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Patient Bill of Rights
 
Chapter 141 of the Acts of 2000
AN ACT RELATIVE TO MANAGED CARE PRACTICES IN THE INSURANCE INDUSTRY.
Whereas, The deferred operation of this act would tend to defeat its purpose, which is to protect the rights of patients and to preserve the public health, therefore it is hereby declared to be an emergency law, necessary for the immediate preservation of the public convenience.
 
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 
SECTION 1 Chapter 6A of the General Laws is hereby amended by inserting after section 16C the following section:-
 
Section 16D (a) The managed care oversight board is hereby established within, but not subject to the control of, the executive office of health and human services. The board shall consist of the following members: the secretary of said office, the commissioner of insurance, the commissioner of public health, the commissioner of the department of mental health, the commissioner of medical assistance, the executive director of the group insurance commission, the director of consumer affairs and business regulation, a physician member of the board of registration in medicine to be appointed by the governor, and the secretary of administration and finance. The board shall be chaired by the secretary of health and human services. Each such member may appoint a designee to serve in the member's place.
 
(b) The board shall appoint an executive director to oversee and coordinate the activities of the board. The board shall be assisted in its duties by the office, which shall provide technical, technological, operational and administrative support. The expenses of the board shall be funded from amounts appropriated from the general fund or any other fiscal resource of the commonwealth designated for such purpose.
 
(c) The board shall have oversight authority over the office of patient protection in the department of public health established by section 217 of chapter 111, and the managed care bureau in the division of insurance established by section 2 of chapter 176O, but the board's authority in this regard shall be limited to coordinating functions between said office and  said bureau and reviewing and commenting upon regulations promulgated by said office and said bureau. The board shall not  have authority to approve or disapprove such regulations except to the extent of a conflict between the regulations  promulgated or proposed or any actions undertaken by said office and said bureau. The board shall take all necessary steps  to coordinate the functions of said office and said bureau in order to avoid, to the maximum extent possible, redundancy and  duplication of effort.
 
(d) There is hereby established an advisory committee to advise the board on issues relating to managed care practices including, but not limited to, issues involving health care cost, quality and access. Said committee shall also have the right to review and comment upon all rules, regulations and guidelines issued by the office of patient protection and the managed care bureau at least 60 days before the date such regulations become final, but in the case of emergency regulations the time period shall be a reasonable time under the circumstances as determined by the secretary of health and human services. Said committee shall designate one person to serve as a liaison to the managed care oversight board. Said committee shall consist of 14 persons to be appointed by the secretary of health and human services one of whom shall represent Health Care  for All; one of whom shall represent the Massachusetts Medical Society; one of whom shall represent the Massachusetts Association of Health Maintenance Organizations; one of whom shall represent the Associated Industries of Massachusetts; one of whom shall represent the Massachusetts Nurses Association; one of whom shall represent the Massachusetts Hospital Association; one of whom shall represent the Ad Hoc Committee to Defend Health Care; one of whom shall represent a mental health consumer advocacy organization; one of whom shall represent a senior citizen organization; one of whom shall represent an organization representing the disabled and chronically ill; one of whom shall represent community health centers; one of whom shall represent the Massachusetts Health Care Purchasers Group; one of whom shall represent the Life Insurance Association of Massachusetts; and one of whom shall represent a utilization review organization not otherwise represented. Said committee shall elect a chair from among its members and adopt bylaws for its proceedings.
 
SECTION 2 Chapter 111 of the General Laws is hereby amended by inserting after section 51F the following section:-
 
Section 51G (1) No original license shall be granted to establish or maintain an acute-care hospital, as defined by section 25B unless there is a determination by the department of the suitability and responsibility of the prospective licensee in accordance with regulations of the department.
For purposes of this section, the department's determination of suitability and responsibility shall include the following factors:
 
(a) the financial capacity of the prospective licensee to operate the hospital in accordance with applicable laws.
 
(b) the history of the prospective licensee in providing acute care, including in states other than the commonwealth, if any, measured by compliance with the applicable statutes and regulations governing the operation of hospitals in such states.
 
(c) the participation of persons residing in the non-profit entity's primary service area in oversight of the resulting hospital.
 
(d) whether the transaction will create a significant effect on the availability or accessibility of health care services to the affected communities.
 
(2) No original license shall be granted to establish or maintain an acute care hospital as defined in section 25B unless all financial transactions, including remuneration of all officers of hospitals affected by the transaction, are disclosed as part of the licensure process, and unless a public hearing is held, according to procedures established in regulation by the department, prior to the granting of the license.
 
(3) No original license shall be granted to establish or maintain an acute-care hospital, as defined by section 25B and any subsequent successor or acquirer, unless the applicant agrees to maintain or increase the percentage of gross patient service revenues allocated to free care. The department may permit the applicant to reduce said percentage if the department determines that demographic or other changes in the hospital's service area justify a reduction in said percentage. The department shall promulgate regulations to enforce this paragraph and any agreement made by an applicant concerning free care.
 
(4) Any hospital shall inform the department 90 days prior to the closing of the hospital or the discontinuance of any essential health service provided therein. The department shall by regulation define "essential health service" for the purposes of this section. The department shall, in the event that a hospital proposes to discontinue an essential health service or services, determine whether any such discontinued services are necessary for preserving access and health status in the hospital's service area, require hospitals to submit a plan for assuring access to such necessary services following the hospital's closure of the service, and assure continuing access to such services in the event that the department determines that their closure will significantly reduce access to necessary services. The department shall conduct a public hearing prior to a determination on the closure of said essential services or of the hospital. No original license shall be granted to establish or maintain an acute-care hospital, as defined by section 25B, unless the applicant submits a plan, to be approved by the department, for the provision of community benefits, including the identification and provision of essential health services. In approving the plan, the department may take into account the applicant's existing commitment to primary and preventive health care services and community contributions as well as the primary and preventive health care services and community contributions of the predecessor hospital. The department may waive this requirement, in whole or in part, at the request of the applicant which has provided or at the time the application is filed, is providing, substantial primary and preventive health care services and community contributions in its service area.
 
(5) No original license shall be granted to establish or maintain an acute care hospital as defined by section 25B which results from the merger or acquisition of the hospital, unless the board of trustees of the hospital publicly presents and evaluates all proposals for such a merger or acquisition according to rules and regulations promulgated by the department.
 
(6) Whenever the department finds upon inspection, or through information in its possession, that a licensee is not in compliance with a requirement established under this section, the department may order the licensee to correct such deficiency. Every such correction order shall include a statement of the deficiencies found, the period prescribed within which the deficiency must be corrected, and the provisions of law relied upon. The department may assess the licensee ordered to correct deficiencies no less than $1,000 and not more than $10,000 per deficiency for each day the deficiency continues to exist beyond the date prescribed for correction. Within seven days of receipt, the affected licensee may file a written request with the department for administrative reconsideration of the order or any portion thereof.
 
SECTION 3 Said chapter 111 is hereby further amended by adding the following section:-
 
Section 217 (a) There is hereby established within the department an office of patient protection. The office shall:-
 
(1) have the authority to administer and enforce the standards and procedures established by sections 13, 14, 15 and 16 of chapter 176O, and to promulgate regulations therefor. Such regulations shall protect the confidentiality of any information about a carrier or utilization review organization, as defined in said chapter 176O, which, in the opinion of the office, and in consultation with the division of insurance, is proprietary in nature. The regulations authorized by this section shall be consistent with, and not duplicate or overlap with, regulations promulgated by the bureau of managed care established in the division of insurance pursuant to said chapter 1760.
 
(2) establish a site on the internet and through other communication media in order to make managed care information collected by the office readily accessible to consumers. Said internet site shall, at a minimum, include (i) the health plan report card developed pursuant to section 24 of chapter 118G , (ii) a chart, prepared by the office, comparing the information obtained on premium revenue expended for health care services as provided pursuant to subsection (3) of paragraph (b) of section 7 of chapter 176O,for the most recent year for which information is available, and (iii) data collected pursuant to paragraph (c).
 
(3) assist consumers with questions or concerns relating to managed care, including but not limited to exercising the grievance and appeals rights established by sections 13 and 14, of said chapter 176O;
 
(4) monitor quality-related health insurance plan information relating to managed care practices.
 
(5) regulate the establishment and functions of review panels established by section 14 of chapter 176O.
 
(6) periodically advise the commissioner, the managed care oversight board established by section 16D of chapter 6A, the joint committee on health care and the joint committee on insurance on actions, including legislation, which may improve the quality of managed care health insurance plans.
 
(b) The commissioner shall establish an external review system for the review of grievances submitted by or on behalf of insureds of carriers pursuant to section 14 of chapter 176O.
 
(c) Each entity that compiles the health plan employer data and information set, so-called, for the National Committee on Quality Assurance, or collects other information deemed by the entity as similar or equivalent thereto, shall, upon submitting said data and information set to the division of health care finance and policy pursuant to section 24 of chapter 118G, concurrently submit to the office of patient protection a copy thereof excluding, at the entity's option, proprietary financial data.
 
SECTION 4 Chapter 112 of the General Laws is hereby amended by inserting after section 5L the following section:-
 
Section 5M
 
SECTION 5 Chapter 118E of the General Laws is hereby amended by inserting after section 17 the following section:-
 
Section 17A (a) As used in this section, the following words shall have the following meanings:
 
"Attending physician", the emergency physician or consultant physician who actively treats the emergency medical condition of a beneficiary at an emergency facility.
 
"Beneficiary", a recipient of medical assistance or medical benefits pursuant to this chapter who is treated in an emergency facility for an emergency medical condition.
 
"Emergency medical condition", a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of a beneficiary or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).
 
"Stabilization for discharge", an emergency medical condition shall be deemed to be stabilized for purposes of discharging a beneficiary, other than for the purpose of transfer from one facility to another facility, when the attending physician has determined that, within reasonable clinical confidence, the beneficiary has reached the point where further care, including diagnostic work-up or treatment, or both, could be reasonably performed on an outpatient basis or a later scheduled inpatient basis if the beneficiary is given a reasonable plan for appropriate follow-up care and discharge instructions, or as further defined in section 1867(e)(3)(A) of the Social Security Act, 42 U.S.C. section 1395dd(e)(3)(A). Stabilization for discharge does not require final resolution of the emergency medical condition.
 
"Stabilization for transfer", an emergency medical condition shall be deemed to be stabilized for transfer if a beneficiary can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the beneficiary is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4) of the Social Security Act, 42 U.S.C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition.
 
(b) Any program of medical assistance or medical benefits for which the division is the primary payor shall cover emergency services provided to a beneficiary for emergency medical conditions. After the beneficiary has been stabilized for discharge or transfer, the division or its designee may require a hospital emergency department to contact the physician on-call designated by the division or its designee for authorization of post-stabilization services to be provided. The hospital emergency department shall take all reasonable steps to initiate contact with the division or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if the division or its designee has not responded to said call within 30 minutes. Notwithstanding the foregoing provision, if the attending physician and said on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician shall prevail and such treatment shall be considered appropriate treatment for an emergency medical condition, if such treatment is consistent with generally accepted principles of professional medical practice and is a covered benefit under said program of medical assistance or medical benefits. Consistent with the foregoing, the division or its designee may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services.
 
(c) The division or its designee may require a beneficiary to contact the division or its designee or the primary care physician of the beneficiary within 48 hours of receiving such emergency services, but notification already given to said division, designee, or primary care physician by the attending physician shall satisfy the requirements of this subsection.
 
(d) Nothing in this section shall be construed to limit retrospective utilization review activities by the division or its designee with respect to screening, stabilization and post-stabilization services for the purposes of assessing quality, utilization patterns and coding and billing practices, but such activities shall not result in retroactive changes to treatment or reimbursement decisions previously made in accordance with this section. In conducting said utilization review activities, the division or its designee shall comply with section 12 of chapter 176O and all applicable state and federal confidentiality provisions.
 
(e) The division or its designee shall clearly state in its brochures, contracts, policy manuals and all printed materials that beneficiaries shall have the option of calling the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent, whenever a beneficiary is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. No beneficiary shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of such emergency medical condition.
 
SECTION 6 Chapter 118G of the General Laws is hereby amended by adding the following section:-
 
Section 24 The division shall develop and issue a document for consumers to be known as the health plan report card,containing information and data providing a basis by which health insurance plans may be evaluated and compared by consumers. The division may contract for the design and production of said report. The report shall be made available to residents of the commonwealth, upon request, by the office of patient protection in the department of public health, and shall be updated and issued annually by said office in consultation with the division. In preparing such report card, the division shall, to the extent possible, use information already reported by health insurance plans, including, but not limited to, the health plan employer data and information set established by the National Committee on Quality Assurance. The division shall consult with the department of public health and the division of insurance in determining the content and format of such report card, and shall make such report card available on the internet site established by the office of patient protection in the department of public health.
 
SECTION 7 Section 24B of chapter 175 of the General Laws, as appearing in the 1998 Official Edition, is hereby
amended by inserting after the first sentence the following two sentences:- Such notices shall include any changes in clinical review criteria, as such term is defined in section 1 of chapter 176O, and a statement of the effect of such changes on the personal liability of the policyholder or subscriber for the cost of any such changes. All notices required by this section shall be provided 60 days before the effective date of such modification.
 
SECTION 8 Said chapter 175 is hereby further amended by inserting after section 47T the following section:-
 
Section 47U (a) As used in this section, the following words shall have the following meanings:
 
"Attending physician", the emergency physician or consultant physician who actively treats the emergency medical condition of an insured at an emergency facility.
 
"Emergency medical condition", a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).
 
"Insured", a subscriber or policyholder of a company licensed to sell health and accident insurance in the commonwealth pursuant to this chapter who is treated in an emergency facility for an emergency medical condition.
 
"Stabilization for discharge", an emergency medical condition shall be deemed to be stabilized for purposes of discharging an insured, other than for the purpose of transfer from one facility to another facility, when the attending physician has determined that, within reasonable clinical confidence, the insured has reached the point where further care, including diagnostic work-up or treatment, or both, could be reasonably performed on an outpatient basis or a later scheduled inpatient basis if the insured is given a reasonable plan for appropriate follow-up care and discharge instructions, or as further defined in section 1867(e)(3)(A) of the Social Security Act, 42 U.S.C. section 1395dd(e)(3)(A). Stabilization for discharge does not require final resolution of the emergency medical condition.
 
"Stabilization for transfer", an emergency medical condition shall be deemed to be stabilized for transfer if an insured can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the insured is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4) of the Social Security Act, 42 U.S.C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition.
 
(b) Any policy of accident or sickness insurance delivered, issued or renewed in the commonwealth pursuant to this chapter shall provide as benefits to all insureds coverage for emergency services provided to an insured for emergency medical conditions. After the insured has been stabilized for discharge or transfer, said policy of insurance may require a hospital emergency department to contact a physician on-call designated by the carrier or its designee for authorization of post-stabilization services to be provided. The hospital emergency department shall take all reasonable steps to initiate contact with the carrier or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if said carrier or its designee has not responded to said call within 30 minutes. Notwithstanding the foregoing provision, in the event the attending physician and said on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician shall prevail and such treatment shall be considered appropriate treatment for an emergency medical condition, provided that such treatment is consistent with generally accepted principles of professional medical practice and is a covered benefit under the policy or contract of the insured with a carrier. Consistent with the foregoing, said carrier or its designee may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services.
 
(c) Said policy of insurance may require an insured to contact either the carrier or its designee or the primary care physician of the insured within 48 hours of receiving such emergency services, but notification already given to said carrier, designee or primary care physician by the attending physician shall satisfy the requirements of this subsection.
 
(d) Nothing in this section shall be construed to limit retrospective utilization review activities by a carrier or its designee with respect to screening, stabilization and post-stabilization services for the purposes of assessing quality, utilization patterns and coding and billing practices, but such activities shall not result in retroactive changes to treatment or reimbursement decisions previously made in accordance with this section. In conducting said utilization review activities, said carrier or its designee shall be in compliance with section 12 of chapter 176O and all applicable state and federal confidentiality provisions.
 
(e) A carrier or its designee shall clearly state in its brochures, contracts, policy manuals and all printed materials that insureds shall have the option of calling the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent whenever an insured is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. No insured shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of such emergency medical condition.
 
SECTION 9
Section 108 of said chapter 175, as appearing in the 1998 Official Edition, is hereby amended by inserting
after the word "expense", in line 462, the first time it appears, the following words:- , medical expense.
 
SECTION 10
Said Section 108 of said chapter 175, as so appearing, is hereby further amended by striking out, in line
469, the words "for any claim relating to dental services".
 
SECTION 11
Section 110 of said chapter 175, as so appearing, is hereby amended by inserting after the word
"expense", in line 198, the first time it appears, the following words:- , medical expense.
 
SECTION 12
Said Section 110of said chapter 175, as so appearing, is hereby further amended by striking out, in line
205, the words "for any claim relating to dental services".
 
SECTION 13
Section 8 of chapter 176A of the General Laws, as so appearing, is hereby amended by striking out, in
lines 38 and 39, the words "for any claims relating to dental services".
 
SECTION 14 Said chapter 176A is hereby further amended by inserting after section 8T the following section:-
 
Section 8U (a) As used in this section, the following words shall have the following meanings:-
 
"Attending physician", the emergency physician or consultant physician who actively treats the emergency medical condition of an insured at an emergency facility.
 
"Emergency medical condition", a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of an insured or another person's health in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).
 
"Insured", a subscriber or policyholder of a company licensed to sell health and accident insurance in the commonwealth pursuant to this chapter who is treated in an emergency facility for an emergency medical condition.
 
"Stabilization for discharge", an emergency medical condition shall be deemed to be stabilized for purposes of discharging an insured, other than for the purpose of transfer from one facility to another facility, when the attending physician has determined that, within reasonable clinical confidence, the insured has reached the point where further care, including diagnostic work-up or treatment, or both, could be reasonably performed on an outpatient basis or a later scheduled inpatient basis if the insured is given a reasonable plan for appropriate follow-up care and discharge instructions, or as further defined in section 1867(e)(3)(A) of the Social Security Act, 42 U.S.C. section 1395dd(e)(3)(A). Stabilization for discharge does not require final resolution of the emergency medical condition.
 
"Stabilization for transfer", an emergency medical condition shall be deemed to be stabilized for transfer if an insured can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the insured is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4), 42 U.S.C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition.
 
(b) Any contract or subscription certificate between an insured and the corporation shall provide as benefits coverage for emergency services provided to an insured for emergency medical conditions. After an insured has been stabilized for discharge or transfer, the corporation or its designee may require a hospital emergency department to contact the physician on-call designated by the corporation or its designee for authorization of post-stabilization services to be provided. The hospital emergency department shall take all reasonable steps to initiate contact with the corporation or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if the corporation or its designee has not responded to said call within 30 minutes. Notwithstanding the foregoing provision, in the event the attending physician and said on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician shall prevail and such treatment shall be considered appropriate treatment for an emergency medical condition provided that such treatment is consistent with generally accepted principles of professional medical practice and is a covered benefit under the contract or subscription certificate of an insured with the corporation. Consistent with the foregoing, the corporation or its designee may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services.
 
(c) Any contract or subscription certificate between an insured and the hospital service corporation may require an insured to contact the corporation or its designee or the primary care physician of the insured within 48 hours of receiving such emergency services, but notification already given to the corporation, its designee or to said primary care physician by the attending physician shall satisfy the requirements of this paragraph.
 
(d) Nothing in this section shall be construed to limit retrospective utilization review activities by the corporation or its designee with respect to screening, stabilization and post-stabilization services for the purposes of assessing quality, utilization patterns and coding and billing practices, but such activities shall not result in retroactive changes to treatment or reimbursement decisions previously made in accordance with this section. In conducting said utilization review activities, the corporation or its designee shall be in compliance with section 12 of chapter 176O and all applicable state and federal confidentiality provisions.
 
(e) The corporation or its designee shall clearly state in its brochures, contracts, policy manuals and all printed materials that insureds shall have the option of calling the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent, whenever an insured is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. No insured shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of such emergency medical condition.
 
SECTION 15 Chapter 176B of the General Laws is hereby amended by inserting after section 4T the following section:-
 
Section 4U (a) As used in this section, the following words shall have the following meanings:-
 
"Attending physician", the emergency physician or consultant physician who actively treats the emergency medical condition of an insured at an emergency facility.
 
"Emergency medical condition", a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of an insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).
 
"Insured", a member or subscriber of a medical service corporation who is treated in an emergency facility for an emergency medical condition, regardless of whether the member's or subscriber's contract with the corporation is delivered, issued or renewed on a group or individual basis.
 
"Stabilization for discharge", an emergency medical condition shall be deemed to be stabilized for purposes of discharging an insured, other than for the purpose of transfer from one facility to another facility, when the attending physician has determined that, within reasonable clinical confidence, the insured has reached the point where further care, including diagnostic work-up or treatment, or both, could be reasonably performed on an outpatient basis or a later scheduled inpatient basis if the insured is given a reasonable plan for appropriate follow-up care and discharge instructions, or as further defined in section 1867(e)(3)(A) of the Social Security Act, 42 U.S.C. section 1395dd(e)(3)(A). Stabilization for discharge does not require final resolution of the emergency medical condition.
 
"Stabilization for transfer", an emergency medical condition shall be deemed to be stabilized for transfer if an insured can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the insured is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4) of the Social Security Act, 42 U.S.C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition.
 
(b) Any contract or subscription certificate between an insured and the corporation shall provide as benefits coverage for emergency services provided to an insured for emergency medical conditions. After an insured has been stabilized for discharge or transfer, the corporation or its designee may require a hospital emergency department to contact the physician on call designated by the corporation or its designee for authorization of post-stabilization services to be provided. The hospital emergency department shall take all reasonable steps to initiate contact with said corporation or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if said corporation or its designee has not responded to said call within 30 minutes. Notwithstanding the foregoing provision, in the event the attending physician and said on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician shall prevail and such treatment shall be considered appropriate treatment for an emergency medical condition provided that such treatment is consistent with generally accepted principles of professional medical practice and is a covered benefit under the contract or subscription certificate of an insured with the corporation. Consistent with the foregoing, said corporation or its designee may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services.
 
(c) Any contract or subscription certificate between an insured and the medical service corporation may require an insured to contact either the corporation or its designee or the primary care physician of the insured within 48 hours of receiving such emergency services, but notification already given to said corporation, designee or said primary care physician by the attending physician shall satisfy the requirements of this paragraph.
 
(d) Nothing in this section shall be construed to limit retrospective utilization review activities by said corporation or its designee with respect to screening, stabilization and post-stabilization services for the purposes of assessing quality, utilization patterns and coding and billing practices, but such activities shall not result in retroactive changes to treatment or reimbursement decisions previously made in accordance with this section. In conducting said utilization review activities, said corporation or its designee shall be in compliance with section 12 of chapter 176O and all applicable state and federal confidentiality provisions.
 
(e) The corporation or its designee shall clearly state in its brochures, contracts, policy manuals and all printed materials that insureds shall have the option of calling the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent, whenever an insured is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. No insured shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of such emergency medical condition.
 
SECTION 16
Section 7 of chapter 176B, as appearing in the 1998 Official Edition, is hereby amended by striking out, in
line 66, the word "sixty" and inserting in place thereof the following figure:- 45.
 
SECTION 17 Said Section 7 of said chapter 176B, as so appearing, is hereby further amended by striking out, in lines 81
and 82, the words "for any claim relating to dental services".
 
SECTION 18
Said Section 7 of said chapter 176B, as so appearing, is hereby further amended by striking out, in line 84,
the word "sixty" and inserting in place thereof the following figure:- 45.
 
 
SECTION 19
Chapter 176G of the General Laws is hereby amended by striking out section 5, as so appearing, and
inserting in place thereof, the following section:-
 
Section 5 (a) As used in this section, the following words shall have the following meanings:-
 
"Attending physician", the emergency physician or consultant physician who actively treats the emergency medical condition of a member at an emergency facility.
 
"Emergency medical condition", a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of a member or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).
 
"Stabilization for discharge", an emergency medical condition shall be deemed to be stabilized for purposes of discharging a member, other than for the purpose of transfer from one facility to another facility, when the attending physician has determined that, within reasonable clinical confidence, the member has reached the point where further care, including diagnostic work-up or treatment, or both, could be reasonably performed on an outpatient basis or a later scheduled inpatient basis if the member is given a reasonable plan for appropriate follow-up care and discharge instructions, or as further defined in section 1867(e)(3)(A) of the Social Security Act, 42 U.S.C. section 1395dd(e)(3)(A). Stabilization for discharge does not require final resolution of the emergency medical condition.
 
"Stabilization for transfer", an emergency medical condition shall be deemed to be stabilized for transfer if a member can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the member is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4) of the Social Security Act, 42 U.S.C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition.
 
(b) A health maintenance organization shall cover emergency services provided to members for emergency medical conditions. After the member has been stabilized for discharge or transfer, the health maintenance organization or its designee may require a hospital emergency department to contact the physician on-call designated by the health maintenance organization or its designee for authorization of post-stabilization services to be provided. The hospital emergency department shall take all reasonable steps to initiate contact with the health maintenance organization or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if the health maintenance organization or its designee has not responded to said call within 30 minutes. Notwithstanding the foregoing provision, in the event the attending physician and said on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician shall prevail and such treatment shall be considered appropriate treatment for an emergency medical condition provided that such treatment is consistent with generally accepted principles of professional medical practice and a covered benefit under the member's evidence of coverage. Consistent with the foregoing, a health maintenance organization may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services.
 
(c) A health maintenance organization may require a member to contact either the health maintenance organization or its designee or the primary care physician of the member within 48 hours of receiving such emergency services, but notification already given to the health maintenance organization or to said primary care physician by the attending physician shall satisfy the requirements of this paragraph.
 
(d) Nothing in this section shall be construed to limit retrospective utilization review activities by a health maintenance organization with respect to screening, stabilization and post-stabilization services for the purposes of assessing quality, utilization patterns and coding and billing practices, but such activities shall not result in retroactive changes to treatment or reimbursement decisions previously made in accordance with this section. In conducting said utilization review activities, the health maintenance organization shall be in compliance with section 12 of chapter 176O and all applicable state and federal confidentiality provisions.
 
(e) A health maintenance organization shall clearly state in its brochures, contracts, policy manuals and printed materials that members shall have the option of calling the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent, whenever an enrollee is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. No member shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of an emergency medical condition.
 
(f) A health maintenance organization shall provide or arrange for indemnity payments to a member or provider for a reasonable amount charged for the cost of emergency medical services by a provider who is not normally affiliated with the health maintenance organization when the member requires services for an emergency medical condition. Said indemnity payment under this section shall not be subject to the insurance laws of the commonwealth.
 
SECTION 20 Section 6 of said Chapter 176G , as so appearing, is hereby amended by adding the following paragraph:-
No contract between a participating provider of health care services and a health maintenance organization shall be issued or delivered in the commonwealth unless it contains a provision requiring that within 45 days after the receipt by the organization of completed forms for reimbursement to the provider of health care services, the health maintenance organization shall (i) make payments for such services provided, (ii) notify the provider in writing of the reason or reasons for nonpayment, or (iii) notify the provider in writing of what additional information or documentation is necessary to complete said forms for such reimbursement. If the health maintenance organization fails to comply with this paragraph for any claims related to the provision of health care services, said health maintenance organization shall pay, in addition to any reimbursement for health care services provided, interest on such benefits, which shall accrue beginning 45 days after the health maintenance organization's receipt of request for reimbursement at the rate of 1.5 per cent per month, not to exceed 18 per cent per year. The provisions of this paragraph relating to interest payments shall not apply to a claim that the health maintenance organization is investigating because of suspected fraud.
 
SECTION 21 Section 7 of said chapter 176G is hereby repealed.
 
SECTION 22
Said chapter 176G is hereby further amended by striking out section 14, as appearing in the 1998 Official
Edition, and inserting in place thereof the following section:-
 
Section 14 Each applicant for licensure or licensure renewal for a health maintenance organization shall submit to the commissioner for his approval and to the office of patient protection in the department of public health such materials as the commissioner shall by regulation require, in a form approved by the commissioner. Said materials shall include, but not be limited to:
 
(1) a copy of the basic organization document such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents establishing the health maintenance organization;
 
(2) a copy of the by-laws, rules and regulations, or similar document, regulating the conduct of the internal affairs of the applicant.
 
(3) a statement generally describing the health maintenance organization, its health care plan or plans, facilities and personnel.
 
(4) an internal operations plan, including an organizational chart, description of organizational structure, a description of the service area and provider network, the roles, functions, responsibilities of and interrelationships among providers, and the methods of provider reimbursement and risk-sharing arrangement.
 
(5) a provider inventory, including a listing of providers by specialty, a calculation of physician to population ratios, and an inventory of owned, operated, contracting and participating provider facilities, including, but not limited to, hospitals, skilled nursing facilities, home health care and medical care services.
 
(6) a copy of every contract form made or to be made between the applicant and any providers of health services, copies of administrative contracts, and a statement of written procedures and standards for the prior review and approval by the applicant of provider subcontracts.
 
(7) a copy of the form of evidence of coverage to be issued to the members.
 
(8) a copy of the form of group contract, if any, which is to be issued to employers, unions, trustees, or other organizations.
 
(9) financial statements showing the applicant's assets, liabilities, and sources of working capital and other sources of financial support and projections of the results of operations for the succeeding three years.