Amendment ID: S2202-129
Amendment 129
Public Health Insurance Program
Messrs. Eldridge, Cyr, Hinds, Feeney and Barrett move to amend the bill by adding the following sections:-
SECTION XX. Chapter 176Q of the General Laws is hereby amended by inserting after section 18 the following section:-
Section 20. Public Health Insurance Program
(a) As used in this chapter, the following words shall have the following meanings, unless the context clearly requires otherwise:-
“Board”, the board of the commonwealth health insurance connector, established by subsection (b) of section 2 of chapter 176Q.
“Carrier”, an insurer licensed or otherwise authorized to transact accident and health insurance under chapter 175; a nonprofit hospital service corporation organized under chapter 176A; a nonprofit medical service corporation organized under chapter 176B; a health maintenance organization organized under chapter 176G.
“Connector”, the commonwealth health insurance connector authority, established by subsection (a) of section 2 of chapter 176Q.
“Health benefit plan”, any individual, general, blanket or group policy of health, accident and sickness insurance issued by an insurer licensed under chapter 175; a group hospital service plan issued by a non-profit hospital service corporation under chapter 176A; a group medical service plan issued by a non-profit medical service corporation under chapter 176B; a group health maintenance contract issued by a health maintenance organization under chapter 176G; a coverage for young adults health insurance plan under section 10 of chapter 176J. The words “health benefit plan” shall not include accident only, credit-only, limited scope vision or dental benefits if offered separately, hospital indemnity insurance policies if offered as independent, non-coordinated benefits, which, for the purposes of this chapter, shall mean policies issued under chapter 175 that provide a benefit not to exceed $500 per day, as adjusted on an annual basis by the amount of increase in the average weekly wages in the commonwealth as defined in section 1 of chapter 152, to be paid to an insured or a dependent, including the spouse of an insured, on the basis of a hospitalization of the insured or a dependent, disability income insurance, coverage issued as a supplement to liability insurance, specified disease insurance that is purchased as a supplement and not as a substitute for a health plan and meets any requirements the commissioner by regulation may set, insurance arising out of a workers’ compensation law or similar law, automobile medical payment insurance, insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in a liability insurance policy or equivalent self-insurance, long-term care if offered separately, coverage supplemental to the coverage provided under 10 U.S.C. section 55 if offered as a separate insurance policy, or any policy subject to chapter 176K or any similar policies issued on a group basis, Medicare Advantage plans or Medicare Prescription drug plans. A health plan issued, renewed or delivered within or without the commonwealth to an individual who is enrolled in a qualifying student health insurance program under section 18 of chapter 15A shall not be considered a health plan for the purposes of this chapter and shall be governed by said chapter 15A. The commissioner of insurance may by regulation define other health coverage as a health benefit plan for the purposes of this chapter.
“Eligible individual”, an individual who is a resident of the commonwealth; provided, however, that the individual is not offered subsidized health insurance by an employer with more than 50 employees.
“Eligible small group”, a sole proprietorship, labor union, educational, professional, civic, trade, church, not-for-profit or social organization or firms, corporations, partnerships or associations actively engaged in business that on at least 50 per cent of its working days during the preceding year employed at least one but not more than 50 employees.
“Eligible large group”, a labor union, educational, professional, civic, trade, church, not-for-profit or social organization or firms, corporations, partnerships or associations actively engaged in business that on at least 50 per cent of its working days during the preceding year employed at least 51 employees.
"Public health insurance program", the public health benefits plan offered through the connector established by subsection (b).
“Seal of approval”, the approval given by the board of the connector to indicate that a health benefit plan meets certain standards regarding quality and value, as established by section 10 of chapter 176Q.
"Trust fund", the Public Health Insurance Trust Fund, established by section 2YYYY of chapter 29.
(b) The connector shall provide for the offering of a public health benefits plan, which shall be known as the public health insurance program, to eligible individuals and groups.
(1) The public health insurance program shall:
(i) be made available exclusively through the connector, alongside health benefit plans receiving the connector seal of approval;
(ii) meet all the requirements to receive the connector seal of approval;
(iii) meet the connector's standards for minimum creditable coverage; and
(iv) comply with subsections (b), (c), and (d) of section 5 of chapter 176Q.
(c) The executive director of the connector may contract with managed care organizations or other health benefits administrators to administer aspects of plans offered under the public health insurance program.
(d) The connector shall establish premium rates for the public health insurance program at a level sufficient to fully finance the costs of health benefits provided by the public health insurance program and administrative costs related to operating the public health insurance program. The board shall establish payment rates for the public health insurance program for services and providers based on parts A and B of Medicare and may determine the extent to which adjustments to base Medicare payment rates shall be made in order to fairly reimburse providers and medical goods and device makers while maintaining a sufficient provider network.
(e) Health care providers, including physicians and hospitals, participating in Medicare are participating providers in the public health insurance program. The connector shall establish a process for participating providers to opt-out of the public health insurance program. The opt-out process shall:
(1) prohibit penalties for non-participating providers;
(2) establish a process for providers to rejoin the program after opting out; and
(3) establish an annual open enrollment period in which providers may decide whether to participate in the public health insurance program.
(f) The connector shall include in its annual reports the activities, receipts, expenditures, and enrollments of the public health insurance program. The public health insurance program shall be subject to the prescription and oversight of the board and state auditor pursuant to section 14 and section 15 of chapter 176Q.
(g) The connector shall promulgate regulations necessary to implement this section.
SECTION XX. Contracts to administer aspects of the public health insurance program pursuant to subsection (c) of section 20 of chapter 176Q shall only be available to Medicaid managed care organizations that have contracted with the commonwealth as of January 1, 2017. Beginning January 1, 2020, the connector may contract with non-Medicaid managed care organizations to administer aspects of the public health insurance program pursuant to subsection (c) of section 20 of chapter 176Q.
SECTION XX. Chapter 26 of the General Laws is hereby amended by inserting after section 8L the following section:-
Section 8M. Risk Adjustment
(a) The commissioner of insurance may make an assessment against a health plan, health insurer, or health maintenance organization doing business in the commonwealth, as well as the public health insurance program established by subsection (b) of section 20 of chapter 176Q , which shall be referred to herein as "risk-adjusted health plans," if the actuarial risk of the enrollees of such plans or coverage for a year is less than the average actuarial risk of all enrollees in all risk-adjusted health plans for such year. Self-insured group health plans, which are subject to 29 U.S.C. chapter 18 § 1001 et seq, shall be exempted from such risk adjustment.
(b) Using the criteria and methods developed under subsection (c), the commissioner of insurance shall provide a payment to risk-adjusted health plans with respect to health insurance coverage if the actuarial risk of the enrollees of such plans or coverage for a year is greater than the average actuarial risk of all enrollees in all risk-adjusted health plans for such year that are not self-insured group health plans.
(c) The commissioner shall establish criteria and methods to be used in carrying out the risk adjustment activities under this section. In calculating the actuarial risk of risk-adjusted health plans, the commissioner may utilize data including but not limited to enrollee demographics, the actual medical costs of enrollees during the previous year, inpatient and outpatient diagnoses in similar fashion as such data are used under parts C and D of title XVIII of the Social Security Act, and such other information as the commissioner determines may be necessary. Upon request, such risk-adjusted health plans shall make information available to the division of insurance for the purposes of risk adjustment under this section. Such information shall be confidential and limited to the minimum amount of personal information necessary. Such information shall not be a public record under clause Twenty-sixth of section 7 of chapter 4 or under chapter 66.
SECTION XX. Chapter 29 of the General Laws is hereby amended by inserting after section 2XXXX the following section:-
Section 2YYYY. There is hereby established and set up on the books of the commonwealth a separate fund to be known as the Public Health Insurance Program Trust Fund. Amounts credited to the trust fund shall be expended without further appropriation for operation of the public health insurance program. Not later than January 1, the comptroller shall report an update of revenues for the current fiscal year. The comptroller shall file this report with the secretary of administration and finance, the office of Medicaid, the joint committee on health care financing, and the house and senate committees on ways and means.
SECTION XX. Subsection (a) of section 5 of chapter 176Q is hereby amended by inserting, after the word "carrier" in line 3, the following words:- , as well as the public health insurance program,
SECTION XX. Section 1 of Chapter 176Q is hereby amended by inserting, after the definition of "Eligible Small Groups", the following definition:-
“Eligible large groups", a labor union, educational, professional, civic, trade, church, not-for-profit or social organization or firms, corporations, partnerships or associations actively engaged in business that on at least 50 per cent of its working days during the preceding year employed at least 51 employees.
SECTION XX. Section 4 of chapter 176Q of the General Laws is hereby amended by inserting after the word “small” in line 3, the following words:- and large
and by striking out, in line 5, the word “group’s”, and inserting in place thereof the following words:- or large group’s
SECTION XX. Section 123 of chapter 58 of the acts of 2006 is hereby amended by striking out the following:- The director shall collaborate with the secretary of health and human services and the group insurance commission to implement a methodology for the purposes of adjusting for variations in clinical risk among populations served by each of the commonwealth health insurance connector contractors. Adjustments to final payments to each of the contractors for a contract year shall be made in accordance with the risk adjustment methodology.
SECTION XX. The public health insurance program established in section 20 of chapter 176Q shall be made available to eligible individuals and eligible small groups through the commonwealth connector no later than January 1, 2019 and to eligible large groups no later than July 1, 2019.