Chapter 58 Sections

Emergency Preamble

Appropriation language

Contains supplemental spending of $15.45 million related to health reform implementation, including public health, and $3 million for outreach and enrollment grants.

Contains supplemental spending of $14.4 million related to health reform, including state agency implementation funds and public health programs.

Provides Health Care Quality and Cost Council - definitions of terms used in QCC statute.

Creates the Health Care Quality and Cost Council that will promote health care quality improvement and cost containment.

M.G.L. c. 6A, § 6J-L: Creates a Health Care Quality and Cost Council to promote health care quality improvement and cost containment.

Creates a MassHealth Payment Policy Advisory Board to review and evaluate Medicaid rates and rate methodologies, especially rates paid to Community Health Centers.

Creates a special commission to study reducing or eliminating the payor assessment paid by insurers and self-insured employers for the Health Safety Net.

Creates a Health Disparities Council within EOHHS to make recommendations to reduce racial and ethnic health disparities in the Commonwealth and to increase diversity among healthcare workers.

Amends Board of Registration in Medicine Trust Fund statute to allow appropriations to carry over into the next fiscal year.

Changes composition of Public Health Council to include members from public health schools, providers, and health advocates.

Creates a new Health Care Access Bureau within the Division of Insurance with responsibility for oversight of the small group and individual health insurance market and affordable health plans, funded by a $600,000 annual assessment on insurance carriers.

Directs the Division of Insurance, in consultation with the Connector, to establish and publish annually minimum standards for health insurance products.

Creates a Commonwealth Care Trust Fund that will receive revenue generated from the Fair Share Contribution, the Free Rider Surcharge, and other revenue that will be used to pay for subsidized health insurance and Medicaid rate increases.

Creates an Essential Community Provider Trust Fund. Funds will be used to make grant payments to hospitals and community health centers in accordance with criteria established by the new Health Safety Net Office.

Creates Medical Assistance Trust Fund to provide supplemental Medicaid payments to providers.

Creates the Department of Developmental Services Trust Fund used to make payments to facilities serving developmentally disabled individuals.

Allows staff of the Connector to receive pension benefits.

Changes current tax law definition of "Code" so that it includes section 223 of the Internal Revenue Code, which creates a deduction for health savings accounts.

Establishes a pediatric palliative care program, administered by the Department of Public Health, to serve children, and the families of children, with life-threatening illnesses.

Chapter 111M provides for the individual mandate to have health insurance coverage. Section 1 provides definitions of "creditable coverage," which also provides that the board of the Connector has authority to further determine "minimum creditable coverage" standards for individual and group health plans; and defines "resident" for purposes of the individual mandate.

Establishes an exemption from the individual mandate for individuals whose religious beliefs prevent them from using medical health care.

Individuals may appeal an adverse decision of eligibility or affordability through an appeals process established by the Connector.

Authorizes the commissioner of revenue to establish regulations to carry out the individual mandate.

Establishes the procedure for implementation of the individual mandate. Qualifying individuals for whom "creditable coverage" is deemed affordable must have "creditable coverage" in place. Individuals must include information about health insurance status on their tax forms. Failure to meet the insurance requirement will result in a penalty, assessed by the department of revenue. All penalties will be deposited in the Commonwealth Care Trust Fund that will contribute to state subsidies for the Commonwealth Care program. • Creates a penalty for non-compliance with the individual mandate as equal to 50% of the lowest premium available for each month the individual did not have creditable insurance, as determined by the Connector.

Requires the Office of Medicaid to submit a report to the legislature on the previous year's activities of the Medical Care Advisory Committee.

Expands MassHealth eligibility for children up to 300% of the Federal Poverty Level, increased from the previous 200% of the Federal Poverty Level. • Prevents MassHealth from establishing disability criteria for determining eligibility that is more restrictive than the federal Social Security standards. • Establishes MassHealth eligibility standards for people with HIV at 200% of the Federal Poverty Level. • Requires the Office of Medicaid to provide statements of coverage to enrollees and verify coverage to the commissioner of revenue.

Expands employee eligibility for participation in the Insurance Partnership Program to 300% of the Federal Poverty Level. • Ensures that Insurance Partnership subsidies are consistent with those provided under the Commonwealth Care program. • Specifies that self-employed individuals enrolled in the Insurance Partnership Program are eligible for employee subsidies only.

States that MassHealth must provide public hearing and notice before restricting eligibility or benefits.

Allows for higher Medicaid reimbursement rates to hospitals that meet certain quality standards and performance benchmarks.

Expands MassHealth CHIP eligibility for children from 200% of the Federal Poverty Level to 300% of the Federal Poverty Level.

Places in statute eligibility criteria for elderly and/or disabled special status immigrant for the MassHealth Essential program.

Changes references from “Uncompensated Care Pool” to “Health Safety Net Trust Fund” and permits sharing of information about Health Safety Net enrollees.

Restores all MassHealth adult benefits cut in 2002, including dental, vision, chiropractic, and prosthetics, effective July 1, 2006. (Note: This section was partially superseded by a provision in the FY 2011 budget authorizing reduction of dental benefits to adults in MassHealth.)

Creates a Wellness Program for MassHealth recipients to encourage healthy outcomes by authorizing incentives, including reduction of MassHealth premiums or copayments, as wellness goals are met.

Provides for the definitions used in the statute establishing the Health Safety Net program.

Creates Health Safety Net Office to replace current Uncompensated Care Pool administration. The Health Safety Net pays acute care hospitals and community health centers for certain essential services provided to uninsured and underinsured Massachusetts residents.

Establishes the Health Safety Net Office which administers the Health Safety Net program and the Health Safety Net Trust Fund.

Establishes the Health Safety Net Trust Fund.

Sets out provisions to determine an acute hospital's payments to the Health Safety Net Trust Fund and mechanisms to enforce the liability.

Sets out provisions to determine acute hospital and ambulatory surgical center surcharge payments to the Health Safety Net Trust Fund.

Establishes provisions governing payments from the Health Safety Net Trust Fund to acute hospitals and community health centers.

Makes technical language changes in the definitions section of the Division of Health Care Finance and Policy statute. The changes relate to the replacement of the Uncompensated Care Pool program with the Health Safety Net.

Amends the Division of Health Care Finance and Policy statute to include references to Health Care Quality and Cost Council and the provider and payer cost trends hearings.

Amended powers of the Division of Health Care Finance and Policy to delete reference to Uncompensated Care Pool.

Sets out provisions to determine an acute hospital's annual assessment to cover a portion of estimated expenses of the Division of Health Care Finance and Policy and the Health Safety Net office.

Requires hospitals to conduct uniform reports to the Division of Health Care Finance and Policy, which must include the names and addresses of employers whose employees receive free care at the hospitals. Amended in 2010 to also require public and private insurance providers to submit to the Division of Health Care Finance and Policy an explanation of charges and costs associated with group and individual insurance plans.

Requires applicants for the Health Safety Net to be enrolled in other publicly-funded health programs, if eligible. Applicants deemed ineligible for such programs are required to provide the name and address of their employer and their own identifying information, including social security number.

Requires creation of a form for employers to verify that they provide section 125 plans. Also requires creation of a form for employers to verify that employees who declined employer sponsored coverage have alternative coverage. Creates fine for employers who falsify or fail to submit forms.

Sets out provisions governing assessment of Free Rider surcharge on certain employers who do not offer health benefits to their employees based on the number of employees, the use of the Free Care Pool, total state-funded costs, and the percentage of employees enrolled in the employer’s health plan.

Provides Connector Commonwealth Care program definitions. Note: the definition of "resident" has been superseded by provisions in the FY 2011 budget and section 95 of chapter 359 of the Acts of 2010.

Establishes the Commonwealth Care health insurance program, the sliding-scale subsidized health insurance program for low-income uninsured residents.

Sets eligibility standards for the Commonwealth Care health insurance program, which provides subsidized insurance to people with incomes under 300% of the Federal Poverty Level who are not eligible for other publicly-funded programs. Subsidies will be paid based on a sliding scale for eligible plans that are procured by the Connector. Subsidies are not available to workers who are provided coverage by their employers; however, the Connector may waive that restriction.

Provides that all residents of Massachusetts have the right to apply for the Commonwealth Care program, to receive written determinations, and to appeal an adverse decision.

Subsidies for the Commonwealth Care program will be paid based on a sliding scale for eligible plans that are procured by the Commonwealth Health Insurance Connector.

Residents eligible for the Commonwealth Care program whose income is below 100% of the Federal Poverty Level will be enrolled in a special health plan with no premium or deductible.

Prohibits an employer from penalizing an employee if an employer must reimburse the Health Safety Net for health care services the employee received.

Creates the Fair Share Contribution, to be paid by employers who do not provide or make a reasonable contribution to health insurance for their employees. The contribution requirement applies to employers with 11 or more employees and is capped at $295 annually per employee.

Provides definitions for General Law chapter 151F, which requires employers with 11 or more employees to maintain a "cafeteria plan" to provide health benefits to workers.

Establishes the requirement that all employers with more than 10 employees must maintain a "Section 125" cafeteria plan to give employees access to pre-tax health insurance payments.

Authorizes the attorney general to enforce the cafeteria plan regulations of employer sponsored health insurance provisions.

Requires family policies to extend coverage to children up to 26 years of age or for 2 years after "loss of dependent status," whichever occurs first.

Requires family policies to extend coverage to children up to 26 years of age or for 2 years after "loss of dependent status," whichever occurs first.

Requires commercial insurers to provide written statements verifying that a health plan provides creditable coverage to both the insured and the Commissioner of Revenue.

Provides that Blue Cross plans may only offer policies to employers if the insurance is offered to all full-time employees. The employer must offer to cover the same premium contribution percentage for each employee but may allow greater contribution percentages to lower paid employees and separate percentages for employees with collective bargaining agreements.

Requires family policies to extend coverage to children up to 26 years of age or for 2 years after "loss of dependent status," whichever occurs first.

Requires commercial insurers to provide written statements verifying that a health plan provides creditable coverage to both the insured and the Commissioner of Revenue.

Blue Cross Blue Shield may only offer coverage to employers if the insurance is offered to all full-time employees. The employer must offer to cover the same premium contribution percentage for each employee but may allow greater contribution percentages to lower paid employees and separate percentages for employees with collective bargaining agreements.

Requires family policies to extend coverage to children up to 26 years of age or for 2 years after "loss of dependent status," whichever occurs first.

Requires insurers to provide written statements verifying that a health plan provides creditable coverage to both the insured and to the commissioner of revenue.

Requires HMO family policies to extend coverage to children up to 26 years of age or for 2 years after "loss of dependent status," whichever occurs first.

Provides that an HMO may only sell a group health plan to employers if the insurance is offered to all full-time employees. The employer must offer to cover the same premium contribution percentage for each employee but may allow greater contribution percentages to lower paid employees and separate percentages for employees with collective bargaining agreements.

An HMO can include a maximum deductible consistent with the maximum contribution requirements allowed for a federally-established Health Savings Account.

Provides that an HMO plan covering a young adult will be approved as a Young Adult Health Benefit Plan if it complies with young adults plan standards.

Requires HMO plan carriers to provide written statements verifying that a health plan provides creditable coverage to both the insured and to the commissioner of revenue.

Provides definitions pertaining to Connector Seal of Approval for private insurace plans.

Establishes a database within the Health Care Access Bureau to track insurance coverage for purposes of complying with the individual mandate. All insurers must report monthly coverage to the Bureau for this database and the information will be shared with DOR.

Allows individuals to purchase coverage through the small group insurance market, and provides that the small group insurance law provisions apply to all small business and individual plans issued by an insurance carrier, by the Connector, or through an intermediary.

Sets the factors used to set premiums for the merged individual and small group market. This section establishes a maximum rate band range from .66 to 1.32 for the following factors: age, industry rate, participation-rate rate, wellness program rate, and tobacco use rate. Additionally, carriers can apply only the following factors outside the rating band in establishing premiums: benefit level, geographic region, adjustment factor for an eligible individual and a small group, and group size. Additionally, requirements are laid out for which carriers with 5,000 or more members will be required to file a plan annually with the Connector to be considered for the "Connector Seal of Approval."

Requires insurance carriers to make available to individuals and small groups information for all plans and prices of plans offered to any other individuals and small groups. • Modifies the current requirement of carriers to make health benefit plans available in the following ways: Requires carriers to offer coverage effective within 30 days after application to any eligible individuals if they request coverage within 63 days of any prior creditable coverage. If the 63 day period has lapsed, carriers must offer coverage effective on the first day of the month following enrollment to eligible individuals who apply during the mandatory biannual open enrollment periods. • For a Trade Act/Health Coverage Tax Credit Eligible Individual, carriers may impose a 6 month exclusion of coverage for pre-existing conditions if the individual had less than 3 months of continuous coverage before becoming eligible for the tax credit or had a break in coverage for more than 62 days before applying for the plan. However, plans offered to individuals without creditable coverage for 18 months prior to application may not be subjected to a waiting period. • A carrier can deny enrollment in any plan if the carrier files with the Commissioner proof of intent to stop selling that plan. • Carriers can require individuals or groups of 1-5 to enroll in plans via the Connector or an intermediary.

Prevents insurance policies from excluding individuals based on age, occupation, health condition, claims experience, duration of coverage or medical condition. • Prevents insurance policies from excluding for more than 6 months preexisting conditions that were medically diagnosed or treated. Pregnancy existing on the date of enrollment is not included as a preexisting condition. • Plans offered to Trade Act/Health Coverage Tax Credit Eligible Persons may not include a waiting period or a pre-existing condition exclusion.

Provides that the Commissioner of the Division of Insurance may approve, according to established criteria, health insurance policies for individuals or small businesses that cover more restricted networks that differ from the overall carrier's network. The Commissioner may also disapprove any proposed rate changes if the Commissioner disapproves proposed rate increases to a small group plan, an insurance carrier must notify all members of the plan that the proposed increase has been disapproved and is subject to a public hearing. The carrier may not implement the proposed rates until the Commissioner has approved the rates.

Requires insurance carriers to disclose to prospective small business customers the surcharge that may be applied to the group’s premium and the participation requirements or participation rate adjustments for each health plan. • Requires insurance carriers to file electronically with the Division of Insurance rates and notification of actuarial methodology and any relevant changes prior to filing.

Requires the governing committee of the carrier-funded small-group reinsurance plan implemented in 1992 to establish a plan to phase out the program by June 2007.

Adds "eligible individuals" to those who do not qualify for "continuous coverage" under the state's mini-COBRA law due to the employer having only one or more than nineteen employees.

Establishes insurance plan coverage criteria for Young Adults to be set by Division of Insurance. Only individuals between 19 & 26 who do not have employer-sponsored coverage are eligible for these products. Only insurance carriers with 5,000 or more enrollees may offer Young Adult plans, and the plans must be offered through the Connector.

Directs governing committee of non-group health reinsurance plan to propose a phase-out plan.

Provides definitions for sections 96, 97, 98, 99, 100 of Chapter 58 of the Acts of 2006.

Provides definitions pertaining to merger of individual and small group health insurance markets.

Prevents insurance carriers from excluding an eligible individual or an eligible dependent, who applied for a health plan within 63 days of termination of prior creditable coverage, from a plan or impose a pre-existing condition exclusion or waiting period in any health plan if the individual meets the following criteria: the individual had 18 or more months of continuous credible coverage before applying, is not eligible for a group plan, and does not have other health insurance coverage. If an eligible individual does not meet the above-mentioned criteria, a carrier may subject the individual to a 6 month waiting period for pre-existing conditions with the exception of emergency services.

Prevents insurance policies from excluding individuals based on age, occupation, health condition, claims experience, duration of coverage or medical condition. • Establishes a maximum waiting period on an individual to 4 months, with the exception of emergency services, for pre-existing conditions that were medically diagnosed or treated only if the individual has been without creditable coverage for more than 18 months before enrolling in the health plan. Late enrollees may not be excluded from a health plan for more than 12 months. • Pregnancy existing on the date of enrollment is not included as a preexisting condition.

Provides definitions for statute establishing the Connector.

Establishes criteria for Connector Seal of Approval product specifications.

Allows for intermediaries and producers to earn commission on individuals enrolled through the Connector.

Provides that Connector administrative operations will be financed through the surcharges it receives from all Connector health plans.

Establishes financial liability of the Connector.

Establishes reporting requirements for the Connector.

Establishes a requirement that the Connector must conduct a study and report on its progress to the Massachusetts Legislature 2 years after operation and every year thereafter.

Directs a study to examine the Connector use of brokers.

Authorizes the Connector to adopt implementation regulations.

Establishes the Connector as an authority within the Executive Office of Administration and Finance. Establishes the governance of the Connector by the 10-member board, chaired by the Secretary of Administration and Finance. The board is made up of 4 state officials and 6 citizens.

Authorizes the Connector Board to offer insurance products to individuals and small businesses, publish a schedule for premiums at which individuals of varying ages are eligible, and establish a schedule for affordability to be used in enforcing the individual mandate based upon percentage of income eligible to be spent on health care.

Specifies that the Connector will offer products to eligible individuals and small groups.

Establishes the criteria that health insurance plans must meet to receive the Seal of Approval and be offered through the Connector.

Outlines small business compliance requirements to participate in Connector health plans.

Authorizes the Connector to administer the Commonwealth Care health insurance program beginning October 1, 2006.

Directs an interagency agreement with the department of revenue for purposes of determining eligibility for Commonwealth Care.

Allows the Group Insurance Commission to allow state employees and contractors who are ineligible for group insurance to purchase a health plan through the Connector.

Extends the Fisherman's Partnership Health Plan until 2012.

Repeals the Distressed Provider Expendable Trust Fund statute.

Provides outreach and enrollment grants to community and public and private nonprofit groups, located in areas with high percentages of uninsured individuals, that provide enrollment assistance, education, and outreach programs to individuals who may be eligible for MassHealth or other subsidized health plans.

Directs MassHealth to increase enrollment in the CommonHealth program for the disabled by 1600 people who were on the waiting list as of April 2006.

Directs MassHealth to increase enrollment in the Family Assistance program for HIV positive individuals by 250 people who were on the waiting list of April 2006.

Directs MassHealth to increase enrollment in the Essential program by 60,000 people who were on the waiting list as of April 2006.

Requires the creation of a MassHealth tobacco cessation and prevention program.

Directs the Secretary of the Executive Office of Health and Human Services to study limited provider networks.

Requires the Department of Public Health to investigate the funding of community health workers to increase overall access to health care, and eliminate health disparities among vulnerable populations.

Directs the Secretary of the Executive Office of Health and Human Services to seek federal CHIP reimbursements where possible.

Requires the Commonwealth to request an amendment to the MassHealth demonstration waiver to implement Chapter 58 of the Acts of 2006 and to seek maximum federal reimbursement available for subsidized health insurance programs.

Allows individuals receiving publicly funded behavioral health services to continue receiving those services notwithstanding the provisions of new insurance programs created by Chapter 58.

Requires a study of the impact of merging the non-group insurance market and small-group health insurance market.

Establishes an open enrollment period for individuals into new plans from May 1, 2007 through July 31, 2007.

Appropriates $5 million to the Mass Technology Park Corporation for the design of computerized physician prescribing systems.

Transfers the balance in the Uncompensated Care Trust Fund, which is to be abolished, to the Health Safety Net Trust Fund.

Transfers the balance in the Distressed Provider Expendable Trust Fund, which is to be abolished, to the Essential Community Provider Trust Fund.

Directs the transfer of $125 million to the Commonwealth Care Trust Fund for the Commonwealth Care program.

Directs the transfer of $290 million from the Commonwealth Care Trust Fund to the Uncompensated Care Trust Fund.

Appropriates $25 million for the Connector initial administrative expenses, including marketing efforts.

Directs supplemental payments to Cambridge Health Alliance and Boston Medical Center.

Provides exclusive rights for three years to Medicaid managed care organizations that have contracted with the Commonwealth to provide managed care to MassHealth members to offer subsidized plans through the Commonwealth Care Health Insurance Program.

Establishes hospital and surcharge payer liability and hospital payments for the Uncompensated Care pool for fiscal year 2007.

Prohibits changes to Uncompensated Care Pool reimbursable services regulations.  

Repeals the moratorium on changes to Uncompensated Care Pool regulations, effective October 1, 2007.

Declares a legislative policy to not add new mandated insurance benefits until 2008.

Authorizes funding for hospital rate increases of $90 million in each of the three fiscal years 2007-2009.

Directs the Secretary of the Executive Office of Health and Human Services to study the cost of allowing primary care givers to enroll in MassHealth.

Authorizes the transfer of funds from the University of Massachusetts related to hospital revenue to the General Fund.

Authorizes the transfer of funds from the University of Massachusetts related to capital appropriations to the General Fund.

Requires the Secretary of the Executive Office of Health and Human Services to develop a plan and timeline to implement health care reform legislation. Progress reports must be made periodically to the legislature.

Directs the Connector's Executive Director to submit a plan of operation and recommendations for amendments to its statute to the Board of the Connector by August 1, 2006.

Directs the Division of Unemployment Assistance and the Division of Health Care Finance and Policy to report on the implementation and impact of the Fair Share Contribution.

Allows hospitals to receive rate increases in 2007 before meeting quality standards.

Requires the Health Care Quality and Cost Council comparison website to be operational by September 2007.

Staggers the initial lengths of terms for new members of the Public Health Council.

Staggers the initial lengths of terms for new members of the Connector Board.

Allows individuals to purchase coverage through the small group insurance market starting July 1, 2007.

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