211 CMR, § 152.11
APPLICANT DISCLOSURE NOTICE PROVIDER NETWORK ACCESS
[Carrier Name
Mailing Address
Customer Service Toll-Free Number]
[[Limited] [Regional]] Provider Network
This plan provides access to providers that are not the same as [name of carrier]'s [general provider network name] provider network.
Your member identification card will display the name of your provider network. The designation ["Limited" or "Regional"] will be on the top right hand side of the card that applies to the health benefit plan you have chosen.
* I understand that I may not change plans during a policy year because of changes to the provider network.
* I understand that the plan provides access to providers that may not be the same as [name of carrier]'s [general provider network name] provider network.
* I have reviewed the [name of network] provider directory or online provider search tool and understand that this plan only provides access to covered benefits from the providers in the [name of network] directory.
* I understand that it is my responsibility to ensure that a provider I voluntarily choose is enrolled in the [name of network] provider network prior to obtaining care.
* In choosing the [name of network] plan, I understand I will be required to choose a different provider for treatment if a provider I now see is not enrolled in the [name of network] provider network.
* I certify that I have received the [guide designated by the Commissioner] prior to beginning and completing the application/enrollment process.
Initials _______ Date _______ ]]
[[Tiered Provider Network]
This Plan assigns network providers to benefit tiers
Your member identification card will display the name of your provider network. The designation ["Tiered"] will be on the top right hand side of the card that applies to the health benefit plan you have chosen.
* I understand that I may not change plans during a policy year because of to the provider network.
* I understand that the plan I have chosen assigns network providers to benefit tiers.
* I understand that I will pay different [copayments, coinsurance, deductibles] based on a provider's assigned benefit tier.
* I understand that the carrier may reassign a provider's assigned benefit tier each year on [identify date].
* I understand that if a provider is reassigned to a different benefit tier, I am responsible to pay a different [copayments, coinsurance, deductibles].
* I have reviewed the [name of network] provider directory and understand that symbols displayed next to each provider identify the exact tier that the provider is assigned.
* I certify that I have received the [guide designated by the Commissioner]" prior to beginning and completing the application/enrollment process.
Initials _______ Date _______ ]]
[Assigned Form#]
211 CMR, § 152.11