Chapter 176G

Section 1. The following words as used in this chapter shall, unless the context clearly requires otherwise, have the following meanings: ''Affiliate'', an affiliate of, or person affiliated with, a specific person, is a person that directly, or indirectly through 1 or more inter…

Section 10. Every health maintenance organization shall annually file with the commissioner, within 60 days of the close of its fiscal year, a report verified by at least 2 principal officers and covering its preceding fiscal year; provided that, if the commissioner determines th…

Section 10A. Notwithstanding any general or special law to the contrary, chapter 176V shall apply to a health maintenance organization governed by this chapter.

Section 10B. Notwithstanding any general or special law to the contrary, chapter 176W shall apply to a health maintenance organization governed by this chapter.

Section 11. Every health maintenance organization entering into a contract with the group insurance commission under chapter thirty-two A, or a county, city, town, or district under chapter thirty-two B, shall comply with the requirements applicable to health care organizations u…

Section 11A. Each employer or other organization which employs or has twenty-five or more employees or members during the full preceding calendar year and which contracts with and contributes to a health maintenance organization for the purpose of providing comprehensive dental b…

Section 12. Nothing in this chapter shall exempt any person from any applicable provisions of chapters one hundred and eleven or one hundred and twelve, including but not limited to, provisions relating to determinations of need, licensure and regulation of hospitals and clinics …

Section 13. No company, person, entity or health care plan not meeting the definition of health maintenance organization specified under this chapter shall use in its name, contract, or literature the term ''health maintenance organization'' or the initials ''HMO''.

Section 14. Each applicant for a health maintenance organization license shall upon initial application submit to the commissioner for his approval such materials as the commissioner shall by regulation require, in a form approved by the commissioner. A health maintenance organiz…

Section 15. Each health maintenance organization shall furnish to the commissioner evidence of a surety bond in an amount satisfactory to the commissioner or deposit with the commissioner cash or sureties acceptable to him in at least the same amount as a guarantee that the oblig…

Section 16. The subscriber contracts, rates and evidence of coverage shall be subject to the disapproval of the commissioner. No such contracts shall be approved if the benefits provided therein are unreasonable in relation to the rate charged, nor if the rates are excessive, ina…

Section 16A. The commissioner shall not disapprove a health maintenance contract: (i) if it complies with the requirements of 42 U.S.C. Sec. 18022(e); or (ii) on the basis that it includes a deductible that is consistent with the requirements for a high deductible plan as defined…

Section 16B. The commissioner shall not disapprove a health maintenance contract offered as coverage for young adults if the health maintenance contract complies with the minimum standards established under section 10 of chapter 176J.

Section 17. The commissioner may promulgate rules and regulations as are necessary to carry out the provisions of this chapter including but not limited to the licensing of agents, who engage in solicitation of enrollment of a health care plan. No rule or regulation shall require…

Section 17A. All health maintenance organizations governed by this chapter which enroll medicare beneficiaries shall provide open enrollment for nongroup medicare beneficiaries commencing on February first and ending March thirty-first of each year, for coverage to be effective n…

Section 19. No health maintenance organization subject to this chapter, and no officer or agent thereof, shall cancel, refuse to issue or renew, or in any way make or permit any distinction or discrimination in the amount or payment of premiums or rates charged, in the length of …

Section 2. Except as hereinafter provided in this chapter, the provisions of chapters one hundred and seventy-five, one hundred and seventy-six A, one hundred and seventy-six B, one hundred and seventy-six C, one hundred and seventy-six E, and one hundred and seventy-six F, shall…

Section 20. Any administrative supervision, rehabilitation or liquidation of a health maintenance organization shall be deemed to be the administrative supervision, rehabilitation or liquidation of an insurance company and shall be instituted on the grounds contained in and condu…

Section 20A. If the commissioner is satisfied, upon examination or other evidence submitted to him, that (1) any health maintenance organization is insolvent or is in an unsound financial condition, (2) its business policies or methods are unsound or improper, (3) its condition o…

Section 21. (a) For purposes of this section, ''participating provider'' shall mean any physician, hospital or other person who, under an express or implied contract with the health maintenance organization or with its contractor or subcontractor, has agreed to provide health car…

Section 22. (a) For purposes of this section, ''health care provider'' shall mean any physician, hospital or other person furnishing health services who has provided such services to members under an express or implied contract or with an expectation of receiving payment, other t…

Section 23. (a) For purposes of this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:- ''Carrier'', a health maintenance organization authorized under this chapter, an insurance company authorized to provide accident …

Section 24. For the purposes of this section the following words shall have the following meanings:— ''Genetic information'', any written recorded individually identifiable result of a genetic test as defined by this section or explanation of such a result. ''Genetic test'', a te…

Section 25. (a) The commissioner shall require upon issuance of an initial license under this chapter that a health maintenance organization shall have an initial adjusted net worth of $1,500,000. (b) Except as provided by subsection (c) or (d), the commissioner shall require tha…

Section 26. (a) Except as provided in subsections (b) and (d), each health maintenance organization shall maintain a deposit with a trustee acceptable to the commissioner through which a custodial or controlled account is utilized of cash, securities or any combination of these o…

Section 27. (a) No person other than the health maintenance organization shall make a tender offer for or a request or invitation for tenders of, or enter into any agreement to exchange securities, or seek to acquire, or acquire, in the open market or otherwise, any voting securi…

Section 28. (a) Every health maintenance organization which may do business in the commonwealth and which is a member of a health maintenance organization holding company system, shall register with the commissioner. Notwithstanding the foregoing, a foreign health maintenance org…

Section 29. (a)(1) Whenever it appears to the commissioner that any health maintenance organization or any director, officer, employee or agent thereof has committed or is about to commit a violation of sections 27 to 29, inclusive, or any rule, regulation or order issued by the …

Section 3. A carrier or any two or more such companies, corporations, or their subsidiaries or affiliates may: (1) organize and operate a health maintenance organization as a line of business, division, department, subsidiary or affiliate under the provisions of this chapter prov…

Section 30. Pursuant to section 8B of chapter 62C, carriers shall provide written statements to residents of the commonwealth for whom creditable coverage is provided and shall provide a separate report verifying those statements to the commissioner of revenue.

Section 31. To the maximum extent possible, every health maintenance organization shall attribute every member to a primary care provider. Members may change their primary care provider, provided that the member gives notice to the carrier.

Section 32. To the extent permissible under applicable state and federal privacy laws, every health maintenance organization shall disclose patient-level data to providers in their network solely for the purpose of carrying out treatment, coordinating care among providers and man…

Section 33. (a) For the purposes of this section, the following words shall, unless the context clearly requires otherwise, have the following meanings: ''Behavioral health services'', care and services for the evaluation, diagnosis, treatment or management of patients with menta…

Section 4. A health maintenance contract shall provide coverage for: (a) pregnant women, infants and children as set forth in section 47C of chapter 175; (b) cardiac rehabilitation as set forth in section 47D of chapter 175; (c) prenatal care, childbirth and postpartum care as se…

Section 4A. Any health maintenance contract shall provide coverage for employees terminated due to a plant closing or covered partial closing as required by the second paragraph of section one hundred and ten D of chapter one hundred and seventy-five and the second paragraph of s…

Section 4AA. For the purposes of this section the following terms shall have the following meanings, unless the context clearly requires otherwise:— ''Acute treatment services'', 24–hour medically supervised addiction treatment for adults or adolescents provided in a medically ma…

Section 4B. No health maintenance organization shall require as a condition to receiving benefits pursuant to this chapter consent to the disclosure of information regarding services for mental disorders under different terms and conditions than consent is required for the disclo…

Section 4C. Any group health maintenance contract shall provide coverage for home care services as set forth in clause (k) of section one hundred and ten of chapter one hundred and seventy-five.

Section 4CC. Any individual or group health maintenance contract shall provide coverage for medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome including, but not limited to, reconstructive surgery, such…

Section 4D. A group health maintenance contract shall provide coverage for nonprescription enteral formulas for home use for which a physician has issued a written order and which are medically necessary for the treatment of malabsorption caused by Crohn's disease, ulcerative col…

Section 4DD. An individual or group health maintenance contract that is issued or renewed shall provide, for any covered drug that is a narcotic substance contained in schedule II pursuant to chapter 94C and subject to cost sharing, that if a person receives a prescription filled…

Section 4E. A group health maintenance contract shall provide coverage for off-label uses of prescription drugs used in the treatment of cancer as set forth in sections forty-seven K and forty-seven L of chapter one hundred and seventy-five; provided, however, that neither the at…

Section 4EE. (a) Any individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall develop a plan to provide adequate coverage and access to a broad spectrum of pain management services, including, but not limited to, non-medic…

Section 4F. Any group health maintenance contract shall provide coverage for a bone marrow transplant or transplants for persons who have been diagnosed with breast cancer that has progressed to metastatic disease; provided, however, that said person shall meet the criteria estab…

Section 4FF. (a) An individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide coverage for: (i) tobacco use cessation counseling; and (ii) all generic United States Food and Drug Administration–approved tobacco cess…

Section 4G. Any individual or group health insurance maintenance contract which provides coverage for prescription drugs shall provide coverage for off-label uses of prescription drugs used in the treatment of HIV/AIDS as set forth in sections forty-seven O and forty-seven P of c…

Section 4GG. Any individual or group health maintenance contract shall provide coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute-onset neuropsychiatric syndrome including, but not limited to, the…

Section 4H. Any individual or group health maintenance contract, except contracts providing supplemental coverage to Medicare or other governmental programs, delivered, issued or renewed by agreement between the insurer and the policyholder, within or without the commonwealth, sh…

Section 4I. Any health maintenance contract shall provide coverage for abortion, as defined in section 12K of chapter 112, abortion-related care, prenatal care, childbirth and postpartum care in accordance with section four of chapter one hundred and seventy-six G. In addition to…

Section 4II. An individual or group health maintenance contract that provides coverage for prescription eye drops shall provide coverage for refills of prescription eye drops in accordance with the Medicare Part D guidelines on early refills of topical ophthalmic products when: (…