Section 51.05 - Evidence of Coverage for Insured Preferred Provider Health Plan Coverage OnlyThe Evidence of Coverage, including all amendments and material changes, must be submitted to the Commissioner for approval.
(1) The Evidence of Coverage must meet the requirements of M.G.L.c. 1761, M.G.L. c. 1760, 211 CMR 51.00 and 52.00: Managed Care Consumer Protections and Accreditation of Carriers.(2) The Evidence of Coverage must also include the following in clear and understandable language: (a) a complete description of the benefit differential between services offered by Preferred Providers and non-preferred providers;(b) Provisions that if a Covered Person receives Emergency Care and cannot reasonably reach a Preferred Provider, payment for such care will be made at the same level and in the same manner as if the Covered Person had been treated by a Preferred Provider;(c) Benefit levels for covered Health Care Services rendered by non-preferred providers must be at least 80% of the Benefit Levels for the same covered Health Care Services rendered by Preferred Providers. 1. Payments made to non-preferred providers shall be a percentage of the provider's fee, up to a Usual and Customary Charge, and not a percentage of the amount paid to Preferred Providers.2. The 80% requirement shall be met if the coinsurance percentage for Health Care Services rendered by a non-preferred provider is no more than 20 percentage points greater than the highest coinsurance percentage for the same Health Care Services rendered by a Preferred Provider, excluding reasonable deductibles and copayments.(d) A description of all benefits required to be provided by law in accordance with all of the provisions of the Organization's enabling or licensing statutes.Amended by Mass Register Issue 1323, eff. 10/7/2016.