SECTION 1. Chapter 118 E,
Section 38 as appearing in the 2010 Official Edition of the Mass General Laws
is hereby amended by inserting at the end thereof of the following new
paragraphs:
“Within 45 days after the
receipt by the Division of completed forms for reimbursement to a physician who
participates in a medical service program established pursuant to this chapter,
or within 15 days if such claim is received electronically, the Division shall
(i) make payments for such services provided by the physician that are services
covered under such medical assistance program and for which claim is made, or
(ii) notify the physician in writing or by electronic means, within 15 days for
written claim forms or 48 hours for electronic claims, of any and all reasons
for non-payment, or (iii) notify the physician in writing or by electronic
means, within 15 days for written claim forms or 48 hours for electronic
claims, of all additional information or documentation that is necessary to
establish such physician’s entitlement to such reimbursement. If the Division
fails to comply with the provisions of this paragraph for any such completed
claim, the Division shall pay, in addition to any reimbursement for health care
services provided to which the physician is entitled, interest on any unpaid
amount of such benefits, which shall accrue beginning 45 days after the
Division's receipt of request for reimbursement, or 15 days after the receipt
of an electronic claim, at the rate of 1.5 per cent per month, not to exceed 18
per cent per year. The provisions of this paragraph relating to interest
payments shall not apply to a claim that the Division is investigating because
of suspected fraud.”
“The division shall
provide written guidelines to providers of medical services that participate in
a medical assistance program established pursuant to this chapter setting forth
a statement of its policies and procedures that is complete, detailed and
specific with regard to what such providers must include in claims for
reimbursement in order to qualify as a completed claim for reimbursement
payment for which any such provider is entitled. Such guidelines shall identify
all of the data and documentation that is to accompany each claim for
reimbursement and shall identify all utilization review and other screening
policies and procedures employed by the division in reviewing such claims
submitted by a provider of medical services.
The Division shall institute no policy or practice of
recoupment, reduction, review or retroactive denial of payments to any
physician or physicians for services provided one year or more prior to the
date of the Division’s initiating said policy or practice. Physicians
must be given written notice by the Division specifying any and all policy
changes which may result in recoupments, reductions or reviews of payments for
physician services at least 90 days prior to the implementation of such
recoupments, reductions or reviews.
SECTION 2. CHAPTER 176O,
as most recently amended by Chapter 224 of the Acts of 2012, is hereby
amended by the deletion of the title and inserting in place thereof the
following new title: HEALTH INSURANCE AND DIVISION OF MEDICAL ASSISTANCE
CONSUMER PROTECTIONS.
SECTION 3. Said Chapter
176 O Section 1 is further amended by the deletion of the following paragraph:
“Carrier'', an insurer
licensed or otherwise authorized to transact accident or 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; and an
organization entering into a preferred provider arrangement under chapter 176I,
but not including an employer purchasing coverage or acting on behalf of its
employees or the employees of one or more subsidiaries or affiliated corporations
of the employer. Unless otherwise noted, the term "carrier'' shall not
include any entity to the extent it offers a policy, certificate or contract
that provides coverage solely for dental care services or visions care
services.”;
And inserting in place thereof the following new
paragraph:
"Carrier", an insurer licensed or otherwise authorized
to transact accident or 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, the Primary Care Clinician Program
or any entity providing managed care services under contract to the
Division, or any similar managed care arrangement of the Division of
Medical Assistance or its successor providing medical care coverage to eligible
individuals under M. G. L. Chapter 118 E; and an organization entering into a
preferred provider arrangement under chapter 176I, but not including an
employer purchasing coverage or acting on behalf of its employees or the
employees of one or more subsidiaries or affiliated corporations of the
employer. Unless otherwise noted, the term "carrier'' shall not include
any entity to the extent it offers a policy, certificate or contract that
provides coverage solely for dental care services or visions care services.”
SECTION 4. Said Chapter
176 O, Section 1 is further amended by the deletion of the following
definition:
"Covered benefits'' or "benefits'', health care
services to which an insured is entitled under the terms of the health benefit
plan.”
And inserting in place thereof the following definition:
"Covered benefits" or "benefits", health
care services to which an insured or a recipient of services under the Division
of Medical Assistance or its successor entity under M. G. L. Chapter 118 E is
entitled under the terms of a health benefit plan or program.
SECTION 5. Said Chapter
176O, Section 1 is further amended by the deletion of the following definition:
"Grievance'', any oral or written complaint submitted to
the carrier which has been initiated by an insured, or on behalf of an insured
with the consent of the insured, concerning any aspect or action of the carrier
relative to the insured, including, but not limited to, review of adverse
determinations regarding scope of coverage, denial of services, quality of care
and administrative operations, in accordance with the requirements of this
chapter.
And inserting in place thereof the following definition:
"Grievance", any oral or written complaint submitted
to the carrier or the Division of Medical Assistance or its successor entity
under M. G. L. Chapter 118 E which has been initiated by an insured or a
recipient of public assistance, or on behalf of an insured or recipient of
public assistance with the consent of the insured or the recipient, concerning
any aspect or action of the carrier or the Division of Medical Assistance or
its successor entity under M. G. L. Chapter 118 E relative to the insured or
the recipient, including, but not limited to, review of adverse determinations
regarding scope of coverage, denial of services, quality of care and
administrative operations, in accordance with the requirements of this chapter.
SECTION 6. Said Chapter
176 O, Section 1 is further amended by the deletion of the following
definition:
"Health benefit plan'', a policy, contract, certificate or
agreement entered into, offered or issued by a carrier to provide, deliver,
arrange for, pay for, or reimburse any of the costs of health care services.
And inserting in place thereof the following definition:
"Health benefit plan", a policy, contract, certificate
or agreement entered into, offered or issued by a carrier to provide, deliver,
arrange for, pay for, or reimburse any of the costs of health care services; or
a managed care arrangement of the Division of Medical Assistance or its
successor entity under M. G. L. Chapter 118 E.
SECTION 7. Said Chapter
176 O, Section 1 is further amended by the deletion of the following
definition:
"Insured'', an enrollee, covered person, insured, member,
policyholder or subscriber of a carrier, including an individual whose
eligibility as an insured of a carrier is in dispute or under review, or any
other individual whose care may be subject to review by a utilization review
program or entity as described under other provisions of this chapter.
And inserting in place thereof the following definition:
"Insured", an enrollee, covered person, insured,
member, policyholder or subscriber of a carrier, including an assistance
recipient of the Division of Medical Assistance, and including an individual
whose eligibility as an insured of a carrier is in dispute or under review, or
any other individual whose care may be subject to review by a utilization
review program or entity as described under other provisions of this chapter.
SECTION 8. Said Chapter
176 O, Section 2(a) is hereby amended by the deletion of lines 1 through 3 and
inserting in place thereof the following:
Section 2. (a) There is hereby established within the
center a bureau of managed care. Said bureau shall by regulation establish
minimum standards for the accreditation of carriers, other than the Division of
Medical Assistance or its successor entity under M. G. L. Chapter 118 E, in the
following areas:
SECTION 9. Said
Chapter 176 O, Section 8 is hereby amended by striking said section in its
entirety and inserting in place thereof the following:
Section 8. A carrier, other than the Division of Medical
Assistance or its successor entity under M. G. L. Chapter 118 E, neglecting to
make and file its annual statement or the materials required by the
commissioner to be filed with the division under this chapter or under chapter
176G in the form and within the time required thereby shall be fined $5,000 for
each day during which such neglect continues after being notified by said
commissioner of such neglect, and, after notice and a hearing by the
commissioner to that effect, its authority to do new business shall cease while
such neglect continues