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SD 1569

An Act lowering health care prices for patients

194th Legislature (2025-2026) Introduced by Pavel Payano

Caps charges at 200% of Medicare for covered services to prevent balance billing and cost-shifting to patients.

House concurred
0
WeVote Research Nonpartisan
Bill Summary · SD 1569

Summary: SD 1569 — An Act lowering health care prices for patients

Overview

SD 1569, introduced February 27, 2025 by Senator Pavel M. Payano, is a proposed Massachusetts bill that aims to reduce patient costs for health care services by capping what health care providers, hospitals, and provider organizations can charge relative to Medicare payments. The House has concurred with the measure. The bill would add a new Section 51M to Chapter 111 of the General Laws.

What the bill would do

  • Establish a price cap: No health care provider, hospital, or provider organization may charge more than 200 percent of the Medicare amount paid for a given service.
  • Coverage scope: The cap applies to services delivered in the normal course of business by:
    • Health care providers
    • Hospitals (including teaching hospitals and certain psychiatric facilities)
    • Provider organizations (networks, physician groups, IPAs, accountable care organizations, labs, imaging facilities, etc.)
  • Balance billing prohibition: Providers, hospitals, and provider organizations must not balance bill patients beyond the amount paid by the payor under this section, except for applicable co-pays, co-insurance, and deductibles.
  • Prohibition on shifting costs: Providers cannot recoup excess amounts by raising charges to other health benefit plans or payers.

Key definitions (Section 51M)

  • Health care provider: Any person or organization delivering, billing, or being paid for health care services.
  • Hospital: Licensed hospital facilities defined under existing law.
  • Provider organization: Any entity contracting with carriers to pay for health care services (e.g., physician groups, networks, hospitals, labs, etc.).

Enforcement and oversight

  • Regulatory authority: The Department of Public Health (or its successor) may promulgate regulations to monitor compliance with the section.
  • Attorney General: The Attorney General will have concurrent authority to review and monitor compliance with the section.

Applicability and impact

  • Affects: Health care providers, hospitals, and provider organizations that deliver or bill for covered services.
  • Patients: Aims to reduce out-of-pocket costs and eliminate surprise balance bills for covered services.
  • Payers: Requires alignment with the Medicare-based pricing framework for service billing.

Timeline and legislative status

  • Referred to the Health Care Financing Committee on February 27, 2025.
  • House concurred with the bill on the same day.

Practical takeaways

  • The bill creates a uniform price ceiling (2x Medicare) for services across providers, hospitals, and networks.
  • It strengthens protections against balance billing beyond patient cost-sharing.
  • It introduces regulatory oversight to ensure compliance and to deter shifting costs to other payers.

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

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