211 CMR, § 152.07 - Evidences of Coverage for Limited, Regional and Tiered Provider Network Plans

(1) In addition to containing the information required under 211 CMR 52.13, the first or cover page of the Evidence of Coverage for a Health Benefit Plan that uses a Limited Provider Network, a Regional Provider Network of a Tiered Provider Network shall disclose prominently and in a clear and conspicuous manner language substantially similar to the following:

(a) A statement of applicable Provider Network:

1. Limited/Regional Provider Network. This plan provides access to a network that is smaller than [name of carrier]'s [general provider network name] provider network. In this plan, members have access to network benefits only from the providers in [name of network]. Please consult the [Limited/Regional] provider directory or visit the provider search tool at [web address] to determine which providers are included in the [name of network].

2. Tiered Provider Network. This plan includes the tiered provider network called [name of network]. In this plan, members pay different levels of [copayments, coinsurance, deductibles] depending on the tier of the provider delivering a covered service or supply. This plan may make changes to a provider's benefit tier annually on [identify date]. Please consult the [name of network] provider directory or visit the provider search tool at [web address] to determine the tier of providers in [name of network].

(b) A statement regarding access to Health Care Services:

1. A description of coverage for Emergency Services, including a statement that an Insured may obtain Health Care Services for an emergency medical condition, including local pre-hospital emergency medical service systems, whenever the Insured has an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency medical services, and that the Carrier will provide coverage of Emergency Services from any Provider.

2. For Health Benefit Plans using Tiered Provider Networks, this statement shall also note that Emergency Services will be covered from all Providers at the cost level of the lowest cost-sharing tier regardless of the tier in which the Health Benefit Plan has classified the Provider providing such Emergency Services within the Tiered Provider Network including for inpatient deductibles if the Insured seeking or receiving emergency services is subsequently admitted.

(2) The member identification card shall prominently display the name of the Provider Network that applies to the Health Benefit Plan. If the Provider Network is a Limited Provider Network, Regional Provider Network or Tiered Provider Network, the term abbreviation "Limited", "Regional;" or "Tiered", respectively, should be prominently displayed on the top right hand side of the card.

(3) A Carrier may use evidences of coverage issued prior to July 1, 2011 in compliance with 211 CMR 152.07. Evidences of Coverage for plans issued or renewed on or after July 1, 2011 shall comply with all of the requirements of 211 CMR 152.07. Carriers shall issue, upon renewal, to at least one subscriber in each household whose coverage renews between July 1, 2011, and June 30, 2012, an Evidence of Coverage that complies with 211 CMR 152.07.

(4) A Carrier shall include in all Evidences of Coverage for a Limited Provider Network, a Regional Provider Network or a Tiered Provider Network a statement detailing the translator and interpretation services that are available to assist Insureds, including a statement that the Carrier will provide, upon request, interpreter and translation services related to the Carrier's application and administrative procedures. The statement regarding available translator and interpretation services shall appear in the Evidence of Coverage in at least the following languages: Arabic, Cambodian, Chinese, English, French, Greek, Haitian-Creole, Italian, Lao, Portuguese, Russian and Spanish.

Notes

211 CMR, § 152.07