(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 9. 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 ambulatory
surgery 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 10.
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
11.
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 12.
Section 9A of c. 118E of the General Laws, as so appearing, is hereby
amended by striking out, in line 75, the figure “200” and inserting in place
thereof the following figure:- 300.
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
12 of chapter 118E of the General Laws, as amended by section 20 of chapter
65 of the acts of 2004, is hereby amended in the fourth paragraph by adding
the following:— The executive office of health and human services shall adopt
regulations which restrict eligibility or covered services only after public
notice and hearing.
SECTION 13B. Section
16C of said chapter 118E, as so appearing, is hereby amended by striking out,
in lines 4 and 20, the figure “200” and inserting in place thereof, in each
instance, the following figure:- 300.
SECTION 13C. 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 fide employee
representative which agreement governs the employment conditions of such 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
13D. 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 14.
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 15.
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
16.
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
17. 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
18.
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 19.
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
20. 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 21.
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 22.
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
23. 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 to carry out this section.
SECTION
24.
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 25. 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
26.
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
27. 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
28. 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
29. 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 in any calendar year
between the reinsurance threshold and the reinsurance limit attributable to
any eligible employee or dependent of an eligible small business with not more
than 5 eligible employees. The initial reinsurance threshold shall be $70,000.
The initial reinsurance limit shall be $500,000. The commissioner shall
increase the reinsurance threshold and limit on an annual basis by an amount
consistent with medical cost trends in the small group market.
(b)
A carrier’s cost and utilization trends applicable to premiums charged to
eligible small businesses 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 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
31. 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 in any calendar year between the reinsurance threshold and the reinsurance
limit attributable to an eligible individual or dependent . The
initial reinsurance threshold shall be $70,000.
The initial reinsurance limit shall be $500,000. The commissioner shall
increase the reinsurance threshold and limit on an annual basis by an amount
consistent with medical cost trends in the nongroup market.
(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
32. 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
33. 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
34.
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;
(ii)
a statement of the principal exclusions, reductions and limitations contained
in the policy or certificate;
(iii) a statement of the terms
under which the policy or certificate, or both, may be continued in force
or discontinued, including any reservation in the policy of a right to change
premium; continuation or conversion provisions of group coverage shall be
specifically described;
(iv) a statement that the outline
of coverage is a summary only, not a contract of insurance, and that the policy
or group master policy contains governing contractual provisions;
(v) a description of the terms under which the policy
or certificate may be returned and premium refunded;
(vi) a brief description of the relationship of cost
of care and benefits; and
(vii) a statement that discloses to the policyholder
or certificate holder whether the policy is intended to be a federally tax-qualified
long-term care insurance contract under section 7702B(b) of the Internal Revenue
Code of 1986, as amended.
(h) A certificate issued pursuant
to a group long-term care insurance policy that is delivered or issued for
delivery in this state shall include:
(1)
a description of the principal benefits and coverage provided in the
policy;
(2)
a statement of the principal exclusions, reductions and limitations
contained in the policy; and
(3)
a statement that the group master policy determines governing contractual
provisions and that the policy is available for viewing in the offices of
the policyholder and will be copied for the certificate holder upon request
at no cost.
(i)
If an application for a long-term care insurance contract or certificate
is approved, the issuer shall deliver the contract or certificate of insurance
to the applicant no later than 30 days after the date of approval.
(j)
At the time of policy delivery, a policy summary shall be delivered
for an individual life insurance policy that provides long-term care benefits
within the policy or by rider. In the
case of direct response solicitations, the insurer shall deliver the policy
summary upon the applicant's request, but regardless of request shall make
delivery no later than at the time of policy delivery.
In addition to complying with all applicable requirements, the summary
shall also include:
(1) an explanation of how the long-term
care benefit interacts with other components of the policy, including deductions
from death benefits;
(2) an illustration of the amount
of benefits, the length of benefit, and the guaranteed lifetime benefits if
any, for each covered person;
(3) any exclusions, reductions and
limitations on benefits of long-term care;
(4) a statement indicating whether
any long term care inflation protection option required by law is available
under this policy;
(5) if applicable to the policy type,
the summary shall also include:
(i)
a disclosure of the effects of exercising other rights under the policy;
(ii)
a disclosure of guarantees related to long-term care costs of insurance charges;
and
(iii)
current and projected maximum lifetime benefits; and
(6) the policy summary listed above
may be incorporated into a basic illustration or into the life insurance policy
summary which is required to be delivered in accordance with applicable regulation.
(k) Any time a long-term care benefit,
funded through a life insurance vehicle by the acceleration of the death benefit,
is in benefit payment status, a monthly report shall be provided to the policyholder. The report shall include:
(1) any long-term care benefits paid
out during the month;
(2) an explanation of any changes
in the policy, e.g. death benefits
or cash values, due to long-term care benefits being paid out; and
(3) the amount of long-term care benefits
existing or remaining.
(l) If a claim under a long-term care
insurance contract is denied, the issuer shall, within 60 days of the date of
a written request by the policyholder or certificate holder, or a representative
thereof:
(1) provide a written explanation
of the reasons for the denial; and
(2) make available all information
directly related to the denial.
(m) Any policy or rider advertised,
marketed or offered as long-term care or nursing home insurance shall comply
with the provisions of this chapter.
Section 6. (a) For a policy or
certificate that has been in force for less than 6 months an insurer may rescind
a long-term care insurance policy or certificate or deny an otherwise valid
long-term care insurance claim upon a showing of misrepresentation that is
material to the acceptance for coverage.
(b) For a policy or certificate
that has been in force for at least 6 months but less than 2 years an insurer
may rescind a long-term care insurance policy or certificate or deny an otherwise
valid long-term care insurance claim upon a showing of misrepresentation that
is both material to the acceptance for coverage and which pertains to the
condition for which benefits are sought.
(c) After a policy or certificate
has been in force for 2 years it is not contestable upon the grounds of misrepresentation
alone; the policy or certificate may be contested only upon a showing that
the insured knowingly and intentionally misrepresented relevant facts relating
to the insured's health.
(d) A long-term care insurance
policy or certificate shall not be field issued based on medical or health
status. For purposes of this subsection
the term "field issued" means a policy or certificate issued by
an agent or a third-party administrator pursuant to the underwriting authority
granted to the agent or third party administrator by an insurer.
(e) If an insurer has paid benefits
under the long-term care insurance policy or certificate, the insurer may
not recover the benefit payments if the policy or certificate is rescinded.
(f) In the event of the death
of the insured, this section shall not apply to the remaining death benefit
of a life insurance policy that accelerates benefits for long-term care.
In this situation, the remaining death benefits under these policies
shall be governed by section 132 of chapter 175.
In all other situations, this section shall apply to life insurance
policies that accelerate benefits for long-term care.
Section 7. (a) Except as provided
in subsection (b), a long-term care insurance policy shall not be delivered
or issued for delivery in this state unless the policyholder or certificate
holder has been offered the option of purchasing a policy or certificate that
includes a non-forfeiture benefit. The offer of a non-forfeiture benefit may be
in the form of a rider that is attached to the policy. In the event the policyholder or certificate
holder declines the non-forfeiture benefit, the insurer shall provide a contingent
benefit upon lapse that shall be available for a specified period of time
following a substantial increase in premium rates.
(b) When a group long-term care
insurance policy is issued, the offer required in subsection (a) shall be
made to the group policyholder. However,
if the policy is issued as group long-term care insurance to a group defined
in clause
(4) the definition of "Group
long-term care" of section 3, other than to a continuing care retirement
community or other similar entity, the offering shall
be
made to each proposed certificate holder.
(c) The commissioner shall promulgate
regulations specifying the type or types of non-forfeiture benefits to be
offered as part of long-term care insurance policies and certificates, the
standards for non-forfeiture benefits, and the rules regarding contingent
benefit upon lapse, including a determination of the specified period of time
during which a contingent benefit upon lapse will be available and the substantial
premium rate increase that triggers a contingent benefit upon lapse as described
in subsection a.
Section 8. The commissioner shall
promulgate reasonable regulations in accordance with chapter 30A to promote
premium adequacy and to protect the policyholder in the event of substantial
rate increases, and to establish minimum standards for marketing practices,
agent compensation, agent testing, penalties and reporting practices for long
term care insurance.
Section 9. In addition to the
penalties provided in chapters 175 and 176D, any insurer and any insurance
producer found to have violated any requirement of this chapter or any regulations
promulgated hereunder, relating to the regulation of long-term care insurance
or the marketing of such insurance, shall be subject to a fine of up to 3
times the amount of any commissions paid for each policy involved in the violation
or up to $10,000, whichever is greater.
SECTION 35.
Item 9110-0100 of section 2 of chapter 177 of the acts of 2001 is hereby
amended by striking out the wording after “community care ombudsman services;”
and inserting in place thereof the following wording:-
provided further, that notwithstanding
any general or special law to the contrary, there shall be a special commission
to study the aging population and the future of long-term care in the commonwealth;
provided further, that said commission shall be charged with evaluating options
and making policy recommendations that can be used to develop legislation
that will address the health care, housing, and pension needs of elders age
60 and older, as well as the status and needs of the long-term care workforce;
provided further, that said commission shall examine eligibility requirements
for medicaid and MassHealth for long-term care, including potential savings
to the commonwealth by adjusting income requirements and asset requirements
and the look-back period; provided further, that said commission shall also
examine ways to provide incentives to people to purchase long-term care insurance,
including but not limited to proposed legislative and executive actions; provided
further, said commission shall consist of the following members: the secretary
of elder affairs or her designee, who shall serve ex officio; a representative
of a labor organization representing long-term care workers; 1 representative
from each of the following organizations: the Massachusetts Council of Home
Care Aide Services, Mass Aging, Mass Home Care, the Alzheimer's Association,
the Massachusetts Extended Care Federation, the American Association of Retired
Persons, the Medicare Advocacy Project, the Home and Health Care Association
of Massachusetts, the Massachusetts Assisted Living Facilities Association,
the Mass Senior Action Council, Massachusetts Association of Older Americans,
the Paraprofessional HealthCare Institute, the Massachusetts Chapter of the
National Alliance of Caregivers, Health Care For All, the Massachusetts chapter
of the National Association of Insurance and Financial Agents, and the Gerontology
Institute at the University of Massachusetts at Boston; a representative of
the insurance industry who has experience in the insurance markets affecting
long-term care who shall be appointed by the governor; and a representative
of the business community who shall be appointed by the governor; provided
further, that the members shall elect a chairperson of said commission; and
provided further, that the commission shall release its first recommendations
to the house and senate committees on ways and means not later than December
31, 2005.
SECTION 36.
The secretary of health and human services shall seek an amendment
to the MassHealth Demonstration Waiver granted by the United States Department
of Health and Human Services under section 1115(a) of the Social Security
Act and authorized by chapter 203 of the acts of 1996 to implement this act
and is hereby further authorized and directed to seek to obtain maximum federal
reimbursement for any provision of this act for which federal financial participation
is available. The secretary shall report quarterly to the joint committee
on health care financing and the house and senate committees on ways and means
on the status of the waiver application
SECTION 37.
The division of health care finance and policy shall file a detailed
report to the joint committee on health care financing on the feasibility
of requiring all residents of the commonwealth to obtain employer-based health
insurance. The report shall consider
the effect of such a law, if any, on: (1) health insurance premiums charged
by private insurers; (2) the number of residents without insurance; (3) the
costs of health insurance for employers; (4) utilization and costs of uncompensated
care pool services; (5) the commonwealth’s fiscal impact; and (6) any other
pertinent issues relating to the feasibility and appropriateness of such a
law. Thed report shall be filed not
later than February 1, 2006.
SECTION 38. (a) Notwithstanding
the provisions of any general or special law to the contrary, but subject
to the provisions of subsection (b) of this section and the provisions of
section 40 of this act, for the purposes of paying providers under chapter
118E of the General Laws, effective for services beginning not later
than January 1, 2006, the division shall
transition to the payment systems and fee schedules used by the United
States Department of Health and Human Services Centers for Medicare &
Medicaid Services to administer the Medicare Program under Title XVIII of
the Social Security Act, including, for purposes of payment for covered hospital
services, all of Medicare’s adjustments for direct and indirect graduate medical
education, disproportionate share, outliers, organ acquisition, bad debt,
new technology and capital, including, but not limited to,
annual increases in the Medicare hospital market basket index.
The division shall modify such payment systems and fee schedules to account
for the following:
i.
the differences between the programs specified in chapter 118E and the
Title XVIII Medicare program, including the services and benefits covered, and,
for purposes of calculating the payment rates for covered hospital services,
the division shall use a grouper and DRG relative weights that have been determined,
in consultation with the MassHealth Payment advisory committee, pursuant to
section 42 of this act, to reimburse
providers at a rate no less than the rate providers are reimbursed by Medicare;
ii.
the extent and duration of such coverage; the populations served; and the requirement
to maximize federal reimbursement; provided, that the division shall implement
payments for covered hospital services as provided for under this section not
later than October 1, 2006; and provided, further, that,
for each of the hospital fiscal years commencing October 1, 2005 and October
1, 2006, the division shall annually calculate rates of payment for covered
hospital services under this section by adjusting the prior year’s rates by
an amount not less than the annual increase in the Medicare hospital market
basket index in accordance with the provisions of this section; ; and provided,
further, that once such systems and fee schedules are fully implemented, the
division shall ensure that the rates paid for covered services under said chapter
118E shall not thereafter be less than rates of payment for comparable services
under the Medicare program.
iii.
Notwithstanding the foregoing provisions of this subsection, the division shall
not increase rates for any provider that is required by this subsection to be
held harmless at its current reimbursement level until such time as increases
in its rates would be warranted by application of the Medicare systems and fee
schedules, as adjusted by the provisions of this subsection.
(b)
Notwithstanding any general or special law to the contrary, for the
purposes of paying community health centers for covered services under chapter
118E of the General Laws, effective for services beginning not later
than October 1, 2006, the division shall pay community health centers a base
rate that shall be no less than the Medicare Federally Qualified Health Center
rate as required under 42 USC section 1395l(a)(3), which the division shall
adjust for wage differences, and to which the division shall add payments
for additional services not included in the base rate including, but not limited
to, EPSDT services, 340B pharmacy, urgent care, and emergency room diversion
services. For the purposes of this section, a community
health center shall be defined as a clinic that provides comprehensive ambulatory
services and that (i) is licensed as a freestanding clinic by the Massachusetts
Department of Public Health pursuant to M.G.L. c.111, s.51; (ii) meets the
qualifications for certification (or provisional certification) by the Division
of Medical Assistance and enters into a provider agreement pursuant to 130
CMR 405.000; (iii) operates in conformance with the requirements of 42 U.S.C.
s254(c); and (d) files cost reports as requested by the Division of Health
Care Finance and Policy.
(c) In updating rates of payment under chapter
118E of the General Laws and making the modifications to the Medicare payment
systems and fee schedules required by this section, the division
shall adopt the advice and counsel, and give due consideration to
the recommendations of the MassHealth Payment advisory board established pursuant
to section 42.
(d) All rates of payment for acute and nonacute
care hospitals, as defined under section 1886(d)(1)(B)(ii) or section 1886(d)(1)(B)(iv)(I)
of the Social Security Act, shall be reasonable and adequate to meet the costs
which shall be incurred by efficiently and economically operated facilities
in order to provide care and services in conformity with applicable state
and federal laws, regulations, and quality and safety standards and to assure
that individuals have reasonable access, taking into account geographic location
and reasonable travel time, to inpatient and outpatient hospital services
of adequate quality. The division shall make adjustments to the calculation
of the federal upper payment limit in order to maximize the amount that may
be paid to providers under the upper payment limit.
These adjustments shall include, but not be limited to, using the Medicaid
paid claims file as the data source; changing the base year for the Medicare
payment to charge ratio; changing the payment inflation and charge increase
assumptions used to update base year data to current year data; and including
in the calculation out-of-state hospital providers who receive payments from
the Massachusetts Medicaid program.
(e) All payments made for the purposes of this
section shall be expended from the Health Care Access and Investments Trust
Fund established pursuant to section 2OOO of chapter 29 of the General Laws.
SECTION 39 . (a) Notwithstanding
any general or special law to the contrary, in any year in which the uncompensated
care pool payment to cost ratio of an acute care hospital or community health
center, as calculated under subsection (b) of this section, falls below 95%,
the division of health care finance and policy shall calculate and make the
additional payments to the affected acute care hospital or community health
center that are required to maintain its uncompensated care pool payment to
cost ratio at 95%. The commonwealth
shall increase its share of the uncompensated care trust fund by an amount
equal to the amount needed to fund such additional payments to all affected
acute care hospitals and community health centers under this subsection.
(b) The division shall calculate the uncompensated
care pool payment to cost ratio for each acute care hospital and community
health center for each pool year by dividing (i) the total pool payments made
to such acute care hospital or community health center pursuant to all general
and special laws effective for the relevant period, without regard, however,
to any additional amounts paid or to be paid to such hospital or community
health center for any period by virtue of subsection (a) of this section,
by (ii) the total allowable uncompensated care costs of such hospital or community
health center, as defined in section 18 of chapter 118G of the General Laws,
for the relevant period.
(c) Rates of payment for providers of hospital
services as calculated pursuant to section 38 shall apply to payments to such
providers for services paid from the uncompensated care pool pursuant to section
18 of chapter 118G of the General Laws.
SECTION 40. Notwithstanding
any general or special law to the contrary and notwithstanding any regulations
of the division of health care finance and policy or the division of medical
assistance to the contrary, effective July 1, 2006, the fees payable under
programs administered by the division of medical assistance for physician
services shall be subject to the following:
(a) For each fiscal year, the fee schedule
for physician services delivered on or after July 1 of that fiscal year shall
consist of the fees for physician services in effect at the end of the immediately
preceding fiscal year, subject to an annual upward inflation adjustment for
each fee as determined by the commissioner of medical assistance. Such annual
adjustment shall be at least equal to any upward adjustment in the United
States Medicare Economic Index for physician services as defined in section
1842 (i) (3) of the Social Security Act.
(b) For the calculation of the fee schedule
for physician services for fiscal years beginning on July 1, 2006, July 1,
2007 and July 1, 2008, each of the fees contained on the schedule of fees
for physician services in effect at the end of the immediately preceding fiscal
year shall, in addition to the adjustments provided for in subsection (a)
of this section, be further adjusted upward by an amount equal to not less
than 7 per cent of the fees in effect for the previous fiscal year. Notwithstanding
the foregoing, adjustments under this subsection shall continue until such
time as fees for physician services are no lower than the average commercial
rate paid to physicians in the Commonwealth, which rate shall be the median
rate calculated using wage-adjusted data from the Medical Group Management
Association.
(c) This section shall apply to physician services
rendered under contracts authorized by section 12 of chapter 118E of the General
Laws unless otherwise specifically agreed to in contract by the providers.
Pursuant to regulations to be promulgated by the division of medical assistance
by January 1, 2006, the division of medical assistance shall pay for, or assure
that all of its contractors responsible for paying for physician services
shall pay for, all office procedures appropriately provided by a physician
practice during a single office visit to a person eligible to receive healthcare
services under programs administered by the division of medical assistance.
(d)
All payments made for the purposes state in this section shall be expended
from the Health Care Access and Investments Fund established pursuant to section
2OOO of chapter 29 of the General Laws.
SECTION 41. (a) There
shall be a quality and cost management initiatives commission, hereinafter
in this section the commission, which shall perform the responsibilities set
forth in subsection (b) of this section. The commission shall consist of the secretary
of health and human services or his designee and twelve members appointed
by the governor as provided in this subsection.
The governor, after consultation with the relevant interests, shall
appoint one member to represent the interests of the medical schools in the
commonwealth, two to represent the interests of physician group practices,
one to represent the interests of academic medical centers, one to represent
the interests of community hospitals, one to represent the interests of carriers
licensed under chapters 175 or 176G of the General Laws and one to represent
the interests of the employer community. The
governor shall appoint one person each from nominations submitted by the following
organizations: the Massachusetts Hospital Association, the Massachusetts Medical
Society, the Massachusetts Association of Health Plans, and Blue Cross Blue
Shield of Massachusetts.
(b) The commission shall consider and report
to the Joint Committee on Health Care Financing and the House and Senate Committees
on Ways and Means, by no later than September 15, 2006, its recommendations
for creating mechanisms by which payments to acute hospitals and physicians
under chapter 118E of the General Laws may incorporate financial incentives
for such providers to provide quality care in a more efficient and effective
manner. In developing its report, the
commission shall consider elements of pay for performance mechanisms, so-called,
including various measures related to the structure, process and outcomes
of medical care delivery and the types of financial incentives that are most
likely to impact positively on the overall quality and cost of care provided
to persons eligible for the various programs administered pursuant to said
chapter 118E. The commission shall
consider the feasibility of providing targeted resources or financial incentives,
in addition to the amounts and annual inflationary adjustments that otherwise
would be paid for hospital and physician services under said chapter 118E,
to promote pay for performance mechanisms, so-called, in the expectation that
the commonwealth will realize savings through improvements in quality and
utilization of services covered by such programs, as a result of of such incentives.
In developing its recommendations, the commission shall consider the
types of pay for performance measures used by private payors, but shall focus
hospital measures on those endorsed and supported by governmental programs,
including but not limited to those developed by the Hospital Quality Alliance
and endorsed by the United States Department of Health and Human Services
Centers for Medicare & Medicaid Services;provided, that no hospital measures
shall be utilized that have not been adopted as a voluntary consensus standard
for hospital care by the National Quality Forum.
The commission shall consider the suitability of available measures
for use with hospitals and physicians in the commonwealth; the cost associated
with developing and implementing new measures; the data needed to devise and
apply such measures as it may recommend; the differential ability of physicians
and acute hospitals to generate necessary
data; the time frames within which such providers may reasonably be expected
to generate data needed to apply such measures; the cost to the providers
to generate such data; the availability, or the feasibility of developing,
financing mechanisms to facilitate the ability of such providers to provide
data and to implement pay for performance measures; and such other factors
as the commission may deem material to its report and recommendations.
SECTION 42. (a) There shall
be a MassHealth payment policy advisory board. The board shall be composed of 11 members of
the health care industry who are knowledgeable in health care finance and
economics. The governor shall appoint 1 co-chairman nominated by the speaker
of the house, 1 co-chairman nominated by the president of the senate, 1 member
nominated by the Massachusetts Hospital Association, 1 member nominated by
the Massachusetts Medical Society, 1 member nominated by the Massachusetts
Extended Care Federation, 1 member nominated by the Home and Health Care Association
of Massachusetts, 1 member nominated by the Massachusetts League of Community
Health Centers, 1 member nominated by the Massachusetts Medicaid Policy Institute,
1 member nominated by the Associated Industries of Massachusetts, 1 member
nominated by the Massachusetts Association of Health Plans and 1 member of
the community.
(b) The board shall have the following powers and
duties:
1) It shall obtain from the division all data and
analysis required to fully meet its charge pursuant to the Health CareAccess
and Investments Trust Fund established in section 2OOO of chapter 29 and sections
38 and 39 of this act and to obtain further data and analysis from the division
of health care finance and policy as authorized in chapter 118G of the General
Laws;
2) It shall review and evaluate rates and payment
systems proposals by the division and recommend Title XIX rates and rate methodology
that are consistent with the Health CareAccess and Investments Trust Fund
and sections 38 and 39 of this act and with the level of funding available
as authorized by the general appropriation act; provided, however, that the
division shall provide the board with the appropriate information not later
then 45 days before the proposals are adopted into regulation; and
3) It shall report to the joint committee on health
care financing and the house and senate committees on ways and means semi-annually
to coincide with the state budget hearings and development.
(c) The executive office of health
and human services shall provide the board with such staff from the division
of health care finance and policy as is necessary to complete needed research
and analysis and enable the committee to make effective recommendations.
Notwithstanding any general or special law to the contrary, all expenditures
under this section shall, subject to appropriation, be funded from the Health
Care Access and Investments Trust Fund; provided, however, that not less than
90 days before implementing any of the payment policies established under
this section, the division shall provide a detailed plan of implementation
of said policies to the joint committee on health care finance and to the
house and senate committee on ways and means.
SECTION 43.
Notwithstanding any general or special law to the contrary, effective
September 1, 2006, each state and community college shall require that all
students enrolled in 9 or more credits shall submit written documentation
evidence of adequate medical insurance coverage. A list of the names, addresses,
and social security numbers of all students indicating any form of MassHealth
insurance coverage shall be forwarded to the Division of Medical Assistance
for evaluation of alternative insurance options. The list shall be subject
to privacy standards pursuant to Public Law 104-191, and the Health Insurance
Portability and Accountability Act of 1996. The division may assist in the
purchase of group health insurance, including insurance offered through a
college or university, on behalf of an eligible MassHealth member, provided
that the division has determined that the purchase of such insurance is cost-effective
and will be provided at no cost to the commonwealth. The division shall deny
liability to any adult who refuses to enroll in other available insurance.
SECTION 44. (a) Notwithstanding
any general or special law to the contrary, any hospital that is eligible
for improved provider rates pursuant to section 38 and 39 shall, not later
than December 1 of each year, submit to the department of public health the
hospital’s plan for compliance with the common program requirements of the
duty hours reductions for resident-physicians as mandated by the Accreditation
Council for Graduate Medical Education (ACGME) for interns, residents and fellows for the following
year from January 1 to December 31.
(b) The plan submitted shall
be formatted so that the following data is easily accessible and understandable,
however, any such data may be aggregated or redacted, as needed to protect
confidentiality:
(1) The schedule for each required
rotation within each accredited program, indicating the number of hours each
week that resident-physicians are scheduled to perform direct patient care.
(2) The maximum, minimum and average
number of days each month that the resident-physicians in each ACGME-accredited
program are scheduled for “In house call.”
(3) The number of days each month
the resident-physician is scheduled to be assigned “At home call.”
(4)
A list of any individual program citations issued by ACGME during the
prior academic year for non-compliance with the duty-hours restrictions.
(5) Copies of the written policies
and procedures mandated by the ACGME Program requirements that are distributed
to resident-physicians and faculty. Each individual program within an institution
must submit its own duty-hours policy requirements.
(6) A description of the back-up
support systems provided by the Institution in cases where patient care responsibilities
are unusually difficult or prolonged or where resident-physician fatigue may
be sufficient to jeopardize care. Each individual program within an institution
must submit its own back-up support policies unless a single policy covers
all programs.
(7) A description of the measures
instituted to reduce the occurrence of resident-physician fatigue, including,
but not limited to, educational material presented to students and faculty.
(e) A hospital that fails
to submit the information required under this section shall be assessed an
administrative fine by the department of up to 5 per cent of the provider
payments to which the hospital would otherwise be entitled under sections
35 and 36. Except for this administrative fine, no hospital, institution
or person shall be held liable in any civil or criminal action or other proceeding
for any failure to comply with a voluntary safe staffing plan submitted under
this section or for any failure to comply with the provisions of this section.
SECTION 45. (a) Notwithstanding any general or special law to
the contrary, there shall be within the department of public health an advisory
committee for resident-physicians. The committee shall be comprised of 11
members to be appointed by the commissioner of public health, 1 of whom shall
be a representative from the Massachusetts Medical Society, 1 of whom shall
be the chancellor of the University of Massachusetts Medical School, 1 of
whom shall be the executive director of the board of registration in medicine
or her designee, 2 of whom shall be representatives of the Massachusetts Hospital
Association, 1 of whom shall be a representative of the committee of interns
and residents/SEIU, , 1 of whom shall be a resident-physician from an academic
medical institution that does not have representation by the committee of
interns and residents/SEIU, 1 of whom shall be a resident-physician from a
community hospital, 1 of whom shall be the director of a graduate medical
education office at a hospital located in the Commonwealth, 1 of whom shall
be a consumer and 1 of whom shall be the executive director of the Betsy Lehman
Center for Patient Safety and Medical Error Reduction who shall serve as the
chairperson of the committee. The members of the committee shall serve without
compensation. Appointments shall be made within 90 days after the effective
date of this act. The committee shall dissolve after completion of the
reports required in this section.
(b) The committee shall make an
investigation and study into the working conditions of resident-physicians
in the commonwealth. Based on the study, the department shall adopt rules
and regulations for the purpose of establishing a model work environment that
promotes quality of care and patient and resident-physician safety. The study
shall consider, but shall not be limited to: limiting resident-physicians
to not more than a total of 80 hours per week and not more than 24 hours per
shift, including time for the transition of patient care information; limiting
resident-physicians who are assigned to patient care responsibilities in an
emergency department to not more than 12 continuous hours; requiring resident-physicians
to have a nonworking period of not less than 16 hours following a 24-hour
shift and at least 10 hours between other scheduled shifts; requiring at least
24 consecutive hours free every 7 days and requiring at least 1 full 48-hour
period off per month; limiting the resident-physician to overnight, on-call
duty in the hospital not more frequently than 1 night in 3; accommodations
that can be made in any recommended time limitations for a state of emergency
declared by the commonwealth that applies with respect to that hospital or
for an emergency situation when a resident-physician is providing critical
physician-care to an individual patient and cannot be replaced; requirements
for each hospital to inform resident-physicians of their rights under any
rules and regulations promulgated by the department; enforcement of such rules
and regulations including, but not limited to, the posting of maximum hours
limitations in all departmental offices, informing all resident-physicians
of their rights to report any violations of the regulations, whistleblower
protections and the use of surveys of resident-physicians and reporting by
hospitals to determine compliance with rules and regulations promulgated under
this section; and requiring that resident-physicians and hospital supervisors
be informed of the effects of acute and chronic sleep deprivation both on
the resident-physicians and on the quality of patient care.
(c) Notwithstanding any
general or special law to the contrary, the committee shall make an investigation
and study into appropriate penalties for violations of any rules and regulations
promulgated pursuant to subsection (a). Based on the study, the department
shall adopt rules and regulations to establish a model work environment that
promotes quality of care and patient and resident-physician safety. The study
shall consider, but shall not be limited to: identifying a position within
the department responsible for investigating all complaints of violations
of any rules and regulations promulgated by the department pursuant to subsection
(b) and the use of monetary and nonmonetary penalties to maximize improvement
of patient safety.
(d) Notwithstanding any general
or special law or rule or regulation to the contrary, the committee shall
make an investigation and study into the process by which complaints shall
be filed with the department. The study shall include, but shall not be limited
to, allowing the filing of anonymous complaints, complaints by resident-physicians,
complaints by consumers and complaints by other health care professionals.
(e) The investigation and study
shall be conducted and recommendations shall be presented to the department
not later than 270 days after the effective date of this act.
(f) For the purposes of this section,
the term 'resident-physician' shall include a medical intern, resident or
fellow enrolled in an ACGME accredited graduate medical education program.
SECTION 46. Notwithstanding
any general or special law or collective bargaining agreement to the contrary,
each city or town shall offer all employees the opportunity to purchase health
care insurance through a plan administered by the city or town. An employee
who declines to obtain such insurance and receives services through the uncompensated
care pool or Medicaid shall be considered a “voluntarily uninsured employee”
for purposes of Chapter 118G.
SECTION 47 Notwithstanding
the provisions of any general or special law to the contrary, any ambulatory
surgical center, so called, that meets the definition of clinic under Section
52 of Chapter 111, as so appearing, shall not require a determination of need
by the department of public health under Section 51 of Chapter 111 or Sections
25B through 25G of Chapter 111, as so appearing, and any ambulatory surgical
center, so called, that meets the definition of clinic under Section 52 of
Chapter 111, as so appearing, or a single specialty hospital, so called, shall
be deemed to be in compliance with the conditions of licensure under section
51 of this chapter if it is accredited by the Joint Commission on Accreditation
of Health Care Organizations (JCAHO) or its equivalent; provided that any
ambulatory surgical center that is in existence as July 1, 2005 must be certified
by Medicare and any ambulatory surgical center that is established after July
1, 2005 must be certified by Medicare and must still be in substantial
compliance with any applicable licensure and regulatory requirements so promulgated
by the department of public health that are not specifically contained within
the JCAHO or an equivalent accreditation; provided further any such ambulatory
surgical center or single specialty hospital shall also meet the following
conditions: (1) agree to contract with the Massachusetts Executive
Office of Health and Human Services to participate as a Massachusetts MassHealth
provider, (2) agree to establish and maintain a percentage of gross
patient service revenues allocated to free care, said percentage shall be
based on the amount provided by a similarly situated acute care hospital in
the same service areas as said center or specialty hospital, and (3) develop
procedures to deal with patients needing emergency level services following
the delivery of services, which may include but not be limited to contracting
with an acute care hospital with an emergency department within geographical
proximity to said center or specialty hospital.
The department shall promulgate regulations to enforce this section
and any agreement made by said center or specialty hospital concerning the
provisions of MassHealth and free care.
SECTION 48.
(a) There shall be established
within the division of insurance, a small group review board to be chaired
by the commissioner of insurance.
(b) The board shall: (i) conduct an analysis of
existing health benefits currently mandated by state law; (ii) not less than
1 year after implementation, review and make recommendations relative to the
operation of the reinsurance program established by this act; (c) recommend
additional steps to further stabilize premiums for small and individual group
insurance; (d) conduct an actuarialy sound study of the impact and benefits
of expanding the small group market from 50 to 75 employees; and (e) make
such additional recommendations as it deems appropriate for promoting competition
or other steps to contain premium costs while ensuring that the interest of
the health insurance consumer is pre-eminent. The board shall consist of 7 members, who are
citizens of the commonwealth, to be appointed by the governor, 1 of whom shall
represent businesses or employers; 2 of whom shall represent the health care
industry, 1 of whom shall be selected from the Massachusetts Association of
Health Plans and 1 of whom shall be selected from the Massachusetts Hospital
Association. One person shall represent a consumer advocacy organization,
who shall be selected from Health Care for All and 1 person shall be a person
with a background actuarial work or health policy and economics.
(c) In considering its recommendations, the board
shall consult and use, where appropriate, standards established by national
accreditation organizations. Notwithstanding the foregoing, the board shall
not be bound by said standards established by such organizations, but wherever
the board proposes standards different from said national standards, it shall
state the reason for such variation, and take into consideration any projected
compliance costs for such variation.=
(d) The board shall make its report relative to
subsection (a) to the joint committee on health care financing not later than
December 1, 2006 and shall make its remaining reports not later than December
31, 2007.
SECTION 49.
It shall be the policy of the general court to impose a moratorium
on all new mandated health benefit legislation until January 1, 2007, or until
the small group review board, established pursuant to section 47 files its
recommendations to the joint committee on health care financing, whichever
occurs first. Joint committees of the
general court and the house and senate committees on ways and means shall
refer all mandated health benefits bills referred to them during the 2005
to 2006 session of the general court, to the small group review board and
shall take no further action on them during that term.
SECTION 50.
(a) The division of health care finance and policy and the executive
office of health and human services, in consultation with other relevant state
agencies, shall conduct a comprehensive review and evaluation of all existing
mandated health benefits, including, but not limited to, those mandated benefits
established pursuant or defined in section 38C of chapter 3, chapters 175,
176A, 176B and176G, respectively, and shall report its findings not later
than June 30, 2006, together with any recommendations for amendment or repeal,
to the joint committee on health care financing and to the small group review
board established pursuant to section 43.
(b) The small group review board
shall hold one or more public hearings on the report required pursuant to
subsection (a), and shall make its recommendations regarding legislation,
if any, not later than December 1, 2006, to the joint committee on health
care financing.
(c) Wherever it can be ascertained,
the party or organization on whose behalf a mandated health benefit law was
enacted shall provide the division of health care finance and policy with
any cost or utilization data that they have. All interested parties supporting
or opposing the retention of any mandated health benefit law shall provide
the division of health care finance and policy with any information relevant
to the division's review. The division shall enter into interagency agreements
as necessary with the division of medical assistance, the group insurance
commission, the department of public health, the division of insurance, and
other state agencies holding utilization and cost data relevant to the division's
review under this section. Such interagency agreements shall ensure that the
data shared under the agreements is used solely in connection with the division's
review under this section, and that the confidentiality of any personal data
is protected. The division of health care finance and policy may also request
data from insurers licensed or otherwise authorized to transact accident or
health insurance under chapter 175, nonprofit hospital service corporations
organized under chapter 176A, nonprofit medical service corporations organized
under chapter 176B, health maintenance organizations organized under chapter
176G, and their industry organizations to complete its analyses. The division
of health care finance and policy may contract with an actuary, or economist
as necessary to complete its analysis. The report shall include, at a minimum
and to the extent that information is available, the following:
(1) the financial impact of each
currently mandated health benefit, including the extent to which the insurance
coverage has increased or decreased the cost of the treatment or service over
the past 5 years, the extent to which the mandated coverage increased the
appropriate or inappropriate use of the treatment or service over the past
5 years, the extent to which the mandated treatment or service served as an
alternative for more expensive or less expensive treatment or service, the
extent to which the insurance coverage affected the number and types of providers
of the mandated treatment or service over the past 5 years, the effects of
mandating the benefit on the cost of health care, particularly the premium,
administrative expenses and indirect costs of large employers, small employers,
employees and non-group purchasers, the direct and indirect benefits and savings
to large employers, small employers, employees and non-group purchasers, the
effect of the mandate on cost shifting between private and public payors of
health care coverage, the cost to health care consumers of not mandating the
benefit in terms of out of pocket costs for treatment or delayed treatment
and the effect on the overall cost of the health care delivery system in the
commonwealth;
(2) the medical efficacy of the
mandated health benefit, including the impact of the benefit to the quality
of patient care and the health status of the population and the results of
any research demonstrating the medical efficacy of the treatment or service
compared to alternative treatments or services or not providing the treatment
or service; and
(3) if the current benefit mandated
coverage of an additional class of practitioners, the results of any professionally
acceptable research demonstrating the medical results achieved by the additional
class of practitioners relative to those previously covered and the methods
of the appropriate professional organization that assures clinical proficiency.
SECTION 51. Notwithstanding the provisions of any general or
special law to the contrary, the Executive Office of Health and Human Services
shall not make any change to the financing, operation or regulation of, or
contracts pertaining to, the provision of behavioral health services to persons
receiving services administered, provided, paid for or procured by the Executive
Office of Health and Human Services, Office of Medicaid, including, but not
limited to services under Title XIX of the Social Security Act, and Title
XXI S-CHIP, and any MassHealth expansion population served under Section 1115
waivers, so-called, nor shall it recommend or procure, by request for response
or otherwise, any such changes, nor shall it seek approval from the Centers
for Medicare and Medicaid Services for any such changes, until it has submitted
a report outlining the proposed changes, together with reasons therefore and
an explanation of the benefits of such changes, to the Joint Committees on
Mental Health and Substance Abuse and Health Care Financing, and in no case
prior to February 15, 2006.
SECTION 52. Notwithstanding the provisions of any general
or special law to the contrary, during fiscal year 2007 and subsequent years,
the secretary of the executive office of health and human services shall implement
actuarially sound rates to the maximum extent allowable, which shall reimburse
certain publicly–operated entities operated by the Cambridge Public Health
Commission and the Boston Public Health Commission, respectively, providing
Title XIX reimbursable services, directly or through contracts with hospitals
under an agreement with said executive office of health and human services,
at levels consistent with their supplemental payments in fiscal year 2006,
as specified in Section 16 of Chapter 45 of the Acts of 2005.
SECTION 53. Notwithstanding
any general or special law to the contrary, the executive office of health
and human services shall create a 2-year pilot program for smoking and tobacco
use cessation treatment and information to include within its MassHealth covered
services. Smoking and tobacco use cessation treatment and information benefits
shall include nicotine replacement therapy, other evidence-based pharmacologic
aids to quitting smoking, and accompanying counseling by a physician, certified
tobacco use cessation counselor, or other qualified clinician. The executive
office shall report annually on the number of enrollees who participate in
smoking cessation services, number of enrollees who quit smoking, and Medicaid
expenditures tied to tobacco use by Medicaid enrollees. The comptroller shall
transfer $7 million from the Health Care Security Trust, established by section
1 of chapter 29D of the General Laws, to the General Fund in fiscal year 2007
and fiscal year 2008 to fund said program.
SECTION 54. Notwithstanding
any general or special law to the contrary, the executive office of health
and human services shall seek federal approval effective July 1, 2006 to enroll
an additional 1,600 people, for a maximum total of 15,600 enrollees, in the
CommonHealth program, so-called, funded in item 4000-0430 in section 2 of
chapter 45 of the acts of 2005.
SECTION 55. Notwithstanding
any general or special law to the contrary, the executive office of health
and human services shall seek federal approval effective July 1, 2006 to enroll
an additional 250 people, for a maximum total of 1,300 enrollees, in the Family
Assistance HIV positive program, so-called, funded in item 4000-1400 in section
2 of chapter 45 of the acts of 2005.
SECTION 56. Notwithstanding
any general or special law to the contrary, the executive office of health
and human services shall seek federal approval effective July 1, 2006 to enroll
an additional 16,000 people, for a maximum total of 60,000 enrollees, in the
MassHealth Essential program, so-called, funded in item 4000-1405 in section
2 of chapter 45 of the acts of 2005.
SECTION 57. The secretary of health and human services shall seek to
obtain federal SCHIP reimbursement, pursuant to the provisions of Title XXI,
for all persons eligible. To the extent S-CHIP funds are not available for
all eligible programs, the secretary shall first seek S-CHIP reimbursement
for Title XXI eligible programs prior to claiming SCHIP reimbursement for
Title XIX eligible programs. The Secretary shall report quarterly to the Joint
Committee on Health Care Financing and the House and Senate Committees on
Ways and Means on the status of federal SCHIP reimbursement.
SECTION 58. There shall be established a Massachusetts health
disparities council, located within, but not subject to the control of, the
executive office of health and human services.
The council shall make recommendations regarding reduction and elimination
of racial and ethnic disparities in health care and health outcomes within
the Commonwealth of Massachusetts. The
disparities shall include, but not be limited to breast, cervical, prostate
and colorectal cancers, stroke and heart attack, heart disease, diabetes,
infant mortality, lupus, HIV/AIDS, asthma and other respiratory illnesses. The council shall address diversity in the health
care workforce, including but not limited to, doctors, nurses and physician
assistants and shall make recommendations on methods to increase the health
care workforce pipeline. The council shall also make recommendations on other
matters impacting upon and relevant to health disparities including but not
limited to the environment and housing.
The council shall initially consist
of the members of the special legislative commission created in Chapter 65,
Section 57 of the Acts of 2004. At the end of the first fiscal year following
the passage of this act, the council membership shall be re-determined by
the Speaker of the House of Representatives, the President of the Senate,
and the Governor.
The council shall file an annual
report at the end of each fiscal year with the office of the Governor, the
Clerk of the House of Representatives, and the Clerk of the Senate. The report
shall include, but not be limited to, recommendations for designing, implementing
and improving programs and services, and proposing appropriate statutory and
regulatory changes to reduce and eliminate disparities in access to health
care services and quality care, and the disparities in medical outcomes in
the Commonwealth, and to address diversity and cultural competency in the
health care workforce, including but not limited to, doctors, nurses and physician
assistants.
SECTION 59 Section 8 shall be effective for tax years beginning
on or after January 1, 2006.
SECTION 60.
Section 34 shall apply to policies delivered, or issued for delivery,
in the commonwealth on or after January 1, 2005.
This chapter is not intended to supersede the obligations of entities
subject to this chapter to comply with applicable insurance laws insofar as
they do not conflict with this chapter, except that laws and regulations designed
and intended to apply to Medicare supplement insurance policies shall apply
to long-term care insurance.
SECTION 61. Section 44 shall
expire on October 30, 2010.
SECTION 62.
Sections 12 and 13B shall be effective on July 1, 2006.
