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