Budget Amendment ID: FY2025-S4-564

EHS 564

Post Acute Care Prior Authorization and Throughput Study

Mr. Feeney moved that the proposed new text be amended by inserting after section __ the following sections: -

"SECTION __. (a) For the purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise:

“Enrollee”, as defined in section 8A of chapter 118E of the General Laws; provided, that “enrollee” shall include “insured” as defined in section 1 of chapter 176O of the General Laws.

“Payer”, the group insurance commission under chapter 32A of the General Laws, the division of medical assistance under chapter 118E of the General Laws, insurance companies organized under chapter 175 of the General Laws, non-profit hospital service corporations organized under chapter 176A of the General Laws, medical service corporations organized under chapter 176B of the General Laws, health maintenance organizations organized under chapter 176G of the General Laws and preferred provider organizations organized under chapter 176I of the General Laws, or a utilization review organization acting under contract with the aforementioned entities.

“Post-acute care facility or agency”, any: (i) facility licensed under chapter 111 of the General Laws to provide inpatient post-acute care services, including, but not limited to skilled nursing facilities, long-term care hospitals, intermediate care facilities, or rehabilitation facilities; or (ii) a home health agency certified by the federal Centers for Medicare and Medicaid Services.

(b) Notwithstanding any general or special law to the contrary, all payers shall approve or deny a request for prior authorization for admission to a post-acute care facility or transition to a post-acute care agency for any inpatient of an acute care hospital requiring covered post-acute care services by the next business day following receipt by the payer of all necessary information to establish medical necessity of the requested service. If the calendar day immediately following the date of submission of the completed request is not a payer’s business day, and the payer cannot otherwise make a determination by the next calendar day, and the receiving post-acute care facility or agency is both open to new admissions and has indicated that said facility or agency will accept the enrollee, then prior authorization shall be waived; provided, that the payer shall provide coverage and may begin its concurrent review of the admission on the next business day; provided further, that the payer shall not retrospectively deny coverage for services to an enrollee admitted to a post-acute care facility or transitioned to a post-acute care agency after a waiver of prior authorization pursuant to this section unless the claim was a result of fraud, waste or abuse. An adverse determination of a prior authorization request pursuant to this section may be appealed by an enrollee or the enrollee’s provider and such appeal, in the case of an enrollee of a commercial payer, shall be subject to the expedited grievance process pursuant to clause (iv) of subsection (b) of section 13 of chapter 176O of the General Laws. An enrollee of an insurance program of the division of medical assistance or the enrollee’s provider may request an expedited appeal of an adverse determination of a prior authorization request. Nothing in this section shall be construed to require a payer to reimburse for services that are not a covered benefit.

(c) In the case of non-emergency transportation between an acute care hospital and a post-acute care facility, payers shall approve or deny a request for prior authorization according to the same process provided pursuant to subsection (b); provided, that once authorization has been granted, said authorization shall be valid for not less than 7 calendar days following approval.

(d) The division of insurance and the division of medical assistance shall issue sub-regulatory guidance to effectuate the purposes of this subsection.

SECTION __. (a) There shall be a task force to study and propose recommendations to address acute care hospital throughput challenges and the impact of persistent delays in discharging patients from acute to post-acute care settings. The task force shall examine: (i) hospital discharge planning and case management practices; (ii) payer administrative barriers to discharge; (iii) legal and regulatory barriers to discharge; (iv) efforts to increase public awareness of health care proxies and the importance of designating a health care agent; (v) post-acute care capacity constraints and additional opportunities to provide financial incentives to increase capacity; (vi) administrative day rates and the cost to hospitals of discharge delays; (vii) enhanced hospital case management practices and reimbursement for wraparound services; (viii) the adequacy of post-acute care facility insurance networks and the establishment of an out-of-network rate for post-acute care facilities; (ix) expanding MassHealth Limited coverage to include post-acute and long-term care services; (x) the effectiveness of interagency coordination to resolve complex case discharges; (xi) the adequacy of reimbursement rates of MassHealth and commercial carriers for nonemergency medical transportation; and (xii) the adequacy of state resources and infrastructure to place complex case discharges in appropriate post-acute care settings.

(b) The task force shall consist of: the secretary of health and human services, or a designee, who shall serve as chair; the assistant secretary for MassHealth, or a designee; the commissioner of mental health, or a designee; the attorney general, or a designee; the commissioner of correction, or a designee; 1 sheriff appointed by the Massachusetts Sheriffs’ Association, Inc.; 1 member representing the division of the probate and family court department of the trial court to be appointed by the chief justice of said division; and 10 members to be appointed by the chair, 1 of whom shall be a representative of the Massachusetts Hospital Association, Inc., 1 of whom shall be a representative of the Massachusetts Senior Care Association, Inc., 1 of whom shall be a representative of the Home Care Alliance of Massachusetts, Inc., 1 of whom shall be a representative of the Massachusetts Academy of Elder Law Attorneys, 1 of whom shall be a representative from the Massachusetts Ambulance Association, Incorporated, 1 of whom shall be a representative from the Massachusetts Association of Health Plans, Inc., 1 of whom shall be a representative from Blue Cross and Blue Shield of Massachusetts, Inc., 1 of whom shall be a representative from an academic medical center located in Worcester county, 1 of whom shall be a representative of an acute care hospital located in Suffolk county and 1 of whom shall be a representative from an acute care hospital designated by the health policy commission as an independent community hospital for the purposes of 105 CMR 100.715(B)(2)(b).

(c) Not later than January 1, 2025, the task force shall submit its report, including its recommendations or any proposed legislation necessary to carry out its recommendations, to the clerks of the house of representatives and the senate, the house and senate committees on ways and means and the joint committee on health care financing."