Student Health Insurance Program Requirements

(1) Required Benefits. A School's Student Health Insurance Program must provide benefits that are substantially equal to the Essential Health Benefits Benchmark Plan, in a manner consistent with the requirements and procedures of 45 CFR § 156.115. (2) Other Requirements. A School's Student Health Insurance Program: (a) may not exclude or limit coverage, except as otherwise permitted by 956 CMR 8.04(3), of any Student who is away from campus for any reason; (b) must include services delivered in accordance with the healing practices of Christian Science; (c) for all plan years beginning January 1, 2014, or later must not impose an annual or lifetime limit on the dollar amount of required benefits for any covered individual, as established in 956 CMR 8.04(1); (d) must offer a prorated premium refund to any Student who paid to enroll in a Student Health Insurance Program for an entire School Year but who is not a Student at the beginning of a term during that School Year, provided the School is not required to offer such a refund to a Student who disenrolls during a term; offer a prorated premium refund to any Student who paid to enroll in a Student Health Insurance Program for an entire School Year but who becomes eligible for a subsidized Health Benefit Plan through the Connector or becomes eligible for MassHealth, and who uses enrollment in such coverage to waive the School's Student Health Insurance Program, provided the refund shall be prorated by term and provided the Student becomes eligible prior to the beginning of the term for which the refund is requested; offer Students the opportunity to enroll in partial year coverage, which may be prorated by term; and specify in writing its policy regarding premium refunds and partial year Student enrollment; (e) must comply with the standards and requirements set out in 45 CFR § 147.136 with regard to internal claims and appeals. Carriers must provide Students with notification of the right of appeal to the Office of Patient Protection; (f) must designate at least one member of the School's staff as the Student Health Insurance Program contact person to help Students with any Student Health Insurance Program issues that may arise; (g) must not consider a Student a late enrollee if a request for enrollment is made within 60 days after termination of coverage under another health insurance plan, including MassHealth and prorate premiums for such Student based on the month of enrollment in the Student Health Program; (h) must comply with the standards and requirements set out in 45 CFR § 147.108 with regard to preexisting condition exclusions; (i) must comply with the standards and requirements set out in 45 CFR §§ 147.104 and 147.106 with regard to availability and renewability of coverage, except for those exemptions applicable to Student health insurance in 45 CFR §147.145(b); (j) must comply with the standards and requirements set out in 45 CFR § 147.110 with regard to discriminating against beneficiaries; (k) must comply with the standards and requirements set out in 45 CFR § 147.128 with regard to rescission of coverage; (l) must comply with the standards and requirements set out in 45 CFR § 147.130 with regard to cost-sharing for preventive services; except that Student administrative health fees are considered in the same manner as in 45 CFR § 147.145(c); (m) must comply with the standards and requirements set out in 45 CFR § 147.138(a) with regard to choice of healthcare professionals; (n) must comply with the standards and requirements set out in 45 CFR § 147.138(b) with regard to coverage of Emergency Services, including services received out of network; (o) must comply with the standards and requirements set out in 45 CFR 148.170 with regard to benefits for mothers and newborns; and (p) must comply with the standards and requirements set out in 45 CFR 148.180 with regard to discrimination based on genetic information. (3) Permissible Exclusions and Limitations. Unless otherwise prohibited by 956 CMR 8.04(1) and (2), a School's Student Health Insurance Program may: (a) impose reasonable exclusions and limitations including different benefit levels for in-network and out-of-network providers; (b) impose reasonable co-payments and deductibles. The School's Student Health Insurance Program must specify the co-pay amount for in-network and out-of-network office, clinic, and hospital visits. Cost-sharing requirements must follow requirements outlined in 956 CMR 5.03(1)(c) through (e). (c) exclude charges reimbursable by any other valid and collectible medical insurance plan, provided that any charges in excess of the limits of such other medical insurance plan must be reimbursed as otherwise provided in the School's Student Health Insurance Program; and (d) exclude hospital or medical care resulting from participation in intercollegiate athletics provided that such care is covered under another health insurance program with equal or greater coverage. (4) Student Health Service. A School may designate its on-campus student health service as an in-network provider for certain health services, so long as the School’s on-campus student health service is equipped to adequately provide such services as required by law. Otherwise the program must arrange for outside providers to act as its in-network service provider(s). (5) Additional Benefits. A School's Student Health Insurance Program may offer benefit levels that exceed the minimum requirements. In designing Student Health Insurance Programs, Schools may take into consideration the following factors: the type and nature of the student body, the size of the campus, the location of the campus, the extent of on-campus health services, the ability of individual Students to purchase Health Benefit Plans, and the ability of the School to join with other Schools for the purpose of securing savings through collective bidding for Student Health Insurance Programs. (6) Disclosure. Schools must make available and accessible to Students, at the same time registration materials become available but no less than 30 days in advance of the registration deadline, information regarding all benefits and services available to the Student under the Student Health Insurance Program together with applicable limitations and exclusions, provided that such information has been approved by the Division of Insurance where the Division of Insurance requires such approval. If such information has not been approved by the Division of Insurance within the specified timeframe, the information must be posted within seven days of receiving approval from the Division of Insurance. Such information, including the Student Health Insurance Program's Evidence of Coverage and contact information for the School Student Health Insurance Program contact person, must be made available on the School's website or via a link on the School's website and its availability communicated by other channels through which student health information is commonly distributed to Students.