General Laws of Massachusetts - Chapter 176I Preferred Provider Arrangements - Section 3 Health benefit plans; minimum requirements

Section 3. Organizations, but not an insurer as defined in paragraph (7) of section one of chapter one hundred and fifty-two, may offer health benefit plans which provide for incentives for covered persons to use the health care services of preferred providers. Such health benefit policies or plans shall meet at least the following minimum requirements:

(a) Benefit levels for health care services rendered by nonpreferred providers shall be at least eighty per cent of the benefit levels for services rendered by preferred providers.

(b) If a covered person receives emergency care and cannot reasonably reach a preferred provider, payment for care related to the emergency shall be made at the same level and in the same manner as if the covered person had been treated by a preferred provider; provided, however, that every brochure, contract, policy manual and all printed materials shall clearly state that covered persons shall have the option of calling the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent, whenever a covered person is confronted with a need for emergency care, and no covered person shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of such use of emergency care;

(c) A procedure shall be specified for resolving consumer complaints and grievances; and

(d) A procedure shall be specified for the disclosure to covered persons of the names of current preferred providers by specialty and geographic area.

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Last modified: September 11, 2015