Bill H.4894

FILED ON: 12/8/2025

HOUSE . . . . . . . . . . . . . . . No. 4894

The Commonwealth of Massachusetts

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In the One Hundred and Ninety-Fourth General Court
(2025-2026)

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An Act to further define medical necessity determinations.

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. Chapter 32A of the General Laws is hereby amended by inserting after section 17Z the following section:-

Section 17AA. For the purposes of this section the following terms shall, unless the context clearly requires otherwise, have the following meanings:

“Mental health acute treatment”, 24-hour medically supervised mental health services provided in an inpatient facility, licensed by the department of mental health, that provides psychiatric evaluation, management, treatment and discharge planning in a structured treatment milieu.

“Mental health crisis stabilization services”, 24-hour clinically managed mental health diversionary or step-down services for adults or adolescents, as defined by MassHealth, usually provided as an alternative to mental health acute treatment or following mental health acute treatment, which may include intensive crisis stabilization counseling, outreach to families and significant others and aftercare planning.

“Community-based acute treatment (CBAT)”, 24-hour clinically managed mental health diversionary or step-down services for children and adolescents, as defined by the department of early education and care, usually provided as an alternative to mental health acute treatment.

“Intensive community-based acute treatment (ICBAT)”, intensive 24-hour clinically managed mental health diversionary or step-down services for children and adolescents, as defined by the department of early education and care, usually provided as an alternative to mental health acute treatment.

The commission shall provide to any active or retired employee of the commonwealth who is insured under the group insurance commission coverage for medically necessary mental health acute treatment and shall not require a preauthorization prior to obtaining treatment. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

The commission shall provide to any active or retired employee of the commonwealth who is insured under the group insurance commission coverage for medically necessary mental health crisis stabilization services for up to 14 days and shall not require preauthorization prior to obtaining such services; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

The commission shall provide to any active or retired employee of the commonwealth who is insured under the group insurance commission coverage for medically necessary community based acute treatment services for up to 21 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 10. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

The commission shall provide to any active or retired employee of the commonwealth who is insured under the group insurance commission coverage for medically necessary intensive community based acute treatment services for up to 14 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION 2. Chapter 118E of the General Laws is hereby amended by inserting after section 10Z the following section:-

Section 10AA. For the purposes of this section the following terms shall, unless the context clearly requires otherwise, have the following meanings:

The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover the cost of medically necessary mental health crisis stabilization services for up to 14 days and shall not require preauthorization prior to obtaining such services; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover the cost of medically necessary community based acute treatment services for up to 21 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 10. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover the cost of medically necessary intensive community based acute treatment services for up to 14 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION 3. Chapter 175 of the General Laws is hereby amended by inserting before section 47CCC the following section:-

Section 47AAA. For the purposes of this section the following terms shall, unless the context clearly requires otherwise, have the following meanings:

Any blanket or general policy of insurance described in subdivision (A), (C), or (D) of section one hundred and ten which is issued or subsequently renewed by agreement between the insurer and the policyholder, within or without the commonwealth, during the period within which this premium is effective, or any policy of accident or sickness insurance as described in section one hundred and eight which provides hospital expense and surgical expense insurance and which is delivered or issued for delivery or subsequently renewed by agreement between the insurer and the policyholder in the commonwealth, during the period within which this provision is effective, or any employers' health and welfare fund which provides hospital expense and surgical expense benefits and which is issued or renewed to any person or group of persons in the commonwealth, during the period within which this provision is effective, shall provide coverage for medically necessary mental health acute treatment and shall not require a preauthorization prior to obtaining treatment. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any blanket or general policy of insurance described in subdivision (A), (C), or (D) of section one hundred and ten which is issued or subsequently renewed by agreement between the insurer and the policyholder, within or without the commonwealth, during the period within which this premium is effective, or any policy of accident or sickness insurance as described in section one hundred and eight which provides hospital expense and surgical expense insurance and which is delivered or issued for delivery or subsequently renewed by agreement between the insurer and the policyholder in the commonwealth, during the period within which this provision is effective, or any employers' health and welfare fund which provides hospital expense and surgical expense benefits and which is issued or renewed to any person or group of persons in the commonwealth, during the period within which this provision is effective, shall provide coverage for medically necessary mental health crisis stabilization services for up to 14 days and shall not require preauthorization prior to obtaining such services; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any blanket or general policy of insurance described in subdivision (A), (C), or (D) of section one hundred and ten which is issued or subsequently renewed by agreement between the insurer and the policyholder, within or without the commonwealth, during the period within which this premium is effective, or any policy of accident or sickness insurance as described in section one hundred and eight which provides hospital expense and surgical expense insurance and which is delivered or issued for delivery or subsequently renewed by agreement between the insurer and the policyholder in the commonwealth, during the period within which this provision is effective, or any employers' health and welfare fund which provides hospital expense and surgical expense benefits and which is issued or renewed to any person or group of persons in the commonwealth, during the period within which this provision is effective, shall provide coverage for medically necessary community based acute treatment services for up to 21 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 10. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any blanket or general policy of insurance described in subdivision (A), (C), or (D) of section one hundred and ten which is issued or subsequently renewed by agreement between the insurer and the policyholder, within or without the commonwealth, during the period within which this premium is effective, or any policy of accident or sickness insurance as described in section one hundred and eight which provides hospital expense and surgical expense insurance and which is delivered or issued for delivery or subsequently renewed by agreement between the insurer and the policyholder in the commonwealth, during the period within which this provision is effective, or any employers' health and welfare fund which provides hospital expense and surgical expense benefits and which is issued or renewed to any person or group of persons in the commonwealth, during the period within which this provision is effective, shall provide coverage for medically necessary intensive community based acute treatment services for up to 14 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION 4. Chapter 176A of the General Laws is hereby amended by inserting after section 8DDD the following section:-

Section 8EEE. For the purposes of this section the following terms shall, unless the context clearly requires otherwise, have the following meanings:

Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary mental health crisis stabilization services for up to 14 days and shall not require preauthorization prior to obtaining such services; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary community based acute treatment services for up to 21 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 10. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary intensive community based acute treatment services for up to 14 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION 5. Chapter 176B of the General Laws is hereby amended by inserting after section 4DDD the following section:-

Section 4EEE. For the purposes of this section the following terms shall, unless the context clearly requires otherwise, have the following meanings:

Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary mental health acute treatment and shall not require a preauthorization prior to obtaining treatment. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary mental health crisis stabilization services for up to 14 days and shall not require preauthorization prior to obtaining such services; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary community based acute treatment services for up to 21 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 10. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary intensive community based acute treatment services for up to 14 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

SECTION 6. Chapter 176G of the General Laws is hereby amended by inserting after section 4VV the following section:-

Section 4WW. For the purposes of this section the following terms shall, unless the context clearly requires otherwise, have the following meanings:

Any individual or group health maintenance contract that is issued or renewed shall provide coverage for medically necessary mental health acute treatment and shall not require a preauthorization prior to obtaining treatment. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any individual or group health maintenance contract that is issued or renewed shall provide coverage for medically necessary mental health crisis stabilization services for up to 14 days and shall not require preauthorization prior to obtaining such services; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any individual or group health maintenance contract that is issued or renewed shall provide coverage for medically necessary community based acute treatment services for up to 21 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 10. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.

Any individual or group health maintenance contract that is issued or renewed shall provide coverage for medically necessary intensive community based acute treatment services for up to 14 days; provided, that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation with the patient and noted in the patient’s medical record.