An Act ensuring access and continuity of care to specialist and hospital services for dually eligible individuals
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| Committee | Recommendation | Vote |
|---|---|---|
| J24 | Accompanied | — |
| Bill | Title | Status |
|---|---|---|
| H4226 | An Act ensuring access and continuity of care to specialist and hospital services for dually eligible individuals | Active |
of Chapter 118E of the General Laws, as appearing in the 2022 Official Edition, is hereby amended by adding the following new paragraph:- "(r) To ensure access to specialist and hospital care for dually eligible individuals residing in the Commonwealth, any dually eligible individual shall be permitted to receive health care services from any specialist or hospital provider in the commonwealth that participates in and is enrolled in Medicare or MassHealth, irrespective of any health plan or provider network limitation and subject to all others terms and conditions of the member’s benefit plan. In such situations where an existing contractual relationship between the health plan and the hospital or specialist provider does not exist, the provider shall be reimbursed by the One Care or SCO plan at the Medicare or MassHealth fee-for-service amount for the service rendered, as applicable, unless the plan and provider already have a contract agreement in place for the covered service, or mutually agree to a different reimbursement amount for the service. (1) To ensure continued access to primary, specialist, and hospital care for our most vulnerable members MassHealth shall require any One Care or SCO plan and provider that has terminated a contract that includes the provision of health care services to One Care or SCO members, to allow impacted members to continue to receive services from their primary care, specialist provider, or any inpatient or outpatient hospital subject to the termination, under the terms of the pre-existing contract, for twelve months following the expiration of any continuity of care requirements that may follow the contractual termination. During this period, plans shall be required to maintain all contractual terms and conditions that were in effect with the provider prior to the notice of termination being sent by either party, including but not limited to reimbursement, unless mutually agreed upon by the plan and the provider. Plans and providers shall be prohibited from using this provision to avoid using good faith efforts to negotiate contractual arrangements."
Section 9d of Chapter 118E of the General Laws, as appearing in the 2022 Official Edition, is hereby amended by adding the following new paragraph:- "(r) To ensure access to specialist and hospital care for dually eligible individuals residing in the Commonwealth, any dually eligible individual shall be permitted to receive health care services from any specialist or hospital provider in the commonwealth that participates in and is enrolled in Medicare or MassHealth, irrespective of any health plan or provider network limitation and subject to all others terms and conditions of the member’s benefit plan. In such situations where an existing contractual relationship between the health plan and the hospital or specialist provider does not exist, the provider shall be reimbursed by the One Care or SCO plan at the Medicare or MassHealth fee-for-service amount for the service rendered, as applicable, unless the plan and provider already have a contract agreement in place for the covered service, or mutually agree to a different reimbursement amount for the service. (1) To ensure continued access to primary, specialist, and hospital care for our most vulnerable members MassHealth shall require any One Care or SCO plan and provider that has terminated a contract that includes the provision of health care services to One Care or SCO members, to allow impacted members to continue to receive services from their primary care, specialist provider, or any inpatient or outpatient hospital subject to the termination, under the terms of the pre-existing contract, for twelve months following the expiration of any continuity of care requirements that may follow the contractual termination. During this period, plans shall be required to maintain all contractual terms and conditions that were in effect with the provider prior to the notice of termination being sent by either party, including but not limited to reimbursement, unless mutually agreed upon by the plan and the provider. Plans and providers shall be prohibited from using this provision to avoid using good faith efforts to negotiate contractual arrangements."