Ensuring access and continuity of care to specialist and hospital services for dually eligible individuals
Summary
This bill would amend Massachusetts General Laws chapter 118E, section 9D, to expand access to specialist and hospital services for “dually eligible” individuals—people who qualify for both Medicare and MassHealth. It would require that these members be allowed to receive care from any specialist or hospital in the Commonwealth that participates in Medicare or MassHealth, even if that provider is outside the member’s health plan network, so long as other plan terms still apply. If there is no existing contract between the plan and the provider, the provider would be paid at the applicable Medicare or MassHealth fee-for-service rate unless the parties agree to a different amount.
Impact
The bill would directly affect MassHealth, One Care plans, and Senior Care Options (SCO) plans by limiting network restrictions for dually eligible members and by setting reimbursement rules for out-of-network specialist and hospital services. It would also require plans to preserve prior contract terms for 12 months after a contract termination, extending continuity of care protections for impacted members and maintaining reimbursement and other terms unless the plan and provider mutually agree otherwise. In practice, the bill would broaden provider access for covered members and constrain how managed care plans can use network changes and contract terminations to limit care.
Sentiment
The available context suggests generally supportive intent, with the bill framed as a patient-access and continuity-of-care measure for some of the Commonwealth’s most vulnerable residents. There is no recorded committee transcript or vote history in the provided material, so no formal opposition or amendment debate is available here. The bill’s language emphasizes access, continuity, and protection against disruption in care, indicating a policy goal that is likely to be viewed favorably by patient advocates and consumer-oriented stakeholders.
Contention
The main potential points of contention are likely to involve cost, network management, and provider contracting. Health plans may object to being required to cover out-of-network specialist and hospital care and to reimburse at fee-for-service rates when no contract exists, while providers may support the access expansion but have differing views on reimbursement levels and contract terms. Another possible issue is the mandated 12-month continuation of pre-existing contract terms after termination, which could be seen as limiting plans’ leverage in negotiations and reducing flexibility to restructure provider networks.
Replaced by
Order relative to authorizing the joint committee on Health Care Financing to make an investigation and study of certain current Senate documents relative to to health care financing matters.