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Session Law

2012

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Chapter 61 AN ACT RELATIVE TO TIERED AND SELECTIVE NETWORK HEALTH PLANS.

Whereas, The deferred operation of this act would tend to defeat its purpose, which is to provide forthwith for the continued health plan coverage of individuals with serious diseases, therefore it is hereby declared to be an emergency law, necessary for the immediate preservation of the public health.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same as follows:

SECTION 1. Chapter 176J of the General Laws is hereby amended by inserting after section 11 the following section:-

Section 11A. (a) For an insured member who (1) is receiving an active course of medical treatment from a health care provider for a serious disease, including but not limited to cancer or cystic fibrosis, that if disrupted in the course of medical treatment would pose an undue hardship to the patient and (2)(i) began this active course of treatment before being enrolled in a reduced or selective network plan where the provider is not part of the reduced or selective network or (ii) began this active course of treatment before being enrolled in a tiered network plan where the provider is in the highest cost-sharing tier, the carrier shall provide coverage for those medically necessary and covered services that are part of that active course of treatment provided by that health care provider, to the extent required by subsection (b).

(b) A carrier to which subsection (a) applies shall cover the health care provider’s services for the duration of the active course of treatment during the plan year, if (1) the insured’s employer offers the insured only a choice of reduced or selective network plans in which the health care provider is not part of any of the offered reduced or selective networks, or a choice of tiered network plans in which the health care provider is in the highest cost-sharing tier; (2) that health care provider is a comprehensive cancer center, pediatric hospital or pediatric specialty unit as defined in section 1 of chapter 118G; and (3) that health care provider is providing the insured with an active course of medical treatment that is not available from another provider in the network of the insured’s plan.

(c) For services provided under this section from a provider that is not in the network of the insured’s plan, patient cost-sharing shall be at the lowest cost-sharing level applicable to those services in the plan, and reimbursement shall be based on median in-network rates of the specific health care provider in that carrier’s private plans in a manner consistent with data filed by that carrier with the division of health care finance and policy; provided, however, that if the specific health care provider does not participate in any other plan of the carrier, then based on negotiated rates. For services provided under this section by a provider in the highest cost-sharing tier of a tiered network plan, patient cost-sharing shall be based on the second-highest cost-sharing tier in that plan.

(d) The commissioner shall adopt regulations to carry out this section.

SECTION 2. Said chapter 176J is hereby further amended by adding the following 2 sections:-

Section 14. If a medically necessary and covered service is not available to a member within the carrier’s provider network, the carrier shall cover the services out-of-network, for as long as the service is unavailable in-network.

Section 15. An insurer offering a tiered network plan shall clearly and conspicuously indicate, in all promotional and agreement materials, the cost-sharing differences for enrollees in the various tiers. The commissioner shall adopt regulations to carry out this section.

SECTION 3. Notwithstanding any general or special law, rule or regulation to the contrary, the division of insurance shall conduct a review of the network adequacy and cost and quality effectiveness of insurance products under section 11 of chapter 176J of the General Laws for the health care needs of children and the health care needs of cancer patients, and shall submit a written report to the house and senate committees on ways and means and the joint committee on health care financing not later than December 31, 2012. The division shall also adopt regulations to address health plan network adequacy, including access to pediatric and cancer services.

SECTION 4. Notwithstanding subsection (b) of section 11A of chapter 176J of the General Laws, for an insured member who, before the effective date of this act, (1) began an active course of medical treatment from a health care provider that is a comprehensive cancer center, pediatric hospital or pediatric specialty unit as defined in section 1 of chapter 118G of the General Laws for a serious disease, including but not limited to, cancer or cystic fibrosis, that if disrupted in the course of medical treatment would pose an undue hardship to the patient and (2)(i) began this active course of treatment before being enrolled in a reduced or selective network plan where the provider is not part of the reduced or selective network or (ii) began this active course of treatment before being enrolled in a tiered network plan where the provider is in the highest cost-sharing tier, the carrier shall provide coverage for those medically necessary and covered services that are part of that active course of treatment provided by that health care provider until April 30, 2013 at the patient cost-sharing levels and reimbursement rates required by subsection (c) of said section 11A of said chapter 176J of the General Laws.

SECTION 5. This act shall take effect on May 1, 2012.

Approved, March 23, 2012.


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