Section 1 As used in this chapter, the following words shall have the following meanings:-

"Adverse determination", a determination, based upon a review of information provided by a carrier or its designated utilization review organization, to deny, reduce, modify, or terminate an admission, continued inpatient stay, or the availability of any other health care services, for failure to meet the requirements for coverage based on medical necessity, appropriateness of health care setting and level of care, or effectiveness.

(e) A carrier may apply to the bureau for deemed accreditation status. A carrier may be deemed to be in compliance with the bureau's standards, and may be so accredited by the bureau, only if the carrier, or an entity with which it contracts: (1) is accredited by a national accreditation organization; (2) is in compliance with all of the requirements of this chapter; and (3) demonstrates compliance with, and has obtained the highest possible rating from said national accreditation organization for: (i) utilization review, (ii) quality management, and (iii) member rights and responsibilities, as promulgated by the bureau pursuant to this chapter. The bureau shall publish by regulation the highest possible rating level in each such category used by every national accreditation organization recognized by the bureau. Nothing in this subsection shall be construed to require a carrier, as a condition of certification, to be in compliance at the highest possible rating with each of the accreditation requirements of a national accreditation organization.

(f) A carrier which is not accredited by the bureau pursuant to this section, and is not otherwise exempt from accreditation, shall not offer for sale, provide, or arrange for the provision of a defined set of health care services to insureds through affiliated and contracting providers or employ utilization review in making decisions about whether services are covered benefits under a health benefit plan.

(g) A carrier shall be exempt from accreditation if in the written opinion of the attorney general, the commissioner of insurance and the commissioner of public health, the health and safety of health care consumers would be materially jeopardized by requiring accreditation of the carrier. Before publishing such written exemption, the attorney general, the commissioner of insurance and the commissioner of public health shall jointly hold at least one public hearing at which testimony from interested parties on the subject of the exemption shall be solicited. A carrier granted such an exemption shall be provisionally accredited and, during such provisional accreditation, shall be subject to review not less than every four months and shall be subject to those requirements of this chapter as deemed appropriate by the commissioner of insurance.

Section 3 (a) The bureau shall investigate all complaints made against a carrier or any entity with which it contracts for allegations of noncompliance with the accreditation requirements established by section 2. The bureau shall notify a carrier when, in the opinion of the bureau, the complaints made against such a carrier indicate a pattern of noncompliance with a particular accreditation requirement. The notice shall detail the alleged noncompliance and establish a hearing date for the matter, which shall be held no later than 21 days after the date of the notice. The hearing shall be conducted pursuant to chapter 30A. The hearing shall provide such a carrier with the opportunity to respond to the alleged noncompliance.

(b) The bureau may, after said hearing, suspend or revoke the accreditation of such a carrier, or reprimand, censure or impose a civil administrative penalty not to exceed $10,000 for each classification of violation.

(5) the criteria by which an insured may be disenrolled or denied enrollment and the involuntary disenrollment rate among insureds of the carrier.

(7) the requirement that an insured's coverage may be canceled, or its renewal refused, only in the following circumstances: (i) failure by the insured or other responsible party to make payments required under the contract; (ii) misrepresentation or fraud on the part of the insured; (iii) commission of acts of physical or verbal abuse by the insured which pose a threat to providers or other insureds of the carrier and which are unrelated to the physical or mental condition of the insured; provided, that the commissioner prescribes or approves the procedures for the implementation of the provisions of this clause; (iv) relocation of the insured outside the service area of the carrier; and (v) non-renewal or cancellation of the group contract through which the insured receives coverage.

(9) a summary description of the utilization review procedures and quality assurance programs used by the carrier, including the toll-free telephone number to be established by the carrier that enables consumers to determine the status or outcome of utilization review decisions.

(10) a statement detailing what translator and interpretation services are available to assist insureds; provided, that the commissioner shall determine in which languages other than English such statement shall be printed.

(12) a summary description of the procedures followed by the carrier in making decisions about the experimental or investigational nature of individual drugs, medical devices or treatments in clinical trials;

(1) a list of health care providers in the carrier's network, organized by specialty and by location and summarizing for each such provider the method used to compensate or reimburse such provider; provided, however, that nothing in this clause shall be construed to require disclosure of the specific details of any financial arrangements between a carrier and a provider; provided, further, 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.

(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.

(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 department of public health.

(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 department of public health 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.

(b) In order that patient care decisions are based on medical need and not on financial incentives, no carrier shall enter into a new contract, revise the risk arrangements in an existing contract, or after July 1, 2001, revise the fee schedule in an existing contract with a physician or physician group which imposes financial risk on such physician or physician group for the costs of medical care, services or equipment provided or authorized by another physician or health care provider unless such contract includes specific provisions with respect to the following:(1) stop loss protection, (2) minimum patient population size for the physician or physician group, and (3) identification of the health care services for which the physician or physician group is at risk.

Section 13 (a) A carrier or utilization review organization shall maintain a formal internal grievance process that provides for adequate consideration and timely resolution of grievances, which shall include but not be limited to: (1) a system for maintaining records of each grievance filed by an insured or on his behalf, and responses thereto, for a period of seven years, which records shall be subject to inspection by the commissioner; (2) the provision of a clear, concise and complete description of the carrier's formal internal grievance process and the procedures for obtaining external review pursuant to section 14 with each notice of an adverse determination; (3) the carrier's toll-free telephone number for assisting insureds in resolving such grievances and the consumer assistance toll-free telephone number maintained by the office of patient protection; (4) a written acknowledgement of the receipt of a grievance within 15 days and a written resolution of each grievance within 30 days from receipt thereof; and (5) a procedure to accept grievances by telephone, in person, by mail, or by electronic means, provided that an oral grievance made by an insured shall be reduced to writing by the carrier and a copy thereof forwarded to the insured by the carrier within 48 hours of receipt. The time limits established by this paragraph may be waived or extended by mutual agreement of the insured and the carrier.

(b) The formal internal grievance process maintained by a carrier or utilization review organization shall provide for an expedited resolution of a grievance concerning a carrier's coverage or provision of immediate and urgently needed services. Said expedited resolution policy shall include, but not be limited to:

(i) a resolution before an insured's discharge from a hospital if the grievance is submitted by an insured who is an inpatient in a hospital.

(ii) provisions for the automatic reversal of decisions denying coverage for services or durable medical equipment, pending the outcome of the appeals process, within 48 hours, or earlier for durable medical equipment at the option of the physician responsible for treatment or proposed treatment of the covered patient, of receipt of certification by said physician that, in the physician's opinion, the service or use of durable medical equipment at issue in a grievance or appeal is medically necessary, that a denial of coverage for such services or durable medical equipment would create a substantial risk of serious harm to the patient, and that the risk of that harm is so immediate that the provision of such services or durable medical equipment should not await the outcome of the normal appeal or grievance process, but, in the event said physician exercises the option of automatic reversal earlier than 48 hours for durable medical equipment, he must further certify as to the specific, immediate and severe harm that will result to the patient absent action within the 48 hour time period;

Section 14 (a) An insured who remains aggrieved by an adverse determination and has exhausted all remedies available from the formal internal grievance process required pursuant to section 13, may seek further review of the grievance by a review panel established by the office of patient protection pursuant to paragraph (5) of subsection (a) of section 217 of chapter 111. The insured shall pay the first $25 of the cost of the review to said office which may waive the fee in cases of extreme financial hardship. The commonwealth shall assess the carrier for the remainder of the cost of the review pursuant to regulations promulgated by the commissioner of public health in consultation with the commissioner of insurance. The office of patient protection shall contract with at least three unrelated and objective review agencies through a bidding process, and refer grievances to one of the review agencies on a random selection basis. The review agencies shall develop review panels appropriate for the given grievance, which shall include qualified clinical decision-makers experienced in the determination of medical necessity, utilization management protocols and grievance resolution, and shall not have any financial relationship with the carrier making the initial determination. The standard for review of a grievance by such a panel shall be the determination of whether the requested treatment or service is medically necessary, as defined herein, and a covered benefit under the policy or contract. The panel shall consider, but not be limited to considering: (i) written documents submitted by the insured, (ii) additional information from the involved parties or outside sources that the review panel deems necessary or relevant, and (iii) information obtained from any informal meeting held by the panel with the parties. The panel shall send final written disposition of the grievance, and the reasons therefor, to the insured and the carrier within 60 days of receipt of the request for review, unless the panel determines additional time is necessary to fully and fairly evaluate the grievance and notifies the carrier and the insured of the decision to extend the review beyond 60 days.

(b) If a grievance is filed concerning the termination of ongoing coverage or treatment, the disputed coverage or treatment shall remain in effect through completion of the formal internal grievance process. An insured may apply to the external review panel to seek continued provision of health care services which are the subject of the grievance during the course of said external review upon a showing of substantial harm to the insured's health absent such continuation, or other good cause as determined by the panel.

(c) The decision of the review panel shall be binding. The superior court shall have jurisdiction to enforce the decision of the review panel.

(d) A carrier shall allow a guardian, conservator, holder of a power of attorney, family member, or other responsible party to act as the insured's representative in the event that an insured is unable to pursue a grievance due to physical or mental disability. An insured may designate such a representative or, if the insured is unable to so designate, a guardian, conservator, holder of a power of attorney or family member, in order of priority, may serve as representative or may designate another responsible party to act as representative. The representative shall have the same rights of grievance as the insured, including the right to review the insured's medical file relevant to a dispute concerning coverage or treatment.

(e) The grievance procedures authorized by this section shall be in addition to any other procedures that may be available to any insured pursuant to contract or law, and failure to pursue, exhaust or engage in the procedures described in this subsection shall not preclude the use of any other remedy provided by any contract or law.

(f) No health care provider nor any agent or employee thereof, shall provide information relative to unpaid charges for health care services to a consumer reporting agency, as defined by section 50 of chapter 93, while an internal or external review under this section is pending, or for 15 days following the resolution of such a grievance.

Section 15 (a) A carrier that allows or requires the designation of a primary care physician shall notify an insured at least 30 days before the disenrollment of such insured's primary care physician and shall permit such insured to continue to be covered for health services, consistent with the terms of the evidence of coverage, by such primary care physician for at least 30 days after said physician is disenrolled, other than disenrollment for quality-related reasons or for fraud. Such notice shall also include a description of the procedure for choosing an alternative primary care physician.

(b) A carrier shall allow any female insured who is in her second or third trimester of pregnancy and whose provider in connection with her pregnancy is involuntarily disenrolled, other than disenrollment for quality-related reasons or for fraud, to continue treatment with said provider, consistent with the terms of the evidence of coverage, for the period up to and including the insured's first postpartum visit.

(c) A carrier shall allow any insured who is terminally ill and whose provider in connection with said illness is involuntarily disenrolled, other than disenrollment for quality-related reasons or for fraud, to continue treatment with said provider, consistent with the terms of the evidence of coverage, until the insured's death.

(d) A carrier shall provide coverage for health services for up to 30 days from the effective date of coverage to a new insured by a physician who is not a participating provider in the carrier's network if: (1) the insured's employer only offers the insured a choice of carriers in which said physician is not a participating provider, and (2) said physician is providing the insured with an ongoing course of treatment or is the insured's primary care physician. With respect to a insured in her second or third trimester of pregnancy, this provision shall apply to services rendered through the first postpartum visit. With respect to an insured with a terminal illness, this provision shall apply to services rendered until death.

(e) A carrier may condition coverage of continued treatment by a provider under subsections (a) to (d), inclusive, upon the provider's agreeing (1) to accept reimbursement from the carrier at the rates applicable prior to notice of disenrollment as payment in full and not to impose cost sharing with respect to the insured in an amount that would exceed the cost sharing that could have been imposed if the provider had not been disenrolled; (2) to adhere to the quality assurance standards of the carrier and to provide the carrier with necessary medical information related to the care provided; and (3) to adhere to such carrier's policies and procedures, including procedures regarding referrals, obtaining prior authorization and providing services pursuant to a treatment plan, if any, approved by the carrier. Nothing in this subsection shall be construed to require the coverage of benefits that would not have been covered if the provider involved remained a participating provider.

(f) A carrier that requires an insured to designate a primary care physician shall allow such a primary care physician to authorize a standing referral for specialty health care provided by a health care provider participating in such carrier's network when (1) the primary care physician determines that such referrals are appropriate, (2) the provider of specialty health care agrees to a treatment plan for the insured and provides the primary care physician with all necessary clinical and administrative information on a regular basis, and (3) the health care services to be provided are consistent with the terms of the evidence of coverage. Nothing in this section shall be construed to permit a provider of specialty health care who is the subject of a referral to authorize any further referral of an insured to any other provider without the approval of the insured's carrier.

(g) No carrier shall require an insured to obtain a referral or prior authorization from a primary care physician for the following specialty care provided by an obstetrician, gynecologist, certified nurse-midwife or family practitioner participating in such carrier's health care provider network: (1) annual preventive gynecologic health examinations, including any subsequent obstetric or gynecological services determined by such obstetrician, gynecologist, certified nurse-midwife or family practitioner to be medically necessary as a result of such examination; (2) maternity care; and (3) medically necessary evaluations and resultant health care services for acute or emergency gynecological conditions. No carrier shall require higher copayments, coinsurance, deductibles or additional cost sharing arrangements for such services provided to such insureds in the absence of a referral from a primary care physician. Carriers may establish reasonable requirements for participating obstetricians, gynecologists, certified nurse-midwives or family practitioners to communicate with an insured's primary care physician regarding the insured's condition, treatment, and need for follow-up care. Nothing in this section shall be construed to permit an obstetrician, gynecologist, certified nurse-midwife or family practitioner to authorize any further referral of an insured to any other provider without the approval of the insured's carrier.

(h) A carrier shall provide coverage of pediatric specialty care, including mental health care, by persons with recognized expertise in specialty pediatrics to insureds requiring such services.

(i) A carrier shall provide health care providers applying to be participating providers who are denied such status with a written reason or reasons for denial of such application.

(j) No carrier shall make a contract with a health care provider which includes a provision permitting termination without cause. A carrier shall provide a written statement to a provider of the reason or reasons for such provider's involuntary disenrollment.

Section 16 (a) The physician treating an insured, shall, consistent with generally accepted principles of professional medical practice and in consultation with the insured, make all clinical decisions regarding medical treatment to be provided to the insured, including the provision of durable medical equipment and hospital lengths of stay. Nothing in this section shall be construed as altering, affecting or modifying either the obligations of any third party or the terms and conditions of any agreement or contract between either the treating physician or the insured and any third party.

(b) A carrier shall be required to pay for health care services ordered by a treating physician if (1) the services are a covered benefit under the insured's health benefit plan; and (2) the services are medically necessary. A carrier may develop guidelines to be used in applying the standard of medical necessity, as defined herein. Any such medical necessity guidelines utilized by a carrier in making coverage determinations shall be: (i) developed with input from practicing physicians in the carrier's or utilization review organization's service area; (ii) developed in accordance with the standards adopted by national accreditation organizations; (iii) updated at least biennially or more often as new treatments, applications and technologies are adopted as generally accepted professional medical practice; and (iv) evidence-based, if practicable. In applying such guidelines, a carrier shall consider the individual health care needs of the insured.

(c) With respect to an insured enrolled in a health benefit plan under which the carrier or utilization review organization only provides administrative services, the obligations of a carrier or utilization review organization created by this section and related to payment shall be limited to recommending to the third party payor that coverage should be authorized.