Section 16: Office of patient protection; powers and duties; external review system
Section 16. (a) There is hereby established within the commission an office of patient protection. The office shall:— (1) have the authority to administer and enforce the standards and procedures established by sections 13, 14, 15 and 16 of chapter 176O. The commission shall promulgate such regulations to enforce this section. Such regulations shall protect the confidentiality of any information about a carrier or utilization review organization, as defined in said chapter 176O, which, in the opinion of the office, and in consultation with the division of insurance, is proprietary in nature and is not in the public interest to disclose. Utilization review criteria, medical necessity criteria and protocols shall be made available upon request to the office and the division of insurance; provided, however, that licensed, proprietary criteria and protocols purchased by a carrier shall not be public records and shall be exempt from disclosure pursuant to clause Twenty-sixth of section 7 of chapter 4 and section 10 of chapter 66. Utilization review criteria, medical necessity criteria and protocols shall be made available to the public at no charge; provided, however, that licensed, proprietary criteria purchased by a carrier or utilization review organization shall not be made available to the public, but such licensed, proprietary criteria relevant to particular treatments and services shall be provided to insureds, prospective insureds and health care providers upon request. The regulations authorized by this section shall be consistent with, and not duplicate or overlap with, regulations promulgated by the bureau of managed care established in the division of insurance pursuant to said chapter 176O;
(2) make managed care information collected by the office readily accessible to consumers on the commission's website. The information shall, at a minimum, include (i) a chart, prepared by the office, comparing the information obtained on premium revenue expended for health care services as provided under paragraph (3) of subsection (b) of section 7 of chapter 176O, for the most recent year for which information is available, and (ii) data collected under paragraph (c);
(3) assist consumers with questions or concerns relating to managed care, including, but not limited to, exercising the grievance and appeals rights established by sections 13 and 14 of said chapter 176O;
(4) monitor quality-related health insurance plan information relating to managed care practices;
(5) regulate the establishment and functions of review panels established by section 14 of chapter 176O;
(6) periodically advise the commission, the commissioner of insurance, the managed care oversight board, established by section 16D of chapter 6A, the joint committee on health care financing and the joint committee on financial services on actions, including legislation, which may improve the quality of managed care health insurance plans;
(7) administer and grant enrollment waivers under paragraph (4) of subsection (a) of section 4 of chapter 176J; provided, however, that the office of patient protection may grant a waiver to an eligible individual who certifies, under penalty of perjury, that such individual did not intentionally forego enrollment into coverage for which the individual is eligible and that is at least actuarially equivalent to minimum creditable coverage; provided further, that the office shall establish, by regulation, standards and procedures for enrollment waivers; and
(8) establish, by regulation, procedures and rules relating to appeals by consumers aggrieved by restrictions on patient choice, denials of services or quality of care resulting from any final action of an ACO, and to conduct hearings and issue rulings on appeals brought by ACO consumers that are not otherwise properly heard through the consumer's payer or provider.
(b) The commission shall establish an external review system for the review of grievances submitted by or on behalf of insureds of carriers under section 14 of chapter 176O, including a process for identifying and referring matters to the division of insurance and the office of the attorney general for review of compliance with state and federal mental health and substance use disorder parity laws. The commission shall establish an external review process for the review of grievances submitted by or on behalf of ACO patients and shall specify the maximum amount of time for the completion of a determination and review after a grievance is submitted. The commission shall establish expedited review procedures applicable to emergency situations, as defined by regulation promulgated by the division.