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SD 3944

Primary Care Task Force Statutory Deliverable #5: Assess the Impact of Health Plan Design on Health Equity and Patient Access to Primary Care Services

194th Legislature (2025-2026)

The bill promotes consumer-friendly cost-sharing that lowers barriers to primary care and preventive services, paired with broader cost-control measures to maintain overall afforda

Placed on file
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Bill Summary · SD 3944

Overview

Bill SD 3944 ( Massachusetts 194th Session) addresses how health plan design, particularly cost sharing, affects health equity and access to primary care. It builds on Statutory Deliverable #4 by emphasizing consumer-friendly cost-sharing structures that promote primary care use while pairing any design changes with efforts to curb underlying health care spending growth. The proposal reflects findings from the Massachusetts Primary Care Access, Delivery, and Payment Task Force (PCTF) and the Massachusetts Health Policy Commission (HPC) on cost sharing, affordability, and administrative burden.

Main purpose and intent

  • Improve health care affordability by reducing barriers created by cost sharing (premiums and out-of-pocket costs) to primary care services.
  • Promote primary care access and patient engagement by designing plans that minimize patient financial barriers and administrative complexity.
  • Ensure cost-sharing reforms are paired with broader strategies that address the underlying drivers of health care cost growth to avoid inadvertent premium increases.
  • Consider and codify examples of innovative plan designs that shift cost sharing away from high deductibles toward lower, more predictable copay structures for primary care.

Key provisions and changes

  • Cost sharing design goals:

    • Minimize deductibles and co-insurance for primary care services to encourage ongoing patient-provider dialogue.
    • Reduce or cap cost sharing for routine, preventive-care-related services (e.g., evidence-based labs and imaging) when these are part of primary care or preventive care visits.
    • Ensure plan designs are compatible with health savings accounts (HSAs) and high-deductible health plans (HDHPs) as allowed by federal guidance.
    • Consider prohibiting or moderating cost sharing for services covered under an advanced primary care payment model, within federal allowances.

  • Administrative burden reduction:

    • Design plans to lessen administrative hurdles for both patients and primary care providers.
    • Recommend reducing prior authorization requirements for evidence-based primary care services and standardizing processes where possible.
    • Aim to ease referral management to streamline access to appropriate care.

  • Coupling cost sharing with cost-control measures:

    • Emphasize that reducing cost sharing should be paired with strategies to reduce overall health care costs and efficiency improvements to avoid premium inflation.
    • Reference DOI actions in the merged market as an example of meaningful cost-sharing regulation.

  • Policy context and rationale:

    • Draws on HPC 2025 Cost Trends Report showing rising cost sharing and its uneven impact across income groups.
    • Highlights the equity concerns associated with deductible-based designs, including unexpected bills, high variability in out-of-pocket costs, and administrative challenges.
    • Acknowledges examples from payers and public programs with innovative cost-sharing approaches (e.g., exempting primary care from deductibles or capping copays).

Who/what is affected

  • Massachusetts residents covered by commercial health plans (individual and small group markets are emphasized in the policy discussions).
  • Primary care practices (independent, pediatric, FQHCs, and hospital-system-based practices) that would participate in or be affected by redesigned plan benefits.
  • Health insurers and the Massachusetts Division of Insurance (DOI), particularly regarding rate filings and cost-sharing regulation.
  • Employers and employees who purchase or receive coverage in the merged market.

Procedural and timeline aspects

  • Deliberation history:

    • November 18, 2025: PCTF Data and Research Workgroup reviewed HPC 2025 findings on cost sharing, affordability, and service-specific cost-sharing trends.
    • April 8, 2026: Full PCTF discussed HPC findings on cost sharing and access to primary care, including real-world examples of plan designs and administrative burdens.

  • Legislative actions:

    • Statutory Deliverable #5 directs ongoing Commonwealth efforts to improve affordability and promote consumer-friendly primary care benefit designs.
    • Cited example: DOI’s 2026-27 rate filing guidance and cap on cost-sharing growth (3.6% for 2027 filings) as a reference point for regulatory action.
    • The bill positions cost-sharing reform as a paired strategy with broader cost-control measures and workforce considerations (to be addressed in later deliverables, including workforce development).

  • Current status:

    • Placed on file as of June 1, 2026.

Potential impacts and considerations

  • Positive impacts:

    • Increased primary care utilization due to lower patient cost-sharing for visits and routine services.
    • Greater financial predictability for patients, reducing surprises from billable ancillary services.
    • Reduced administrative burden on providers and patients, improving care experience and coordination.

  • Potential challenges:

    • Balancing reduced cost sharing with overall premium costs; need for complementary spending reforms to avoid premium hikes.
    • Implementation complexity across diverse plan designs and payer systems.
    • Ensuring federal alignment for HSA-compatible plans and any exemptions from deductibles.

Key takeaways

  • The bill emphasizes consumer-friendly cost-sharing designs that promote primary care access and health equity.
  • It calls for reducing deductibles and co-insurance for primary care and preventive services, while limiting administrative burdens.
  • It stresses pairing cost-sharing reforms with broader cost-control measures to ensure overall affordability, referencing regulatory actions already taken by DOI.
  • The measure builds on HPC and PCTF findings to guide future policy and regulatory adjustments in the Massachusetts health care system.

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

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