Section 52.13 - Evidences of Coverage(1)Evidences of Coverage as to a Carrier. It shall constitute delivery of an Evidence of Coverage if a Carrier chooses to, upon or after enrollment, require the Insured to designate whether the Insured wants to receive an Evidence of Coverage electronically or in writing. If no option is designated, the Evidence of Coverage shall be provided electronically. If the Insured designates written notice, a Carrier shall issue and deliver to at least one adult Insured in the household an Evidence of Coverage. If the Insured designates electronic notice, a Carrier shall refer the Insured to a resource where the information described in such Evidence of Coverage can be accessed including, but not limited to, an Internet Website. In such instance, the Evidence of Coverage must meet the requirements of 211 CMR 52.13(4). An electronic copy of the Evidence of Coverage shall always be delivered to the group representative in the case of a group policy.
(2)Evidences of Coverage as to Dental and Vision Carriers. Dental and Vision Carriers shall issue and deliver to at least one adult Insured in each household residing in Massachusetts, upon enrollment: (a) an Evidence of Coverage;(b) a summary of the information contained in the Evidence of Coverage; or(c) refer the Insured to resources where the information described in such Evidence of Coverage can be accessed, including, but not limited to, an Internet Website. Dental and Vision Carriers shall be exempt from the provisions of 211 CMR 52.13(3)(b), (h) through (j), (q) through (x), (z) and (aa).
(3)Evidence of Coverage Requirements. An Evidence of Coverage shall contain a clear, concise and complete statement of all of the information described at 211 CMR 52.13(3)(a) through (aa). In addition, for Limited, Regional and Tiered Network Plans, an Evidence of Coverage shall also contain any information as required by 211 CMR 152.00: Health Benefit Plans Using Limited, Regional or Tiered Provider Networks. (a) The health, Dental or Vision Care Services and any other Benefits to which the Insured is entitled on a nondiscriminatory basis, including Benefits mandated by state or federal law;(b) The prepaid fee which must be paid by or on behalf of the Insured and an explanation of any grace period for the payment of any Health Benefit Plan premium;(c) The toll-free telephone number and website established by the Carrier to identify the Network status of an identified health care Provider and present Provider cost and location information and an explanation of the information that an Insured may obtain through such toll-free number and website.(d) The limitations on the scope of: 1. Health Care Services and any other Benefits to be provided, including:a. an explanation of any Facility fee, allowed amount, coinsurance, copayment, deductible or other amount that the Insured may be responsible to pay to obtain Covered Benefits from Network or Out-of-Network Providers; andb. an explanation of the information that an Insured may obtain through the toll-free number and website established by the Carrier under 211 CMR 52.14(4).2. Dental or Vision Care Services and any other Benefits to be provided, including an explanation of any deductible or copayment feature.(e) All restrictions relating to preexisting condition limitations or exclusions, or a statement that there are no preexisting condition limitations or exclusions if there are none under the Health, Dental or Vision Benefit Plan;(f) A description of the locations where, and the manner in which, Health, Dental or Vision Care Services and other Benefits may be obtained, and, additionally, for Health Care Services: 1. the method to locate Provider directory information on a Carrier's website and the method to obtain a paper Provider directory;2. an explanation that whenever a proposed admission, procedure or covered service that is Medically Necessary is not available to an Insured within the Carrier's Network, the Carrier will cover the out-of-Network admission, procedure or service, and the Insured will not be responsible for paying more than the amount which would be required for a similar admission, procedure or service offered within the Carrier's Network; and3. an explanation that whenever a location where Health Care Services are provided is part of a Carrier's Network, the Carrier will cover Medically Necessary covered Benefits delivered at that location, and an explanation that the Insured will not be responsible for paying more than the amount required for Network services delivered at that location even if part of the Medically Necessary Covered Benefits are performed by out-of-Network Provider(s), unless the Insured has a reasonable opportunity to choose to have the service performed by a Network Provider.(g) A description of eligibility of coverage for dependents, including a summary description of the procedure by which dependents may be added to the plan;(h) The criteria by which an Insured may be disenrolled or denied enrollment. 211 CMR 52.13(3)(h) shall apply to Carriers, including Dental and Vision Carriers.(i) The involuntary disenrollment rate among Insureds of the Carrier. 211 CMR 52.13(3)(i) shall apply to Carriers, including Dental and Vision Carriers. 1. For the purposes of 211 CMR 52.13(3)(i), Carriers shall exclude all Administrative Disenrollments, Insureds who are disenrolled because they have moved out of a health plan's Service Area, Insureds whose continuation of coverage periods have expired, former dependents who no longer qualify as dependents, or Insureds who lose coverage under an employer sponsored plan because they have ceased employment or because their employer group has cancelled coverage under the plan, reduced the numbers of hours worked, become disabled, retired or died.2. For the purposes of 211 CMR 52.13(3)(i), the term "involuntary disenrollment" means that a Carrier has terminated the coverage of the Insured due to any of the reasons contained in 211 CMR 52.13(3)(j)2. and 3.(j) The requirement that an Insured's coverage may be canceled, or its renewal refused may a rise only in the circumstances listed in 211 CMR 52.13(3)(j)1. through 5. 211 CMR 52.13(3)(j) shall apply to Carriers, including Dental and Vision Carriers. 1. failure by the Insured or other responsible party to make payments required under thecontract;2. misrepresentation or fraud on the part of the Insured;3. commission of acts of physical or verbal abuse by the Insured which pose a threat to Providers or other Insureds of the Carrier and which are unrelated to the physical or mental condition of the Insured; provided, that the Commissioner prescribes or approves the procedures for the implementation of the provisions of 211 CMR 52.13(3)(i)3.;4. relocation of the Insured outside the Service Area of the Carrier; or5. non-renewal or cancellation of the group contract through which the Insured receives coverage;(k) A description of the Carrier's, including a Dental or Vision Carrier's, method for resolving Insured Inquiries and Complaints. For a Health Benefit Plan, this description shall include a description of the internal Grievance process and the external review process consistent with 958 CMR 3.000: Health Insurance Consumer Protection, including a description of the process for seeking expedited internal review and concurrent expedited internal and external reviews pursuant to 958 CMR 3.000;(l) A statement telling Insureds how to obtain the report regarding Grievances pursuant to 958 CMR 3.600(1)(d) from the Office of Patient Protection;(m) A description of the Office of Patient Protection, including its toll-free telephone number, facsimile number, and Internet Website;(n) A summary description of the procedure, if any, for out-of-Network referrals and any additional charge for utilizing out-of-network Providers. 211 CMR 52.13(3)(n) shall apply to Carriers, including Dental and Vision Carriers;(o) A summary description of the Utilization Review procedures and quality assurance programs used by the Carrier, including a Dental or Vision Carrier, including the toll-free telephone number to be established by the Carrier that enables consumers to determine the status or outcome of Utilization Review decisions;(p) A statement regarding all products/plans detailing what translator and interpretation services are available to assist Insureds, including that the Carrier will provide, upon request, interpreter and translation services related to administrative procedures. The statement must appear in at least the languages identified by the Centers for Medicare & Medicaid Services as the top non-English languages in Massachusetts, 211 CMR 52.13(3)(p) shall apply to Carriers, including Dental and Vision Carriers.(q) A list of prescription drugs excluded from any closed or restricted formulary available to Insureds under the Health Benefit Plan; provided, that the Carrier shall annually disclose any changes in such a formulary, and shall provide a toll-free telephone number to enable consumers to determine whether a particular drug is included in the closed or restricted formulary. A Carrier will be deemed to have met the requirements of 211 CMR 52.13(3)(q) if the Carrier does all of the following:1. provides a complete list of prescription drugs that are included in any closed or restricted formulary;2. clearly states that all other prescription drugs are excluded;3. provides a toll-free number that is updated within 48 hours of any change in the closed or restricted formulary to enable Insureds to determine whether a particular drug is included in or excluded from the closed or restricted formulary;4. provides an Internet Website that is updated as soon as practicable relative to anychange in the closed or restricted formulary to enable Insureds to determine whether a particular drug is included in or excluded from the closed or restricted formulary; and5. clearly states that there shall be no financial penalty for a patient's choice to receive a lesser quantity of any opioid contained in schedule II or III of M.G.L. c. 94C, § 3, and lists each of such schedule II or III drugs.(r) A summary description of the procedures followed by the Carrier in making decisions about the experimental or investigational nature of individual drugs, medical devices or treatments in clinical trials;(s) Requirements for continuation of coverage mandated by state and federal law;(t) A description of coordination of Benefits consistent with 211 CMR 38.00: Coordination of Benefits (COB);(u) A description of coverage for emergency care and a statement that Insureds have the opportunity to obtain Health Care Services for an Emergency Medical Condition, including the option of calling the local pre-hospital emergency medical service system, whenever the Insured is confronted with an Emergency Medical Condition which in the judgment of a prudent layperson would require pre-hospital emergency services;(v) If the Carrier offers services through a Network or through Participating Providers, the following statements regarding continued treatment:1. If the Carrier allows or requires the designation of a Primary Care Provider, a statement that the Carrier will notify an Insured at least 30 Days before the disenrollment of such Insured's Primary Care Provider and shall permit such Insured to continue to be covered for Health Services, consistent with the terms of the Evidence of Coverage, by such Primary Care Provider for at least 30 Days after said Provider is disenrolled, other than disenrollment for quality related reasons or for fraud. The statement shall also include a description of the procedure for choosing an alternative Primary Care Provider.2. A statement that the Carrier will allow any female Insured who is in her second or third trimester of pregnancy and whose Provider in connection with her pregnancy is involuntarily disenrolled, other than disenrollment for quality-related reasons or for fraud, to continue treatment with said Provider, consistent with the terms of the Evidence of Coverage, for the period up to and including the Insured's first postpartum Visit.3. A statement that the Carrier will allow any Insured who is Terminally Ill and whose Provider in connection with said illness is involuntarily disenrolled, other than disenrollment for quality related reasons or for fraud, to continue treatment with said Provider, consistent with the terms of the Evidence of Coverage, until the Insured's death.4. A statement that the Carrier will provide coverage for Health Services for up to 30 Days from the effective date of coverage to a new Insured by a Provider who is not a Participating Provider in the Carrier's Network if: a. the Insured's employer only offers the Insured a choice of Carriers in which said Provider is not a Participating Provider; andb. said Provider is providing the Insured with an ongoing course of treatment or is the Insured's Primary Care Provider; andc. With respect to an Insured in her second or third trimester of pregnancy,211 CMR 52.13(3)(v)4. shall apply to services rendered through the first postpartum Visit. With respect to an Insured with a Terminal Illness, 211 CMR 52.13(3)(v)4.shall apply to services rendered until death;5. A Carrier may condition coverage of continued treatment by a Provider under211 CMR 52.13(3)(v)1. through 4. upon the Provider's agreeing as follows:a. to accept reimbursement from the Carrier at the rates applicable prior to notice of disenrollment as payment in full and not to impose Cost Sharing with respect to the Insured in an amount that would exceed the Cost Sharing that could have been imposed if the Provider had not been disenrolled;b. to adhere to the quality assurance standards of the Carrier and to provide the Carrier with necessary medical information related to the care provided; andc. to adhere to the Carrier's policies and procedures, including procedures regarding referrals, obtaining prior authorization and providing services pursuant to a treatment plan, if any, approved by the Carrier;6. Nothing in 211 CMR 52.13(3)(v) shall be construed to require the coverage of Benefits that would not have been covered if the Provider involved remained a Participating Provider;(w) If a Carrier requires an Insured to designate a Primary Care Provider, a statement that the Carrier will allow the Primary Care Provider to authorize a standing referral for Specialty health Care provided by a Health Care Provider participating in the Carrier's Network when:1. the Primary Care Provider determines that such referrals are appropriate;2. the Provider of Specialty Care agrees to a treatment plan for the Insured and provides the Primary Care Provider with all necessary clinical and administrative information on a regular basis; and3. the Health Care Services to be provided are consistent with the terms of the Evidence of Coverage. Nothing in 211 CMR 52.13(3)(v) shall be construed to permit a Provider of Specialty health Care who is the subject of a referral to authorize any further referral of an Insured to any other Provider without the approval of the Insured's Carrier;
(x) If a Carrier requires an Insured to obtain referrals or prior authorization from a Primary Care Provider for Specialty Care, a statement that the Carrier will not require an Insured to obtain a referral or prior authorization from a Primary Care Provider for the following Specialty Care provided by an obstetrician, gynecologist, certified nurse midwife or family practitioner participating in such Carrier's Health Care Provider Network and that the Carrier will not require higher copayments, coinsurance, deductibles or additional Cost-Sharing features for such services provided to such Insureds in the absence of a referral from a Primary Care Provider:1. annual preventive gynecologic health examinations, including any subsequent obstetric or gynecological services determined by such obstetrician, gynecologist, certified nurse midwife or family practitioner to be Medically Necessary as a result of such examination;3. medically necessary evaluations and resultant Health Care Services for acute or emergency gynecological conditions. Carriers may establish reasonable requirements for participating obstetricians, gynecologists, certified nurse midwives or family practitioners to communicate with an Insured's Primary Care Provider regarding the Insured's condition, treatment, and need for follow-up care; and nothing in 211 CMR 52.13(3)(x) shall be construed to permit an obstetrician, gynecologist, certified nurse midwife or family practitioner to authorize any further referral of an Insured to any other Provider without the approval of the Insured's Carrier;
(y) If a Carrier offers a Site of Service Plan, the Carrier must prominently and clearly specify on the cover of the Evidence of Coverage and related promotional materials that care delivered by certain Network Providers or at certain Network locations may only be available when deemed medically necessary for the patient's condition. In addition, prior to offering Site of Service Plans, the Carrier is to provide notice to covered members and to Network Providers prior to the Site of Service Plan being issued or renewed.(z) A statement that the Carrier will provide coverage of pediatric Specialty Care, including, for the purposes of 211 CMR 52.13(3)(x), mental health care, by persons with recognized expertise in Specialty pediatrics to Insureds requiring such services.(aa) If a Carrier allows or requires an Insured to designate a Primary Care Provider, a statement that the Carrier shall provide the Insured with an opportunity to select a Participating Provider Nurse Practitioner or a Participating Provider Physician Assistant as a Primary Care Provider or to change his or her Primary Care Provider to a Participating Provider Nurse Practitioner or a Participating Provider Physician Assistant at any time during the Insured's coverage period.(bb) Evidence that the Carrier will provide coverage on a nondiscriminatory basis for covered services when delivered or arranged for by a Participating Provider Nurse Practitioner or a Participating Provider Physician Assistant. For the purposes of 211 CMR 52.13(3)(bb), nondiscriminatory basis shall mean that a Carrier's plan does not contain any annual or lifetime dollar or unit of service limitation imposed on coverage for the care provided by a Participating Provider Nurse Practitioner or Participating Provider Physician Assistant which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the same services by other Participating Providers, in accordance with M.G.L. c. 176R, § 16(1) and c. 176S, § 1;(cc) A statement that the Carrier shall be required to pay for Health Care Services ordered by a treating physician or a Primary Care Provider if the Health Services are a Covered Benefit under the Insured's Health Benefit Plan and the Health Services are Medically Necessary.(4)Internet Websites. If the Carrier, including any Dental or Vision Carrier, refers the Insured to resources where the information described in the Evidence of Coverage can be accessed including, but not limited to, an Internet Website, such Carrier must be able to demonstrate compliance with applicable law, and with the following with respect to the Internet Website:(a) The Carrier has issued and delivered written notice to the Insured that includes: 1. All necessary information and a clear explanation of the manner by which Insured scan access their specific Evidence of Coverage and any amendments thereto through such Internet Website;2. A list of the specific information to be furnished by the Carrier through an Internet Website;3. The significance of such information to the Insured;4. The Insured's right to receive, free of charge, a paper copy of Evidences of Coverage and any amendments thereto at any time;5. The manner by which the Insured can exercise the right to receive a paper copy at no cost to the Insured; and6. A toll free number for the Insured to call with any questions or requests including, but not limited to, a request for the Carrier to provide assistance for the Insured with finding a Provider.(b) The Carrier has taken reasonable measures to ensure that the information and documents furnished in an Internet Website is substantially the same as that contained in its paper documents. All notice and time requirements applicable to Evidences of Coverage shall apply to information and documents furnished by an Internet Website.(c) The Carrier has taken reasonable measures to ensure that it furnishes, upon request of the Insured, a paper copy of the Evidence of Coverage and any amendments thereto.(5)Group Plans. A Carrier, including a Dental and Vision Carrier, shall always deliver at least one Evidence of Coverage to the group representative of a group plan, notwithstanding the provisions of 211 CMR 52.13, 52.14 or 52.15.(6)General Notice of Material Changes. A Carrier, including a Dental and Vision Carrier, shall provide to at least one adult Insured in each household residing in Massachusetts, or in the case of a group policy, to the group representative, notice of all Material Changes to the Evidence of Coverage.(7)Advance Notice of Material Modifications. A Carrier, including a Dental or Vision Carrier, shall issue and deliver to at least one adult Insured in each household residing in Massachusetts, or in the case of a group policy, to the group representative, prior notice of material modifications in covered services under the Health, Dental or Vision Benefit Plan, at least 60 Days before the effective date of the modifications. Such notices shall include the following: (a) any changes in Clinical Review Criteria; and(b) a statement of the effect of such changes on the personal liability of the Insured for the cost of any such changes.(8)Advance Filing of Evidence of Coverage. A Carrier, including a Dental or Vision Carrier, shall submit all Evidences of Coverage to the Bureau at least 30 Days prior to their effective dates.(9)Dates Required. Every Evidence of Coverage described in 211 CMR 52.13 must contain the effective date, date of issue and, if applicable, expiration date.(10)Workers' Compensation. A Carrier that provides specified services through a workers' compensation preferred Provider arrangement shall be deemed to have met the requirements of211 CMR 52.13 if it has met the requirements of 211 CMR 51.00: Preferred Provider Health Plans and Workers' Compensation Preferred Provider Arrangements and 452 CMR 6.00: Utilization Review and Quality Assessment.(11) Certain Requirements also Applicable to Evidences of Coverage for Dental and Vision Carriers. The following provisions of 211 CMR 52.13 shall also apply to Evidences of Coverage issued by Dental and Vision Carriers: 211 CMR 52.13(4) through (10).Amended by Mass Register Issue 1345, eff. 8/11/2017.Amended by Mass Register Issue 1509, eff. 11/24/2023.