Massachusetts 2025-2026 Regular Session

Massachusetts House Bill H1144 Compare Versions

Only one version of the bill is available at this time.

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2	2	HOUSE DOCKET, NO. 2326 FILED ON: 1/16/2025
3	3	HOUSE . . . . . . . . . . . . . . . No. 1144
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Paul J. Donato
8	8	_________________
9	9	To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
10	10	Court assembled:
11	11	The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
12	12	An Act to protect health care consumers from surprise billing.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :DATE ADDED:Paul J. Donato35th Middlesex1/16/2025 1 of 10
16	16	HOUSE DOCKET, NO. 2326 FILED ON: 1/16/2025
17	17	HOUSE . . . . . . . . . . . . . . . No. 1144
18	18	By Representative Donato of Medford, a petition (accompanied by bill, House, No. 1144) of
19	19	Paul J. Donato relative to non-contracted and non-emergency healthcare billing. Financial
20	20	Services.
21	21	The Commonwealth of Massachusetts
22	22	_______________
23	23	In the One Hundred and Ninety-Fourth General Court
24	24	(2025-2026)
25	25	_______________
26	26	An Act to protect health care consumers from surprise billing.
27	27	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
28	28	of the same, as follows:
29	29	1 SECTION 1. Chapter 111 of the General Laws is hereby amended by inserting after
30	30	2section 51L the following 2 sections:-
31	31	3 Section 51M. (a) As used in this section and section 51N, the following terms shall have
32	32	4the following meanings:-
33	33	5 “Campus”, a hospital’s main buildings, the physical area immediately adjacent to a
34	34	6hospital’s main buildings and other areas and structures that are not strictly contiguous to the
35	35	7main buildings but are located within 250 yards of the main buildings or other area that has been
36	36	8determined by the Centers for Medicare and Medicaid Services to be part of a hospital’s campus.
37	37	9 “Facility fee”, a fee charged, billed or collected by a health care provider for hospital
38	38	10services provided in a facility that is owned or operated, in whole or in part, by a hospital or
39	39	11health system that is intended to compensate the health care provider for operational expenses
40	40	12and is separate and distinct from a professional fee. 2 of 10
41	41	13 “Health care provider”, shall have the same meaning as in section 1 of chapter 6D.
42	42	14 “Hospital”, a hospital licensed pursuant to section 51 of chapter 111.
43	43	15 “Professional fee”, a fee charged or billed by a health care provider for professional
44	44	16medical services.
45	45	17 (b) A health care provider shall not charge, bill or collect a facility fee except for: (i)
46	46	18services provided on a hospital’s campus; (ii) services provided at a facility that includes a
47	47	19licensed hospital emergency department; or (iii) emergency services provided at a licensed
48	48	20satellite emergency facility.
49	49	21 (c) Notwithstanding subsection (b), a health care provider shall not charge, bill, or collect
50	50	22a facility fee for a service identified by the commission pursuant to its authority in section 20 of
51	51	23chapter 6D as a service that may reliably be provided safely and effectively in settings other than
52	52	24hospitals.
53	53	25 (d) The department shall promulgate regulations necessary to implement this section and
54	54	26impose penalties for non-compliance consistent with the department’s authority to regulate
55	55	27health care providers. A health care provider that violates any provision of this section or the
56	56	28rules and regulations adopted pursuant hereto shall be punished by a fine of not more than
57	57	29$1,000 per occurrence.
58	58	30 Section 51N. (a) If a health care provider charges or bills a facility fee for services, the
59	59	31health care provider shall provide any patient receiving such service with written notice that such
60	60	32a fee will be charged and may be billed separately. 3 of 10
61	61	33 (b) If a health care provider is required to provide a patient with notice under subsection
62	62	34(a) and a patient’s appointment is scheduled to occur not less than 10 days after the appointment
63	63	35is made, the health care provider shall provide written notice and explanation to the patient by
64	64	36first class mail, encrypted electronic means or a secure patient Internet portal not less than 3 days
65	65	37after the appointment is made. If an appointment is scheduled to occur less than 10 days after the
66	66	38appointment is made or if the patient arrives without an appointment, the notice shall be provided
67	67	39to the patient on the facility’s premises.
68	68	40 If a patient arrives without an appointment, a health care provider shall provide written
69	69	41notice and explanation to the patient prior to the care if practicable, or if prior notice is not
70	70	42practicable, the health care provider shall provide an explanation of the fee to the patient within a
71	71	43reasonable period of time; provided, however, that the explanation of the fee shall be provided
72	72	44before the patient leaves the facility. If the patient is incapacitated or otherwise unable to read,
73	73	45understand and act on the patient’s rights, the notice and explanation of the fee shall be provided
74	74	46to the patient’s representative within a reasonable period of time.
75	75	47 (c) A facility at which facility fees for services are charged, billed, or collected shall
76	76	48clearly identify itself as being associated with a hospital, including by stating the name of the
77	77	49hospital that owns or operates the location in its signage, marketing materials, Internet web sites,
78	78	50and stationery.
79	79	51 (d) If a health care provider charges, bills, or collects facility fees at a given facility,
80	80	52notice shall be posted in that facility informing patients that a patient may incur higher financial
81	81	53liability as compared to receiving the service in a non-hospital facility. Notice shall be 4 of 10
82	82	54prominently displayed in locations accessible to and visible by patients, including in patient
83	83	55waiting areas.
84	84	56 (e)(1) If a location at which health care services are provided without facility fees
85	85	57changes status such that facility fees would be permissible at that location under section 51M,
86	86	58and the health care provider that owns or operates the location elects to charge, bill, or collect
87	87	59facility fees, the health care provider shall provide written notice to all patients who received
88	88	60services at the location during the previous calendar year not later than 30 days after the change
89	89	61of status. The notice shall state that: (i) the location is now owned or operated by a hospital; (ii)
90	90	62certain health care services delivered at the facility may result in separate facility and
91	91	63professional bills for services; and (iii) patients seeking care at the facility may incur higher
92	92	64financial liability at that location due to its change in status.
93	93	65 (2) In cases in which a written notice is required by paragraph (1), the health care
94	94	66provider that owns or operates the location shall not charge or bill a facility fee for services
95	95	67provided at that location until not less than 30 days after the written notice is provided.
96	96	68 (3) A notice required or provided under paragraph (1) shall be filed with the department
97	97	69not later than 30 days after its issuance.
98	98	70 (f) The department may promulgate regulations necessary to implement this section and
99	99	71impose penalties for non-compliance consistent with the department’s authority to regulate
100	100	72health care providers. A health care provider that violates any provision of this section or the
101	101	73rules and regulations adopted pursuant hereto shall be punished by a fine of not more than
102	102	74$1,000 per occurrence. In addition to any penalties for noncompliance that may be established by
103	103	75the department, a violation of this section shall be an unfair trade practice under chapter 93A. 5 of 10
104	104	76 SECTION 2. Section 228 of said chapter 111 of the General Laws is hereby amended by
105	105	77striking out subsection (e) and inserting in place thereof the following subsection:-
106	106	78 (e) A health care provider shall determine if it participates in a patient’s health benefit
107	107	79plan prior to said patient’s admission, procedure or service for conditions that are not emergency
108	108	80medical conditions as defined in section 1 of chapter 176O. If the health care provider does not
109	109	81participate in the patient’s health benefit plan and the admission, procedure or service was
110	110	82scheduled more than 7 days in advance of the admission, procedure or service, such provider
111	111	83shall notify the patient verbally and in writing of that fact not less than 7 days before the
112	112	84scheduled admission, procedure or service. If the health care provider does not participate in the
113	113	85patient’s health benefit plan and the admission, procedure or service was scheduled less than 7
114	114	86days in advance of the admission, procedure or service, such provider shall notify the patient
115	115	87verbally of that fact not less than 2 days before the scheduled admission, procedure or service or
116	116	88as soon as is practicable before the scheduled admission, procedure or service, with written
117	117	89notice of that fact to be provided upon the patient’s arrival at the scheduled admission, procedure
118	118	90or service. If a health care provider that does not participate in the patient’s health benefit plan
119	119	91fails to provide the required notifications under this subsection, or if the provider is rendering
120	120	92unforeseen out-of-network services, as defined in subsection (a) of section 30 of chapter 176O,
121	121	93the provider shall not bill the insured except for any applicable copayment, coinsurance or
122	122	94deductible that would be payable if the insured received the service from a participating health
123	123	95care provider under the terms of the insured’s health benefit plan. Nothing in this subsection
124	124	96shall relieve a health care provider from the requirements under subsections (b) to (d), inclusive.
125	125	97 SECTION 3. Section 1 of chapter 175H of the General Laws is hereby amended by
126	126	98adding the following definitions:- 6 of 10
127	127	99 “Impermissible facility fee,” a facility fee, as defined in section 51L of chapter 111, that
128	128	100is not charged, billed or collected in accordance with paragraphs (b) or (c) of said section 51L of
129	129	101said chapter 111.
130	130	102 “Surprise bill,” a bill received by an insured for unforeseen out-of-network services, as
131	131	103defined in section 30 of chapter 176O.
132	132	104 SECTION 4. Said chapter 175H of the General Laws is hereby further amended by
133	133	105striking out in their entirety sections 5 and 6 and inserting in place thereof the following
134	134	106sections:-
135	135	107 Section 5. The attorney general may conduct an investigation of an alleged violation of
136	136	108this chapter and may commence a proceeding pursuant to section 4. Additionally, the attorney
137	137	109general has the authority to initiate a civil action under this chapter. When the attorney general
138	138	110has determined that a provider has violated this chapter, the attorney general shall notify the
139	139	111department of public health, the department of mental health, the board of registration in
140	140	112medicine or any other relevant licensing authorities, of that determination. Those licensing
141	141	113authorities may, upon their own investigation or upon notification from the attorney general that
142	142	114a provider licensed by that authority has violated this section, impose penalties for non-
143	143	115compliance consistent with their authority to regulate those providers.
144	144	116 Section 6. A person who receives a health care benefit or payment from a health care
145	145	117corporation or health care insurer or other person or entity, which such person knows that he or
146	146	118she is not entitled to receive or be paid, or a person who knowingly presents or causes to be
147	147	119presented with fraudulent intent a claim which contains a false statement, including but not
148	148	120limited to a payment or false statement regarding an impermissible facility fee shall be liable to 7 of 10
149	149	121the health care corporation or health care insurer or other person or entity for the full amount of
150	150	122the benefit or payment made, and for reasonable attorneys’ fees and costs, inclusive of costs of
151	151	123investigation. A health care corporation or health care insurer or other injured person or entity
152	152	124may bring a civil action under this chapter in the superior court department of the trial court.
153	153	125 Section 6A. A person who receives a health care benefit or payment from a health care
154	154	126corporation or health care insurer or other person or entity shall not be permitted to forward a
155	155	127surprise bill to a person covered under an insured health plan. A person who violates this section
156	156	128shall be liable to the health care corporation or health care insurer or other person or entity for
157	157	129penalties and for reasonable attorneys’ fees and costs, inclusive of costs of investigation. A
158	158	130health care corporation or health care insurer or other injured person or entity may bring a civil
159	159	131action under this chapter in the superior court department of the trial court.
160	160	132 SECTION 5. Chapter 176J of the General Laws is hereby amended by inserting after
161	161	133section 17 the following new section:-
162	162	134 Section 18. Carriers shall reimburse evaluation and management services delivered by an
163	163	135off-campus hospital outpatient department, clinic, ambulatory surgical center, or stand-alone
164	164	136emergency department, and ambulatory services commonly provided in office-based settings,
165	165	137including but not limited to laboratory tests, imaging, and diagnostic services, and clinician-
166	166	138administered drugs that are identified by the health policy commission, as equivalent to the non-
167	167	139facility rate in the Medicare physician fee schedule that applies to physician offices.
168	168	140 SECTION 6. Chapter 176O of the General Laws is hereby amended by inserting after
169	169	141section 29 the following section:- 8 of 10
170	170	142 Section 30. (a) As used in this section, “unforeseen out-of-network service” shall mean
171	171	143the following: (1) health care services rendered by an out-of-network provider for emergency
172	172	144medical conditions, including post-stabilization services resulting from an emergency medical
173	173	145condition; (2) non-emergency health care services rendered by an out-of-network provider at an
174	174	146in-network facility, including but not limited to: (i) services for emergency medicine,
175	175	147anesthesiology, pathology, radiology, or neonatology, or services rendered by assistant surgeons,
176	176	148hospitalists, and intensivists; (ii) health care services rendered by an out-of-network provider
177	177	149without the insured’s advanced knowledge, pursuant to the requirements set forth in subsections
178	178	150(b) through (e) of section 228 of chapter 111; (iii) health care services provided by an out-of-
179	179	151network provider if there is no in-network provider who can furnish such health care service at
180	180	152such facility; (iv) health care services rendered by an out-of-network provider, including an out-
181	181	153of-network laboratory, radiologist, or pathologist, where the health care services were referred,
182	182	154or an insured’s specimen was sent, by a participating provider to an out-of-network provider; or
183	183	155(v) unforeseen health care services that arise at the time health care services are rendered that
184	184	156must necessarily be rendered by an out-of-network provider; and (3) health care services
185	185	157delivered by an ambulance service provider licensed by the department of public health pursuant
186	186	158to section 6 of chapter 111C.
187	187	159 (b) An insured shall only be required to pay an out-of-network provider who renders an
188	188	160unforeseen out-of-network service the applicable coinsurance, copayment, deductible or other
189	189	161out-of-pocket expense that would be imposed if the service was rendered by a participating
190	190	162provider. Payments made by an insured pursuant to this section shall count towards any in-
191	191	163network deductible or out-of-pocket maximum pursuant to the terms and conditions of an
192	192	164insured’s health benefit plan. 9 of 10
193	193	165 (c) A carrier shall reimburse an out-of-network provider who renders an unforeseen out-
194	194	166of-network service to an insured at the carrier’s median contracted rate for that service in the
195	195	167geographic region in the relevant market. Such payment shall constitute payment in full to the
196	196	168out-of-network provider and the out-of-network provider shall not bill the insured for any
197	197	169amount except for any in-network cost sharing amount owed for such service.
198	198	170 (d) With respect to an entity providing or administering a self-funded health benefit plan
199	199	171governed by the provisions of the federal Employee Retirement Income Security Act of 1974, 29
200	200	172U.S.C. § 1001 et seq. and its plan members, this section shall only apply if the plan elects to be
201	201	173subject to the provisions of this section. To elect to be subject to the provisions of this section,
202	202	174the self-funded health benefit plan shall provide notice to the division on an annual basis, in a
203	203	175form and manner prescribed by the division, attesting to the plan’s participation and agreeing to
204	204	176be bound by the provisions of this section. The self-funded health benefit plan shall amend the
205	205	177health benefit plan, coverage policies, contracts and any other plan documents to reflect that the
206	206	178benefits of this section shall apply to the plan’s members.
207	207	179 (e) This section shall not be construed to require a carrier to cover health care services not
208	208	180required by law or by the terms and conditions of an insured’s health benefit plan. Nothing in
209	209	181this section shall require a carrier to pay for health care services delivered to an insured that are
210	210	182not covered benefits under the terms of the insured’s health benefit plan.
211	211	183 (f) Nothing in this section shall require a carrier to pay for nonemergency services
212	212	184delivered to an insured if the insured had a reasonable opportunity to choose to have the service
213	213	185performed by a network provider participating in the insured’s health benefit plan. Evidence that 10 of 10
214	214	186an insured had a reasonable opportunity to choose to have the service performed by a
215	215	187participating provider may include, but is not limited to, a consent waiver signed by the insured.
216	216	188 (g) The commissioner shall promulgate regulations to implement this section.