§ 27 — Development and use of common summary of payments form; implementation of education plan

[Text of section applicable as provided by 2018, 63, Sec. 2.]

Section 27. (a) The division shall develop a common summary of payments form to be used by all carriers in the commonwealth and provided to health care consumers with respect to provider claims submitted to a payer. The common summary of payments form shall be written in an easily readable and understandable format showing the consumer's responsibility, if any, for payment of any portion of a health care provider claim. The division shall allow the development and use of forms that may be exchanged securely through electronic means. Carriers shall not be obligated to issue a common summary of payments form for provider claims that consist solely of requests for co-payment.

(b) Carriers shall issue common summary of payments forms at the member level for each insured member. Carriers may establish a standard method of delivery of common summary of payments forms. All carriers shall permit the following individuals to choose, in writing, an alternative method of receiving the common summary of payments form: (i) a subscriber who is legally authorized to consent to care for the insured member; (ii) an insured member who is legally authorized to consent to that member's own care; or (iii) another party who has the exclusive legal authorization to consent to care for the insured member. The alternative methods of receiving the common summary of payments form shall include, but not be limited to: (A) sending a paper form to the address of the subscriber; (B) sending a paper form to the address of the insured member; (C) sending a paper form to any alternate address upon request of the insured member; or (D) allowing the subscriber, the insured member or both to access the form through electronic means; provided, however, that such access is provided in compliance with any applicable state and federal laws and regulations pertaining to data privacy and security including, but not limited to, subpart A of 45 CFR 160 and subpart C of 45 CFR 164, chapters 93H and 93I and 201 CMR 17.00.

(c) All carriers shall also permit an individual not authorized under subsection (b) but who is legally authorized to consent to care for an insured member to request, and shall accommodate a reasonable request by such individual to receive, the forms on behalf of the member through any of the alternative methods enumerated in subsection (b), provided that the individual clearly states in writing that the disclosure of all or part of the information could endanger the individual or the insured member. Upon receipt of such a request, carriers shall not inquire as to the reasons for, or otherwise seek to confirm, the endangerment.

(d) The preferred method of receipt selected pursuant to subsection (b) shall be valid until the insured member submits a request in writing for a different method; provided, however, that a carrier shall not be required to maintain more than 1 alternate address for a member. Carriers shall comply with an insured member's request pursuant to this subsection not later than 3 business days after receipt of the request.

(e) Carriers shall not specify or describe sensitive health care services in a common summary of payments form. The division shall define sensitive health care services for the purposes of this section. In determining that definition, the division shall consider the recommendations of the National Committee on Vital and Health Statistics and similar regulations in other states and shall consult with experts in fields including, but not be limited to, infectious disease, reproductive and sexual health, domestic violence and sexual assault and mental health and substance use disorders.

(f) In the event that the insured member has no liability for payment for any procedure or service, carriers shall permit all insured members who are legally authorized to consent to care, or parties legally authorized to consent to care for the insured member, to request suppression of common summary of payments forms for a specific service or procedure, in which case the common summary of payments forms shall not be issued; provided, however, that the insured member clearly makes the request orally or in writing. The carrier may request verification of the request in writing following an oral request. A carrier shall not require an explanation as to the basis for an insured member's request to suppress the common summary of payments forms, unless otherwise required by law or court order.

(g) The insured member's ability to request the preferred method of receipt pursuant to subsection (b) and to request suppression of the common summary of payments forms pursuant to subsection (f) shall be communicated in plain language and in a clear and conspicuous manner in evidence of coverage documents, member privacy communications and on every common summary of payments form and shall be conspicuously displayed on the carrier's member website and online portals for individual members.

(h) The division shall issue guidance as necessary to implement and enforce this section, which shall include requirements for reasonable reporting by carriers to the division regarding compliance and the number and type of complaints received regarding noncompliance with this section.

(i) The division, in collaboration with the department of public health, shall develop and implement a plan to educate providers and consumers regarding the rights of insured members and the responsibilities of carriers to promote compliance with this section. The plan shall include, but not be limited to, staff training and other education for hospitals, community health centers, school-based health centers, physicians, nurses and other licensed health care professionals, as well as administrative staff including, but not limited to: (i) all staff involved in patient registration and confidentiality education; and (ii) billing staff involved in processing insurance claims. The plan shall be developed in consultation with groups representing health care insurers, providers and consumers, including consumer organizations concerned with the provision of sensitive health care services.