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H 4226

Ridge View HS boys basketball champs

2025-2026 Regular Session Introduced by Terry Alexander and 121 co-sponsors

Requires One Care/SCO to let dual-eligible MassHealth/Medicare recipients see any MA provider, pay FFS if no contract, and guarantee 12-month continuity after termination.

Introduced and adopted
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Bill Summary · H 4226

Summary — H 4226 (2025)

Title: An Act ensuring access and continuity of care to specialist and hospital services for dually eligible individuals
Bill Number: H 4226
Sponsor / Presented by: Rep. James J. O'Day (14th Worcester)
Classification: Resolution / statutory amendment language included
Introduced / Adopted: Introduced and adopted 03/26/2025; filed 05/22/2025; referred and acted on in subsequent committee steps (see timeline below)
Related: Replaces HD 4744

Purpose and intent

The bill is intended to ensure that Massachusetts residents who are "dually eligible" (enrolled in both Medicare and MassHealth) have reliable access to specialist and hospital care regardless of managed-care network restrictions, and to preserve continuity of care following termination of a plan–provider contract. The language would apply to One Care and Senior Care Options (SCO) plans serving dually eligible individuals.

Key provisions

  • Adds a new paragraph to Section 9d of Chapter 118E (Mass. General Laws) that:
    • Allows any dually eligible individual residing in the Commonwealth to receive care from any specialist or hospital provider in Massachusetts that participates in and is enrolled in Medicare or MassHealth, irrespective of a member’s health plan or provider network limitations — subject to the other terms and conditions of the member’s benefit plan.
    • Where no contract exists between the plan (One Care or SCO) and the specialist/hospital provider, requires the plan to reimburse the provider at the applicable Medicare or MassHealth fee‑for‑service amount for the services rendered — unless there is an existing contract or the plan and provider mutually agree to a different rate.
  • Continuity‑of‑care following contract termination:
    • If a plan and a provider terminate a contract that covered One Care or SCO members, the plan and provider must allow impacted members to continue receiving services from their primary care provider, specialists, or inpatient/outpatient hospital subject to the termination.
    • This continuation must be under the terms of the pre‑existing contract for 12 months after any other continuity‑of‑care requirement period has expired.
    • During the 12‑month period, the plan must maintain contractual terms and conditions (including reimbursement) that were in effect prior to the notice of termination 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: Dually eligible individuals (Medicare + MassHealth) enrolled in One Care or SCO plans in Massachusetts.
  • Affected entities:
    • One Care and SCO managed‑care plans (must permit access and reimburse at specified rates when no contract exists).
    • Specialist and hospital providers enrolled in Medicare or MassHealth (gain access rights and a payment fallback).
    • MassHealth (responsible for oversight/implementation).
  • Potential secondary effects: plan financial exposure for out‑of‑network services, potential changes in contract negotiation dynamics between plans and providers.

Procedural status & timeline (selected)

  • 03/26/2025 — Introduced and adopted (House)
  • 05/22/2025 — Filed (House Docket No. 4744)
  • 05/29/2025 — Referred to the committee on House Rules
  • 06/12/2025 — Reported; referred to Joint Rules; rules suspended and referred to the committee on Public Health
  • 06/16/2025 — Senate concurred
  • Hearings scheduled/rescheduled for 09/29/2025 (public/virtual hearings noted)

Notes and observations

  • The bill text in the docket also includes a separate ceremonial House resolution (congratulating Ridge View High School boys basketball team). That resolution appears to be a distinct, non‑substantive item and may have been included in the same filing or docket entry; it does not affect the statutory amendments described above.
  • Fiscal impacts are not stated in the text; requiring plans to reimburse out‑of‑network providers at Medicare/MassHealth FFS rates and preserving contract terms for 12 months could have budgetary or premium implications for managed‑care plans and potentially for MassHealth oversight resources.
  • The provision strengthens beneficiary protections for continuity of care and reduces barriers to accessing specialists and hospitals enrolled in public programs.

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

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