Massachusetts Health Insurance Enforcement and Consumer Protections Grant Award

Cycle I Grant Application Summary

Massachusetts Grantee: Commonwealth of Massachusetts Division of Insurance

Award Date: October 31, 2016

Total Award: $1,206,525.03

Baseline Award: $476,998

Selected Market Reforms Amount: $480,000

Workload Award Amount: $249,527.03

• Section 2713 - The Commonwealth of Massachusetts Division of Insurance will audit the claims experience of health insurance issuers. These audits will determine whether consumers are using services in conjunction with tobacco cessation products as provided for in the Federal guidelines and Massachusetts Division of Insurance Bulletins. The Division will review health insurance issuers’ policies to determine whether specific provisions exist to raise consumer awareness of the availability of these preventive services and products at no additional cost. Finally, the Division will examine if carriers are complying with Federal Affordable Care Act (ACA) requirements regarding coverage for contraception services and coverage of certain lactation services.

• Section 2718 - The Commonwealth of Massachusetts Division of Insurance will conduct a study to determine how insurers in other states have reduced administrative costs and improved Medical Loss Ratios (MLR) since the inception of the ACA. The Division will audit health insurance issuers to ensure compliance with all federal and state requirements pertaining to filing MLR information. The Division will compare the carrier’s Federal MLR reporting form against the Supplemental Health Care Exhibit that each carrier submitted; verifying that the issuer correctly determined the number of employees an employer employed, as well as the accompanying group size and market classification for such coverage; determine the basis of the carrier’s allocation methodology and ensure it was reasonable, including the allocation among different lines of business and different but affiliated legal entities; review the description of each of the carrier’s quality improving activities to confirm they meet regulatory definitions; and for any issuers owing a rebate, conduct a test of a sample of rebates to ensure payment in accordance with the regulation; and finally, review year-to-year differences and compile trend information. The Division of Insurance will complete an aggregate report summarizing the findings.

• Section 2726 - The Commonwealth of Massachusetts Division of Insurance will conduct a project to determine whether health insurance issuers are setting up road blocks for patients who seek behavioral health services. The Division of Insurance will review health insurance issuers’ provider networks pertaining to specific behavioral health services, such as autism services. The Division will examine information and disclosures provided to consumers in relation to consumers’ right to appeal a decision of adverse determination, in order to assess health insurance issuers’ compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA). The Division will collect information to identify health insurance issuers’ non-quantitative treatment limitations in behavioral health services in comparison to medical services. Finally, health insurance issuers are currently self-reporting to the Division of Insurance to show compliance with MHPAEA, and the Division of Insurance will perform a thorough audit of the processes in place to ensure compliance.