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HOUSE DOCKET, NO. 4027 FILED ON: 1/17/2025
HOUSE . . . . . . . . . . . . . . . No. 1235
The Commonwealth of Massachusetts
_________________
PRESENTED BY:
John J. Lawn, Jr.
_________________
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 updating the mandated benefit review process.
_______________
PETITION OF:
NAME:DISTRICT/ADDRESS :DATE ADDED:John J. Lawn, Jr.10th Middlesex1/17/2025Dennis C. Gallagher8th Plymouth1/23/2025 1 of 6
HOUSE DOCKET, NO. 4027 FILED ON: 1/17/2025
HOUSE . . . . . . . . . . . . . . . No. 1235
By Representative Lawn of Watertown, a petition (accompanied by bill, House, No. 1235) of
John J. Lawn, Jr. and Dennis C. Gallagher relative to the mandated benefit review process.
Financial Services.
The Commonwealth of Massachusetts
_______________
In the One Hundred and Ninety-Fourth General Court
(2025-2026)
_______________
An Act updating the mandated benefit review process.
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 3 of the General Laws is hereby amended by striking out section
238C, as so appearing, and inserting in place thereof the following section:-
3 Section 38C. (a) As used in this section, the following words shall, unless the context
4clearly requires otherwise, have the following meanings:-
5 “Center”, the center for health information and analysis established under chapter 12C.
6 “Mandated health benefit bill”, a bill that mandates health insurance coverage for (i)
7treatments or services from a particular type of health care provider or health care professional;
8(ii) screening, diagnosis, or treatment of a particular disease or condition; or (iii) a particular type
9of treatment or service, or of medical equipment, medical supplies, or drugs used in connection
10with a treatment or service, provided, that such coverage is offered as part of a policy or policies
11of group life and accidental death and dismemberment insurance covering persons in the service
12of the commonwealth, and group general or blanket insurance providing hospital, surgical, 2 of 6
13medical, dental, and other health insurance benefits covering persons in the service of the
14commonwealth, and their dependents organized under chapter 32A, individual or group health
15insurance policies offered by an insurer licensed or otherwise authorized to transact accident or
16health insurance organized under chapter 175, a nonprofit hospital service corporation organized
17under chapter 176A, a nonprofit medical service corporation organized under chapter 176B, a
18health maintenance organization organized under chapter 176G, or an organization entering into
19a preferred provider arrangement under chapter 176I, any health plan issued, renewed, or
20delivered within or without the commonwealth to a natural person who is a resident of the
21commonwealth, including a certificate issued to an eligible natural person which evidences
22coverage under a policy or contract issued to a trust or association for said natural person and his
23dependent, including said person's spouse organized under chapter 176M.
24 (b) The house and senate committees on ways and means when reporting favorably
25mandated health benefit bill referred to them, shall include a review and evaluation conducted by
26the center pursuant to this section.
27 (c) Upon the request of the house committee on ways and means or the senate committee
28on ways and means, the center shall conduct a review and evaluation of the mandated health
29benefit bill, in consultation with other relevant state agencies, and shall report to the committee
30within 180 days of the request, or pursuant to a timeline agreed to by the committee and the
31center. If the center fails to report to the appropriate committee within the allotted time, said
32committee may report favorably on the mandated health benefit bill without including a review
33and evaluation from the center. The center shall post each analysis on a searchable website as
34defined in section 14C of chapter 7 and make every analysis available to the public upon request. 3 of 6
35 (d) When reviewing a mandated health benefit bill the center shall prepare a written
36analysis with relevant data on the following:
37 (1) Public health impacts, including, but not limited to, the following:
38 (A) The impact on the health of the community, including the reduction of communicable
39disease and the benefits of prevention such as those provided by childhood immunizations and
40prenatal care.
41 (B) The impact on the health of the community, including diseases and conditions where
42disparities in outcomes associated with the social determinants of health as well as gender, race,
43sexual orientation, or gender identity are established in peer-reviewed scientific and medical
44literature.
45 (C) The extent to which the benefit or service reduces premature death and the economic
46loss associated with disease.
47 (2) Medical impacts, including, but not limited to, the following:
48 (A) The extent to which the benefit or service is generally recognized by the medical
49community as being effective in the screening, diagnosis, or treatment of a condition or disease,
50as demonstrated by a review of scientific and peer-reviewed medical literature.
51 (B) The extent to which the benefit or service is generally available and utilized by
52treating physicians.
53 (C) The contribution of the benefit or service to the health status of the population,
54including the results of any research demonstrating the efficacy of the benefit or service
55compared to alternatives, including not providing the benefit or service. 4 of 6
56 (D) The extent to which mandating the benefits or services would not diminish or
57eliminate access to currently available health care benefits or services.
58 (3) Financial impacts, including, but not limited to, the following:
59 (A) The extent to which the coverage will increase or decrease the benefit or cost of the
60benefit or service over the next 5 years.
61 (B) The extent to which the coverage will increase the utilization of the benefit or service,
62or will be a substitute for, or affect the cost of, alternative benefits or services over the next 5
63years.
64 (C) The extent to which the coverage will increase or decrease the administrative
65expenses of health care service plans and health insurers and the premium and expenses of
66subscribers, enrollees, and policyholders.
67 (D) The impact of this coverage on anticipated costs or savings estimated upon
68implementation for one subsequent calendar year, or, if applicable, two subsequent calendar
69years through a long-range estimate.
70 (E) The potential cost or savings to the private sector, including the impact on large and
71small employers, employees and nongroup purchasers, other retirement systems funded by the
72state or by a local government, individuals purchasing individual health insurance and publicly
73funded state health insurance programs, including MassHealth and the Massachusetts Health
74Connector
75 (F) The extent to which costs resulting from lack of coverage or are or would be shifted
76to other payers, including both public and private entities. 5 of 6
77 (G) The extent to the costs to health care consumers of not mandating the benefit in terms
78of out-of-pocket costs for treatment or delayed treatment.
79 (H) The extent to which mandating the proposed benefit or service would not diminish or
80eliminate access to currently available health care benefits or services over the next 5 years.
81 (I) The extent to which the benefit or service is generally utilized by a significant portion
82of the population
83 (J) The extent to which health care coverage for the benefit or service is already generally
84available.
85 (K) The level of public demand for health care coverage for the benefit or service,
86including the level of interest of collective bargaining agents in negotiating privately for
87inclusion of this coverage in group contracts, and the extent to which the mandated benefit or
88service is covered by self-funded employer groups.
89 (L) The impact of this coverage on the total cost of health care.
90 (M) In assessing and preparing a written analysis of the financial impact of legislation
91proposing to mandate a benefit or service pursuant to this paragraph, the center shall use a
92certified actuary or other person with relevant knowledge and expertise to determine the
93financial impact.
94 (4) The impact on essential health benefits, as defined in 956 CMR 5.00 and 42 U.S.C. §
9518022(b), and the impact on the Massachusetts Health Connector.
96 (5) Legislative impacts on health insurance benefit design, cost sharing, premiums, and
97other health insurance topics. 6 of 6
98 (6) The medical efficacy of mandating the benefit, including the impact of the benefit to
99the quality of patient care and the health status of the population and the results of any research
100demonstrating the medical efficacy of the treatment or service compared to alternative treatments
101or services or not providing the treatment or service.
102 (7) If the legislation seeks to mandate coverage of an additional class of practitioners, the
103results of any professionally acceptable research demonstrating the medical results achieved by
104the additional class of practitioners relative to those already covered and the methods of the
105appropriate professional organization that assures clinical proficiency.
106 (e) The center shall issue a comprehensive report at least once every 5 years on the cost
107and public health impact of all existing mandated benefits. In conjunction with this review, the
108center shall consult with the department of public health and the University of Massachusetts
109Medical School in a clinical review of all mandated benefits to ensure that all mandated benefits
110continue to conform to existing standards of care in terms of clinical appropriateness or
111evidence-based medicine. The center may file legislation that would amend or repeal existing
112mandated benefits that no longer meet these standards.