Information updated August 2, 2006
In July 2004, State legislators took the first step toward a constitutional amendment to "ensure that no Massachusetts resident lacks comprehensive, affordable and equitably financed health insurance…" The legislature needed to vote again during the 2005-2006 session on whether to allow the initiative to appear on the statewide election ballot. They did indeed act and passed a bill in April 2006. On July 12, 2006, the legislature voted 118-76 to send the amendment to constitutional committee for study. This will delay the ability for this to appear on the November 2006 ballot, but advocates hope that it will be on the November 2008 ballot.
A 2006 poll found that more than 75% of Mass. residents approve of the amendment.
In2000 Massachusetts passed one of the toughest HMO laws in the nation. The bill places HMO’s under increased oversight by state authorities, and includes a patient bill of rights- one of the strongest of the 40 such bills enacted by states to date.
Passage of the bill coincided with a ballot initiative that would have required the state to provide universal health coverage for all citizens by 2002. The ballot question, supported by almost 100,000 signatures, helped break a three-year HMO logjam because legislators were worried that if they didn’t pass a bill the ballot question would enact what they consider radical reforms. The ballot initiative failed, though H.B. 4525 is a significant step forward.
The law also includes provisions requiring insurers to:
1)Enact a "prudent layperson" rule: Enrollees may seek emergency room care under the "prudent layperson" rule without prior approval from their health plan.
2) Allows for standing referrals: Patients with chronic illnesses have the ability to obtain a standing referral to a specialist without approval from a primary care physician.
3)Eliminate financial incentives: Health plans can no longer use financial incentives to physicians to delay or restrict the provision of care.
4) Allow physicians to determine "medical necessity": Health plans must defer to physicians on the determination of medical necessity of health care services, consistent with generally accepted medical principles.
The bill also will create:
1)An office of Patient Protection within the Department of Public Health to be set up to issue managed care report cards, set up a Web site for consumers, monitor quality and help patients with questions about their plans.
2) Create a new Managed Care Bureau in the Mass. Department of Insurance with new oversight authority over health plans. The office will investigate consumer complaints and monitor health plan administration, including provider payments and accreditation status. Patients will now be able to appeal HMO decisions to an independent panel of health-care consultants
Missingfrom the reform package is the right to sue insurance companies for mistreatment, an alternative available to HMO customers in California and Texas. The bill also does not help the approximately 600,000 residents of the state who don’t have health insurance, though it does provide for a study of universal coverage. In addition, about 40 percent of health insurance consumers in the state are not covered by the law. These employees, who work for large companies that provide self-insured health plans, fall under federal insurance laws that do not include a patients’ bill of rights.
The full text of the act is available from the Massachusetts Legislature (Chapter 141 of the Acts of 2000).