Carrier's Coverage Conditions

(1) A carrier may condition coverage of continued treatment by a provider under 958 CMR 3.500 through 3.502, upon the provider's agreeing: (a) to accept reimbursement from the carrier at the rates applicable prior to the notice of disenrollment as payment in full; (b) to not impose cost sharing with respect to the insured in an amount that would exceed the cost sharing that could have been imposed if the provider had not been disenrolled; (c) to adhere to the quality assurance standards of the carrier and to provide the carrier with necessary medical information related to the care provided; and, (d) to adhere to such carrier's policies and procedures, including procedures regarding referrals, obtaining prior authorization and providing treatment pursuant to a treatment plan, if any, approved by the carrier. (2) A carrier may condition coverage of treatment by a provider under 958 CMR 3.503 upon the provider's agreeing: (a) to accept reimbursement from the carrier at the rates applicable to participating providers as payment in full; (b) to not impose cost sharing with respect to the insured in an amount that would exceed the cost sharing that could have been imposed if the provider participated in the carrier's network; (c) to adhere to the quality assurance standards of the carrier and to provide the carrier with necessary medical information related to the care provided; and (d) to adhere to the carrier's policies and procedures, including procedures regarding referrals, obtaining prior authorization and providing treatment pursuant to a treatment plan, if any, approved by the carrier. (3) Nothing in 958 CMR 3.500 through 3.502 or 3.504 shall be construed to require the coverage of benefits that would not have been covered if the provider involved had remained a participating provider. Nothing in 958 CMR 3.503 shall be construed to require coverage of benefits that would not have been covered if the provider involved was a participating provider.