to file the statement pursuant to subsection (a) is a partnership, limited partnership, limited liability company, syndicate or other group, the commissioner may require that the information required by subparagraphs (1) to (12), inclusive, shall be given with respect to each partner of such partnership or limited partnership, each member or manager of such limited liability company, each member of such syndicate or group and each person who controls such partner, member or manager. If any such partner, member, manager or person is a corporation or the person required to file the statement referred to in said subsection (a) is a corporation, the commissioner may require that the information called for by said subparagraphs (1) to (12), inclusive, shall be given with respect to such corporation, each officer and director of such corporation and each person who is directly or indirectly the beneficial owner of more than ten percent of the outstanding voting securities of such corporation. If any material change occurs in the facts set forth in the statement filed with the commissioner and sent to such health maintenance organization pursuant to this section, an amendment setting forth such change, together with copies of all documents and other material relevant to such change, shall be filed with the commissioner and sent to such health maintenance organization within two business days after the person learns of such change. (c) If any offer, request, invitation, agreement or acquisition referred to in subsection (a) is proposed to be made by means of a registration statement under the Securities Act of 1933, 5 U.S.C. section 77, et seq., or in circumstances requiring the disclosure of similar information under the Securities Act of 1934, 15 U.S.C. sections 78a to 78k, inclusive, or under a law of any state requiring similar registration or disclosure, the person required to file the statement referred to in said subsection (a) may utilize such documents in furnishing the information called for by that statement. (d)(1) The commissioner shall approve any merger or other acquisition of control referred to in subsection (a) unless, after a public hearing on the merger or other acquisition, he finds that: (i) after the change of control, the domestic health maintenance organization referred to in said subsection (a) would not be able to satisfy such requirements as the commissioner may, by rule or regulation, establish for an organization seeking approval as a health maintenance organization under this chapter; (ii) the effect of the merger or other acquisition of control would be substantially to lessen competition in the health care insurance market in this commonwealth or tend to create a monopoly in the commonwealth; (iii) the financial condition of any acquiring party is such as might jeopardize the financial stability of the health maintenance organization, or prejudice the interests of its subscribers, policyholders or enrolled members; (iv) the terms of the offer, request, invitation, agreement or acquisition referred to in said subsection (a) are unfair and unreasonable to the subscribers, policyholders or enrolled members of the health maintenance organization; (v) the plans or proposals which the acquiring party has to liquidate the health maintenance organization, sell its assets or any seat on its board of directors, or consolidate or merge it with any person, or to make any other material change in its business or corporate structure or management, are unfair and unreasonable to the subscribers, policyholders or enrolled members of the health maintenance organization and not in the public interest; (vi) the competence, experience and integrity of those persons who would control the operation of the health maintenance organization are such that it would not be in the interest of the subscribers, policyholders or enrolled members of the health maintenance organization or of the public to permit the merger or other acquisition of control; or (vii) the acquisition is likely to be hazardous or prejudicial to the health insurance buying public or to the actual enrollees under health insurance plans in the commonwealth. (2) The public hearing referred to in subparagraph (1) of subsection (d) shall be held within 30 days after the statement required by subsection (a) is filed, and at least 20 days notice thereof shall be given by the commissioner to the person filing the statement. The person filing the statement shall give not less than 7 days notice of such public hearing to the health maintenance organization and to such other persons as the commissioner may designate. The commissioner shall make a determination within 30 days after the conclusion of such hearing. At the hearing, the person filing the statement, the health maintenance organization, any person to whom notice of hearing was sent, and any other person whose interest may be affected thereby, shall have the right to present evidence, examine and cross-examine witnesses, offer oral or written arguments in connection therewith, and shall be entitled to conduct discovery proceedings in the same manner as is presently allowed in the superior court department of the trial court. All discovery proceedings shall be concluded not later than 3 days before the commencement of the public hearing. (3) The commissioner may retain at the acquiring party's expense any attorneys, actuaries, accountants and other experts not otherwise a part of the commissioner's staff as may be reasonably necessary to assist the commissioner in reviewing the proposed acquisition of control. (4) The commissioner may condition the approval of the merger or other acquisition on the removal of the basis of disapproval within a specified period of time. (e) This section shall not apply to any offer, request, invitation, agreement or acquisition that the commissioner by order shall exempt from this section as: (1) not having been made or entered into for the purpose, and not having the effect, of changing or influencing the control of a domestic health maintenance organization, or (2) otherwise not comprehended within the purposes of this section. (f) The following shall be violations of this section: (1) The failure to file any statement, amendment or other material required to be filed pursuant to subsection (a) or (b); or (2) The effectuation or any attempt to effectuate an acquisition of control of, or merger with, a domestic health maintenance organization unless the commissioner has given his approval thereto. (g) The courts of the commonwealth shall be vested with jurisdiction over any person not resident, domiciled or authorized to do business in the commonwealth who files a statement with the commissioner under this section and over all actions involving such person arising out of violations of this section, and each such person shall be deemed to have performed acts equivalent to and constituting an appointment by such a person of the commissioner to be his true and lawful attorney upon whom may be served all lawful process in any action, suit or proceeding arising out of violations of this section. Copies of all such lawful process shall be served on the commissioner and transmitted by registered or certified mail by the commissioner to such person at his last known address. (h) Nothing in this section shall be construed to relieve any health maintenance organization or any person acquiring control of a health maintenance organization of any obligation arising on their part under chapter 180 with respect to any transaction contemplated under this section; and to the extent that any transaction contemplated under this section requires the approval, consent or endorsement of the attorney general pursuant to chapter 180, or otherwise, such approval, consent or endorsement shall first be obtained in writing from the attorney general prior to the filing of the statement required by subsection (b), and such written approval, consent or endorsement shall be filed with the commissioner along with the statement required by subsection (b).

M.G.L. c. 176G, § 28 Registration with commissioner

c. 176G, § 28. Registration with commissioner Section 28. (a) Every health maintenance organization which may do business in the commonwealth and which is a member of a health maintenance organization holding company system, shall register with the commissioner. Notwithstanding the foregoing, a foreign health maintenance organization shall not be required to register with the commissioner if the foreign health maintenance organization is subject to registration requirements and standards adopted by statute or regulation in the jurisdiction of its domicile which are substantially similar to those contained in subsection (a) to subsection (m), inclusive, subsection (q) and subsection (s). Any health maintenance organization which is subject to registration under this section shall register within 15 days after it becomes subject to registration, or 180 days after the effective date of this section, whichever is later, and annually thereafter for the previous calendar year, unless the commissioner for good cause shown extends the time for registration, and then within such extended time. The commissioner may require any foreign health maintenance organization authorized to do business in the commonwealth that is a member of a health maintenance organization holding company system and that is not subject to registration under this section to furnish a copy of the registration statement, the summary specified in subsection (c), or other information filed by such health maintenance organization with the insurance regulatory authority of the jurisdiction of its domicile. (b) Every health maintenance organization subject to registration shall file the registration statement on a form prescribed by the commissioner, which shall contain the following current information: (1) any material change to the information submitted pursuant to section 14; (2) the identity and relationship of every member of the health maintenance organization holding company system; (3) the following agreements in force, and transactions currently outstanding or which have occurred during the last calendar year between such health maintenance organization and any affiliates: (i) loans, other investments, or purchases, sales or exchanges of securities of any affiliates by the health maintenance organization or of the health maintenance organization by its affiliates; (ii) purchases, sales or exchange of assets; (iii) transactions not in the ordinary course of business; (iv) guarantees or undertakings for the benefit of an affiliate which result in an actual or contingent exposure of the health maintenance organization's assets to liability, other than health maintenance contracts entered into in the ordinary course of the health maintenance organization's business; (v) all management agreements, service contracts and cost-sharing arrangements; but, all records and information regarding contracts entered into with providers disclosed under this clause shall be confidential and open only to the inspection of the commissioner, his examiners and assistants. Nothing herein shall be construed to prohibit the required production of the records, and information contained in the reports of the health maintenance organization, before a court of the commonwealth or a master or auditor appointed by the court, in a criminal or civil proceeding, affecting the health maintenance organization, its officers, directors or employees; (vi) reinsurance agreements; (vii) dividends and other distributions to shareholders or members; and (viii) consolidated tax allocation agreements; (4) any pledge of the health maintenance organization's stock or assets, including stock or assets of any subsidiary or controlling affiliate, for a loan made to any member of a health maintenance organization holding company system; and (5) other matters concerning transactions between the health maintenance organization and any affiliates as may be included from time to time in any registration forms adopted or approved by the commissioner. (c) All registration statements shall contain a summary outlining all items in the current registration statement representing changes from the prior registration statement. (d) No information need be disclosed on the registration statement filed pursuant to subsection (b) if such information is not material for the purposes of this section. Unless the commissioner by rule, regulation or order provides otherwise, sales, purchases, exchanges, loans or extensions of credit, investments or guarantees or any transaction involving one-half of one percent or less of a health maintenance organization's admitted assets as of the next preceding December 31 shall not be deemed material for purposes of this section. (e) Subject to subsection (q), each domestic health maintenance organization shall report to the commissioner all dividends and other distributions to its shareholders or members within 5 business days following the declaration thereof, and at least 10 business days, commencing from the date of receipt by the commissioner, prior to the payment thereof. No domestic health maintenance organization shall pay any dividend or make any distribution to its shareholders or members from other than unassigned funds unless the commissioner shall have approved such dividend or distribution. For purposes of this section, the term ''unassigned funds'' shall have the same meaning as that term is used in the latest applicable form approved by the National Association of Insurance Commissioners. (f) Any person within a health maintenance organization holding company system subject to registration shall be required to provide complete and accurate information to a health maintenance organization, where such information is reasonably necessary to enable the health maintenance organization to comply with sections 27 to 29, inclusive. (g) The commissioner may require or allow 2 or more affiliated health maintenance organizations subject to registration hereunder to file a consolidated registration statement. (h) The commissioner may allow a health maintenance organization that is authorized to do business in the commonwealth and that is part of a health maintenance organization holding company system to register on behalf of any affiliated health maintenance organization that is required to register under subsection (a) and to file all information and material required to be filed under this section. (i) This section shall not apply to any health maintenance organization, information or transaction if and to the extent that the commissioner by rule, regulation or order shall exempt the same from the provisions of this section. (j) Any person that has in the past filed a registration statement indicating affiliation with any other health maintenance organization or membership in a health maintenance organization holding company system may file with the commissioner a disclaimer of affiliation with any authorized health maintenance organization or such a disclaimer may be filed by such health maintenance organization or any member of a health maintenance organization holding company system. The disclaimer shall fully disclose all material relationships and bases for affiliation between such person and such health maintenance organization as well as the basis for disclaiming such affiliation. After a disclaimer has been filed, the health maintenance organization shall not be relieved of any duty to register or report under this section which may arise out of the health maintenance organization's relationship with such person unless and until the commissioner allows such a disclaimer. The commissioner shall disallow such a disclaimer only after furnishing all parties in interest with notice and opportunity to be heard and after making specific findings of fact to support such disallowance. (k) The failure to file a registration statement or any summary of the registration statement thereto required by this section within the time specified for such filing shall be a violation of this section. (l) Transactions within a health maintenance organization holding company system to which a health maintenance organization subject to registration is a party shall be subject to the standards specified by the commissioner by rule, regulation or order, including the following: (1) the terms shall be fair and reasonable; (2) charges or fees for services performed shall be reasonable; (3) expenses incurred and payment received shall be allocated to the health maintenance organization in conformity with section 10; (4) the books, accounts and records of each party to all such transactions shall be so maintained as to clearly and accurately disclose the nature and details of the transactions including such accounting information as is necessary to support the reasonableness of the charges or fees to the respective parties; and (5) the health maintenance organization's net worth following any dividends or distributions to affiliates shall be reasonable in relation to the health maintenance organization's outstanding liabilities, adequate to its financial needs, and otherwise in conformance with the provisions of this chapter. (m) The following transactions involving a domestic health maintenance organization and any person in its holding company system may not be entered into unless the health maintenance organization has notified the commissioner in writing of its intention to enter into any such transaction at least 30 days prior thereto, or such shorter period as the commissioner may permit, and the commissioner has not disapproved it within such period. (1) sales, purchases, exchanges, loans or extensions of credit, guarantees, or investments provided such transactions are equal to or exceed the lesser of 3 per cent of the health maintenance organization's admitted assets or 25 per cent of net worth as of the next preceding December 31; (2) loans or extensions of credit to any person who is not an affiliate, where the health maintenance organization makes such loans or extensions of credit with the agreement or understanding that the proceeds of such transactions, in whole or in substantial part, are to be used to make loans or extensions of credit to, to purchase assets of, or to make investments in, any affiliate of the health maintenance organization making such loans or extensions of credit provided such transactions are equal to or exceed the lesser of 3 per cent of the health maintenance organization's admitted assets or 25 per cent of net worth as of the next preceding December 31; (3) reinsurance agreements or modifications to the agreements in which the reinsurance premium or a change in the health maintenance organization's liabilities equals or exceeds the lesser of 3 per cent of the health maintenance organization's admitted assets or 25 per cent of net worth as of the next preceding December 31, including those agreements which may require as consideration the transfer of assets from a health maintenance organization to a non-affiliate, if an agreement or understanding exists between the health maintenance organization and non-affiliate that any portion of such assets will be transferred to one or more affiliates of the health maintenance organization; (4) all management agreements, service contracts, all cost-sharing arrangements which are not based on statutory accounting principles and all cost-sharing arrangements which would be reportable as transactions on the health maintenance organization's annual report under section 10. The commissioner may exempt from the requirements of this subsection any management agreement, service contract or cost-sharing arrangement; and (5) any transactions, specified by regulation, which the commissioner determines may adversely affect the interests of the health maintenance organization's policyholders or enrolled members. Notification shall be provided to the commissioner for transactions in clauses (1) to (5), inclusive, which increase or decrease the health maintenance organization's net worth as of the next preceding December 31 by 5 per cent or more. The notification shall accompany the next quarterly financial statement filing. Nothing in this section shall authorize or permit any transactions which would otherwise be contrary to law, or to relieve any health maintenance organization or other person of any obligation arising under chapter 180. (n) A domestic health maintenance organization may not enter into transactions that are part of a plan or series of like transactions with persons within the holding company system if the purpose of those separate transactions is to avoid the statutory threshold amount and thus avoid the review that would occur otherwise. If the commissioner determines that such separate transactions were entered into over any 12–month period for the purpose of avoiding the statutory threshold amount, he may exercise his authority under subsection (b) of section 29. (o) The commissioner, in reviewing transactions pursuant to subsections (1) and (m), shall consider whether the transactions comply with the standards set forth in subsection (1) and whether they may adversely affect the interests of policyholders or enrolled members. (p) The commissioner shall be notified within 30 days of any investment of the domestic health maintenance organization in any one corporation if the total investment in such corporation by the health maintenance organization holding company system of which the health maintenance organization is a member exceeds ten percent of such corporation's voting securities or ownership interest. (q) No domestic health maintenance organization shall pay any extraordinary dividend or make any other extraordinary distributions to its shareholders, members or officers until 30 days after the commissioner receives notice of the declaration thereof and has not within such period disapproved such payment, or the commissioner approves such payment. For purposes of this section, an extraordinary dividend or distribution includes any dividend or distribution of cash or other property, whose fair market value together with other dividends or distributions made within the preceding 12 months exceeds the greater of (i) 10 per cent of such health maintenance organization's net worth as of the next preceding December 31, or (ii) the net income of the health maintenance organization for the 12–month period ending the next preceding December 31. Notwithstanding any other general law to the contrary, a health maintenance organization may declare an extraordinary dividend or distribution which is conditional on the commissioner's approval thereof, and such a declaration shall confer no rights upon any person until the commissioner has approved the payment of such dividend or distribution or the commissioner has not disapproved such payment within the 30 day period set by this subsection. (r)(1) Notwithstanding the control of a domestic health maintenance organization by any person, the officers and directors of the health maintenance organization shall not thereby be relieved of any obligation or liability to which they would otherwise be subject by law, and the health maintenance organization shall be managed so as to assure its separate operating identity consistent with this chapter, and other applicable law. (2) Nothing herein shall preclude a domestic health maintenance organization from having or sharing a common management or cooperative or joint use of personnel, property or services with one or more other persons under arrangements meeting the standards of subsection (1). (s) For purposes of sections 27 to 29, inclusive, in determining whether a health maintenance organization's net worth is reasonable in relation to the health maintenance organization's outstanding liabilities and adequate to its financial needs, the following factors, among others, shall be considered: (1) the size of the health maintenance organization as measured by its assets, capital and net worth, reserves, premium writings, insurance in force and other appropriate criteria; (2) the nature and extent of the health maintenance organization's reinsurance program; (3) the quality, diversification and liquidity of the health maintenance organization's investment portfolio; (4) the recent past and projected future trend in the size of the health maintenance organization's investment portfolio and net worth; (5) the net worth maintained by other comparable health maintenance organizations; (6) the adequacy of the health maintenance organization's reserves; (7) the quality and liquidity of investments of the health maintenance organization and any members of its holding company system. The commissioner may treat any such investment as a disallowed asset for purposes of determining the adequacy of net worth whenever in his judgment such investment so warrants; (8) the quality of the health maintenance organization's earnings and the extent to which the reported earnings include extraordinary items; (9) the extent to which the insurer's business is diversified among the several lines of insurance; and (10) the number and size of risks insured in each line of business. (t)(1) Subject to the limitation contained in this section and in addition to the powers conferred upon the commissioner by section 10 relating to the examination of health maintenance organizations, the commissioner shall also have the power to order any health maintenance organization approved under this chapter to produce such records, books, or other information papers in the possession of the health maintenance organization or its affiliates as are reasonably necessary to ascertain the financial condition of such health maintenance organization or to determine compliance with this chapter. In the event such health maintenance organization fails to comply with such order, the commissioner shall have the power to examine the health maintenance organization and such affiliates to obtain such information. (2) The commissioner may retain, at the expense of the health maintenance organization, such attorneys, actuaries, accountants and other experts not otherwise a part of the commissioner's staff as shall be reasonably necessary to assist in the conduct of the examination under subparagraph (1). Any persons so retained shall be under the direction and control of the commissioner and shall act in a purely advisory capacity. (3) Each registered health maintenance organization producing records, books and papers for said examination pursuant to said subparagraph (1) shall be liable for and shall pay the expense of such examination. (u) Notwithstanding any other provisions of the General Laws, including clause Twenty-sixth of section 7 of chapter 4 and chapter 66, all information, documents and copies thereof obtained by or disclosed to the commissioner or any other person in the course of an examination or investigation made pursuant to subsection (t) and all information reported pursuant to section 28, shall be given confidential treatment and shall be open only to the inspection of the commissioner, or examiners and assistants. Access to such confidential material may be granted by the commissioner to the National Association of Insurance Commissioners, to the insurance department of any other state or country or to law enforcement officials of the commonwealth or any other state or agency of the federal government at any time, so long as the agency or office receiving the information agrees in writing to hold such material confidential. Such confidential materials shall not be subject to subpoena and shall not be made public by the commissioner, the National Association of Insurance Commissioners, or any other person, without the prior written consent of the health maintenance organization to which it pertains unless the commissioner, after giving the health maintenance organization who would be affected thereby, notice and opportunity to be heard, determines that the interest of policyholders, members, shareholders, enrolled members or the public will be served by the publication thereof, in which event he may publish all or any part thereof in such manner as he may deem appropriate. (v) The commissioner may, pursuant to chapter 30A, upon notice and opportunity for all interested parties to be heard, issue such rules, regulations and orders as shall be necessary to carry out sections 27 to 29, inclusive.

M.G.L. c. 176G, § 29 Violations of Secs. 27 to 29; application for order enjoining violations of Secs. 27 to 29; penalties

c. 176G, § 29. Violations of Secs. 27 to 29; application for order enjoining violations of Secs. 27 to 29; penalties Section 29. (a)(1) Whenever it appears to the commissioner that any health maintenance organization or any director, officer, employee or agent thereof has committed or is about to commit a violation of sections 27 to 29, inclusive, or any rule, regulation or order issued by the commissioner thereunder, the commissioner may apply to the superior court department of the trial court for Suffolk county for an order enjoining such health maintenance organization or such director, officer, employee or agent thereof from violating or continuing to violate said sections 27 to 29, inclusive, or any such rule, regulation or order, and for such other equitable relief as the nature of the case and the interest of the health maintenance organization's policyholders, enrolled members, creditors, shareholders, members or the public may require. (2) No security which is the subject of any agreement or arrangement regarding acquisition, or which is acquired or to be acquired, in contravention of sections 27 to 29, inclusive, or of any rule, regulation or order issued by the commissioner thereunder, may be voted at any shareholder's meeting, or may be counted for quorum purposes, and any action of shareholders requiring the affirmative vote of a percentage of shares may be taken as though such securities were not issued and outstanding; but no action taken at any such meeting shall be invalidated by the voting of such securities, unless the action would materially affect control of the health maintenance organization or unless the courts of this commonwealth have so ordered. If a health maintenance organization or the commissioner has reason to believe that any security, membership or board of directors appointment or election rights of the health maintenance organization has been or is about to be acquired in contravention of sections 27 to 29, inclusive, of any rule, regulation or order issued by the commissioner thereunder, the health maintenance organization or the commissioner may apply to the superior court department of the trial court for Suffolk county to enjoin any offer, request, invitation, agreement or acquisition made in contravention of sections 27 to 29, inclusive, or any rule, regulation or order issued by the commissioner thereunder, to enjoin the voting of any security so acquired, to void any vote of such security already cast at any meeting of shareholders, and for such other equitable relief as the nature of the case and the interest of the health maintenance organization's policyholders, enrolled members, creditors, shareholders, members or the public may require. (3) In any case where a person has acquired or is proposing to acquire any voting securities, membership or board of directors appointment or election rights of a health maintenance organization in violation of sections 27 to 29, inclusive, or any rule, regulation or order issued by the commissioner thereunder, the superior court department of the trial court for Suffolk county, or the superior court department of the trial court for the county in which the health maintenance organization has its principal place of business, may, on such notice as the court deems appropriate, upon the application of the health maintenance organization or the commissioner seize or sequester any voting securities of the health maintenance organization owned directly or indirectly by such person, and issue such order with respect thereto as may be appropriate to effectuate sections 27 to 29, inclusive. Notwithstanding any other provision of law, for the purposes of said sections 27 to 29, inclusive, the sites of the ownership of the securities of domestic health maintenance organizations shall be deemed to be in the commonwealth. (b)(1) Any health maintenance organization failing, without just cause, to file any registration statement as required in sections 27 to 29, inclusive, may be required, after notice and hearing, to pay a penalty of $500 for each day's delay. The maximum penalty under this section shall be $10,000. The commissioner may reduce the penalty if the health maintenance organization demonstrates to the commissioner that the imposition of the penalty would constitute a financial hardship to the health maintenance organization. (2) Every director or officer of a health maintenance organization holding company system who knowingly violates, participates in, or assents to, or who knowingly shall permit any of the officers or agents of the health maintenance organization to engage in transactions or make investments which have not been properly reported or submitted pursuant to subsection (a), (m) or (q) of section 28, or which violate any provisions of sections 27 to 29, inclusive, may if so determined by the commissioner, pay, in their individual capacity, a civil forfeiture of not more than $5,000 per violation, after notice and hearing before the commissioner. In determining the amount of the civil forfeiture, the commissioner shall take into account the appropriateness of the forfeiture with respect to the gravity of the violation, the history of previous violations and such other matters as justice may require. (3) Whenever it appears to the commissioner that any health maintenance organization subject to sections 27 to 29, inclusive, or any director, officer, employee or agent thereof has engaged in any transaction or entered into a contract which is subject to subsections (i) to (v), inclusive, of section 28 and which would not have been approved had such approval been requested, the commissioner may order the health maintenance organization to cease and desist immediately any further activity under that transaction or contract. After notice and hearing the commissioner may also order the health maintenance organization to void any such contracts and restore the status quo if such action is in the best interest of the health maintenance organization's policyholders, enrolled members, creditors, subscribers or the public. (4) Whenever it appears to the commissioner that any health maintenance organization or any director, officer, employee or agent thereof has committed a willful violation of sections 27 to 29, inclusive, the commissioner may report the facts to the attorney general or to the proper district attorneys. Any health maintenance organization that willfully violates any provision of sections 27 to 29, inclusive, may be fined not more than $10,000. Any individual who willfully violates any provision of said sections 27 to 29, inclusive, may be fined in his individual capacity not more than $5,000 per violation. (5) Any officer, director, or employee of a health maintenance organization holding company system who willfully and knowingly subscribes to or makes or causes to be made any false statements, false reports or false filings with the intent to deceive the commissioner in the performance of his duties under sections 27 to 29, inclusive, upon conviction thereof, shall be imprisoned for not more than two years or fined $5,000, or both. The officer, director or employee shall pay any fines imposed in his individual capacity. (c) Whenever it appears to the commissioner that any person has committed a violation of sections 27 to 29, inclusive, which so impairs the financial condition of a domestic health maintenance organization as to threaten insolvency or make the further transaction of business by it hazardous to its policyholders, enrolled members, creditors, subscribers, or the public, then the commissioner may proceed as provided in sections 20 and 20A and chapter 175J. (d)(1) If an order for liquidation or rehabilitation of a domestic health maintenance organization has been entered, the receiver appointed under such order shall have a right to recover on behalf of the health maintenance organization, (i) from any parent corporation or holding company or person or affiliate who otherwise controlled the health maintenance organization, the amount of distributions, other than distributions of shares of the same class of stock, paid by the health maintenance organization on its capital stock, or (ii) any payment in the form of a bonus, termination settlement or extraordinary lump sum salary adjustment made by the health maintenance organization or its subsidiaries to a director, officer or employee, where the distribution or payment pursuant to clauses (i) or (ii) is made at any time during the one year preceding the petition for liquidation, conservation or rehabilitation, as the case may be, subject to the limitations of paragraphs (2), (3) and (4) of this subsection. (2) No such distribution shall be recoverable if the parent corporation or affiliate shows that when paid such distribution was lawful and reasonable, and that the health maintenance organization did not know and could not reasonably have known that such distribution might adversely affect the ability of the health maintenance organization to fulfill its contractual obligations. (3) Any person who was a parent corporation or holding company or a person who otherwise controlled the health maintenance organization or affiliate at the time such distributions were paid shall be liable up to the amount of distributions or payments under paragraph (1) such person received. Any person who otherwise controlled the health maintenance organization at the time such distributions were declared shall be liable up to the amount of distributions he would have received if they had been paid immediately. If 2 or more persons are liable with respect to the same distributions, they shall be jointly and severally liable. (4) The maximum amount recoverable under this subsection shall be the amount needed in excess of all other available assets of the impaired or insolvent health maintenance organization to pay the contractual obligations of the impaired or insolvent health maintenance organization. (5) To the extent any person liable under paragraph (3) is insolvent or otherwise fails to pay claims due from it pursuant to said paragraph (3), its parent corporation or holding company or person who otherwise controlled the health maintenance organization or affiliate at the time the distribution was paid, shall be jointly and severally liable for any resulting deficiency in the amount recovered from such parent corporation or holding company or person who otherwise controlled it. (e) Whenever it appears to the commissioner that any person has committed a violation of sections 27 to 29, inclusive, which makes the continued operation of a health maintenance organization contrary to the interest of the policyholders, enrolled members or the public, the commissioner may, after giving notice and an opportunity to be heard, suspend, revoke or refuse to renew such health maintenance organization's license or authority to do business in the commonwealth for such period as he finds is required to protect the interests of the policyholders, enrolled members or the public. Any such determination shall be accompanied by specific findings of fact and conclusions of law. (f)(1) Any person aggrieved by any act, determination, rule, regulation or order or any other action of the commissioner pursuant to sections 27 to 29, inclusive, may appeal therefrom to the superior court department of the trial court for Suffolk county. The court shall conduct its review without a jury and by trial de novo, except that if all parties, including the commissioner, so stipulate, the review shall be confined to the record. Portions of the record may be introduced by stipulation into evidence in a trial de novo as to those parties so stipulating. (2) The filing of an appeal pursuant to this subsection shall stay the application of any such rule, regulation, order or other action of the commissioner to the appealing party unless the court, after giving such party notice and an opportunity to be heard, determines that such a stay would be detrimental to the interest of policyholders, enrolled members, shareholders, creditors, members or the public. (3) Any person aggrieved by any failure of the commissioner to act or make a determination required by sections 27 to 29, inclusive, may petition the superior court department of the trial court for Suffolk county for a writ in the nature of a mandamus or a peremptory mandamus directing the commissioner to act or make such determination forthwith.

M.G.L. c. 176G, § 30 Statement for individuals provided with creditable coverage; reporting

c. 176G, § 30. Statement for individuals provided with creditable coverage; reporting Section 30. Pursuant to section 8B of chapter 62C, carriers 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. 176G, § 31 Attribution of members to a primary care provider

c. 176G, § 31. Attribution of members to a primary care provider Section 31. To the maximum extent possible, every health maintenance organization 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. 176G, § 32 Disclosure of patient-level data and contracted prices of individual health care services by carriers to providers

c. 176G, § 32. Disclosure of patient-level data and contracted prices of individual health care services by carriers to providers Section 32. To the extent permissible under applicable state and federal privacy laws, every health maintenance organization 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 health maintenance organization 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. Health maintenance organizations 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. 176G, § 33 Coverage for health care services delivered via telehealth by a contracted health care provider

c. 176G, § 33. Coverage for health care services delivered via telehealth by a contracted health care provider Section 33. (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 member and a health maintenance 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) A carrier 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. A carrier shall not be required to reimburse a health care provider for a health care service that is not a covered benefit under the plan or reimburse a health care provider not contracted under the plan except as provided for under subclause (i) of clause (4) of the second sentence of subsection (a) of section 6 of chapter 176O. (d) A health care provider shall not be required to document a barrier to an in-person visit nor shall the type of setting where telehealth services are provided be limited for health care services provided via telehealth; provided, however, that a patient may decline receiving services via telehealth in order to receive in-person services. (e) A contract that provides coverage for telehealth services may contain a provision for a deductible, copayment or coinsurance requirement for a health care service provided via telehealth as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to an in-person consultation or in-person delivery of services. The rate of payment for telehealth services provided via interactive audio-video technology may be greater than the rate of payment for the same service delivered by other telehealth modalities. (f) Coverage that reimburses a provider with a global payment, as defined in section 1 of chapter 6D, shall account for the provision of telehealth services to set the global payment amount. (g) Health maintenance 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/Chapter176GFetched: 10/20/2026