Massachusetts 2025-2026 Regular Session

Massachusetts Senate Bill S867 Compare Versions

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

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2	2	SENATE DOCKET, NO. 1906 FILED ON: 1/17/2025
3	3	SENATE . . . . . . . . . . . . . . No. 867
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Cindy F. Friedman
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 relative to primary care for you.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :Cindy F. FriedmanFourth MiddlesexRebecca L. RauschNorfolk, Worcester and Middlesex1/28/2025Joanne M. ComerfordHampshire, Franklin and Worcester2/21/2025Mike Connolly26th Middlesex3/5/2025 1 of 45
16	16	SENATE DOCKET, NO. 1906 FILED ON: 1/17/2025
17	17	SENATE . . . . . . . . . . . . . . No. 867
18	18	By Ms. Friedman, a petition (accompanied by bill, Senate, No. 867) of Cindy F. Friedman,
19	19	Rebecca L. Rausch, Joanne M. Comerford and Mike Connolly for legislation relative to primary
20	20	care for you. Health Care Financing.
21	21	[SIMILAR MATTER FILED IN PREVIOUS SESSION
22	22	SEE SENATE, NO. 750 OF 2023-2024.]
23	23	The Commonwealth of Massachusetts
24	24	_______________
25	25	In the One Hundred and Ninety-Fourth General Court
26	26	(2025-2026)
27	27	_______________
28	28	An Act relative to primary care for you.
29	29	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
30	30	of the same, as follows:
31	31	1 SECTION 1. Section 1 of chapter 6D of the General Laws, as appearing in the 2022
32	32	2Official Edition, is hereby amended by inserting after the definition of “After-hours care” the
33	33	3following definitions:-
34	34	4 “Aggregate primary care baseline expenditures”, the sum of all primary care
35	35	5expenditures, as defined by the center, in the commonwealth in the calendar year preceding the
36	36	6year in which the aggregate primary care expenditure target applies.
37	37	7 “Aggregate primary care expenditure target”, the targeted sum, set by the commission in
38	38	8section 9A, of all primary care expenditures, as defined by the center, in the commonwealth in
39	39	9the calendar year in which the aggregate primary care expenditure target applies. 2 of 45
40	40	10 SECTION 2. Said section 1 of said chapter 6D, as so appearing, is hereby further
41	41	11amended by inserting after the definition of “Physician” the following definitions:-
42	42	12 “Primary care baseline expenditures”, the sum of all primary care expenditures, as
43	43	13defined by the center, by or attributed to an individual health care entity in the calendar year
44	44	14preceding the year in which the primary care expenditure target applies.
45	45	15 “Primary care expenditure target”, the targeted sum, set by the commission in section 9A,
46	46	16of all primary care expenditures, as defined by the center, by or attributed to an individual health
47	47	17care entity in the calendar year in which the entity’s primary care expenditure target applies.
48	48	18 SECTION 3. Chapter 6D of the General Laws, as amended by section 3 of chapter 342 of
49	49	19the acts of 2024, is hereby amended by inserting after section 3A the following section:-
50	50	20 Section 3B. (a) There shall be within the commission a primary care board to: (i) study
51	51	21primary care access, delivery and payment in the commonwealth; (ii) develop and issue
52	52	22recommendations to stabilize and strengthen the primary care system and the increase of
53	53	23recruitment and retention in the primary care workforce; and (iii) increase the financial
54	54	24investment in and patient access to primary care across the commonwealth.
55	55	25 (b) The board shall consist of: the secretary of health and human services or a designee,
56	56	26who shall serve as co-chair; the executive director of the health policy commission or a designee,
57	57	27who shall serve as co-chair; the assistant secretary for MassHealth or a designee; the executive
58	58	28director of the center for health information and analysis or a designee; the commissioner of
59	59	29insurance or a designee; the chairs of the joint committee on health care financing or their
60	60	30designees; 1 member from the American Academy of Family Physicians Mass Chapter, Inc.; 1
61	61	31member from the Massachusetts chapter of the American Academy of Pediatrics; 1 member 3 of 45
62	62	32from a rural health care practice with expertise in primary care who shall be appointed by the
63	63	33secretary of health and human services; 1 member from Community Care Cooperative, Inc.; 1
64	64	34member from the Massachusetts Medical Society with expertise in primary care; 1 member from
65	65	35the Massachusetts Coalition of Nurse Practitioners, Inc. with expertise in primary care or in
66	66	36delivering care in a community health center; 1 member from the Massachusetts Association of
67	67	37Physician Associates, Inc. with expertise in primary care; 1 member from the Massachusetts
68	68	38chapter of the National Association of Social Workers, Inc. with expertise in behavioral health in
69	69	39a primary care setting; 1 member from the Massachusetts League of Community Health Centers,
70	70	40Inc.; 1 member from the Massachusetts Health and Hospital Association, Inc.; 1 member from
71	71	41the Massachusetts Association of Health Plans, Inc.; 1 member from Blue Cross and Blue Shield
72	72	42of Massachusetts, Inc.; 1 health care executive with expertise in the delivery of primary care in a
73	73	43community setting and expertise in health benefit plan design, who shall be appointed by the
74	74	44executive director of the health policy commission; 1 member from the Associated Industries of
75	75	45Massachusetts, Inc.; 1 member from the Retailers Association of Massachusetts, Inc.; 1 member
76	76	46from Health Care For All, Inc.; 1 member from the Massachusetts Chapter of the American
77	77	47College of Physicians; 1 member from the Massachusetts Primary Care Alliance for Patients;
78	78	48and 1 member from Massachusetts Health Quality Partners, Inc.
79	79	49 (c) The board shall develop recommendations to: (i) define primary care services, codes
80	80	50and providers; (ii) develop a standard set of data reporting requirements for private and public
81	81	51health care payers, providers and provider organizations to enable the commonwealth and private
82	82	52and public health care payers to track payments for primary care services including, but not
83	83	53limited to, fee-for-service, prospective payments, value-based payments and grants to primary
84	84	54care providers, fees levied on a primary care provider by a provider organization or hospital 4 of 45
85	85	55system of which the primary care provider is affiliated and provider spending on primary care
86	86	56services; (iii) propose payment models to increase private and public reimbursement for primary
87	87	57care services, including, but not limited to, an all-payer primary care capitation model; (iv)
88	88	58assess the impact of health plan design on health equity and patient access to primary care
89	89	59services; (v) monitor and track the needs of and service delivery to residents of the
90	90	60commonwealth; (vi) create short-term and long-term workforce development plans to increase
91	91	61the supply and distribution of and improve working conditions of primary care clinicians and
92	92	62other primary care workers; and (vii) strengthen the integration of primary care and behavioral
93	93	63health and increase investment in behavioral health. The board may make additional
94	94	64recommendations and propose legislation necessary to carry out its recommendations.
95	95	65 (d) The board shall, in consultation with the center, define the data required to satisfy the
96	96	66contents of this section. The center shall adopt regulations to require providers and private and
97	97	67public health care payers to submit data or information necessary for the board to fulfill its duties
98	98	68under this section. Any data collected shall be public and available through the Massachusetts
99	99	69Primary Care Dashboard maintained by the center and Massachusetts Health Quality Partners,
100	100	70Inc.
101	101	71 (e)(1) The board shall propose a standard all-payer primary care capitation model, under
102	102	72which private payers shall pay participating providers or provider organizations a prospective,
103	103	73per-member per-month payment for patients attributed to the participating provider or provider
104	104	74organization for primary care. The proposed model shall include, but not be limited to: (i)
105	105	75definitions of primary care services, codes, and providers; (ii) per-member per-month rate
106	106	76methodology; (iii) enhanced payments for advanced primary care services and investments; (iv)
107	107	77patient cost-sharing limits for primary care; (v) member attribution methodology; (vi) primary 5 of 45
108	108	78care quality measures; (vii) primary care reimbursement and spending reporting requirements for
109	109	79participating providers or provider organizations; and (viii) audits of participating providers or
110	110	80provider organizations.
111	111	81 (2) In developing the per-member per-month rate methodology, the board may consider
112	112	82the historical monthly primary care spending per patient at the primary care provider or provider
113	113	83organization level, the historical monthly primary care spending per patient statewide, the
114	114	84primary care expenditure data published in the center’s annual report under section 16 of chapter
115	115	8512C, and any other factors deemed relevant by the board. The per-member per-month payment
116	116	86may be adjusted based on: (i) a participating provider or provider organization’s adoption of
117	117	87advanced primary care services and investment in primary care services; (ii) the quality of
118	118	88patient care delivered by a participating provider or provider organization; and (iii) the clinical
119	119	89and social risk of patients attributed to a participating provider or provider organization for
120	120	90primary care. The board shall consider the per-member per-month rate methodology established
121	121	91in the MassHealth primary care sub-capitation program.
122	122	92 (3) The board shall identify advanced primary care services and investments in primary
123	123	93care delivery that may qualify participating providers or provider organizations for enhanced
124	124	94payments under the all-payer primary care capitation model. Advanced primary care services and
125	125	95investments shall be evidence-informed or evidence-based, improve primary care quality,
126	126	96increase primary care access, enhance a patient’s primary care experience, or promote health
127	127	97equity in primary care. Advanced primary care services and investments shall include, but not be
128	128	98limited to: (i) employing community health workers or health coaches as part of the primary care
129	129	99team; (ii) investing in social determinants of health; (iii) collaborating with primary care-based
130	130	100clinical pharmacists; (iv) integrating behavioral health care with primary care; (v) offering 6 of 45
131	131	101substance use disorder treatment, including medication-assisted treatment, telehealth services,
132	132	102including telehealth consultations with specialists, medical interpreter services, home care,
133	133	103patient advisory groups, and group visits; (vi) using clinician optimization programs to reduce
134	134	104documentation burden, including, but not limited to, medical scribes and ambient voice
135	135	105technology; (vii) investing in care management, including employing social workers to help
136	136	106manage the care for patients with complicated health needs; (viii) establishing systems to
137	137	107facilitate end of life care planning and palliative care; (ix) developing systems to evaluate patient
138	138	108population health to help determine which preventative medicine interventions require patient
139	139	109outreach; (x) offering walk-in or same-day care appointments or extended hours of availability;
140	140	110and (xi) any other primary care service deemed relevant by the board. The board shall consider
141	141	111care delivery requirements established in the MassHealth primary care sub-capitation program.
142	142	112 (4) The board shall develop clinical tiers with minimum care delivery standards based on
143	143	113advanced primary care services and investments identified in paragraph (3) and establish
144	144	114enhanced payment rates for each clinical tier under the all-payer primary care capitation model.
145	145	115In determining the enhanced payment rates, the board shall consider the strength of evidence that
146	146	116the advanced service or investment will: (i) improve patient health; (ii) enhance patient
147	147	117experience; (iii) improve clinician experience, including reducing administrative burden; (iv)
148	148	118decrease total medical expense; and (v) promote health equity. The board shall consider the
149	149	119clinical tiers established in the MassHealth primary care sub-capitation program.
150	150	120 (5) The board shall identify not more than 8 quality measures related to: (i) care
151	151	121continuity, comprehensiveness, and coordination; (ii) patient access to primary care; and (iii)
152	152	122patient experience. 4 of the 8 quality measures shall be measures of patient experience and 1
153	153	123shall be a person-centered primary care measure. Each quality measure shall be patient-centered, 7 of 45
154	154	124appropriate for a primary care setting, and supported by peer-reviewed, evidence-based research
155	155	125that the measure is actionable and that its use will lead to improvements in patient health. The
156	156	126board shall develop standard reporting requirements for the quality measures and standard per-
157	157	127member per-month rate adjustment methodology based on quality measures. The board shall
158	158	128consider MassHealth quality indicators for managed care entities.
159	159	129 (6) The board shall identify measures of clinical and social complexity that promote
160	160	130health equity and minimize opportunities to artificially increase the clinical and social
161	161	131complexity of a patient panel. The board shall develop standard per-member per-month rate
162	162	132adjustment methodology based on measures of clinical and social complexity.
163	163	133 (7) The board shall develop member attribution methodology to assign patients to
164	164	134participating providers or provider organizations for primary care under the all-payer primary
165	165	135care capitation model. The board shall consider the member attribution process established in the
166	166	136MassHealth primary care sub-capitation program.
167	167	137 (8) The board shall develop an attestation, reporting and audit process for participating
168	168	138providers or provider organizations. The board shall consider the attestation, reporting and audit
169	169	139process established in the MassHealth primary care sub-capitation program.
170	170	140 SECTION 4. Section 8 of said chapter 6D, as so appearing, is hereby amended by
171	171	141striking out subsection (a) and inserting in place thereof the following subsection:-
172	172	142 (a) Not later than October 1 of every year, the commission shall hold public hearings
173	173	143based on the report submitted by the center under section 16 of chapter 12C comparing the
174	174	144growth in total health care expenditures to the health care cost growth benchmark for the
175	175	145previous calendar year and comparing the growth in actual aggregate primary care expenditures 8 of 45
176	176	146for the previous calendar year to the aggregate primary care expenditure target. The hearings
177	177	147shall examine health care provider, provider organization and private and public health care
178	178	148payer costs, prices and cost trends, with particular attention to factors that contribute to cost
179	179	149growth within the commonwealth’s health care system and challenge the ability of the
180	180	150commonwealth’s health care system to meet the benchmark established under section 9 or the
181	181	151aggregate primary care expenditure target established under section 9A.
182	182	152 SECTION 5. Said section 8 of said chapter 6D, as so appearing, is hereby further
183	183	153amended by inserting after the word “health”, in line 95, the following words:- and primary care.
184	184	154 SECTION 6. Said chapter 6D is hereby further amended by inserting after section 9 the
185	185	155following section:-
186	186	156 Section 9A. (a) The commission shall establish an aggregate primary care expenditure
187	187	157target for the commonwealth, which the commission shall prominently publish on its website.
188	188	158 (b) The commission shall establish the aggregate primary care expenditure target and the
189	189	159primary care expenditure target as follows:
190	190	160 (1) For the calendar year 2027, the aggregate primary care expenditure target and the
191	191	161primary care expenditure target shall be equal to 8 per cent of total health care expenditures in
192	192	162the commonwealth;
193	193	163 (2) For the calendar year 2028, the aggregate primary care expenditure target and the
194	194	164primary care expenditure target shall be equal to 10 per cent of total health care expenditures in
195	195	165the commonwealth; 9 of 45
196	196	166 (3) For the calendar year 2029, the aggregate primary care expenditure target and the
197	197	167primary care expenditure target shall be equal to 12 per cent of total health care expenditures in
198	198	168the commonwealth; and
199	199	169 (4) For calendar years 2030 and beyond, if the commission determines that an adjustment
200	200	170in the aggregate primary care expenditure target and the primary care expenditure target is
201	201	171reasonably warranted, the commission may recommend modification to such targets, provided,
202	202	172that such targets shall not be lower than 12 per cent of total health care expenditures in the
203	203	173commonwealth.
204	204	174 (c) Prior to making any recommended modification to the aggregate primary care
205	205	175expenditure target and the primary care expenditure target under paragraph (4) of subsection (b),
206	206	176the commission shall hold a public hearing. The public hearing shall be based on the report
207	207	177submitted by the center under section 16 of chapter 12C, comparing the aggregate primary care
208	208	178expenditures to the aggregate primary care expenditure target, any other data submitted by the
209	209	179center and such other pertinent information or data as may be available to the commission. The
210	210	180hearings shall examine the performance of health care entities in meeting the primary care
211	211	181expenditure target and the commonwealth’s health care system in meeting the aggregate primary
212	212	182care expenditure target. The commission shall provide public notice of the hearing at least 45
213	213	183days prior to the date of the hearing, including notice to the joint committee on health care
214	214	184financing. The joint committee on health care financing may participate in the hearing. The
215	215	185commission shall identify as witnesses for the public hearing a representative sample of
216	216	186providers, provider organizations, payers and such other interested parties as the commission
217	217	187may determine. Any other interested parties may testify at the hearing. 10 of 45
218	218	188 (d) Any recommendation of the commission to modify the aggregate primary care
219	219	189expenditure target and the primary care expenditure target under paragraph (4) of subsection (b)
220	220	190shall be approved by a two thirds vote of the board.
221	221	191 SECTION 7. Said chapter 6D, as so appearing, is hereby further amended by inserting
222	222	192after section 10 the following section:-
223	223	193 Section 10A. (a) For the purposes of this section, “health care entity” shall mean any
224	224	194entity identified by the center under section 18 of chapter 12C.
225	225	195 (b) The commission shall provide notice to all health care entities that have been
226	226	196identified by the center under section 18 of chapter 12C for failure to meet the primary care
227	227	197expenditure target. Such notice shall state that the center may analyze the performance of
228	228	198individual health care entities in meeting the primary care expenditure target and, beginning in
229	229	199calendar year 2027, the commission may require certain actions, as established in this section,
230	230	200from health care entities so identified.
231	231	201 (c) In addition to the notice provided under subsection (b), the commission may require
232	232	202any health care entity that is identified by the center under section 18 of chapter 12C for failure
233	233	203to meet the primary care expenditure target to file and implement a performance improvement
234	234	204plan. The commission shall provide written notice to such health care entity that they are
235	235	205required to file a performance improvement plan. Within 45 days of receipt of such written
236	236	206notice, the health care entity shall either:
237	237	207 (1) file a performance improvement plan with the commission; or 11 of 45
238	238	208 (2) file an application with the commission to waive or extend the requirement to file a
239	239	209performance improvement plan.
240	240	210 (d) The health care entity may file any documentation or supporting evidence with the
241	241	211commission to support the health care entity’s application to waive or extend the requirement to
242	242	212file a performance improvement plan. The commission shall require the health care entity to
243	243	213submit any other relevant information it deems necessary in considering the waiver or extension
244	244	214application; provided, however, that such information shall be made public at the discretion of
245	245	215the commission.
246	246	216 (e) The commission may waive or delay the requirement for a health care entity to file a
247	247	217performance improvement plan in response to a waiver or extension request filed under
248	248	218subsection (c) in light of all information received from the health care entity, based on a
249	249	219consideration of the following factors: (1) the primary care baseline expenditures, costs, price
250	250	220and utilization trends of the health care entity over time, and any demonstrated improvement to
251	251	221increase the proportion of primary care expenditures; (2) any ongoing strategies or investments
252	252	222that the health care entity is implementing to invest in or expand access to primary care services;
253	253	223(3) whether the factors that led to the inability of the health care entity to meet the primary care
254	254	224expenditure target can reasonably be considered to be unanticipated and outside of the control of
255	255	225the entity; provided, that such factors may include, but shall not be limited to, market dynamics,
256	256	226technological changes and other drivers of non-primary care spending such as pharmaceutical
257	257	227and medical devices expenses; (4) the overall financial condition of the health care entity; and
258	258	228(5) any other factors the commission considers relevant. 12 of 45
259	259	229 (f) If the commission declines to waive or extend the requirement for the health care
260	260	230entity to file a performance improvement plan, the commission shall provide written notice to the
261	261	231health care entity that its application for a waiver or extension was denied and the health care
262	262	232entity shall file a performance improvement plan.
263	263	233 (g) The commission shall provide the department of public health any notice requiring a
264	264	234health care entity to file and implement a performance improvement plan pursuant to this
265	265	235section. In the event a health care entity required to file a performance improvement plan under
266	266	236this section submits an application for a notice of determination of need under section 25C or 51
267	267	237of chapter 111, the notice of the commission requiring the health care entity to file and
268	268	238implement a performance improvement plan pursuant to this section shall be considered part of
269	269	239the written record pursuant to said section 25C of chapter 111.
270	270	240 (h) A health care entity shall file a performance improvement plan: (1) within 45 days of
271	271	241receipt of a notice under subsection (c); (2) if the health care entity has requested a waiver or
272	272	242extension, within 45 days of receipt of a notice that such waiver or extension has been denied; or
273	273	243(3) if the health care entity is granted an extension, on the date given on such extension. The
274	274	244performance improvement plan shall identify specific strategies, adjustments and action steps the
275	275	245entity proposes to implement to increase the proportion of primary care expenditures. The
276	276	246proposed performance improvement plan shall include specific identifiable and measurable
277	277	247expected outcomes and a timetable for implementation.
278	278	248 (i) The commission shall approve any performance improvement plan that it determines
279	279	249is reasonably likely to address the underlying cause of the entity’s inability to meet the primary
280	280	250care expenditure target and has a reasonable expectation for successful implementation. 13 of 45
281	281	251 (j) If the board determines that the performance improvement plan is unacceptable or
282	282	252incomplete, the commission may provide consultation on the criteria that have not been met and
283	283	253may allow an additional time period, up to 30 calendar days, for resubmission.
284	284	254 (k) Upon approval of the proposed performance improvement plan, the commission shall
285	285	255notify the health care entity to begin immediate implementation of the performance improvement
286	286	256plan. Public notice shall be provided by the commission on its website, identifying that the health
287	287	257care entity is implementing a performance improvement plan. All health care entities
288	288	258implementing an approved performance improvement plan shall be subject to additional
289	289	259reporting requirements and compliance monitoring, as determined by the commission. The
290	290	260commission shall provide assistance to the health care entity in the successful implementation of
291	291	261the performance improvement plan.
292	292	262 (l) All health care entities shall, in good faith, work to implement the performance
293	293	263improvement plan. At any point during the implementation of the performance improvement
294	294	264plan the health care entity may file amendments to the performance improvement plan, subject to
295	295	265approval of the commission.
296	296	266 (m) At the conclusion of the timetable established in the performance improvement plan,
297	297	267the health care entity shall report to the commission regarding the outcome of the performance
298	298	268improvement plan. If the performance improvement plan was found to be unsuccessful, the
299	299	269commission shall either: (1) extend the implementation timetable of the existing performance
300	300	270improvement plan; (2) approve amendments to the performance improvement plan as proposed
301	301	271by the health care entity; (3) require the health care entity to submit a new performance 14 of 45
302	302	272improvement plan under subsection (c); or (4) waive or delay the requirement to file any
303	303	273additional performance improvement plans.
304	304	274 (n) Upon the successful completion of the performance improvement plan, the identity of
305	305	275the health care entity shall be removed from the commission’s website.
306	306	276 (o) The commission may submit a recommendation for proposed legislation to the joint
307	307	277committee on health care financing if the commission determines that further legislative
308	308	278authority is needed to achieve the health care quality and spending sustainability objectives of
309	309	279section 9A, assist health care entities with the implementation of performance improvement
310	310	280plans or otherwise ensure compliance with the provisions of this section.
311	311	281 (p) If the commission determines that a health care entity has: (1) willfully neglected to
312	312	282file a performance improvement plan with the commission by the time required in subsection (h);
313	313	283(2) failed to file an acceptable performance improvement plan in good faith with the
314	314	284commission; (3) failed to implement the performance improvement plan in good faith; or (4)
315	315	285knowingly failed to provide information required by this section to the commission or that
316	316	286knowingly falsifies the same, the commission may assess a civil penalty to the health care entity
317	317	287of not more than $500,000 for a first violation, not more than $750,000 for a second violation
318	318	288and not more than the amount by which the health care entity failed to meet the primary care
319	319	289expenditure target for a third or subsequent violation. The commission shall seek to promote
320	320	290compliance with this section and shall only impose a civil penalty as a last resort.
321	321	291 (q) The commission shall promulgate regulations necessary to implement this section. 15 of 45
322	322	292 (r) Nothing in this section shall be construed as affecting or limiting the applicability of
323	323	293the health care cost growth benchmark established under section 9, and the obligations of a
324	324	294health care entity thereto.
325	325	295 SECTION 8. Section 1 of chapter 12C of the General Laws, as appearing in the 2022
326	326	296Official Edition, is hereby amended by inserting after the definition of “Acute hospital” the
327	327	297following definitions:-
328	328	298 “Aggregate primary care baseline expenditures”, the sum of all primary care expenditures
329	329	299in the commonwealth in the calendar year preceding the year in which the aggregate primary
330	330	300care expenditure target applies.
331	331	301 “Aggregate primary care expenditure target”, the targeted sum, set by the commission in
332	332	302section 9A of chapter 6D, of all primary care expenditures in the commonwealth in the calendar
333	333	303year in which the aggregate primary care expenditure target applies.
334	334	304 SECTION 9. Said section 1 of said chapter 12C, as so appearing, is hereby further
335	335	305amended by inserting after the definition of “Patient-centered medical home” the following
336	336	306definitions:-
337	337	307 “Primary care baseline expenditures”, the sum of all primary care expenditures, as
338	338	308defined by the center, by or attributed to an individual health care entity in the calendar year
339	339	309preceding the year in which the primary care expenditure target applies.
340	340	310 “Primary care expenditure target”, the targeted sum, set by the commission in section 9A,
341	341	311of all primary care expenditures, as defined by the center, by or attributed to an individual health
342	342	312care entity in the calendar year in which the entity’s primary care expenditure target applies. 16 of 45
343	343	313 SECTION 10. Said section 16 of said chapter 12C, as so appearing, is hereby further
344	344	314amended by adding the following subsections:-
345	345	315 (d) The center shall publish the aggregate primary care baseline expenditures in its annual
346	346	316report.
347	347	317 (e) The center, in consultation with the commission, shall determine the primary care
348	348	318baseline expenditures for individual health care entities and shall report to each health care entity
349	349	319its respective primary care baseline expenditures annually, by October 1.
350	350	320 SECTION 11. Said chapter 12C, as so appearing, is hereby further amended by striking
351	351	321out section 18 and inserting in place thereof the following section:-
352	352	322 Section 18. The center shall perform ongoing analysis of data it receives under this
353	353	323chapter to identify any payers, providers or provider organizations: (i) whose increase in health
354	354	324status adjusted total medical expense or total medical expense is considered excessive and who
355	355	325threaten the ability of the state to meet the health care cost growth benchmark established by the
356	356	326health care finance and policy commission under section 10 of chapter 6D; or (ii) whose
357	357	327expenditures fail to meet the primary care expenditure target under section 9A of chapter 6D;
358	358	328provided, however, that the provider or provider organization provides primary care services.
359	359	329The center shall confidentially provide a list of the payers, providers and provider organizations
360	360	330to the health policy commission such that the commission may pursue further action under
361	361	331sections 10 and 10A of chapter 6D.
362	362	332 SECTION 12. Chapter 15A of the General Laws, as appearing in the 2022 Official
363	363	333Edition, is hereby amended by inserting after section 18 the following new section:- 17 of 45
364	364	334 Section 18A. (a) For the purposes of this section, the following terms shall have the
365	365	335following meanings unless the context clearly requires otherwise:
366	366	336 “Federally Qualified Health Center”, any entity receiving a grant under 42 U.S.C. 254B.
367	367	337 “Federally Qualified Health Center Services”, as such term is defined in 42 U.S.C.
368	368	3381396(a)(2)(C), and as further defined in 101 CMR 304.00.
369	369	339 (b) Notwithstanding any general or special law to the contrary, any student health
370	370	340insurance program or plan authorized under Section 18 of Chapter 15A shall ensure that the rate
371	371	341of payment for any Federally Qualified Health Center services provided to a patient by a
372	372	342community health center, shall be reimbursed in an amount at least equivalent to the annual
373	373	343aggregate revenue that the health center would have received if reimbursed by MassHealth
374	374	344pursuant to methodology that conforms with 42 U.S.C. § 1396a(bb) and 1396b(m)(2)(A)(ix) as
375	375	345they appear in Title 42 of the United States Code as of January 1, 2025.
376	376	346 SECTION 13. Chapter 32A of the General Laws, as appearing in the 2022 Official
377	377	347Edition, is hereby amended by striking out section 31 and inserting in place thereof the following
378	378	348sections:-
379	379	349 Section 31. (a) The commission shall provide to any active or retired employee of the
380	380	350commonwealth who is insured under the group insurance commission benefits on a
381	381	351nondiscriminatory basis for medically necessary emergency services programs, as defined in
382	382	352section 1 of chapter 175. Services delivered by emergency services programs shall be deemed
383	383	353medically necessary and shall not require prior authorization. Services delivered by emergency
384	384	354service programs shall be covered with no patient cost-sharing; provided, however, that cost- 18 of 45
385	385	355sharing shall be required if the applicable plan is governed by the Federal Internal Revenue Code
386	386	356and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
387	387	357 (b) The commission shall ensure that payment for outpatient services delivered by
388	388	358emergency services programs through a mental health center designated as a community
389	389	359behavioral health center pursuant to section 13D½ of chapter 118E shall be structured as a
390	390	360bundled rate per encounter using the same Healthcare Common Procedure Coding System code
391	391	361adopted by MassHealth and at a rate no less than the prevailing MassHealth rate for the same set
392	392	362of bundled services.
393	393	363 Section 31A. (a) For the purposes of this section, the following terms shall have the
394	394	364following meanings:
395	395	365 “Behavioral health urgent care provider”, a mental health center designated as a
396	396	366behavioral health urgent care provider under 130 CMR 429.000.
397	397	367 “Behavioral health urgent care services”, shall include, but not be limited to: (i)
398	398	368diagnostic psychiatric evaluations; (ii) individual, group, couple, and family therapy; (iii)
399	399	369psychotherapy for crisis; (iv) case consultation; (v) family consultation; or (vi) evaluation and
400	400	370management medication visits provided by a designated behavioral health urgent care provider.
401	401	371 (b) The commission shall provide to any active or retired employee of the commonwealth
402	402	372who is insured under the group insurance commission benefits on a nondiscriminatory basis for
403	403	373medically necessary behavioral health urgent care services provided by a behavioral health
404	404	374urgent care provider. Services delivered by a behavioral health urgent care provider shall be
405	405	375deemed medically necessary and shall not require prior authorization. Services delivered by a
406	406	376behavioral health urgent care provider shall be covered with no patient cost-sharing; provided, 19 of 45
407	407	377however, that cost-sharing shall be required if the applicable plan is governed by the Federal
408	408	378Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-
409	409	379sharing for this service.
410	410	380 (c) The commission shall ensure that payment for any services provided by a behavioral
411	411	381health urgent care provider include a rate add-on of at least 20 per cent over any negotiated fee
412	412	382schedule, provided that a carrier shall not lower a negotiated fee schedule to comply with this
413	413	383section. For purposes of this section, a carrier shall pay a rate add-on of at least 20 per cent for all
414	414	384behavioral health urgent care services delivered by a behavioral health urgent care provider
415	415	385regardless of whether the presenting reason for care is determined to be an urgent behavioral
416	416	386health need.
417	417	387 SECTION 14. Said chapter 32A, as so appearing, is hereby amended by inserting after
418	418	388section 33 the following 2 sections:-
419	419	389 Section 34. (a) For the purposes of this section, the following words shall have the
420	420	390following meanings:-
421	421	391 “All-payer primary care capitation model”, a standard value-based, prospective payment
422	422	392model under which health insurers pay participating providers or provider organizations per-
423	423	393member per-month payments for patients attributed to the participating providers or provider
424	424	394organizations for primary care. The per-member per-month payment may be adjusted based on:
425	425	395(i) a participating provider or provider organization’s adoption of advanced primary care services
426	426	396and investment in primary care services; (ii) the quality of patient care delivered by a
427	427	397participating provider or provider organization; and (iii) the clinical and social risk of patients
428	428	398attributed to a participating provider or provider organization for primary care; provided, 20 of 45
429	429	399however, that implementation of the all-payer primary care capitation model complies with
430	430	400division of insurance rules, regulations and guidelines.
431	431	401 “Division”, the division of insurance.
432	432	402 (b) The commission shall implement the all-payer primary care capitation model in
433	433	403accordance with division rules, regulations and guidelines, including, but not limited to: (i)
434	434	404definitions of primary care services, codes, and providers; (ii) per-member per-month rate
435	435	405methodology; (iii) enhanced payments for advanced primary care services and investments; (iv)
436	436	406patient cost-sharing limits for primary care; (v) member attribution methodology; (vi) primary
437	437	407care quality measures; (vii) primary care reimbursement and spending reporting requirements for
438	438	408participating primary care providers and health care organizations; and (viii) audits of
439	439	409participating primary care providers and health care organizations.
440	440	410 (c) The commission shall provide contracted primary care providers and health care
441	441	411organizations with the option to participate in the all-payer primary care capitation model and
442	442	412receive per-member per-month payments for any active or retired employee of the
443	443	413commonwealth insured under the commission who is attributed to a primary care provider.
444	444	414 (d) Payments made to primary care providers and health care organizations participating
445	445	415in the all-payer primary care capitation model shall be included in the health status adjusted total
446	446	416medical expense and total medical expense calculated by the center for health information and
447	447	417analysis under section 16 of chapter 12C.
448	448	418 (e) Participating primary care providers and health care organizations shall attest to
449	449	419meeting the criteria for clinical tiers and submit to audits by the commission. 21 of 45
450	450	420 (f) Participating primary care providers and health care organizations shall submit
451	451	421primary care expenditure reports and internal contracts related to primary care delivery and
452	452	422payment to the division, the center for health information and analysis and the health policy
453	453	423commission in accordance with division rules, regulations and guidelines.
454	454	424 (g) Participating primary care providers and health care organizations shall select 4
455	455	425quality measures, as defined by the division, to measure and report to the commission annually.
456	456	426 Section 35. (a) For the purposes of this section, the following terms shall have the
457	457	427following meanings unless the context clearly requires otherwise:
458	458	428 “Federally Qualified Health Center”, any entity receiving a grant under 42 U.S.C. 254B.
459	459	429 “Federally Qualified Health Center Services”, as such term is defined in 42 U.S.C.
460	460	4301396d(a)(2)(C), and as further defined in 101 CMR 304.00.
461	461	431 (b) Notwithstanding any general or special law to the contrary, the commission shall
462	462	432ensure that the rate of payment for any federally qualified health center services provided to a
463	463	433patient by a community health center shall be reimbursed in an amount not less than equivalent
464	464	434to the annual aggregate revenue that the health center would have received if reimbursed by
465	465	435MassHealth pursuant to methodology that conforms with 42 U.S.C. 1396a(bb) and
466	466	4361396b(m)(2)(A)(ix), as appearing in Title 42 of the United States Code as of January 1, 2025.
467	467	437 SECTION 15. Section 1 of chapter 175 of the General Laws, as appearing in the 2022
468	468	438Official Edition, is hereby amended by striking out the definition of “Emergency services
469	469	439programs” and inserting in place thereof the following definition:- 22 of 45
470	470	440 “Emergency services programs”, community-based organizations providing emergency
471	471	441psychiatric services, including, but not limited to, behavioral health crisis assessment,
472	472	442intervention and stabilization services 24 hours per day, 7 days per week, through: (i) mobile
473	473	443crisis intervention services for youth; (ii) mobile crisis intervention services for adults; (iii)
474	474	444emergency service provider community-based locations; (iv) emergency departments of acute
475	475	445care hospitals or satellite emergency facilities; (v) youth community crisis stabilization services;
476	476	446(vi) adult community crisis stabilization services; and (vii) a mental health center designated as a
477	477	447community behavioral health center pursuant to section 13D½ of chapter 118E, including
478	478	448outpatient behavioral health bundled services delivered by these centers.
479	479	449 SECTION 16. Said chapter 175, as so appearing, is hereby amended by striking out
480	480	450section 47RR and inserting in place thereof the following section:-
481	481	451 Section 47RR. (a) An individual policy of accident and sickness insurance issued under
482	482	452section 108 that provides hospital expense and surgical expense insurance or a group blanket or
483	483	453general policy of accident and sickness insurance issued under section 110 that provides hospital
484	484	454expense and surgical expense insurance that is issued or renewed within or without the
485	485	455commonwealth shall provide benefits on a nondiscriminatory basis for medically necessary
486	486	456emergency services programs as defined in section 1. Services delivered by emergency services
487	487	457programs shall be deemed medically necessary and shall not require prior authorization. Services
488	488	458delivered by emergency service programs shall be covered with no patient cost-sharing;
489	489	459provided, however, that cost-sharing shall be required if the applicable plan is governed by the
490	490	460Federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition
491	491	461on cost-sharing for this service. 23 of 45
492	492	462 (b) An individual policy of accident and sickness insurance issued pursuant to section
493	493	463108 that provides hospital expense and surgical expense insurance or a group blanket or general
494	494	464policy of accident and sickness insurance issued pursuant to section 110 that provides hospital
495	495	465expense and surgical expense insurance that is issued or renewed within or without the
496	496	466commonwealth shall ensure that reimbursement for outpatient services delivered by emergency
497	497	467services programs through a mental health center designated as a community behavioral health
498	498	468center pursuant to section 13D½ of chapter 118E, shall be structured as a bundled rate per
499	499	469encounter using the same Healthcare Common Procedure Coding System code adopted by
500	500	470MassHealth and at a rate no less than the prevailing MassHealth rate for the same set of bundled
501	501	471services.
502	502	472 SECTION 17. Chapter 175 of the General Laws, as amended by section 31 of chapter
503	503	473342 of the acts of 2024, is hereby amended by inserting after section 47CCC the following 3
504	504	474sections:-
505	505	475 Section 47DDD. (a) For the purposes of this section, the following words shall have the
506	506	476following meanings:-
507	507	477 “All-payer primary care capitation model”, a standard value-based, prospective payment
508	508	478model under which health insurers pay participating providers or provider organizations per-
509	509	479member per-month payments for patients attributed to the participating providers or provider
510	510	480organizations for primary care. The per-member per-month payment may be adjusted based on:
511	511	481(i) a participating provider or provider organization’s adoption of advanced primary care services
512	512	482and investment in primary care services; (ii) the quality of patient care delivered by a
513	513	483participating provider or provider organization; and (iii) the clinical and social risk of patients 24 of 45
514	514	484attributed to a participating provider or provider organization for primary care; provided,
515	515	485however, that implementation of the all-payer primary care capitation model complies with
516	516	486division of insurance rules, regulations and guidelines.
517	517	487 “Division”, the division of insurance.
518	518	488 “Provider organization”, as defined in section 1 of chapter 6D.
519	519	489 (b) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or
520	520	490renewed within the commonwealth and which is considered creditable coverage under section 1
521	521	491of chapter 111M shall implement the all-payer primary care capitation model in accordance with
522	522	492division rules, regulations and guidelines, including, but not limited to: (i) definitions of primary
523	523	493care services, codes, and providers; (ii) per-member per-month rate methodology; (iii) enhanced
524	524	494payments for advanced primary care services and investments; (iv) patient cost-sharing limits for
525	525	495primary care; (v) member attribution methodology; (vi) primary care quality measures; (vii)
526	526	496primary care reimbursement and spending reporting requirements for participating primary care
527	527	497providers and provider organizations; and (viii) audits of participating primary care providers
528	528	498and provider organizations.
529	529	499 (c) The carrier shall provide contracted primary care providers and provider organizations
530	530	500with the option to participate in the all-payer primary care capitation model and receive per-
531	531	501member per-month payments for enrollees attributed to the primary care provider or provider
532	532	502organization for primary care.
533	533	503 (d) Payments made to primary care providers and provider organizations participating in
534	534	504the all-payer primary care capitation model shall be included in the health status adjusted total 25 of 45
535	535	505medical expense and total medical expense calculated by the center for health information and
536	536	506analysis under section 16 of chapter 12C.
537	537	507 (e) Participating primary care providers and provider organizations shall attest to meeting
538	538	508the criteria for clinical tiers and submit to audits by the commission.
539	539	509 (f) Participating primary care providers and provider organizations shall submit primary
540	540	510care expenditure reports and internal contracts related to primary care delivery and payment to
541	541	511the division, the center for health information and analysis and the health policy commission in
542	542	512accordance with division rules, regulations and guidelines.
543	543	513 (g) Participating primary care providers and provider organizations shall select 4 quality
544	544	514measures, as defined by the division, to measure and report to the commission annually.
545	545	515 Section 47EEE. (a) For the purposes of this section, the following terms shall have the
546	546	516following meanings unless the context clearly requires otherwise:
547	547	517 “Federally Qualified Health Center”, any entity receiving a grant under 42 U.S.C. 254B.
548	548	518 “Federally Qualified Health Center Services”, as such term is defined in 42 U.S.C.
549	549	5191396d(a)(2)(C), and as further defined in 101 CMR 304.00.
550	550	520 (b) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or
551	551	521renewed within the commonwealth and which is considered creditable coverage under section 1
552	552	522of chapter 111M shall ensure that the rate of payment for any federally qualified health center
553	553	523services provided to a patient by a community health center shall be reimbursed in an amount not
554	554	524less than equivalent to the annual aggregate revenue that the health center would have received if
555	555	525reimbursed by MassHealth pursuant to methodology that conforms with 42 U.S.C. 1396a(bb) 26 of 45
556	556	526and 1396b(m)(2)(A)(ix), as appearing in Title 42 of the United States Code as of January 1,
557	557	5272025.
558	558	528 (c) Any entity licensed by the division of insurance and providing reimbursement to
559	559	529federally qualified health centers for services provided to patients, including, but not limited to,
560	560	530non-profit hospital service corporations, medical service corporations, dental service
561	561	531corporations, health maintenance organizations and preferred provider organizations or any other
562	562	532entity not specifically enumerated hereunder licensed by the division of insurance and providing
563	563	533reimbursement to federally qualified health centers for services provided to patients, shall submit
564	564	534an annual report to the division of insurance as a condition of their licensure evidencing that the
565	565	535total reimbursement to federally qualified health centers for services provided to patients in the
566	566	536prior year was equivalent to the annual aggregate revenue the health center would have received
567	567	537if reimbursed by MassHealth.
568	568	538 (d) The division of insurance shall consult with MassHealth to receive technical
569	569	539assistance regarding the per visit payment rate for each federally qualified health center for a
570	570	540given year. MassHealth shall provide the division of insurance with a proxy rate for any federally
571	571	541qualified health center who has not received an individual prospective payment system rate and
572	572	542the division of insurance shall make available to health plans upon request the necessary
573	573	543prospective payment system rate information regarding their contracted federally qualified health
574	574	544centers so that the health plan can ensure compliance with this requirement.
575	575	545 Section 47FFF. For the purposes of this section, the following terms shall have the
576	576	546following meanings unless the context clearly requires otherwise: 27 of 45
577	577	547 “Behavioral health urgent care provider”, a mental health center designated as a
578	578	548behavioral health urgent care provider under 130 CMR 429.000.
579	579	549 “Behavioral health urgent care services”, shall include, but not be limited to: (i)
580	580	550diagnostic psychiatric evaluations; (ii) individual, group, couple, and family therapy; (iii)
581	581	551psychotherapy for crisis; (iv) case consultation; (v) family consultation; or (vi) evaluation and
582	582	552management medication visits provided by a designated behavioral health urgent care provider.
583	583	553 (b) An individual policy of accident and sickness insurance issued under section 108 that
584	584	554provides hospital expense and surgical expense insurance or a group blanket or general policy of
585	585	555accident and sickness insurance issued under section 110 that provides hospital expense and
586	586	556surgical expense insurance that is issued or renewed within or without the commonwealth shall
587	587	557provide benefits on a nondiscriminatory basis for medically necessary behavioral health urgent
588	588	558care services provided by a behavioral health urgent care provider. Services delivered by a
589	589	559behavioral health urgent care provider shall be deemed medically necessary and shall not require
590	590	560prior authorization. Services delivered by a behavioral health urgent care provider shall be
591	591	561covered with no patient cost-sharing; provided, however, that cost-sharing shall be required if the
592	592	562applicable plan is governed by the Federal Internal Revenue Code and would lose its tax-exempt
593	593	563status as a result of the prohibition on cost-sharing for this service.
594	594	564 (c) An individual policy of accident and sickness insurance issued pursuant to section 108
595	595	565that provides hospital expense and surgical expense insurance or a group blanket or general
596	596	566policy of accident and sickness insurance issued pursuant to section 110 that provides hospital
597	597	567expense and surgical expense insurance that is issued or renewed within or without the
598	598	568commonwealth shall ensure that payment for any services provided by a behavioral health urgent 28 of 45
599	599	569care provider include a rate add-on of at least 20 per cent over any negotiated fee schedule,
600	600	570provided that a carrier shall not lower a negotiated fee schedule to comply with this section. For
601	601	571purposes of this section, a carrier shall pay a rate add-on of at least 20 per cent for all behavioral
602	602	572health urgent care services delivered by a behavioral health urgent care provider regardless of
603	603	573whether the presenting reason for care is determined to be an urgent behavioral health need.
604	604	574 SECTION 18. Chapter 176A of the General Laws, as appearing in the 2022 Official
605	605	575Edition, is hereby amended by striking out section 8TT and inserting in place thereof the
606	606	576following section:-
607	607	577 Section 8TT. (a) A contract between a subscriber and the corporation under an individual
608	608	578or group hospital service plan that is delivered, issued or renewed within or without the
609	609	579commonwealth shall provide benefits on a nondiscriminatory basis for medically necessary
610	610	580emergency services programs, as defined in section 1 of chapter 175. Services delivered by
611	611	581emergency services programs shall be deemed medically necessary and shall not require prior
612	612	582authorization. Services delivered by emergency service programs shall be covered with no
613	613	583patient cost-sharing; provided, however, that cost-sharing shall be required if the applicable plan
614	614	584is governed by the Federal Internal Revenue Code and would lose its tax-exempt status as a
615	615	585result of the prohibition on cost-sharing for this service.
616	616	586 (b) A contract between a subscriber and the corporation under an individual or group
617	617	587hospital service plan that is delivered, issued or renewed within or without the commonwealth
618	618	588shall ensure that reimbursement for outpatient services delivered by emergency services
619	619	589programs through a mental health center designated as a community behavioral health center
620	620	590pursuant to section 13D½ of chapter 118E, shall be structured as a bundled rate per encounter 29 of 45
621	621	591using the same Healthcare Common Procedure Coding System code adopted by MassHealth and
622	622	592at a rate no less than the prevailing MassHealth rate for the same set of bundled services.
623	623	593 SECTION 19. Chapter 176A of the General Laws, as amended by section 33 of chapter
624	624	594342 of the acts of 2024, is hereby amended by inserting after section 8DDD the following 3
625	625	595sections:-
626	626	596 Section 8EEE. (a) For the purposes of this section, the following words shall have the
627	627	597following meanings:-
628	628	598 “All-payer primary care capitation model”, a standard value-based, prospective payment
629	629	599model under which health insurers pay participating providers or provider organizations per-
630	630	600member per-month payments for patients attributed to the participating providers or provider
631	631	601organizations for primary care. The per-member per-month payment may be adjusted based on:
632	632	602(i) a participating provider or provider organization’s adoption of advanced primary care services
633	633	603and investment in primary care services; (ii) the quality of patient care delivered by a
634	634	604participating provider or provider organization; and (iii) the clinical and social risk of patients
635	635	605attributed to a participating provider or provider organization for primary care; provided,
636	636	606however, that implementation of the all-payer primary care capitation model complies with
637	637	607division of insurance rules, regulations and guidelines.
638	638	608 “Division”, the division of insurance.
639	639	609 “Primary care provider”, a health care professional qualified to provide general medical
640	640	610care for common health care problems who; (1) supervises, coordinates, prescribes, or otherwise
641	641	611provides or proposes health care services; (2) initiates referrals for specialist care; and (3)
642	642	612maintains continuity of care within the scope of practice. 30 of 45
643	643	613 “Provider organization”, as defined in section 1 of chapter 6D.
644	644	614 (b) Any contract between a subscriber and the corporation under an individual or group
645	645	615hospital service plan that is delivered, issued or renewed within the commonwealth shall
646	646	616implement the all-payer primary care capitation model in accordance with division rules,
647	647	617regulations and guidelines, including, but not limited to: (i) definitions of primary care services,
648	648	618codes, and providers; (ii) per-member per-month rate methodology; (iii) enhanced payments for
649	649	619advanced primary care services and investments; (iv) patient cost-sharing limits for primary care;
650	650	620(v) member attribution methodology; (vi) primary care quality measures; (vii) primary care
651	651	621reimbursement and spending reporting requirements for participating providers and provider
652	652	622organizations; and (viii) audits of participating providers and provider organizations.
653	653	623 (c) The carrier shall provide contracted primary care providers and provider organizations
654	654	624with the option to participate in the all-payer primary care capitation model and receive per-
655	655	625member per-month payments for enrollees attributed to the primary care provider or provider
656	656	626organization for primary care.
657	657	627 (d) Payments made to primary care providers and provider organizations participating in
658	658	628the all-payer primary care capitation model shall be included in the health status adjusted total
659	659	629medical expense and total medical expense calculated by the center for health information and
660	660	630analysis under section 16 of chapter 12C.
661	661	631 (e) Participating primary care providers and provider organizations shall attest to meeting
662	662	632the criteria for clinical tiers and submit to audits by the commission.
663	663	633 (f) Participating primary care providers and provider organizations shall submit primary
664	664	634care expenditure reports and internal contracts related to primary care delivery and payment to 31 of 45
665	665	635the division, the center for health information and analysis and the health policy commission in
666	666	636accordance with division rules, regulations and guidelines.
667	667	637 (g) Participating primary care providers and provider organizations shall select 4 quality
668	668	638measures, as defined by the division, to measure and report to the commission annually.
669	669	639 Section 8FFF. (a) For the purposes of this section, the following terms shall have the
670	670	640following meanings unless the context clearly requires otherwise:
671	671	641 “Federally Qualified Health Center”, any entity receiving a grant under 42 U.S.C. 254B.
672	672	642 “Federally Qualified Health Center Services”, as such term is defined in 42 U.S.C.
673	673	6431396d(a)(2)(C), and as further defined in 101 CMR 304.00.
674	674	644 (b) Any contract between a subscriber and the corporation under an individual or group
675	675	645hospital service plan that is delivered, issued or renewed within the commonwealth shall ensure
676	676	646that the rate of payment for any federally qualified health center services provided to a patient by
677	677	647a community health center shall be reimbursed in an amount not less than equivalent to the
678	678	648annual aggregate revenue that the health center would have received if reimbursed by
679	679	649MassHealth pursuant to methodology that conforms with 42 U.S.C. 1396a(bb) and
680	680	6501396b(m)(2)(A)(ix), as appearing in Title 42 of the United States Code as of January 1, 2025.
681	681	651 Section 8GGG. (a) For the purposes of this section, the following terms shall have the
682	682	652following meanings unless the context clearly requires otherwise:
683	683	653 “Behavioral health urgent care provider”, a mental health center designated as a
684	684	654behavioral health urgent care provider under 130 CMR 429.000. 32 of 45
685	685	655 “Behavioral health urgent care services”, shall include, but not be limited to: (i)
686	686	656diagnostic psychiatric evaluations; (ii) individual, group, couple, and family therapy; (iii)
687	687	657psychotherapy for crisis; (iv) case consultation; (v) family consultation; or (vi) evaluation and
688	688	658management medication visits provided by a designated behavioral health urgent care provider.
689	689	659 (b) A contract between a subscriber and the corporation under an individual or group
690	690	660hospital service plan that is delivered, issued or renewed within or without the commonwealth
691	691	661shall provide benefits on a nondiscriminatory basis for medically necessary behavioral health
692	692	662urgent care services provided by a behavioral health urgent care provider. Services delivered by
693	693	663a behavioral health urgent care provider shall be deemed medically necessary and shall not
694	694	664require prior authorization. Services delivered by a behavioral health urgent care provider shall
695	695	665be covered with no patient cost-sharing; provided, however, that cost-sharing shall be required if
696	696	666the applicable plan is governed by the Federal Internal Revenue Code and would lose its tax-
697	697	667exempt status as a result of the prohibition on cost-sharing for this service.
698	698	668 (c) A contract between a subscriber and the corporation under an individual or group
699	699	669hospital service plan that is delivered, issued or renewed within or without the commonwealth
700	700	670shall ensure that payment for any services provided by a behavioral health urgent care provider
701	701	671include a rate add-on of at least 20 per cent over any negotiated fee schedule, provided that a
702	702	672carrier shall not lower a negotiated fee schedule to comply with this section. For purposes of this
703	703	673section, a carrier shall pay a rate add-on of at least 20 per cent for all behavioral health urgent
704	704	674care services delivered by a behavioral health urgent care provider regardless of whether the
705	705	675presenting reason for care is determined to be an urgent behavioral health need. 33 of 45
706	706	676 SECTION 20. Chapter 176B of the General Laws, as appearing in the 2022 Official
707	707	677Edition, is hereby amended by striking out section 4TT and inserting in place thereof the
708	708	678following section:-
709	709	679 Section 4TT. (a) A subscription certificate under an individual or group medical service
710	710	680agreement delivered, issued or renewed within or without the commonwealth shall provide
711	711	681benefits on a nondiscriminatory basis for medically necessary emergency services programs, as
712	712	682defined in section 1 of chapter 175. Services delivered by emergency services programs shall be
713	713	683deemed medically necessary and shall not require prior authorization. Services delivered by
714	714	684emergency service programs shall be covered with no patient cost-sharing; provided, however,
715	715	685that cost-sharing shall be required if the applicable plan is governed by the Federal Internal
716	716	686Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing
717	717	687for this service.
718	718	688 (b) A subscription certificate under an individual or group medical service agreement
719	719	689delivered, issued or renewed within or without the commonwealth shall ensure that
720	720	690reimbursement for outpatient services delivered by emergency services programs through a
721	721	691mental health center designated as a community behavioral health center pursuant to section
722	722	69213D½ of chapter 118E, shall be structured as a bundled rate per encounter using the same
723	723	693Healthcare Common Procedure Coding System code adopted by MassHealth and at a rate no less
724	724	694than the prevailing MassHealth rate for the same set of bundled services.
725	725	695 SECTION 21. Chapter 176B of the General Laws, as amended by section 34 of chapter
726	726	696342 of the acts of 2024, is hereby amended by inserting after section 4DDD the following 3
727	727	697sections:- 34 of 45
728	728	698 Section 4EEE. (a) For the purposes of this section, the following words shall have the
729	729	699following meanings:-
730	730	700 “All-payer primary care capitation model”, a standard value-based, prospective payment
731	731	701model under which health insurers pay participating providers or provider organizations per-
732	732	702member per-month payments for patients attributed to the participating providers or provider
733	733	703organizations for primary care. The per-member per-month payment may be adjusted based on:
734	734	704(i) a participating provider or provider organization’s adoption of advanced primary care services
735	735	705and investment in primary care services; (ii) the quality of patient care delivered by a
736	736	706participating provider or provider organization; and (iii) the clinical and social risk of patients
737	737	707attributed to a participating provider or provider organization for primary care; provided,
738	738	708however, that implementation of the all-payer primary care capitation model complies with
739	739	709division of insurance rules, regulations and guidelines.
740	740	710 “Division”, the division of insurance.
741	741	711 “Provider organization”, as defined in section 1 of chapter 6D.
742	742	712 (b) A subscription certificate under an individual or group medical service agreement
743	743	713delivered, issued or renewed within the commonwealth and which is considered creditable
744	744	714coverage under section 1 of chapter 111M shall implement the all-payer primary care capitation
745	745	715model in accordance with division rules, regulations and guidelines, including, but not limited to:
746	746	716(i) definitions of primary care services, codes, and providers; (ii) per-member per-month rate
747	747	717methodology; (iii) enhanced payments for advanced primary care services and investments; (iv)
748	748	718patient cost-sharing limits for primary care; (v) member attribution methodology; (vi) primary
749	749	719care quality measures; (vii) primary care reimbursement and spending reporting requirements for 35 of 45
750	750	720participating primary care providers and provider organizations; and (viii) audits of participating
751	751	721primary care providers and provider organizations.
752	752	722 (c) The carrier shall provide contracted primary care providers and provider organizations
753	753	723with the option to participate in the all-payer primary care capitation model and receive per-
754	754	724member per-month payments for enrollees attributed to the primary care provider or provider
755	755	725organization for primary care.
756	756	726 (d) Payments made to primary care providers and provider organizations participating in
757	757	727the all-payer primary care capitation model shall be included in the health status adjusted total
758	758	728medical expense and total medical expense calculated by the center for health information and
759	759	729analysis under section 16 of chapter 12C.
760	760	730 (e) Participating primary care providers and provider organizations shall attest to meeting
761	761	731the criteria for clinical tiers and submit to audits by the commission.
762	762	732 (f) Participating primary care providers and provider organizations shall submit primary
763	763	733care expenditure reports and internal contracts related to primary care delivery and payment to
764	764	734the division, the center for health information and analysis and the health policy commission in
765	765	735accordance with division rules, regulations and guidelines.
766	766	736 (g) Participating primary care providers and provider organizations shall select 4 quality
767	767	737measures, as defined by the division, to measure and report to the commission annually.
768	768	738 Section 4FFF. (a) For the purposes of this section, the following terms shall have the
769	769	739following meanings unless the context clearly requires otherwise:
770	770	740 “Federally Qualified Health Center”, any entity receiving a grant under 42 U.S.C. 254B. 36 of 45
771	771	741 “Federally Qualified Health Center Services”, as such term is defined in 42 U.S.C.
772	772	7421396d(a)(2)(C), and as further defined in 101 CMR 304.00.
773	773	743 (b) A subscription certificate under an individual or group medical service agreement
774	774	744delivered, issued or renewed within the commonwealth and which is considered creditable
775	775	745coverage under section 1 of chapter 111M shall ensure that the rate of payment for any federally
776	776	746qualified health center services provided to a patient by a community health center shall be
777	777	747reimbursed in an amount not less than equivalent to the annual aggregate revenue that the health
778	778	748center would have received if reimbursed by MassHealth pursuant to methodology that conforms
779	779	749with 42 U.S.C. 1396a(bb) and 1396b(m)(2)(A)(ix), as appearing in Title 42 of the United States
780	780	750Code as of January 1, 2025.
781	781	751 4GGG. (a) For the purposes of this section, the following terms shall have the following
782	782	752meanings unless the context clearly requires otherwise:
783	783	753 “Behavioral health urgent care provider”, a mental health center designated as a
784	784	754behavioral health urgent care provider, under 130 CMR 429.000.
785	785	755 “Behavioral health urgent care services”, shall include, but not be limited to: (i)
786	786	756diagnostic psychiatric evaluations; (ii) individual, group, couple, and family therapy; (iii)
787	787	757psychotherapy for crisis; (iv) case consultation; (v) family consultation; and (vi) evaluation and
788	788	758management medication visits provided by a designated behavioral health urgent care provider.
789	789	759 (b) A subscription certificate under an individual or group medical service agreement
790	790	760delivered, issued or renewed within or without the commonwealth shall provide benefits on a
791	791	761nondiscriminatory basis for medically necessary behavioral health urgent care services provided
792	792	762by a behavioral health urgent care provider. Services delivered by a behavioral health urgent care 37 of 45
793	793	763provider shall be deemed medically necessary and shall not require prior authorization. Services
794	794	764delivered by a behavioral health urgent care provider shall be covered with no patient cost-
795	795	765sharing; provided, however, that cost-sharing shall be required if the applicable plan is governed
796	796	766by the Federal Internal Revenue Code and would lose its tax-exempt status as a result of the
797	797	767prohibition on cost-sharing for this service.
798	798	768 (c) A subscription certificate under an individual or group medical service agreement
799	799	769delivered, issued or renewed within or without the commonwealth shall ensure that payment for
800	800	770any services provided by a behavioral health urgent care provider include a rate add-on of at least
801	801	77120 per cent over any negotiated fee schedule, provided that a carrier shall not lower a negotiated
802	802	772fee schedule to comply with this section. For purposes of this section, a carrier shall pay a rate
803	803	773add-on of at least 20 per cent for all behavioral health urgent care services delivered by a
804	804	774behavioral health urgent care provider regardless of whether the presenting reason for care is
805	805	775determined to be an urgent behavioral health need.
806	806	776 SECTION 22. Chapter 176E of the General Laws, as so appearing in the 2022 Official
807	807	777Edition, is hereby amended by inserting after section 15A the following section:-
808	808	778 Section 15B. (a) For the purposes of this section, the following terms shall have the
809	809	779following meanings unless the context clearly requires otherwise:
810	810	780 “Federally Qualified Health Center”, any entity receiving a grant under 42 U.S.C. 254B.
811	811	781 “Federally Qualified Health Center Services”, as such term is defined in 42 U.S.C.
812	812	7821396d(a)(2)(C), and as further defined in 101 CMR 304.00. 38 of 45
813	813	783 (b) Notwithstanding any general or special law to the contrary, any dental service
814	814	784corporation organized under this chapter shall ensure that the rate of payment for any federally
815	815	785qualified health center services provided to a patient by a community health center shall be
816	816	786reimbursed in an amount not less than equivalent to the annual aggregate revenue that the health
817	817	787center would have received if reimbursed by MassHealth pursuant to methodology that conforms
818	818	788with 42 U.S.C. 1396a(bb) and 1396b(m)(2)(A)(ix), as appearing in Title 42 of the United States
819	819	789Code as of January 1, 2025.
820	820	790 SECTION 23. Chapter 176G of the General Laws, as appearing in the 2022 Official
821	821	791Edition, is hereby amended by striking out section 4LL and inserting in place thereof the
822	822	792following section:-
823	823	793 Section 4LL. (a) An individual or group health maintenance contract that is issued or
824	824	794renewed within or without the commonwealth shall provide benefits on a nondiscriminatory
825	825	795basis for medically necessary emergency services programs, as defined in section 1 of chapter
826	826	796175. Services delivered by emergency services programs shall be deemed medically necessary
827	827	797and shall not require prior authorization. Services delivered by emergency service programs shall
828	828	798be covered with no patient cost-sharing; provided, however, that cost-sharing shall be required if
829	829	799the applicable plan is governed by the Federal Internal Revenue Code and would lose its tax-
830	830	800exempt status as a result of the prohibition on cost-sharing for this service.
831	831	801 (b) An individual or group health maintenance contract that is issued or renewed within
832	832	802or without the commonwealth shall ensure that reimbursement for outpatient services delivered
833	833	803by emergency services programs through a mental health center designated as a community
834	834	804behavioral health center pursuant to section 13D½ of chapter 118E, shall be structured as a 39 of 45
835	835	805bundled rate per encounter using the same Healthcare Common Procedure Coding System code
836	836	806adopted by MassHealth and at a rate no less than the prevailing MassHealth rate for the same set
837	837	807of bundled services.
838	838	808 SECTION 24. Chapter 176G of the General Laws, as amended by section 35 of chapter
839	839	809342 of the acts of 2024, is hereby amended by inserting after section 4VV the following 3
840	840	810sections:-
841	841	811 Section 4WW. (a) For the purposes of this section, the following words shall have the
842	842	812following meanings:-
843	843	813 “All-payer primary care capitation model”, a standard value-based, prospective payment
844	844	814model under which health insurers pay participating providers or provider organizations per-
845	845	815member per-month payments for patients attributed to the participating providers or provider
846	846	816organizations for primary care. The per-member per-month payment may be adjusted based on:
847	847	817(i) a participating provider or provider organization’s adoption of advanced primary care services
848	848	818and investment in primary care services; (ii) the quality of patient care delivered by a
849	849	819participating provider or provider organization; and (iii) the clinical and social risk of patients
850	850	820attributed to a participating provider or provider organization for primary care; provided,
851	851	821however, that implementation of the all-payer primary care capitation model complies with
852	852	822division of insurance rules, regulations and guidelines.
853	853	823 “Division”, the division of insurance.
854	854	824 “Provider organization”, as defined in section 1 of chapter 6D. 40 of 45
855	855	825 (b) An individual group health maintenance contract that is issued or renewed within or
856	856	826without the commonwealth and which is considered creditable coverage under section 1 of
857	857	827chapter 111M shall implement the all-payer primary care capitation model in accordance with
858	858	828division rules, regulations and guidelines, including, but not limited to: (i) definitions of primary
859	859	829care services, codes, and providers; (ii) per-member per-month rate methodology; (iii) enhanced
860	860	830payments for advanced primary care services and investments; (iv) patient cost-sharing limits for
861	861	831primary care; (v) member attribution methodology; (vi) primary care quality measures; (vii)
862	862	832primary care reimbursement and spending reporting requirements for participating primary care
863	863	833providers and provider organizations; and (viii) audits of participating primary care providers
864	864	834and provider organizations.
865	865	835 (c) The carrier shall provide contracted primary care providers and provider organizations
866	866	836with the option to participate in the all-payer primary care capitation model and receive per-
867	867	837member per-month payments for enrollees attributed to the primary care provider or provider
868	868	838organization for primary care.
869	869	839 (d) Payments made to primary care providers and provider organizations participating in
870	870	840the all-payer primary care capitation model shall be included in the health status adjusted total
871	871	841medical expense and total medical expense calculated by the center for health information and
872	872	842analysis under section 16 of chapter 12C.
873	873	843 (e) Participating primary care providers and provider organizations shall attest to meeting
874	874	844the criteria for clinical tiers and submit to audits by the commission.
875	875	845 (f) Participating primary care providers and provider organizations shall submit primary
876	876	846care expenditure reports and internal contracts related to primary care delivery and payment to 41 of 45
877	877	847the division, the center for health information and analysis and the health policy commission in
878	878	848accordance with division rules, regulations and guidelines.
879	879	849 (g) Participating primary care providers and provider organizations shall select 4 quality
880	880	850measures, as defined by the division, to measure and report to the commission annually.
881	881	851 Section 4XX. (a) For the purposes of this section, the following terms shall have the
882	882	852following meanings unless the context clearly requires otherwise:
883	883	853 “Federally Qualified Health Center”, any entity receiving a grant under 42 U.S.C. 254B.
884	884	854 “Federally Qualified Health Center Services”, as such term is defined in 42 U.S.C.
885	885	8551396d(a)(2)(C), and as further defined in 101 CMR 304.00.
886	886	856 (b) Notwithstanding any general or special law to the contrary, any health maintenance
887	887	857organization organized under this chapter shall ensure that the rate of payment for any federally
888	888	858qualified health center services provided to a patient by a community health center shall be
889	889	859reimbursed in an amount not less than equivalent to the annual aggregate revenue that the health
890	890	860center would have received if reimbursed by MassHealth pursuant to methodology that conforms
891	891	861with 42 U.S.C. 1396a(bb) and 1396b(m)(2)(A)(ix), as appearing in Title 42 of the United States
892	892	862Code as of January 1, 2025.
893	893	863 4YY. (a) For the purposes of this section, the following terms shall have the following
894	894	864meanings unless the context clearly requires otherwise:
895	895	865 “Behavioral health urgent care provider”, a mental health center designated as a
896	896	866behavioral health urgent care provider under 130 CMR 429.000. 42 of 45
897	897	867 “Behavioral health urgent care services”, shall include, but not be limited to: (i)
898	898	868diagnostic psychiatric evaluations; (ii) individual, group, couple, and family therapy; (iii)
899	899	869psychotherapy for crisis; (iv) case consultation; (v) family consultation; or (vi) evaluation and
900	900	870management medication visits provided by a designated behavioral health urgent care provider.
901	901	871 (b) An individual or group health maintenance contract that is issued or renewed within
902	902	872or without the commonwealth shall provide benefits on a nondiscriminatory basis for medically
903	903	873necessary behavioral health urgent care services provided by a behavioral health urgent care
904	904	874provider. Services delivered by a behavioral health urgent care provider shall be deemed
905	905	875medically necessary and shall not require prior authorization. Services delivered by a behavioral
906	906	876health urgent care provider shall be covered with no patient cost-sharing; provided, however, that
907	907	877cost-sharing shall be required if the applicable plan is governed by the Federal Internal Revenue
908	908	878Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this
909	909	879service.
910	910	880 (c) An individual or group health maintenance contract that is issued or renewed within
911	911	881or without the commonwealth shall ensure that payment for any services provided by a
912	912	882behavioral health urgent care provider include a rate add-on of at least 20 per cent over any
913	913	883negotiated fee schedule, provided that a carrier shall not lower a negotiated fee schedule to
914	914	884comply with this section. For purposes of this section, a carrier shall pay a rate add-on of at least
915	915	88520 per cent for all behavioral health urgent care services delivered by a behavioral health urgent
916	916	886care provider regardless of whether the presenting reason for care is determined to be an urgent
917	917	887behavioral health need.
918	918	888 SECTION 25. Section 80 of chapter 343 of the acts of 2024 is hereby repealed. 43 of 45
919	919	889 SECTION 26. Not later than June 15, 2026, the primary care board established under
920	920	890section 3B of chapter 6D shall issue its report of the findings and recommendations under
921	921	891clauses (i) and (ii) of subsection (c) of section 3B of chapter 6D with the clerks of the house of
922	922	892representatives and the senate, the house and senate committees on ways and means, the joint
923	923	893committee on health care financing, the center for health information and analysis, the health
924	924	894policy commission and the division of insurance.
925	925	895 SECTION 27. Not later than September 15, 2026, the primary care board established
926	926	896under section 3B of chapter 6D shall issue its report of the findings and recommendations under
927	927	897clause (iii) of subsection (c) of section 3B of chapter 6D with the clerks of the house of
928	928	898representatives and the senate, the house and senate committees on ways and means, the joint
929	929	899committee on health care financing, the center for health information and analysis, the health
930	930	900policy commission and the division of insurance.
931	931	901 SECTION 28. Not later than December 15, 2026, the primary care board established
932	932	902under section 3B of chapter 6D shall issue its report of the findings and recommendations under
933	933	903clauses (iv) and (v) of subsection (c) of section 3B of chapter 6D with the clerks of the house of
934	934	904representatives and the senate, the house and senate committees on ways and means, the joint
935	935	905committee on health care financing, the center for health information and analysis, the health
936	936	906policy commission and the division of insurance.
937	937	907 SECTION 29. Not later than March 15, 2027, the primary care board established under
938	938	908section 3B of chapter 6D shall issue its report of the findings and recommendations under
939	939	909clauses (vi) and (vii) of subsection (c) of section 3B of chapter 6D with the clerks of the house of
940	940	910representatives and the senate, the house and senate committees on ways and means, the joint 44 of 45
941	941	911committee on health care financing, the center for health information and analysis, the health
942	942	912policy commission and the division of insurance.
943	943	913 SECTION 30. Subsection (e) of section 16 of chapter 12C of the General Laws shall take
944	944	914effect October 1, 2026.
945	945	915 SECTION 31. Sections 12 through 24, inclusive, shall apply to all contracts entered into,
946	946	916renewed or amended on or after July 1, 2028.
947	947	917 SECTION 32. The center for health information and analysis shall define “primary care
948	948	918expenditures” for the purposes of analyzing and reporting primary care baseline expenditures for
949	949	919health entities pursuant to section 16 of chapter 12C and comparing primary care baseline
950	950	920expenditures of health entities against the primary care expenditure target pursuant to section 18
951	951	921of chapter 12C not later than June 30, 2027. The center shall consider recommendations from the
952	952	922primary care board established under section 3B of chapter 6D when defining “primary care
953	953	923expenditures”.
954	954	924 SECTION 33. The division of insurance shall promulgate rules and regulations for
955	955	925implementation of the all-payer primary care capitation model by carriers under sections 14, 17,
956	956	92619, 21 and 24 not later than December 31, 2027. Rules and regulations shall include, but not be
957	957	927limited to: (i) definitions of primary care services, codes, and providers; (ii) per-member per-
958	958	928month rate methodology; (iii) enhanced payments for advanced primary care services and
959	959	929investments; (iv) patient cost-sharing limits for primary care; (v) member attribution
960	960	930methodology; (vi) primary care quality measures; (vii) primary care reimbursement and spending
961	961	931reporting requirements for participating providers and provider organizations; and (viii) audits of
962	962	932participating providers and provider organizations. The division shall require the same all-payer 45 of 45
963	963	933primary care capitation model to be implemented by carriers under sections 14, 17, 19, 21 and
964	964	93424. The division shall consider recommendations from the primary care board established under
965	965	935section 3B of chapter 6D when developing and implementing rules and regulations.
966	966	936 SECTION 34. The division of insurance shall promulgate rules and regulations for the
967	967	937issuance of payments to community health centers under sections 12, 14, 17, 19, 21, 22 and 24
968	968	938not later than January 1, 2027.