PETITION OF:

SECTION 1. Section 16L of Chapter 6A is hereby amended by inserting after Subsection (q) the following new section:

(r) The Health Care Quality and Cost Council shall hold an annual public hearing to examine the factors that contribute to the cost premium increases for health benefit plans. All carriers issuing health benefit plans pursuant to Chapters 176J, 176M, and 176Q, licensed under Chapters 175, 176A, 176B and 176G, and all Medicaid managed care organizations, other than carriers or Medicaid managed care organizations with fewer than 10,000 covered lives in the commonwealth, shall be required to present oral and written testimony in a format specified by the Council as part of the hearing. The Council shall require carriers to provide testimony related to anticipated changes in premium rates, provider reimbursement rates, utilization, administrative costs, and capital investments and other matters as determined by the Council.

The Council shall identify the 10 largest providers based on total health plan reimbursements in each of the following categories: integrated delivery systems, acute hospitals, freestanding ambulatory surgical centers, physician group practices, rehabilitation hospitals and skilled nursing facilities. Each identified provider shall be required to provide oral and written testimony in a format determined by the Council as part of the hearing. The Council may require additional providers to provide testimony as it determines to be appropriate. The Council shall require providers to provide testimony on changes in health plan and public program reimbursement rates, utilization, labor and supply costs, administrative costs and capital investments and other matters as determined by the Council. The Council shall utilize claims data it has collected from health plans to determine the top ten entities for each provider type.

Within 30 days following the hearing, the Council shall issue a public report summarizing its findings and any recommendations.

SECTION 2. Chapter 111 of the General Laws is hereby amended by inserting after Section 70G the following three sections:-

Section 70H. (a) As used in this section, the following words, unless the context clearly requires otherwise, shall have the following meanings:-

"Department", the department of public health.

"Hospital", any institution, however named, whether conducted for charity or for profit, which is advertised, announced, established, or maintained for the purpose of caring for persons admitted thereto for diagnosis, medical, surgical or restorative treatment which is rendered within said institution.

"Hospital-acquired infection", a localized or systemic condition (1) that results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and (2) that was not present or incubating at the time of admission to the hospital.

"Secretary", the secretary of the executive office of health and human services

(b) Every hospital shall collect data on hospital-acquired infection rates for the specific clinical procedures determined by the department by regulation, including, but not limited to the following categories: -

(1) Surgical site infections;

(2) Ventilator-associated pneumonia;

(3) Central line-related bloodstream infections;

(4) Urinary tract infections; and

(5) Other categories as provided under subsection (e) of this section.

(c)(1) Every Hospital shall submit monthly reports on their Hospital-acquired infection rates to the department. Monthly reports shall be submitted according to a schedule set forth in regulations adopted by the department. Data in monthly reports must cover a period ending not earlier than one month prior to submission of the report. Monthly reports shall be made available to the public at each Hospital and through the Department on its website in a style and format that can be easily understood by the public.

(2) If the Hospital is a division or subsidiary of another entity that owns or operates other Hospitals or related organizations, the monthly report shall be for the specific division or subsidiary and not combined with any other division, subsidiary or entity.

(d) (1) The statewide infection prevention and control program established in item 4570-1502 of section 2A of chapter 58 of the acts of 2006, and the Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Healthcare Associated Infection, referred to in this section as the Expert Panel, shall assist the Department in the development of all aspects of the Department's methodology for collecting, analyzing, and disclosing the information collected under this section, including collection methods, formatting, and methods and means for release and dissemination.

(2) The Department shall disclose the data collection and analysis methodology as well as any public disclosure of hospital-acquired infection rates to the public through its website.

(3) The Department and the Expert Panel shall evaluate at least annually the quality and accuracy of Hospital information reported under this section and the data collection, analysis, and dissemination methodologies.

(e) The Department may, after consultation with the Expert Panel, require Hospitals to collect data on Hospital-acquired infection rates in categories in addition to those set forth in subsection (b).

(f) (1) The Department shall annually submit to the joint committees on public health and health care finance and the clerks of the house and senate a report summarizing the hospital monthly reports and shall publish the annual report on its website. The Department may issue quarterly informational bulletins at its discretion, summarizing all or part of the information submitted in the Hospital quarterly reports.

(2) All reports issued by the Department pursuant to this section shall be risk adjusted, consistent with the recommendations of the Expert Panel.

(3) The annual report shall annually compare the risk-adjusted Hospital-acquired infection rates, collected under subsection (c) of this section, for each individual hospital in the state. The Department, in consultation with the Expert Panel, shall make this comparison as easy to comprehend as possible for the benefit of health care consumers. The report shall also include an executive summary, written in plain language that shall include, but not be limited to, a discussion of findings, conclusions, and trends concerning the overall state of Hospital-acquired infections in the state, including a comparison to prior years. The report may include policy recommendations.

(4) The Department shall publicize the report and its availability as widely as practical to interested parties, including, but not limited to, Hhospitals, providers, media organizations, health insurers, health maintenance organizations, purchasers of health insurance, organized labor, consumer or patient advocacy groups, and individual consumers. The annual report shall be made available through the Department’s web site and also to any person upon request.

(5) No Hospital report or department disclosure may contain information identifying a patient, Hospital employee, or licensed health care professional in connection with a specific infection incident.

(g) A patient's right of confidentiality shall not be violated in any manner. Notwithstanding any general or special law to the contrary, patient social security numbers and any other information that could be used to identify an individual patient shall not be released.

(h) Every Hospital shall file with the Department on an annual basis a plan for reducing the number of Hospital-acquired infections reportable under this section to zero or as close to zero as feasible. A Hospital’s plan shall be consistent , in accordance with the recommendation of the statewide infection prevention and control program established in item 4570-1502 of section 2A of chapter 58 of the acts of 2006, and the Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Healthcare Associated Infection.

(i) Notwithstanding any general or special law to the contrary, no health care professional or a health care facility may bill any third party payer, including the Commonwealth, an insurer licensed or otherwise authorized to transact accident or health insurance organized under chapter 175, a nonprofit hospital service corporation organized under chapter 176A, a nonprofit medical service corporation organized under chapter 176B, a health maintenance organization organized under chapter 176G and an organization entering into a preferred provider arrangement under chapter 176I, for the treatment of any Hospital-acquired infection reportable under this section, and no health care professional or health care facility may bill the patient for such treatment.

(j) A determination by the Department that a Hospital has violated the provisions of subsections (a) to (g) inclusive of this section may result in any or all of the following:

(1) Termination or suspension of licensure or other sanctions, as imposed by the department, relating to licensure under this chapter.

(2) A civil penalty of up to $1,000 per day per violation for each day the hospital is in violation of the act.

(k) The Department shall promulgate regulations consistent with this section.

Section 70I. (a) As used in this section, the following words, unless the context clearly requires otherwise, shall have the following meanings:-

"Health care facility" shall have the same meaning as found in section 70E.

"Health care professional", a person licensed or otherwise authorized under Massachusetts law to provide health care services, including:-

(1) a doctor, nurse, physician assistant, nurse practitioner, clinical nurse specialist, certified nurse anesthetist, certified nurse midwife, respiratory therapist, psychologist, certified social worker, registered dietitian or nutrition professional, physical or occupational therapist, pharmacist, or other individual health care practitioner; and

(2) any other health care professional specified in regulations promulgated by the secretary of the executive office of health and human services.

(b) Each Health care facility shall report to the Department the occurrence of any of the adverse medical events, known as "never events", described in items (1) to (6) of this subsection as soon as is reasonably and practically possible, but no later than 15 working days after discovery of the event. The report shall be filed in a format specified by the Department and shall identify the facility, but shall not include any information identifying any of the health care professionals, facility employees, or patients involved. The Department may consult with experts and organizations familiar with patient safety when developing the format for reporting and in further defining events in order to be consistent with industry standards. These reports shall be available to the public through the Department's website.

(1) Surgical events reportable under this subsection shall include:-

(i) surgery performed on a wrong body part that is not consistent with the documented informed consent for that patient. Reportable events under this clause do not include situations requiring prompt action that occur in the course of surgery or situations whose urgency precludes obtaining informed consent;

(ii) surgery performed on the wrong patient;

(iii) the wrong surgical procedure performed on a patient that is not consistent with the documented informed consent for that patient. Reportable events under this clause do not include situations requiring prompt action that occur in the course of surgery or situations whose urgency precludes obtaining informed consent;

(iv) retention of a foreign object in a patient after surgery or other procedure, excluding objects intentionally implanted as part of a planned intervention and objects present prior to surgery that are intentionally retained; and

(v) death during or immediately after surgery of a normal, healthy patient who has no organic, physiologic, biochemical, or psychiatric disturbance and for whom the pathologic processes for which the operation is to be performed are localized and do not entail a systemic disturbance.

(2) Product or device events reportable under this subsection shall include:-

(i) patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the facility when the contamination is the result of generally detectable contaminants in drugs, devices, or biologics regardless of the source of the contamination or the product;

(ii) patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended. Device includes, but is not limited to, catheters, drains, and other specialized tubes, infusion pumps, and ventilators; and

(iii) patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a facility, excluding deaths associated with neurosurgical procedures known to present a high risk of intravascular air embolism.

(3) Patient protection events reportable under this subsection include:-

(i) an infant discharged to the wrong person;

(ii) patient death or serious disability associated with patient disappearance for more than 4 hours, excluding events involving adults who have decision-making capacity; and

(iii) patient suicide or attempted suicide resulting in serious disability while being cared for in a facility due to patient actions after admission to the facility, excluding deaths resulting from self-inflicted injuries that were the reason for admission to the facility.

(4) Care management events reportable under this subsection include:-

(i) patient death or serious disability associated with a medication error, including, but not limited to, errors involving the wrong drug, the wrong dose, the wrong patient, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration, excluding reasonable differences in clinical judgment on drug selection and dose;

(ii) patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products;

(iii) maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a facility, including events that occur within 42 days postdelivery and excluding deaths from pulmonary or amniotic fluid embolism, acute fatty liver of pregnancy, or cardiomyopathy;

(iv) patient death or serious disability directly related to hypoglycemia, the onset of which occurs while the patient is being cared for in a facility;

(v) death or serious disability, including kernicterus, associated with failure to identify and treat hyperbilirubinemia in neonates during the first 28 days of life. "Hyperbilirubinemia" means bilirubin levels greater than 30 milligrams per deciliter;

(vi) stage 3 or 4 ulcers acquired after admission to a facility, excluding progression from stage 2 to stage 3 if stage 2 was recognized upon admission; and

(vii) patient death or serious disability due to spinal manipulative therapy.

(5) Environmental events reportable under this subsection include:-

(i) patient death or serious disability associated with an electric shock while being cared for in a facility, excluding events involving planned treatments such as electric countershock;

(ii) any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances;

(iii) patient death or serious disability associated with a burn incurred from any source while being cared for in a facility;

(iv) patient death associated with a fall while being cared for in a facility; and

(v) patient death or serious disability associated with the use of restraints or bedrails while being cared for in a facility.

(6) Criminal events reportable under this subsection include:-

(i) an instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider;

(ii) abduction of a patient of any age;

(iii) sexual assault on a patient within or on the grounds of a facility; and

(iv) death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds of a facility.

(c) The Department shall annually submit to the joint committees on health care finance and public health and the clerks of the house and senate a report summarizing the never events reported to the Department during the previous year and shall publish the annual report on the internet. The Department may issue quarterly informational bulletins at its discretion, summarizing all or part of the information reported by health care facilities.

(d) Notwithstanding any general or special law to the contrary, no health care professional or a Health care facility may bill any third party payer, including the commonwealth, an insurer licensed or otherwise authorized to transact accident or health insurance organized under chapter 175, a nonprofit hospital service corporation organized under chapter 176A, a nonprofit medical service corporation organized under chapter 176B, a health maintenance organization organized under chapter 176G and an organization entering into a preferred provider arrangement under chapter 176I, for services that resulted in any of the adverse health care “never events” listed above, and no health care professional or health care facility may bill the patient for such services.

(e) A determination by the Department that a Hospital has violated the provisions of this section may result in any of the following:

(1) Termination or suspension of licensure or other sanctions relating to licensure under this chapter, as determined by the department.

(2) A civil penalty of up to $1,000 per day per violation for each day the hospital is in violation of the act.

Section 70J. (a) As used in this section, the following words, unless the context clearly requires otherwise, shall have the following meanings:-

"Potentially preventable hospital readmission", a patient's readmission to a Hospital within 30 days of a discharge from a Hospital, due to a condition that indicates the readmission was potentially preventable during the initial Hospital stay, as further defined by regulations.

(b). The Department shall collect data from Hhospitals on potentially preventable Hhospital readmissions. The Department may promulgate regulations regarding the data to be collected, and shall collect sufficient data to determine for each hospital a rate of potentially preventable hospital readmissions. The Department shall post on a website potentially preventable Hospital readmission data and rates for each Hospital. The rates shall be adjusted annually, or as the Department determines.

(c) Notwithstanding any general or special law to the contrary, no Hospital may bill any third party payer, including the Commonwealth, an insurer licensed or otherwise authorized to transact accident or health insurance organized under chapter 175, a nonprofit hospital service corporation organized under chapter 176A, a nonprofit medical service corporation organized under chapter 176B, a health maintenance organization organized under chapter 176G and an organization entering into a preferred provider arrangement under chapter 176I, for services related to a preventable hospital readmission, and no Hospital may bill the patient for such services.

SECTION 3. Section 25C of Chapter 111 of the General Laws is hereby amended by inserting after the word “therefore” the following new language: “followed by review and approval by the Attorney General of the Commonwealth, pursuant to Section 11M of Chapter 12 and by the Inspector General of the Commonwealth, pursuant to Section 16 of Chapter 12A.

Chapter 111 is further amended by inserting in Section 51, in the second paragraph after the words “department” the following new language” the Office of the Attorney General and the Inspector General”.

Chapter 12 of the General Laws is hereby amended by inserting after Section 11L the following new section:

Section 11M: The Attorney General shall have concurrent jurisdiction with the Inspector General to review all applications for Determination of Need filed pursuant to Section 25C of Chapter 111. Following initial approval by the Department of Public Health, all Determination of Need applications shall be sent to the Office of the Attorney General for review and approval.

The Attorney General shall approve a project only if the Attorney General determines that the project will not have an adverse effect on competition in health care market. Following the review the Attorney General shall report to the Department of Public Health the results of said review. No project shall be approved by the Department of Public Health without approval of the Attorney General.

Chapter 12A of the General Laws is hereby amended by inserting after Section 15 the following new section:

Section 16: The Inspector General shall have concurrent jurisdiction with the Attorney General to review all applications for Determination of Need filed pursuant to Section 25C of Chapter 111. Following initial approval by the Department of Public Health, all Determination of Need applications shall be sent to the Office of the Attorney General.

The Inspector General shall approve a project only if the Inspector General determines that the project will not result in fraud, waste or abuse of public funds. In determining whether a project will result in the waste or abuse of public funds, the Inspector General shall give due consideration to whether the project is likely to increase rates of payment to providers and whether the project is likely to result in an inappropriate increase in utilization of health care services. Following the review the Inspector General shall report to the Department of Public Health the results of said review. No project shall be approved by the Department of Public Health without approval of the Inspector General.

SECTION 4. (a) Notwithstanding any general or special laws to the contrary, there shall be a special commission to examine the creation of a mechanism for stop-loss reinsurance. The commission shall determine the impact of various attachment points on premiums for policies issued pursuant to chapter 176J of the general laws. The commission shall make recommendations on (1) the process and factors for determining the initial attachment point and for revising the attachment point and (2) potential revenue sources for the mechanism .

(b) The commission shall consist of the commissioner of insurance, who shall serve as chair; the secretary of administration and finance; the commissioner of the division of health care finance and policy; 3 members appointed by the president of the senate, including an actuary in good standing with the American Society of Actuaries, a health economist, and a member of the senate; and 3 members appointed by the speaker of the house, an actuary in good standing with the American Society of Actuaries, a health economist, and a member of the house of representatives.

(d) The commission shall submit a report on its findings and make recommendations to the general court no later than December 31, 2008.

SECTION 5. Chapter 211B of the General Laws is hereby amended by inserting at the end of Section 19 the following Section 19A:

Section 19A. Pilot Project for Medical Malpractice Court Initiative Committee

(a) Establishment. A pilot project creating medical malpractice court committees is established for the purpose of developing an approach to adjudicating medical disputes arising between patients and health care providers that is evidence-based and provides appropriate and fair compensation to claimants. Committees shall be located in the counties of Berkshire, Worcester, and Suffolk. Pilot courts shall be applicable to claimants residing within the named counties. The three pilot courts, as established herein, shall have exclusive jurisdiction over all actions for malpractice, error or mistake against a provider of health care arising within the county. The committees shall be under the direct supervision of the chief justice of administration and management. The chief justice shall be responsible to fund, coordinate, and evaluate activities of the committees within said counties to screen and refer cases to the medical malpractice pilot courts.

The chief justice for administration and management shall monitor and evaluate the cost, impact and effectiveness of activities undertaken to screen and refer cases to a medical malpractice pilot court and report annually to the general court on his findings. The annual report should identify unmet needs and promising opportunities for additional screening and referral activities and recommend legislative actions required to implement these activities.

(b)(1) Committee Composition. Each committee shall be composed of the following persons:

a district judge presiding in such county, appointed by the chief justice for administration and management, who will serve as committee chair;
1 member representing the county clerk’s office within the county
The Attorney General of the Commonwealth or her designee
The Commissioner of the Division of Insurance, or her designee
One member representing the Massachusetts Medical Society
One member representing the Massachusetts Hospital Association
One member representing the defense trial bar
One member representing the plaintiff trial bar
One member representing a consumer organization

(c). The county committees shall be responsible for establishing a medical malpractice pilot court within each of the named counties to be operational no later than January 1, 2009. The committees shall meet no later than January 15, 2008. In establishing said courts, the committees shall:

Establish procedures for the operation of the courts;
Establish a process for filing and processing civil actions for medical malpractice claims;
Establish evidence-based standards to be used in resolving disputes; and
Develop a schedule for awarding damages that is based proportionally on the negligence of the provider and set maximum amounts for awards. In no event shall damages for pain and suffering exceed the amount of damages available pursuant to section 60H of chapter 231. The provisions of section 85K of chapter 231 shall apply, as applicable, to actions adjudicated as part of the pilot program.

(d). The chief justice for administration and management on July 1, 2009, shall report to the general court on the progress and outcomes of each committee on achieving the goals of the pilot. On January 1, 2010, the chief justice for administration and management shall report to the general court on the operation of the pilot courts and make recommendations for expanding the medical malpractice courts to all districts in the Commonwealth.

SECTION 6. Chapter 176O of the general laws is hereby amended by inserting after section 17, the following new section:

Section 18. (a) As used in this section, the following words, unless the context clearly requires otherwise, shall have the following meanings:

(b) Beginning January 1, 2010, all hospitals, physician practices and carriers conduct the following transactions electronically:

Eligibility for a health plan transaction, as described under Code of Federal Regulations, title 45, part 162, subpart L;
Health care payment and remittance advise transaction, as described under Code of Federal Regulations, title 45, part 162, subpart P;
Health care claims or equivalent encounter information transaction, as described under Code of Federal Regulations, title 45, part 162, subpart K;

SECTION 7. Section 38C of Chapter 3 of the General Laws, is hereby amended by adding after subsection (d) the following:

(e). Within 60 days following receipt of the Division of Health Care Finance and Policy’s report to the general court on the efficacy of existing State Mandated Health Benefits, the joint committee on financial services shall report appropriate legislation to repeal those State Mandated Health Benefits identified by the Division of Health Care Finance and Policy that no longer conform to existing standards of care in terms of clinical appropriateness or evidence-based medicine.

SECTION 8. Subsection (n) of Section 16L of Chapter 6A of the General Laws is hereby amended by inserting the following at the end of the first sentence:

The Council shall provide grants to individuals and entities that engage in comparative effectiveness studies that compare the effectivenessof different medical treatments and services for the same condition. The council shall make the results of these studies available to the public on the consumer quality and cost information website.

SECTION 9. Chapter 175 of the General Laws 175 is hereby amended by inserting after section 111H, the following section:—

Section 111I. (a) Except as otherwise provided in this section, the commissioner shall not disapprove a policy of accident and sickness insurance which provides hospital expense and surgical expense insurance solely on the basis that it does not include coverage for at least 1 mandated benefit.

(b) The commissioner shall not approve a policy of accident and sickness insurance which provides hospital expense and surgical expense insurance unless it provides, at a minimum, coverage for:

(1) pregnant women, infants and children as set forth in section 47C;

(2) prenatal care, childbirth and postpartum care as set forth in section 47F;

(3) cytologic screening and mammographic examination as set forth in section 47G;

(3A) diabetes-related services, medications, and supplies as defined in section 47N;

(4) early intervention services as set forth in said section 47C; and

(5) mental health services as set forth in section 47B; provided however, that if the policy limits coverage for outpatient physician office visits, the commissioner shall not disapprove the policy on the basis that coverage for outpatient mental health services is not as extensive as required by said section 47B, if the coverage is at least as extensive as coverage under the policy for outpatient physician services.

(c) The commissioner shall not approve a policy of accident and sickness insurance which provides hospital expense and surgical expense insurance that does not include coverage for at least one mandated benefit unless the carrier continues to offer at least one policy that provides coverage that includes all mandated benefits.

(d) For purposes of this section, “mandated benefit” shall mean a requirement in this chapter that requires coverage for specific health services, specific diseases or certain providers of health care.

(e) The commissioner may promulgate rules and regulations as are necessary to carry out this section.

(f) Notwithstanding any special or general law to the contrary, no plan approved by the commissioner under this section shall be available to an employer who has provided a policy of accident and sickness insurance to any employee within 12 months.

Chapter 176A of the General Laws is hereby amended by inserting after section 1D the following section:

Section 1E. (a) Except as otherwise provided in this section, the commissioner shall not disapprove a contract between a subscriber and the corporation under an individual or group hospital services plan solely on the basis that it does not include coverage for at least one mandated benefit.

(b) The commissioner shall not approve a contract unless it provides, at a minimum, coverage for:

(1) pregnant women, infants and children as set forth in section 8B;

(2) prenatal care, childbirth and postpartum care as set forth in section 8H;

(3) cytologic screening and mammographic examination as set forth in section 8J;

(3A) diabetes-related services, medications, and supplies as defined in section 8P;

(4) early intervention services as set forth in said section 8B; and

(5) mental health services as set forth in section 8A; provided however, that if the contract limits coverage for outpatient physician office visits, the commissioner shall not disapprove the contract on the basis that coverage for outpatient mental health services is not as extensive as required by said section 8A, as long as such coverage is at least as extensive as coverage under the contract for outpatient physician services.

(c) The commissioner shall not approve a contract that does not include coverage for at least one mandated benefit unless the corporation continues to offer at least one contract that provides coverage that includes all mandated benefits.

(e) The commissioner may promulgate rules and regulations as are necessary to carry out this section.

(f) Notwithstanding any special or general law to the contrary, no plan approved by the commissioner under this section shall be available to an employer who has provided a hospital services plan, to any employee within 12 months.

Chapter 176B of the General Laws is hereby further amended by inserting after section 6B, the following section:—

Section 6C. (a) Except as otherwise provided in this section, the commissioner shall not disapprove a subscription certificate solely on the basis that it does not include coverage for at least one mandated benefit.

(b) The commissioner shall not approve a subscription certificate unless it provides, at a minimum, coverage for:

(1) pregnant women, infants and children as set forth in section 4C;

(2) prenatal care, childbirth and postpartum care as set forth in section 4H;

(3) cytologic screening and mammographic examination;

(3A) diabetes-related services, medications and supplies as defined in section 4S;

(4) early intervention services as set forth in said section 4C; and

(5) mental health services as set forth in section 4A; provided however, that if the subscription certificate limits coverage for outpatient physician office visits, the commissioner shall not disapprove the subscription certificate on the basis that coverage for outpatient mental health services is not as extensive as required by said section 4A, as long as such coverage is at least as extensive as coverage under the subscription certificate for outpatient physician services.

(c) The commissioner shall not approve a subscription certificate that does not include coverage for at least 1 mandated benefit unless the corporation continues to offer at least one subscription certificate that provides coverage that includes all mandated benefits.

(e) The commissioner may promulgate rules and regulations as are necessary to carry out this section.

(f) Notwithstanding any special or general law to the contrary, no plan approved by the commissioner under this section shall be available to an employer who has provided a subscription certificate, to any employee within 12 months.

Chapter 176G of the General Laws is hereby amended by inserting after Section 16 the following new section:

Section 16A. (a) Except as otherwise provided in this section, the commissioner shall not disapprove a health maintenance contract solely on the basis that it does not include coverage for at least 1 mandated benefit.

(b) The commissioner shall not approve a health maintenance contract unless it provides coverage for:

(1) pregnant women, infants and children as set forth in section 4;

(2) prenatal care, childbirth and postpartum care as set forth in said section 4 and section 4I;

(3) cytologic screening and mammographic examination as set forth in said section 4;

(3A) diabetes-related services, medications and supplies as defined in section 4H;

(4) early intervention services as set forth in said section 4; and

(5) mental health services as set forth in section 4M; provided however, that if the health maintenance contract limits coverage for outpatient physician office visits pursuant to section 16, the commissioner shall not disapprove the health maintenance contract on the basis that coverage for outpatient mental health services is not as extensive as required by said section 4M as long as such coverage is at least as extensive as coverage under the health maintenance contract for outpatient physician services.

(c) The commissioner shall not approve a health maintenance contract that does not include coverage for at least one mandated benefit unless the health maintenance organization continues to offer at least one health maintenance contract that provides coverage that includes all mandated benefits.

(e) The commissioner may promulgate rules and regulations as are necessary to carry out the provisions of this section.

(f) Notwithstanding any special or general law to the contrary, no plan approved by the commissioner under this section shall be available to an employer who has provided a health maintenance contract, to any employee within 12 months.

SECTION 10. Subsection (b) of section 38C of Chapter 3 of the General Laws is hereby amended by inserting at the end thereof the following:

Notwithstanding the foregoing or any general or special law or regulation to the contrary, no mandated health benefit bill shall be reported favorably by any joint committee of the general court or the house or senate committees on ways and means, unless and until the rate of increase in the Consumer Price Index (CPI) for medical care services as reported by the United States Bureau of Labor Statistics remains at zero or below zero for two consecutive years. The Division of Health Care Finance and Policy shall file an annual report with the house and senate committees on ways and means, the joint committee on insurance and the joint committee on health care no later than the last day of January for the previous year certifying the rate of increase in the CPI for medical care services.

SECTION 11. Chapter 111 of the General Laws is hereby amended by inserting at the end of Section 70J the following:

Chapter 111: Section 70K. Reduction of Duplicate Diagnostic Services

Section 70K. Each hospital in the Commonwealth shall file with the Department, within thirty (30) days of the start of the hospital fiscal year, a written plan designed to eliminate the duplication of unnecessary diagnostic services performed on a patient by another hospital or diagnostic facility. The plan shall include the following:

1) Current procedures for sending and receiving diagnostic, imaging and other test results from or to another hospital or provider of care;

2) A defined procedure for determining whether any such test results can be appropriately used in the patient's treatment; and

3) A plan to improve the hospital's ability to send and receive such test results from or to other providers of care.

The Department shall notify the hospital that the plan has been approved or disapproved within thirty (30) days after filing, based on a determination as to whether the plan adequately addresses the issues of patient safety and costs of duplicating diagnostic tests. If such plan has not been acted upon by the department within thirty (30) days, the plan shall be deemed approved. If the Department disapproves of such plan, the hospital shall submit a revised plan within thirty (30) days. If the revised plan continues to be disapproved, or if a hospital fails to submit a plan, the commissioner may issue an order that such a plan be submitted immediately. If such an order is issued, health insurance carriers may deny payment for any duplicate services furnished unless the hospital can establish that the duplicate service was medically necessary and appropriate. In the event that a carrier denies payment for duplicate services, the hospital may not bill the insured for those services.

SECTION 12. Section 51 of Chapter 111 of the General Laws is hereby amended by inserting at the end thereof the following:

Each hospital in the Commonwealth that operates an Emergency Room shall annually file with the Department, within thirty (30) days of the start of the hospital fiscal year, a written operating plan designed to eliminate emergency room overcrowding and diversions. The plan shall include the following:

1) A comprehensive assessment of emergency room wait times for the prior fiscal year, including the average wait time and the number of complaints submitted to the hospital regarding wait times in the emergency room, and a review of steps taken to reduce the wait time. The assessment shall also include the number of hours the emergency room was on diversion status, broken down by day of the week, and the actual number of emergency diversions for the prior fiscal year;

2) A summary of the specific measures that the hospital will take in the current fiscal year to eliminate overcrowding in the emergency room, such as adjusting elective surgery schedules to reduce variability;

3) The anticipated impact the plan will have on staffing ratios and, after the first year, the actual impact the plan has had for the previous year;

4) A defined set of measures by which to assess the plan’s success, such as the number of emergency room diversions, the average wait time to receive emergency services, and/or the percentage of patients in a bed within one hour of arriving in the emergency room;

The Department shall notify the hospital that the plan has been approved or disapproved within twenty (20) days after filing, based on a determination as to whether the plan adequately addresses the needs of emergency room patients. If such plan has not been acted upon by the Department within twenty (20) days, the plan shall be deemed approved. If the Department disapproves of such plan, the hospital shall submit a revised plan within twenty (20) days. If the revised plan continues to be disapproved, or if a hospital fails to submit a plan, the commissioner may take any action deemed appropriate.

SECTION 13. CHAPTER 118E of the General Laws is hereby amended by inserting after Section 60,the following new Section:

Section 61. (a) As used in this chapter the following terms and phrases shall have the following meanings:

"MassHealth Essential", a MassHealth program for the long-term unemployed and for disabled long-term unemployed aliens with special status who have income at or below 100 percent of the Federal Poverty Level and are not eligible for MassHealth Basic; provided that persons meet the eligibility requirements established in section 9A of chapter 118E of the General Laws; provided further that persons eligible under subsection (7) of section 16D of chapter 118E shall also be eligible to receive benefits as part of this program.

(b) The Division of Medical Assistance shall make provisions to allow those persons enrolled in the MassHealth Essential program and meeting the eligibility requirements established under the MassHealth program to be eligible to enroll in Medicaid managed care organizations in accordance with the enrollment and assignment processes for other eligible categories and at the appropriate levels of premium.

SECTION 14. Chapter 175 of the General Laws is hereby amended by inserting after section 3C, the following section:

3D: Study of Duplicative Regulations

(a) The Commissioner of Insurance, shall, in conjunction with the Office of the Attorney General and the Commissioner of the Department of Public Health, convene a study of existing state health care statutory and regulatory requirements that duplicate or are in conflict with existing Federal statutes and regulations and issue a report to the General Court, no later than July 1, 2008. The report shall include a list of the state laws rules and regulations found to be duplicative of or directly conflict federal statutes, rules and regulation and a determination of the necessity of said state statute, rule or regulation.

(b) The Commission shall meet no later than January 1, 2008.

(c) Within 60 days of receipt of the report required under subsection (a) of this section, the joint committee on health care financing shall report appropriate legislation to implement the recommendations of the commission.

SECTION 15. Section 16L of Chapter 6A is hereby amended by inserting after Subsection (r) the following new Subsection:

(s) The Council shall conduct a review of all existing state health care data reporting requirements for hospitals, health plans, physicians and other health care entities to identify such reporting requirements that are inconsistent and duplicative. Following the review the Council shall make recommendations for eliminating duplicative reporting requirements and establish one standardized data collection to be used by all state agencies.

SECTION 16. Chapter 175 is hereby amended by inserting after Section 3D the following new Section:

Section 3E: (a) The Commissioner shall convene a commission the purpose of which will be to study ongoing initiatives and to make recommendations for additional methods to further and simplify administrative services and practices in health care.

(b) The Commission shall consist of the commissioner, who shall serve as chair; the secretary of administration and finance; the commissioner of the division of health care finance and policy; the executive director of the commonwealth health insurance connector authority; the executive director of the health care quality and cost council; 1 representative from the Massachusetts Association of Health Plans; 1 representative from the Massachusetts Hospital Association; 1 representative from the Massachusetts Medical Society; 1 member representing an employer organization; 1 member appointed by the Senate President; and 1 member appointed by the speaker of the House of Representatives.

(d) The commission shall seek input from carriers and health care providers, including hospitals, and physicians on methods and develop recommendations foe administrative and operational streamlining health care practices and services. The commission shall issue a report on its findings and facilitate, where appropriate, the implementation of said report.

(e) The commission shall submit a report on its findings and make recommendations to the general court no later than December 31 2008.

SECTION 17. Section 1 of Chapter 176O of the General Laws is hereby amended by inserting after the definition of “health care services” the following new definition:--“hospital-based physician”, a pathologist, anesthesiologist, radiologist or emergency room physician who practices exclusively within the inpatient or outpatient hospital setting and who provides health care services to a carrier’s insured only as a result of the insured being directed to the hospital inpatient or outpatient setting. This definition may be expanded, after consultation with a statewide advisory committee composed of but not limited to a representative from the Massachusetts Medical Society, the Massachusetts Hospital Association, the Massachusetts Association of Health Plans, the Massachusetts Association of Medical Staff Services, and Blue Cross Blue Shield of Massachusetts, by regulation to include additional categories of physicians who practice exclusively within the inpatient or outpatient hospital setting and who provide health care services to a carrier’s insured only as a result of the insured being directed to the hospital inpatient or outpatient setting.

Chapter 176O of the General Laws is hereby amended by inserting after section 2 the following new sections:--

Section 2A. (a) The bureau shall adopt the “Integrated Massachusetts Application for Initial Credentialing/Appointment” and the “Integrated Massachusetts Application for Recredentialing/Re-Appointment.” The bureau, after consultation with a statewide advisory committee composed of but not limited to a representative from the Massachusetts Medical Society, the Massachusetts Hospital Association, the Massachusetts Association of Health Plans, the Massachusetts Association of Medical Staff Services, and Blue Cross Blue Shield of Massachusetts shall make any revisions to the statewide uniform physician credentialing application forms. Such forms shall not be applicable in those instances where the carrier has both delegated credentialing to a provider organization and does not require submission of a credentialing application.

(b) A carrier shall not use any initial physician credentialing application form other than the uniform initial physician application form or a uniform electronic version of said form. A carrier shall not use any physician recredentialing application form other than the uniform physician recredentialing application form or a uniform electronic version of said form. A carrier may require that the appropriate physician profile be submitted in addition to the uniform physician recredentialing application form.

(c) A carrier shall act upon and complete the credentialing process for 95 percent of complete initial physician credentialing applications submitted by or on behalf of a physician applicant within 30 calendar days of receipt of a complete application. An application shall be considered complete if it contains all of the following elements:

(i) the application form is signed and appropriately dated by the physician applicant;

(ii) all information on the application is submitted in a legible and complete manner and any affirmative answers are accompanied by explanations satisfactory to the carrier;

(iii) a current curriculum vitae with appropriate required dates;

(iv) a signed, currently dated Applicant’s Authorization to Release Information form;

(v) copies of the applicant’s current licenses in all states in which the physician practices;

(vi) a copy of the applicant’s current Massachusetts controlled substances registration and a copy of the applicant’s current federal DEA controlled substance certificate or, if not available, a letter describing prescribing arrangements;

(vii) a copy of the applicant’s current malpractice face sheet coverage statement including amounts and dates of coverage;

(viii) hospital letter or verification of hospital privileges or alternate pathways;

(ix) documentation of board certification or alternate pathways;

(x) documentation of training, if not board certified;

(xi) there are no affirmative responses on questions related to quality or clinical competence;

(xii) there are no modifications to the Applicant’s Authorization to Release Information Form;

(xiii) there are no discrepancies between the information submitted by or on behalf of the physician and information received from other sources; and

(xiv) the appropriate health plan participation agreement, if applicable.

(d) A carrier shall report to a physician applicant or designee the status of a submitted initial credentialing application within a reasonable timeframe. Said report shall include, but not be limited to, the application receipt date and, if incomplete, an itemization of all missing or incomplete items. A carrier may return an incomplete application to the submitter. A physician applicant or designee shall be responsible for any and all missing or incomplete items.

(e) A carrier shall notify a physician applicant of the carrier’s credentialing committee’s decision on an initial credentialing application within four business days of the decision. Said notice shall include the committee’s decision and the decision date.

(f) A physician, other than a primary care provider compensated on a capitated basis, who has been credentialed pursuant to the terms of this section shall be allowed to treat a carrier’s insureds and shall be reimbursed by the carrier for covered services provided to a carrier’s insureds effective as of the carrier’s credentialing committee’s decision date. A primary care physician compensated on a capitated basis who has been credentialed pursuant to the terms established in this section shall be allowed to treat a carrier’s insureds and shall be reimbursed by the carrier for covered services provided to the carrier’s insureds effective no later than the first day of the month following the carrier’s credentialing committee’s decision date.

(g) This section shall not apply to the credentialing and recredentialing by carriers of psychiatrists or hospital-based physicians by carriers.

Section 2B.

(a) The bureau’s accreditation requirements related to credentialing and recredentialing shall not require a carrier to complete the credentialing or recredentialing process for hospital-based physicians.

(b) Except as provided in paragraph (d), a carrier shall not require a hospital-based physician to complete the credentialing and recredentialing process established pursuant to the bureau’s accreditation requirements.

(c) A carrier may establish an abbreviated data submission process for hospital-based physicians. Except as provided in paragraph (d) of this section, said process shall be limited to a review of the data elements required to be collected and reviewed pursuant to applicable regulations of the board of registration in medicine and shall not include primary source verification or a carrier’s credentialing committee review.

(d) In the event that the carrier determines that there is a need to further review a hospital-based physician’s credentials due to quality of care concerns, complaints from insureds, applicable law or other good faith concerns, the carrier may conduct such review as is necessary to make a credentialing or recredentialing decision.

(e) Nothing in this section shall be construed to prohibit a carrier from requiring a physician to submit information or taking other actions necessary for the carrier to comply with the applicable regulations of the board of registration in medicine.

(f) The bureau, after consultation with a statewide advisory committee composed of but not limited to a representative from Massachusetts Hospital Association, the Massachusetts Medical Society, the Massachusetts Association of Health Plans, the Massachusetts Association of Medical Staff Services, and Blue Cross and Blue Shield of Massachusetts, shall develop standard criteria and oversight guidelines that may be used by carriers to delegate the credentialing function to providers. Such criteria and oversight guidelines shall meet applicable accreditation standards.