Whereas, The deferred operation of this act would tend to defeat its purpose, which is forthwith to expand access to health care for Massachusetts residents, therefore it is hereby declared to be an emergency law, necessary for the immediate preservation of the public health.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same as follows:
SECTION 1. To provide for supplementing certain items in the general appropriation act and other appropriation acts for fiscal year 2006 for the purpose of funding certain costs associated with health care reform, the sums set forth in section 2 are hereby appropriated from the General Fund unless specifically designated otherwise in this act or in those other appropriation acts, for the several purposes and subject to the conditions specified in this act or in these other appropriation acts and subject to laws regulating the disbursement of public funds for the fiscal year ending June 30, 2006. The sums in said section 2 shall be in addition to any amounts previously appropriated and made available for the purposes of those items, provided further, that all funds appropriated in this section shall not revert and shall be available for expenditure until June 30, 2007.
SECTION 2.
Executive office of Health and human services
Office of the Secretary
4000-0352 ........................................................ $3,000,000
Department of Public Health
4513-1026 ........................................................... $750,000
4513-1112 ......................................................... $1,000,000
4513-1114 ........................................................... $750,000
4513-1115 ........................................................... $250,000
4513-1121 .......................................................... $200,000
4530-9000 ......................................................... $1,000,000
4570-1500 ......................................................... $4,000,000
4590-0300 ......................................................... $4,000,000
EXECUTIVE OFFICE OF ECONOMIC DEVELOPMENT
Division of Insurance
7006-0020 For costs related to the special commission to examine and study the impact of merging the non-group insurance market as defined in chapter 176M of the General Laws and small-group health insurance market as defined in chapter 176J of the General Laws, established pursuant to section 114 of this act .................... $500,000
SECTION 2A. To provide for certain unanticipated obligations of the commonwealth, to provide for an alteration of purpose for current appropriations, and to meet certain requirements of law, the sums set forth in this section are hereby appropriated from the General Fund unless specifically designated otherwise, for the several purposes and subject to the conditions specified in this section, and subject to laws regulating the disbursement of public funds for the fiscal year ending June 30, 2006. The sums shall be in addition to any amounts previously appropriated and made available for the purposes of these items, provided further, that all funds appropriated in this section shall not revert and shall be available for expenditure until June 30, 2007.
EXECUTIVE OFFICE FOR ADMINISTRATION AND FINANCE
Reserves
1599-2006 For a reserve to fund the additional administrative costs associated with the implementation of this act, including, but not limited to, costs of commonwealth personnel and overtime, contracts, and the purchase of new information technologies as necessary; provided further, that the secretary may transfer from the sum appropriated herein to other items of appropriation and allocations for fiscal years 2006 and 2007 such amounts as are necessary to meet said costs where the amounts otherwise available are insufficient for the purpose, in accordance with a transfer plan which shall be filed in advance with the house and senate committees on ways and means; and provided further, that the secretary may only transfer such amounts to other items of appropriation and allocations within the executive office for administration and finance, the executive office of health and human services, and the division of insurance; and provided further that the secretary shall transfer funds from the sum appropriated herein for the cost of the health care quality and cost council in fiscal year 2007.......................... $10,000,000
Executive office of Health and human services
Office of the Secretary
4000-0140 For the operation of the Betsy Lehman center for patient safety and medical error reduction established in section 16E of chapter 6A of the General Laws....................................... $500,000
4000-0301 For the costs of MassHealth provider and member audit and utilization review activities including, but not limited to, eligibility verification, disability evaluations, provider financial and clinical audits and other initiatives intended to enhance program integrity; provided, that $150,000 shall be expended for the operation of the Medicaid fraud control unit within the office of the attorney general; and provided further, that $150,000 shall be expended for MassHealth auditing within the office of the state auditor $1,500,000
Department of Public Health
4513-1111 For an osteoporosis education and prevention program; provided, that the program shall include, but not be limited to: (1) development or identification of educational materials to promote public awareness of the cause of osteoporosis, options for prevention and the value of early detection and possible treatments, including their benefits and risks, to be made available to consumers, particularly targeted to high risk groups; (2) development or identification of professional education programs for health care providers; (3) development and maintenance of a list of current providers of specialized services for the prevention and treatment of osteoporosis; and (4) a program for awareness, prevention and treatment of hip fractures $100,000
4513-1122 For an ovarian cancer screening, education and treatment program; provided, that no funds shall be expended in the AA object class for any personnel-related costs............................. $200,000
4513-1116 For a renal disease program; provided, that not less than $100,000 shall be expended for renal disease programs administered by the National Kidney Foundation of Massachusetts, Rhode Island, Vermont and New Hampshire, including organ donor awareness, nutritional supplements and early intervention services for those affected with renal disease and those at risk of renal disease................................................... $100,000
4516-0264 For a diabetes screening and outreach program to raise public awareness and provide outreach and education for high risk individuals, including, but not limited to, targeted populations of adolescents and the elderly............................................................................................................................. $350,000
4570-1502 For the purposes of implementing a proactive statewide infection prevention and control program; provided, that notwithstanding any general or special law to the contrary, the department of public health shall, through its division of health care quality, develop a proactive statewide infection prevention and control program in licensed health care facilities following protocols of the Centers for Disease Control for the purposes of implementation and adherence to infection control practices that are the keys to preventing the transmission of infectious diseases, including respiratory diseases spread by droplet or airborne routes; provided further, that recommended infection control practices shall include, but not be limited to, hand hygiene; standard precautions and transmission-based precautions, including contact, droplet and airborne, and respiratory hygiene; and provided further, that the infection prevention and control program shall include mandatory education in the recommended infection control practices for licensed health care personnel and employees of licensed health care facilities and penalties for individual and institutional noncompliance with Centers for Disease Control protocols..................................... $1,000,000
4590-1503 For the pediatric palliative care program established in section 24K of chapter 111 of the General Laws..................... $800,000
SECTION 3. Chapter 6A of the General Laws is hereby amended by inserting after section 16I the following 6 sections:—
Section 16J. As used in this section and in sections 16K and 16L, the following words shall, unless the context clearly requires otherwise, have the following meanings:—
“Clinician”, a health care professional licensed under chapter 112.
“Council”, the health care quality and cost council, established by section 16K.
“Facility”, a hospital, clinic or nursing home licensed under chapter 111 or a home health agency.
“Health care provider”, a clinician, a facility or a physician group practice.
“Insurer”, a carrier authorized to transact accident and health insurance under chapter 175, a nonprofit hospital service corporation licensed under chapter 176A, a nonprofit medical service corporation licensed under chapter 176B, a dental service corporation organized under chapter 176E, an optometric service corporation organized under chapter 176F and a health maintenance organization licensed under chapter 176G.
“Physician group practice”, 2 or more physicians who deliver patient care, make joint use of equipment and personnel and divide income by a prearranged formula.
Section 16K. There shall be a health care quality and cost council within, but not subject to control of, the executive office of health and human services. The council shall establish health care quality improvement and cost containment goals. The goals shall be designed to promote high-quality, safe, effective, timely, efficient, equitable and patient-centered health care. The council shall receive staff assistance from the executive office of health and human services and may, subject to appropriation, employ such additional staff or consultants as it may deem necessary. The council shall consist of the secretary of health and human services, the auditor of the commonwealth or his designee, the inspector general or his designee, the attorney general or his designee, the commissioner of insurance, the executive director of the group insurance commission, and 7 persons to be appointed by the governor, 1 of whom shall be a representative of a health care quality improvement organization recognized by the federal Centers for Medicare and Medicaid services, 1 of whom shall be a representative of the Institute for Healthcare Improvement, Inc. recommended by the organization’s board of directors, 1 of whom shall be a representative of the Massachusetts Chapter of the National Association of Insurance and Financial Advisors, 1 of whom shall be a representative of the Massachusetts Association of Health Underwriters, 1 of whom shall be a representative of the Massachusetts Medicaid Policy Institute, 1 of whom shall be an expert in health care policy from a foundation or academic institution and 1 of whom shall represent a non-governmental purchaser of health insurance. The representatives of nongovernmental organizations shall serve staggered 3-year terms. The council shall be chaired by the secretary of health and human services.
Section 16L. (a) The council shall develop and coordinate the implementation of health care quality improvement goals that are intended to lower or contain the growth in health care costs while improving the quality of care, including reductions in racial and ethnic health disparities. For each such goal, the council shall identify the steps needed to achieve the goal; estimate the cost of implementation; project the anticipated short-term or long-term financial savings achievable to the health care industry and the commonwealth, and estimate the expected improvements in the health status of health care consumers in the commonwealth.
(b) The council may, subject to chapter 30B, contract with an independent health care organization to provide the council with technical assistance related to its duties including, but not limited to, the development of health care quality goals, cost containment goals, performance measurement benchmarks, the design and implementation of health quality interventions, the construction of a consumer health information website and the preparation of reports, including any reports as required by this section. The independent health care organization shall have a history of demonstrating the skill and expertise necessary to: (i) collect, analyze and aggregate data related to costs and quality across the health care continuum; (ii) identify, through data analysis quality improvement areas; (iii) work with Medicare, MassHealth, other payers’ data and clinical performance measures; (iv) collaborate in the design and implementation of quality improvement measures; (v) establish and maintain security measures necessary to maintain confidentiality and preserve the integrity of the data; (vi) design and implement health care quality improvement interventions with health care service providers; and (vii) identify and, when necessary, develop appropriate measures of cost and quality for inclusion in the website. To the extent possible, the independent organization shall collaborate with other organizations that develop, collect and publicly report health care cost and quality measures.
(c) Any independent organization under contract with the council shall develop and update on an annual basis a reporting plan specifying the cost and quality measures to be included on the internet site. The reporting plan shall be consistent with the requirements of subsections (a) and (b). The organization shall give consideration to those measures that are already available in the public domain and to whether it is cost effective for the council to license commercially available comparative data and consumer decision support tools. If the organization determines that making available through the internet site only those measures already available in the public domain would not fully comply with subsection (b) or would not provide consumers with sufficient information to make informed health care choices, the organization shall develop appropriate measures for inclusion on the internet site and shall specify in the reporting plan the sources from which it proposes to obtain the data necessary to construct those measures and any specifications for reporting of that data by insurers and health care providers. As part of the reporting plan, the organization shall determine for each service that comparative information is to be included on the internet site whether it is more practical and useful to: (1) list that service separately or as part of a group of related services; and (2) combine the cost information for each facility and its affiliated clinicians and physician practices or to list facility and professional costs separately. The independent organization shall submit the reporting plan and any periodic revisions to the council. The council shall, after due consideration and public hearing, adopt or reject the reporting plan or any revisions. If the council rejects the reporting plan or any revisions, the council shall state its reasons therefor. The reporting plan and any revisions adopted by the council shall be promulgated by the council.
(d) Insurers and health care providers shall submit data to the council or to the independent organization on behalf of the council, as required by regulations promulgated under subsection (e). If any insurer or health care provider fails to submit required data to the council on a timely basis, the council shall provide written notice to the insurer or provider. If the insurer or health care provider fails, without just cause, to provide the required information within 2 weeks following receipt of said written notice, the insurer or provider may be required to pay a penalty of $1,000 for each week of delay; provided, however, that the maximum penalty under this section shall be $50,000.
(e) The council may promulgate additional rules and regulations relative to the type of information that reasonably may be required and the format in which it should be provided for the implementation the quality improvement and cost containment goals.
(f) The council may adopt by-laws for itself and for its advisory committee for the efficient operation of both organizations, and may recommend that public or private health care organizations be responsible for overseeing implementation of a goal and may assist these organizations in developing implementation plans.
(g) The council shall develop performance measurement benchmarks for its goals and publish such benchmarks annually, after consultation with lead agencies and organizations and the council’s advisory committee. Such benchmarks shall be developed in a way that advances a common national framework for quality measurement and reporting including, but not limited to measures that are approved by the National Quality Forum and adopted by the Hospitals Quality Alliance and other national groups concerned with quality. Performance benchmarks shall be clinically important and include both process and outcome data, shall be standardized, timely, and allow and encourage physicians, hospitals and other health care professionals to improve their quality of care. Any data reported by the council should be accurate and evidence-based, and not imply distinctions where comparisons are not statistically significant. Members of the advisory committee established by this section shall have reasonable opportunity to review and comment on all reports before public release.
(h) The council shall establish and maintain a consumer health information website. The website shall contain information comparing the cost and quality of health care services and may also contain general information related to health care as the council determines to be appropriate. The website shall be designed to assist consumers in making informed decisions regarding the medical care and informed choices between health care providers. Information shall be presented in a format that is understandable to the average consumer. The council shall take appropriate action to publicize the availability of its website and make available written documentation available upon request and as necessary.
(i) The internet site shall provide updated information on a regular basis, at least annually, and additional comparative cost and quality information shall be posted as determined by the council. To the extent possible, the internet site shall include: (i) comparative quality information by facility, clinician or physician group practice for each service or category of service for which comparative cost information is provided, (ii) general information related to each service or category of service for which comparative information is provided; and (iii) comparative quality information by facility, clinician or physician practice that is not service-specific, including information related to patient safety and satisfaction.
(j) The council shall conduct annual public hearings to obtain input from health care industry stakeholders, health care consumers and the general public regarding the goals and the performance measurement benchmarks. The council shall invite the stakeholders involved in implementing or achieving each goal to assist with the implementation and evaluation of progress for each goal.
(k) The council shall review and file a report, not less than annually, with the joint committee on health care financing and the clerks of the house and senate on its progress in achieving the goals of improving quality and containing or reducing health care costs. Reports of the council shall be made available electronically through an internet site.
(l) The council shall establish an advisory committee to allow the broadest possible involvement of health care industry and other stakeholders in the establishment of its goals and the review of its progress. The advisory committee shall include 1 member representing the Massachusetts Medical Society, 1 member representing the Massachusetts Hospital Association, 1 member representing the Massachusetts Association of Health Plans, 1 member representing Blue Cross Blue Shield of Massachusetts, 1 member representing the Massachusetts AFL-CIO, 1 member representing the Massachusetts League of Community Health Centers, 1 member representing Health Care For All, Inc., 1 member representing the Massachusetts Public Health Association, 1 member representing the Massachusetts Association of Behavioral Health Systems, 1 member representing the Massachusetts Extended Care Federation, 1 member representing the Massachusetts Council of Human Service Providers, 1 member representing the Home Care Alliance of Massachusetts, 1 member representing Associated Industries of Massachusetts, 1 member of the Massachusetts Business Roundtable, 1 member of the Massachusetts Taxpayers Foundation, 1 member of the Massachusetts chapter of the National Federation of Independent Business, 1 member of the Massachusetts Biotechnology Council, 1 member representing the Blue Cross Blue Shield Foundation, 1 member representing the Massachusetts chapter of the American Association of Retired Persons, 1 member representing the Massachusetts Coalition of Taft Hartley Trust Funds, and additional members to be appointed by the governor which shall include, but not be limited to, a representative of the mental health field, a representative of pediatric health care, a representative of primary care, a representative of medical education, a representative of racial or ethnic minority groups concerned with health care, a representative of hospice care, a representative of the nursing profession and a representative of the pharmaceutical field.
(m) The council may recommend legislation or regulatory changes, including recommendations for the commonwealth's health care payment methodologies to promote the health care quality and cost containment goals set by the council, and the council may promulgate regulations under this section.
(n) Subject to appropriation, the council may disburse funds in the form of grants or loans to assist members of the health care industry in implementing the goals of the council.
(o) All meetings of the council shall conform to chapter 30A, except that the council, through its bylaws, may provide for executive sessions of the council. No action of the council shall be taken in an executive session.
(p) The members of the council shall not receive a salary or per diem allowance for serving as members of the council but shall be reimbursed for actual and necessary expenses reasonably incurred in the performance of their duties. The expenses may include reimbursement for reasonable travel and living expenses while engaged in council business.
(q) The council may, subject to chapter 30B and subject to appropriation, procure equipment, office space, goods and services, including the development and maintenance of the website.
Section 16M. (a) There shall be a MassHealth payment policy advisory board. The board shall consist of the secretary of health and human services or his designee, who shall serve as chair, the commissioner of health care financing and policy, and 12 other members: 1 member appointed by the speaker of the house; 1 member appointed by the president of the senate; 1 member appointed by the Massachusetts Hospital Association; 1 member appointed by the Massachusetts Medical Society; 1 member appointed by the Massachusetts Extended Care Federation; 1 member appointed by Mass Aging Services Association, 1 member appointed by the Home Care Alliance of Massachusetts; 1 member appointed by the Massachusetts League of Community Health Centers; 1 member appointed by Mental Health and Substance Abuse Corporations of Massachusetts; 1 member appointed by the Massachusetts Medicaid Policy Institute; 1 member appointed by the Massachusetts Association of Behavioral Health Systems; 1 member appointed by Planned Parenthood League of Massachusetts; and 2 members appointed by the governor, 1 member representing managed care organizations contracting with MassHealth and 1 member being an expert in medical payment methodologies from a foundation or academic institution.
(b) The board shall have the following powers and duties:—
(1) to obtain from the office of Medicaid all data and analysis required to fully meet its charge under this section 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) to conduct public hearings;
(3) to review and evaluate rates and payment systems by the office of Medicaid and recommend Title XIX rates and rate methodologies that provide fair compensation for MassHealth services and promote high-quality, safe, effective, timely, efficient, culturally competent and patient-centered care. The board shall specifically review rates and rate methodologies for MassHealth services provided by community health centers. The division shall provide the board with the appropriate information not later than 45 days before the proposals are adopted into regulation; and
(4) to 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 staff from the division of health care finance and policy necessary to complete needed research and analysis and enable the committee to make effective recommendations. 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 the policies to the joint committee on health care financing and to the house and senate committees on ways and means.
Section 16N. There shall be a special commission to study the feasibility of reducing or eliminating the contribution made by contributing employers to the Uncompensated Care Trust Fund. The commission shall consist of: the secretary of health and human services or his designee, who shall serve as chair; the commissioner of health care finance and policy or his designee; the commissioner of insurance or his designee; 2 members appointed by the speaker of the house of representatives; 1 member appointed by the minority leader of the house of representatives; 2 members appointed by the president of the senate; and 1 member appointed by the minority leader of the senate.
The study shall evaluate the amount of reimbursements provided from the uncompensated care pool, or any successor fund, for the medical care of the uninsured or underinsured patients in the commonwealth on the first day of each hospital fiscal year and compare it to the amount of reimbursements provided from the uncompensated care pool, or any successor fund, for the medical care of the uninsured or underinsured patients in the commonwealth on the first day of the preceding hospital fiscal year in order to determine whether a decrease or elimination of the contribution by contributing employers is possible based on the amount of reduction, if any, in the amount of reimbursements provided from the uncompensated care pool, or any successor fund, for the medical care of the uninsured or underinsured patients in the commonwealth during a hospital fiscal year.
The commission shall report annually to the senate president, minority leader of the senate, senate committee on ways and means, speaker of the house of representatives, minority leader of the house of representatives and the house committee on ways and means no later than the first day in December.
Section 16O. There shall be a 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. 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. The council may 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 consist of 34 members: 1 member representing the secretary of health and human services; 1 member representing the commissioner of public health; 1 member representing the director of the office of Medicaid; 3 members of the house of representatives, 1 of whom shall be designated by the speaker of the house as co-chair of the commission; 3 members of the senate, 1 of whom shall be designated by the senate president as co-chair of the commission; 1 member representing the American Cancer Society Massachusetts Division; 1 member representing the American Heart Association New England Division; 1 member representing Massachusetts General Hospital; 1 member representing Brigham and Women's Hospital; 1 member representing the Dana Farber Cancer Center; 1 member representing the Massachusetts League of Community Health Centers; 1 member representing the Massachusetts Medical Society; 1 member representing Boston Public Health Commission; 1 member representing the Office of Multicultural Health in the Department of Public Health; 1 member representing the Springfield Health Department; 1 member representing the Worcester Health Department; 2 members representing the nursing profession, 1 of whom shall be designated by Massachusetts School Nurses Organization and 1 of whom shall be designated by the Massachusetts Association of Public Health Nurses; 1 member representing the Massachusetts Association of Health Plans; 1 member representing the Program to Eliminate Health Disparities at the Harvard School of Public Health; 1 member representing Boston Medical Center Corporation; 1 member from the Massachusetts Public Health Association; 4 members from communities disproportionately affected by health disparities to be appointed by the speaker of the house; and 4 members from communities disproportionately affected by health disparities to be appointed by the senate president. The council membership shall be re-determined by the speaker of the house of representatives, the president of the senate and the governor on July 1, 2007.
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, proposals for 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 shall address diversity and cultural competency in the health care workforce, including but not limited to, doctors, nurses and physician assistants.
SECTION 4. Section 35M of chapter 10 of the General Laws, as appearing in the 2004 Official Edition, is hereby amended by striking out, in lines 10 and 11, the following words:— “; but, any unexpended balance at the end of the fiscal year shall revert to the General Fund”.
Section 3. (a) There shall be a public health council to advise the commissioner of public health and to perform other duties as required by law. The council shall consist of the commissioner of public health as chairperson and 17 members appointed for terms of 6 years under this section. The commissioner may designate 1 of the members as vice chairperson and may appoint subcommittees or special committees as needed.
(b) Five of the appointed members shall be the chancellor of the University of Massachusetts Medical School or his designee; the dean of the University of Massachusetts Amherst School of Public Health and Health Sciences or his designee; the dean of the Harvard University School of Public Health or his designee; the dean of Public Health Program at Tufts University School of Medicine or his designee, and the dean of the Boston University School of Public Health or his designee.
(c) Six of the appointed members shall be providers of health services: 1 shall be the chief executive officer of an acute care hospital appointed by the Massachusetts Hospital Association; 1 shall be the chief executive officer of a skilled nursing facility appointed by the Massachusetts Extended Care Federation; 2 shall be registered nurses, to be appointed by the board of registration of nurses and shall be the highest vote-getters on a mail ballot sent to the address of record of all registered nurses licensed by the board of registration of nurses, 1 of whom shall be a nurse executive; and 2 shall be physicians appointed by the Massachusetts Medical Society, 1 of whom shall be a primary care physician.
(d) Six of the appointed members shall be non-providers: 1 shall be appointed by the secretary of elder affairs; 1 shall be appointed by the secretary of veterans' services; 1 shall be appointed by Health Care For All, Inc.; 1 shall be appointed by the Coalition for the Prevention of Medical Errors, Inc.; 1 shall be appointed by the Massachusetts Public Health Association; and 1 shall be appointed by the Massachusetts Community Health Worker Network.
(e) For purposes of this section, "non-provider" shall mean a person whose background and experience indicate that he is qualified to act on the council in the public interest; who, and whose spouse, parents, siblings or children, have no financial interest in a health care facility; who, and whose spouse has no employment relationship to a health care facility, to a nonprofit service corporation established under chapters 176A to 176E, inclusive, or to a corporation authorized to insure the health of individuals; and who, and whose spouse, is not licensed to practice medicine.
(f) Upon the expiration of the term of office of an appointive member, his successor shall be appointed in the same manner as the original appointment, for a term of 6 years and until the qualification of his successor. The members shall be appointed not later than 60 days after a vacancy. The council shall meet at least once a month, and at such other times as it shall determine by its rules, or when requested by the commissioner or any 4 members. The appointive members shall receive $100 per day that the council meets, and their reasonably necessary traveling expenses while in the performance of their official duties.
SECTION 6. Chapter 26 of the General Laws is hereby amended by inserting after section 7 the following section:—
Section 7A. There shall be in the division of insurance a health care access bureau overseen by a deputy commissioner for health care access, whose duties shall include, subject to the direction of the commissioner of insurance, administration of the division’s statutory and regulatory authority for oversight of the small group and individual health insurance market, oversight of affordable health plans, including coverage for young adults, as well as the dissemination of appropriate information to consumers about health insurance coverage and access to affordable products. The commissioner shall appoint at least the following employees of the health care access bureau: a deputy commissioner for health access, a health care finance expert, an actuary, and a research analyst. They shall devote their full time to the duties of their office, shall be exempt from chapters 30 and 31, and shall serve at the pleasure of the commissioner. The commissioner may appoint such other employees as the bureau may require.
SECTION 6A. Chapter 26 of the General Laws is hereby amended by inserting after section 7A the following section:—
Section 7B. For the purposes of implementing chapter 111M, the health care access bureau shall maintain a database of members of health benefit plans. Carriers licensed under chapters 175, 176A, 176B, and 176G and the office of Medicaid shall report on the first day of each month to the bureau the names, and any other identifying information as determined by the division of insurance, of each resident of the commonwealth for whom creditable coverage, as defined in said chapter 111M, was provided during the previous month. The division shall enter into an inter-agency agreement with the department of revenue for purposes of implementing said chapter 111M and, in consultation with the department of revenue, shall adopt regulations defining the content of such reports, which shall be limited to the minimum amount of personal information necessary for the purposes of said chapter 111M. These reports shall not contain any information pertaining to previous or current health conditions or treatments. The division of insurance may transfer the content of the database to the department of revenue for the purposes of implementing chapter 111M.
SECTION 7. Section 8H of said chapter 26, as appearing in the 2004 Official Edition, is hereby amended by inserting after the second paragraph the following paragraph:—
The division of insurance, in consultation with the commonwealth health insurance connector established by chapter 176Q, shall establish and publish minimum standards and guidelines at least annually for each type of health benefit plans, except qualified student health insurance plans as set forth in section 18 of chapter 15A, provided by insurers and health maintenance organizations doing business in the commonwealth.
SECTION 8. Chapter 29 of the General Laws is hereby amended by inserting after section 2NNN the following 4 sections:—
Section 2OOO. There is hereby established and set up on the books of the commonwealth a separate fund to be known as the Commonwealth Care Trust Fund, in this section called the trust fund. There shall be credited to the trust fund: (a) all contributions collected under section 188 of chapter 149, (b) all revenue from surcharges imposed under section 18B of chapter 118G, (c) any transfers from the Health Safety Net Trust Fund, established by section 57 of chapter 118E, (d) any funds that may be appropriated or transferred for deposit into the trust fund for the purposes of the demonstration program approved the Secretary of the United States Department of Health and Human Services under section 1115 of the Social Security Act, as extended or renewed from time to time and (e) revenue deposited pursuant to penalties collected under chapter 111M. Amounts credited to the trust fund shall be expended without further appropriation for programs designed to increase health coverage, including a program of subsidized health insurance provided to low-income residents of the commonwealth under chapter 118H and rate increases to certain Medicaid providers and supplemental payments to certain publicly operated or public-service hospital entities, as determined by law. Money from the trust fund may be transferred to the Uncompensated Care Trust Fund, established by section 18 of chapter 118G, or any successor fund, as necessary to provide payments to acute hospitals and community health centers for reimbursable health services. Not later than January 1, the comptroller shall report an update of revenues for the current fiscal year and prepare estimates of revenues to be credited to the trust fund in the subsequent fiscal year. The comptroller shall file this report with the secretary of administration and finance, the office of Medicaid, the joint committee on health care financing, and the house and senate committees on ways and means. If revenues credited to the trust fund are less than the amounts estimated to be credited to the trust fund, the comptroller shall duly notify the secretary, office and committees that this revenue deficiency shall require proportionate reductions in expenditures from the revenues available to support programs appropriated from the trust fund.
Section 2PPP. There is hereby established and set up on the books of the commonwealth a separate fund to be known as the Essential Community Provider Trust Fund, in this section called the trust fund. There shall be credited to the trust fund: (a) any funds that may be appropriated or transferred for deposit into the trust fund; and (b) any income derived from investment of amounts credited to the trust fund. In conjunction with the preparation of the commonwealth’s annual financial report, the comptroller shall prepare and issue an annual report detailing the revenues and expenditures of the trust fund. The comptroller shall certify payments, including payments during the accounts payable period, in anticipation of revenues, including receivables due and collectibles during the months of July and August, from the trust fund for the purpose of making authorized expenditures. The health safety net office shall administer the trust fund and disburse funds from the trust fund for the purpose of payments to acute hospitals and community health centers under clause (6) of paragraph (b) of section 56 and any further regulations promulgated by the office.
Section 2QQQ. There is hereby established and set up on the books of the commonwealth a separate fund to be known as the Medical Assistance Trust Fund, in this section called the trust fund, administered by the secretary of health and human services. There shall be credited to the trust fund: (a) any funds directed to the commonwealth from public entities, and (b) federal reimbursements related to medical assistance payments funded by such funds. All amounts credited to the trust fund shall be available for expenditure by the secretary to be used for medical assistance payments to entities authorized by the general court, and for which a public entity has contractually agreed to direct funds to the trust fund. Any amount in excess of such medical assistance payments may be credited to the General Fund and the amount of all such expenditures shall be subject to annual approval by the general court. The maximum payments from the trust fund shall not exceed those permissible for federal reimbursement under Title XIX or Title XXI of the Social Security Act or any successor federal law. The comptroller may make payments, including payments during the accounts payable period, in anticipation of revenues, including receivables due and collectibles during the months of July and August, and shall establish procedures for reconciling overpayments or underpayments from the trust fund. Such procedures shall include, but not be limited to, appropriate mechanisms for refunding public funds directed to the trust fund and federal reimbursements upon recoupment of any such overpayments. The secretary of health and human services shall submit to the secretary of administration and finance and the house and senate committees on ways and means a schedule of such payments 10 days before any expenditures, and no funds shall be expended without an enforceable agreement with or legal obligation imposed upon a public entity to make an intergovernmental transfer in an appropriate amount to the trust fund.
Section 2RRR. There is hereby established and set up on the books of the commonwealth a separate fund to be known as the Department of Mental Retardation Trust Fund, in this section called the trust fund, administered by the secretary of health and human services. There shall be credited to the trust fund: (a) any receipts from the assessment collected under section 27 of chapter 118G, including transfers by the department of mental retardation of amounts sufficient to pay the assessment for public facilities, (b) any federal financial participation received by the commonwealth as a result of expenditures funded by such assessments, and (c) any interest thereon. The secretary may authorize expenditures of amounts from such trust fund without further appropriation. The comptroller shall transfer to the trust fund no later than the first business day of each quarter, the amounts indicated by the department of mental retardation to provide the appropriate payment adjustments for operating the intermediate care facilities for the mentally retarded and the community residences serving individuals with mental retardation. The comptroller shall establish procedures necessary to effectuate this section, including procedures for the proper transfer, accounting, and expenditures of funds. The comptroller may make payments in anticipation of receipts and shall establish procedures for reconciling overpayments and underpayments from the trust fund. The secretary shall report semi-annually to the house and senate committees on ways and means on the revenue and expenditure activity within the trust fund.
SECTION 9. Section 1 of chapter 32 of the General Laws, as appearing in the 2004 Official Edition, is hereby amended by inserting after the word “Authority”, in line 211, the first time it appears, the following words:— , commonwealth health insurance connector.
SECTION 10. Section 1 of chapter 62 of the General Laws is hereby amended by striking out the definition “Code”, as amended by section 3 of chapter 163 of the acts of 2005, and inserting in place thereof the following definition:—
(c) “Code”, the Internal Revenue Code of the United States, as amended on January 1, 2005 and in effect for the taxable year; but Code shall mean the Code as amended and in effect for the taxable year for sections 62(a)(1), 72, 223, 274(m), 274(n), 401 through 420, inclusive, 457, 529, 530, 3401 and 3405 but excluding sections 402A and 408(q).
SECTION 11. Chapter 111 of the General Laws is hereby amended by inserting after section 24J the following section:—
Section 24K. There is hereby established the pediatric palliative care program. Said program shall be administered by the department, subject to appropriation, under this section and regulations promulgated hereunder. The program shall assist eligible children with a life-limiting illness and their families or guardians with services designed to achieve an improved quality of life and to meet the physical, emotional and spiritual needs experienced during the course of illness, death and bereavement.
Children less than 19 years of age shall be eligible for said program if they meet the requirements established by the department, which shall include:—
(a) a diagnosis of a life-limiting illness, including but not limited to, cancer, AIDS, congenital anomalies and other advanced illnesses; provided however, no requirement regarding life expectancy shall be imposed; and
(b) a requirement that the eligible child not be covered by a third-party payer for the services provided by said program.
Services provided by the program shall be determined by the department and shall include, but not be limited to, consultations for pain and symptom management, case management and assessment, social services, counseling, bereavement services, volunteer support services, and respite services, provided by professional or volunteer staff under professional supervision. Services shall be provided by hospice programs licensed under section 57D who meet such other criteria as the department may establish by regulation, including demonstrated expertise in pediatric palliative care. The department may by regulation establish limits on services provided by said program. The program established by this section shall not give rise to enforceable legal rights in any party or an enforceable entitlement to the services described in this section and nothing stated in this section shall be construed as giving rise to such enforceable legal rights or such enforceable entitlement.
SECTION 12. The General Laws are hereby amended by inserting after chapter 111L the following chapter:—
CHAPTER 111M.
INDIVIDUAL HEALTH COVERAGE
Section 1. As used in this chapter, the following words shall, unless the context clearly requires otherwise, have the following meanings:—
“Creditable coverage”, coverage of an individual under any of the following health plans or as a named beneficiary receiving coverage on another’s plan with no lapse of coverage for more than 63 days: (a) an individual or group health plan which meets the definition of “minimum creditable coverage” as established by the board of the connector; (b) a health plan, including, but not limited to, a health plan issued, renewed or delivered within or without the commonwealth to an individual who is enrolled in a qualifying student health insurance program under section 18 of chapter 15A or a qualifying student health program of another state; (c) Part A or Part B of Title XVIII of the Social Security Act; (d) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928; (e) 10 U.S.C. 55; (f) a medical care program of the Indian Health Service or of a tribal organization; (g) a state health benefits risk pool; (h) a health plan offered under 5 U.S.C. 89; (i) a public health plan as defined in federal regulations authorized by the Public Health Service Act, section 2701(c)(1)(I), as amended by Public Law 104-191; (j) a health benefit plan under the Peace Corps Act, 22 U.S.C. 2504(e); (k) coverage for young adults under section 10 of chapter 176J; (l) any other qualifying coverage required by the Health Insurance Portability and Accountability Act of 1996, as amended, or by regulations promulgated under that act, provided that no plan issued as a supplemental health insurance policy, including but not limited to, accident only, credit only, limited scope vision or dental benefits if offered separately; hospital indemnity insurance policies if offered as independent, non-coordinated benefits which for the purposes of this chapter shall mean policies issued under chapter 175 which provide a benefit not to exceed $500 per day, as adjusted on an annual basis by the amount of increase in the average weekly wages in the commonwealth as defined in section 1 of chapter 152, to be paid to an insured or a dependent, including the spouse of an insured, on the basis of a hospitalization of the insured or a dependent; disability income insurance; coverage issued as a supplement to liability insurance; specified disease insurance that is purchased as a supplement and not as a substitute for a health plan and meets any requirements the commissioner by regulation may set; insurance arising out of a workers compensation law or similar law; automobile medical payment insurance; insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in a liability insurance policy or equivalent self insurance; long-term care if offered separately; coverage supplemental to the coverage provided under 10 U.S.C. 55 if offered as a separate insurance policy; or any policy subject to chapter 176K or any similar policies issued on a group basis, Medicare Advantage plans or Medicare Prescription drug plans shall qualify as creditable coverage.
“Resident”, a person who has:—
(1) obtained an exemption under clause Seventeenth, Seventeenth C, Seventeenth C ½, Seventeenth D, Eighteenth, Twenty-second, Twenty-second A, Twenty-second B, Twenty-second C, Twenty-second D, Twenty-second E, Thirty- seventh, Thirty-seventh A, Forty-first, Forty-first A, Forty-first B, Forty- first C, Forty-second or Forty-third of section 5 of chapter 59;
(2) obtained an exemption under section 5C of said chapter 59;
(3) filed a Massachusetts resident income tax return under chapter 62;
(4) obtained a rental deduction under subparagraph (9) of paragraph (a) of Part B of section 3 of chapter 62;
(5) declared in a home mortgage settlement document that the mortgaged property located in the commonwealth would be occupied as his principal residence;
(6) obtained homeowner's liability insurance coverage on property that was declared to be occupied as a principal residence;
(7) filed a certificate of residency and identified his place of residence in a city or town in the commonwealth in order to comply with a residency ordinance as a prerequisite for employment with a governmental entity;
(8) paid on his own behalf or on behalf of a child or dependent of whom the person has custody, resident in-state tuition rates to attend a state-sponsored college, community college or university;
(9) applied for and received public assistance from the commonwealth for himself or his child or dependent of whom he has custody;
(10) has a child or dependent, of whom he has custody, who is enrolled in a public school in a city or town in the commonwealth, unless the cost of such education is paid for by him, such child or dependent, or by another education jurisdiction;
(11) is registered to vote in the commonwealth;
(12) obtained any benefit, exemption, deduction, entitlement, license, permit or privilege by claiming principal residence in the commonwealth; or
(13) is a resident under any other written criteria under which the commissioner of revenue may determine residency in the commonwealth.
Section 2. (a) As of July 1, 2007, the following individuals age 18 and over shall obtain and maintain creditable coverage so long as it is deemed affordable under the schedule set by the board of the connector, established by chapter 176Q: (1) residents of the commonwealth; or (2) individuals who become residents of the commonwealth within 63 days, in the aggregate. Residents who within 63 days have terminated any prior creditable coverage, shall obtain and maintain creditable coverage within 63 days of such termination.
(b) Every person who files an individual return as a resident of the commonwealth, either separately or jointly with a spouse, shall indicate on the return, in a manner prescribed by the commissioner of revenue, whether such person, as of the last day of the taxable year for which the return is filed, (i) had creditable coverage in force as required under paragraph (a) whether covered as an individual or as a named beneficiary of a policy covering multiple individuals, (ii) claims an exemption under section 3, or (iii) had a certificate issued under section 3 of chapter 176Q. If the person does not so indicate, or indicates that he did not have such coverage in force, then the tax shall be computed on the return without benefit of the personal exemption set forth in paragraph (b) of Part B of section 3 of chapter 62, or, in the case of a person who files jointly with a spouse, without benefit of one-half of the personal exemption set forth in such paragraph. If the person indicates that he had such coverage in force but the commissioner determines, based on the information available to him, that such requirement of paragraph (a) was not met, then the commissioner shall compute the tax for the taxable year without benefit of the personal exemption set forth in paragraph (b) of Part B of section 3 of chapter 62, or, in the case of a person who files jointly with a spouse, without benefit of one-half of the personal exemption set forth in such paragraph, first giving notice to such person of his intent to do so and an opportunity for a hearing, under rules prescribed by the commissioner. The commonwealth shall have all enforcement and collection procedures available under chapter 62C to collect any penalties assessed under this section.
(c) The commissioner shall deposit all penalties collected into the Commonwealth Care Trust Fund, established by section 2OOO of chapter 29.
Section 3. An individual shall be exempt from section 2 if he files a sworn affidavit with his income tax return stating that he did not have creditable coverage and that his sincerely held religious beliefs are the basis of his refusal to obtain and maintain creditable coverage during the 12 months of the taxable year for which the return was filed. Any individual who claimed an exemption but received medical health care during the taxable year for which the return is filed shall be liable for providing or arranging for full payment for the medical health care and be subject to the penalties in subsection (b) of section 2.
Section 4. An individual subject to section 2, who disputes the determination of applicability or affordability, as enforced by the department of revenue, may seek a review of this determination through an appeal established by the board of the commonwealth health insurance connector, under chapter 176Q; provided, however, that no additional penalties shall be enforced against an individual seeking review until the review is complete and any subsequent appeals are exhausted.
Section 5. The commissioner of revenue, in consultation with the board of the commonwealth health insurance connector, established by chapter 176Q, shall promulgate such rules and regulations, as necessary, to carry out this chapter.
SECTION 13. Section 2 of said chapter 111M, inserted by section 12 of this act, is hereby amended by striking out subsection (b) and inserting in place thereof the following subsection:—
(b) Every person who files an individual income tax return as a resident of the commonwealth, either separately or jointly with a spouse, shall indicate on the return, in a manner prescribed by the commissioner of revenue, whether such person (i) had creditable coverage in force for each of the 12 months of the taxable year for which the return is filed as required under paragraph (a) whether covered as an individual or as a named beneficiary of a policy covering multiple individuals, (ii) claims an exemption under section 3, or (iii) had a certificate issued under section 3 of chapter 176Q. If the person fails to indicate or indicates that he did not have such coverage in force, then a penalty shall be assessed on the return. If the person indicates that he had such coverage in force but the commissioner determines, based on the information available to him, that such requirement of paragraph (a) was not met, then the commissioner shall assess the penalty. If in any taxable year, in whole or in part, a taxpayer does not comply with the requirement of paragraph (a), the commissioner shall retain any amount overpaid by the taxpayer for purposes of making payments described in paragraph (c); provided, however, that the amount retained shall not exceed 50 per cent of the minimum insurance premium for creditable coverage for which the individual would have qualified during the previous year. The penalty shall be assessed for each of the months the individual did not meet the requirement of paragraph (a); provided, that any lapse in coverage of 63 days or less shall not be counted in calculating the penalty; and, provided further, that nothing in this paragraph shall be considered to authorize the commissioner to retain any amount for such purposes that otherwise would be paid to a claimant agency or agencies as debts described in clauses (i) to (vii), inclusive, of section 13 of chapter 62D. If the amount retained is insufficient to meet the penalty assessed, the commissioner shall notify the taxpayer of the balance due on the penalty and related interest. The commonwealth shall have all enforcement and collection procedures available under chapter 62C to collect any penalties assessed under this section.
SECTION 14. Section 6 of chapter 118E of the General Laws, as appearing in the 2004 Official Edition, is hereby amended by adding the following paragraph:—
The office of Medicaid shall make a report to the committee on health care financing and to house and senate committees on ways and means no later than October 1 of each year on the previous state fiscal year’s activities of the medical care advisory committee. The report shall include, but not be limited to, the names and titles of committee members, dates of committee meetings, agendas and minutes or notes from such meetings, and any correspondence, memorandum, recommendations or other product of the committee’s work.
SECTION 15. Subsection (2) of section 9A of said chapter 118E of the General Laws, as so appearing, is hereby amended by striking out clause (c) and inserting in place thereof the following clause:—
(c) children and adolescents, from birth to 18 years, inclusive, whose financial eligibility as determined by the division exceeds 133 per cent but is not more than 300 per cent of the federal poverty level, including such children and adolescents made eligible for medical benefits under this chapter by Title XXI of the Social Security Act.
SECTION 16. Said section 9A of said chapter 118E, as so appearing, is hereby further amended by inserting after the word “eligibility”, in line 112, the following words:— ; provided, however, that the division shall not establish disability criteria for applicants or recipients which are more restrictive than the criteria authorized by Title XVI of the Social Security Act, 42 U.S.C. 1381 et seq.
SECTION 17. Said section 9A of said chapter 118E, as so appearing, is hereby further amended by striking out, in line 115, the figure “133” and inserting in place thereof the following figure:— 200.
SECTION 18. Said section 9A of said chapter 118E, as so appearing, is hereby further amended by adding the following subsection:—
(15) The office of Medicaid shall report monthly to the health care access bureau, established by section 7A of chapter 26, a listing of all individuals for whom creditable coverage is provided as of the first day of the month.
SECTION 19. Section 9C of said chapter 118E is hereby amended by striking out the definition “Eligible employee” and inserting in place thereof the following definition:—
“Eligible employee”, an employee: (i) who is employed by an eligible employer; (ii) who resides in the commonwealth; (iii) who has not attained age 65; (iv) whose employer or family member’s employer has not in the last 6 months provided insurance coverage for which the individual is eligible; and (v) who meets the financial and other eligibility standards set forth in regulations promulgated by the division, if the gross family income standard does not exceed 300 per cent of the federal poverty level; provided further that clause (iv) shall not apply to employees participating in the program established under this chapter as of June 30, 2006.
SECTION 20. Section 9C of said chapter 118E, as so appearing, is hereby amended by inserting after the word “employees”, in line 56, the following words:— ; and, provided further, that the amount of the subsidy shall not be greater than that of the subsidy the employee would have received if enrolled in the subsidized insurance program under chapter 118H.
SECTION 21. Subsection (2) of said section 9C of said chapter 118E, as so appearing, is hereby amended by striking out paragraph (B) and inserting in place thereof the following paragraph:—
(B) a subsidy program to assist the self-employed single individual and the self-employed husband and wife with reducing the cost of premiums or other costs of purchasing qualified medical insurance; provided, however, that the amount of said subsidies may vary with the income or insurance costs of said persons and their families under 1 or more sliding fee schedules set forth in regulations promulgated by the division and may be paid directly to or on behalf of said persons; and provided further, that the amount of the subsidy shall not be greater than that of the subsidy the employee would have received if enrolled in the subsidized insurance program under chapter 118H.
SECTION 22. Paragraph (C) of said subsection (2) of said section 9C of said chapter 118E, as so appearing, is hereby amended by adding the following sentence:— No payments authorized under this paragraph shall be made to a self-employed individual or a self-employed husband and wife.
SECTION 23. Said section 9C of said chapter 118E, as so appearing, is hereby further amended by striking out subsection (5).
SECTION 24. The fourth paragraph of section 12 of said chapter 118E, as so appearing, is hereby amended by adding the following sentence:— Rules and regulations which restrict eligibility or covered services require a public hearing under section 2 of chapter 30A.
SECTION 25. Said chapter 118E is hereby further amended by inserting after section 13A the following section:—
Section 13B. Hospital rate increases shall be made contingent upon hospital adherence to quality standards and achievement of performance benchmarks, including the reduction of racial and ethnic disparities in the provision of health care. Such benchmarks shall be developed or adopted by the executive office of health and human services so as to advance a common national framework for quality measurement and reporting, drawing on measures that are approved by the National Quality Forum and adopted by the Hospitals Quality Alliance and other national groups concerned with quality, in addition to the Boston Public Health Commission Disparities Project Hospital Working Group Report Guidelines. The office of Medicaid shall consult with the Massachusetts health care quality and cost council, established under section 16K of chapter 6A and the MassHealth payment policy advisory board established under section 16M of said chapter 6A, during the process of developing these quality standards and performance benchmarks.
SECTION 26. 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.
(7) Notwithstanding subsection (3), a person who is not a citizen of the United States but who is either a qualified alien within the meaning of section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 or is otherwise permanently residing in the United States under color of law shall be eligible to receive benefits under MassHealth Essential if such individual meets the categorical and financial eligibility requirements under MassHealth; provided further that such individual is either age 65 or older, or between age 19 and 64, inclusive, and disabled. Such individual shall not be subject to sponsor income deeming or related restrictions.
SECTION 28. The seventh paragraph of section 23 of said chapter 118E, as so appearing, is hereby amended by striking out clause (2) and inserting in place thereof the following clause:—
(2) persons for whom hospitals and community health centers claim reimbursement payments from the Health Safety Net Fund, established by section 57 of chapter 118E.
Section 53. The division shall include within its covered services for adults all federally optional services that were included in its state plan or demonstration program in effect on January 1, 2002. Covered services for adults in the MassHealth Essential program shall include dental services to the same extent as such services were covered for adults in the MassHealth Basic program as of January 1, 2002.
Section 54. The executive office of health and human services shall implement, in cooperation with the department of public health, a wellness program for MassHealth enrollees to encourage activities that lead to desired health outcomes, including smoking cessation, diabetes screening for early detection, teen pregnancy prevention, cancer screening for early detection and stroke education for enrolled individuals. To the extent enrollees comply with the goals of the wellness program, the executive office shall reduce MassHealth premiums and/or copayments proportionally. The executive office shall report annually on the number of enrollees who meet at least 1 wellness goal, the premiums collected from the enrollees, and the reduction of premiums due to enrollees meeting wellness goals to the joint committee on health care financing and the house and senate committees on ways and means.
SECTION 30. Said chapter 118E is hereby further amended by adding the following 6 sections:—
Section 55. As used in this section and sections 56 to 60, inclusive, the following words shall, unless the context clearly requires otherwise, have the following meanings:—
"Acute hospital", the teaching hospital of the University of Massachusetts Medical School and any hospital licensed under section 51 of chapter 111 and which contains a majority of medical-surgical, pediatric, obstetric and maternity beds, as defined by the department of public health.
"Allowable reimbursement", payment to acute hospitals and community health centers for health services provided to uninsured patients of the commonwealth under section 60 and any further regulations promulgated by the office.
“Ambulatory surgical center”, a distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and meets the requirements of the federal Health Care Financing Administration for participation in the Medicare program.
“Ambulatory surgical center services”, services described for purposes of the Medicare program under 42 U.S.C. 1395k(a)(2)(F)(I). These services include facility services only and do not include surgical procedures.
“Bad debt”, an account receivable based on services furnished to a patient which: (i) is regarded as uncollectible, following reasonable collection efforts consistent with regulations of the office, which regulations shall allow third party payers to negotiate with hospitals to collect the bad debts of its enrollees; (ii) is charged as a credit loss; (iii) is not the obligation of a governmental unit or the federal government or any agency thereof; and (iv) is not a reimbursable health care service.
“Community health center”, a health center operating in conformance with the requirements of Section 330 of United States Public Law 95-626, including all community health centers which file cost reports as requested by the division of health care finance and policy.
“Critical access services”, those health services which are generally provided only by acute hospitals, as further defined in regulations promulgated by the division.
“Director”, the director of the health safety net office.
“DRG”, a patient classification scheme known as diagnosis related grouping, which provides a means of relating the type of patients a hospital treats, such as its case mix, to the cost incurred by the hospital.
“Emergency bad debt”, bad debt resulting from emergency services provided by an acute hospital to an uninsured or underinsured patient or other individual who has an emergency medical condition that is regarded as uncollectible, following reasonable collection efforts consistent with regulations of the office.
“Emergency medical condition”, a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the health of the person or another person in serious jeopardy, serious impairment to body function or serious dysfunction of any body organ or part or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. 1295dd(e)(1)(B).
“Emergency services”, medically necessary health care services provided to an individual with an emergency medical condition.
“Financial requirements”, a hospital’s requirement for revenue which shall include, but not be limited to, reasonable operating, capital and working capital costs, and the reasonable costs associated with changes in medical practice and technology.
“Fund”, the Health Safety Net Trust Fund, established by section 57 of chapter 118E.
“Fund fiscal year”, the 12-month period starting in October and ending in September.
“Gross patient service revenue”, the total dollar amount of a hospital’s charges for services rendered in a fiscal year.
“Health services”, medically necessary inpatient and outpatient services as mandated under Title XIX of the Federal Social Security Act. Health services shall not include: (1) nonmedical services, such as social, educational and vocational services; (2) cosmetic surgery; (3) canceled or missed appointments; (4) telephone conversations and consultations; (5) court testimony; (6) research or the provision of experimental or unproven procedures including, but not limited to, treatment related to sex-reassignment surgery and pre-surgery hormone therapy; and (7) the provision of whole blood, but the administrative and processing costs associated with the provision of blood and its derivatives shall be payable.
“Office”, the health safety net office, established by section 56.
“Payments subject to surcharge”, all amounts paid, directly or indirectly, by surcharge payors to acute hospitals for health services and ambulatory surgical centers for ambulatory surgical center services; provided, however, that “payments subject to surcharge” shall not include: (i) payments, settlements and judgments arising out of third party liability claims for bodily injury which are paid under the terms of property or casualty insurance policies; (ii) payments made on behalf of Medicaid recipients, Medicare beneficiaries or persons enrolled in policies issued under chapter 176K or similar policies issued on a group basis; and provided further, that “payments subject to surcharge” may exclude amounts established by regulations promulgated by the division for which the costs and efficiency of billing a surcharge payor or enforcing collection of the surcharge from a surcharge payor would not be cost effective.
“Pediatric hospital”, an acute care hospital which limits services primarily to children and which qualifies as exempt from the Medicare Prospective Payment system regulations.
“Pediatric specialty unit”, a pediatric unit of an acute care hospital in which the ratio of licensed pediatric beds to total licensed hospital beds as of July 1, 1994 exceeded 0.20. In calculating that ratio, licensed pediatric beds shall include the total of all pediatric service beds, and the total of all licensed hospital beds shall include the total of all licensed acute care hospital beds, consistent with Medicare’s acute care hospital reimbursement methodology as put forth in the Provider Reimbursement Manual Part 1, Section 2405.3G.
“Private sector charges”, gross patient service revenue attributable to all patients less gross patient service revenue attributable to Titles XVIII and XIX, other public-aided patients, reimbursable health services and bad debt.
“Reimbursable health services”, health services provided to uninsured and underinsured patients who are determined to be financially unable to pay for their care, in whole or part, under applicable regulations of the office; provided that the health services are emergency, urgent and critical access services provided by acute hospitals or services provided by community health centers; and provided further, that such services shall not be eligible for reimbursement by any other public or private third-party payer.
“Resident”, a person living in the commonwealth, as defined by the office by regulation; provided, however, that such regulation shall not define as a resident a person who moved into the commonwealth for the sole purpose of securing health insurance under this chapter. Confinement of a person in a nursing home, hospital or other medical institution shall not in and of itself, suffice to qualify such person as a resident.
“Surcharge payor”, an individual or entity that pays for or arranges for the purchase of health care services provided by acute hospitals and ambulatory surgical center services provided by ambulatory surgical centers, as defined in this section; provided, however, that the term “surcharge payor” shall not include Title XVIII and Title XIX programs and their beneficiaries or recipients, other governmental programs of public assistance and their beneficiaries or recipients and the workers’ compensation program established by chapter 152.
“Underinsured patient”, a patient whose health insurance plan or self-insurance health plan does not pay, in whole or in part, for health services that are eligible for reimbursement from the health safety net trust fund, provided that such patient meets income eligibility standards set by the office.
“Uninsured patient”, a patient who is a resident of the commonwealth, who is not covered by a health insurance plan or a self-insurance health plan and who is not eligible for a medical assistance program.
Section 56. (a) There is hereby established a health safety net office within the office of Medicaid. The director of Medicaid shall, in consultation with the secretary of health and human services, appoint the director of the health safety net office. The director shall have such educational qualifications and administrative and other experience as the commissioner and secretary determine to be necessary for the performance of the duties of director including, but not limited to, experience in the field of health care financial administration.
(b) The office shall have the following powers and duties:—
(1) to administer the Health Safety Net Trust Fund, established by section 57 of chapter 118E, and to require payments to the fund consistent with acute hospitals' and surcharge payors’ liability to the fund, as determined under sections 58 and 59, and any further regulations promulgated by the office;
(2) to set, after consultation with the division of health care finance and policy established by section 2 of chapter 118G, reimbursement rates for payments from the fund to acute hospitals and community health centers for reimbursable health services provided to uninsured and underinsured patients and to disburse monies from the fund consistent with such rates; provided that the office shall implement a fee-for-service reimbursement system for acute hospitals;
(3) to promulgate regulations further defining: (a) eligibility criteria for reimbursable health services; (b) the scope of health services that are eligible for reimbursement by the Health Safety Net Trust Fund; (c) standards for medical hardship; and (d) standards for reasonable efforts to collect payments for the costs of emergency care. The office shall implement procedures for verification of eligibility using the eligibility system of the office of Medicaid and other appropriate sources to determine the eligibility of uninsured and underinsured patients for reimbursable health services and shall establish other procedures to ensure that payments from the fund are made for health services for which there is no other public or private third party payer, including disallowance of payments to acute hospitals and community health centers for free care provided to individuals if reimbursement is available from other public or private sources; and
(4) to develop programs and guidelines to encourage maximum enrollment of uninsured individuals who receive health services reimbursed by the fund into health care plans and programs of health insurance offered by public and private sources and to promote the delivery of care in the most appropriate setting, provided that the programs and guidelines are developed in consultation with the commonwealth health insurance connector, established by chapter 176Q. Such programs shall not deny payments from the fund because services should have been provided in a more appropriate setting if the hospital was required to provided such services under 42 U.S.C. 1395 (dd);
(5) to conduct a utilization review program designed to monitor the appropriateness of services for which payments were made by the fund and to promote the delivery of care in the most appropriate setting; and to administer demonstration programs that reduce health safety net trust fund liability to acute hospitals, including a demonstration program to enable disease management for patients with chronic diseases, substance abuse and psychiatric disorders through enrollment of patients in community health centers and community mental health centers and through coordination between these centers and acute hospitals, provided, that the office shall report the results of such reviews annually to the joint committee on health care financing and the house and senate committees on ways and means;
(6) to administer the Essential Community Provider Trust Fund, established by section 2PPP of chapter 29, and to make expenditures from that fund without further appropriation for the purpose of improving and enhancing the ability of acute hospitals and community health centers to serve populations in need more efficiently and effectively, including, but not limited to, the ability to provide community-based care, clinical support, care coordination services, disease management services, primary care services, and pharmacy management services through a grant program. The office shall consider applications from acute hospitals and community health centers in awarding the grants. The criteria for selection shall include, but not be limited to, the following criteria:—
(i) the financial performance of the provider as determined, in the case of applications from acute hospitals, quarterly by the division of health care finance and policy and by consulting other appropriate measurements of financial performance;
(ii) the percentage of patients with mental or substance abuse disorders served by a provider;
(iii) the numbers of patients served by a provider who are chronically ill, elderly, or disabled;
(iv) the payer mix of the provider, with preference given to acute hospitals where a minimum of 63 per cent of the acute hospital’s gross patient service revenue is attributable to Title XVIII and Title XIX of the federal Social Security Act or other governmental payors, including reimbursements from the Health Safety Net Fund;
(v) the percentage of total annual operating revenue that funding received in fiscal years 2005 and 2006 from the Distressed Provider Expendable Trust Fund comprised for the provider; and
(vi) the cultural and linguistic challenges presented by the populations served by the provider.
(7) to enter into agreements or transactions with any federal, state or municipal agency or other public institution or with a private individual, partnership, firm, corporation, association or other entity, and to make contracts and execute all instruments necessary or convenient for the carrying on of its business;
(8) to secure payment, without imposing undue hardship upon any individual, for unpaid bills owed to acute hospitals by individuals for health services that are ineligible for reimbursement from the Health Safety Net Trust Fund which have been accounted for as bad debt by the hospital and which are voluntarily referred by a hospital to the department for collection; provided, however that such unpaid charges shall be considered debts owed to the commonwealth and all payments received shall be credited to the fund; and provided, further, that all actions to secure such payments shall be conducted in compliance with a protocol previously submitted by the office to the joint committee on health care financing;
(9) to require hospitals and community health centers to submit to the office such data as it reasonably deems necessary; and
(10) to make, amend and repeal rules and regulations to effectuate the efficient use of monies from the Health Safety Net Trust Fund; provided, however, that the regulations shall be adopted only after notice and hearing and only upon consultation with the board of the commonwealth health insurance connector, the secretary of health and human services, the director of the office of Medicaid and representatives of the Massachusetts Hospital Association, the Massachusetts Council of Community Hospitals, the Alliance of Massachusetts Safety Net Hospitals and the Massachusetts League of Community Health Centers.
(11) to provide an annual report at the close of each fund fiscal year, in consultation with the office of Medicaid, to the joint committee on health care financing and the house and senate committees on ways and means, evaluating the processes used to determine eligibility for reimbursable health services, including the Virtual Gateway, so-called. The report shall include (i) an analysis of the effectiveness of these processes in enforcing eligibility requirements for publicly funded health programs and in enrolling uninsured residents into programs of health insurance offered by public and private sources; (ii) an assessment of the impact of these processes on the level of reimbursable health services by providers; and (iii) recommendations for ongoing improvements that will enhance the performance of eligibility determination systems and reduce hospital administrative costs.
Section 57. (a) There is hereby established a Health Safety Net Trust Fund, in this section and sections 58 to 60, inclusive, called the fund, which shall be administered by the health safety net office. Expenditures from the fund shall not be subject to appropriation unless otherwise required by law. The purpose of the fund shall be to maintain a health care safety net by reimbursing hospitals and community health centers for a portion of the cost of reimbursable health services provided to low-income, uninsured or underinsured residents of the commonwealth. The office shall administer the fund using such methods, policies, procedures, standards and criteria that it deems necessary for the proper and efficient operation of the fund and programs funded thereby in a manner designed to distribute the fund resources as equitably as possible.
(b) The fund shall consist of all amounts paid by acute hospitals and surcharge payors under sections 58 and 59; all appropriations for the purpose of payments to acute hospitals or community health centers for health services provided to uninsured and underinsured residents; any transfers from the Commonwealth Care Trust Fund, established by section 2OOO of chapter 29; and all property and securities acquired by and through the use of monies belonging to the fund and all interest thereon. Amounts placed in the fund shall, except for amounts transferred to the Commonwealth Care Trust Fund, be expended by the office for payments to hospitals and community health centers for reimbursable health services provided to uninsured and underinsured residents of the commonwealth, consistent with the requirements of this section and section 60 and the regulations promulgated by the office; provided, that $6,000,000 shall be expended annually from the fund for demonstration projects that use case management and other methods to reduce the liability of the fund to acute hospitals. Any annual balance remaining in the fund after such payments have been made shall be transferred to the Commonwealth Care Trust Fund. All interest earned on the amounts in the fund shall be deposited or retained in the fund. The director shall from time to time requisition from the fund such amounts as he deems necessary to meet the current obligations of the office for the purposes of the fund and estimated obligations for a reasonable future period.
Section 58. (a) An acute hospital's liability to the fund shall equal the product of (1) the ratio of its private sector charges to all acute hospitals’ private sector charges; and (2) $160,000,000. Before October 1 of each year, the office, in consultation with the division of health care finance and policy, shall establish each acute hospital's liability to the fund using the best data available, as determined by the division, and shall update each acute hospital's liability to the fund as updated information becomes available. The office shall specify by regulation an appropriate mechanism for interim determination and payment of an acute hospital's liability to the fund.
(b) An acute hospital's liability to the fund shall in the case of a transfer of ownership be assumed by the successor in interest to the acute hospital.
(c) The office shall establish by regulation an appropriate mechanism for enforcing an acute hospital's liability to the fund in the event that an acute hospital does not make a scheduled payment to the fund. These enforcement mechanisms may include (1) notification to the office of Medicaid requiring an offset of payments on the Title XIX claims of any such acute hospital or any health care provider under common ownership with the acute care hospital or any successor in interest to the acute hospital, and (2) the withholding by the office of Medicaid of the amount of payment owed to the fund, including any interest and late fees, and the transfer of the withheld funds into the fund. If the office of Medicaid offsets claims payments as ordered by the office, it shall not be considered to be in breach of contract or any other obligation for the payment of noncontracted services, and providers whose payment is offset under order of the division shall serve all Title XIX recipients under the contract then in effect with the office of Medicaid, or, in the case of a noncontracting or disproportionate share hospital, under its obligation for providing services to Title XIX recipients under this chapter. In no event shall the office direct the office of Medicaid to offset claims unless an acute hospital has maintained an outstanding obligation to the health safety net fund for a period longer than 45 days and has received proper notice that the division intends to initiate enforcement actions under the regulations of the office.
Section 59. (a) Acute hospitals and ambulatory surgical centers shall assess a surcharge on all payments subject to surcharge as defined in section 1. The surcharge shall be distinct from any other amount paid by a surcharge payor for the services of an acute hospital or ambulatory surgical center. The surcharge amount shall equal the product of (i) the surcharge percentage and (ii) amounts paid for these services by a surcharge payor. The office shall calculate the surcharge percentage by dividing $160,000,000 by the projected annual aggregate payments subject to the surcharge. The office shall determine the surcharge percentage before the start of each fund fiscal year and may redetermine the surcharge percentage before April 1 of each fund fiscal year if the office projects that the initial surcharge established the previous October will produce less than $150,000,000 or more than $170,000,000. Before each succeeding October 1, the office shall redetermine the surcharge percentage incorporating any adjustments from earlier years. In each determination or redetermination of the surcharge percentage, the office shall use the best data available as determined by the division and may consider the effect on projected surcharge payments of any modified or waived enforcement under subsection (e). The office shall incorporate all adjustments, including, but not limited to, updates or corrections or final settlement amounts, by prospective adjustment rather than by retrospective payments or assessments.
(b) Each acute hospital and ambulatory surgical center shall bill a surcharge payor an amount equal to the surcharge described in subsection (a) as a separate and identifiable amount distinct from any amount paid by a surcharge payor for acute hospital or ambulatory surgical center services. Each surcharge payor shall pay the surcharge amount to the office for deposit in the Health Safety Net Trust Fund on behalf of said acute hospital or ambulatory surgical center. Upon the written request of a surcharge payor, the office may implement another billing or collection method for the surcharge payor; provided, however, that the office has received all information that it requests which is necessary to implement such billing or collection method; and provided further, that the office shall specify by regulation the criteria for reviewing and approving such requests and the elements of such alternative method or methods.
(c) The office shall specify by regulation appropriate mechanisms that provide for determination and payment of a surcharge payor’s liability, including requirements for data to be submitted by surcharge payors, acute hospitals and ambulatory surgical centers.
(d) A surcharge payor’s liability to said Health Safety Net Trust Fund shall in the case of a transfer of ownership be assumed by the successor in interest to the surcharge payor.
(e) The office shall establish by regulation an appropriate mechanism for enforcing a surcharge payor’s liability to said Health Safety Net Trust Fund in the event that a surcharge payor does not make a scheduled payment to said Health Safety Net Trust Fund; provided, however, that the office may, for the purpose of administrative simplicity, establish threshold liability amounts below which enforcement may be modified or waived. Such enforcement mechanism may include assessment of interest on the unpaid liability at a rate not to exceed an annual percentage rate of 18 per cent and late fees or penalties at a rate not to exceed 5 per cent per month. Such enforcement mechanism may also include notification to the division of medical assistance requiring an offset of payments on the claims of the surcharge payor, any entity under common ownership or any successor in interest to the surcharge payor, from the division of medical assistance in the amount of payment owed to the Health Safety Net Trust Fund including any interest and penalties, and to transfer the withheld funds into said fund. If the division of medical assistance offsets claims payments as ordered by the office, said division of medical assistance shall be deemed not to be in breach of contract or any other obligation for payment of noncontracted services, and a surcharge payor whose payment is offset under order of the division shall serve all Title XIX recipients under the contract then in effect with the division of medical assistance. In no event shall the office direct the division of medical assistance to offset claims unless the surcharge payor has maintained an outstanding liability to the Health Safety Net Trust Fund for a period longer than 45 days and has received proper notice that said office intends to initiate enforcement actions under the regulations of the office.
(f) If a surcharge payor fails to file any data, statistics or schedules or other information required under this chapter or by any regulation promulgated by the office, the office shall provide written notice to the payor. If a surcharge payor fails to provide required information within 2 weeks after the receipt of written notice, or falsifies the same, he shall be subject to a civil penalty of not more than $5,000 for each day on which 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. The attorney general shall bring any appropriate action, including injunctive relief, as may be necessary for the enforcement of this chapter.
Section 60. (a) Reimbursements from the fund to hospitals and community health centers for health services provided to uninsured individuals shall be made in the following manner, and shall be subject to further rules and regulations promulgated by the office.
(1) Reimbursements made to acute hospitals shall be based on actual claims for health services provided to uninsured and underinsured patients that are submitted to the office, and shall be made only after determination that the claim is eligible for reimbursement under this chapter and any additional regulations promulgated by the office. Reimbursements for health services provided to residents of other states and foreign countries shall be prohibited, and the office shall make payments to acute hospitals using fee-for-service rates calculated as provided in paragraphs (4) and (5).
(2) The office shall, in consultation with the office of Medicaid, develop and implement procedures to verify the eligibility of individuals for whom health services are billed to the fund and to ensure that other coverage options are used fully before services are billed to the fund, including procedures adopted under section 35. The office shall review all claims billed to the fund to determine whether the patient is eligible for medical assistance under this chapter and whether any third party is financially responsible for the costs of care provided to the patient. In making these determinations, the office shall verify the insurance status of each individual for whom a claim is made using all sources of data available to the office. The office shall refuse to allow payments or shall disallow payments to acute hospitals and community health centers for free care provided to individuals if reimbursement is available from other public or private sources, provided that payments shall not be denied from the fund because services should have been provided in a more appropriate setting if the hospital was required to provide these services under 42 U.S.C. 1395(dd).
(3) The office shall require acute hospitals and community health centers to screen each applicant for reimbursed care for other sources of coverage and for potential eligibility for government programs, and to document the results of that screening. If an acute hospital or community health center determines that an applicant is potentially eligible for Medicaid or for the commonwealth care health insurance program, established by chapter 118H, or another assistance program, the acute hospital or community health center shall assist the applicant in applying for benefits under that program. The office shall audit the accounts of acute hospitals and community health centers to determine compliance with this section and shall deny payments from the fund for any acute hospital or community health center that fails to document compliance with this section.
(4) The office shall reimburse acute hospitals for health services provided to individuals based on the payment systems in effect for acute hospitals used by the United States Department of Health and Human Services Centers for Medicare & Medicaid Services to administer the Medicare Program under Title XVIII of the Social Security Act, including all of Medicare’s adjustments for direct and indirect graduate medical education, disproportionate share, outliers, organ acquisition, bad debt, new technology and capital and the full amount of the annual increase in the Medicare hospital market basket index. The division shall, in consultation with the division of health care finance and policy and the Massachusetts Hospital Association, promulgate regulations necessary to modify these payment systems to account for:—
(i) the differences between the program administered by the office and the Title XVIII Medicare program, including the services and benefits covered;
(ii) grouper and DRG relative weights for purposes of calculating the payment rates to reimburse acute hospitals at rates no less than the rates they are reimbursed by Medicare;
(iii) the extent and duration of covered services;
(iv) the populations served;
(v) and any other adjustments to the payment methodology under this section as deemed necessary by the office, based upon circumstances of individual hospitals.
Following implementation of this section, the office shall ensure that the allowable reimbursement rates under this section for health services provided to uninsured individuals shall not thereafter be less than rates of payment for comparable services under the Medicare program, taking into account the adjustments required by this section.
(5) For the purposes of paying community health centers for health services provided to uninsured individuals under this section, the office shall pay community health centers a base rate that shall be no less than the then-current Medicare Federally Qualified Health Center rate as required under 42 U.S.C. 13951 (a)(3), and the office shall add payments for additional services not included in the base rate, including, but not limited to, EPSDT services, 340B pharmacy, urgent care, and emergency room diversion services.
(6) Reimbursements to acute hospitals and community health centers for bad debt shall be made upon submission of evidence, in a form to be determined by the office, that reasonable efforts to collect the debt have been made.
(b) By April 1 of the year preceding the start of the fund fiscal year, the office shall, after consultation with the division of health care finance and policy, and using the best data available, provide an estimate of the projected total reimb