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H 4226

An Act ensuring access and continuity of care to specialist and hospital services for dually eligible individuals

194th Legislature (2025-2026) Introduced by Jim O'Day

Massachusetts bill establishing care continuity protections for low-income seniors and disabled persons with both Medicare and Medicaid coverage to prevent specialist and hospital service disruptions.

Accompanied a study order, see H5354 (under House Rule 27)
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Bill Summary · H 4226

Legislative bill overview

H 4226 addresses healthcare access for "dually eligible" individuals—those covered by both Medicare and Medicaid. The bill aims to ensure these vulnerable patients maintain continuity of care with specialists and hospitals when transitioning between or managing dual coverage. The legislation appears designed to prevent coverage gaps or service interruptions that can occur at the intersection of federal and state insurance programs.

Why is this important

Dually eligible individuals are typically low-income seniors and disabled persons who rely on both programs for comprehensive coverage. Gaps in specialist or hospital access can lead to delayed treatments, hospital readmissions, and worse health outcomes. This bill addresses a real coordination problem between Medicare and Medicaid that currently affects hundreds of thousands of Massachusetts residents.

Potential points of contention

  • Cost implications: Mandating continuity of care may increase state Medicaid expenditures or require higher provider reimbursement rates, raising questions about budget impact
  • Provider participation: Hospitals and specialists may resist new requirements without corresponding payment increases, potentially affecting service availability
  • Federal-state coordination: The bill operates in a space governed by federal Medicare rules, creating potential conflicts or implementation complications with CMS (Centers for Medicare & Services)
  • Definition and scope: The specific definition of "access and continuity" and which services are covered may be contested by insurers versus patient advocates

Compiled from official sources — confirm details with the bill’s official record.

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