Section 152.04 - Tiered Provider Network Plans(1) A Carrier proposing to offer a Health Benefit Plan that uses a Tiered Provider Network with variations on cost-sharing between Provider tiers, shall submit to the Division materials demonstrating that: (a) The Carrier has notified each Provider of its right to opt out of a new Health Benefit Plan with a Tiered Provider Network at least 60 days before the Carrier submits the new plan to the Commissioner.(b) The Carrier maintains up to date enrollment systems, Marketing Materials and Evidences of Coverage that identify for all Providers, employers and Insureds the Providers in the Provider Network specifying each Network Provider's designated tier in each Health Benefit Plan.(c) The Carrier has a clearly articulated system in place for Providers to appeal to the Carrier the tier in which each is placed. Descriptions of criteria such as data sources and methodologies for placing Providers in specific tiers shall be made available to a Provider prior to the appeal process.(d) Variations on cost-sharing between Provider tiers are reasonable in relation to the premium charged: 1. Carriers may offer more than two benefit level tiers of Providers within the Tiered Provider Network; and2. Variations among each of the benefit level tiers must be reasonable in relation to the premium charged.(2) A Carrier must use defined criteria and evaluation systems that are coordinated by appropriate Carrier staff and overseen by the Carrier's medical director to classify Providers by benefit level tier.(3) A Carrier shall provide detailed information on its website and available in paper form, on request, about its Tiered Network Plan(s), including, but not limited to: (a) The Providers participating in the Tiered Network Plan;(b) The selection criteria used to select the Providers;(c) The potential for Providers to move from one tier to another at any time; and(d) The tier, if any, in which each Provider is classified.(4) A Carrier may reclassify Providers within Health Benefit Plans using a Tiered Provider Network among the tiers as follows: (a) A provider may be reclassified from a lower cost sharing tier to a higher cost sharing tier only on the Carrier's Reclassification Date.(b) A Carrier that is reclassifying a Provider from a lower cost-sharing tier to a higher cost-sharing tier shall submit the following information to the Division: 1. At least five months prior to the effective date of the change in tier, the Carrier shall submit to the Division a copy of the material the Carrier will use to notify all Providers within the Tiered Provider Network who are expected to be reclassified to a higher cost-sharing tier, which shall explain: a. The tier in which the Provider is being classified;b. The process and the Health Benefit Plan-specific data used by the Carrier to make the reclassification decision;c. The process by which the Provider may obtain additional information regarding the Carrier's reclassification decision;d. Notification of the Provider's right to appeal to the Carrier the reclassification decision within 30 days after receiving notice of such decision from the Carrier; ande. The process by which the Provider may appeal the reclassification decision to the Carrier, which shall be completed by the Carrier within 40 days after the Provider received notice of such decision from the Carrier;2. A copy of Provider directories and internet-based list of the Providers in Health Benefit Plans using the Tiered Provider Network, which shall be updated and submitted to the Division at least 90 days before the Reclassification Date with a list of the tier in which each Provider will be classified; and3. At least 90 days before the Reclassification Date, a Carrier shall provide to the Division a copy of any material changes to Marketing Material that will be used in employer and individual open enrollment documents for coverage effective on or after the Reclassification Date to notify all prospective subscribers and renewing subscribers of the new tiering classifications.4. At least 90 days before the Reclassification Date, the Carrier shall submit a copy of all information that shall be provided to subscribers pursuant to 211 CMR 152.04(5).(5) For any Health Benefit Plans that will be in effect on the Reclassification Date, the Carrier shall make a reasonable effort to provide, by mail or electronically, certain information to subscribers at least 30 days before the Reclassification Date. This information shall include, but not be limited to the following notices: (a) If the Carrier allows or requires the designation of a PCP, a statement provided to all subscribers whose PCP has been reclassified to a higher cost-sharing tier which shall describe the process used to reclassify Providers, explain how to access a list of the reclassified Providers and describe the procedure for choosing an alternative PCP to obtain treatment at the same cost-sharing level.(b) If a subscriber is in her second or third trimester of pregnancy and a Provider in connection with her pregnancy is reclassified to a higher cost-sharing level, the statement provided to such a subscriber shall identify the process used to reclassify the Provider, the new benefit tier for the Provider and the new cost-sharing level for continued treatment by that Provider. The statement also shall include a description of the procedure for choosing an alternative Provider to continue treatment associated with the pregnancy.(c) If a Carrier is aware that a subscriber is terminally ill and a Provider providing treatment in connection with such illness is reclassified to a higher cost-sharing level, a statement shall be provided to such subscriber identifying the process used to reclassify the Provider, the new benefit tier for the Provider treating the illness and the new cost-sharing level for continued treatment by that Provider and a description of the procedure for choosing an alternative Provider to continue treatment associated with the illness.