1 of 1
HOUSE DOCKET, NO. 2519 FILED ON: 1/16/2025
HOUSE . . . . . . . . . . . . . . . No. 1229
The Commonwealth of Massachusetts
_________________
PRESENTED BY:
Michael P. Kushmerek
_________________
To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:
The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
An Act to further define medical necessity determinations.
_______________
PETITION OF:
NAME:DISTRICT/ADDRESS :DATE ADDED:Michael P. Kushmerek3rd Worcester1/16/2025 1 of 14
HOUSE DOCKET, NO. 2519 FILED ON: 1/16/2025
HOUSE . . . . . . . . . . . . . . . No. 1229
By Representative Kushmerek of Fitchburg, a petition (accompanied by bill, House, No. 1229)
of Michael P. Kushmerek for legislation to further define medical necessity determinations.
Financial Services.
The Commonwealth of Massachusetts
_______________
In the One Hundred and Ninety-Fourth General Court
(2025-2026)
_______________
An Act to further define medical necessity determinations.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
of the same, as follows:
1 SECTION 1. Chapter 32A of the General Laws is hereby amended by inserting after
2section 17R the following section:-
3 Section 17S. For the purposes of this section the following terms shall, unless the context
4clearly requires otherwise, have the following meanings:
5 “Mental health acute treatment”, 24-hour medically supervised mental health services
6provided in an inpatient facility, licensed by the department of mental health, that provides
7psychiatric evaluation, management, treatment and discharge planning in a structured treatment
8milieu.
9 “Mental health crisis stabilization services”, 24-hour clinically managed mental health
10diversionary or step-down services for adults or adolescents, as defined by MassHealth, usually
11provided as an alternative to mental health acute treatment or following mental health acute 2 of 14
12treatment, which may include intensive crisis stabilization counseling, outreach to families and
13significant others and aftercare planning.
14 “Community-based acute treatment (CBAT)”, 24-hour clinically managed mental health
15diversionary or step-down services for children and adolescents, as defined by the department of
16early education and care, usually provided as an alternative to mental health acute treatment.
17 “Intensive community-based acute treatment (ICBAT)”, intensive 24-hour clinically
18managed mental health diversionary or step-down services for children and adolescents, as
19defined by the department of early education and care, usually provided as an alternative to
20mental health acute treatment.
21 The commission shall provide to any active or retired employee of the commonwealth
22who is insured under the group insurance commission coverage for medically necessary mental
23health acute treatment and shall not require a preauthorization prior to obtaining treatment.
24Medical necessity shall be determined by the treating clinician in consultation with the patient
25and noted in the patient’s medical record.
26 The commission shall provide to any active or retired employee of the commonwealth
27who is insured under the group insurance commission coverage for medically necessary mental
28health crisis stabilization services for up to 14 days and shall not require preauthorization prior to
29obtaining such services; provided, that the facility shall provide the carrier both notification of
30admission and the initial treatment plan within 48 hours of admission; provided further, that
31utilization review procedures may be initiated on day 7. Medical necessity shall be determined
32by the treating clinician in consultation with the patient and noted in the patient’s medical record. 3 of 14
33 The commission shall provide to any active or retired employee of the commonwealth
34who is insured under the group insurance commission coverage for medically necessary
35community based acute treatment services for up to 21 days; provided, that the facility shall
36provide the carrier both notification of admission and the initial treatment plan within 48 hours
37of admission; provided further, that utilization review procedures may be initiated on day 10.
38Medical necessity shall be determined by the treating clinician in consultation with the patient
39and noted in the patient’s medical record.
40 The commission shall provide to any active or retired employee of the commonwealth
41who is insured under the group insurance commission coverage for medically necessary
42intensive community based acute treatment services for up to 14 days; provided, that the facility
43shall provide the carrier both notification of admission and the initial treatment plan within 48
44hours of admission; provided further, that utilization review procedures may be initiated on day
457. Medical necessity shall be determined by the treating clinician in consultation with the patient
46and noted in the patient’s medical record.
47 SECTION 2. Chapter 118E of the General Laws is hereby amended by inserting after
48section 10N the following section:-
49 Section 10O. For the purposes of this section the following terms shall, unless the context
50clearly requires otherwise, have the following meanings:
51 “Mental health acute treatment”, 24-hour medically supervised mental health services
52provided in an inpatient facility, licensed by the department of mental health, that provides
53psychiatric evaluation, management, treatment and discharge planning in a structured treatment
54milieu. 4 of 14
55 “Mental health crisis stabilization services”, 24-hour clinically managed mental health
56diversionary or step-down services for adults or adolescents, as defined by MassHealth, usually
57provided as an alternative to mental health acute treatment or following mental health acute
58treatment, which may include intensive crisis stabilization counseling, outreach to families and
59significant others and aftercare planning.
60 “Community-based acute treatment (CBAT)”, 24-hour clinically managed mental health
61diversionary or step-down services for children and adolescents, as defined by the department of
62early education and care, usually provided as an alternative to mental health acute treatment.
63 “Intensive community-based acute treatment (ICBAT)”, intensive 24-hour clinically
64managed mental health diversionary or step-down services for children and adolescents, as
65defined by the department of early education and care, usually provided as an alternative to
66mental health acute treatment.
67 The division and its contracted health insurers, health plans, health maintenance
68organizations, behavioral health management firms and third party administrators under contract
69to a Medicaid managed care organization or primary care clinician plan shall cover the cost of
70medically necessary mental health acute treatment and shall not require a preauthorization prior
71to obtaining treatment. Medical necessity shall be determined by the treating clinician in
72consultation with the patient and noted in the patient’s medical record.
73 The division and its contracted health insurers, health plans, health maintenance
74organizations, behavioral health management firms and third party administrators under contract
75to a Medicaid managed care organization or primary care clinician plan shall cover the cost of
76medically necessary mental health crisis stabilization services for up to 14 days and shall not 5 of 14
77require preauthorization prior to obtaining such services; provided, that the facility shall provide
78the carrier both notification of admission and the initial treatment plan within 48 hours of
79admission; provided further, that utilization review procedures may be initiated on day 7.
80Medical necessity shall be determined by the treating clinician in consultation with the patient
81and noted in the patient’s medical record.
82 The division and its contracted health insurers, health plans, health maintenance
83organizations, behavioral health management firms and third party administrators under contract
84to a Medicaid managed care organization or primary care clinician plan shall cover the cost of
85medically necessary community based acute treatment services for up to 21 days; provided, that
86the facility shall provide the carrier both notification of admission and the initial treatment plan
87within 48 hours of admission; provided further, that utilization review procedures may be
88initiated on day 10. Medical necessity shall be determined by the treating clinician in
89consultation with the patient and noted in the patient’s medical record.
90 The division and its contracted health insurers, health plans, health maintenance
91organizations, behavioral health management firms and third party administrators under contract
92to a Medicaid managed care organization or primary care clinician plan shall cover the cost of
93medically necessary intensive community based acute treatment services for up to 14 days;
94provided, that the facility shall provide the carrier both notification of admission and the initial
95treatment plan within 48 hours of admission; provided further, that utilization review procedures
96may be initiated on day 7. Medical necessity shall be determined by the treating clinician in
97consultation with the patient and noted in the patient’s medical record. 6 of 14
98 SECTION 3. Chapter 175 of the General Laws is hereby amended by inserting after
99section 47NN the following section:-
100 Section 47OO. For the purposes of this section the following terms shall, unless the
101context clearly requires otherwise, have the following meanings:
102 “Mental health acute treatment”, 24-hour medically supervised mental health services
103provided in an inpatient facility, licensed by the department of mental health, that provides
104psychiatric evaluation, management, treatment and discharge planning in a structured treatment
105milieu.
106 “Mental health crisis stabilization services”, 24-hour clinically managed mental health
107diversionary or step-down services for adults or adolescents, as defined by MassHealth, usually
108provided as an alternative to mental health acute treatment or following mental health acute
109treatment, which may include intensive crisis stabilization counseling, outreach to families and
110significant others and aftercare planning.
111 “Community-based acute treatment (CBAT)”, 24-hour clinically managed mental health
112diversionary or step-down services for children and adolescents, as defined by the department of
113early education and care, usually provided as an alternative to mental health acute treatment.
114 “Intensive community-based acute treatment (ICBAT)”, intensive 24-hour clinically
115managed mental health diversionary or step-down services for children and adolescents, as
116defined by the department of early education and care, usually provided as an alternative to
117mental health acute treatment. 7 of 14
118 Any policy, contract, agreement, plan or certificate of insurance issued, delivered or
119renewed within the commonwealth, which is considered creditable coverage under section 1 of
120chapter 111M, shall provide coverage for medically necessary mental health acute treatment and
121shall not require a preauthorization prior to obtaining treatment. Medical necessity shall be
122determined by the treating clinician in consultation with the patient and noted in the patient’s
123medical record.
124 Any policy, contract, agreement, plan or certificate of insurance issued, delivered or
125renewed within the commonwealth, which is considered creditable coverage under section 1 of
126chapter 111M, shall provide coverage for medically necessary mental health crisis stabilization
127services for up to 14 days and shall not require preauthorization prior to obtaining such services;
128provided, that the facility shall provide the carrier both notification of admission and the initial
129treatment plan within 48 hours of admission; provided further, that utilization review procedures
130may be initiated on day 7. Medical necessity shall be determined by the treating clinician in
131consultation with the patient and noted in the patient’s medical record.
132 Any policy, contract, agreement, plan or certificate of insurance issued, delivered or
133renewed within the commonwealth, which is considered creditable coverage under section 1 of
134chapter 111M, shall provide coverage for medically necessary community based acute treatment
135services for up to 21 days; provided, that the facility shall provide the carrier both notification of
136admission and the initial treatment plan within 48 hours of admission; provided further, that
137utilization review procedures may be initiated on day 10. Medical necessity shall be determined
138by the treating clinician in consultation with the patient and noted in the patient’s medical record. 8 of 14
139 Any policy, contract, agreement, plan or certificate of insurance issued, delivered or
140renewed within the commonwealth, which is considered creditable coverage under section 1 of
141chapter 111M, shall provide coverage for medically necessary intensive community based acute
142treatment services for up to 14 days; provided, that the facility shall provide the carrier both
143notification of admission and the initial treatment plan within 48 hours of admission; provided
144further, that utilization review procedures may be initiated on day 7. Medical necessity shall be
145determined by the treating clinician in consultation with the patient and noted in the patient’s
146medical record.
147 SECTION 4. Chapter 176A of the General Laws is hereby amended by inserting after
148section 8OO the following section:-
149 Section 8PP. For the purposes of this section the following terms shall, unless the context
150clearly requires otherwise, have the following meanings:
151 “Mental health acute treatment”, 24-hour medically supervised mental health services
152provided in an inpatient facility, licensed by the department of mental health, that provides
153psychiatric evaluation, management, treatment and discharge planning in a structured treatment
154milieu.
155 “Mental health crisis stabilization services”, 24-hour clinically managed mental health
156diversionary or step-down services for adults or adolescents, as defined by MassHealth, usually
157provided as an alternative to mental health acute treatment or following mental health acute
158treatment, which may include intensive crisis stabilization counseling, outreach to families and
159significant others and aftercare planning. 9 of 14
160 “Community-based acute treatment (CBAT)”, 24-hour clinically managed mental health
161diversionary or step-down services for children and adolescents, as defined by the department of
162early education and care, usually provided as an alternative to mental health acute treatment.
163 “Intensive community-based acute treatment (ICBAT)”, intensive 24-hour clinically
164managed mental health diversionary or step-down services for children and adolescents, as
165defined by the department of early education and care, usually provided as an alternative to
166mental health acute treatment.
167 Any contract between a subscriber and the corporation under an individual or group
168hospital service plan which is delivered, issued or renewed within the commonwealth shall
169provide coverage for medically necessary mental health acute treatment and shall not require a
170preauthorization prior to obtaining treatment. Medical necessity shall be determined by the
171treating clinician in consultation with the patient and noted in the patient’s medical record.
172 Any contract between a subscriber and the corporation under an individual or group
173hospital service plan which is delivered, issued or renewed within the commonwealth shall
174provide coverage for medically necessary mental health crisis stabilization services for up to 14
175days and shall not require preauthorization prior to obtaining such services; provided, that the
176facility shall provide the carrier both notification of admission and the initial treatment plan
177within 48 hours of admission; provided further, that utilization review procedures may be
178initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation
179with the patient and noted in the patient’s medical record.
180 Any contract between a subscriber and the corporation under an individual or group
181hospital service plan which is delivered, issued or renewed within the commonwealth shall 10 of 14
182provide coverage for medically necessary community based acute treatment services for up to 21
183days; provided, that the facility shall provide the carrier both notification of admission and the
184initial treatment plan within 48 hours of admission; provided further, that utilization review
185procedures may be initiated on day 10. Medical necessity shall be determined by the treating
186clinician in consultation with the patient and noted in the patient’s medical record.
187 Any contract between a subscriber and the corporation under an individual or group
188hospital service plan which is delivered, issued or renewed within the commonwealth shall
189provide coverage for medically necessary intensive community based acute treatment services
190for up to 14 days; provided, that the facility shall provide the carrier both notification of
191admission and the initial treatment plan within 48 hours of admission; provided further, that
192utilization review procedures may be initiated on day 7. Medical necessity shall be determined
193by the treating clinician in consultation with the patient and noted in the patient’s medical record.
194 SECTION 5. Chapter 176B of the General Laws is hereby amended by inserting after
195section 4OO the following section:-
196 Section 4PP. For the purposes of this section the following terms shall, unless the context
197clearly requires otherwise, have the following meanings:
198 “Mental health acute treatment”, 24-hour medically supervised mental health services
199provided in an inpatient facility, licensed by the department of mental health, that provides
200psychiatric evaluation, management, treatment and discharge planning in a structured treatment
201milieu.
202 “Mental health crisis stabilization services”, 24-hour clinically managed mental health
203diversionary or step-down services for adults or adolescents, as defined by MassHealth, usually 11 of 14
204provided as an alternative to mental health acute treatment or following mental health acute
205treatment, which may include intensive crisis stabilization counseling, outreach to families and
206significant others and aftercare planning.
207 “Community-based acute treatment (CBAT)”, 24-hour clinically managed mental health
208diversionary or step-down services for children and adolescents, as defined by the department of
209early education and care, usually provided as an alternative to mental health acute treatment.
210 “Intensive community-based acute treatment (ICBAT)”, intensive 24-hour clinically
211managed mental health diversionary or step-down services for children and adolescents, as
212defined by the department of early education and care, usually provided as an alternative to
213mental health acute treatment.
214 Any subscription certificate under an individual or group medical service agreement
215delivered, issued or renewed within the commonwealth shall provide coverage for medically
216necessary mental health acute treatment and shall not require a preauthorization prior to
217obtaining treatment. Medical necessity shall be determined by the treating clinician in
218consultation with the patient and noted in the patient’s medical record.
219 Any subscription certificate under an individual or group medical service agreement
220delivered, issued or renewed within the commonwealth shall provide coverage for medically
221necessary mental health crisis stabilization services for up to 14 days and shall not require
222preauthorization prior to obtaining such services; provided, that the facility shall provide the
223carrier both notification of admission and the initial treatment plan within 48 hours of admission;
224provided further, that utilization review procedures may be initiated on day 7. Medical necessity 12 of 14
225shall be determined by the treating clinician in consultation with the patient and noted in the
226patient’s medical record.
227 Any subscription certificate under an individual or group medical service agreement
228delivered, issued or renewed within the commonwealth shall provide coverage for medically
229necessary community based acute treatment services for up to 21 days; provided, that the facility
230shall provide the carrier both notification of admission and the initial treatment plan within 48
231hours of admission; provided further, that utilization review procedures may be initiated on day
23210. Medical necessity shall be determined by the treating clinician in consultation with the
233patient and noted in the patient’s medical record.
234 Any subscription certificate under an individual or group medical service agreement
235delivered, issued or renewed within the commonwealth shall provide coverage for medically
236necessary intensive community based acute treatment services for up to 14 days; provided, that
237the facility shall provide the carrier both notification of admission and the initial treatment plan
238within 48 hours of admission; provided further, that utilization review procedures may be
239initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation
240with the patient and noted in the patient’s medical record.
241 SECTION 6. Chapter 176G of the General Laws is hereby amended by inserting after
242section 4GG the following section:-
243 Section 4HH. For the purposes of this section the following terms shall, unless the
244context clearly requires otherwise, have the following meanings:
245 “Mental health acute treatment”, 24-hour medically supervised mental health services
246provided in an inpatient facility, licensed by the department of mental health, that provides 13 of 14
247psychiatric evaluation, management, treatment and discharge planning in a structured treatment
248milieu.
249 “Mental health crisis stabilization services”, 24-hour clinically managed mental health
250diversionary or step-down services for adults or adolescents, as defined by MassHealth, usually
251provided as an alternative to mental health acute treatment or following mental health acute
252treatment, which may include intensive crisis stabilization counseling, outreach to families and
253significant others and aftercare planning.
254 “Community-based acute treatment (CBAT)”, 24-hour clinically managed mental health
255diversionary or step-down services for children and adolescents, as defined by the department of
256early education and care, usually provided as an alternative to mental health acute treatment.
257 “Intensive community-based acute treatment (ICBAT)”, intensive 24-hour clinically
258managed mental health diversionary or step-down services for children and adolescents, as
259defined by the department of early education and care, usually provided as an alternative to
260mental health acute treatment.
261 Any individual or group health maintenance contract that is issued or renewed shall
262provide coverage for medically necessary mental health acute treatment and shall not require a
263preauthorization prior to obtaining treatment. Medical necessity shall be determined by the
264treating clinician in consultation with the patient and noted in the patient’s medical record.
265 Any individual or group health maintenance contract that is issued or renewed shall
266provide coverage for medically necessary mental health crisis stabilization services for up to 14
267days and shall not require preauthorization prior to obtaining such services; provided, that the
268facility shall provide the carrier both notification of admission and the initial treatment plan 14 of 14
269within 48 hours of admission; provided further, that utilization review procedures may be
270initiated on day 7. Medical necessity shall be determined by the treating clinician in consultation
271with the patient and noted in the patient’s medical record.
272 Any individual or group health maintenance contract that is issued or renewed shall
273provide coverage for medically necessary community based acute treatment services for up to 21
274days; provided, that the facility shall provide the carrier both notification of admission and the
275initial treatment plan within 48 hours of admission; provided further, that utilization review
276procedures may be initiated on day 10. Medical necessity shall be determined by the treating
277clinician in consultation with the patient and noted in the patient’s medical record.
278 Any individual or group health maintenance contract that is issued or renewed shall
279provide coverage for medically necessary intensive community based acute treatment services
280for up to 14 days; provided, that the facility shall provide the carrier both notification of
281admission and the initial treatment plan within 48 hours of admission; provided further, that
282utilization review procedures may be initiated on day 7. Medical necessity shall be determined
283by the treating clinician in consultation with the patient and noted in the patient’s medical record.