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Section 15: Amended Definition of "Infertility"

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.

Section 14: Employer Health Insurance Responsibility Disclosure Form

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.

Section 13: Reporting Requirements for Total Medical Expenses, Relative Prices, and Hospital Costs

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. 


Each year, DHCFP must annually report and post on its website information on TME, relative prices, and hospital inpatient and outpatient costs. Providers will have 10 days advance notice of the public release or posting to review the data.  DHCFP is required to request TME data for Medicare patients from the Centers for Medicare & Medicaid Services (CMS). The uniform reporting is intended to allow DHCFP to track statewide and regional trends in the cost, utilization, and availability of medical services.  

DHCFP is required to notify payers of any reporting deadlines and may penalize payers that fail to report by the deadlines.

Section 12: Relative Prices

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.

Section 11: Total Medical Expenses

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.

Section 10: Therapeutic Contact Lenses

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.

Section 1: Monitoring of Existing Mandated Benefits

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.

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