General Laws of Massachusetts - Chapter 176O Health Insurance Consumer Protections
- Massachusetts General Laws - Definitions - Chapter 176O, Section 1
As used in this chapter, the following words shall have the following meanings:-- [ Definition of "Adverse determination'' effective until January 1, 2014. For text...
- Massachusetts General Laws - Bureau of managed care - Chapter 176O, Section 2
(a) There is hereby established within the division a bureau of managed care. Said bureau shall by regulation establish minimum standards for the accreditation of...
- Massachusetts General Laws - Complaints against carriers; notice; hearing - Chapter 176O, Section 3
(a) The bureau shall investigate all complaints made against a carrier or any entity with which it contracts for allegations of noncompliance with the accreditation...
- Massachusetts General Laws - Refusal of carriers to contract with eligible health, dental or vision care providers solely because providers have practiced good faith advocacy on behalf of patients - Chapter 176O, Section 4
A carrier, including a dental or vision carrier, shall not refuse to contract with or compensate for covered services an otherwise eligible health, dental or...
- Massachusetts General Laws - Contracts; liability - Chapter 176O, Section 5
No contract between a carrier, including a dental or vision carrier, and a health, dental or vision care provider for the provision of services to...
- Massachusetts General Laws - Acceptance and recognition of information submitted pursuant to current coding standards and guidelines required; use of standardized claim formats - Chapter 176O, Section 5A
(a) Subject to subsection (c), for the purposes of processing claims for health care services submitted by a health care provider and to provide uniformity...
- Massachusetts General Laws - Policies and procedures to enforce Sec. 5A - Chapter 176O, Section 5B
To ensure uniformity and consistency in the submission and processing of claims for health care services pursuant to section 5A, the bureau of managed care...
- Massachusetts General Laws - Failure of carrier to comply with coding standards and guidelines; notice; penalty - Chapter 176O, Section 5C
If the commissioner determines that a carrier is neglecting to comply with the coding standards and guidelines under this chapter in the form and within...
- Massachusetts General Laws - Evidence of coverage to be delivered to covered adults by health, dental and vision care providers; contents - Chapter 176O, Section 6
(a) A carrier shall issue and deliver to at least one adult insured in each household residing in the commonwealth, upon enrollment, an evidence of...
- Massachusetts General Laws - Information provided by carrier upon enrollment or upon request - Chapter 176O, Section 7
(a) A carrier shall provide to at least one adult insured in each household upon enrollment, and to a prospective insured upon request, the following...
- Massachusetts General Laws - Failure by carrier to file annual statement; fine - Chapter 176O, Section 8
A carrier neglecting to make and file its annual statement or the materials required by the commissioner to be filed with the division under this...
- Massachusetts General Laws - Utilization review programs; annual attestations - Chapter 176O, Section 9
A carrier shall annually provide a written attestation to the commissioner that the utilization review program of the carrier or its designee complies with all...
- Massachusetts General Laws - Agreements or contracts between carrier and health care provider prohibited if containing certain provisions - Chapter 176O, Section 9A
A carrier shall not enter into an agreement or contract with a health care provider if the agreement or contract contains a provision that: (a)(i)...
- Massachusetts General Laws - Alternate payment arrangements involving downside risk prohibited without risk certificate - Chapter 176O, Section 9B
Carriers shall not be permitted to enter into or continue alternate payment arrangements involving downside risk with provider organizations that have not received a risk...
- Massachusetts General Laws - Contractual financial incentive plans - Chapter 176O, Section 10
(a) No contract between a carrier, including a dental or vision carrier, and a licensed health, dental or vision care provider group shall contain any...
- Massachusetts General Laws - Rights of health benefit plans to include as providers religious non-medical providers - Chapter 176O, Section 11
Nothing in this chapter shall be construed to restrict or limit the rights of health benefit plans to include as providers religious non-medical providers, require...
- Massachusetts General Laws - Utilization review - Chapter 176O, Section 12
[Subsection (a) effective until October 1, 2015. For text effective October 1, 2015, see below.] (a) Utilization review conducted by a carrier or a utilization...
- Massachusetts General Laws - Formal internal grievance process; expedited resolution policy - Chapter 176O, Section 13
(a) A carrier or utilization review organization shall maintain a formal internal grievance process that is compliant with the Patient Protection and Affordable Care Act,...
- Massachusetts General Laws - Review panel; patient protection office - Chapter 176O, Section 14
[ Subsection (a) effective until January 1, 2014. For text effective January 1, 2014, see below.] (a) An insured who remains aggrieved by an adverse...
- Massachusetts General Laws - Disenrollment of provider; continuation of treatment; specialty health care coverage - Chapter 176O, Section 15
(a) A carrier that allows or requires the designation of a primary care provider shall notify an insured at least 30 days before the disenrollment...
- Massachusetts General Laws - Clinical decisions regarding medical treatment made by treating physicians; payment for health care services ordered by treating physician or primary care provider - Chapter 176O, Section 16
(a) The physician treating an insured, shall, consistent with generally accepted principles of professional medical practice and in consultation with the insured, make all clinical...
- Massachusetts General Laws - Regulations; promulgation - Chapter 176O, Section 17
[ Text of section effective until January 1, 2014. For text effective January 1, 2014, see below.] The commissioner shall promulgate regulations to enforce sections...
- Massachusetts General Laws - Responsibility of carrier for behavioral health services compliance - Chapter 176O, Section 18
A carrier for whom a behavioral health manager is administering behavioral health services shall be responsible for the behavioral health manager’s failure to comply with...
- Massachusetts General Laws - Display of name and telephone number of health service manager on enrollment cards of carrier - Chapter 176O, Section 19
A carrier for whom a behavioral health manager is administering behavioral health services shall state on its new enrollment cards issued in the normal course...
- Massachusetts General Laws - Information provided to insured adults by behavioral health manager; submission of material changes; workers’ compensation; preferred provider arrangements - Chapter 176O, Section 20
(a) A behavioral health manager shall provide the following information to at least 1 adult insured in each household covered by their services: (1) a...
- Massachusetts General Laws - Submission by carrier of annual comprehensive financial statement - Chapter 176O, Section 21
(a) Each carrier shall submit an annual comprehensive financial statement to the division detailing carrier costs from the previous calendar year; provided, however, that for...
- Massachusetts General Laws - Participation in medical assistance program as condition for participation in carrier’s provider network - Chapter 176O, Section 22
Notwithstanding any other general or special law to the contrary, each carrier shall require, as a condition of participation in the carrier’s provider network by...
- Massachusetts General Laws - Disclosure by carrier upon request for estimated or maximum allowed amount or charge for a proposed admission, procedure or service and amount insured responsible to pay; establishment of toll-free telephone number and website - Chapter 176O, Section 23
[ Text of effective until October 1, 2013. For text effective October 1, 2013, see below.] All carriers shall establish a toll-free telephone number and...
- Massachusetts General Laws - Internal appeals processes for risk-bearing provider organizations; patient’s right to third-party advocate; external review process - Chapter 176O, Section 24
[Text of section added by 2012, 224, Sec. 206 effective October 1, 2013. See 2012, 224, Sec. 293.] (a) All risk-bearing provider organizations certified under...
- Massachusetts General Laws - Use and acceptance of specifically designated prior authorization forms - Chapter 176O, Section 25
[Text of section added by 2012, 224, Sec. 207A effective January 1, 2014. See 2012, 224, Sec. 294.] (a) A payer or any entity acting...
- Massachusetts General Laws - Establishment of standardized processes and procedures for the determination of patient’s health benefit plan eligibility at or prior to time of service - Chapter 176O, Section 26
The commissioner shall establish standardized processes and procedures applicable to all health care providers and payers for the determination of a patient’s health benefit plan...
- Massachusetts General Laws - Development of common summary of payments form - Chapter 176O, Section 27
The division shall develop a common summary of payments form to be used by all health care payers in the commonwealth that is provided to...
Last modified: September 11, 2015