Governor Deval Patrick's Budget Recommendation - House 1 Fiscal Year 2008

Governor's Budget Recommendation FY2008

Executive Office of Health and Human Services


Suggestions Awards Board

SECTION 5.   Section 31A of chapter 7 of the General Laws, as so appearing, is hereby amended by striking out, in line 19, the words "subject to appropriation, expend sums" and inserting in place thereof the following words:- retain a portion of new revenues received or savings generated in other items of appropriation and may expend these retained amounts without further appropriation.

 

Collection of Fraudulent Overpayments by DTA

SECTION 7.   The first paragraph of subsection (a) of section 30 of chapter 18 of the General Laws, as appearing in the 2004 Official Edition, is hereby amended by adding the following 2 sentences:- At the expiration of any period of probation or court supervision, the commissioner of probation shall provide the department with information regarding the amount of any uncollected balance of an overpayment obligation under the judgment or order of the court. The department may use any means provided by law to collect the balance under a judgment or order of a court, or to collect an overpayment obligation established by an administrative hearing decision of the department or by voluntary agreement.

 

Medicare Part D and Prescription Advantage

SECTION 8.   Section 39 of chapter 19A of the General Laws, as so appearing, is hereby amended by inserting after subsection (s) the following 3 subsections:-

          (t) Cost sharing required of enrollees in the form of co-payments, premiums, and deductibles, or any combination of these forms, shall be adjusted by the department to reflect price trends for outpatient prescription drugs, as determined by the secretary. In addition to the eligibility requirements set forth in this section, to be considered eligible for the program, individuals who receive Medicare and are applying for, or are then enrolled in, the program shall also be enrolled in a Medicare prescription drug plan, a Medicare Advantage prescription drug plan, or in a plan which provides creditable prescription drug coverage as defined by section 104 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, in this section called MMA, and which provides coverage of the cost of prescription drugs actuarially equal to or better than that provided by Medicare Part D, in this section called a creditable coverage plan.

          (u) In addition to the eligibility requirements set forth in this section, to be considered eligible for the program, individuals who receive Medicare and are applying for, or are then enrolled in, the program, who may qualify for the low-income subsidy provided under MMA Subpart P - Premiums and cost-sharing subsidies for low-income individuals, shall apply for those subsidies. To the extent permitted by MMA and regulations adopted under it, and all other applicable federal law, the program may apply on behalf of a member for enrollment into a Medicare prescription drug plan or for the low-income subsidy provided under MMA and may receive information about the member's eligibility and enrollment status necessary for the operation of the program.

          (v) For enrollees who qualify for enrollment in a Medicare Part D plan, the program shall provide a supplemental source of financial assistance for prescription drug costs, in this section called supplemental assistance in lieu of the catastrophic prescription drug coverage provided under this section. The program shall provide supplemental assistance for premiums, deductibles, payments, and co-payments required by a Medicare prescription drug plan or Medicare Advantage prescription drug plan, and shall provide supplemental assistance for deductibles, payments and co-payments required by a creditable coverage plan. The department may take steps for the coordination of these benefits. The department shall establish the amount of the supplemental assistance it will provide enrollees based on a sliding income scale and the coverage provided by the enrollees' Medicare prescription drug plan, Medicare Advantage prescription drug plan, or creditable coverage plan. In addition to the eligibility requirements set forth in this section, to be considered eligible for the program, an individual must have a household income of less than 500 per cent of the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. section 9902(2). Residents of the commonwealth who are not eligible for Medicare will continue to be eligible for the program under this section.

 

Repeal Health Care Security Trust Fund

SECTION 13.   Chapter 29D of the General Laws is hereby repealed.

 

Redistribution of the Physician Licensing Cycle

SECTION 16.   Section 2 of chapter 112 of the General Laws, as so appearing, is hereby amended by striking out the sixth paragraph and inserting in place thereof the following paragraph:-

          The board shall require that all physicians registered in the commonwealth renew their certificates of registration with the board at 2-year intervals. Effective in 2008, physicians born in an even-numbered year and registered in the commonwealth shall renew their certificates of registration with the board on their birthday in each succeeding even-numbered year, and physicians born in odd-numbered years shall renew their certificates of registration with the board on their birthday in each succeeding odd-numbered year. Physicians who renew their certificates of registration with the board in the year 2008 and who were born in an odd-numbered year shall renew their certificates of registration with the board on their birthday in the year 2011 if they pay a fee equal to one and a half times the fee determined for a 2-year renewal. Physicians who renew their certificates of registration with the board in the year 2007 and who were born in an even-numbered year shall renew their certificates of registration with the board on their birthday in the year 2010 if they pay a fee equal to one and a half times the fee determined for a 2-year renewal. Nothing in this section shall prevent the board from specifying the duration of limited licenses at its discretion, but if the birthday of any physician who shall be registered under this section shall occur within 3 months after original registration, that person need not renew the registration until the person's birthday in the second year following that birthday. For the purposes of this section, the birthday of a person born on February 29 shall be considered to be February 28. The renewal application shall be accompanied by a fee determined under the previously mentioned section and shall include the physician's name, license number, home address, office address, specialties, the principal setting of the physician's practice, and whether the person is an active or inactive practitioner.

 

MassHealth - Employer-Sponsored Insurance Right of Subrogation

SECTION 17.   Section 9A of chapter 118E of the General Laws, as amended by section 17 of chapter 324 of the acts of 2006, is hereby further amended by adding the following subsection:-

          (16) The executive office of health and human services shall enroll MassHealth members in available employer-sponsored health insurance if that insurance meets the criteria for MassHealth payment of premium assistance, and if federal approval will be obtained to ensure federal reimbursement for premium assistance for that insurance.

 

Children's Medical Security Plan Premiums

SECTION 18.   Section 10F of said chapter 118E, as appearing in the 2004 Official Edition, is hereby amended by striking out subsection (d) and inserting in place thereof the following subsection:-

          (d) The cost of this program shall be funded in part by premiums contributed by enrollees. These premiums shall be set forth in regulations of the executive office of health and human services.

 

Codify MassHealth Essential

SECTION 19.   Chapter 118E of the General Laws is hereby further amended by inserting after section 10F the following section :-

          Section 10G. The executive office of health and human services shall administer a program of preventive and primary care for chronically unemployed persons who are not receiving unemployment insurance benefits, whom the office determines to be long-term unemployed. These persons shall meet the eligibility requirements in section 9A, but their income shall not exceed the federal poverty level. Persons who are employed intermittently or on a non-regular basis shall not be excluded. The office may restrict provision of care to persons under this program to certain providers, taking into account capacity, continuity of care, and geographic considerations. The office may limit or close enrollment in this program if necessary to ensure that expenditures for this program do not exceed the amount appropriated. Persons eligible under subsection (7) of section 16D shall also be eligible to receive benefits under this program.

 

MassHealth - Third Party Liability to Satisfy Federal Law

SECTION 20.   Chapter 118E of the General Laws is hereby further amended by striking out section 23, as amended by section 28 of chapter 58 of the acts of 2006, and inserting in place thereof the following section:-

          Section 23. (a) As used in this section, health care insurer, health insurer and health insurance shall include, but not be limited to, any health insurance company, health maintenance organization, group or nongroup health plan, self-insured plan, service benefit plan, managed care organization, pharmacy benefit manager, or other public or private third party that is, by statute, contract, agreement, or arrangement legally responsible for payment of a claim for health care benefits.

          (b) Notwithstanding any general or special law, rule or regulation to the contrary, the division shall be subrogated to the rights of any recipient of medical assistance under this chapter and may take any and all actions available to that recipient to secure benefits under any policy issued by any health care insurer that is or may be liable to pay for health care benefits obtained by a recipient of medical assistance to the extent of any health care benefits provided by the division on behalf of the recipient or the recipient's dependents. A health care insurer shall reimburse the division for any health care benefits provided by the division on behalf of a recipient of medical assistance, and shall not reduce the amount of the total reimbursement by any division payment, but any part of the total that is a reimbursement for a division payment shall not exceed the amount actually paid by the division.

          (c) No health care insurer shall require written authorization from the recipient before honoring the division's rights under this section. A health insurer must respond to any inquiry by the division about a claim for payment for any health care benefits and may not deny any claim for payment for any health care benefits solely on the basis of the date of submission of the claim, the type of format for the claim form, or a failure to present proper documentation at the point of sale that is the basis of the claim, if the claim is submitted by the division within a 3-year period beginning on the date on which the service was furnished, and if any action by the division to enforce its rights with respect to a claim is filed within 6 years after the submission of the claim to the health insurer.

          (d) A recipient of medical assistance or any person legally obligated to support and have actual or legal custody of a recipient of medical assistance shall inform the division of any health insurance available to that recipient upon initial application and redetermination for eligibility for assistance and shall make known the nature and extent of any health insurance coverage to any person or institution that provides medical benefits to the recipient or his or her dependent.

          (e) A health care insurer shall not take into account that an individual is eligible for or is receiving benefits from the division when enrolling an individual or issuing a policy or agreement covering the individual, or administering or renewing a policy or agreement, or when making any payment for health care benefits to the individual or on behalf of the individual; nor shall any policy or agreement issued, administered, or renewed by a health care insurer contain any provision denying or reducing health care benefits to an individual who is eligible for or is receiving benefits from the division.

          (f) A provider of medical assistance under this chapter shall determine whether any recipient for whom it provides medical care or services which are or may be eligible for reimbursement under this chapter is a subscriber or beneficiary of a health insurance plan. The division is the payor of last resort, and accordingly a provider shall request payment for medical care or services it provides from a health insurer which is or may be liable for the medical care or services so provided, before payment is requested from the division.

          (g) Payment by the division under the medical assistance programs established by this chapter shall constitute payment in full; after receiving this payment a provider may not recover from any health insurer an amount greater than the amount paid by the division for any service for which the division is to be the payor of last resort.

          (h) Notwithstanding any general or special law or rule or regulation to the contrary, all holders of health insurance information, including, but not limited to, health insurers doing business in the commonwealth, all private and public entities who employ individuals in the commonwealth, and all agencies of the commonwealth, shall provide sufficient information to the division, or in the case of those agencies, shall make other arrangements mutually satisfactory to both agencies, to enable the division: (a) to identify whether any of the following persons are or could be beneficiaries under any policy of insurance in the commonwealth: (1) persons applying for or receiving medical assistance or benefits under this chapter or health services through an agency under the executive office of health and human services, (2) persons for whom hospitals and community health centers claim reimbursement payments from the Health Safety Net Fund, established by section 35 of chapter 118G; and (b) to determine the nature of the coverage that is or was provided, including cost, scope, terms, periods of coverage, and any identifying name, address or number of the policy of insurance. .All public and private entities who employ individuals in the commonwealth shall provide, when requested by any employee applying for or receiving benefits provided by the division, written information to the employee describing the availability of health insurance, if any, provided by or through the employer. The failure of an employer to provide an employee with the information shall not be grounds for denial of benefits by the division.

          (i) The division may, after notice and opportunity for hearing, garnish the wages, salary, or other employment income of, and shall, with the assistance of the department of revenue under section 3 of chapter 62D, withhold amounts from state tax refunds to, any person who: (a) is required by court or administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance under this chapter; (b) has received payment from a third party for the costs of those services to the child; but, (c) has not used the payments to reimburse either the other parent or guardian of the child or the provider of the services, to the extent necessary to reimburse the division for expenditures for those costs.

 

MassHealth - Wellness Program

SECTION 21.   Section 54 of said chapter 118E, inserted by section 29 of said chapter 58, is hereby amended by striking out the second and third sentences and inserting in place thereof the following 2 sentences:- The executive office may reduce MassHealth premiums or copayments, or offer other incentives to encourage enrollees to comply with wellness goals. The executive office shall report annually to the joint committee on health care financing and the house and senate committees on ways and means on the number of enrollees who meet at least 1 wellness goal, any reduction of copayments or premiums, and any other incentives provided because enrollees met wellness goals.

 

Transfer of the Health Safety Net Office to HCFP (2 of 3)

SECTION 23.   Section 1 of chapter 118G of the General Laws, as amended by sections 22 and 23 of chapter 324 of the acts of 2006, is hereby amended by inserting after the definition of "Acute hospital" the following definition:-
"Allowable reimbursement", payments to acute hospitals and community health centers for health services provided to uninsured patients of the commonwealth under section 38 and any further regulations adopted by the office.

and is further amended by striking out the definition of "Bad debt" and inserting in place thereof the following definition:-
"Bad debt", an account receivable based on services furnished to a patient which: (i) is regarded as uncollectible, following reasonable collection efforts consistent with regulations of the office, which regulations shall allow third party payers to negotiate with hospitals to collect the bad debts of its enrollees; (ii) is charged as a credit loss; (iii) is not the obligation of a governmental unit or the federal government or any agency thereof; and (iv) is not a reimbursable health care service.

and is hereby further amended by inserting after the definition of "Dependent" the following definition:-
"Director", the director of the health safety net office.

and is further amended by striking out the definition of "Emergency bad debt" and inserting in place thereof the following definition:-
"Emergency bad debt", bad debt resulting from emergency services provided by an acute hospital to an uninsured or underinsured patient or other individual who has an emergency medical condition that is regarded as uncollectible, following reasonable collection efforts consistent with regulations of the office.

and is further amended by striking out the definition of "Financial requirements" and inserting in place thereof the following definition:-
"Financial requirements", a hospital's requirement for revenue which shall include, but not be limited to, reasonable operating, capital and working capital costs, and the reasonable cost associated with changes in medical practice and technology.

and is hereby further amended by inserting after the definition of "Free care" the following 2 definitions:-

"Fund", the Health Safety Net Trust Fund, established by section 35.

"Fund fiscal year", the 12-month period starting on October 1 and ending on September 30.

and is hereby further amended by inserting striking out the definition of "medically necessary services" and inserting in place thereof the following definition:-
"Medically necessary services" or "health services", medically necessary inpatient and outpatient services as mandated under Title XIX. Health services shall not include: (i) non-medical services, such as social, educational and vocational services; (ii) cosmetic surgery; (iii) cancelled or missed appointments; (iv) telephone conversations and consultations; (v) court testimony; (vi) research or the provision of experimental or unproven procedures, including, but not limited to, treatment related to sex reassignment surgery and pre-surgery hormone therapy; and (vii) the provision of whole blood, but the administrative and processing costs associated with the provision of blood and its derivative shall be payable.

and is hereby further amended by inserting after the definition of "Non-providing employer" the following definition:-
"Office", the health safety net office, established by section 34.

and is further amended by striking out the definition of "Payments from non-providing employers" and inserting in place thereof the following definition:-
"Payments from non-providing employers", all amounts paid to the Commonwealth Care Trust Fund by non-providing employers.

and is further amended by striking out the definition of "Payments subject to surcharge" and inserting in place thereof the following definition:-
"Payments subject to surcharge", all amounts paid, directly or indirectly, by surcharge payers to acute hospitals for health services and ambulatory surgical centers for ambulatory surgical center services, but "payments subject to surcharge" shall not include: (i) payments, settlements and judgments arising out of third party liability claims for bodily injury which are paid under the terms of property or casualty insurance policies; (ii) payments made on behalf of Medicaid recipients, Medicare beneficiaries, or persons enrolled in policies issued under chapter 176K or similar policies issued on a group basis; and "payments subject to surcharge" may exclude amounts established by regulation adopted by the division for which the cost and efficiency of billing a surcharge payer or enforcing collection of the surcharge from a surcharge payer would not be cost effective.

and is hereby further amended by inserting after the definition of "Purchaser" the following definition:-
"Reimbursable Health Services", health services provided to uninsured and underinsured patients who are determined to be financially unable to pay for their care, in whole or in part, under applicable regulations of the office; provided that the health services are emergency, urgent and critical access services provided by acute hospitals or services provided by community health centers; and provided further, that the services shall not be eligible for reimbursement by any other public or private third party payer.

and is hereby further amended by inserting after the definition of "Title XIX" the following definition:-
"Underinsured patient", a patient whose health insurance plan or self-insurance health plan does not pay, in whole or in part, for health services that are eligible for reimbursement from the Health Safety Net Trust Fund, provided that the patient meets income eligibility standards set by the office.

and is hereby further amended by striking out the definition of "Uninsured patient" and inserting in place thereof the following definition:-
"Uninsured patient", a patient who is a resident of the commonwealth, who is not covered by a health insurance plan or a self-insurance health plan and who is not eligible for a medical assistance program.

 

Hospital Assessments for HCFP and HSNO Administrative Funding

SECTION 24.   Section 5 of said chapter 118G, as amended by section 40 of chapter 58 of the acts of 2006, is hereby further amended by inserting after the second sentence the following sentence:- The assessed amount shall not be less than 65 percent of the total expenses appropriated for the division and the health safety net office.

 

Move Nursing Home Assessment to General Fund for MassHealth

SECTION 25.   Section 25 of said chapter 118G, as appearing in the 2004 Official Edition, is hereby amended by striking out, in lines 24 and 25, the words "Health Care Security Trust Fund established by chapter 29D" and inserting in place thereof the following words:- General Fund.

 

Transfer of the Health Safety Net Office to HCFP (3 of 3)

SECTION 26.   Said chapter 118G of the General Laws is hereby further amended by adding the following 4 sections:-

          Section 34. (a) There shall be a health safety net office within the division of health care finance and policy. The commissioner shall, in consultation with the secretary of health and human services and the Medicaid director, appoint the director of the health safety net office. The director shall have such educational qualifications and administrative and other experience as the commissioner, secretary, and Medicaid director determine to be necessary for the performance of the duties of director including, but not limited to, experience in the field of health care financial administration.
          (b) The office shall have the following powers and duties:-
          (1) to administer the Health Safety Net Trust Fund, established by section 35 of chapter 118G, and to require payments to the fund consistent with acute hospitals' and surcharge payors' liability to the fund, as determined under sections 36 and 37, and any further regulations adopted by the office;
          (2) to set, after consultation with the office of Medicaid, reimbursement rates for payments from the fund to acute hospitals and community health centers for reimbursable health services provided to uninsured and underinsured patients and to disburse monies from the fund consistent with those rates; provided that the office shall implement a fee-for-service reimbursement system for acute hospitals;
          (3) to adopt regulations further defining: (a) eligibility criteria for reimbursable health services; (b) the scope of health services that are eligible for reimbursement by the Health Safety Net Trust Fund; (c) standards for medical hardship; and (d) standards for reasonable efforts to collect payments for the costs of emergency care. The office shall implement procedures for verification of eligibility using the eligibility system of the office of Medicaid and other appropriate sources to determine the eligibility of uninsured and underinsured patients for reimbursable health services and shall establish other procedures to ensure that payments from the fund are made for health services for which there is no other public or private third party payer, including disallowance of payments to acute hospitals and community health centers for free care provided to individuals if reimbursement is available from other public or private sources;
          (4) to develop programs and guidelines to encourage maximum enrollment of uninsured individuals who receive health services reimbursed by the fund into health care plans and programs of health insurance offered by public and private sources and to promote the delivery of care in the most appropriate setting, provided that the programs and guidelines are developed in consultation with the commonwealth health insurance connector, established by chapter 176Q. These programs shall not deny payments from the fund because services should have been provided in a more appropriate setting if the hospital was required to provided the services under 42 U.S.C. 1395 (dd);
          (5) to conduct a utilization review program designed to monitor the appropriateness of services for which payments were made by the fund and to promote the delivery of care in the most appropriate setting; and to administer demonstration programs that reduce Health Safety Net Trust Fund liability to acute hospitals, including a demonstration program to enable disease management for patients with chronic diseases, substance abuse and psychiatric disorders through enrollment of patients in community health centers and community mental health centers and through coordination between these centers and acute hospitals, provided, that the office shall report the results of these reviews annually to the joint committee on health care financing and the house and senate committees on ways and means;
          (6) to administer, in consultation with the office of Medicaid, the Essential Community Provider Trust Fund, established by section 2PPP of chapter 29, and to make expenditures from that fund without further appropriation for the purpose of improving and enhancing the ability of acute hospitals and community health centers to serve populations in need more efficiently and effectively, including, but not limited to, the ability to provide community-based care, clinical support, care coordination services, disease management services, primary care services, and pharmacy management services through a grant program. The office shall consider applications from acute hospitals and community health centers in awarding the grants. The criteria for selection shall include, but not be limited to, the following criteria:-
          (i) the financial performance of the provider as determined, in the case of applications from acute hospitals, quarterly by the division of health care finance and policy and by consulting other appropriate measurements of financial performance;
          (ii) the percentage of patients with mental or substance abuse disorders served by a provider;
          (iii) the numbers of patients served by a provider who are chronically ill, elderly, or disabled;
          (iv) the payer mix of the provider, with preference given to acute hospitals where a minimum of 63 per cent of the acute hospital's gross patient service revenue is attributable to Title XVIII and Title XIX of the federal Social Security Act or other governmental payors, including reimbursements from the Health Safety Net Fund;
          (v) the percentage of total annual operating revenue that funding received in fiscal years 2005 and 2006 from the Distressed Provider Expendable Trust Fund comprised for the provider; and
          (vi) the cultural and linguistic challenges presented by the populations served by the provider.
          (7) to enter into agreements or transactions with any federal, state or municipal agency or other public institution or with a private individual, partnership, firm, corporation, association or other entity, and to make contracts and execute all instruments necessary or convenient for the carrying on of its business;
          (8) to secure payment, without imposing undue hardship upon any individual, for unpaid bills owed to acute hospitals by individuals for health services that are ineligible for reimbursement from the Health Safety Net Trust Fund which have been accounted for as bad debt by the hospital and which are voluntarily referred by a hospital to the department for collection; provided, however that the unpaid charges shall be considered debts owed to the commonwealth and all payments received shall be credited to the fund; and provided, further,that all actions to secure these payments shall be conducted in compliance with a protocol previously submitted by the office to the joint committee on health care financing;
          (9) to require hospitals and community health centers to submit to the office data that it reasonably considers necessary;
          (10) to make, amend and repeal rules and regulations to effectuate the efficient use of monies from the Health Safety Net Trust Fund, but the regulations shall be adopted only after notice and hearing and only upon consultation with the board of the commonwealth health insurance connector, the secretary of health and human services, the director of the office of Medicaid and representatives of the Massachusetts Hospital Association, the Massachusetts Council of Community Hospitals, the Alliance of Massachusetts Safety Net Hospitals and the Massachusetts League of Community Health Centers; and
          (11) to provide an annual report at the close of each fund fiscal year, in consultation with the office of Medicaid, to the joint committee on health care financing and the house and senate committees on ways and means, evaluating the processes used to determine eligibility for reimbursable health services, including the Virtual Gateway. The report shall include (i) an analysis of the effectiveness of these processes in enforcing eligibility requirements for publicly-funded health programs and in enrolling uninsured residents into programs of health insurance offered by public and private sources; (ii) an assessment of the impact of these processes on the level of reimbursable health services by providers; and (iii) recommendations for ongoing improvements that will enhance the performance of eligibility determination systems and reduce hospital administrative costs.

          Section 35. (a) There shall be a Health Safety Net Trust Fund, in this section and sections 36 to 38, inclusive, called the fund, which shall be administered by the health safety net office. Expenditures from the fund shall not be subject to appropriation unless otherwise required by law. The purpose of the fund shall be to maintain a health care safety net by reimbursing hospitals and community health centers for a portion of the cost of reimbursable health services provided to low-income, uninsured or underinsured residents of the commonwealth. The office shall administer the fund using such methods, policies, procedures, standards and criteria that it considers necessary for the proper and efficient operation of the fund and programs funded by it in a manner designed to distribute the fund resources as equitably as possible.
          (b) The fund shall consist of all amounts paid by acute hospitals and surcharge payors under sections 36 and 37; all appropriations for the purpose of payments to acute hospitals or community health centers for health services provided to uninsured and underinsured residents; any transfers from the Commonwealth Care Trust Fund, established by section 2OOO of chapter 29; and all property and securities acquired by and through the use of monies belonging to the fund and all interest on them. Amounts placed in the fund shall, except for amounts transferred to the Commonwealth Care Trust Fund, be expended by the office for payments to hospitals and community health centers for reimbursable health services provided to uninsured and underinsured residents of the commonwealth, consistent with the requirements of this section and section 38 and the regulations adopted by the office; provided, that $6,000,000 shall be expended annually from the fund for demonstration projects that use case management and other methods to reduce the liability of the fund to acute hospitals. Any annual balance remaining in the fund after these payments have been made shall be transferred to the Commonwealth Care Trust Fund. All interest earned on the amounts in the fund shall be deposited or retained in the fund. The director shall from time to time requisition from the fund amounts that he considers necessary to meet the current obligations of the office for the purposes of the fund and estimated obligations for a reasonable future period.

          Section 36. (a) An acute hospital's liability to the fund shall equal the product of (1) the ratio of its private sector charges to all acute hospitals' private sector charges; and (2) $160,000,000. Before October 1 of each year, the office, in consultation with the office of Medicaid, shall establish each acute hospital's liability to the fund using the best data available, as determined by the division, and shall update each acute hospital's liability to the fund as updated information becomes available. The office shall specify by regulation an appropriate mechanism for interim determination and payment of an acute hospital's liability to the fund.
          (b) An acute hospital's liability to the fund shall in the case of a transfer of ownership be assumed by the successor in interest to the acute hospital.
          (c) The office shall establish by regulation an appropriate mechanism for enforcing an acute hospital's liability to the fund in the event that an acute hospital does not make a scheduled payment to the fund. These enforcement mechanisms may include (1) notification to the office of Medicaid requiring an offset of payments on the Title XIX claims of that acute hospital or any health care provider under common ownership with the acute care hospital or any successor in interest to the acute hospital, and (2) the withholding by the office of Medicaid of the amount of payment owed to the fund, including any interest and late fees, and the transfer of the withheld funds into the fund. If the office of Medicaid offsets claims payments as ordered by the office, it shall not be considered to be in breach of contract or any other obligation for the payment of non-contracted services, and providers whose payment is offset under order of the division shall serve all Title XIX recipients under the contract then in effect with the office of Medicaid, or, in the case of a non-contracting or disproportionate share hospital, under its obligation for providing services to Title XIX recipients under this chapter. In no event shall the office direct the office of Medicaid to offset claims unless an acute hospital has maintained an outstanding obligation to the Health Safety Net Fund for a period longer than 45 days and has received proper notice that the division intends to initiate enforcement actions under the regulations of the office.

          Section 37. (a) Acute hospitals and ambulatory surgical centers shall assess a surcharge on all payments subject to surcharge as defined in section 1. The surcharge shall be distinct from any other amount paid by a surcharge payor for the services of an acute hospital or ambulatory surgical center. The surcharge amount shall equal the product of (i) the surcharge percentage and (ii) amounts paid for these services by a surcharge payor. The office shall calculate the surcharge percentage by dividing $160,000,000 bythe projected annual aggregate payments subject to the surcharge. The office shall determine the surcharge percentage before the start of each fund fiscal year and may redetermine the surcharge percentage before April 1 of each fund fiscal year if the office projects that the initial surcharge established the previous October will produce less than $150,000,000 or more than $170,000,000. Before each succeeding October 1, the office shall redetermine the surcharge percentage incorporating any adjustments from earlier years. In each determination or redetermination of the surcharge percentage, the office shall use the best data available as determined by the division and may consider the effect on projected surcharge payments of any modified or waived enforcement under subsection (e). The office shall incorporate all adjustments, including, but not limited to, updates or corrections or final settlement amounts, by prospective adjustment rather than by retrospective payments or assessments.
          (b) Each acute hospital and ambulatory surgical center shall bill a surcharge payor an amount equal to the surcharge described in subsection (a) as a separate and identifiable amount distinct from any amount paid by a surcharge payor for acute hospital or ambulatory surgical center services. Each surcharge payor shall pay the surcharge amount to the office for deposit in the Health Safety Net Trust Fund on behalf of that acute hospital or ambulatory surgical center. Upon the written request of a surcharge payor, the office may implement another billing or collection method for the surcharge payor; provided, however, that the office has received all information that it requests which is necessary to implement the billing or collection method; and provided further, that the office shall specify by regulation the criteria for reviewing and approving such requests and the elements of such alternative method or methods.
          (c) The office shall specify by regulation appropriate mechanisms that provide for determination and payment of a surcharge payor's liability, including requirements for data to be submitted by surcharge payors, acute hospitals and ambulatory surgical centers.
          (d) A surcharge payor's liability to the Health Safety Net Trust Fund shall in the case of a transfer of ownership be assumed by the successor in interest to the surcharge payor.
          (e) The office shall establish by regulation an appropriate mechanism for enforcing a surcharge payor's liability to the Health Safety Net Trust Fund if a surcharge payor does not make a scheduled payment to the fund, but the office may, for the purpose of administrative simplicity, establish threshold liability amounts below which enforcement may be modified or waived. The enforcement mechanism may include assessment of interest on the unpaid liability at a rate not to exceed an annual percentage rate of 18 per cent and late fees or penalties at a rate not to exceed 5 per cent per month. The enforcement mechanism may also include notification to the office of Medicaid requiring an offset of payments on the claims of the surcharge payor, any entity under common ownership or any successor in interest to the surcharge payor, from the office of Medicaid in the amount of payment owed to the Health Safety Net Trust Fund including any interest and penalties, and to transfer the withheld funds into the fund. If the office of Medicaid offsets claims payments as ordered by the office, the office of Medicaid shall be considered not to be in breach of contract or any other obligation for payment of noncontracted services, and a surcharge payor whose payment is offset under order of the division shall serve all Title XIX recipients under the contract then in effect with the executive office of health and human services. In no event shall the office direct the office of Medicaid to offset claims unless the surcharge payor has maintained an outstanding liability to the Health Safety Net Trust Fund for a period longer than 45 days and has received proper notice that the office intends to initiate enforcement actions under the regulations of the office.
          (f) If a surcharge payor fails to file any data, statistics or schedules or other information required under this chapter or by any regulation adopted by the office, the office shall provide written notice to the payor. If a surcharge payor fails to provide required information within 2 weeks after the receipt of written notice, or falsifies the same, he shall be subject to a civil penalty of not more than $5,000 for each day on which the violation occurs or continues, which penalty may be assessed in an action brought on behalf of the commonwealth in any court of competent jurisdiction. The attorney general shall bring any appropriate action, including injunctive relief, that may be necessary for the enforcement of this chapter.

          Section 38. (a) Reimbursements from the fund to hospitals and community health centers for health services provided to uninsured individuals shall be made in the following manner, and shall be subject to further rules and regulations promulgated by the office.
          (1) Reimbursements made to acute hospitals shall be based on actual claims for health services provided to uninsured and underinsured patients that are submitted to the office, and shall be made only after determination that the claim is eligible for reimbursement under this chapter and any additional regulations adopted by the office. Reimbursements for health services provided to residents of other states and foreign countries shall be prohibited, and the office shall make payments to acute hospitals using fee-for-service rates calculated as provided in paragraphs (4) and (5).
          (2) The office shall, in consultation with the office of Medicaid, develop and implement procedures to verify the eligibility of individuals for whom health services are billed to the fund and to ensure that other coverage options are used fully before services are billed to the fund, including procedures adopted under section 35 of chapter 118G. The office shall review all claims billed to the fund to determine whether the patient is eligible for medical assistance under chapter 118G and whether any third party is financially responsible for the costs of care provided to the patient. In making these determinations, the office shall verify the insurance status of each individual for whom a claim is made using all sources of data available to the office. The office shall refuse to allow payments or shall disallow payments to acute hospitals and community health centers for free care provided to individuals if reimbursement is available from other public or private sources, but payments shall not be denied from the fund because services should have been provided in a more appropriate setting if the hospital was required to provide these services under 42 U.S.C. 1395(dd).
          (3) The office shall require acute hospitals and community health centers to screen each applicant for reimbursed care for other sources of coverage and for potential eligibility for government programs, and to document the results of that screening. If an acute hospital or community health center determines that an applicant is potentially eligible for Medicaid or for the commonwealth care health insurance program, established by chapter 118H, or another assistance program, the acute hospital or community health center shall assist the applicant in applying for benefits under that program. The office shall audit the accounts of acute hospitals and community health centers to determine compliance with this section and shall deny payments from the fund for any acute hospital or community health center that fails to document compliance with this section.
          (4) The office shall reimburse acute hospitals for health services provided to individuals based on the payment systems in effect for acute hospitals used by the United States Department of Health and Human Services Centers for Medicare & Medicaid Services to administer the Medicare Program under Title XVIII of the Social Security Act, including all of Medicare's adjustments for direct and indirect graduate medical education, disproportionate share, outliers, organ acquisition, bad debt, new technology and capital and the full amount of the annual increase in the Medicare hospital market basket index. The office shall, in consultation with the office of Medicaid and the Massachusetts Hospital Association, adopt regulations necessary to modify these payment systems to account for:-
          (i) the differences between the program administered by the office and the Title XVIII Medicare program, including the services and benefits covered;
          (ii) grouper and DRG relative weights for purposes of calculating the payment rates to reimburse acute hospitals at rates no less than the rates they are reimbursed by Medicare;
          (iii) the extent and duration of covered services;
          (iv) the populations served; and
          (v) any other adjustments to the payment methodology under this section as considered necessary by the office, based upon circumstances of individual hospitals.
          Following implementation of this section, the office shall ensure that the allowable reimbursement rates under this section for health services provided to uninsured individuals shall not thereafter be less than rates of payment for comparable services under the Medicare program, taking into account the adjustments required by this section.
          (5) For the purposes of paying community health centers for health services provided to uninsured individuals under this section, the office shall pay community health centers a base rate that shall be no less than the then-current Medicare Federally Qualified Health Center rate as required under 42 U.S.C. 13951 (a)(3), and the office shall add payments for additional services not included in the base rate, including, but not limited to, EPSDT services, 340B pharmacy, urgent care, and emergency room diversion services.
          (6) Reimbursements to acute hospitals and community health centers for bad debt shall be made upon submission of evidence, in a form to be determined by the office, that reasonable efforts to collect the debt have been made.
          (b) By April 1 of the year preceding the start of the fund fiscal year, the office shall, after consultation with the office of Medicaid, and using the best data available, provide an estimate of the projected total reimbursable health services provided by acute hospitals and community health centers and emergency bad debt costs, the total funding available, and any projected shortfall after adjusting for reimbursement payments to community health centers. If a shortfall in revenue exists in any fund fiscal year to cover projected costs for reimbursement of health services, the office shall allocate that shortfall in a manner that reflects each hospital's proportional financial requirement for reimbursements from the fund, including, but not limited to, the establishment of a graduated reimbursement system and under any additional regulations adopted by the office.
          (c) The executive office of health and human services directly or through the division shall enter into interagency agreements with the department of revenue to verify income data for patients whose health care services are reimbursed by the Health Safety Net Trust Fund and to recover payments made by the fund for services provided to individuals who are ineligible to receive reimbursable health services or on whose behalf the fund has paid for emergency bad debt. The division shall adopt regulations requiring acute hospitals to submit data that will enable the department of revenue to pursue recoveries from individuals who are ineligible for reimbursed health services and on whose behalf the fund has made payments to acute hospitals for emergency bad debt. Any amounts recovered shall be deposited in the Health Safety Net Trust Fund, established by section 35 of chapter 118G.
          (d) The office shall not at any time make payments from the fund for any period in excess of amounts that have been paid into or are available in the fund for that period, but the office may temporarily prorate payments from the fund for cash flow purposes.

 

Court Ordered Evaluations of Competency to Stand Trial (1 of 2)

SECTION 29.   Section 15 of chapter 123 of the General Laws, as appearing in the 2004 Official Edition, is hereby amended by striking out paragraph (b) and inserting in place thereof the following paragraph:-

          (b) If after the examination described in paragraph (a), the court has reason to believe that further examination is necessary in order to determine whether mental illness or mental defect have so affected a person that he is not competent to stand trial or not criminally responsible for the crime or crimes with which he has been charged, the court may order further examination. Unless the person is committed in accordance with this section, the examination shall be completed within 20 days, or such other period of time as the court may order. The examination shall be conducted by 1 or more qualified physicians or 1 or more qualified psychologists and shall be conducted at the court house if the person is released on recognizance, at the place of detention where the person is being held, or other less restrictive setting as might be ordered by the court, unless the court makes written findings, based on the examination described in paragraph (a), or such further evidence as the court may require that (1) the person is mentally ill; (2) failure to commit the person for observation and further examination would cause likelihood of serious harm; and, (3) observation or further examination being ordered cannot be adequately or safely provided at the court house, a place of detention, or other less restrictive setting, in which case the court may order that the person be committed to a facility or, if the person is a male and appears to require strict security, at the Bridgewater state hospital, for a period not to exceed 20 days for observation and further examination. No order shall be issued for further observation or examination of criminal responsibility unless the court certifies that the order is issued in compliance with Rule 14 of the Massachusetts Rules of Criminal Procedure. Copies of the complaints or indictments and the physician's or psychologist's report under paragraph (a) shall be made available to the qualified physician or psychologist, and if the person is committed shall be delivered to the facility or the hospital with the person. If, before the expiration of this 20-day period, an examining qualified physician or an examining qualified psychologist completes the examination, upon 5 days notice and the filing of the report of the examination, any person committed under this section shall be returned to the court for proceedings as the court considers warranted. If, before the expiration of the 20-day period, an examining qualified physician or examining qualified psychologist believes that observation for more than 20 days is necessary, he shall so notify the court and shall request in writing an extension of the 20-day period, specifying the reason or reasons for which further observation is necessary. Upon the receipt of this request, the court may extend the observation period, but in no event shall the period exceed 40 days from the date of the initial court order of hospitalization. If a person who has been committed under this section requests continued care and treatment during the pendency of the criminal proceedings against him and the superintendent or medical director agrees to provide this care and treatment, the court may order the further commitment of the person at the facility or the Bridgewater state hospital. If the person requests to terminate this care and treatment, or the superintendent or medical director withdraws his agreement to provide this care and treatment, the person shall be returned immediately to the court for further proceedings that the court considers warranted.

 

Court Ordered Evaluations of Competency to Stand Trial (2 of 2)

SECTION 30.   Section 15 of said chapter 123, as so appearing, is hereby further amended by striking out paragraph (e) and inserting in place thereof the following paragraph:-

          (e) After a finding of guilty on a criminal charge, and prior to sentencing, the court may order a psychiatric or other clinical examination. If after this examination, the court has reason to believe that further examination and observation is necessary, it may, upon the making of written findings as provided in paragraph (b), also order a period of observation in a facility, or at the Bridgewater state hospital if the court determines that strict security is required and if the person is male. The purpose of this observation or examination shall be to aid the court in sentencing. If the person is committed under this section, the period of observation or examination shall not exceed 40 days. During this period of observation, the superintendent or medical director may petition the court for further commitment of the person. The court, after imposing sentence on the person, may hear the petition as provided in section 18, and if the court makes necessary findings as set forth in section 8, it may in its discretion commit the person to a facility or the Bridgewater state hospital. The order of commitment shall be valid for a period of 6 months. All subsequent proceedings for commitment shall take place under said section 18 in the district court which has jurisdiction of the facility or hospital. A person committed to a facility or Bridgewater state hospital under this section shall have this time credited against the sentence imposed as provided in paragraph (c) of said section 18.

 

Hospital Rate Pay for Performance

SECTION 36.   Chapter 58 of the acts of 2006 is hereby amended by striking out section 128 and inserting in place thereof the following section: -

Section 128. Notwithstanding any general or special law to the contrary, in fiscal year 2007, and in accordance with section 13B of chapter 118E of the General Laws, $90,000,000 shall be made available from the Commonwealth Care Trust Fund, established by section 2OOO of chapter 29 of the General Laws, to pay for an increase in the Medicaid rates paid to acute hospitals, as defined in section 1 of chapter 118G of the General Laws, and physicians, but not less than 15 per cent of the increase shall be allocated to rate increases for physicians. For fiscal year 2008, an additional $90,000,000 for a total of $180,000,000, shall be made available to pay for an increase in the Medicaid rates paid to acute hospitals, as defined in said section 1 of said chapter 118G of the General Laws, and physicians, but not less than 15 per cent of the increase shall be allocated to rate increases for physicians. For fiscal year 2009, an additional $90,000,000, for a total of $270,000,000, shall be made available to pay for an increase in the Medicaid rates paid to acute hospitals, as defined in said section 1 of said chapter 118G, and physicians, but not less than 15 per cent of the increase shall be allocated to rate increases for physicians. A portion of the fiscal year 2008 and fiscal year 2009 hospital rate increases relating to adherence to quality standards and achievement of performance benchmarks under section 13B of chapter 118E of the General Laws may be paid in the succeeding fiscal year. For purposes of payments to hospitals under this section, fiscal year shall mean the hospital fiscal year, and for purposes of any payments to physicians under this section, fiscal year shall mean the state fiscal year. Fiscal year 2008 and 2009 payments are subject to specific appropriation to the executive office of health and human services MassHealth program accounts for this purpose.

 

Essential Community Provider Trust Fund

SECTION 37.   Notwithstanding any general or special law to the contrary, the comptroller, in consultation with the secretary of health and human services, shall develop a schedule for transferring not less than $28,000,000 from the General Fund to the Essential Community Provider Trust Fund established under section 2PPP of chapter 29 of the General Laws for the purpose of making payments to acute care hospitals and community health centers in fiscal year 2008. The secretary shall authorize expenditures from the fund without further appropriation for the purpose of a grant program to improve and enhance the ability of acute care hospitals and community health centers to serve populations in need, more efficiently and effectively, including, but not limited to, the ability to provide community-based care, clinical support, care coordination services, disease management services, primary care services and pharmacy management services through a grant program. The secretary shall consider applications from acute care hospitals and community health centers in awarding the grants.

 

Transfer Fund Balances

SECTION 44.   (a) Beginning July 1, 2007, the comptroller shall transfer $380,520,000 from the General Fund to the State Retiree Benefits Trust Fund established by section 24 of chapter 32A of the General Laws, according to a schedule developed in consultation with the state treasurer and the secretary of administration and finance.
          (b) As of June 30, 2007, the comptroller shall transfer to the General Fund the balance in the Health Care Quality Improvement Trust Fund, established by section 2EEE of chapter 29 of the General Laws.
          (c) As of July 1, 2007, the comptroller shall transfer $50,000,000 from the Health Care Security Trust to the General Fund, to be used subject to appropriation for the following programs of the department of public health: substance abuse services, public health promotion and disease prevention, and universal immunization.
          (d) As of January 1, 2008, the comptroller shall transfer the balance in the Health Care Security Trust to the State Retiree Benefits Trust Fund.

 

Transfers Among Health Care Funds

SECTION 47.   (a) Notwithstanding any general or special law to the contrary, the comptroller shall, in consultation with the state treasurer, the secretary of administration and finance and the secretary of health and human services, develop a schedule for transferring funds among the General Fund, the Commonwealth Care Trust Fund established by section 2OOO of chapter 29 of the General Laws and the Health Safety Net Trust Fund established by section 35 of chapter 118G of the General Laws. Not less than $628,800,000 shall be transferred from the General Fund to the Commonwealth Care Trust Fund and not less than $33,900,000 shall be transferred from the Commonwealth Care Trust Fund to the Health Safety Net Trust Fund. The schedule shall provide for transfers in increments considered appropriate to meet the cash flow needs of these funds. The transfers shall not begin before July 1, 2007 and shall be completed on or before June 30, 2008. The secretary of administration and finance, in consultation with the secretary of health and human services and the executive director of the commonwealth health insurance connector, shall from time to time evaluate the revenue needs of the health safety net program funded by the Health Safety Net Trust Fund and the Commonwealth Care subsidized health insurance program funded from the Commonwealth Care Trust Fund, and if necessary, transfer monies between these funds for the purpose of ensuring that sufficient revenues are available to support projected program expenditures.
          (b) Notwithstanding any general or special law to the contrary, on or before October 1, 2007 and without further appropriation, the comptroller shall transfer from the General Fund to the Health Safety Net Trust Fund established under section 35 of chapter 118G of the General Laws, an amount not to exceed $45,000,000 for the purpose of making initial gross payments to qualifying acute care hospitals for the hospital fiscal year beginning October 1, 2007. These payments shall be made to hospitals before, and in anticipation of, the payment by hospitals of their gross liability to this fund. The comptroller shall transfer from this fund to the General Fund not later than June 30, 2008, the amount of the transfer authorized in this section and any allocation of that amount as certified by the director of the health safety net office.

 

UMass/Health and Human Services Interagency Service Agreements

SECTION 49.   Notwithstanding any general or special law to the contrary, the executive office of health and human services under section 16 of chapter 6A of the General Laws, acting in its capacity as the single state agency under Title XIX of the Social Security Act and as the principal agency for all of the agencies within the executive office, and other federally assisted programs administered by the executive office, may enter into interdepartmental services agreements with the University of Massachusetts medical school to perform activities that the secretary, in consultation with the comptroller, determines are appropriate and within the scope of the proper administration of Title XIX and other federal funding provisions to support the programs and activities of the executive office. These activities shall include: (1) providing administrative services, including, but not limited to, activities such as providing the medical expertise to support or administer utilization management activities, determining eligibility based on disability, supporting case management activities and similar initiatives; (2) providing consulting services related to quality assurance, program evaluation and development, integrity and soundness and project management; and (3) providing activities and services for the purpose of pursuing federal reimbursement or avoiding costs, third party liability and recouping payments to third parties. Federal reimbursement for any expenditures made by the University of Massachusetts medical school relative to federally reimbursable services the university provides under these interdepartmental service agreements or other contracts with the executive office of health and human services shall be distributed to the university, and recorded distinctly in the state accounting system. The secretary may negotiate contingency fees for activities and services related to the purpose of pursuing federal reimbursement or avoiding costs, and the comptroller shall certify these fees and pay them upon the receipt of this revenue, reimbursement or demonstration of costs avoided. Contracts for contingency fees shall not extend longer than 3 years, and shall not be renewed without prior review and approval from the executive office of administration and finance. The secretary shall not pay contingency fees in excess of $40,000,000 for state fiscal year 2008. The secretary of health and human services shall submit to the secretary of administration and finance and the senate and house committees on ways and means a quarterly report detailing the amounts of the agreements, the ongoing and new projects undertaken by the university, the amounts spent on personnel and the amount of federal reimbursement and recoupment payments that the university collected.

 

Special Education Provider Rate Freeze

SECTION 50.   Notwithstanding any general or special law to the contrary, the operational services division which, under section 274 of chapter 110 of the acts of 1993, is responsible for determining prices for programs under chapter 71B of the General Laws, shall set those prices in fiscal year 2008 at the same level calculated for fiscal year 2007, except the prices for those programs for extraordinary relief, as defined in 808 CMR 1.06(4). Programs for which prices in fiscal year 2007 were lower than the full amount permitted by the operational services division shall be permitted to charge in fiscal year 2008 the full price calculated for fiscal year 2007.