Budget Amendment ID: FY2023-S4-412

EHS 412

Access and continuity of care to specialist and hospital services for dually eligibles

Ms. Chandler moved that the proposed new text be amended by inserting after Section 78 the following section:-

SECTION XX. Section 9D of Chapter 118E of the general laws is hereby amended by adding the following new paragraph (r):

(r) To ensure access to specialist and hospital care for dual eligible members, any dually eligible individual shall be permitted to receive health care services from any specialist or hospital provider in the commonwealth, irrespective of any health plan or provider network limitation. In such situations the provider shall be reimbursed the fee-for-service amount by Medicare or MassHealth for the service, including when the member is enrolled in a One Care or SCO plan, unless the plan and provider mutually agree to a different reimbursement amount for the service.

(r-1) To ensure continued access to primary, specialist, and hospital care for our most vulnerable seniors, MassHealth shall require any One Care or SCO plan and provider that has terminated a contract that includes the provision of health care services to One Care or SCO members, to allow impacted members to continue to receive services from their  primary care, specialist provider, or any inpatient or outpatient hospital subject to the termination, under the terms of the pre-existing contract, for twelve months following the expiration of any continuity of care requirements that may follow the contractual termination. During this period, plans shall be required to maintain all contractual terms and conditions that were in effect with the provider prior to the notice of termination being sent by either party, including but not limited to reimbursement, unless mutually agreed upon by the plan and the provider. Plans and providers shall be prohibited from using this provision to avoid using good faith efforts to negotiate contractual arrangements.