Health Care Consumers

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.

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.

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.

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.

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.

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.

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 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.