Section 7: Information provided by carrier upon enrollment or upon request
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 information:
(1) a list of health care providers in the carrier's network, organized by specialty and by location and summarizing on its internet website for each such provider: (i) the method used to compensate or reimburse such provider, including details of measures and compensation percentages tied to any incentive plan or pay for performance provision; (ii) the provider price relativity, as defined in and reported under section 10 of chapter 12C; (iii) the provider's health status adjusted total medical expenses, as defined in and reported under said section 10 of said chapter 12C; and (iv) current measures of the provider's quality based on measures from the Standard Quality Measure Set, as defined in the regulations promulgated by the center for health information analysis; provided, however, that if any specific providers or type of providers requested by an insured are not available in said network, or are not a covered benefit, such information shall be provided in an easily obtainable manner; provided, further, that the carrier shall prominently promote providers based on quality performance as measured by the standard quality measure set and cost performance as measured by health status adjusted total medical expenses and relative prices;
(2) a statement that physician profiling information, so-called, may be available from the board of registration in medicine;
(3) a summary description of the process by which clinical guidelines and utilization review criteria are developed;
(4) the voluntary and involuntary disenrollment rate among insureds of the carrier;
(5) a statement that insureds have the opportunity to obtain health care services for an emergency medical condition, including the option of calling the local pre-hospital emergency medical service system, whenever the insured is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services; and
(6) a statement that the information specified in paragraph (b) is available to the insured or prospective insured from the office of patient protection in the health policy commission.
(7) a statement: (i) that an insured has the right to request referral assistance from a carrier if the insured or the insured's primary care provider has difficulty identifying medically necessary services within the carrier's network; (ii) that the carrier, upon request by the insured, shall identify and confirm the availability of these services directly; and (iii) that the carrier, if necessary, shall obtain out-of-network services if they are unavailable within the network.
(b) A carrier shall provide all of the information required under section 6 and subsection (a) of this section to the office of patient protection in the health policy commission and, in addition, shall provide to said office the following information:
(1) a list of sources of independently published information assessing insured satisfaction and evaluating the quality of health care services offered by the carrier;
(2) the percentage of physicians who voluntarily and involuntarily terminated participation contracts with the carrier during the previous calendar year for which such data has been compiled and the three most common reasons for voluntary and involuntary physician disenrollment;
(3) the percentage of premium revenue expended by the carrier for health care services provided to insureds for the most recent year for which information is available;
(4) a report detailing, for the previous calendar year, the total number of; (i) filed grievances, grievances that were approved internally, grievances that were denied internally, and grievances that were withdrawn before resolution; and (ii) external appeals pursued after exhausting the internal grievance process and the resolution of all such external appeals. The report shall identify for each such category, to the extent such information is available, the demographics of such insureds, which shall include, but need not be limited to, race, gender and age; and
(5) a report detailing for the previous calendar year the total number of: (i) medical or surgical claims submitted to the carrier; (ii) medical or surgical claims denied by the carrier; (iii) mental health or substance use disorder claims submitted to the carrier; (iv) mental health or substance use disorder claims denied by the carrier; and (v) medical or surgical claims and mental health or substance use disorder claims denied by the carrier because: (A) the insured failed to obtain pre-treatment authorization or referral for services; (B) the service was not medically necessary; (C) the service was experimental or investigational; (D) the insured was not covered or eligible for benefits at the time services occurred; (E) the carrier does not cover the service or the provider under the insured's plan; (F) duplicate claims had been submitted; (G) incomplete claims had been submitted; (H) coding errors had occurred; or (I) of any other specified reason.