PETITION OF:

SECTION 1. Section 1 of chapter 176G of the General Laws, as most recently amended by sections 34 to 39 of chapter 141 of the Acts of 2003, is hereby further amended by adding the following: “Carve out”, a company organized under the laws of the commonwealth or organized under the laws of another state and qualified to do business in the commonwealth, that has entered into a contractual arrangement with a health maintenance organization to provide or arrange for the provision of behavioral health services to voluntarily enrolled members of said health maintenance organization.

SECTION 2. Section 10 of chapter 176G of the General Laws, as most recently amended by section 41 of chapter 141 of the Acts of 2003, is hereby further amended by inserting after the phrase, “Every health maintenance organization”, as it appears therein, the following: and carve out.

SECTION 3. Chapter 176G of the General Laws, as most recently amended by section 5 of chapter 430 of the Acts of 2004, is hereby further amended by adding the following section: Required Disclosures

(1) A carve out shall provide to at least one adult insured in each household        upon enrollment, and to a prospective insured upon request, the following information

(a) a statement that physician profiling information, so-called, may be available from the Board of Registration in Medicine for physicians licensed to practice in Massachusetts;

(b) a summary description of the process by which clinical guidelines and utilization review criteria are developed;

(c) A notice to insureds regarding emergency medical conditions that states all of the following:

1. 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 by dialing the emergency telephone access number 911, or its local equivalent, whenever the insured is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services;

2. that no insured shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent;

3. that no insured will be denied coverage for medical and transportation expenses incurred as a result of such emergency medical condition; and

4. if the carve out requires an insured to contact either the carve out or its designee or the primary care physician of the insured within 48 hours of receiving emergency services,

that notification already given to the carve out, designee or primary care physician by the attending emergency physician shall satisfy that requirement.

(e) a description of the Office of Patient Protection and a statement that the information specified in 211 CMR 52.16 is available to the insured or prospective insured from the Office of Patient Protection.

(2) The information required by this section may be contained in the evidence of coverage and need not be provided in a separate document.

(3) Every disclosure described in this section must contain the effective date, date of issue and, if applicable, expiration date.

(4) Carve outs shall submit material changes to the disclosures required by this section to the Bureau at least 30 days before their effective dates.

(5) Carve outs shall submit material changes to the disclosures required by to at least one adult insured in every household residing in Massachusetts at least once every two years.

(6) A carve out that provides specified services through a workers' compensation preferred provider arrangement shall be deemed to have met the requirements of this section if it has met the requirements of 211 CMR 112.00 and 452 CMR 6.00.

SECTION 4. Chapter 176G of the General Laws as most recently amended by section 5 of chapter 430 of the Acts of 2004, is hereby further amended by inserting after section 29 the following section:

Section 30. Any health maintenance organization for whom a carve-out is administering behavioral and mental health services, shall be responsible for the carve-out’s failure to comply with the requirements of said chapter 176G in the same manner as if the health maintenance organization failed to comply with said provisions.

SECTION 5. Chapter 176G of the General Laws as most recently amended by section 5 of chapter 430 of the Acts of 2004, is hereby further amended by inserting after section 30 the following section:

Section 31. Any health maintenance organization for whom a carve-out is administering behavioral and mental health services, shall state on its enrollment card the name of the carve-out and its telephone number to ensure coverage for such services.

SECTION 6. Section 7 of chapter 176O of the General Laws as added by section 27 of chapter 141 of the Acts of 2000, is hereby amended by inserting after sub-section (b)(4) the following sub-section:

(b)(5) a report, submitted annually, that details the following: the number of times per year an insured seeks assistance from the carrier in obtaining a referral for inpatient mental and behavioral health services; outpatient mental and behavioral health services; and for those inpatient and outpatient services obtained that are provided out-of-network due to their unavailability within the network. The reporting for each of these three categories must list adults and children separately. The reporting must also be further sub-divided into regional totals, the geographic regions as defined by the department of mental health in accordance with 104 CMR 26.02.

SECTION 7. Section 7 of chapter 176O of the General Laws as added by section 27 of chapter 141 of the Acts of 2000, is hereby amended by inserting after sub-section (a)(6) the following sub-section:

(a)(7) a statement that an insured has the right to request referral assistance from a carrier if the insured, or his or her primary care physician, has difficulty identifying services within the carrier’s network; that the carrier shall, upon request by the insured, identify and confirm the availability of these services directly; and that if necessary, the carrier must obtain services out-of-network if they are unavailable from within the network.