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Private Insurance Data Requirements in Massachusetts

Massachusetts law requires that all consumers have access to their personal or medical information from an insurance company.  An individual who seeks his or her recorded personal information from the insurance company must submit a written request to the insurance company.1  There are also regulations in place that prevent health insurance companies from disclosing consumers’ privileged or personal information without the individual’s written authorization.2  As part of Massachusetts health care overhaul, employers and employees are required to fill out a health insurance responsibility form, on which insurance coverage is reported.  This information cannot be made public, however, it may be shared with the Department of Revenue, the Commonwealth Health Insurance Connector, and the Health Care Access Bureau within the Department of Insurance, for enforcement purposes.3

All insurers must inform their consumers of how to file grievances,4 establish a policy for consumers to file grievances5 and as well as system to maintain records of each grievance and its outcome.6  Any confidential medical information obtained as part of the grievance process cannot be released unless the individual authorizes its release in writing.7  Additionally, health insurers are required to provide its consumers with a list of providers, information about their rights as consumers, and payment, cost and utilization information, upon request.8

Massachusetts also requires private health plans to report all individuals who are also recipients of medical assistance to the Division of Insurance.  The law prohibits the health plan from being held liable for the release of this information.9  Further reporting required by the state includes uniform reporting of information from private payers of health care to allow the Division of Health Care Finance and Policy to analyze changes in cost and utilization, reporting of claims data in order to develop and maintain a database of health care claims, and reporting of summary information about plans and costs, and provider payments.10

 

Footnotes

  • 1. M.G.L.A. 175I §8
  • 2. M.G.L.A. 175I §13
  • 3. M.G.L.A. 118G §6C
  • 4. 105 MA ADC 128.301
  • 5. 105 MA ADC 128.302; 105 MA ADC 128.300
  • 6. 105 MA ADC 128.303
  • 7. 105 MA ADC 128.313
  • 8. M.G.L.A. 176O §7
  • 9. M.G.L.A. 26 §8H
  • 10. M.G.L.A. 118G §6

 

Private Insurance Data Requirements in Massachusetts

Subtopic Statute/Regulation Description
Health plan required reporting 956. Mass. Code Regs. 8.06. - Recordkeeping “Recordkeeping”   Requiresschools maintain records sufficient to demonstrate compliance with 956 Mass. Code Regs. 8.00, including:...
956. Mass. Code Regs. 8.07. - Reporting “Reporting”   Each school must report to the Division, the total number of students who are required to participate in their school'...
Mass. Gen. Laws. Ann. ch. 112, §5C - Reports by insurers of malpractice claims or actions “Reports by insurers of malpractice claims or actions; liability”   Every insurer or risk management organization must report to the...
Mass. Gen. Laws. Ann. ch. 176O, § 7 - Information Provided by Carrier Upon Enrollment or Upon Request A health insurance carrier must provide the following information to an insured person either upon enrollment or to a prospective consumer upon...
Private Insurance Data Requirements 958. Mass. Code Regs. 3.001. - Scope and Purpose All insurance carriers must establish a system for internal grievance procedures and establish standards for external reviews of adverse...
958. Mass. Code Regs. 3.300. - Right to an Internal Grievance Process An insurance carrier is required to have an internal grievance procedure that has adequate consideration and timely resolution of grievances....
958. Mass. Code Regs. 3.301. - Information on Internal Grievance Process The insurance carrier must provide the insured with a written description of the internal grievance procedure, a customer assistance number, and...
958. Mass. Code Regs. 3.302. - Form and Manner of Request The insurance carrier must have a process to accept grievances by phone, in person, by mail, or electronic means.  All oral grievances must be...
958. Mass. Code Regs. 3.303. - Carrier and Utilization Review Organization Records of Grievances Carrier and Utilization Review Organization Records of Grievances The insurance carrier must establish a system to maintain records of each grievance...
958. Mass. Code Regs. 3.313. - Confidentiality An insured individual must sign a release before an insurance carrier can release medical or treatment information or other information as part of an...
958. Mass. Code Regs. 3.409. - Medical Records and Information “Medical Records and Information”   This section establishes how carriers shall make good faith efforts to obtain records relevant...
Mass. Gen. Laws. Ann. ch. 175I, § 13 - Personal or privileged information from insurance transactions; disclosure An insurance company may not disclose any personal or privileged information received in the course of business unless the individual has provided a...
Mass. Gen. Laws. Ann. ch. 175I, § 8 - Recorded personal information; medical record information; disclosure; fees An insurance company must make any personal information collected about an individual available to the individual to whom it refers.  An...
Disclosure of information held by health plan, including notice requirements 958. Mass. Code Regs. 3.416. - Confidentiality - External Review “Confidentiality - External Review”   In order to release medical and treatment information or other information obtained as part of...
Mass. Gen. Laws. Ann. ch. 111M, §3 - Exemption for refusal of coverage based upon sincerely held religious belief; administration; data sharing “Exemption for refusal of coverage based upon sincerely held religious belief; administration; data sharing”   An individual shall...
Cost reporting by insurance companies (Cross reference Provider Resource Use) 958. Mass. Code Regs. 3.600. - Reporting Requirements “Reporting Requirements”   Carriers must provide the information set forth in this section to the Office of Patient Protection each...
Mass. Gen. Laws. Ann. ch. 12C, § 10 - Reporting requirements for private and public health care payers and third-party administrators The Center for Health Information and Analysis must require the uniform reporting of information from public and private health care payers,...