HOUSE DOCKET, NO. 4116        FILED ON: 1/17/2025

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No.         

The Commonwealth of Massachusetts

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PRESENTED BY:

Michael S. Day

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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 to streamline patient disclosure requirements.

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PETITION OF:

HOUSE DOCKET, NO. 4116        FILED ON: 1/17/2025

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No.         

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 streamline patient disclosure requirements.

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 111 of the General Laws, as appearing in the 2022 Official Edition, is hereby amended by striking section 228, as amended by section 25 of chapter 260 of the acts of 2020, and replacing it with the following section:-

Section 228. (a)(1) Upon scheduling an admission, procedure or service for a patient or prospective patient for a condition that is not an emergency medical condition, as defined in section 1 of chapter 176O, or upon request by a patient or prospective patient, a health care provider shall disclose whether the health care provider is participating in the patient’s health benefit plan; provided, however, that if a patient or prospective patient schedules a series of admissions, procedures or services as part of a continued course of treatment, the health care provider does not need to affirmatively make this disclosure for subsequent admissions, procedures or services for that course of treatment so long as the initial disclosure to the patient was documented; provided further, that if the health care provider’s status as participating in the patient’s health benefit plan changes during a continued course of treatment, the health care provider shall inform a patient of this change in status.

(2) If the health care provider is participating in the patient’s or prospective patient’s health benefit plan, the health care provider shall provide the patient’s health insurance carrier with a good faith estimate of the expected billing and diagnostic codes for any admission, procedure or service; provided, however, that a participating health care provider shall also inform the patient or prospective patient that the patient or prospective patient may obtain additional information about any applicable out-of-pocket costs pursuant to section 23 of chapter 176O. A health insurance carrier shall then provide the patient with the estimated amount the insured will be responsible to pay for a proposed admission, procedure or service in the form of a notification in clear and understandable language as required under the Public Health Service Act section 2799B–6, as added by Section 112 of Title I of Division BB of the Consolidated Appropriations Act of 2021 as codified at 42 USC section 300gg-136. The health insurance carrier must provide the patient with the estimated amount the insured will be responsible to pay for a proposed admission, procedure or service within 3 business days if their admission, procedure or service is scheduled at least 10 days in advance, or within 1 business day if there are fewer than 10 days before the admission, procedure or service.

(3) If the health care provider is not participating in the patient’s or prospective patient’s health benefit plan, or the patient is uninsured or otherwise not using their health benefit plan, the health care provider shall

provide patients with relevant cost information regarding the scheduled admission, procedure or service, including a good faith estimate of the charge amount and the amount of any facility fees for the admission, procedure or service; provided further that the provider shall inform the patient or prospective patient that the patient or prospective patient will be responsible for the amount of the charge and the amount of any facility fees for the admission, procedure or service not covered through the patient’s health benefit plan and shall inform the patient or prospective patient that the patient or prospective patient may be able to obtain the admission, procedure or service at a lower cost from a health care provider who participates in the patient’s or prospective patient’s health benefit plan. A good faith estimate under this section shall be furnished to a patient no more than 1 business day after the day the appointment was scheduled if the appointment was scheduled at least 3 business days before the admission, procedure or service and within 3 business days of scheduling if the appointment is made at least 10 business days in advance. Providers may comply with this section through compliance with notice requirements for providers under the in Public Health Service Act section 2799B–6, as added by Section 112 of Title I of Division BB of the Consolidated Appropriations Act of 2021, as implemented under 45 CFR section 149.610(c).

(b) If a health care provider that does not participate in the patient’s health benefit plan, or is providing care to a patient that does not have insurance or is not using their health benefit plan, fails to provide the required notifications under this section, the provider shall not bill the insured except for any applicable copayment, coinsurance or deductible that would be payable if the insured received the service from a participating health care provider under the terms of the insured’s health benefit plan.

(c) The commissioner may implement and enforce this section and impose penalties for: (i) non-compliance consistent with the department’s authority to regulate health care providers; provided, however, that the penalty for non-compliance shall not exceed $2,500 in each instance; provided further that the department shall not impose a penalty if a provider has been subject to a penalty by the Centers for Medicare and Medicaid Services for the same violation; and (ii) non-compliance consistent with the department’s authority to regulate health insurance carriers; provided, however, that the penalty for non-compliance shall not exceed $2,500 in each instance; provided further that the department shall not impose a penalty if a health insurance carrier has been subject to a penalty by the Centers for Medicare and Medicaid Services or Massachusetts division of insurance for the same violation. A health care provider and health insurance carrier that violates any provision of this section or the rules and regulations adopted pursuant to this subsection shall be liable for penalties as provided in this subsection.

SECTION 2. Subsection 2(a)(2) shall take effect upon the effective date of regulations implementing 42 USC section 300gg-136