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S 856

Increases the number of members on the state commission of correction

2025 Regular Session Introduced by April Baskin and 11 co-sponsors

Guarantees dually eligible Massachusetts residents can access any Medicare/MassHealth participating specialist or hospital in-state, regardless of plan networks, with continuity of

REFERRED TO CORRECTION
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Bill Summary · S 856

Summary — S. 856 (Senate No. 856): Ensuring access and continuity of specialist and hospital care for dually eligible individuals

Note: the bill text filed in the Massachusetts General Court (presented by Sen. Sal N. DiDomenico) addresses access and continuity of care for “dually eligible” individuals (those eligible for both Medicare and MassHealth). Some metadata supplied with the request (title, sponsors, committee names) appears inconsistent with the Massachusetts filing; this summary focuses on the statutory text and Massachusetts context as filed.

Purpose

To guarantee that Massachusetts residents who are dually eligible for Medicare and MassHealth can access necessary specialist and hospital services across the Commonwealth regardless of their managed care plan network limitations, and to preserve continuity of care when contracts between plans and providers terminate.

Key provisions

  • Adds a new paragraph (r) to Section 9d of Chapter 118E (Massachusetts General Laws).
  • Access outside plan networks:
    • Any dually eligible individual may receive care from any specialist or hospital in Massachusetts that participates in Medicare or MassHealth, irrespective of a health plan’s network limitations, subject to the other terms and conditions of the member’s benefit plan.
  • Reimbursement where no contract exists:
    • If a provider and a One Care or SCO plan do not have an existing contract for the service rendered, the provider must be reimbursed by the One Care or SCO plan at the Medicare or MassHealth fee-for-service (FFS) rate, unless a contract already exists or the parties mutually agree to a different rate.
  • Continuity after contract termination:
    • If a One Care or SCO plan and a provider terminate a contract that covered care for One Care/SCO members, impacted members must be allowed to continue receiving services from their primary care provider, specialist, or inpatient/outpatient hospital under the pre-existing contract terms for 12 months following the expiration of any continuity-of-care requirements that apply after termination.
    • Plans must maintain contractual terms (including reimbursement) that were in effect prior to notice of termination during this 12‑month period, unless the plan and provider mutually agree otherwise.
    • Plans and providers are prohibited from using this provision to avoid negotiating in good faith.

Who is affected

  • Primary beneficiaries: Massachusetts residents dually eligible for Medicare and MassHealth (One Care and SCO enrollees).
  • Health plans: One Care and SCO managed care plans.
  • Providers: specialist physicians, hospitals (inpatient and outpatient), and primary care providers participating in Medicare or MassHealth.
  • MassHealth (state agency) — responsible for enforcing plan requirements.

Procedural status (as provided)

  • Filed/presented 1/16/2025 (Mass. General Court, Sen. Sal N. DiDomenico).
  • Legislative activity records indicate passage in the Senate (05/20/2025) and delivery to the House/Assembly; later referred to “Correction” and other committees per docket entries. (Note: the docket includes multiple, possibly duplicated entries — see “Notes” below.)

Potential impacts and considerations

  • Improves access to out-of-network specialist and hospital care for dually eligible members.
  • May increase financial exposure for One Care/SCO plans if required to reimburse at FFS rates where higher than negotiated in-network rates or if utilization shifts out of plan networks.
  • May encourage plans and providers to negotiate or renegotiate contracts rather than rely on FFS fallback; explicit prohibition against using the provision to avoid good-faith negotiation seeks to limit gaming.
  • Operational questions include how requests are processed, documentation required, and coordination of benefits between Medicare and MassHealth.

Notes / discrepancies

  • Some header metadata (bill title, listed sponsors, and committees) appears inconsistent or drawn from other jurisdictions; this summary prioritizes the Massachusetts statutory text as filed and enacted actions recorded in the Massachusetts docket. If you want a version tied strictly to federal sponsors/committees, please provide the exact document to reconcile differences.

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

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