HOUSE DOCKET, NO. 94452 FILED ON: 1/28/2010
HOUSE . . . . . . . . . . . . . . No. 4452
The Commonwealth of Massachusetts
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By Ms. Stanley of West Newbury, for the committee on Healthcare Financing, on Senate, No. 2170 and House, No. 4331, a Bill
relative to an a
fford
able health p
lan
(House, No. 4452). January 28, 2010.
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An Act Relative to an Affordable Health Pl
an.
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FOR THE COMMITTEE:
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Name:
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District/Address:
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Harriett L. Stanley
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2nd Essex
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The Commonwealth of Massachusetts
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In the Year Two Thousand and Ten
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An Act Relative to an Affordable Health Plan.
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. Chapter 176J of the General Laws, as appearing in the 2008 Official Edition, is hereby amended by adding the foll
owing section:-
Section 11. As used in this section, the following words shall have the following meanings:
"Statutory reimbursement rate," with respect to payment to a health care provider for services rendered to any person covered under an "Affordable
Health Plan", 110 percent of the Medicare reimbursement rate for those services as if they were rendered to a Medicare beneficiary not taking into consideration any beneficiary cost sharing. For services or supplies for which there is no Medicare reimbur
sement amount, the amount as determined by the commissioner of the division of health care finance and policy is to be consistent with Medicare payment policies at a 110 percent level and set in consultation with the commissioner of insurance.
“Medical l
oss ratio,” the ratio of claims incurred to premiums earned, expressed as a percentage.
(a) As a condition of doing business in the commonwealth, a carrier that offers health benefit plans to eligible small businesses and eligible individuals, as defined b
y chapter 176J, shall offer an "Affordable Health Plan" to all eligible individuals and small businesses, both within the connector, for such carriers participating in the connector, and for all such carriers outside the connector. This "Affordable Health
Plan" shall contain benefits that are actuarially equivalent to the lowest level benefit plan available to the general public within the connector, other than the young adult plan. Payment for all services, other than outpatient pharmacy benefits, for all
providers under "Affordable Health Plans" shall be consistent with the requirements as included in paragraph (b).
(b) Claims for services shall be adjudicated at the in-network benefit level or, if applicable under the terms of the plan, the out-of-networ
k benefit level based on the participation status of the
provider in the carrier’s network. Every health care provider licensed in the commonwealth which provides covered services to a person covered under "Affordable Health Plans" must provide such servic
e to any such person, as a condition of their licensure, and must accept payment at the lowest of the statutory reimbursement rate, an amount equal to the actuarial equivalent of the statutory reimbursement rate, or the applicable contract rate with the ca
rrier for the carrier’s product offering with the lowest level benefit plan available to the general public within the connector, other than the young adult plan, and may not balance bill such person for any amount in excess of the amount paid by the carri
er pursuant to this section, other than applicable co-payments, co-insurance and deductibles.
(c) Providers shall not attempt to recoup such excess amounts by increasing charges to other health benefit plans or other payers. The division of health care fi
nance and policy shall monitor provider charges to ensure compliance with this section and shall report any non-compliance to the attorney general. The division of health care finance and policy shall promulgate regulations enforcing this subsection, whic
h shall include penalties for noncompliance.
(d) Existing contracts between providers and carriers shall comply with the requirements of this section as to the reimbursement rate and providers shall provide services to individuals under "Affordable Healt
h Plans" under such existing contracts with carriers. A provider that participates in a carrier’s network or any health benefit plan shall not refuse to participate in the carrier’s network with respect to the “Affordable Health Plan”.
(e) Carriers that
offer health benefit plans to eligible small businesses and eligible individuals, as defined by chapter 176J shall maintain an aggregate medical loss ratio for all coverage offered under said chapter 176J that does not exceed 85 percent, and shall limit ag
gregate post-tax underwriting surpluses for all coverage offered under said chapter 176J to 2 percent.
The division of insurance shall promulgate regulations to monitor and ensure compliance with this subsection.
SECTION 2. Section 11 of Chapter 176J is h
ereby repealed.
SECTION 3. Section 2 of this act shall take effect on January 1, 2013.
