HOUSE DOCKET, NO. 1676        FILED ON: 1/17/2013

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 944

The Commonwealth of Massachusetts

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PRESENTED BY:

Stephen Kulik

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To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:

The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:

An Act establishing a consumer bill of rights in tiered and reduced network health plans.

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PETITION OF:

HOUSE DOCKET, NO. 1676        FILED ON: 1/17/2013

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 944

The Commonwealth of Massachusetts

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In the Year Two Thousand Thirteen

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An Act establishing a consumer bill of rights in tiered and reduced network health plans.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 

SECTION 1. Subsection (b) of section 11 of chapter 176J of the General Laws is hereby amended by striking out the second sentence and inserting in place thereof the following sentences:– Carriers shall tier providers  The commissioner shall determine by regulation standard tiering criteria to be used by all carriers based on health outcomes, quality performance as measured by the standard quality measure set and by cost performance as measured by health status adjusted total medical expenses and relative prices. The criteria shall require that all providers of the same type who are participants in a particular Accountable Care Organization or Patient Centered Medical Home, as defined in section 1 of chapter 6D, shall be classified in the same tier.

SECTION 2. Section 11 of chapter 176J of the General Laws is hereby amended by striking out subsection (c) and inserting in place thereof the following subsection:–

(c) The commissioner shall promulgate by regulation uniform criteria for determining network adequacy for a tiered network plan based on the availability of sufficient network providers in the carrier’s overall network of providers, including standards for adequate geographic proximity of providers to members, taking into account distance, travel time and availability of public transportation. In determining network adequacy, the commissioner shall require that carriers classify providers into tiers so that every member enrolled in a plan has reasonable access to at least one provider in the lowest cost-sharing tier for every covered service.

SECTION 3. Section 11 of chapter 176J of the General Laws is hereby amended by striking out subsection (f) and inserting in place thereof the following subsection:–

(f) Carriers may: (i) reclassify provider tiers; and (ii) determine provider participation in selective and tiered plans no more than once per calendar year except that carriers may reclassify providers from a higher cost tier to a lower cost tier or add providers to a selective network at any time. If the carrier reclassifies provider tiers or providers participating in a selective plan during the course of an account year, the carrier shall provide affected members of the account with information regarding the plan changes at least 30 days before the changes take effect. If a member is in a course of treatment with a mental health provider who is reclassified to a higher cost tier, the member shall be permitted to remain with the provider with cost sharing at the previous lower cost tier for one year following the reclassification.  Carriers shall provide information understandable to an average consumer on their websites and though a toll-free telephone number that includes an option of talking to a live person about any tiered or selective network plan, including but not limited to, a searchable list of the providers participating in the plan, the selection criteria for those providers and where applicable, the tier in which each provider is classified. The information shall clearly distinguish among different facilities of a provider if those facilities are in different tiers or are excluded from a selective plan.   All promotional materials for tiered and selective plans must include a readily understandable general explanation of the cost sharing and tiering elements of the plan, and a prominent notice of the web site and toll-free telephone number where a consumer may find more information about the cost sharing and tiering elements. The commissioner shall monitor the web sites and telephone response services for completeness, accuracy and understandability. The commissioner may conduct consumer surveys and focus groups reviewing carrier tiered and selective network plan web sites and telephone response services, and shall issue guidelines for best practices.