Section 52.05 - Application for Accreditation(1)Timing of Application. (a) Carriers must submit biennial renewal applications by July 1st for renewals to be effective on November 1st.(b) A Carrier seeking initial Accreditation must submit an application at least 90 Days prior to the date on which it intends to offer Health Benefit Plans.(2)Inapplicability of Accreditation Requirements.(a) A Carrier that provides coverage for Limited Health Services only, that does not provide services through a Network or through Participating Providers or for which other requirements set forth in 211 CMR 52.05 are otherwise inapplicable may indicate within its application which of those items are inapplicable to its Health Benefit Plan and provide an explanation of why the Carrier is exempt from each particular requirement.(b) A Carrier that provides coverage for specified services through a workers' compensation preferred Provider arrangement may provide evidence of compliance with 211 CMR 51.00:Preferred Provider Health Plans and Workers' Compensation Preferred Provider Arrangements and 452 CMR 6.00: Utilization Review and Quality Assessment to satisfy the materials required by 211 CMR 52.05(3)(b), (e), (g), (h), (i), (j), (l), and (n). A Carrier that provides coverage for specified services through a workers' compensation preferred Provider arrangement may provide evidence of compliance with 211 CMR 51.00 and 452 CMR 6.00 to satisfy the materials required by 211 CMR 52.05(4)(d) and (g).(3)Initial Application. Any Carrier seeking initial Accreditation under M.G.L. c. 176O must submit an application that contains at least the materials applicable for Massachusetts described in 211 CMR 52.05(3)(a) through (s) in a format specified by the Commissioner. Any Carrier that contracts with another organization to perform any of the functions specified in 211 CMR 52.00 is responsible for collecting and submitting all of such materials from the contracting organization. (a) A filing fee of $1,000 made payable to the Commonwealth of Massachusetts;(b) A complete description of the Carrier's Utilization Review policies and procedures;(c) A written attestation by a company officer to the Commissioner that the Utilization Review program of the Carrier or its designee complies with all applicable state and federal laws concerning confidentiality and reporting requirements;(d) A copy of the most recent existing survey described in 211 CMR 52.07(10);(e) A complete description of the Carrier's internal Grievance procedures consistent with958 CMR 3.000: Health Insurance Consumer Protection and a complete description of the external review process consistent with 958 CMR 3.000: Health Insurance Consumer Protection;(f) A complete description of the Carrier's process to establish guidelines for Medical Necessity consistent with 958 CMR 3.000: Health Insurance Consumer Protection;(g) A complete description of the Carrier's quality management and improvement policies and procedures;(h) A complete description of the Carrier's credentialing policies and procedures for all Participating Providers;(i) A complete description of the Carrier's policies and procedures for providing or arranging for the provision of Preventive Health Services;(j) A sample of every Provider contract used by the Carrier or the organization with which the Carrier contracts, unless the Commissioner has requested the Provider contract under 52.05(3)(k);(k) All contracts the Carrier has with a subcontracting organization and/or delegated vendor that performs Utilization Review, member services, or pharmacy benefit management on behalf of the Carrier, as well as any Provider contracts requested by the Commissioner;(l) A statement that advises the Bureau whether the Carrier has contracts with Providers that places the Provider into a Limited, Regional, or Tiered Network Plan subject to 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks. If the Carrier has any such contract, the Carrier shall identify the contracts in which such arrangements exist and identify the sections of the contracts that comply with 211 CMR 152.05: Provider Contracts in Limited, Regional and Tiered Provider Network Plans;(m) A statement that advises the Bureau whether the Carrier has contracts with Providers that places the Provider into a Limited, Regional, or Tiered Network Plan subject to 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks. If the Carrier has any such contract, the Carrier shall identify the contracts in which such arrangements exist and identify the sections of the contracts that comply with 211 CMR 152.05: Provider Contracts in Limited, Regional and Tiered Provider Network Plans;(n) A complete description of the Carrier's Network adequacy standards, along with an access analysis meeting the requirements of 211 CMR 52.12(2);(o) A copy of every Provider directory used by the Carrier, including a summary description of the insured's Telehealth coverage and access to Telehealth services including, but not limited to, Behavioral Health Services, Chronic Disease Management, and Primary Care Services via Telehealth, as well as the telecommunications technology platforms that are available for insureds to use to access Telehealth services;(p) Evidence satisfactory to the Commissioner that the Carrier is providing adequate access within its Network to pain management services, including non-opioid and non-pharmaceutical service options;(q) Evidence satisfactory to the Commissioner that the Carrier is providing adequate access within its Network to Behavioral Health Services, Chronic Disease Management, and Primary Care Services via Telehealth, including the following:1. Communications for use with Providers that specify the Providers' service and documentation standards necessary in order for Telehealth services to be covered by the Carrier;2. A statement that restricts covered Telehealth visits to those that are compatible with state/federal privacy standards;3. A list of the services that will not be covered when provided to a covered person viaTelehealth, and an explanation for why these services are not covered;4. An explanation of how and when cost-sharing (copayments, coinsurance, and deductibles) will apply for Telehealth services, and if cost-sharing is waived, a description of the exact circumstances under which the cost-sharing will be waived with a company officer stating how the Carrier intends to reimburse Providers for Telehealth services, including an identification of the billing codes, location codes or other codes that the Carrier intends to use to reimburse Providers for Telehealth services, and the following information for Telehealth services.5. A statement of how the Carrier intends to reimburse Providers for the following Telehealth services: a. Behavioral Health Services;b. Primary Care Services;c. Chronic Disease Management Services;d. Physical exams, including those that have both Telehealth and in-person components; and6. When Telehealth may be used for follow-up care, including but not limited to follow-up care provided by Asynchronous Telehealth that may be considered less than a Visit, a description of how the Carrier intends to reimburse Providers for these follow-up Telehealth services;(r) The Evidence of Coverage for every product offered by the Carrier;(s) A copy of each disclosure described in 211 CMR 52.14, if applicable;(t) A written attestation by a company officer that the Carrier has complied with 211 CMR 52.16;(u) An explanation of how the Carrier, directly or through any entity that manages or administers mental health or substance use disorder benefits for the Carrier, utilizes a base fee schedule for evaluation and management services for Behavioral Health Providers that is not less than the base fee schedule used for evaluation and management services for Primary Care Providers of the same or similar licensure type and in the same geographic region, and an explanation how the Carrier has established such a base fee schedule for Behavioral Health Providers while not lowering its base fee schedule for Primary Care Providers; and(v) Any additional information as deemed necessary by the Commissioner.(4)Renewal Application. Any Carrier seeking renewal of Accreditation under M.G.L. c. 176O must submit an application that contains at least the materials for Massachusetts described in211 CMR 52.05(4)(a) through (m) in a format specified by the Commissioner. Any Carrier that contracts with another organization to perform any of the functions specified in 211 CMR 52.00 is responsible for collecting and submitting all of such materials from the contracting organization. (a) A filing fee of $1,000 made payable to the Commonwealth of Massachusetts;(b) A written attestation by a company officer to the Commissioner that the Utilization Review Program of the Carrier or its designee complies with all applicable state and federal laws concerning confidentiality and reporting requirements;(c) A copy of the most recent survey described in 211 CMR 52.07(10);(d) A sample of every Provider contract used by the Carrier or the organization with which the Carrier contracts since the Carrier's most recent Accreditation, unless the Commissioner has requested the Provider contract under 52.05(4)(e);(e) All contracts the Carrier has with a subcontracting organization or delegated vendor that performs Utilization Review, medical management, member services, or pharmacy benefits management on behalf of the Carrier, as well as any Provider contracts requested by the Commissioner;(f) A statement that advises the Bureau whether the Carrier has issued new contracts or revised existing contracts with Providers that places the Provider into a limited, regional, or tiered network subject to 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks. If the Carrier has made any of the specified changes, the Carrier shall identify the contracts in which such changes were made and identify the sections of the contracts that comply with 211 CMR 152.05: Provider Contracts in Limited, Regional and Tiered Provider Network Plans;(g) A statement that advises the Bureau whether the Carrier has issued new contracts or revised existing contracts with Providers that places the Provider into a limited, regional, or tiered Network subject to 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks. If the Carrier has made any of the specified changes, the Carrier shall identify the contracts in which such changes were made and identify the sections of the contracts that comply with 211 CMR 152.05: Provider Contracts in Limited, Regional and Tiered Provider Network Plans;(h) Any Material Change made to the Carrier's Network adequacy standards, along with an access analysis meeting the requirements of 211 CMR 52.11(2);(i) The Evidence of Coverage for every product offered by the Carrier, and for every product that has Insureds but is no longer offered, which was revised since the Carrier's most recent Accreditation;(j) A copy of each Provider directory used by the Carrier, including a summary description of the insured's Telehealth coverage and access to Telehealth services including, but not limited to, Behavioral Health Services, Chronic Disease Management, and Primary Care Services via Telehealth, as well as the telecommunications technology platforms that are available for insureds to use to access Telehealth services;(k) Material Changes to any of the information contained in 211 CMR 52.05(3)(b), (e), (f), (g), (h), (i), and (s);(l) Evidence satisfactory to the Commissioner that the Carrier is providing adequate access within its Network to pain management services, including non-opioid and non-pharmaceutical service options;(m) Evidence satisfactory to the Commissioner that the Carrier is providing adequate access within its Network to Behavioral Health Services, Chronic Disease Management, and Primary Care Services via Telehealth, including the following; 1. The communications for use with Providers that specify the Providers' service and documentation standards necessary in order for Telehealth services to be covered by the Carrier;2. A statement that restricts covered Telehealth visits to those that are compatible with state/federal privacy standards;3. A list of the services that will not be covered when provided to a covered person via Telehealth, and an explanation for why these services are not covered;4. An explanation of how and when cost-sharing (copayments, coinsurance, and deductibles) will apply for Telehealth services, and if cost-sharing is waived, a description of the exact circumstances under which the cost-sharing will be waived, with a company officer stating how the Carrier intends to reimburse Providers for Telehealth services, including an identification of the billing codes, location codes or other codes that the Carrier intends to use to reimburse Providers for Telehealth services;5. A statement of how the Carrier intends to reimburse Providers for the following Telehealth services:(a) Behavioral Health Services;(b) Primary Care Services;(c) Chronic Disease Management Services; and(n) Evidence that the Carrier, directly or through any entity that manages or administers mental health or substance use disorder benefits for the Carrier, utilizes a base fee schedule for evaluation and management services for Behavioral Health Providers that is not less than the base fee schedule used for evaluation and management services for Primary Care Providers of the same or similar licensure type and in the same geographic region, and an explanation how the Carrier has established such a base fee schedule for Behavioral Health Providers while not lowering its base fee schedule for Primary Care Providers;(o) A written attestation by a company officer that the Carrier has complied with 211 CMR 52.16; and(p) Any additional information as deemed necessary by the Commissioner.(5)Application for Deemed Accreditation. A Carrier seeking deemed Accreditation pursuant to 211 CMR 52.04 shall submit an application that contains the materials described in 211 CMR 52.05(5)(a) through (d). (a) For initial applicants, the information required by 211 CMR 52.05(3).(b) For renewal applicants, the information required by 211 CMR 52.05(4).(c) Proof in a form satisfactory to the Commissioner that the Carrier has attained:1. a score equal to or above 80% of the standard in effect at the time of the most recent review by NCQA for the Accreditation of Managed Care Organizations, in the categories of utilization management, quality management and improvement, and members' rights and responsibilities;2. a score equal to or above the rating of "accredited" in the categories of utilization management, Network management, quality management and member protections for the most recent review of health plan standards by URAC; or3. for Non-gatekeeper Preferred Provider Plans, a score equal to or above 80% of the standard in effect at the time of the most recent review by NCQA for the Accreditation of preferred Provider organizations, in the categories of utilization management, quality management and improvement, and enrollees' rights and responsibilities.4. for Non-gatekeeper Preferred Provider Plans, a score equal to or above the rating of "accredited" in the most recent review of health utilization management standards by URAC and a score equal or above the rating of "accredited" in the categories of Network management, quality management and member protections for the most recent review of health Network standards by URAC.(d) Proof in a form satisfactory to the Commissioner that the Carrier has attained: 1. a score equal to or above 80% of the standard in effect at the time of the most recent review by NCQA for the Accreditation of Managed Care Organizations, in the category of credentialing and recredentialing;2. a score equal to or above the rating of "accredited" in the category of Provider credentialing for the most recent review of health plan standards by URAC; or3. for Non-gatekeeper Preferred Provider plans, a score equal to or above 80% of the standard in effect at the time of the most recent review by NCQA for the Accreditation of preferred Provider organizations in the category of credentialing and recredentialing.4. for Non-gatekeeper Preferred Provider Plans, a score equal to or above the rating of "accredited" in the category of Provider credentialing for the most recent review of health Network standards by URAC.(6)Application to be Reviewed as a Non-gatekeeper Preferred Provider Plan. A Carrier shall submit a statement signed by a corporate officer certifying that none of the Carrier's insured plans require the Insured to designate a Primary Care Provider to coordinate the delivery of care or receive referrals from the Carrier or any Network Provider as a condition of receiving Benefits at the preferred benefit level.(7)Material Changes. Carriers shall submit to the Bureau any Material Changes to any of the items under 211 CMR 52.05(3) and (4) at least 30 Days before the effective date of the changes.Amended by Mass Register Issue 1345, eff. 8/11/2017.Amended by Mass Register Issue 1509, eff. 11/24/2023.