Chapter 288 Sections

Emergency Preamble to allow law to take effect immediately

Directs the Division of Health Care Finance and Policy (DHCFP) to analyze the impact of existing mandated insurance benefits on public health and overall health care costs and issue a report to the legislature at least once every 4 years. DHCFP must consult with the Department of Public Health and UMass Medical School to ensure that all mandated benefits continue to meet clinical standards of care. DHCFP may file legislation to amend or repeal existing mandates.

Adds 3 seats to the Health Care Quality and Cost Council (QCC), including representatives of small and large business and a licensed clinician. Members of the QCC must vote annually to select a chair and new 4-member executive committee. The QCC is also designated as an independent public entity, not subject to the supervision and control of any other executive office. The QCC will no longer be permitted to meet in Executive Session.

Adds new definition of "wellness program" to the Group Insurance Commission statute.

Requires the Group Insurance Commission to develop a wellness program for enrollees and to offer reductions in premiums or co-payments, or other incentives to encourage enrollees to comply with the wellness program goals. After 1 year of implementation, the GIC must issue a report to the legislature noting collective data, including level of participation and health services participants received and the savings incurred as a result of the program.

Permits a physician or an optometrist to dispense and sell therapeutic contact lenses in-office, as long as dispensing the medication contained in the lenses is within his or her scope of practice.

Requires every health care provider to track and report quality information at least annually according to Department of Public Health regulations.

Authorizes the Office of Patient Protection (OPP) to grant waivers, according to standards and procedures it sets, for people to enroll in a managed care health plan outside of a mandatory open enrollment period. To get a waiver, individuals must certify under the penalty of perjury that they did not intentionally forego enrollment into coverage, and the plan must meet minimum creditable coverage standards. The Office of Patient Protection was created to assist individuals enrolled in a Massachusetts managed care health plan with questions or problems in obtaining covered services. The OPP may also assist individuals in appealing a denial of an insurance claim or access to service. In addition to monitoring quality-related health insurance plan information relating to managed care practices, the OPP must publish on its website the health plan report cards and a chart comparing premium amounts various health insurance companies spend on health care services for consumers.

Establishes a commission on falls prevention to study the effects of falls on older adults and the health care costs associated with such falls. In addition to suggesting strategies for reducing health care costs associated with falls, the commission must recommend effective preventive measures to protect older adults, including the creation of support programs to reach out to the most vulnerable. The commission must submit an annual report to the legislature noting the commission's progress and recommendations.

Authorizes optometrists to use and prescribe certain therapeutic medications, including the in-office dispensing and sale of therapeutic contact lenses, as long as the medication contained within the lenses is within the provider's designated scope of practice.

Adds new definition of “Health Status Adjusted Total Medical Expense” within the Division of Health Care Finance and Policy (DHCFP) statute. This definition relates to health care payer reporting requirements. The Division of Insurance (DOI) and DHCFP will determine uniform methodologies for calculating and reporting insurer medical loss ratios, health status adjusted total medical expenses, hospital costs and expenses, and relative prices paid by insurers to providers. These agencies will collect and publicly report this information.

Adds new definition of “Relative Prices” within the Division of Health Care Finance and Policy (DHCFP) statute.
 
This definition relates to provider reimbursement rates. The Division of Insurance (DOI) and DHCFP will determine uniform methodologies for calculating and reporting insurer medical loss ratios, health status adjusted total medical expenses, hospital costs and expenses, and relative prices paid by insurers to providers. DOI and DHCFP will collect and publicly report this information.

Adds to existing Division of Health Care Finance and Policy (DHCFP) payer data submission requirements by including health status adjusted total medical expenses (TME) by provider group, relative prices paid to every health care provider in the payer’s network by type of provider, and hospital inpatient and outpatient costs. Payers must report each of the three new data categories according to a uniform methodology determined by DHCFP.  Hospitals must report to DHCFP inpatient and outpatient costs, including direct and indirect costs, according to a uniform methodology. 

Requires that Health Insurance Responsibility Disclosure (HIRD) forms, which employers with 11 or more full time equivalent employees are required to submit to the Division of Health Care Finance and Policy (DHCFP) to verify that they provide section 125 plans and to verify that employees who declined employer sponsored insurance have alternative coverage, be shared with the Department of Revenue, the Commonwealth Health Insurance Connector Authority and the Health Care Access Bureau within the Division of Insurance for enforcement purposes.

Any individually identifiable information will not be public record.

Expands the existing infertility insurance benefit mandate to require coverage for women over age 35 who are unable to conceive for at least 6 months. Length of time necessary for women under age 35 remains at 1 year.

If a woman conceives but is unable to carry the pregnancy to live birth, the time she attempted to conceive prior to that pregnancy is to be included in the 1 year or 6 month calculation. This section applies to any general insurance policies that provide pregnancy-related insurance benefits.

Expands the existing infertility mandate to require coverage for women over age 35 who are unable to conceive for at least 6 months. Length of time necessary for women under age 35 remains at 1 year. This section applies to plans offered by Blue Cross Blue Shield of Massachusetts. If a woman conceives but is unable to carry the pregnancy to live birth, the time she attempted to conceive prior to that pregnancy is to be included in the 1 year or 6 month calculation.

Expands the existing infertility mandate to require coverage for women over age 35 who are unable to conceive for at least 6 months. Length of time necessary for women under age 35 remains at 1 year. This section applies to plans offered by Blue Cross Blue Shield of Massachusetts.

If a woman conceives but is unable to carry the pregnancy to live birth, the time she attempted to conceive prior to that pregnancy is to be included in the 1 year or 6 month calculation.

Modifies definition of unfair or deceptive insurance acts to include health plan insurance contracts that base reimbursement rates to a health care provider by reference to the price paid, or the average of prices paid, to that provider from any other plan. In addition, an insurer may not refuse to negotiate with a provider based on that provider’s other contracts, type of license, or affiliation with other health plans.

In general, an insurance company must not falsely advertise or misrepresent the nature of an insurance policy or its benefits, discriminate between similarly situated individuals in determining benefits eligibility, engage in unfair claim settlement practices, or fail to maintain a record of grievances.

Modifies the definition of unfair or deceptive insurance practices by including insurers that arrange for an employee to apply for individual health insurance coverage for the purpose of then excluding that employee from an employer-sponsored health plan, for which the employee is eligible, to reduce costs for other individuals in the employer-sponsored health plan.

Amends the definition of “eligible individual” to restrict eligibility for individual coverage to individuals who are not seeking to replace employer-sponsored coverage that complies with minimum creditable coverage standards.

Defines "qualified association" to include a Massachusetts nonprofit or not-for-profit corporation or organization focused on advancing the occupational, professional, trade, or industry interests, other than obtaining health insurance, of association members.

The organization must be active for at least 5 years before seeking qualified association status and must have at least 100 members, including individuals or small businesses that are actively involved in the organization and attained membership without regard to health status.

Defines "small business group purchasing cooperative" that may be used interchangeably with "group purchasing cooperative" to indicate a nonprofit or not-for-profit corporation or association, certified as a qualified association, that negotiates health coverage for all its members with one or more health plans.

Defines "wellness program" or "health management program" to indicate a program designed to improve the overall health of participants.

Requires that the age rate adjustment factor, used by health plans to calculate rates for eligible individuals and small groups, be applied on a year to year basis in order to more evenly distribute the rate of increase. In addition to age, an insurer may also calculate rates based on an individual’s or small group’s business industry, participation rate of members, wellness program discount, and tobacco use. The maximum premium rate offered to members cannot exceed 2 times the lowest premium rate offered to members within a particular class of business.

Allows the Commissioner of the Division of Insurance to conduct a study to determine whether rating factors that an insurer may use to determine annual base premium rates or individual group premiums for plans offered in the small group health insurance market inappropriately increase costs in relation to the risks of a particular small group. The Commissioner may adopt changes to regulations as necessary each July 1 for rates effective the following January 1 to modify rate adjustment factors.

When determining annual base premium rates, an insurer may consider an individual’s or small group’s business industry, age of members in a particular class of business, participation rate of members, wellness program discount, and tobacco use of its participants. The maximum premium rate offered to members cannot exceed 2 times the lowest premium rate offered to members within a particular class of business.

In general, after a carrier considers all rate adjustment factors, the base rate of any plan an insurer offers to individuals and small groups must fall within rate bands ranging between 0.66 and 1.32.

A carrier, however, may also consider certain additional base rate adjustment factors that establish a base rate outside of the rate band. These factors include: geographic region, group size, the relative actuarial value of the available health plan compared to the value of other health plans offered within a particular class of business, and the average relative actuarial value of at least 4 different base rate categories, including: single, 2 adults, 1 adult and children, and family. The Commissioner will establish at least five distinct regions for the purposes of area rate adjustments. Any additional adjustment factors must apply uniformly to every eligible member of a particular group.

Restricts eligible individuals from enrolling in a health plan outside of a mandatory annual open enrollment period of July 1 through August 15 beginning in 2012. Section 26 of this Act, which applies only to 2011, establishes two open enrollment periods of January 1 through February 15 and July 1 through August 15. Waivers may be granted by the Office of Patient Protection. The legislation limits the time during which an individual may enroll in a health plan for the purpose of stabilizing the merged small group and individual insurance markets and lowering health care premiums. These limitations help to prevent individuals from buying insurance only when they need medical services and then dropping coverage after insurance pays for the treatment.

Amends Section 26 to further restrict eligible individuals from enrolling in a health plan outside of a mandatory annual enrollment period of July 1 through August 15 beginning in 2012. The legislature intended the authorization of only one mandatory open enrollment period per year to stabilize the merged insurance market and to lower health care premiums by preventing individuals from buying insurance only when they need medical services and then dropping coverage after insurance pays for the treatment.

Establishes circumstances under which an insurance carrier may deny enrollment or cancel a health benefit plan even though individuals or small groups remain eligible for the plan. Once a carrier has closed the health benefit plan to new individuals and small groups, the carrier may cancel and discontinue benefits of the health benefit plan to all members.  The cancellation, however, is not effective until the enrolled individual’s or small group’s next enrollment anniversary.

In general, a carrier may discontinue a health benefit plan for an eligible individual or small business if a member repeatedly fails to pay premiums, has committed fraud or misrepresented eligibility status, has failed to comply with specific plan provisions, has voluntary ceased coverage, or has failed to comply with carrier’s requests for information that the carrier deems necessary to verify the application for coverage under a plan.

The Commissioner of the Division of Insurance will oversee and regulate insurance carrier denials and cancellations.

Requires that carriers offering health benefit plans for individuals or small groups report to the Division of Insurance (DOI) the current and projected Medical Loss Ratio (MLR) for health plans, projected administrative expenses, and other specific financial information.

Requires that carriers file changes to small group base rates 90 days prior to effective date. The DOI Commissioner must disapprove changes that are excessive, inadequate or unreasonable in relation to the benefits charged. Base rates filed by a carrier shall be presumptively disapproved as excessive if:

• Administrative expenses increase by more than the most recent percentage increase in the New England medical CPI; or

• A carrier’s contribution to surplus exceeds 1.9% (or 2.5% for carrier’s with a Risk Based Capital Ratio below 300% for four consecutive quarters); or

• The aggregate MLR for all small group plans is less than 88%.  

If a carrier’s rates are disapproved solely for failing to meet the MLR threshold, the rates will not be presumptively disapproved if the projected MLR increases by at least 1% over the MLR for the previous 12 months.  At the end of the year covered by the filing, if the MLR is less than the 88% threshold, carriers must issue refunds equal to the amount of premium above that which is necessary to achieve an MLR of 88%.

The DOI Commissioner must hold a public hearing if a proposed base rate has been presumptively disapproved, at which the Attorney General may intervene.  The DOI must notify carriers of a disapproved rate at least 45 days before the proposed effective date. Within 10 days, the carrier may request a hearing, which must be scheduled within 15 days and a decision must be issued within 30 days after the hearing.

Increases the required minimum Medical Loss Ratio (established in Section 29) from 88% to 90% effective October 1, 2011 to September 30, 2012.

Starting October 1, 2012, a carrier’s base rate changes will no longer be presumptively disapproved based on administrative expenses, surplus or Medical Loss Ratio (MLR).  The Division of Insurance (DOI), however, will continue to have authority to disapprove a carrier’s proposed change to base rates that are excessive, inadequate or unreasonable. If a proposed rate has been disapproved, a health plan issuer must inform all employees and individuals covered under the small group product that the proposed rate has been disapproved.

The DOI Commissioner must hold a public hearing if a proposed base rate has been presumptively disapproved, at which the Attorney General may intervene. The DOI must notify carriers of a disapproved rate at least 45 days before the proposed effective date. Within 10 days, the carrier may request a hearing, which must be scheduled within 15 days and a decision must be issued within 30 days after the hearing.

Requires selective or tiered network plan to be offered by all health plans that provide coverage through a closed network of health care providers to at least 5,000 individuals, employees, and dependents in the individual and small group maket. The plan must offer enrollees in at least one geographic area at least one selective or tiered provider network plan at a premium rate that is at least 12% lower than a plan with comparable benefits but without a selective network of providers.

The Division of Insurance (DOI) will determine network adequacy based on listed factors. Carriers may reclassify provider tiers or determine participation in selective or tiered network plans once per calendar year but may add providers or move them to a lower cost tier at any time. Carriers must provide 30 days notice prior to reclassification of providers. Each health plan must report on its website information about the tiered or selective plan and on providers participating in the plan. The DOI must report annually to the legislature on utilization trends of individuals and groups in these plans.

Section 32 is effective during 2011, and is replaced by Section 33, which expands Section 32 to include methods a health plan may use to achieve cost savings within the selective or tiered plan.

Expands Section 32 to include methods that a health plan may use to achieve cost savings within the selective or tiered plan available to the individual and small business market, such as excluding from a tiered or selective network those providers with similar or lower quality based on the standard quality measure set and higher health status adjusted total medical expense or relative price, or by increasing member cost sharing for non-emergency services rendered by those providers.

The Division of Insurance must establish regulations requiring uniform reporting of tiering information, including a detailed description of the methodology used to determine how providers were tiered, at least 90 days before any tiered network becomes effective.

Creates a market for up to six small business group purchasing cooperatives to operate in the state. The purpose of creating the cooperatives is to allow small businesses to combine purchasing power and to seek lower premiums as a larger group. Division of Insurance (DOI) must establish an application and certification process for the cooperatives and must certify up to six applications that meet DOI requirements. Approved group purchasing cooperatives may cover up to a combined number of 85,000 covered lives at any given time.

Plan benefits must include those mandated by the state as well as access to a wellness program. At least 33% of covered employees of each cooperative must commit to enrolling in the health management programs the cooperative must provide. A cooperative may not deny coverage to any employee or dependent of association members based on health condition, age, race, or sex. Premiums for a particular plan offered to a member of a cooperative must be equal to or less than premiums an insurer would charge that small business if it was seeking benefits outside of the cooperative.

Products may be sold through brokers, licensed agents and the Connector.

Within 2 years of the first small business group purchasing cooperative certification, DOI must report to the legislature on the cost savings to members of the cooperatives, any impact the cooperatives have on the state risk pool and premium costs in the merged market, and whether DOI should continue certifying cooperatives.

Requires any insurance carrier that has a combined total of at least 5,000 eligible individuals, employees, and dependents, and wishes to continue offering health plans in the individual and small group market, to file a plan with each group purchasing cooperative if the group purchasing cooperative requests such health plan proposal for its next plan year. Any health plan option offered to a cooperative must include all state mandated benefits, and must apply the same preexisting coverage limitations, waiting periods, open enrollment periods and rating rules as applied to small groups outside the cooperative.

Amended to clarify that carriers offering coverage to individuals, including those who renew through the Connector, are considered to be participating in the nongroup health insurance market.

By way of background, any carrier that offers health plans in the small business market to more than 5,000 employees and dependents, and offers eligible individuals a guaranteed issue managed care plan, a guaranteed issue medical plan, or a guaranteed issue preferred provider plan will be included in the nongroup health insurance market.

Amended to allow a carrier to seek approval from the Commissioner of the Division of Insurance (DOI) to discontinue a closed guarantee issue health plan pursuant to DOI regulations. Prior to this amendment, a carrier could only discontinue a closed guarantee issue health plan if the number of subscribers in the plan was less than 25% of the plan’s 2004 subscriber total. Furthermore, no carrier may deny coverage to, impose any pre-existing condition exclusion, or impose any waiting period on an individual or dependent who is eligible for a guaranteed issue health plan.

The Bureau of Managed Care within the Division of Insurance (DOI) is directed to require, as a condition of accreditation, that carriers adopt uniform standards and methodologies for credentialing health care providers. Also, any carrier that contracts with a third party administrator must ensure that the third party complies with the standards. By way of background, the Bureau of Managed Care within DOI determines standards and procedures for accreditation of health insurance carriers. The Bureau must consult with the Division of Health Care Finance and Policy, the Department of Public Health, the Group Insurance Commission, the Centers for Medicare and Medicaid Services, and each health insurance carrier to develop the standards.

Adds to the information insurers must provide to consumers to include the location, specialty, and methods of compensation or reimbursement for each provider in a plan’s network, a provider’s price relativity, health status adjusted total medical expense, and quality performance based on measures from the Standard Quality Measure Set standards developed by the Department of Public Health. The information specific to each provider in a carrier’s network must be provided on a health insurance carrier’s website, to at least one plan member per subscriber household, and to each prospective insured upon request.

Prohibits certain contracting practices between insurance carriers and health care providers including the following: provisions that guarantee a health care provider the right to participate in a select network or tiered network plan; requirements that all members of a provider group be included in the same tier in a tiered network plan or all be included in a select network plan; requiring provider participation in a new select or tiered network plan without granting providers the right to opt out of the new plans; requiring or permitting carriers or providers to alter contracts based on agreements with other carriers and providers; and requiring or permitting carriers to make supplemental payments without first publicly disclosing the amount and purpose of each such supplemental payment to the Insurance Commissioner.

Several functions of the Health Care Quality and Cost Council (QCC) are repealed, including the establishment of performance measures, quality benchmarks and health IT goals, as well as development of annual health care quality improvement goals. The QCC will still provide quality information through its website. The QCC will consider programs designed to improve patient safety, reduce preventable hospital readmissions, prevent chronic disease, improve coordination of care, and reduce variations in care.

Requires insurance carriers, including third party administrators of insurance plans, to report information to the Division of Insurance (DOI) on premiums earned, membership, medical loss ratio, and other detailed financial information associated with business operations. Carriers must annually report this information to DOI each April 1st to avoid a late penalty and may subsequently be subject to an audit. Information collected under this provision will be available to the public, and DOI must issue an annual report of information collected under this provision to the legislature. Any carrier that reports a risk-based capital ratio over 700% must participate in a public hearing to determine what portion of excess funds will go toward reducing the costs of health benefit plans or for health care quality improvement.

DOI may develop procedures to carry out the requirements of this section, including requiring the registration of third party administrators and standardizing reporting criteria, after consulting with state and federal agencies and affected carriers to ensure that regulations are not duplicative.

Restricts eligibility for individual coverage through the Health Connector to individuals who are not seeking to replace employer-sponsored coverage that complies with minimum creditable coverage standards.

Expands the Connector Board from 10 to 11 members to include a seat for a member of the Massachusetts chapter of the National Association of Health Underwriters to be appointed by the governor. The Commonwealth Health Connector is an independent public authority established under the 2006 health reform law (Chapter 58) to set health reform policies and offer subsidized coverage to low-income adults and allow for comparison and purchase of non-subsidized private health insurance plans to individuals and groups. The Secretary for Administration and Finance serves as chairperson. Each person appointed to the Board may serve a term of 3 years and may be eligible for reappointment.

Requires that the Health Connector give at least 90 days notice to the legislature before implementing any changes to minimum creditable coverage standards.

In addition to establishing the standards for minimum creditable coverage, other responsibilities assigned to the Health Connector Board include offering insurance products to individuals and small businesses, publishing a schedule for premiums at which individuals of varying ages are eligible, and establishing a schedule for affordability to be used in enforcing the individual mandate based upon percentage of income eligible to be spent on health care.

Directs the Health Connector, in coordination with the Department of Public Health, to create a small group wellness pilot program to encourage small businesses to implement employee wellness incentive programs. The Health Connector shall provide funding and technical assistance to eligible qualified small businesses for program implementation. Funding for the subsidy program is limited and subject to state appropriation, so the Health Connector may cap enrollment in the program if funds are insufficient to meet the costs of enrolling new employers.

The Health Connector must establish regulations necessary to implement this program and annually report to the legislature on the enrollment and impact of small group wellness incentive programs.

Prohibits the Health Connector from using any of the data obtained from the Department of Revenue for solicitations or advertising.

Authorizes the Health and Educational Facilities Authority (HEFA) to collect fees and administrative costs associated with the delegation of funds to various programs.

Section 188 of chapter 240 of the acts of 2010 subsequently dissolved HEFA and merged its functions into MassDevelopment.

Authorizes the Health and Educational Facilities Authority (HEFA) to allocate capital reserve funds to Community Hospital and Community Health Center Capital Reserve Funds created in Section 48 of this Act. These funds will support community hospitals and community health centers through loans and grant programs according to terms in Section 48 of this Act. Section 188 of chapter 240 of the acts of 2010 subsequently dissolved HEFA and merged its functions into MassDevelopment.

Creates Community Hospital and Community Health Center Capital Reserve Funds for the benefit of nonprofit community hospitals and nonprofit community health centers licensed by the Department of Public Health. These funds are to be used solely for the payment of the principal of Health and Education Facilities Authority (HEFA) bonds. Fund beneficiaries include only facilities where the ratio of the number of physician residents-in-training to the number of inpatient beds does not exceed 0.25. The Office of Health and Human Services and the Office of Administration and Finance may require that fund beneficiaries submit financial records to verify eligibility and agree to certain terms of lending, including reimbursement to the fund in the event a facility defaults on repayment of a loan. Section 188 of chapter 240 of the acts of 2010 subsequently dissolved HEFA and merged its functions into MassDevelopment.

Prevents the Commonwealth from raising taxes for the purpose of financing Community Hospital and Community Health Center Capital Reserve Funds. Section 188 of chapter 240 of the acts of 2010 dissolved HEFA and merged its functions into MassDevelopment.

Instructs the Division of Insurance (DOI), in consultation with the Division of Health Care Finance and Policy, to establish regulations directing health insurance carriers to calculate and report medical loss ratios of health benefit plans. The regulations must provide definitions for carriers to distinguish between medical claims expenditures and administrative cost expenditures. Before adopting final regulations, DOI must consult with designated stakeholders.

Instructs the Division of Health Care Finance and Policy (DHCFP), in consultation with the Division of Insurance, to establish regulations directing health insurance carriers to calculate and report health status adjusted total medical expenses for provider groups determined by zip code. In the regulations, DHCFP must specify a uniform method for calculating total medical expenses among each provider group, determine which non-claim related payments must be included in the calculations, account for health status and number of patients within each group, and specify reporting requirements.

Instructs the Division of Health Care Finance and Policy (DHCFP), in consultation with the Division of Insurance, to establish regulations directing health insurance carriers to calculate and report relative prices paid to health care facilities and providers. In the regulations, DHCFP must specify a method to account for a uniform mix of products and services and all non-claims related payments to providers.

Instructs the Division of Health Care Finance and Policy (DHCFP), in consultation with the Division of Insurance, to establish regulations directing hospitals to calculate and report all costs, including inpatient and outpatient costs and direct and indirect costs. Calculations must include costs and cost trends for labor, debt-related expenses, advertising and marketing, insurance, health information technology, management, research, academic costs, contributions, and all business operation costs. Before adopting final regulations, DHCFP must consult with designated stakeholders.

Instructs the Department of Public Health to organize a statewide advisory committee to develop and recommend a standard set of quality measurements for health care providers by January 1, 2011. The governor must appoint 6 representatives of health facility and provider organizations to join 10 state officials on the advisory committee.

In developing the Standard Quality Measure Set for 2010, the committee may only consider adopting state and federal quality and safety measures already in existence. In 2011, the committee may consider amending the Set to include nationally recognized quality measures that are not yet developed. At a minimum, the Set must include measures specified in this section.

The advisory committee must annually recommend to DPH updates to the Standard Quality Measure Set by each November 1st.

Allows individuals to renew health insurance coverage in 2010 outside of the biannual open enrollment period of January 1 through February 15 and July 1 through August 15 if the coverage will expire before the following open enrollment period in 2011 for a period of less than one year. Note that Section 27 of this Act reduces the biannual open enrollment period to only one annual open enrollment period during July 1 through August 15 effective January 1, 2011.

Directs the Secretary of Health and Human Services to organize a working group consisting of many state agencies and health care community stakeholders to identify ways to streamline health care administration requirements and reduce reporting requirements through the use of a single all-payer database.

The group must issue a report to the legislature by April 1, 2011 identifying steps each agency will take to collectively simplify administrative and reporting requirements.

Directs the Division of Insurance (DOI), in consultation with the Executive Office of Health and Human Services, to establish regulations by December 1, 2011 to simplify health care facility and provider administrative duties of processing claims for health care services. At a minimum, the regulations must create a standard prior authorization form for providers and must specify uniform standards for determining member eligibility and processing provider appeals of denied claims. Establishes a new commission to study the feasibility and financial implications of mandating a single claims administration system that would require the participation of all public and private health insurance payers, other than Medicare, in the Commonwealth. DOI must consult with this commission before adopting regulations under this section.

Establishes a special commission to study the impact of reducing the number of health plans that a health insurance provider may maintain and offer to individuals and employers.

Directs relevant policymaking agencies to consider the special needs of children and pediatric patients when developing and utilizing data standards, quality measurement systems, wellness initiatives, or making comparisons of costs and prices. Policymakers may require that comparative data and reports related to pediatric patients and providers be segregated from adult patients and providers.

Establishes a special commission to study the financial needs of community hospitals, with a focus on use of technology, maintaining adequate facilities, meeting the health care needs of the general population in the next decade and determining potential sources of capital to meet those needs. The commission is also directed to evaluate the role of public programs, payments, and regulations in supporting capital accumulation, and make recommendations to the legislature to advance the ability of community hospitals to meet the expected demand. The commission must hold hearings as part of its investigation and submit its findings in a report to the legislature by December 31, 2011.

Directs the Department of Public Health to conduct a study on the impact of expanding the availability of primary care health care services in community hospitals, including the number and types of procedures primary care providers perform, related changes in revenue, recruitment and retention of primary care providers, and changes in types of compensation for services. DPH must issue a report to the legislature by April 1, 2011 summarizing its findings and making recommendations to strengthen community hospitals.

Directs the Division of Health Care Finance and Policy to continue submitting to the legislature an annual public health access beneficiary employer report that must include names and addresses of employers whose employees and/or their dependents receive public medical assistance or medical benefits, the number of employees and/or dependents receiving public benefits, the cost to the Commonwealth for providing the benefits, and whether the employer offers health benefits to its employees.

Directs the Division of Medical Assistance to revise the Independent Clinical Laboratory Manual to include licensed substance abuse treatment programs as authorized prescribers of random substance treatment-related urine drug screens.

Requires that the Division of Health Care Finance and Policy (DHCFP) encourage providers and payers to adopt a payment system on a bundled payment, rather than fee-for-service, basis to reduce costs and improve quality and coordination of health care services. DHCFP must assist providers and payers to adopt such a payment system by making technical support available to them. DHCFP must also examine existing and proposed bundled payment models and publish results of research, study the effects of federal programs that promote bundled payment systems, and identify financial resources that may become available to providers while they implement bundled payment systems. The statute encourages DHCFP to implement pilot bundled payment programs before April 1, 2011 for at least 2 acute conditions or procedures where health benefit payers will reimburse health care providers for inpatient services, as well as certain pre- and post-inpatient stay, on a bundled payment basis. DHCFP is also encouraged to implement additional pilot bundled payment programs for at least 2 chronic conditions by July 1, 2011. DHCFP must file reports with the legislature detailing the efforts it undertakes to support providers and payers to implement bundled payment programs and the progress it makes toward implement the encouraged pilot programs.

Directs the Division of Insurance (DOI) to complete a study by July 31, 2011 to determine whether the 90 day reporting requirement established in Section 31 of this Act gives health insurance carriers a sufficient amount of lead time to make accurate proposals of plan changes to DOI. DOI may recommend a more appropriate length of time if necessary.

Directs the Division of Insurance (DOI) to annually set a limit on the amount of impact that rate adjustment factors may have on the annual base rate increase for an individual or small group.

Provides that a health care provider may contract to provide supplemental funding to a health insurance carrier to be used to issue a premium reimbursement or other form of refund for eligible individuals and small groups currently enrolled in all health benefit plans under the carrier. The Division of Insurance (DOI) must issue a public report listing participating providers and the estimated refunds for individuals and small groups.

Creates a special commission on provider price reform to study rising cost trends of health insurance and the impact of reimbursement rates that health insurers pay to providers. The commission must examine policies that reduce disparities in provider reimbursement rates while enhancing competition, fairness, and cost efficiency in the health care market. Any recommendation the commission offers to the legislature must be consistent with recommendations of the Special Commission on the Health Care Payment System established in Section 44 of Chapter 305 of the Acts of 2008. The commission must consult with state agencies and other organizations with expertise in health care reform and a reasonable number of affected parties before making recommendations. The commission must submit a report of its findings and recommendations to the legislature by September 30, 2011.

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