Whereas, The deferred operation of this act would tend to defeat its purpose, which is to improve forthwith the access to affordable, safe, high quality health care, therefore it is hereby declared to be an emergency law, necessary for the immediate preservation of the public health and convenience.

SECTION 1.  The general court finds that:

(a) The most recent analysis by the Blue Cross Foundation/Urban Institute “Road Map Project,” estimates that the number of uninsured in Massachusetts is 532,376.  Of this number 73% are working and 72.8% are below 400% of the federal poverty guidelines. 

(b) The Institute of Medicine of the National Academies of Science estimate that lack of health insurance reduces life span leading to 18,000 premature deaths a year in the United States including residents of the commonwealth, because of health conditions exacerbated by lack of access to care by the uninsured, and affects the productivity of Americans with serious health conditions.

(c) The commonwealth already expends over $1.1 billion in uncompensated care through the Free Care Pool at the expense of taxpayers and the economy in the form of higher health care premiums and workforce productivity.

(d) Rapidly rising health care costs and health insurance premiums are harming the economic vitality of the commonwealth and its employers, making it difficult for employees and municipalities to pay for their share of health insurance costs, threatening to reverse the progress made in the commonwealth of reducing the number of the uninsured.

(e) Extending coverage to the uninsured in the commonwealth could result in economic and social benefits due to improved health of as much as $1.2 to $1.7 billion per year.  These benefits are estimated to exceed the incremental cost of expanding coverage by as much as a ratio of 3:1.  Other economic and social benefits of covering the uninsured include:

(1) reduced incidence of personal bankruptcies -  more than one half of all personal bankruptcies are directly correlated to unpaid health care expenses;

(2) minimized cost shifting of higher premiums to consumers and appropriate use of low-cost medical settings;

(3) lower payments toward taxpayer funded programs due to better health outcomes and improved health of underserved and low-income population; and

(4) improved workforce productivity.

SECTION 2.  Chapter 3 of the General Laws is hereby amended by striking out section 38C, as appearing in the 2002 Official Edition, and inserting in place thereof, the following section:-

     Section 38C.  For the purposes of this section, a mandated health benefit proposal shall be one that mandates health insurance coverage for specific health services, specific diseases or certain providers of health care services as part of a policy or policies of group life and accidental death and dismemberment insurance covering persons in the service of the commonwealth, and group general or blanket insurance providing hospital, surgical, medical, dental and other health insurance benefits covering persons in the service of the commonwealth and their dependents organized under chapter 32A, individual or group health insurance policies offered by 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, an organization entering into a preferred provider arrangement under chapter 176I, and any health plan issued, renewed or delivered within or without the commonwealth to a natural person who is a resident of the commonwealth, including a certificate issued to an eligible natural person which evidences coverage under a policy or contract issued to a trust or association for the natural person and his dependent, including the person's spouse organized under chapter 176M.

SECTION 2A.  Chapter 17 of the General Laws is hereby amended by striking out section 3, as so appearing, and inserting in place thereof the following section:–

Section 3. There shall be a public health council to advise the commissioner of public health at the request of the commissioner and to perform such other duties as required by law.  The council shall consist of the commissioner of public health as chairperson and 14 members appointed for terms of 6 years in accordance with this section.  The commissioner may designate one of the members as vice chairperson and may appoint such subcommittees or special committees as may be needed. 

            Three of the appointed members shall be the chancellor of the University of Massachusetts Medical School or his designee; the dean of the Harvard University School of Public Health or his designee; and the dean of the Boston University School of Public Health or his designee.

Six of the appointed members shall be providers of health services, 1 of whom shall be the chief executive officer of an acute care hospital appointed by the Massachusetts Hospital Association, 1 of whom shall be the chief executive officer of a skilled nursing facility appointed by the Massachusetts Extended Care Federation, 1 of whom shall be a nurse executive appointed by the Massachusetts Organization of Nurse Executives, 1 of whom shall be a registered nurse chosen by the board of registration of nurses who shall be the highest vote-getter on a mail ballot sent to the address of record of all registered nurses licensed by the board of registration of nurses, and 2 of whom shall be physicians appointed by the Massachusetts Medical Society.

Five of the appointed members shall be non-providers, 1 of whom shall be appointed by the secretary of elder affairs, 1 of whom shall be appointed by the secretary of veterans’ services, 1 of whom shall be appointed by Health Care For All, Inc.; 1 of whom shall be appointed by the Coalition for the Prevention of Medical Errors, Inc.; and 1 of whom shall be appointed by the Massachusetts Public Health Association.

For the purposes of this section “non-provider” shall mean a person whose background and experience indicate that he or she is qualified to act on the council in the public interest, who, and whose spouse, parents, siblings or children, has no financial interest in a health care facility, who, and whose spouse, has no employment relationship to a health care facility, to a nonprofit service corporation established in accordance with chapters 176 A to 176E, inclusive, nor to a corporation authorized to insure the health of individuals, and who, and whose spouse, is not licensed to practice medicine.

Upon the expiration of the term of office of an appointive member, his successor shall be appointed in the same manner as the original appointment, for a term of 6 years and until the qualification of his successor. The council shall meet at least once a month, and at such other times as it shall determine by its rules, or when requested by the commissioner or any four members. The appointive members shall receive $100 a day while in conference, and their necessary traveling expenses while in the performance of their official duties.

SECTION 3.  Section 7 of chapter 26 of the General Laws, as so appearing, is hereby amended by striking out the first sentence and inserting in place thereof the following sentence:-  The commissioner of insurance may appoint and remove, with the approval of the governor, a first deputy commissioner for health care access, an actuary, a research analyst, a chief examiner and such additional deputies, examiners, assistant actuaries and inspectors as the commissioner may require.

SECTION 3A.  Said chapter 26 is hereby further amended by inserting after section 7 the following section:-

Section 7A.  There shall be a deputy commissioner for health care access whose duties shall include, subject to the direction of the commissioner, administration of the division’s statutory and regulatory authority for oversight of the small group and non-group health insurance markets, oversight of affordable health plans, including coverage for young adults, as well as the dissemination of appropriate information to consumers relative to health insurance coverage and access to affordable products.

SECTION 4.   The General Laws are hereby further amended by inserting after chapter 28A the following chapter:-

CHAPTER 28B.

 CONSUMER HEALTH CARE QUALITY & COST INFORMATION BOARD

Section 1.         As used in this chapter, the following terms shall have the following meanings unless the context clearly requires otherwise:

“Board”, the consumer health care costs information board established in section 2.

“Clinician”, any of the following heath care professionals licensed pursuant to chapter 112: a physician, podiatrist,  physical therapist, occupational therapist, dentist, optometrist, nurse, nurse practitioner, chiropractor, psychologist,  independent clinical social worker, speech-language pathologist, audiologist, marriage and family therapist and a mental health counselor.

 “Facility”, a hospital, clinic or nursing home licensed pursuant to chapter 111 or a home health agency. 

“Health care provider”, a clinician, a facility or a physician group practice. 

“Insurer”, a carrier authorized to transact accident and health insurance pursuant to chapter 175, a nonprofit hospital service corporation licensed pursuant to chapter 176A, a nonprofit medical service corporation licensed pursuant to chapter 176B, a dental service corporation organized pursuant to chapter 176E, an optometric service corporation organized pursuant to chapter 176F and a health maintenance organization licensed pursuant to chapter 176G.

“Physician group practice”, 2 or more physicians who deliver patient care, make joint use of equipment and personnel, and divide income by a prearranged formula.

Section 2.  There shall be a consumer health care costs information board.  The board shall consist of the secretary of health and human services, the commissioner of insurance, the executive director of the group insurance commissioner, the chief of the public protection bureau of the office of the attorney general, a representative of the Massachusetts Medicaid policy institute, a representative of Healthcare For All and a private purchaser of insurance appointed by the governor.  The board shall be chaired by the commissioner of insurance.  The board shall make available to the public, primarily through an internet site, comparative information on the cost and quality of health care services. 

Section 3.  (a)  The board shall establish and maintain a consumer health information internet site.  The website shall contain information comparing the cost and quality of health care services and may also contain general information related to health care as the board determines to be appropriate.  The website shall be designed to assist consumers in making informed decisions regarding their medical care and informed choices between health care providers.  Information shall be presented in a format that is understandable to the average consumer.  The board shall take appropriate action to publicize the availability of its internet site and make available written documentation available upon request and as necessary.

(b)  Not later than January 1, 2006, the internet site shall be operational and, at a minimum, include links to other internet sites that display comparative cost and quality information.  

(c)  Not later than January 1, 2007, the internet site shall, at a minimum, include comparative cost information by facility and, as applicable, by clinician or physician group practice for obstetrical services, physician office visits, high-volume elective surgical procedures, high-volume diagnostic tests and high-volume therapeutic procedures.  Cost information shall include, at a minimum, the average payment for each service or category or service received by each facility, clinician or physician practice on behalf of insured patients.   Cost information shall be aggregated for all insurers and the board shall not publicly release the payment rates of any individual insurer.

(d)  The internet site shall be provide updated information on a regular basis, at least annually, and additional comparative cost and quality information shall be posted as determined by the board.  To the extent possible, the internet site shall include: (i) comparative quality information by facility, clinician or physician group practice for each service or category of service for which comparative cost information is provided, (ii) general information related to each service or category of service for which comparative information is provided; and (iii) comparative quality information by facility, clinician or physician practice that is not service-specific, including information related to patient safety and satisfaction.    

Section 4.  The board shall contract with an independent organization to provide the board with technical assistance related to its duties including, but not limited to, development and maintenance of the internet site and the reporting plan required pursuant to section f5.  The independent organization shall possesses the skill and expertise necessary to: (i) identify and, when necessary, develop appropriate measures of cost and quality for inclusion on the website; (ii) collect and analyze data related to cost and quality; and (iii) present data on the internet site in a format understandable to consumers.  To the extent possible, the organization shall collaborate with other organizations that develop, collect and publicly report cost and quality measures.

Section 5.  Any independent organization under contract with the board shall develop and update on an annual basis a reporting plan specifying the cost and quality measures to be included on the internet site.  The reporting plan shall be consistent with the requirements of section 3.  The organization shall give consideration to those measures that are already available in the public domain and to whether it is cost effective for the board to license commercially available comparative data and consumer decision support tools.  If the organization determines that making available through the internet site only those measures already available in the public domain would not fully comply with section 3 or would not provide consumers with sufficient information to make informed health care choices, the organization shall  develop appropriate measures for inclusion on the internet site and shall specify in the reporting plan the sources from which it proposes to obtain the data necessary to construct those measures and any specifications for reporting of that data by insurers and health care providers.  As part of the reporting plan, the organization shall determine for each service that comparative information is to be included on the internet site whether it is more practical and useful to: (i) list that service separately or as part of a group of related services; and (ii) combine the cost information for each facility and its affiliated clinicians and physician practices or to list facility and professional costs separately.  The independent organization shall submit the reporting plan, and any periodic revisions, to the board.  The board shall, after due consideration and public hearing, adopt or reject the reporting plan or any revisions.  If the board rejects the reporting plan or any revisions, the board shall state its reasons therefor.  The reporting plan and any revisions adopted by the board shall be promulgated as a by regulation by the commissioner. 

Section 6.  Insurers and health care providers shall submit data to the board or to the independent organization on behalf of the board, as required by regulations promulgated pursuant to section 5.  Any insurer or health care provider failing, without just cause, to submit required data to the board on a timely basis may be required, after notice and hearing, to pay a penalty of  $1,000 for each week’s delay.  The maximum penalty under this section shall be $50,000.

SECTION 5.  Chapter 29 of the General Laws is hereby amended by inserting after section 2CCC the following  section:-

Section 2DDD. (a) There shall be established and set up on the books of the commonwealth a separate fund to be known as the Reinsurance Trust Fund.  There shall be credited to the fund all amounts received under section 15A of this act.  The commissioner of insurance shall authorize expenditures from the fund for the purposes of reimbursing carriers, as defined in section 1 of chapter 176J, for all costs which that the carriers may incur in claims pursuant to section 10 of said chapter 176J and section 7 of chapter 176M.  The commissioner of revenue shall collaborate with the commissioner of insurance and the commissioner of health care finance and policy to determine the appropriate methodology and mechanisms by which to the employees, pursuant to said section 15A of this act.  Nothing in this section shall prohibit the commissioner of insurance from contracting with a third party to administer the fund. The commissioner of insurance shall promulgate regulations necessary to implement this section.  The commissioner of insurance shall, not later than October 1 of each year, file a detailed report in writing to the joint committee on health care financing, the joint committee on financial services and the house and senate committees on ways and means regarding the methodology and mechanism used in ascertaining any assessments, pursuant to said section 15A of this act, the methodology used for reimbursing eligible carriers and the disbursements made, by carrier and amount, the fiscal year ending on the preceding June 30. Said commissioner may submit any additional information he considers appropriate and may file recommendations to improve, adjust or modify the mechanism established pursuant to said section 15A of this act.

(b) There shall be a reinsurance trust fund advisory board, consisting of 13 members, who shall be citizens of the commonwealth, to be appointed by the governor, 2 of whom shall be persons representing businesses or employers; 4 of whom shall be persons representing the health care industry, 1 of whom shall be selected from the Massachusetts Association of Health Plans; 1 of whom shall be selected from the Massachusetts Hospitals Association, 1 of whom shall be selected from the Massachusetts Medical Society, 1 of whom shall be selected from the Massachusetts League of Community Health Centers, 1 of whom shall be a representative of a consumer advocacy organization, 1 of whom shall have a background in health policy and economics and 1 of whom shall represent the public. The Advisory board shall designate the chairman of the advisory board by unanimous vote. Members shall serve for a term of 3 years. Vacancies shall be filled by appointment by the governor for the remainder of the unexpired term. All members shall serve until the qualification of their respective successors. Members shall serve without compensation.  The advisory board shall advise the commissioner of insurance and the commissioner of health care finance and policy on the administration, oversight and operation of the fund, including but not limited to, reviewing and making recommendations on assessment methodologies, pursuant to section 18B of Chapter 118G of the General Laws, assessment levels, appropriate funding and disbursement levels and other requirements or criteria specific to the fund or its structure.  The advisory board shall, from time to time, submit recommendations to the legislature on any legislative changes it deems necessary for the successful operation of the fund or its structure.

SECTION 6. Chapter 32A of the General Laws is hereby amended by inserting after section 10E the following section:-

            Section 10F. The commission shall establish a plan of long term care insurance on the terms and conditions it considers to be in the best interest of the commonwealth and its employees.  With respect to any long term care insurance which is in effect for an employee there shall be withheld from the salary or wages of the employee the premium for the insurance and the commonwealth shall make no contribution to the premium.  The commission shall use its best efforts to ensure that all premium payments by employees are eligible for favorable tax treatment available under federal and state law.

SECTION 7.  The first paragraph of section 7A of chapter 32B of the General Laws, as appearing in the 20002 Official Edition, is hereby amended by striking out the last sentence and inserting in place thereof the following 2 sentences:-  Notwithstanding any general or special law or collective bargaining agreement to the contrary, in the case of a city, the city council acting with the approval of the mayor subject to the charter of said city, in the case of a town having a town council, the town council, and in every other town, the town meeting, shall set its maximum total monthly premium contribution, but, no eligible employee shall be required to pay more than 50 per cent of the total monthly premium cost or rate. Subject to the above limitations, a governmental unit may provide different subsidiary or additional rates to any group or class within that unit.

SECTION 8.  Section 1 of chapter 62 of the General Laws is hereby amended by striking out paragraph (c), as so appearing, and inserting in place thereof the following paragraph:-

(c) "Code'', the Internal Revenue Code of the United States, as amended on January 1, 1998 and in effect for the taxable year; provided, however, that Code shall mean the Code as amended and in effect for the taxable year for sections 62(a)(1), 72, 223, 274(m), 274(n), 401 through 420, inclusive, 457, 529, 530, 3401 and 3405 but excluding sections 402A and 408(q).

SECTION 9.  Chapter 111 of the General Laws is hereby amended by inserting after section 24J the following section:–

Section 24K. (a) The department shall, subject to appropriation, establish a community health worker outreach program to provide community-based education and health promotion activities to communities facing barriers to health care services in the commonwealth, particularly ethnic and racial minority communities, and to enhance the community health worker workforce.

(b) The program shall prepare a comprehensive outreach services plan, which shall be updated and filed with the house and senate committees on ways and means and the joint committee on health care financing annually. The plan shall identify barriers to health care services, including cultural and language differences between health care providers and their patients, limited accessibility of health care facilities and providers, lack of transportation, inadequate understanding of MassHealth and other health care programs by eligible persons and providers who are unfamiliar with community needs. The plan shall detail a strategy for providing community-based education and health promotion services to reduce such barriers and improve public health. The strategy shall include, but not be limited to:

(i) activities to bridge cultural, linguistic and logistical gaps between health care providers and communities facing such barriers, particularly minority and low-income communities;

(ii) activities to achieve increased awareness of and higher rates of enrollment in MassHealth and other health programs, including the uncompensated care pool;

(iii) activities to increase the use of primary care and reduce inappropriate use of hospital emergency rooms; and

(iv) activities to improve the health status of such communities, including health education, information and referral services, and other activities.

(c) The program shall establish an advisory board representing communities with high rates of un-insurance, ethnic and racial minorities and people facing barriers to health care services throughout the commonwealth. The advisory board shall review the activities of the program, assist in the preparation and implementation of the comprehensive outreach services plan, and advise the department on the activities of the program.

(d) The program shall, subject to appropriation, competitively bid for and contract with organizations providing community health outreach services to implement the plan.  Preference shall be given to organizations familiar with the communities to be served and known to members of that community. The program shall institute a training curriculum and community health worker certification program for such organizations to insure high standards and quality of services.

(e) The program may enter into an interagency agreement with the division of medical assistance for the provision of services by the program, and shall seek maximum federal financial participation for expenditures made by the program. The division shall work cooperatively with the department to secure federal financial participation with the goal of integrating community health workers into the activities of the division, and shall report to annually the house and senate committees on ways and means and the joint committee on health care finance, the results of a study on the feasibility of incorporating community health worker services into rates paid to providers of medical benefits by the division.

           SECTION 10. Section 52 of Chapter 111 of the general laws, as appearing in the 2002 official edition, is hereby amended by adding at the end of the third sentence in the definition of “Clinic” the following:

“; provided further that any Medicare-certified entity or provider that operates exclusively for the purpose of providing single or multi-specialty ambulatory medical or surgical services, as defined by section twenty-five B, shall be defined a clinic for purposes of licensure under section fifty-one of this chapter.

SECTION 11.  Section 25C of said chapter 111, as so appearing, is hereby amended by adding the following paragraph:- 

            Notwithstanding the any general or special law or rule or regulation to the contrary, an acute-care hospital may acquire new technology or major movable equipment, cyberknifes, positron emission tomography machines or other diagnostic equipment used to provide innovative service, without obtaining a determination of need from the department of public health, and that all the uses associated with those technologies shall not be a substantial change in services.

SECTION 12.  Chapter 112 of the General Laws is hereby amended by inserting after section 12B the following section:-

Section 12B ½ . No physician duly registered under section 2, 2 A, 9, 9A or 9B, no physician assistant duly registered under the section 9I or his employing or supervising physician, and no nurse duly registered or licensed under section 74, 74A or 76, or resident in another state, in the District of Columbia or in a province of Canada, and duly registered therein, who, in good faith, as a volunteer and without fee, renders uncompensated care or treatment, other than in the ordinary course of his practice, shall be liable in a suit for damages as a result of his acts or omissions, nor shall he be liable to a hospital for its expenses if, under such uncompensated care conditions, he orders a person hospitalized or causes his admission.

SECTION 13.  Chapter 118E of the General Laws is hereby amended by striking out section 9C, as appearing in the 2002 Official Edition, and inserting in place thereof the following section:-

            Section 9C. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise:

            "Eligible employee'', (i) an employee of an eligible or qualified employer; (ii) who resides in the commonwealth; (iii) who has not attained age 65; and (iv) who meets the financial and other eligibility standards set forth in regulations promulgated by the division; provided, however, that the gross family income standard shall not exceed 300 per cent of the federal poverty level.

            Eligible employer'', (i) an individual or an unincorporated business that employs at least 1 resident of the commonwealth; (ii) a corporation, including a foreign corporation, other than a governmental entity, that employs at least 1 resident of the commonwealth; or (iii) a corporation or an unincorporated entity that is exempt from taxation under the provisions of section 501(c) of the Internal Revenue Code of the United States, as amended and in effect for the taxable year; provided however, that to be eligible, the employer shall employ not more than 75 employees and shall meet the eligibility requirements set forth in this section and in regulations promulgated by the division; and provided, further, that the method of determining the number of employees an employer has and the amount and types subsidies available to an eligible employer based upon employee family status shall be determined by the division.

            "Eligible self-employed husband and wife'', a married couple with or without dependents: (i) where either spouse receives gross income from self employment; (ii) where both spouses reside in the commonwealth; (iii) where neither spouse has attained age 65; and (iv) who meets the financial and other eligibility standards set forth in regulations promulgated by the division; provided, however, that the gross family income standard shall not exceed 300 per cent of the federal poverty level.

"Eligible self-employed single individual'', a person with or without dependents: (i) who receives gross income from self-employment; (ii) who resides in the commonwealth; (iii) who has not attained age 65; and (iv) who meets the financial and other eligibility standards set forth in regulations promulgated by the division; provided, however, that the gross family income standard shall not exceed 300 per cent of the federal poverty level.

            ”Qualified medical insurance'', “qualified medical insurance”, “qualified individual medical insurance'', ""qualified two-person family medical insurance'' and ""qualified family medical insurance'' as defined in regulations promulgated by the commissioner of insurance pursuant to section 3C of chapter 175.

(b) The division shall assist the director of labor and workforce development, subject to this section, to establish Health Care Plus, an insurance reimbursement program for certain employees or employers for the purpose of reducing or eliminating the amount of contributions or payments made by such employees or employers toward the cost of qualified medical insurance and which shall consist of the following 3 programs:

(1) an employee subsidy program to assist eligible employees with reducing or eliminating their contribution to premiums or other employment-based costs of qualified medical insurance provided by an eligible employer for which the employer pays not less than 50 per cent of the premium or cost; provided, however, that the amount of the subsidies may vary with the contribution of the employees to the cost of their qualified medical insurance, and with the income of the employees and their families, in accordance with a sliding fee schedule set forth in regulations promulgated by the division, and may be paid directly to or on behalf of eligible employees.

(2) a subsidy program to assist the self-employed single individual and the self-employed husband and wife with reducing or eliminating the cost of premiums or other costs of purchasing qualified medical insurance; provided, however, that the amount of subsidies may vary with the income or insurance costs of the persons and their families, in accordance with a sliding fee schedule set forth in regulations promulgated by the division, and may be paid directly to or on behalf of those persons; and provided further, that the division may choose various options in establishing the program, including but not limited to, establishing: (i) subsidies for the self-employed which may be for an amount which incorporates payments otherwise available to such self-employed individual or spouse under subsection (e); (ii) sliding fee schedules that may incorporate such payments; or (iii) sliding fee schedules which may be otherwise adjusted so that such persons receive overall assistance comparable, but not necessarily identical, in its effect to that received by similarly situated eligible employees under the program established under clause (3).

(3) an employer health care incentive program for the purpose of reducing the cost to employers of providing or maintaining qualified medical insurance for their eligible low-income employees; provided, however, that the eligible employer shall pay at least 50 per cent of the premium cost of such qualified medical insurance; and provided further, that the division may limit payments under this program, using a reasonable methodology, in relation to the participation of said employer's employees in the subsidy program provided for in clause (1).

(c) The subsidy programs shall constitute additional medical benefits to expansion beneficiaries in accordance with the terms and conditions of a demonstration project as defined in subsection (1) of section 9A. The division may, subject to the terms and conditions of the demonstration project, include in the demonstration project the program described in paragraph (C) of subsection (2); provided, however, that the division may implement the program if it is not included within the demonstration project.

(d) The amount of payments for each employer under clause (3) of subsection (b) shall be as follows: (i) $600 for each eligible employee for whom the eligible employer pays at least 50 per cent of the cost of qualified individual medical insurance; (ii) $1,200 for each eligible employee for whom the eligible employer pays at least 50 per cent of the cost of qualified two-person family medical insurance, and (iii) $1,500 for each eligible employee for whom the eligible employer pays at least 50 per cent of the cost of qualified family medical insurance; provided, however, that the division may use any reasonable data sources in determining the number of eligible employees of an eligible employer qualifying for such payments under this subsection. The director of labor and workforce development, in collaboration with the division, may implement annual inflation increases to said payments, based on certain criteria as determined by the director and the division and subject to the requirements of the budget neutrality plan established by section 9B. 

(e) The amount of payments for each self-employed single individual or each self-employed husband and wife under clause 2 of subsection (b) may include the following amounts: (i) $600 for an eligible self-employed single individual if the individual purchases qualified individual medical insurance; (ii) $1,200 for an eligible self-employed single individual with a dependent child or for an eligible self-employed husband and wife filing a joint return and who have no dependent children, if the individual or husband and wife purchase qualified two-person family medical insurance; or (iii) $1,500 for an eligible self-employed single individual with two or more dependent children, or for an eligible self-employed husband and wife filing a joint return and who have dependent children, if the individual or the husband and wife purchase qualified family medical insurance; provided, however, that the payment shall not exceed the amount of the net premium cost to the self-employed persons of the insurance, and shall be in conformity with the regulations of the division. The director of labor and workforce development, in collaboration with the division, may implement annual inflation increases to the payments, based on certain criteria as determined by the director and the division and subject to the requirements of the budget neutrality plan established by section 9B. 

(f) The director of labor and workforce development, in collaboration with the division, may require, as a condition for receiving benefits under this section and solely for the purposes of determining the eligibility of any employee, self-employed single individual, or self-employed husband and wife, the consent of any applicant to the disclosure to the division and to the United States Department of Health and Human Services pursuant to subsection (10) of prior year's tax information and any other information demonstrating the income level of such persons. The director in collaboration with the division, may employ additional eligibility criteria to ensure, where appropriate, that no person or employer receives payments or assistance under more than 1 category of persons or employers eligible for payment or assistance.

(g) The income and other eligibility requirements for the programs provided under subsection (a) may be modified from time to time to ensure that projected expenditures for such benefits are within the amounts available and within the amounts projected to be available. The director of labor and workforce development, in collaboration with the division, shall set forth in enrollment of qualified individuals regulations changes in eligibility requirements, including changes necessary to ensure compliance with the budget neutrality requirements of section 9B.

(h) The director of labor and workforce development, in collaboration with the division, may, in lieu of cash payments or otherwise, issue to individuals vouchers or other documents certifying that the division will pay a specified amount for medical insurance under specified circumstances.

(i) If, during the term of the demonstration project as it pertains to programs authorized under this section, the director of labor and workforce development, in collaboration with the division, proposes modifications to the demonstration project which require approval by the director, the division may implement said modifications upon the director’s  approval, subject to the terms of that approval, and, if required, the enactment of authorizing legislation.

(j) Data and information obtained by the division pursuant to subsection (f) to determine eligibility under this chapter shall be available for inspection by the director or his designee for the specific purpose of substantiating expenditures made under this section.

(k) The division shall establish an intragovernmental service agreement or collaboration with the director of labor and workforce development for the purposes of implementing the provisions of this chapter  and may arrange with other agencies of the commonwealth, including the department of revenue, as provided in subsection (11) of section 9A, to administer said programs

(l) This section shall not give rise to, nor be construed as giving rise to, enforceable legal rights for any party or an enforceable entitlement to benefits other than to the extent that such rights or entitlements exist pursuant to the regulations of the commissioner of insurance and the regulations of the commissioner of revenue subsection (a), the regulations of the division, or the terms and conditions of the demonstration project.

(m) Expenditures under this section shall, subject to appropriation, be funded by the MassHealth insurance reimbursement program account established by subsection (c) of section 18 of chapter 118G. Aggregate expenditures made by the director of labor and workforce development, in collaboration with the division, for the insurance reimbursement program shall not exceed $120,000,000 in any fiscal year, and shall be subject to the requirements of the budget neutrality plan established by section 9B.

(n) The director of labor and workforce development, in collaboration with the division, shall provide quarterly reports to the committee on health care financing and to the house and senate committee on ways and means on the implementation status and budget impact of the programs established under this section.  The programs may be offered separately and may be implemented at different times, and a plan relative to each program may be submitted separately.

SECTION 13A.  Section 1 of chapter 118G of the General Laws is hereby amended by inserting after the definition of "Non-acute hospital", as appearing in the 2002 Official  Edition, the following definition:

            ""Non-providing employer", an employer of a person receiving free care or Medicaid, so-called, pursuant to Chapter 118E of the General laws ; provided, however, that the term "non-providing employer" shall not include:

(i) an employer that, for such person receiving free care or Medicaid, offers to pay for or arrange for the purchase of health insurance coverage;

(ii) an employer that is signatory to or obligated under a negotiated, bonafide collective bargaining agreement between such employer and bona fideemployee representative which agreement governs the employment conditions ofsuch person receiving free care; or

(iii) an employer that employs not more than 50.  For the purposes of this definition, an employer shall not be considered to pay for or arrange for the purchase of health care services provided by acute hospitals and ambulatory surgical center services provided by ambulatory surgical centers by making or arranging for any payments to the uncompensated care pool.

SECTION 13B.  Said Section 1 of said chapter 118G is hereby further amended by inserting after the definition of "Pool", as so appearing, the following definition:

            ""Payments from Non-providing Employers", all amounts paid to the

Uncompensated Care Trust Fund by non-providing employers.

SECTION 13C.  Said Section 1 of said chapter 118G is hereby further amended by inserting after the definition of “Uninsured patient”, as so appearing, the following definition:-

            “Voluntarily uninsured employee”, an uninsured patient: (i) whose gross family income exceeds 300 per cent of the federal poverty level; (ii) whose employer has offered to pay for or arrange for the purchase of health insurance; and (iii) who has declined to obtain such health insurance.

SECTION 13D.  Section 6 of said chapter 118G, as so appearing, is hereby amended by inserting after the first paragraph, the following paragraph:-

            In addition, such uniform reporting shall provide the name and address and such other identifying information as may be needed relative to the employer of any patient for whom health care services were rendered pursuant to this chapter and for whom reimbursement from the uncompensated care pool has been requested. 

SECTION 14.  Said chapter 118G of the General Laws is hereby amended by inserting after section 6A the following 2 sections:-

SECTION 6B.  Notwithstanding any general or special law to the contrary, an applicant for uncompensated care pool assistance shall, if eligible, be enrolled in MassHealth pursuant to section 9A, chapter 118E or in Health Care Plus, formerly the Insurance Partnership, as provided in section 9C of said chapter 118E.  An applicant deemed ineligible for either program, or who is self-employed and who is unable to make all or part of the payment for health services, shall provide the name and address of his employer or, if self-employed, his name, address, social security number and date of birth.  The director of labor and workforce development, in collaboration with the division, shall collaborate with the division of insurance and the department of revenue to implement this section and sections 6C and 18 and section 41 of chapter 268.           

Section 6C.  The division shall promulgate a form labeled “Health Insurance Responsibility Disclosure” to be completed and signed, under oath, by every employer and employee doing business in the commonwealth.  The form shall indicate whether the employer has offered to pay for or arrange for the purchase of health care insurance, whether the employee has accepted or declined such coverage and whether the employee has an alternative source of health insurance coverage.  The form shall contain a statement that an employee who chooses to decline health insurance coverage offered by an employer shall be legally responsible for that employee’s health care costs, if any, and shall be charged for the use of any uncompensated care pool services.  The division may make arrangements with other agencies of the commonwealth, including the department of revenue, to distribute and collect forms to all employers and employees in the commonwealth

SECTION 15.  Said chapter 118G is hereby further amended by inserting after section 11 the following section:–

Section 11A.  (a) The division shall monitor and review payments to MassHealth providers as specified in section 13 of chapter 118E. The division, in consultation with the state auditor, shall annually prepare analyses for the advisory board established pursuant to said section on the following:

(i)      a comparison of Title XIX and Title XVIII provider rates for comparable services; 

(ii)    an historical analysis comparing Medicare and Medicaid annual inflation updates;

(iii)   adequacy of medicaid payments to providers with particular attention to community hospitals, physicians and other providers located in rural and isolated areas;.

(iv)  adequacy of Medicaid payment for emergency care rendered as required by 42 USC 1395(dd) and competent interpreter services provided pursuant to section 25J of chapter 111; and

(v)     adequacy of medicaid payments to allow providers to cover at least half the cost of employee health care insurance.

(b)  The division shall annually transmit to the governor, the speaker of the house and president of the senate, a MassHealth cost-shifting report. The MassHealth cost-shifting report shall determine the extent to which rates charged by providers to health insurance plans are increased due to inadequate payments by commonwealth governmental units under Title XIX. The report shall further estimate the increased costs of health insurance plan premiums due to inadequate payments by commonwealth governmental units under Title XIX. In preparing the report, the state auditor shall consult with representatives of providers and shall have access to all information of the division.

SECTION 15A.  Said chapter 118G is hereby amended by inserting after section 18A the following section:-

Section 18B. (a) The division shall, upon verification of the provision of services and costs to a patient who works for a non-providing employer or to a dependent of such person, assess a free rider surcharge on the non-providing employer in accordance with regulations promulgated by the division. 

(b) The amount of the free rider surcharge on non-providing employers shall be not less than 50 per cent and not greater than 100 per cent of the cost of free care provided to said employer's employee or the employee’s dependent, and may include an additional surcharge for administrative expenses incurred by the division. 

(c) The formula for assessing free rider surcharges on non-providing employers shall be set forth in regulations promulgated by the division that shall be based on factors including, but not limited to: (i)  the number of incidents during the past year in which employees of the non-providing employer received services from the uncompensated care pool or Medicaid, pursuant to Chapter 118E of the General Laws; (ii) the number of persons employed by the non-providing employer; (iii) the proportion of employees for whom the non-providing employer provides health insurance.

(d) The division shall, upon verification of the provisions of services and costs thereof to a patient who is a voluntarily uninsured employee or to a dependent of such a person, assess a free rider surcharge on the patient in accordance with regulations promulgated by the division.

(e) The amount of the “free rider” surcharge on a voluntarily uninsured employee shall be not less than 30 per cent and not greater than 100 per cent of the cost of free care provided to said employee or the employee’s dependent, and may include an additional surcharge for administrative expenses incurred by the division. 

(f)  The formula for assessing “free rider” surcharges on non-providing employers shall be set forth in regulations promulgated by the division that shall be based on factors including, but not limited to: (i)  the number of incidents during the past year in which the employee received services from the uncompensated care pool or Medicaid, pursuant to Chapter 118E of the General Laws ; (ii)  the gross annual income of the employee’s family; (iii)  the total assets of the employee’s family.             

(g)  If the patient is employed by more than one non-providing employer at the time he or she receives services, the division shall assess a free rider surcharge on each said employer consistent with the formula established pursuant to this section.

(h) The division shall specify by regulation appropriate mechanisms for implementing free rider surcharges on non-providing employers and voluntarily uninsured employees.  Said regulations shall include, but not be limited to, the following provisions:

(i) Appropriate mechanisms that provide for determination and payment of surcharge by a non-providing employer or a voluntarily uninsured employee, including requirements for data to be submitted by employers, employees, acute hospitals and ambulatory surgical centers, and other persons.

(j) Penalties for nonpayment or late payment by the surcharged person or entity, including 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.

(k)   All surcharge payments made under this Section shall be deposited into Reinsurance Trust Fund, pursuant to section 2DDD of chapter 29.

(l) A non-providing employer's liability to said pool shall in the case of a transfer of ownership be assumed by the successor in interest to the non-providing employer's.

(m) Any non-providing employer that fails to file any data, statistics or schedules or other information required under this chapter or by any regulation promulgated by the division or which falsifies the same, shall be subject to a civil penalty of not more than $5,000 for each week on which such violation occurs or continues, which penalty may be assessed in an action brought on behalf of the commonwealth in any court of competent jurisdiction.

(n) The attorney general shall bring any appropriate action, including injunctive relief, as may be necessary for the enforcement of this chapter.

(o)  No employer shall discriminate against any employee on the basis of the employee’s receipt of Uncompensated Care Pool services, the employee’s reporting or disclosure of his or her employer’s identity and other information about the employer, the employee’s completion of a Health Insurance Responsibility Disclosure form, or any facts or circumstances relating to “free rider” surcharges assess against the employer in relation to the employee.  Violation of this sub-section shall constitute a per se violation of Chapter 93A.

(p)  A hospital, surgical center, health center or other entity that provides uncompensated care pool services shall provide any uninsured patient with written notice of the criminal penalties for committing fraud in connection with the receipt of uncompensated care pool services, as provided in section 41 of chapter 268.  The division shall promulgate a standard written notice form to be made available to health care providers in English and foreign languages.  The form shall further include written notice of every employee’s protection from employment discrimination pursuant to this section.

SECTION 16.  Chapter 149 of the General Laws is hereby amended by inserting after section 6D the following new section:

Section 6D ½.  No employee shall be penalized by an employer as a result of such employee's filing of an application to the uncompensated care pool or otherwise providing notice to the division of health care finance and policy or to a health care provider in regard to the need for health care services for that employee that results in the employer being required to reimburse the pool in whole or in part.

SECTION 16A.  Section 108 of chapter 175 of the General Laws is hereby amended by striking out subsection (3) and inserting the following subsection:-

(3) It purports to insure only 1 person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyholder, 2 or more eligible members of that family, including husband, wife, dependent children or any children under a specified age which shall not exceed 25 years and any other person dependent upon the policyholder; provided, however, that where a policy provides for termination of a dependent child's coverage at a specified age and where such a child is mentally or physically incapable of earning his own living on the termination date, the policy shall continue to insure such child while the policy is in force and so long as such incapacity continues, if due proof of such incapacity is received by the insurer within 31 days of such termination date. The term "dependent children'' as used in this subsection shall include children of adopting parents during the pendency of adoption proceedings under chapter 210; and.

SECTION 17.  Chapter 175 of the General Laws is hereby amended by inserting after section 110K the following new section:

Section 110L. Every policy of insurance issued or subsequently renewed shall provide coverage to persons who are college age, non-student dependents, up to age 25, who are unemployed and have no other form or type of health insurance.  This paragraph shall apply to any policy issued or renewed within or without the commonwealth and which covers residents of the commonwealth.

SECTION 18.  Said chapter 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;

(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 1 mandated benefit unless the carrier continues to offer at least 1 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.

 SECTION 19.  Chapter 176A of the General Laws is hereby amended by inserting after section 1D the following new 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 1 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;

(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 1 mandated benefit unless the corporation continues to offer at least 1 contract 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 tocarry out this section.

SECTION 20.  Chapter 176A of the General Laws is hereby amended by inserting after section 8Y the following section:-

Section 8Z. Any subscription certificate under a group nonprofit hospital service agreement, except certificates which provide supplemental coverage to Medicare or other governmental programs which shall be delivered, issued or renewed in the commonwealth, shall provide, as benefits to all group members having a principal place of employment within the commonwealth, coverage to persons who are college age, non-student dependents, up to age 25, who are unemployed and have no other form or type of health insurance.

SECTION 21. Chapter 176B of the General Laws is hereby amended by inserting after section 4Y the following section:-

Section 4Z. Any subscription certificate under an individual or group medical service agreement which shall be delivered or issued or renewed in this commonwealth shall provide as benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth, coverage to persons who are college age, non-student dependents, up to age 25, who are unemployed and have no other form or type of health insurance.

SECTION 22.  Said chapter 176B 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 1 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;

(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 1 subscription certificate 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.

SECTION 23.  Chapter 176G of the General Laws is hereby amended by inserting after section 4Q the following section:-

Section 4R. A health maintenance contract shall provide coverage to persons who are college age, non-student dependents, up to age 25, who are unemployed and have no other form or type of health insurance, as required by section 110L of chapter 175.

SECTION 24.  Said chapter 176G of the General Laws is hereby amended by inserting after section 16 the following 2 sections:

Section 16A.  (a)  The commissioner shall not disapprove or reject a health maintenance contract solely on the basis that it includes any of the following provisions:

(1)        a deductible that is consistent with the requirements set forth in section 223 of the Internal Revenue Code, or any successor statute;

(2)        reasonable and actuarially sound co-insurance for covered services; or

(3)        reasonable annual limits on coverage for physician office visits, outpatient laboratory and diagnostic  services and other outpatient services; provided, however, that an annual unit of service limit on coverage for a particular category of services shall be deemed to be reasonable if the health maintenance organization submits an actuarial memorandum demonstrating that the unit of service limit is not less than 2 times the average expected utilization for that category of services, and that an annual dollar limit on coverage for a particular category of services shall be deemed to be reasonable if the carrier submits an actuarial memorandum demonstrating that the dollar limit is not less  than 4 times the average expected level of incurred claims for that category of services.

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

Section 16B.    (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;

(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 1 mandated benefit unless the health maintenance organization continues to offer at least 1 health maintenance contract 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 the provisions of this section.

SECTION 25.  Section 3 of chapter 176J of the General Laws is hereby repealed.

SECTION 26.  Said chapter 176J is hereby further amended by inserting after section 3 the following 2 sections:-

Section 3A.  Premiums charged to every eligible small business with not more than 5 eligible employees for a health benefit plan issued or renewed on or after January 1, 2006 shall satisfy the following requirements:

(1) The group base premium rates charged by a carrier to any eligible small business with not more than 5 eligible employees during a rating period shall not exceed 1.25 times the group base premium rate which could be charged by that carrier to the eligible small business not more than 5 eligible employees with the lowest group base premium rate for that rate basis type for that class of business.

(2)  A carrier may establish a benefit level rate adjustment for all eligible small businesses with not more than 5 eligible employees which shall be expressed as a number. The number shall represent the relative actuarial value of the benefit level of the health benefit plan issued to that eligible small business as compared to the actuarial value of other health benefit plans within that class of business. If a carrier chooses to establish benefit level rate adjustments, every eligible small business with not more than 5 eligible employees shall be subject to the applicable benefit level rate adjustment.

(3)      The commissioner shall annually establish not less than 5 distinct regions of the commonwealth for the purposes of area rate adjustments. A carrier may establish an area rate adjustment for each distinct region, the value of which shall range from .8 to 1.2. If a carrier chooses to establish area rate adjustments, every eligible small business with not more than 5 employees within each area shall be subject to the applicable area rate adjustment.

(4)  A carrier may establish a group size rate adjustment, the value of which shall range from .95 to 1.05. The group size rating shall be based only upon actual administrative costs or other business costs borne by the carrier for serving groups of varying sizes. If a carrier chooses to establish group size rate adjustments, every eligible small business with not more than 5 eligible employees shall be subject to the applicable group size rate adjustment.

(5)  A carrier may establish participation-rate rate adjustments for any health benefit plan for any ranges of participation rates below the minimum participation requirements established in accordance with the participation requirement as defined in section 2, the value of which shall be expressed as a number. The participation-rate rate adjustments shall be based upon actuarially sound analysis of the differences in the experience of eligible small businesses with not more than 5 eligible employees with different participation rates. If a carrier chooses to establish participation-rate rate adjustments, every eligible small business with not more than 5 eligible employees with a participation rate within the ranges defined by the carrier shall be subject to the applicable participation-rate rate adjustment.

(6)      A carrier may establish a wellness program rate discount for any eligible small business with not more than 5 eligible employees which provides employee wellness programs which meet minimum standards established by the commissioner. The value of the wellness program rate discount shall range from .95 to .99.  If a carrier establishes a wellness program rate discount, every eligible small business with not more than 5 eligible employees with a wellness program that meets such standards shall be subject to the applicable wellness program rate discount.

(7)  Notwithstanding any other provision of this section, for health benefit plans renewed between January 1, 2006 and December 31, 2007, a carrier shall not increase the premium charged to an eligible small business with not more than 5 eligible employees by more than 14 per cent of the rate which applied during the previous year; provided, however, that the rate increase limitation shall not include any premium rate increase which is based on the carrier’s annual cost and utilization trends or changes in the attained age of the eligible small business’ eligible employees and dependents.

Section 3B.  Premiums charged to every eligible small business with at least 6 eligible employees for a health benefit plan issued or renewed on or after January 1, 2006, shall satisfy the following requirements:

(1)  The group base premium rates charged by a carrier to any eligible small business with at least 6 eligible employees during a rating period shall not exceed 2 times the group base premium rate which could be charged by that carrier to the eligible small business with at least 6 eligible employees with the lowest group base premium rate for that rate basis type within that class of business.

 (2)  A carrier may establish a benefit level rate adjustment for all eligible small businesses with at least 6 eligible employees which shall be expressed as a number. The number shall represent the relative actuarial value of the benefit level of the health benefit plan issued to that eligible small business as compared to the actuarial value of other health benefit plans issued to eligible small businesses with at least 6 eligible employees within that class of business. If a carrier chooses to establish benefit level rate adjustments, every eligible small business with at least 6 eligible employees shall be subject to the applicable benefit level rate adjustment.

(3)  The commissioner shall annually establish not less than 5 distinct regions of the commonwealth for the purposes of area rate adjustments. A carrier may establish an area rate adjustment for each distinct region, the value of which shall range from .8 to 1.2.  If a carrier chooses to establish area rate adjustments, every eligible small business with at least 6 eligible employees within each area shall be subject to the applicable area rate adjustment.

(4)  A carrier may establish a group size rate adjustment, the value of which shall range from .95 to1.05. The group size rating must be based only upon actual administrative costs or other business costs borne by the carrier for serving groups of varying sizes. If a carrier chooses to establish group size rate adjustments, every eligible small business with at least 6 eligible employees shall be subject to the applicable group size rate adjustment.

(5)  A carrier may establish participation-rate rate adjustments for any health benefit plan for any ranges of participation rates below the minimum participation requirements established in accordance with the definition of participation requirement in section 2, the value of which shall be expressed as a number. The participation-rate rate adjustments shall be based upon actuarially sound analysis of the differences in the experience of eligible small businesses with at least 6 eligible employees with different participation rates.  If a carrier chooses to establish participation-rate rate adjustments, every eligible small business with at least 6 eligible employees with a participation rate within the ranges defined by the carrier shall be subject to the applicable participation-rate rate adjustment.

  (6)  A carrier may establish a wellness program rate discount for any eligible small businesses with at least 6 eligible employees which provide employee wellness programs which meet minimum standards established by the commissioner. The value of the wellness program rate discount shall range from .95 to .99.  If a carrier establishes a wellness program rate discount, every eligible small business with at least 6 eligible employees with a wellness program that meets such standards shall be subject to the applicable wellness program rate discount.

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

SECTION 27.  Said chapter 176J is hereby further amended adding the following section:-

Section 10.       (a) The commissioner shall reimburse a carrier an amount equal to 90 per cent of claims costs attributable to any eligible employee or dependent of an eligible small business with not more than 5 eligible employees between $100,000 and $500,000 dollars in a calendar year. 

(b) A carrier’s cost and utilization trends applicable to premiums charged to eligible small businesses with not more than 5 eligible employees shall reflect anticipated reimbursements pursuant to this section.  

(c) Reimbursements to carriers pursuant to this section shall be made from the Individual Group Reinsurance Fund established in section 2DDD of chapter 29.

(d)  The commissioner shall promulgate regulations necessary to implement this section.  Nothing in this section shall prohibit the commissioner of insurance from contracting with a third party to administer the fund.

SECTION 28.  Section 2 of chapter 176M of the General Laws, as appearing in the 2002 Official Edition, is hereby amended by striking out subsection (d) and inserting in place thereof the following subsection:

(d)  A carrier that participates in the nongroup health insurance market shall make available to eligible individuals a standard guaranteed issue health plan established pursuant to subsection (c) and may make available to eligible individuals up to 6   alternative guaranteed issue health plans with benefits and cost-sharing requirements, including deductibles, that differ from the standard guaranteed issue health plan.  A carrier may offer 1 alternative plan that is the alternative plan that was offered by the a carrier as of January 1, 2006, as modified from time to time in the ordinary course of business.  A carrier may offer not more than 3 alternative benefit plans that satisfy the requirements set forth in section 223 of the Internal Revenue Code, or any successor statute.  A carrier may offer not more than 2 alternative benefit plans that include reasonable and medically appropriate annual limits on coverage for physician office visits and outpatient services.  A carrier shall not make available an alternative plan unless the plan has been filed with and approved by the commissioner of insurance.  The commissioner shall approve an alternative plan if it: (1) is consistent with the requirements of the carrier’s licensing statute; (2) contains a disclosure form, which shall be provided to a potential insured, that clearly and concisely states the limitations on the scope of health services and any other benefits to be provided, including an explanation of any deductible, co-insurance or co-payment feature; and (3) offers a 10-day free look period in compliance with chapter 176D and any regulations promulgated thereunder. A carrier shall adhere to all other provisions of this chapter when offering any guaranteed issue health plan. The commissioner shall promulgate regulations relative to the alternative plans permissible pursuant to this section.  The regulations shall establish parameters for cost-sharing and benefit limits applicable to alternative plans so as to reduce the potential for adverse selection between carriers offering the same type of alternative plan.  The regulations shall permit a health maintenance organization to offer alternative guaranteed-issue health plans that are consistent with sections 16A and 16B of chapter 176G.

SECTION 29.  Said chapter 176M is hereby further amended by adding the following section:-

Section 7.  (a)   The commissioner shall reimburse a carrier an amount equal to 90 per cent of claims costs attributable to an eligible individual or dependent enrolled in a guaranteed-issue health plan between $100,000 and $500,000 in a calendar year. 

(b)  A carrier’s cost and utilization trends applicable to premiums charged for guaranteed-issue health plan shall reflect anticipated reimbursements pursuant to this section.  

(c)  Reimbursements to carriers pursuant to this section shall be made from the Individual Group Reinsurance Fund established in section 2DDD of chapter 29.

(d)  The commissioner shall promulgate regulations necessary to implement this section.  Nothing in this section shall prohibit the commissioner of  insurance from contracting with a third party to administer the fund.

SECTION 30.  Section 1 of chapter 176O of the General Laws, as appearing in the 2002 Official Edition, is hereby amended by inserting after the definition of “Health care services” the following 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 insureds only as a result of the insureds being directed to the hospital inpatient or outpatient setting. This definition may be expanded, upon consultation with the Massachusetts Hospital Association, the Massachusetts Medical Society, the Massachusetts Association of Health Plans and Blue Cross and 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 insureds only as a result of the insureds being directed to the hospital inpatient or outpatient setting.

SECTION 31.  Said chapter 176O is hereby amended by inserting after section 2 the following 2 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” and any revisions thereto, as developed and updated from time to time by the Massachusetts Medical Society, the Massachusetts Hospital Association, the Massachusetts Association of Health Plans and Blue Cross Blue Shield of Massachusetts as 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 the 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 the form.  A carrier may require that the appropriate physician profile be submitted in addition to the uniform physician recedentialing application form. 

            (c)  A carrier shall act upon and complete the credentialing process for 95 per cent of complete initial physician credentialing applications submitted by or on behalf of a physician applicant within 30 calendar days of receipt of a completed 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 Drug Enforcement Administration 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)           a 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)              documentation that 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.  The 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 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 4 business days of the decision.  The 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 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 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 insured effective not 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 recredentilaing by carriers of psychiatrists or hospital-based physicians by carriers.

            Section 2B.  (a)  The bureau’s accreditation requirements related to credentialing and recredentiling shall not require a carrier to complete the credentialing or recredentialing process for hospital-based physicians. 

(b)  Except as provided in subsection (d), a carrier shall not require a hospital-based physician to complete the credentialing and recredentiailng 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 subsection (d), the 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 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 Massachusetts Hospital Association, the Massachusetts Medical Society, the Massachusetts Association of Health Plans and Blue Cross and Blue Shield of Massachusetts shall work to 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.

SECTION 31A.  The General Laws are hereby amended by inserting after chapter 176P the following chapter:-

CHAPTER 176Q

LONG TERM CARE INSURANCE.

Section 1.  The purpose of this chapter shall be to promote the public interest and the availability of long-term care insurance policies, to protect applicants for long-term care insurance from unfair or deceptive sales or enrollment practices, to establish standards for long-term care insurance, to facilitate public understanding and comparison of long-term care insurance policies, and to promote flexibility and innovation in the development of long-term care insurance coverage.

            Section 2. This chapter shall beknown and may be cited as the Long-Term Care Insurance Act.

            Section 3. As used in this chapter the following words shall, unless the context requires otherwise, have the following meanings:-

            "Applicant", in the case of an individual long-term care insurance policy, the person who seeks to contract for benefits; or, in the case of a group long-term care insurance policy, the proposed certificate holder.

            "Certificate", a certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery within the commonwealth.

            "Commissioner", the commissioner of insurance.

            "Group long-term care insurance", a long-term care insurance policy that is delivered or issued for delivery within the commonwealth and issued to:-

            (1) one or more employers or labor organizations, or to a trust or to the trustees of a fund established by 1 or more employers or labor organizations, or a combination thereof, for employees or former employees, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations; or

            (2) any professional, trade or occupational association for its members or former or retired members, or combination thereof, if the association:

(i) is composed of individuals all of whom are, or were, actively engaged in the same profession, trade or occupation; and

(ii) has been maintained in good faith for purposes other than obtaining insurance; or

            (3) an association, or a trust, or the trustees of a fund established, created or maintained for the benefit of members of 1 or more associations; but, before advertising, marketing or offering the policy within the commonwealth, the association, or the insurer of the association, shall file evidence with the commissioner that the association has at the outset a minimum of 100 persons and has been organized and maintained in good faith for purposes other than that of obtaining insurance; has been in active existence for at least 1 year; and have a constitution and bylaws that provide that:

(i) the association holds regular meetings not less than annually to further purposes of the members;

(ii) except for credit unions, the association collects dues or solicits contributions from members; and

(iii) the members have voting privileges and representation on the governing board and committees.

            Thirty days after the filing, the association shall be considered to have satisfied the organizational requirements, unless the commissioner makes a finding that the association does not satisfy those organizational requirements.

            (4) A group other than those described in paragraphs (1), (2) and (3), subject to a finding by the commissioner that:-

(i) the issuance of the group policy is not contrary to the best interest of the public;

(ii) the issuance of the group policy would result in economies of acquisition or administration; and

(iii) the benefits are reasonable in relation to the premiums charged.

            "Long-term care insurance", any insurance policy or rider: (1) advertised, marketed, offered or designed to provide coverage for not less than 12 consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis; (2) for 1 or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services; and (3) provided in a setting other than an acute care unit of a hospital.  The term includes group and individual annuities and life insurance policies or riders that provide directly, or supplement, long-term care insurance.  The term also includes a policy or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity.  The term shall also include qualified long-term care insurance contracts.  Long-term care insurance shall not include any insurance policy that is offered primarily to provide basic Medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset-protection coverage, accident only coverage, specified disease or specified accident coverage, or limited benefit health coverage.  With regard to life insurance, this term shall not include life insurance policies that accelerate the death benefit specifically for 1 or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention or permanent institutional confinement, and that provide the option of a lump-sum payment for those benefits and where neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care.  Notwithstanding any other provision of this chapter, any product advertised, marketed or offered as long-term care insurance shall be subject to this chapter.

            "Policy", any policy, contract, subscriber agreement, rider or endorsement delivered or issued for delivery within the commonwealth by an insurer authorized to issue policies upon the lives of persons in the commonwealth or to provide accident and health insurance under chapter 175; a fraternal benefit society authorized under chapter 176; a nonprofit hospital service corporation authorized under chapter 176A, a nonprofit medical service corporation authorized under chapter 176B or a health maintenance organization authorized under chapter 176G.

            (1) "Qualified long-term care insurance contract" or "federally tax-qualified long-term care insurance contract" an individual or group insurance contract that meets the requirements of Section 7702B(b) of the Internal Revenue Code of 1986, as amended, as follows:

            (a) The only insurance protection provided under the contract is coverage of qualified long-term care services.  A contract shall not fail to satisfy the requirements of this subparagraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate;

            (b) The contract does not pay or reimburse expenses incurred for services or items to the extent that the expenses are reimbursable under Title XVIII of the Social Security Act, as amended, or would be so reimbursable but for the application of a deductible or coinsurance amount.  The requirements of this subparagraph do not apply to expenses that are reimbursable under Title XVIII of the Social Security Act only as a secondary payor.  A contract shall not fail to satisfy the requirements of this subparagraph by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate;

            (c) The contract is guaranteed renewable, within the meaning of section 7702B(b)(1)(C) of the Internal Revenue Code of 1986, as amended;

            (d) The contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed except as provided in paragraph (e);

            (e) All refunds of premiums, and all policyholder dividends or similar amounts, under the contract are to be applied as a reduction in future premiums or to increase future benefits, except that a refund on the event of death of the insured or a complete surrender or cancellation of the contract cannot exceed the aggregate premiums paid under the contract; and

            (f) The contract meets the consumer protection provisions set forth in Section 7702B(g) of the Internal Revenue Code of 1986, as amended.

            (2) "Qualified long-term care insurance contract" or "federally tax-qualified long term care insurance contract" also means the portion of a life insurance contract that provides long-term care insurance coverage by rider or as part of the contract and that satisfies the requirements of Sections 7702B(b) and (e) of the Internal Revenue Code of 1986, as amended.

            Section 4. No group long-term care insurance policy may be offered to a resident of the commonwealth under a group policy issued in another state to a group described in clause (4) of the definition of "group long-term care insurance" of section 3,  unless the commonwealth or another state having statutory and regulatory long-term care insurance requirements substantially similar to those adopted in the commonwealth has made a determination that the requirements set forth in said clause (4) have been met.

            Section 5. (a) The commissioner shall promulgate regulations that include standards for full and fair disclosure setting forth the manner, content and required disclosures for the sale of long-term care insurance policies and certificates, terms of renewability, initial and subsequent conditions of eligibility, non-duplication of coverage provisions, coverage of dependents, preexisting conditions, termination of insurance, continuation or conversion, probationary periods, limitations, exceptions, reductions, elimination periods, requirements for replacement, offer of inflation protection, recurrent conditions and definitions of terms.

            (b) A long-term care insurance policy shall not:-

            (1) be cancelled, non-renewed or otherwise terminated on the grounds of the age or the deterioration of the mental or physical health of the insured individual or certificate holder;

            (2) contain a provision establishing a new waiting period in the event existing coverage is converted to, or replaced by, a new or other form within the same company, except with respect to an increase in benefits voluntarily selected by the insured individual or group policyholder; or

            (3) provide coverage for skilled nursing care only or provide significantly more coverage for skilled care in a facility than coverage for lower levels of care.

            (c)(1) A long-term care insurance policy, or certificate other than a policy or certificate thereunder, issued to a group as defined in clause (1) of the definition of "Group long-term care" of section 3 shall not use a definition of "preexisting condition" that is more restrictive than the following: Preexisting condition means a condition for which medical advice or treatment was recommended by, or received from a provider of health care services, within 24 months preceding the effective date of coverage of an insured person.

            (2) A long-term care insurance policy or certificate other than a policy or certificate thereunder issued to a group as defined in clause (1) of the definition of "Group long-term care" of section 3 shall not exclude coverage for a loss or confinement that is the result of a preexisting condition unless the loss or confinement begins within 6 months following the effective date of coverage of an insured person.

            (3) Notwithstanding this subsection (c), an insurer may use an application form designed to elicit the complete health history of an applicant, and, on the basis of the answers on that application, underwrite in accordance with that insurer's established underwriting standards.  Unless otherwise provided in the policy or certificate, a preexisting condition, regardless of whether it is disclosed on the application need not be covered until the waiting period described in subsection (2) expires.  No long-term care insurance policy or certificate may exclude or use waivers or riders of any kind to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions beyond the waiting period described in subsection (2).

            (d) A long-term care insurance policy shall not be delivered or issued for delivery in this state if the policy:

            (1) conditions eligibility for any benefits on a prior hospitalization requirement;

            (2) conditions eligibility for benefits provided in an institutional care setting on the receipt of a higher level of institutional care; or

            (3) conditions eligibility for any benefits other than waiver of premium, post-confinement, post-acute care or recuperative benefits on a prior institutionalization requirement.

            (e) The commissioner may adopt regulations establishing loss ratio standards for long-term care insurance policies provided that a specific reference to long-term care insurance policies is contained in the regulation.

            (f) Long-term care insurance applicants shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the applicant is not satisfied for any reason.  Long-term care insurance policies and certificates shall have a notice prominently printed on the first page or attached thereto stating in substance that the applicant shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded if, after examination of the policy or certificate, other than a certificate issued pursuant to a policy issued to a group defined in clause (1) of the definition of "Group long-term care" of section 3, the applicant is not satisfied for any reason.  This subsection shall also apply to denials of applications and any refund must be made within 30 days of the return or denial.

            (g)(1) An outline of coverage shall be delivered to a prospective applicant for long-term care insurance at the time of initial solicitation through means that prominently direct the attention of the recipient to the document and its purpose.  In the case of producer solicitations, an insurance producer shall deliver the outline of coverage prior to the presentation of an application or enrollment form.  In the case of direct response solicitations, the outline of coverage shall be presented in conjunction with any application or enrollment form.  In the case of a policy issued to a group defined in clause (1) of the definition of "Group long-term care" of section 3, an outline of coverage shall not be required to be delivered, provided that the information described in clauses (i) to (vi), inclusive, of paragraph (2) is contained in other materials relating to enrollment.  Upon request, these other materials shall be made available to the commissioner.

            (2) The commissioner shall prescribe a standard format, including style, arrangement and overall appearance, and the content of an outline of coverage. The outline of coverage shall include:

(i) a description of the principal benefits and coverage provided in the policy or certificate;