805 CMR 5.00: Miscellaneous

Date: 11/14/2017
Organization: Group Insurance Commission
Regulatory Authority: Group Insurance Commission
Official Version: Published by the Massachusetts Register

This is an unofficial version of Commonwealth regulations and is posted here for the convenience of the public. It is not an official statement of the regulations.

These miscellaneous provisions address GIC’s exclusive authority to negotiate benefit contracts authorized by G. L. c. 32A, restrict advertisement and other similar communications on GIC benefits without Commission approval, provide for reimbursements rel

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Group Insurance Commission

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Main Phone (617) 727-2310

M-F 8:45 a.m.-5 p.m.

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5.01: Relationship of Department Heads, The Commission and Employees

The Commission has the exclusive responsibility to negotiate all contracts for benefits authorized by M.G.L. c. 32A, M.G.L. c. 32B, §§ 19 and 23, and accompanying regulations. Department heads, including agency heads, reporting location heads, and Group Insurance Coordinators are required to conduct all matters relating to Commission programs described in 805 CMR 5.00 with the Commission unless the Commission's Executive Director gives prior approval.

5.02: Solicitation of Employees

External persons and entities must obtain prior written approval of the Commission's Executive Director to discuss Commission matters with individual employees or groups of employees. If approval is given, group meetings or discussions shall only be conducted at the employees' workplace during duty hours and are subject to the department or agency head's prior approval.

(1) All informational gatherings held for potential Municipal Insureds and Municipal Employers must include representatives of all of the Commission's health plans that serve the area to attend the gatherings to the extent that such meetings are attended by any health plan representatives.

(2) Health Plans, insurance carriers, agents, brokers or representatives are prohibited from advertising to or soliciting any benefit plans or programs to groups for whom the Commission is the exclusive sponsor. Entities with Commission benefits must offer to their employees, retirees, and survivors all such benefits for which their Insureds are eligible, and may not offer competing benefits, except where expressly authorized in statute. After written notice to the Commission, Municipal Employers and Municipal Insureds who are considering withdrawal from Commission Health Coverage may advertise for or solicit such plans or programs in order to procure other health coverage after withdrawal. Any person or entity that the Commission determines has violated the provisions of 805 CMR 5.02 shall be ineligible to bid on Commission business for a period of up to five years.

5.03: Participation of Non-state Funded Employers

Other than Municipal Employers, non-state funded employers whose employees, retirees, or survivors participate in Commission coverage as expressly mandated by state law shall directly reimburse the Commission for premium payments made on behalf of the employers' Insureds, together with an administrative fee. Reimbursing entities shall pay the Commission no later than 30 days from the date of the Commission's invoice. The Commission may include in its administrative fee a charge determined by the State Comptroller for late payment. Such late charge shall be billed separately and identified on a subsequent Commission invoice.

5.04: Providers and Benefits

(1) A participating Nurse Practitioner operating within the scope of his or her license, including all regulations requiring collaboration with a physician under M.G.L. c. 112, § 80B, shall be considered qualified as primary care providers for the Commissions' Insureds. Health Plans that fail to comply with the law's provisions will be deemed a prima facie violation of the Consumer Choice of Nurse Practitioner Services Act and a breach of its contract with the Commission, subject to a fine or other such remedies as the Commission determines to be reasonable.

(1A) A participating Physician Assistant operating within the scope of his or her license, including all regulations requiring collaboration with a physician under M.G.L. c. 112, § 9E, shall be considered qualified as primary care providers for the Commissions' Insureds. Any Commission health plan that fails to comply with the provisions of M.G.L. c. 176S will be deemed to have violated the Consumer Choice of Physician Assistant Act and to have breached its contract with the Commission, subject to a fine or other such remedies as the Commission determines to be reasonable.

(2) Health plans that require Insureds to designate a primary care provider shall provide clear and concise information to Insureds that they may select a participating Nurse Practitioner or Physician Assistant as a primary care provider or may change their medical provider to a participating Nurse Practitioner or Physician Assistant. Insureds' Evidence of Coverage shall also contain a clear, concise and complete statement that the carrier will provide benefit coverage to subscribers on a Nondiscriminatory Basis for covered services when delivered or arranged for by a participating Nurse Practitioner or Physician Assistant.

(3) Notwithstanding any general or special law to the contrary, the Commission's health plans shall include and make available to Insureds the same type of information about participating Nurse Practitioners or Physician Assistants as they provide about their participating physicians, and shall display the participating Nurse Practitioner and Physician Assistant information in the same manner and format as they do for their participating physicians.

5.05 Failure to Report

Other than Municipal Employers who are addressed elsewhere in these regulations, an employer whose employees, retirees, or survivors participate in Commission coverage fails repeatedly or egregiously to notify the Commission within 60 days of a termination or other loss of eligibility due to a change in employment status, the Commission may assess against the employer a financial penalty of $100 per ineligible person per month, or the amount by which actual claims for any ineligible person exceeded premiums paid by the employer for that person, whichever is greater.

Contact

Phone

Main Phone (617) 727-2310

M-F 8:45 a.m.-5 p.m.

Online

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