H 5630

HOUSE . . . . . . . . . . . . . . . No. 5630
     Text of House document No. 5618, being House amendments of the Senate Bill relative to
     primary care for you (Senate bill No. 3141), as amended by the House. July 30, 2026.
  The Commonwealth of Massachusetts
  _______________
  In the One Hundred and Ninety-Fourth General Court
  (2025-2026)
  _______________
  By striking out all after the enacting clause and inserting in place thereof the following:–
1SECTION 1. Section 1 of chapter 6D of the General Laws, as appearing in the 2024
2 Official Edition, is hereby amended by inserting after the definition of “After-hours care” the
3 following 2 definitions:-
4“Aggregate primary care expenditures”, the annual per capita sum of all primary care
5 expenditures in the commonwealth.
6“Aggregate primary care expenditure target”, the target amount of aggregate primary care
7 expenditures for a calendar year, as established pursuant to section 9A.
8SECTION 2. Said section 1 of said chapter 6D, as so appearing, is hereby further
9 amended by inserting after the definition of “Physician” the following 4 definitions:-
10“Primary care”, the provision of coordinated, comprehensive medical services, on both a
11 first-contact and a continuous basis, by a primary care provider.
12“Primary care expenditures”, payments for primary care services and other payments that
13 directly support the delivery of primary care services, which shall be limited to the following:
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14(i) payments for services delivered by a primary care provider in an outpatient setting, by
15 telehealth, or in a patient’s home, nursing facility or other residential care setting;
16(ii) payments for preventive medicine services delivered by a primary care provider,
17 including examinations, screenings, assessments and counseling;
18(iii) payments for the administration of injections, infusions and vaccines by a primary
19 care provider;
20(iv) payments for care coordination, care management, transitional care management and
21 chronic disease management delivered by or under the direction of a primary care provider;
22(v) payments for behavioral health services delivered in a primary care setting by a
23 primary care provider or by a behavioral health clinician integrated into a primary care practice;
24(vi) payments for preventive obstetric and gynecologic evaluation and management
25 services, including annual preventive visits, screening services, and such other obstetric and
26 gynecologic services as the center may determine function as primary care services; and
27(vii) non-claims payments that support the delivery of primary care, including population
28 health payments, practice infrastructure payments, care management payments, performance and
29 quality payments, shared savings payments net of recoupments, capitation, sub-capitation and
30 full-risk payments, and other non-claims payments designated by the center.
31“Primary care infrastructure support”, capital, operating or in-kind support furnished by a
32 provider or provider organization to build or sustain its capacity to deliver primary care services,
33 including clinical and information technology, data infrastructure, practice management support,
34 workforce recruitment, training and development, and cross-subsidization of primary care
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35 operating losses by the provider or provider organization’s other operations; provided, however,
36 that “primary care infrastructure support” shall not include any amount included in primary care
37 expenditures.
38“Primary care investment”, the total commitment of financial resources by a provider or
39 provider organization to support the delivery of primary care services, consisting of the provider
40 or provider organization’s total primary care expenditures and primary care infrastructure
41 support.
42SECTION 3. Said section 1 of said chapter 6D, as so appearing, is hereby further
43 amended by inserting after the definition of “Primary care provider” the following definition:-
44“Primary care services”, health care services furnished by a primary care provider to
45 promote health, prevent disease, diagnose and treat illness and injury and provide ongoing,
46 comprehensive and coordinated care.
47SECTION 4. Section 8 of said chapter 6D, as so appearing, is hereby amended by
48 inserting after the word “year”, in line 6, the following words:- and comparing the growth in
49 aggregate primary care expenditures to the aggregate primary care expenditure target established
50 in section 9A.
51SECTION 5. Said section 8 of said chapter 6D, as so appearing, is hereby further
52 amended by inserting after the word “models”, in line 62, the following words:- , primary care.
53SECTION 6. Said chapter 6D is hereby further amended by inserting after section 9 the
54 following section:-
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55Section 9A. (a) The commission shall administer and monitor the aggregate primary care
56 expenditure target for the commonwealth. The commission shall prominently publish the
57 applicable aggregate primary care expenditure target and the methodology used to calculate it on
58 its website.
59(b)(1) The aggregate primary care expenditure target for calendar year 2030 shall be the
60 dollar amount produced by multiplying 9 per cent by total health care expenditures in the
61 commonwealth for calendar year 2030.
62(2) The aggregate primary care expenditure target for calendar year 2033 shall be the
63 dollar amount produced by multiplying 12 per cent by total health care expenditures in the
64 commonwealth for calendar year 2033.
65(3) The aggregate primary care expenditure target for calendar year 2036 and each year
66 thereafter shall be the dollar amount produced by multiplying 15 per cent by total health care
67 expenditures in the commonwealth for the applicable calendar year.
68(c) Beginning in calendar year 2028, the center shall monitor and annually report the
69 commonwealth’s progress toward the applicable target next due pursuant to subsection (b),
70 including, for each calendar year, the actual aggregate primary care expenditures for such year
71 and their percentage of total health care expenditures in the commonwealth. Nothing in this
72 subsection shall require the commonwealth to attain a specified level of annual progress before
73 the applicable target year.
74(d) The commission, in collaboration with the center, the group insurance commission
75 and the division of insurance, shall monitor the implementation of this section with the goal of
76 ensuring that any increase in primary care spending does not result in an increase in the growth
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77 of overall health care expenditure trends or any net new increase in health insurance premiums
78 and cost-sharing.
79(e) The commission shall promulgate regulations necessary to implement this section.
80SECTION 7. Section 10 of said chapter 6D of the General Laws, as so appearing, is
81 hereby amended by striking out subsections (b) through (f), inclusive, and inserting in place
82 thereof the following 6 subsections:-
83(b) The commission shall provide notice to all health care entities that have been
84 identified by the center under section 18 of chapter 12C as exceeding the health care cost growth
85 benchmark for any given year. Such notice shall state that the center may analyze the cost
86 growth and, where applicable, the primary care investment of each health care entity and the
87 commission may require certain actions, as established in this section, from health care entities
88 so identified.
89(c) For calendar year 2015, if the commission finds, based on the center’ annual report,
90 the commission’s annual cost trend hearings or any other pertinent information, that the average
91 percentage change in cumulative total health care expenditures from 2013 to 2014 exceeded the
92 average health care cost growth benchmark from 2013 to 2014, and in order to support the state’s
93 efforts to meet future health care cost growth benchmarks, as established in section 9, the
94 commission shall establish procedures to assist health care entities to improve efficiency and
95 reduce cost growth by requiring certain health care entities to file and implement a performance
96 improvement plan.
97Beginning in calendar year 2016, if the commission finds, based on the center’s annual
98 report, the commission’s annual cost trend hearings or any other pertinent information, that the
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99 percentage change in total health care expenditures exceeded the health care cost growth
100 benchmark in the previous calendar year, and in order to support the state’s efforts to meet future
101 health care cost growth benchmarks, as established in said section 9, the commission shall
102 establish procedures to assist health care entities to improve efficiency and reduce cost growth by
103 requiring certain health care entities to file and implement a performance improvement plan.
104Beginning in calendar year 2028, if the commission finds, based on the center’s annual
105 report, the commission’s annual cost trend hearings or any other pertinent information, that the
106 percentage change in total health care expenditures exceeded the health care cost growth
107 benchmark in the previous calendar year, and in order to support the state’s efforts to meet future
108 health care cost growth benchmarks, as established in said section 9, and future aggregate
109 primary care expenditure targets, as established in section 9A, the commission shall establish
110 procedures to assist health care entities to improve efficiency, increase primary care investment,
111 and reduce cost growth by requiring certain health care entities to file and implement a primary
112 care commitment, where applicable, or a performance improvement plan.
113(d)(1) For each health care entity identified by the center under section 18 of chapter 12C,
114 the commission may, after reviewing the analysis of the health care entity’s primary care
115 investment conducted by the center pursuant to section 18A of said chapter 12C, its growth in
116 health status adjusted total medical expense, and any other information as the commission
117 considers relevant, pursue the following actions: (i) conclude its review without further action;
118 (ii) require, where applicable, the health care entity to file a primary care commitment under
119 section 10A, or (iii) require the health care entity to file a performance improvement plan under
120 subsection (e).
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121(2) The commission may require a health care entity to propose a primary care
122 commitment under clause (ii) of paragraph (1) where the commission identifies significant
123 concerns about the health care entity’s growth in health status adjusted total medical expense and
124 determines that: (i) the center’s analysis under section 18A of chapter 12C or any other pertinent
125 information indicate, where applicable, that inadequate primary care investment by the health
126 care entity is plausibly contributing to the health care entity’s growth in health status adjusted
127 total medical expense; (ii) a primary care commitment could reasonably be expected to address
128 such concerns; (iii) the entity has been identified under section 18 of chapter 12C in any prior
129 year and, (iv) where the entity has previously entered into a primary care commitment under
130 section 10A, the outcomes described in the center’s analysis are materially inconsistent with the
131 outcomes that the commitment was reasonably expected to produce; and (v) based on the entity’s
132 overall financial condition, that the entity has the capacity to increase its primary care
133 investment.
134(3) Nothing in this subsection shall be construed to require the commission to first require
135 a primary care commitment before requiring a performance improvement plan.
136(e) In addition to the notice provided under subsection (b), the commission may require
137 any health care entity that is identified by the center under section 18 of chapter 12C as
138 exceeding the health care cost growth benchmark established under section 9 to file a
139 performance improvement plan with the commission. The commission shall provide written
140 notice to such health care entity that they are required to file a performance improvement plan.
141 Within 45 days of receipt of such written notice, the health care entity shall either:
142(1) file a performance improvement plan with the commission; or
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143(2) file an application with the commission to waive or extend the requirement to file a
144 performance improvement plan.
145(f) The health care entity may file any documentation or supporting evidence with the
146 commission to support the health care entity’s application to waive or extend the requirement to
147 file a performance improvement plan pursuant to subsection (e). The commission shall require
148 the health care entity to submit any other relevant information it deems necessary in considering
149 the waiver or extension application; provided, however, that such information shall be made
150 public at the discretion of the commission.
151(g) The commission may waive or delay the requirement for a health care entity to file a
152 performance improvement plan in response to a waiver or extension request filed under
153 subsection (e) in light of all information received from the health care entity, based on a
154 consideration of the following factors:
155(1) the costs, price and utilization trends of the health care entity over time, and any
156 demonstrated improvement to reduce health status adjusted total medical expenses;
157(2) any ongoing strategies or investments that the health care entity is implementing to
158 improve future long-term efficiency and reduce cost growth;
159(3) whether the factors that led to increased costs for the health care entity can reasonably
160 be considered to be unanticipated and outside of the control of the entity. Such factors may
161 include, but shall not be limited to, age and other health status adjusted factors and other cost
162 inputs such as pharmaceutical expenses and medical device expenses;
163(4) the overall financial condition of the health care entity;
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164(5) a significant difference between the growth rate of potential gross state product and
165 the actual economic growth benchmark, as determined under section 7H1/2 of chapter 29;
166(6) any primary care commitment filed or implemented under section 10A, and
167(7) any other factors the commission considers relevant.
168SECTION 8. Said section 10 of said chapter 6D, as so appearing, is hereby further
169 amended by striking out, in line 146, the words “subsection (d)” and inserting in place thereof
170 the following:- subsection (e).
171SECTION 9. Said section 10 of said chapter 6D, as so appearing, is hereby further
172 amended by striking out, in lines 159 and 160, the words “or third-party administrators shall be
173 excluded from this definition.”.
174SECTION 10. Said chapter 6D is hereby further amended by inserting after section 10
175 the following section:-
176Section 10A. (a) For the purposes of this section, “health care entity” shall mean a clinic,
177 hospital, ambulatory surgical center, physician organization, or accountable care organization
178 that provides primary care services, or a payer; provided, however, that physician contracting
179 units with a patient panel of 15,000 or fewer, or which represents providers who collectively
180 receive less than $25,000,000 in annual net patient service revenue from carriers shall be exempt.
181(b) If the commission requires a health care entity to propose a primary care commitment
182 under clause (ii) of paragraph (1) of subsection (d) of section 10, the commission shall provide
183 written notice to the health care entity that includes the analysis prepared by the center pursuant
184 to section 18A of chapter 12C.
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185(c) Within 60 days of receipt of such notice, the health care entity shall file a proposed
186 primary care commitment with the commission. The primary care commitment shall be
187 generated by the health care entity and shall contain an explanation of the following: (i) the
188 expected effect of the proposed increase in primary care investments on the quality of and access
189 to primary care services for patients served by the health care entity, including, as applicable,
190 reduced appointment wait times, as measured by the third next available appointment for new
191 and established patients, toward a goal of routine primary care appointments being available
192 within 7 calendar days; (ii) the amount by which the commitment is expected to increase the
193 health care entity’s primary care expenditures; and (iii) how the commitment is expected to
194 address the factors contributing to the health care entity’s growth in health status adjusted total
195 medical expense, which may include expected reductions in utilization by the health care entity’s
196 patient population that could be avoided through more accessible or more effective primary care.
197(d) A provider or provider organization may propose a primary care commitment that
198 may include, but shall not be limited to: (i) increases in the payment rates the provider
199 organization pays to primary care providers and primary care practices, including practices it
200 owns or controls and primary care practices with which it contracts; (ii) care management and
201 care coordination staffing; (iii) behavioral health integration; (iv) appointment access, including
202 same-day and next-day capacity, extended hours and telehealth; (v) primary care scheduling,
203 population health and clinical information infrastructure; and (vi) increases in the health care
204 entity’s primary care infrastructure support.
205(e) A payer may propose a primary care commitment that may include, but shall not be
206 limited to: (i) increases in contracted payment rates for primary care services; (ii) non-claims
207 payments to primary care providers, including care management, population health and practice
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208 infrastructure payments; (iii) adoption of, or increases in payment under, a qualifying advanced
209 primary care payment model approved under section 31 of chapter 176O; (iv) reductions in the
210 administrative burden borne by primary care providers with which it contracts, including
211 reductions in prior authorization requirements applicable to primary care services; (v) benefit
212 design that improves member access to primary care, including reductions in member cost-
213 sharing for primary care services; and (vi) such other measures as support the delivery of
214 primary care to the payer’s members. A primary care commitment proposed by a payer shall: (A)
215 describe the sources from which the proposed investments will be funded, which may include
216 reallocation of existing expenditures, reductions in administrative expense, or projected
217 reductions in avoidable utilization by the payer’s members; and (B) demonstrate that the
218 commitment will not result in a net new increase in premiums or member cost-sharing. The
219 commission shall transmit a copy of any primary care commitment proposed by a payer to the
220 commissioner of insurance.
221(f) The commission shall accept a proposed primary care commitment that it determines
222 is reasonably likely to: (i) improve the access of patients and members served by the health care
223 entity to primary care; (ii) contribute to the attainment by the commonwealth of the aggregate
224 primary care expenditure target established under section 9A; and (iii) address the factors
225 contributing to the health care entity’s growth in health status adjusted total medical expense. If
226 the commission determines a proposed commitment to be unacceptable or incomplete, it may
227 provide consultation on the criteria that have not been met and may allow an additional period of
228 up to 30 calendar days for resubmission; provided, however, that all aspects of the primary care
229 commitment shall be proposed by the health care entity and the commission shall not require
230 specific elements for acceptance.
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231(g) The commission shall promulgate regulations necessary to implement this section.
232SECTION 11. Section 11 of said chapter 6D, as appearing in the 2024 Official Edition, is
233 hereby amended by striking out subsection (b) and inserting in place thereof the following
234 subsection:-
235(b) The commission shall require that all provider organizations report the following
236 information for registration and renewal: (i) organizational charts showing the ownership,
237 governance and operational structure of the provider organization, including any clinical
238 affiliations, parent entities, corporate affiliates, significant equity investors, health care real estate
239 investment trusts, management services organizations and community advisory boards; (ii) the
240 number of affiliated health care professional full-time equivalents and the number of
241 professionals affiliated with or employed by the organization; (iii) with respect to provider
242 organizations that provide primary care services: (A) each acquisition of or affiliation with a
243 primary care practice during the reporting year; (B) the disaggregated number of full-time
244 equivalent primary care physicians, nurses, nurse practitioners, physician assistants and care
245 coordinators; (C) the organization’s current primary care patient panel; (D) information
246 regarding provider capacity, which shall include, but not be limited to, patient panel size and
247 wait times measured as the third next available appointment for new and established patients; (E)
248 for each primary care practice site operated by or affiliated with the provider organization, the
249 site of service, whether the site is licensed as a hospital or as a hospital satellite or outpatient
250 department, whether the organization billed for primary care services furnished at the site on a
251 provider-based basis, and whether any such site was licensed or reclassified as a hospital satellite
252 or outpatient department during the reporting year; and (F) information about movement of
253 funds, including the distribution of claims and non-claims payments from payers to providers,
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254 including primary care providers employed and affiliated with the provider organization and the
255 allocation of expenses to support primary care providers; (iv) the name and address of licensed
256 facilities; and (v) such other information as the commission considers appropriate.
257SECTION 11A. Said chapter 6D is hereby further amended by inserting after section 22
258 the following section:-
259Section 22A. (a) For the purposes of this section, “pharmacy desert” shall have the same
260 meaning as defined in section 38A of chapter 112.
261(b) The office of health resource planning, established under section 22, shall conduct a
262 focused assessment not less than every 5 years on supply, distribution and capacity of pharmacy
263 and pharmacological services pursuant to subsection (b) of said section 22. The office, when
264 conducting its focused assessment, shall also identify the number of existing and potential
265 pharmacy deserts in the commonwealth and conduct an analysis of their impact or potential
266 impact on access to pharmacy and pharmacological services for residents of existing and
267 potential pharmacy deserts.
268(c) The focused assessment shall include: (i) an assessment on impacted neighborhoods
269 and patient populations; (ii) an assessment on the impact of pharmacy deserts on access to
270 medications and health care outcomes; (iii) an assessment of the geographical and financial
271 barriers to obtaining medications faced by individuals living in pharmacy deserts; (iv) an
272 assessment of the average distance and travel time to a pharmacy from an impacted
273 neighborhood, and the transportation options available; (v) an assessment on the impact of
274 pharmacy deserts on overall health care costs, including the costs of emergency department visits
275 and hospitalizations; (vi) an assessment on the factors contributing to the closures of pharmacies
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276 across the commonwealth, including population changes, local market dynamics and pharmacy
277 density, changes in consumer purchasing behavior, reimbursement pressure, and supply-side
278 constraints; and (vii) policy recommendations to address current pharmacy deserts and limit the
279 creation of new ones.
280(d) The office shall, upon completion of the focused assessment required under
281 subsection (b), present to the board of the commission its findings, and shall file a report with the
282 commission, the center, the department of public health, and the clerks of the senate and house of
283 representatives, the house and senate committees on ways and means, the joint committee on
284 health care financing.
285SECTION 12. Section 1 of chapter 12C of the General Laws, as appearing in the 2024
286 Official Edition, is hereby amended by inserting after the definition of “acute hospital” the
287 following 2 definitions:-
288“Aggregate primary care expenditures”, the annual per capita sum of all primary care
289 expenditures in the commonwealth.
290“Aggregate primary care expenditure target”, the target amount of aggregate primary care
291 expenditures for a calendar year, as established pursuant to section 9A of chapter 6D.
292SECTION 13. Said section 1 of said chapter 12C, as so appearing, is hereby further
293 amended by inserting after the definition of “Hospital service corporation” the following
294 definition:-
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295“Independent primary care practice”, a medical practice providing primary care services
296 that is majority owned by licensed primary care providers who furnish primary care services
297 through the practice and that is not controlled by any other person or entity.
298SECTION 14. Said section 1 of said chapter 12C, as so appearing, is hereby further
299 amended by inserting after the definition of “pharmacy benefit manager” the following 6
300 definitions:-
301“Primary care”, the provision of coordinated, comprehensive medical services, on both a
302 first-contact and a continuous basis, by a primary care provider.
303“Primary care expenditures”, payments for primary care services and other payments that
304 directly support the delivery of primary care services, which shall be limited to the following:
305(i) payments for services delivered by a primary care provider in an outpatient setting, by
306 telehealth, or in a patient’s home, nursing facility or other residential care setting;
307(ii) payments for preventive medicine services delivered by a primary care provider,
308 including examinations, screenings, assessments and counseling;
309(iii) payments for the administration of injections, infusions and vaccines by a primary
310 care provider;
311(iv) payments for care coordination, care management, transitional care management and
312 chronic disease management delivered by or under the direction of a primary care provider;
313(v) payments for behavioral health services delivered in a primary care setting by a
314 primary care provider or by a behavioral health clinician integrated into a primary care practice;
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315(vi) payments for preventive obstetric and gynecologic evaluation and management
316 services, including annual preventive visits, screening services, and such other obstetric and
317 gynecologic services as the center determines function as primary care services; and
318(vii) non-claims payments that support the delivery of primary care, including population
319 health payments, practice infrastructure payments, care management payments, performance and
320 quality payments, shared savings payments net of recoupments, capitation, sub-capitation and
321 full-risk payments, and other non-claims payments designated by the center.
322“Primary care infrastructure support”, capital, operating or in-kind support furnished by a
323 provider or provider organization to build or sustain its capacity to deliver primary care services,
324 including clinical and information technology, data infrastructure, practice management support,
325 workforce recruitment, training and development, and cross-subsidization of primary care
326 operating losses by the provider or provider organization’s other operations; provided, however,
327 that “primary care infrastructure support” shall not include any amount included in primary care
328 expenditures.
329“Primary care investment”, the total commitment of financial resources by a provider or
330 provider organization to support the delivery of primary care services, consisting of the provider
331 or provider organization’s total primary care expenditures and primary care infrastructure
332 support.
333“Primary care provider”, a health care professional qualified to provide general medical
334 care for common health care problems, who supervises, coordinates, prescribes or otherwise
335 provides or proposes health care services, initiates referrals for specialist care and maintains
336 continuity of care within the scope of practice.
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337“Primary care services”, health care services furnished by a primary care provider to
338 promote health, prevent disease, diagnose and treat illness and injury and provide ongoing,
339 comprehensive and coordinated care.
340SECTION 15. Said chapter 12C is hereby further amended by inserting after section 15
341 the following section:-
342Section 15A. (a) The center shall promulgate regulations establishing the billing codes,
343 provider types and payment categories used to identify expenditures within each category of
344 primary care expenditures set forth in clauses (i) to (vii), inclusive, in the definition of “primary
345 care expenditures” in section 1; provided, however, that the center’s regulations shall not exclude
346 a category of expenditure described in said definition, or establish a category of expenditure not
347 described in said definition.
348(b) The regulations shall: (i) establish methodologies for measuring and tracking pediatric
349 primary care expenditures separately from adult primary care expenditures; (ii) establish
350 methodologies for measuring primary care expenditures by municipality and by rural cluster, as
351 designated by the department of public health; (iii) measure both primary care expenditures and
352 total health care expenditures net of prescription drug rebates; and (iv) be informed by, and to the
353 extent appropriate aligned with, methodologies used in other states, to facilitate cross-state
354 comparison.
355(c) The center shall develop a methodology for identifying, measuring and reporting non-
356 claims payments that directly support the delivery of primary care and primary care
357 infrastructure support. For any capitated, sub-capitated or full-risk payment, the center shall
358 develop a methodology for determining the portion that is attributable to primary care services
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359 and for tracing the portion of any such payment that is allocated to and retained at the primary
360 care practice level.
361(d) The center shall minimize administrative burden by relying on existing data
362 submissions by payers, providers and provider organizations to implement this section.
363(e) The center shall publish on its website the complete list of billing codes, provider
364 types and payment categories identified under subsection (a).
365SECTION 16. Section 16 of said chapter 12C, as so appearing, is hereby amended by
366 adding the following subsection:-
367(d) The center shall publish in its annual report (i) the aggregate primary care
368 expenditures together with the commonwealth’s performance against the aggregate primary care
369 expenditure target, and (ii) aggregate, de-identified information regarding primary care
370 investment analyses conducted pursuant to section 18A.
371SECTION 17. Section 18 of said chapter 12C, as so appearing, is hereby amended by
372 adding the following paragraph:-
373For a health care entity, as defined in subsection (a) of section 10A of chapter 6D, that is
374 identified by the center and referred to the commission under this section, the center shall also
375 provide the commission with an analysis of the health care entity’s primary care investment
376 conducted pursuant to section 18A.
377SECTION 18. Said chapter 12C is hereby further amended by inserting after section 18
378 the following section:-
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379Section 18A. (a) The center shall conduct an analysis of the primary care investment of
380 each health care entity, as defined in subsection (a) of section 10A of chapter 6D, for which the
381 center is required to provide an analysis to the commission under section 18. The analysis shall
382 evaluate (i) the primary care expenditures by or attributed to each entity, (ii) the entity’s primary
383 care expenditures expressed as a percentage of the entity’s health status adjusted total medical
384 expense, (iii) the entity’s primary care infrastructure support, where applicable, (iv) the year-
385 over-year change in primary care expenditures for the previous 3 years, and (v) the matters
386 described in subsections (b) to (e), inclusive, as applicable to the entity.
387(b) In the case of providers and provider organizations, the analysis in subsection (a) shall
388 address the following:
389(i) the entity’s capacity to increase its primary care investment without material adverse
390 effect on its financial condition and without materially contributing to growth in its health status
391 adjusted total medical expense, based on an assessment of the entity’s operating margin and
392 financial trend, the size and health adjusted status of its attributed patient population and its share
393 of the market in which it principally operates;
394(ii) the extent to which the entity’s attributed patient population experiences utilization
395 that could be avoided through more accessible or more effective primary care, based on an
396 assessment of the rate of emergency department visits by the entity’s patients that are classified
397 as non-emergent, or as emergent but treatable in a primary care setting, preventable
398 hospitalizations and the rate of unplanned hospital readmissions of the entity’s patients within 30
399 days of discharge, risk-standardized in the manner used by the center in its annual report on
400 hospital-wide all-payer readmissions;
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401(iii) the primary care needs of the population the entity serves, based on an assessment of
402 the clinical and social acuity of its attributed patient population, the share of that population
403 residing in municipalities or rural clusters identified by the department of public health as having
404 limited primary care access and the difference between primary care expenditures in the entity’s
405 principal market and the aggregate primary care expenditure target; and
406(iv) the effect of the entity’s conduct on the primary care market in which it operates,
407 based on an assessment of the entity’s acquisitions of or affiliations with primary care practices,
408 conversion of independent primary care practices to employed practices, its reclassification of
409 primary care practice sites as hospital satellites or outpatient departments, its use of provider-
410 based billing for primary care services and the portion of the payments it receives for primary
411 care services that is allocated to and retained at the primary care practice level.
412(c) In the case of payers, the analysis in subsection (a) shall address the following:
413(i) the extent to which the payer’s payment and administrative practices support the
414 delivery of primary care, as determined by an assessment of its primary care expenditures as a
415 share of the total health care expenditures attributed to the payer;
416(ii) the trend in contracted rates paid by the payer for primary care evaluation and
417 management services;
418(iii) the extent to which primary care providers and provider organizations with which the
419 payer contracts have elected to participate in a qualifying advanced primary care payment model
420 approved under section 31 of chapter 176O;
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421(iv) the extent to which the payer’s prior authorization, utilization management and other
422 administrative requirements applicable to primary care services and services commonly ordered
423 or furnished by primary care providers support or impede timely access to primary care; and
424(v) such other payment or administrative practices affecting primary care as the center
425 considers appropriate.
426(d) In conducting the analysis in subsection (a), the center shall take into account, as
427 applicable, the following factors: (i) the extent to which workforce shortages constrain
428 investment capacity for reasons outside the entity’s control; (ii) the entity’s organizational
429 mission and scope of services, including the proportion of its services that are specialty or
430 tertiary in nature; (iii) the extent to which the entity serves a disproportionate share of patients
431 covered by public health care payers including the volume of services it provides that are
432 reimbursed by the health safety net trust fund established in section 66 of chapter 118E; (iv)
433 whether a limited capacity to increase primary care investment is attributable to the entity’s
434 payer mix, financial condition or the acuity of the population it serves; and (v) recent capital or
435 operating investments in primary care infrastructure, including care management staffing,
436 behavioral health integration and appointment scheduling systems, and other primary care
437 infrastructure support that may not be reflected in claims-based expenditure data.
438(e) The center shall conduct the analysis using data collected pursuant to this chapter and
439 chapter 6D and shall not impose new data collection requirements for the purpose of this section.
440(f) The analysis shall not be a public record as defined by clause Twenty-sixth of section
441 7 of chapter 4 or section 10 of chapter 66 and shall be provided only to the commission and to
442 the entity to which it pertains.
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443(g) The center shall promulgate regulations necessary to implement this section.
444SECTION 19. Chapter 23G of the General Laws is hereby amended by adding the
445 following section:-
446Section 50. (a) For the purposes of this section, “high public payer community hospital”
447 shall have the same meaning as in section 25C¾ of chapter 111.
448(b) There shall be established and set up on the books of the commonwealth a fund to be
449 known as the Community Hospital Capital Access Fund, to be administered by the agency
450 without further appropriation.
451(c) The fund shall be credited with: (i) contributions received pursuant to subsection (p)
452 of section 25C of chapter 111; (ii) appropriations, bond premiums or other monies authorized by
453 the general court and specifically designated for credit to the fund; (iii) gifts, grants and
454 donations from public or private sources; (iv) investment income earned on amounts in the fund;
455 and (v) fees, premiums, loan repayments or other amounts received by the agency in connection
456 with the use of the fund under subsection (d). Amounts remaining in the fund at the end of a
457 fiscal year shall not revert to the General Fund and shall remain available for expenditure in
458 subsequent fiscal years.
459(d) The agency may use amounts in the fund to: (i) establish and maintain debt service
460 reserve funds or other reserve accounts in support of bonds or notes issued by or on behalf of a
461 high public payer community hospital; provided that the agency’s obligation with respect to any
462 such reserve fund or account shall be limited to the amount deposited in the fund or account; (ii)
463 provide grants and loans for construction, renovation or other capital expenditures for patient
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464 care activities at a high public payer community hospital; and (iii) pay the reasonable and
465 necessary costs of administering the fund.
466(e) Not later than October 1 of each year, the agency shall report to the clerks of the
467 house of representatives and the senate, the house and senate committees on ways and means,
468 and the joint committee on health care financing on the following: (i) the contributions received
469 from amounts required pursuant to subsection (p) of section 25C of chapter 111 during the
470 preceding fiscal year; (ii) the amount, recipient and purpose of each expenditure or commitment
471 from the fund; and (iii) an assessment of the fund’s effect on the availability and cost of capital
472 for high public payer community hospitals.
473SECTION 20. Chapter 29 of the General Laws is hereby amended by striking out section
474 2FFFF and inserting in place thereof the following section:-
475Section 2FFFF. (a) There shall be established upon the books of the commonwealth a
476 separate fund to be known as the Health Care Workforce Transformation Fund, hereinafter called
477 the fund. The purpose of the fund shall be to: (i) expand education, training and career pathways;
478 (ii) recruit and retain the health care workforce; (iii) improve equitable access to high-quality
479 health care services; (iv) promote culturally competent and community-based care; and (v)
480 support the commonwealth’s attainment of the aggregate primary care expenditure target
481 established under section 9A of chapter 6D.
482(b) The fund shall be administered by the secretary of health and human services, in
483 consultation with the secretary of labor and workforce development, the commissioner of higher
484 education, and the Health Care Workforce Advisory Council established under section 25M of
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485 chapter 111. The secretary of health and human services shall establish criteria for the allocation
486 of the fund, which shall be posted on the executive office of health and human services’ website.
487(c) There shall be credited to the fund: (i) such amounts as may be transferred from the
488 commonwealth federal matching and debt reduction fund under section 2EEEEEE, inserted by
489 section 2 of chapter 214 of the acts of 2024; (ii) repayments received from participants in the
490 workforce loan repayment program under section 25N of chapter 111; (iii) any revenue from
491 appropriations or other monies authorized by the general court and specifically designated to be
492 credited to the fund; and (iv) any gifts, grants, private contributions, investment income earned
493 on the fund’s assets and all other sources. Money remaining in the fund at the end of a fiscal year
494 shall not revert to the General Fund and shall be available for expenditure in the following fiscal
495 year.
496(d)(1) In each fiscal year through fiscal year 2036, not less than 80 per cent of available
497 funds shall be expended or obligated for the recruitment, training, retention or geographic
498 distribution of primary care providers. Expenditures under this subsection shall include, but shall
499 not be limited to:
500(i) the health care workforce loan repayment program established under section 25N of
501 chapter 111, to the extent that repayment assistance is awarded to primary care providers;
502(ii) the primary care residency grant program established under section 25N ½ of chapter
503 111; and
504(iii) the primary care workforce development and loan forgiveness grant program
505 established under section 25N¾ of chapter 111.
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506(e) Monies in the fund may also be expended for the following purposes:
507(i) addressing documented workforce shortages and improving retention in the health
508 care industry;
509(ii) expanding clinical education and training capacity, including clinical placements,
510 preceptorships, clerkships and rural rotations, and supporting faculty development and
511 instructional resources;
512(iii) expanding educational pathways, including accelerated and advanced degree
513 programs, apprenticeships and training and career advancement for currently employed or
514 unemployed health care workers;
515(iv) providing scholarships, tuition assistance, stipends, loan repayment and other
516 educational assistance;
517(v) reducing health disparities and expanding the delivery of culturally and linguistically
518 responsive care;
519(vi) supporting emerging care delivery models, regional partnerships, educational
520 innovation and workforce planning.
521(f) The secretary may award competitive grants from the fund to carry out the purposes of
522 this section. Eligible applicants shall include, but shall not be limited to: public and private
523 institutions of higher education, vocational technical schools and school districts; hospitals,
524 community health centers, behavioral health providers, primary care practices and other health
525 care providers; workforce development boards, one-stop career centers and municipalities;
526 nonprofit and community-based organizations; employers, employer associations, labor
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527 organizations and joint labor-management partnerships; and any partnership among such
528 applicants.
529(g) The secretary shall annually report to the clerks of the house of representatives and
530 the senate, the house and senate committees on ways and means, the joint committee on public
531 health, the joint committee on health care financing and the joint committee on labor and
532 workforce development on the administration of the fund. The report shall include: (i) the
533 revenue credited to the fund and the amount of expenditures attributable to administrative costs;
534 (ii) an assessment of statewide and regional workforce needs and educational capacity, and
535 progress toward statewide priorities; (iii) the impact of the fund on health care workforce
536 shortages and on access to primary care; and (iv) any recommendations for future investments or
537 for legislative or administrative changes necessary to carry out the purposes of this section. The
538 report shall be posted on the executive office of health and human services’ website.
539SECTION 21. Section 2EEEEEE of said chapter 29, as appearing in the 2024 Official
540 Edition, is hereby amended by striking out, in line 73, the words “and (iii)” and inserting in place
541 thereof the following words:- (iii) protecting the commonwealth from the elimination, reduction
542 or material delay of federal funds upon a determination by the secretary that the elimination,
543 reduction or material delay of such federal funds would materially impact public health, safety or
544 welfare or the fiscal stability of the commonwealth or any of its political subdivisions, in
545 accordance with guidance issued by the executive office for administration and finance; (iv)
546 improving the financial stability of hospitals and community health centers in the commonwealth
547 that provide health care to low-income, uninsured or underinsured residents, including by
548 transferring any amounts in the fund to the Health Safety Net Trust Fund established in section
549 66 of chapter 118E, in accordance with guidance issued by the executive office for
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550 administration and finance in consultation with the executive office of health and human
551 services; (v) funding pay-as-you-go capital for any capital project or program up to the amount
552 otherwise authorized by the general court for such project or program in chapter 238 of the acts
553 of 2024, in accordance with guidance issued by the executive office for administration and
554 finance; (vi) strengthening the primary care and health care workforce of the commonwealth,
555 including by transferring any amounts in the fund to the Health Care Workforce Transformation
556 Fund established in section 2FFFF; and (vii).
557SECTION 22. Chapter 32A of the General Laws is hereby amended by inserting after
558 section 17AA, inserted by section 39 of chapter 137 of the acts of 2026, the following 3
559 sections:-
560Section 17BB. (a) As used in this section, the following words shall, unless the context
561 clearly requires otherwise, have the following meanings:-
562“Federally qualified health center”, a community health center as defined in 101 C.M.R.
563 304 for which the division of medical assistance has established a prospective payment system
564 rate.
565“Federally qualified health center services”, services provided by a federally qualified
566 health center for which reimbursement is determined under the medical and behavioral health
567 prospective payment system methodology applicable to federally qualified health centers
568 pursuant to 101 C.M.R. 304.
569(b) The commission shall ensure that the total reimbursement payable with respect to an
570 encounter for federally qualified health center services covered by the commission and provided
571 to a patient by a federally qualified health center is not less than the applicable rate that the
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572 federally qualified health center would have received from MassHealth for the same encounter as
573 of January 1 of the applicable calendar year, determined in accordance with the prospective
574 payment system methodology established under 42 U.S.C. sections 1396a(bb) and
575 1396b(m)(2)(A)(ix), as implemented by MassHealth and in effect on January 1, 2025.
576(c) The commission shall consult with the division of medical assistance for technical
577 assistance regarding the prospective payment system rate and methodology for each federally
578 qualified health center for the applicable year.
579Section 17CC. (a) For the purposes of this section, the terms “health care facility” and
580 “health care provider” shall have the same meanings as defined in section 1 of chapter 111O.
581(b) The commission shall not deny, limit or condition coverage for an otherwise covered
582 health care service solely because the service is delivered by a health care provider participating
583 in a mobile integrated health care program approved by the department of public health pursuant
584 to chapter 111O. Health care services delivered through an approved mobile integrated health
585 care program shall be covered to the same extent as if they were provided in a health care
586 facility, and the rates of payment for an otherwise covered service shall not be reduced solely
587 because the service was delivered through an approved mobile integrated health care program.
588(c) Coverage provided pursuant to this section may be subject to a deductible, copayment
589 or coinsurance applicable to a health care service delivered through an approved mobile
590 integrated health care program; provided, however, that the deductible, copayment or
591 coinsurance shall not exceed the deductible, copayment or coinsurance applicable to the same
592 service when provided in a health care facility.
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593Section 17DD. (a) As used in this section, the following words shall, unless the context
594 clearly requires otherwise, have the following meanings:
595“Biomarker”, a molecular, genetic or biochemical characteristic, including gene
596 mutations, characteristics of genes or protein expression, that is objectively measured and
597 evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic
598 responses to a specific therapeutic intervention, including known gene-drug interactions for
599 medications being considered for use or already being administered.
600“Biomarker testing”, the analysis of a patient’s tissue, blood or other biospecimen for the
601 presence of a biomarker, including, but not limited to, single-analyte tests, multi-plex panel tests,
602 protein expression and whole exome, whole genome and whole transcriptome sequencing
603 performed at a laboratory facility that is either CLIA-certified or CLIA-waived by the federal
604 Food and Drug Administration; provided, however, that biomarker testing shall not include
605 testing for the purpose of screening in asymptomatic individuals
606“CLIA certified”, holding a certificate issued by the federal Centers for Medicare and
607 Medicaid Services under the Clinical Laboratory Improvement Amendments of 1988 authorizing
608 a laboratory to perform testing on human specimens.
609“CLIA waived”, holding a certificate of waiver issued under the Clinical Laboratory
610 Improvement Amendments of 1988 authorizing a laboratory to perform only those tests
611 categorized as waived by the federal Food and Drug Administration under 42 C.F.R. section
612 493.15.
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613“Clinical utility”, the test result provides information that is used in the formulation of a
614 treatment or monitoring strategy that informs a patient’s outcome and impacts the clinical
615 decision. Clinical utility shall be established by any of the following:
616(i) the labeled indications for a test approved or cleared by the federal Food and Drug
617 Administration;
618(ii) a test indicated in the FDA-approved labeling of a drug, including as a companion
619 diagnostic;
620(iii) warnings and precautions in the FDA-approved labeling of a drug;
621(iv) a national coverage determination of the federal Centers for Medicare and Medicaid
622 Services, or a local coverage determination issued by the Medicare Administrative Contractor; or
623(v) a nationally recognized clinical practice guideline.
624“Nationally recognized clinical practice guidelines”, evidence-based clinical practice
625 guidelines developed by independent organizations or medical professional societies utilizing a
626 transparent methodology and reporting structure and with a conflict of interest policy, including,
627 but not limited to those of the National Comprehensive Cancer Network or the American Society
628 of Clinical Oncology.
629(b) The commission shall provide to any active or retired employee of the commonwealth
630 who is insured under the group insurance commission coverage for biomarker testing, pursuant
631 to criteria established under subsection (c); provided, that coverage shall be applied in a manner
632 that limits disruptions in care including the need for multiple biopsies or biospecimen samples.
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633(c) Biomarker testing shall be covered when the test: (i) is conducted at either a CLIA-
634 certified or CLIA-waived laboratory and (ii) provides clinical utility to the enrollee, as
635 demonstrated by medical and scientific evidence establishing that the result will be used to
636 select, initiate, exclude, or discontinue a specific therapy, or to determine appropriate dosing of a
637 specific therapy.
638(d) In the case of coverage that requires prior authorization, a carrier or a utilization
639 review organization subject to this section shall approve or deny a prior authorization request and
640 notify the enrollee, the enrollee’s health care provider and any entity requesting authorization of
641 the service within 5 business days. If additional delay would result in significant risk to the
642 insured’s health or well-being, a carrier or a utilization review organization shall approve or deny
643 the request within 48 hours. If a response by a carrier or utilization review organization is not
644 received within the time required under this subsection, said request or appeal shall be deemed
645 granted.
646(e) The patient and prescribing practitioner shall have access to a clear, readily accessible
647 and convenient processes to request an exception to a coverage policy or an adverse utilization
648 review determination. The process shall be made readily accessible on the carrier’s website.
649SECTION 23. Said chapter 32A is hereby further amended by adding the following 2
650 sections:-
651Section 35. The commission shall offer, to each primary care provider with which it
652 contracts, a qualifying advanced primary care payment model meeting the requirements
653 established by the commissioner of insurance under section 31 of chapter 176O. Participation
654 shall be at the election of the primary care provider or provider organization. The commission
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655 shall annually report to the commissioner of insurance the information described in subsection (i)
656 of said section 31 of said chapter 176O.
657Section 36. The commission shall make available to an insured the estimated rebates and
658 shall comply with the requirements applicable to a carrier under section 32 of chapter 176O. Any
659 pharmacy benefit manager, affiliated entity or third-party administrator acting on behalf of the
660 commission shall be subject to said section 32 of said chapter 176O to the same extent as if
661 acting on behalf of a carrier. Annually, not later than April 1, the commission shall file with the
662 commissioner of insurance the report described in subsection (d) of said section 32 of said
663 chapter 176O.
664SECTION 23A. Section 24N of chapter 111 of the General Laws, as most recently
665 amended by section 28 of chapter 73 of the acts of 2025, is hereby further amended by striking
666 out subsections (c) and (d) and inserting in place thereof the following subsections:-
667(c) There shall be a vaccine program advisory council consisting of the commissioner of
668 public health or a designee, who shall serve as chair; the medical director of the universal
669 immunization program of the department of public health established under section 24I; the
670 executive director for the center for health information and analysis or a designee; the executive
671 director of the commonwealth health insurance connector authority or a designee; 1 person to be
672 appointed by the director of Medicaid, who shall be a representative of managed care
673 organizations contracting with MassHealth; 3 persons to be appointed by the commissioner of
674 insurance, each of whom shall be a representative of 1 of the 3 health insurance companies
675 having the most insured lives in the commonwealth; and 7 persons to be appointed by the
676 commissioner of public health, 1 of whom shall be a representative of an employer that self-
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677 insures for health coverage who shall be appointed from lists of nominees submitted by statewide
678 associations of employers, 1 of whom shall be a member of the Massachusetts Medical Society,
679 1 of whom shall be a member of the Massachusetts chapter of the American Academy of
680 Pediatrics, 1 of whom shall be a member of the Massachusetts Academy of Family Physicians,
681 and 3 of whom shall be physicians licensed to practice in the commonwealth and who shall have
682 expertise in the area of childhood vaccines. The council shall recommend the amount of funding
683 needed each fiscal year by calculating the total non-federal program cost.
684(d) Under regulations adopted by the commissioner of public health, each surcharge
685 payor in the commonwealth shall pay to the commissioner of public health, for deposit in the
686 Vaccine Purchase Trust Fund, a routine childhood immunizations surcharge assessed by the
687 commissioner. By January 1 of each year, the commissioner of public health shall determine the
688 total amount of the surcharge for the current fiscal year by determining the final amount required
689 to be included in the Vaccine Purchase Trust Fund for the current fiscal year to cover the
690 estimated costs to purchase, store and distribute immunizations for routine childhood
691 immunizations and to administer the fund and the immunization registry, established pursuant to
692 section 24M. The amount shall take into consideration the limitations on expenditures described
693 in subsection (b) any anticipated surplus or deficit in the trust fund, and shall exclude any costs
694 anticipated to be covered by federal contribution. Any increase in the surcharge amount for the
695 prior fiscal year shall not be more than the percentage set as the health care cost growth
696 benchmark, established under section 9 of chapter 6D, unless the commissioner of public health
697 submits a detailed report to the clerks of the house of representatives and senate who shall
698 forward the report to the house and senate committees on ways and means, the house and senate
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699 chairs of the joint committee on public health and the house and senate chairs of the joint
700 committee on health care financing explaining the need for the increase.
701SECTION 24. Section 25C of chapter 111 of the General Laws, as amended by section
702 180 of chapter 102 of the acts of 2026, is hereby further amended by adding the following
703 subsection:-
704(p) Notwithstanding any general or special law or regulation to the contrary, the
705 department shall require, as a condition of approval of an application for a determination of need
706 for a substantial capital expenditure, that the applicant pay an amount equal to not less than 2 per
707 cent of the capital expenditure amount of a proposed project, which shall be transmitted by the
708 department to the Community Hospital Capital Access Fund established in section 50 of chapter
709 23G; provided, however, that this subsection shall not apply to a determination of need
710 application filed by, or for the direct benefit of, a high public payer community hospital, as
711 defined in section 25C¾; and provided further, that the aggregate amount of all required
712 contributions imposed with respect to the proposed project, including the contribution required
713 under this subsection, shall not exceed 5 per cent of the capital expenditure amount of the
714 proposed project.
715SECTION 25. Said chapter 111 is hereby further amended by inserting after section
716 25C½ the following section:-
717Section 25C¾. (a) As used in this section, the following words shall, unless the context
718 clearly requires otherwise, have the following meanings:
719“High public payer community hospital”, (i) an acute care hospital established under
720 chapter 147 of the acts of 1995 and its corporate affiliates; (ii) a non-state, government public
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721 hospital system established pursuant to chapter 147 of the acts of 1996; or (iii) an acute care
722 hospital classified as a community-high public payer hospital by the center for health
723 information and analysis in its most recently published Massachusetts Acute Hospital Profiles, or
724 successor publication.
725“Priority review designation”, a designation issued by the department entitling an
726 applicant to the review procedures set forth in this section.
727“Qualifying priority project”, a proposed project by a high public payer community
728 hospital or another provider that is a joint venture partner, corporate affiliate or clinical affiliate
729 with a high public payer community hospital that addresses a documented state or regional
730 unmet health care need, including but not limited to: (i) increased capacity for primary care,
731 behavioral health or maternal health services; (ii) services provided in a health professional
732 shortage area or medically underserved area; (iii) innovative models of care delivery that support
733 the goals of the state health resource plan established under section 22 of chapter 6D; or (iv) any
734 other category so designated by the department, consistent with the state health resource plan.
735(b) An applicant for a qualifying priority project may request priority review designation
736 not less than 30 days before filing notice of intent for a determination of need application. The
737 department shall grant or deny a request for priority review designation within 30 days of its
738 submission.
739(c) Within 15 days after a grant of priority review designation, the department shall
740 convene a scoping conference with the applicant to identify which, if any, application
741 requirements, supporting documentation or review factors applicable to the determination of
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742 need application may be permitted to be verified following approval, consistent with subsection
743 (f).
744(d) An applicant with priority review designation may submit application materials,
745 supporting documentation and other information required for a determination of need application
746 on a rolling basis, as each is completed, rather than as a single, complete application, and the
747 department may commence its review of each submission upon receipt.
748(e) The department shall issue a decision on an application with priority review
749 designation within 60 days after the initial filing of the determination of need application,
750 notwithstanding that additional application materials may be submitted pursuant to subsection
751 (d). To the extent feasible, the department shall conduct any independent cost analysis, and the
752 health policy commission shall conduct any cost and market impact review under section 13 of
753 chapter 6D, concurrently with its review under this section.
754(f) If the department determines that an application requirement, supporting
755 documentation or review factor of a qualifying proposed project can be verified following
756 approval, the department may issue a conditional determination of need, conditioned on the
757 applicant’s compliance with post-approval reporting requirements established by the department.
758 The department may revoke a conditional determination of need, or require a corrective action
759 plan, upon an applicant’s failure to comply with post-approval reporting requirements.
760(g) The department may, by regulation, set a reduced filing fee otherwise applicable to an
761 application with priority review designation filed by, or on behalf of, a high public payer
762 community hospital or its joint venture partner, corporate affiliate, or clinical affiliate
763 experiencing material financial hardship.
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764SECTION 25A. Said chapter 111 is hereby further amended adding the following
765 section:-
766Section 251. (a) The department shall implement a provider immunization brand choice
767 requirement as part of the commonwealth’s universal immunization program pursuant to sections
768 24I and 24N and in any other existing or future immunization program for children or adults
769 administered through the state using local, state or federal funds.
770(b)(1) Pursuant to the provider immunization brand choice requirement, for all categories
771 of immunizations included in the programs described in subsection (a), all healthcare providers
772 participating in these programs shall be able to select any brand or type of any immunization,
773 including any combination immunization and dosage form, as long as the immunization is
774 licensed or authorized for emergency use by the federal Food and Drug Administration,
775 recommended by the national Centers for Disease Control and Prevention Advisory Committee
776 on Immunization Practices or is recommended by national professional medical societies.
777(2) The universal immunization program shall reflect adequate patient and provider
778 immunization brand choice to preserve clinical judgement for healthcare providers, enhance
779 vaccine confidence, stabilize the vaccine supply and encourage access to future vaccines. The
780 department may exclude certain brand vaccines based on concerns for the health and safety of
781 patients or excessive purchase cost in comparison to comparable agents. This section shall not
782 apply in the event of a shortage or delay in vaccine availability, disaster or public health
783 emergency, terrorist attack, hostile military or paramilitary action or extraordinary law
784 enforcement emergency.
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785SECTION 26. Section 2 of chapter 111O of the General Laws, as appearing in the 2024
786 Official Edition, is hereby amended by adding the following 3 subsections:-
787(c) The department may establish by regulation application and registration fees for
788 mobile integrated health care programs approved pursuant to this chapter; provided, however,
789 that the department may waive or reduce application and registration fees for a mobile integrated
790 health care program that primarily provides behavioral health services.
791(d) An approved mobile integrated health care program shall, to the extent practicable,
792 notify and coordinate ongoing care with a patient’s primary care provider regarding services
793 rendered not later than 72 hours after the encounter to support continuity of care.
794(e) An approved mobile integrated health care program may accept a referral from a
795 patient’s primary care provider for chronic disease management, post-discharge follow-up or
796 preventive care services.
797SECTION 26A. Chapter 112 of the General Laws is hereby amended by inserting after
798 section 38 the following section:-
799Section 38A. (a) For the purposes of this section, a “pharmacy desert” shall mean an area
800 where there is no or limited access to pharmacies due to factors including, but not limited to: (i)
801 geographic location, specifically areas where the nearest pharmacy is more than 2 miles away in
802 urban areas, more than 5 miles away in suburban areas, and more than 15 miles away in rural
803 areas; (ii) distance and travel time, defined as travel time exceeding 15 minutes by car or 30
804 minutes by public transportation; (iii) limited access to transportation, both public and private,
805 including areas with infrequent public transit services or where at least 20 per cent of the
806 population lacks access to private vehicles.
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807(b) Any entity that intends to close a pharmacy or pharmacy department registered by the
808 board for the transaction of a drug business, as defined in section 37, shall notify the board in
809 writing not less than 60 days before the proposed closure date. The entity shall send a copy of the
810 notice to the members of the general court who represent the municipality in which the pharmacy
811 or pharmacy department is located, and the clerk of the municipality in which the pharmacy or
812 pharmacy department is located, who shall distribute the notice to the appropriate local officials.
813 Within 15 days of receipt of the notice of the intended closing, the board shall conduct a review
814 to determine whether the intended closing is likely to result in the creation of a pharmacy desert
815 based on the most recent focused assessment performed by the office of health resource planning
816 pursuant to section 22A of chapter 6D. If the board finds that the intended closing is likely to
817 result in the creation of a pharmacy desert, the board shall conduct a public hearing not less than
818 30 calendar days prior to the proposed closure date set out in the entity’s notice. At the public
819 hearing, the board shall present information on alternative sources of pharmacy services
820 available to impacted consumers and allow interested parties the opportunity to share comments
821 and concerns about the proposed closure. Such interested parties may include, but not be limited
822 to, impacted residents, municipal government officials, the members of the general court who
823 represent the municipality in which the pharmacy or pharmacy department is located, local
824 health care providers, and neighborhood associations or other community associations.
825SECTION 27. Chapter 118E of the General Laws is hereby amended by inserting after
826 section 10AA, inserted by section 72 of chapter 137 of the acts of 2026, the following 2
827 sections:-
828Section 10BB. (a) For the purposes of this section, the terms “health care facility” and
829 “health care provider” shall have the same meanings as defined in section 1 of chapter 111O.
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830(b) The division and its contracted health insurers, health plans, health maintenance
831 organizations, behavioral health management firms and third-party administrators under contract
832 to a Medicaid managed care organization, accountable care organization or primary care
833 clinician plan shall not deny, limit or condition coverage for an otherwise covered health care
834 service solely because the service is delivered by a health care provider participating in a mobile
835 integrated health care program approved by the department of public health pursuant to chapter
836 111O. Health care services delivered through an approved mobile integrated health care program
837 shall be covered to the same extent as if they were provided in a health care facility, and the rates
838 of payment for an otherwise covered service shall not be reduced solely because the service was
839 delivered through an approved mobile integrated health care program.
840(c) Coverage provided pursuant to this section may be subject to a deductible, copayment
841 or coinsurance applicable to a health care service delivered through an approved mobile
842 integrated health care program; provided, however, that the deductible, copayment or
843 coinsurance shall not exceed the deductible, copayment or coinsurance applicable to the same
844 service when provided in a health care facility.
845Section 10CC. (a) As used in this section, the following words shall, unless the context
846 clearly requires otherwise, have the following meanings:
847“Biomarker”, a molecular, genetic or biochemical characteristic, including gene
848 mutations, characteristics of genes or protein expression, that is objectively measured and
849 evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic
850 responses to a specific therapeutic intervention, including known gene-drug interactions for
851 medications being considered for use or already being administered.
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852“Biomarker testing”, the analysis of a patient’s tissue, blood or other biospecimen for the
853 presence of a biomarker, including, but not limited to, single-analyte tests, multi-plex panel tests,
854 protein expression and whole exome, whole genome and whole transcriptome sequencing
855 performed at a laboratory facility that is either CLIA-certified or CLIA-waived by the federal
856 Food and Drug Administration; provided, however, that biomarker testing shall not include
857 testing for the purpose of screening in asymptomatic individuals
858“CLIA certified”, holding a certificate issued by the federal Centers for Medicare and
859 Medicaid Services under the Clinical Laboratory Improvement Amendments of 1988 authorizing
860 a laboratory to perform testing on human specimens.
861“CLIA waived”, holding a certificate of waiver issued under the Clinical Laboratory
862 Improvement Amendments of 1988 authorizing a laboratory to perform only those tests
863 categorized as waived by the federal Food and Drug Administration under 42 C.F.R. section
864 493.15.
865“Clinical utility”, the test result provides information that is used in the formulation of a
866 treatment or monitoring strategy that informs a patient’s outcome and impacts the clinical
867 decision. Clinical utility shall be established by any of the following:
868(i) the labeled indications for a test approved or cleared by the federal Food and Drug
869 Administration;
870(ii) a test indicated in the FDA-approved labeling of a drug, including as a companion
871 diagnostic;
872(iii) warnings and precautions in the FDA-approved labeling of a drug;
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873(iv) a national coverage determination of the federal Centers for Medicare and Medicaid
874 Services, or a local coverage determination issued by the Medicare Administrative Contractor; or
875(v) a nationally recognized clinical practice guideline.
876“Nationally recognized clinical practice guidelines”, evidence-based clinical practice
877 guidelines developed by independent organizations or medical professional societies utilizing a
878 transparent methodology and reporting structure and with a conflict of interest policy, including,
879 but not limited to those of the National Comprehensive Cancer Network or the American Society
880 of Clinical Oncology.
881(b) The division and its contracted health insurers, health plans, health maintenance
882 organizations, behavioral health management firms and third-party administrators under contract
883 to a Medicaid managed care organization, accountable care organization or primary care
884 clinician plan shall provide to any active or retired employee of the commonwealth who is
885 insured under the group insurance commission coverage for biomarker testing, pursuant to
886 criteria established under subsection (c); provided, that coverage shall be applied in a manner
887 that limits disruptions in care including the need for multiple biopsies or biospecimen samples.
888(c) Biomarker testing shall be covered when the test: (i) is conducted at either a CLIA-
889 certified or CLIA-waived laboratory; and (ii) provides clinical utility to the enrollee, as
890 demonstrated by medical and scientific evidence establishing that the result will be used to
891 select, initiate, exclude or discontinue a specific therapy, or to determine appropriate dosing of a
892 specific therapy.
893(d) In the case of coverage that requires prior authorization, a carrier or a utilization
894 review organization subject to this section shall approve or deny a prior authorization request and
  42 of 83
895 notify the enrollee, the enrollee’s health care provider and any entity requesting authorization of
896 the service within 5 business days. If additional delay would result in significant risk to the
897 insured’s health or well-being, a carrier or a utilization review organization shall approve or deny
898 the request within 48 hours. If a response by the division or utilization review organization is not
899 received within the time required under this subsection, said request or appeal shall be deemed
900 granted.
901(e) The patient and prescribing practitioner shall have access to a clear, readily accessible
902 and convenient processes to request an exception to a coverage policy or an adverse utilization
903 review determination. The process shall be made readily accessible on the carrier’s website.
904SECTION 28. Said chapter 118E is hereby further amended by inserting after section
905 13D½ the following section:-
906Section 13D¾. (a) For the purposes of this section, the term “community health center”
907 shall mean any entity reimbursed as a community health center under this chapter.
908(b) Notwithstanding any general or special law to the contrary, and to the maximum
909 extent permitted under federal law and in a manner that preserves the maximum available federal
910 financial participation, reimbursement for community health centers under this chapter, shall be
911 determined using the prospective payment system methodology that conforms with 42 U.S.C.
912 sections 1396a(bb) and 1396b(m)(2)(A)(ix), as in effect on January 1, 2025.
913SECTION 29. Chapter 175 of the General Laws is hereby amended by inserting after
914 section 47DDD, inserted by section 77 of chapter 137 of the acts of 2026, the following 3
915 sections:-
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916Section 47EEE. (a) As used in this section, the following words shall, unless the context
917 clearly requires otherwise, have the following meanings:-
918“Federally qualified health center”, a community health center as defined in 101 C.M.R.
919 304 for which the division of medical assistance has established a prospective payment system
920 rate.
921“Federally qualified health center services”, services provided by a federally qualified
922 health center for which reimbursement is determined under the medical and behavioral health
923 prospective payment system methodology applicable to federally qualified health centers
924 pursuant to 101 C.M.R. 304.
925(b) Any carrier offering a policy, contract, agreement, plan or certificate of insurance
926 issued, delivered or renewed within the commonwealth shall ensure that the total reimbursement
927 payable with respect to an encounter for federally qualified health center services covered by the
928 carrier and provided to a patient by a federally qualified health center is not less than the
929 applicable rate that the federally qualified health center would have received from MassHealth
930 for the same encounter as of January 1 of the applicable calendar year, determined in accordance
931 with the prospective payment system methodology established under 42 U.S.C. sections
932 1396a(bb) and 1396b(m)(2)(A)(ix), as implemented by MassHealth and in effect on January 1,
933 2025.
934(c) The division of insurance shall consult with the division of medical assistance for
935 technical assistance regarding the prospective payment system rate and methodology for each
936 federally qualified health center for the applicable year.
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937Section 47FFF. (a) For the purposes of this section, the terms “health care facility” and
938 “health care provider” shall have the same meanings as defined in section 1 of chapter 111O.
939(b) Any carrier offering a policy, contract, agreement, plan or certificate of insurance
940 issued, delivered or renewed within the commonwealth shall not deny, limit or condition
941 coverage for an otherwise covered health care service solely because the service is delivered by a
942 health care provider participating in a mobile integrated health care program approved by the
943 department of public health pursuant to chapter 111O. Health care services delivered through an
944 approved mobile integrated health care program shall be covered to the same extent as if they
945 were provided in a health care facility, and the rates of payment for an otherwise covered service
946 shall not be reduced solely because the service was delivered through an approved mobile
947 integrated health care program.
948(c) Coverage provided pursuant to this section may be subject to a deductible, copayment
949 or coinsurance applicable to a health care service delivered through an approved mobile
950 integrated health care program; provided, however, that the deductible, copayment or
951 coinsurance shall not exceed the deductible, copayment or coinsurance applicable to the same
952 service when provided in a health care facility.
953Section 47GGG. (a) As used in this section, the following words shall, unless the context
954 clearly requires otherwise, have the following meanings:
955“Biomarker”, a molecular, genetic or biochemical characteristic, including gene
956 mutations, characteristics of genes or protein expression, that is objectively measured and
957 evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic
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958 responses to a specific therapeutic intervention, including known gene-drug interactions for
959 medications being considered for use or already being administered.
960“Biomarker testing”, the analysis of a patient’s tissue, blood or other biospecimen for the
961 presence of a biomarker, including, but not limited to, single-analyte tests, multi-plex panel tests,
962 protein expression and whole exome, whole genome and whole transcriptome sequencing
963 performed at a laboratory facility that is either CLIA-certified or CLIA-waived by the federal
964 food and drug administration; provided, however, that biomarker testing does not include testing
965 for the purpose of screening in asymptomatic individuals
966“CLIA certified”, holding a certificate issued by the federal Centers for Medicare and
967 Medicaid Services under the Clinical Laboratory Improvement Amendments of 1988, 42 U.S.C.
968 section 263 authorizing a laboratory to perform testing on human specimens.
969“CLIA waived”, holding a certificate of waiver issued under the Clinical Laboratory
970 Improvement Amendments of 1988 authorizing a laboratory to perform only those tests
971 categorized as waived by the federal Food and Drug Administration under 42 C.F.R. section
972 493.15.
973“Clinical utility”, the test result that provides information that is used in the formulation
974 of a treatment or monitoring strategy that informs a patient’s outcome and impacts the clinical
975 decision. Clinical utility shall be established by any of the following:
976(i) the labeled indications for a test approved or cleared by the federal Food and Drug
977 Administration;
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978(ii) a test indicated in the FDA-approved labeling of a drug, including as a companion
979 diagnostic;
980(iii) warnings and precautions in the FDA-approved labeling of a drug;
981(iv) a national coverage determination of the federal Centers for Medicare and Medicaid
982 Services, or a local coverage determination issued by the Medicare Administrative Contractor; or
983(v) a nationally recognized clinical practice guideline.
984“Nationally recognized clinical practice guidelines”, evidence-based clinical practice
985 guidelines developed by independent organizations or medical professional societies utilizing a
986 transparent methodology and reporting structure and with a conflict of interest policy, including,
987 but not limited to those of the National Comprehensive Cancer Network or the American Society
988 of Clinical Oncology.
989(b) Any carrier offering a policy, contract, agreement, plan or certificate of insurance
990 issued, delivered or renewed within the commonwealth shall provide to any active or retired
991 employee of the commonwealth who is insured under the group insurance commission coverage
992 for biomarker testing, pursuant to criteria established under subsection (c); provided, that
993 coverage shall be applied in a manner that limits disruptions in care including the need for
994 multiple biopsies or biospecimen samples.
995(c) Biomarker testing shall be covered when the test: (i) is conducted at either a CLIA-
996 certified or CLIA-waived laboratory and (ii) provides clinical utility to the enrollee, as
997 demonstrated by medical and scientific evidence establishing that the result will be used to
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998 select, initiate, exclude or discontinue a specific therapy, or to determine appropriate dosing of a
999 specific therapy.
1000  (d) In the case of coverage that requires prior authorization, a carrier or a utilization
1001   review organization subject to this section shall approve or deny a prior authorization request and
1002   notify the enrollee, the enrollee’s health care provider and any entity requesting authorization of
1003   the service within 5 business days. If additional delay would result in significant risk to the
1004   insured’s health or well-being, a carrier or a utilization review organization shall approve or deny
1005   the request within 48 hours. If a response by a carrier or utilization review organization is not
1006   received within the time required under this subsection, said request or appeal shall be deemed
1007   granted.
1008  (e) The patient and prescribing practitioner shall have access to a clear, readily accessible
1009   and convenient processes to request an exception to a coverage policy or an adverse utilization
1010   review determination. The process shall be made readily accessible on the carrier’s website.
1011  SECTION 29A. Section 11 of chapter 175M of the General Laws, as appearing in the
1012   2024 Official Edition, is hereby amended by adding the following subsection:-
1013  (f) An employer with not more than 25 employees shall be permitted to submit a private
1014   plan subject to the requirements of paragraph (1) of subsection (a) to the department directly;
1015   provided, that such employer shall be exempt from the requirements set forth in clause (i) and
1016   (iii) of paragraph (2) of subsection (a).
1017  SECTION 30. Chapter 176A of the General Laws hereby amended by inserting after
1018   section 8EEE, inserted by section 81 of said chapter 137, the following 3 sections:-
  48 of 83
1019  Section 8FFF. (a) As used in this section, the following words shall, unless the context
1020   clearly requires otherwise, have the following meanings:-
1021  “Federally qualified health center”, a community health center as defined in 101 C.M.R.
1022   304 for which the division of medical assistance has established a prospective payment system
1023   rate.
1024  “Federally qualified health center services”, services provided by a federally qualified
1025   health center for which reimbursement is determined under the medical and behavioral health
1026   prospective payment system methodology applicable to federally qualified health centers
1027   pursuant to 101 C.M.R. 304.
1028  (b) Any contract between a subscriber and the corporation under an individual or group
1029   hospital service plan that is delivered, issued or renewed within the commonwealth shall ensure
1030   that the total reimbursement payable with respect to an encounter for federally qualified health
1031   center services covered by the contract and provided to a patient by a federally qualified health
1032   center is not less than the applicable rate that the federally qualified health center would have
1033   received from MassHealth for the same encounter as of January 1 of the applicable calendar
1034   year, determined in accordance with the prospective payment system methodology established
1035   under 42 U.S.C. sections 1396a(bb) and 1396b(m)(2)(A)(ix), as implemented by MassHealth and
1036   in effect on January 1, 2025.
1037  (c) The division of insurance shall consult with the division of medical assistance for
1038   technical assistance regarding the prospective payment system rate and methodology for each
1039   federally qualified health center for the applicable year.
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1040  Section 8GGG. (a) For the purposes of this section, the terms “health care facility” and
1041   “health care provider” shall have the same meanings as defined in section 1 of chapter 111O.
1042  (b) Any contract between a subscriber and the corporation under an individual or group
1043   hospital service plan that is delivered, issued or renewed within the commonwealth shall not
1044   deny, limit or condition coverage for an otherwise covered health care service solely because the
1045   service is delivered by a health care provider participating in a mobile integrated health care
1046   program approved by the department of public health pursuant to chapter 111O. Health care
1047   services delivered through an approved mobile integrated health care program shall be covered
1048   to the same extent as if they were provided in a health care facility, and the rates of payment for
1049   an otherwise covered service shall not be reduced solely because the service was delivered
1050   through an approved mobile integrated health care program.
1051  (c) Coverage provided pursuant to this section may be subject to a deductible, copayment
1052   or coinsurance applicable to a health care service delivered through an approved mobile
1053   integrated health care program; provided, however, that the deductible, copayment or
1054   coinsurance shall not exceed the deductible, copayment or coinsurance applicable to the same
1055   service when provided in a health care facility.
1056  Section 8HHH. (a) As used in this section, the following words shall, unless the context
1057   clearly requires otherwise, have the following meanings:
1058  “Biomarker”, a molecular, genetic or biochemical characteristic, including gene
1059   mutations, characteristics of genes or protein expression, that is objectively measured and
1060   evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic
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1061   responses to a specific therapeutic intervention, including known gene-drug interactions for
1062   medications being considered for use or already being administered.
1063  “Biomarker testing”, the analysis of a patient’s tissue, blood or other biospecimen for the
1064   presence of a biomarker, including, but not limited to, single-analyte tests, multi-plex panel tests,
1065   protein expression and whole exome, whole genome and whole transcriptome sequencing
1066   performed at a laboratory facility that is either CLIA-certified or CLIA-waived by the federal
1067   food and drug administration; provided, however, that biomarker testing does not include testing
1068   for the purpose of screening in asymptomatic individuals
1069  “CLIA certified”, holding a certificate issued by the federal Centers for Medicare and
1070   Medicaid Services under the Clinical Laboratory Improvement Amendments of 1988 authorizing
1071   a laboratory to perform testing on human specimens.
1072  “CLIA waived”, holding a certificate of waiver issued under the Clinical Laboratory
1073   Improvement Amendments of 1988 authorizing a laboratory to perform only those tests
1074   categorized as waived by the federal Food and Drug Administration under 42 C.F.R. section
1075   493.15.
1076  “Clinical utility”, the test result provides information that is used in the formulation of a
1077   treatment or monitoring strategy that informs a patient’s outcome and impacts the clinical
1078   decision. Clinical utility shall be established by any of the following:
1079  (i) the labeled indications for a test approved or cleared by the federal Food and Drug
1080   Administration;
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1081  (ii) a test indicated in the FDA-approved labeling of a drug, including as a companion
1082   diagnostic;
1083  (iii) warnings and precautions in the FDA-approved labeling of a drug;
1084  (iv) a national coverage determination of the federal Centers for Medicare and Medicaid
1085   Services, or a local coverage determination issued by the Medicare Administrative Contractor; or
1086  (v) a nationally recognized clinical practice guideline.
1087  “Nationally recognized clinical practice guidelines”, evidence-based clinical practice
1088   guidelines developed by independent organizations or medical professional societies utilizing a
1089   transparent methodology and reporting structure and with a conflict of interest policy, including,
1090   but not limited to those of the National Comprehensive Cancer Network or the American Society
1091   of Clinical Oncology.
1092  (b) Any contract between a subscriber and the corporation under an individual or group
1093   hospital service plan that is delivered, issued or renewed within the commonwealth shall provide
1094   to any active or retired employee of the commonwealth who is insured under the group insurance
1095   commission coverage for biomarker testing, pursuant to criteria established under subsection (c);
1096   provided, that coverage shall be applied in a manner that limits disruptions in care including the
1097   need for multiple biopsies or biospecimen samples.
1098  (c) Biomarker testing shall be covered when the test: (i) is conducted at either a CLIA-
1099   certified or CLIA-waived laboratory and (ii) provides clinical utility to the enrollee, as
1100   demonstrated by medical and scientific evidence establishing that the result will be used to
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1101   select, initiate, exclude, or discontinue a specific therapy, or to determine appropriate dosing of a
1102   specific therapy.
1103  (d) In the case of coverage which requires prior authorization, a carrier or a utilization
1104   review organization subject to this section shall approve or deny a prior authorization request and
1105   notify the enrollee, the enrollee’s health care provider and any entity requesting authorization of
1106   the service within 5 business days. If additional delay would result in significant risk to the
1107   insured’s health or well-being, a carrier or a utilization review organization shall approve or deny
1108   the request within 48 hours. If a response by a carrier or utilization review organization is not
1109   received within the time required under this subsection, said request or appeal shall be deemed
1110   granted.
1111  (e) The patient and prescribing practitioner shall have access to a clear, readily
1112   accessible, and convenient processes to request an exception to a coverage policy or an adverse
1113   utilization review determination. The process shall be made readily accessible on the carrier’s
1114   website.
1115  SECTION 31. Chapter 176B of the General Laws is hereby amended by inserting after
1116   section 4EEE, inserted by section 82 of said chapter 137, the following 3 sections:-
1117  Section 4FFF. (a) As used in this section, the following words shall, unless the context
1118   clearly requires otherwise, have the following meanings:-
1119  “Federally qualified health center”, a community health center as defined in 101 C.M.R.
1120   304 for which the division of medical assistance has established a prospective payment system
1121   rate.
  53 of 83
1122  “Federally qualified health center services”, services provided by a federally qualified
1123   health center for which reimbursement is determined under the medical and behavioral health
1124   prospective payment system methodology applicable to federally qualified health centers
1125   pursuant to 101 C.M.R. 304.
1126  (b) A subscription certificate under an individual or group medical service agreement
1127   delivered, issued or renewed within the commonwealth shall ensure that the total reimbursement
1128   payable with respect to an encounter for federally qualified health center services covered by the
1129   subscription and provided to a patient by a federally qualified health center is not less than the
1130   applicable rate that the federally qualified health center would have received from MassHealth
1131   for the same encounter as of January 1 of the applicable calendar year, determined in accordance
1132   with the prospective payment system methodology established under 42 U.S.C. sections
1133   1396a(bb) and 1396b(m)(2)(A)(ix), as implemented by MassHealth and in effect on January 1,
1134   2025.
1135  (c) The division of insurance shall consult with the division of medical assistance for
1136   technical assistance regarding the prospective payment system rate and methodology for each
1137   federally qualified health center for the applicable year.
1138  Section 4GGG. (a) For the purposes of this section, the terms “health care facility” and
1139   “health care provider” shall have the same meanings as defined in section 1 of chapter 111O.
1140  (b) A subscription certificate under an individual or group medical service agreement
1141   delivered, issued or renewed within the commonwealth shall not deny, limit or condition
1142   coverage for an otherwise covered health care service solely because the service is delivered by a
1143   health care provider participating in a mobile integrated health care program approved by the
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1144   department of public health pursuant to chapter 111O. Health care services delivered through an
1145   approved mobile integrated health care program shall be covered to the same extent as if they
1146   were provided in a health care facility, and the rates of payment for an otherwise covered service
1147   shall not be reduced solely because the service was delivered through an approved mobile
1148   integrated health care program.
1149  (c) Coverage provided pursuant to this section may be subject to a deductible, copayment
1150   or coinsurance applicable to a health care service delivered through an approved mobile
1151   integrated health care program; provided, however, that the deductible, copayment or
1152   coinsurance shall not exceed the deductible, copayment or coinsurance applicable to the same
1153   service when provided in a health care facility.
1154  Section 4HHH. (a) As used in this section, the following words shall, unless the context
1155   clearly requires otherwise, have the following meanings:
1156  “Biomarker”, a molecular, genetic or biochemical characteristic, including gene
1157   mutations, characteristics of genes or protein expression, that is objectively measured and
1158   evaluated as an indicator of normal biological processes, pathogenic processes or pharmacologic
1159   responses to a specific therapeutic intervention, including known gene-drug interactions for
1160   medications being considered for use or already being administered.
1161  “Biomarker testing”, the analysis of a patient’s tissue, blood or other biospecimen for the
1162   presence of a biomarker, including, but not limited to, single-analyte tests, multi-plex panel tests,
1163   protein expression and whole exome, whole genome and whole transcriptome sequencing
1164   performed at a laboratory facility that is either CLIA-certified or CLIA-waived by the federal
  55 of 83
1165   food and drug administration; provided, however, that biomarker testing does not include testing
1166   for the purpose of screening in asymptomatic individuals
1167  “CLIA certified”, holding a certificate issued by the federal Centers for Medicare and
1168   Medicaid Services under the Clinical Laboratory Improvement Amendments of 1988 authorizing
1169   a laboratory to perform testing on human specimens.
1170  “CLIA waived”, holding a certificate of waiver issued under the Clinical Laboratory
1171   Improvement Amendments of 1988 authorizing a laboratory to perform only those tests
1172   categorized as waived by the federal Food and Drug Administration under 42 C.F.R. section
1173   493.15.
1174  “Clinical utility”, the test result provides information that is used in the formulation of a
1175   treatment or monitoring strategy that informs a patient’s outcome and impacts the clinical
1176   decision. Clinical utility shall be established by any of the following:
1177  (i) the labeled indications for a test approved or cleared by the federal Food and Drug
1178   Administration;
1179  (ii) a test indicated in the FDA-approved labeling of a drug, including as a companion
1180   diagnostic;
1181  (iii) warnings and precautions in the FDA-approved labeling of a drug;
1182  (iv) a national coverage determination of the federal Centers for Medicare and Medicaid
1183   Services, or a local coverage determination issued by the Medicare Administrative Contractor; or
1184  (v) a nationally recognized clinical practice guideline.
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1185  “Nationally recognized clinical practice guidelines”, evidence-based clinical practice
1186   guidelines developed by independent organizations or medical professional societies utilizing a
1187   transparent methodology and reporting structure and with a conflict of interest policy, including,
1188   but not limited to those of the National Comprehensive Cancer Network or the American Society
1189   of Clinical Oncology.
1190  (b) A subscription certificate under an individual or group medical service agreement
1191   delivered, issued or renewed within the commonwealth shall provide to any active or retired
1192   employee of the commonwealth who is insured under the group insurance commission coverage
1193   for biomarker testing, pursuant to criteria established under subsection (c); provided, that
1194   coverage shall be applied in a manner that limits disruptions in care including the need for
1195   multiple biopsies or biospecimen samples.
1196  (c) Biomarker testing shall be covered when the test: (i) is conducted at either a CLIA-
1197   certified or CLIA-waived laboratory and (ii) provides clinical utility to the enrollee, as
1198   demonstrated by medical and scientific evidence establishing that the result will be used to
1199   select, initiate, exclude, or discontinue a specific therapy, or to determine appropriate dosing of a
1200   specific therapy.
1201  (d) In the case of coverage which requires prior authorization, a carrier or a utilization
1202   review organization subject to this section shall approve or deny a prior authorization request and
1203   notify the enrollee, the enrollee’s health care provider and any entity requesting authorization of
1204   the service within 5 business days. If additional delay would result in significant risk to the
1205   insured’s health or well-being, a carrier or a utilization review organization shall approve or deny
1206   the request within 48 hours. If a response by a carrier or utilization review organization is not
  57 of 83
1207   received within the time required under this subsection, said request or appeal shall be deemed
1208   granted.
1209  (e) The patient and prescribing practitioner shall have access to a clear, readily
1210   accessible, and convenient processes to request an exception to a coverage policy or an adverse
1211   utilization review determination. The process shall be made readily accessible on the carrier’s
1212   website.
1213  SECTION 32. Chapter 176E of the General Laws is hereby amended by inserting after
1214   section 15A the following section:-
1215  Section 15B. (a) As used in this section, the following words shall, unless the context
1216   clearly requires otherwise, have the following meanings:-
1217  “Federally qualified health center”, a community health center as defined in 101 C.M.R.
1218   304 for which the division of medical assistance has established a prospective payment system
1219   rate.
1220  “Federally qualified health center services”, services provided by a federally qualified
1221   health center for which reimbursement is determined under the dental prospective payment
1222   system methodology applicable to federally qualified health centers pursuant to 101 C.M.R. 304.
1223  (b) A dental service corporation organized under this chapter shall ensure that the total
1224   reimbursement payable with respect to an encounter for federally qualified health center services
1225   covered by the dental service corporation and provided to a patient by a federally qualified health
1226   center is not less than the applicable rate that the federally qualified health center would have
1227   received from MassHealth for the same encounter as of January 1 of the applicable calendar
  58 of 83
1228   year, determined in accordance with the prospective payment system methodology established
1229   under 42 U.S.C. sections 1396a(bb) and 1396b(m)(2)(A)(ix), as implemented by MassHealth and
1230   in effect on January 1, 2025.
1231  (c) The division of insurance shall consult with the division of medical assistance for
1232   technical assistance regarding the prospective payment system rate and methodology for each
1233   federally qualified health center for the applicable year.
1234  SECTION 33. Chapter 176G of the General Laws is hereby amended by inserting after
1235   section 4WW, inserted by section 83 of chapter 137 of the acts of 2026, the 3 following
1236   sections:-
1237  Section 4XX. (a) As used in this section, the following words shall, unless the context
1238   clearly requires otherwise, have the following meanings:-
1239  “Federally qualified health center”, a community health center as defined in 101 C.M.R.
1240   304 for which the division of medical assistance has established a prospective payment system
1241   rate.
1242  “Federally qualified health center services”, services provided by a federally qualified
1243   health center for which reimbursement is determined under the medical and behavioral health
1244   prospective payment system methodology applicable to federally qualified health centers
1245   pursuant to 101 C.M.R. 304.
1246  (b) A health maintenance organization organized pursuant to this chapter shall ensure that
1247   the total reimbursement payable with respect to an encounter for federally qualified health center
1248   services covered by the health maintenance organization and provided to a patient by a federally
  59 of 83
1249   qualified health center is not less than the applicable rate that the federally qualified health center
1250   would have received from MassHealth for the same encounter as of January 1 of the applicable
1251   calendar year, determined in accordance with the prospective payment system methodology
1252   established under 42 U.S.C. sections 1396a(bb) and 1396b(m)(2)(A)(ix), as implemented by
1253   MassHealth and in effect on January 1, 2025.
1254  (c) The division of insurance shall consult with the division of medical assistance for
1255   technical assistance regarding the prospective payment system rate and methodology for each
1256   federally qualified health center for the applicable year.
1257  Section 4YY. (a) For the purposes of this section, the terms “health care facility” and
1258   “health care provider” shall have the same meanings as defined in section 1 of chapter 111O.
1259  (b) A health maintenance organization organized pursuant to this chapter shall not deny,
1260   limit or condition coverage for an otherwise covered health care service solely because the
1261   service is delivered by a health care provider participating in a mobile integrated health care
1262   program approved by the department of public health pursuant to chapter 111O. Health care
1263   services delivered through an approved mobile integrated health care program shall be covered
1264   to the same extent as if they were provided in a health care facility, and the rates of payment for
1265   an otherwise covered service shall not be reduced solely because the service was delivered
1266   through an approved mobile integrated health care program.
1267  (c) Coverage provided pursuant to this section may be subject to a deductible, copayment
1268   or coinsurance applicable to a health care service delivered through an approved mobile
1269   integrated health care program; provided, however, that the deductible, copayment or
  60 of 83
1270   coinsurance shall not exceed the deductible, copayment or coinsurance applicable to the same
1271   service when provided in a health care facility.
1272  Section 4ZZ. (a) As used in this section, the following words shall, unless the context
1273   clearly requires otherwise, have the following meanings:
1274  “Biomarker”, a molecular, genetic or biochemical characteristic, including gene
1275   mutations, characteristics of genes or protein expression, that is objectively measured and
1276   evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic
1277   responses to a specific therapeutic intervention, including known gene-drug interactions for
1278   medications being considered for use or already being administered.
1279  “Biomarker testing”, the analysis of a patient’s tissue, blood or other biospecimen for the
1280   presence of a biomarker, including, but not limited to, single-analyte tests, multi-plex panel tests,
1281   protein expression, and whole exome, whole genome, and whole transcriptome sequencing
1282   performed at a laboratory facility that is either CLIA-certified or CLIA-waived by the federal
1283   food and drug administration; provided, however, that biomarker testing does not include testing
1284   for the purpose of screening in asymptomatic individuals
1285  “CLIA certified”, holding a certificate issued by the federal Centers for Medicare and
1286   Medicaid Services under the Clinical Laboratory Improvement Amendments of 1988 authorizing
1287   a laboratory to perform testing on human specimens.
1288  “CLIA waived”, holding a certificate of waiver issued under the Clinical Laboratory
1289   Improvement Amendments of 1988 authorizing a laboratory to perform only those tests
1290   categorized as waived by the federal Food and Drug Administration under 42 C.F.R. section
1291   493.15.
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1292  “Clinical utility”, the test result provides information that is used in the formulation of a
1293   treatment or monitoring strategy that informs a patient’s outcome and impacts the clinical
1294   decision. Clinical utility shall be established by any of the following: (i) the labeled indications
1295   for a test approved or cleared by the federal Food and Drug Administration; (ii) a test indicated
1296   in the FDA-approved labeling of a drug, including as a companion diagnostic; (iii) warnings and
1297   precautions in the FDA-approved labeling of a drug; (iv) a national coverage determination of
1298   the federal Centers for Medicare and Medicaid Services, or a local coverage determination issued
1299   by the Medicare Administrative Contractor; or (v) a nationally recognized clinical practice
1300   guideline.
1301  “Nationally recognized clinical practice guidelines”, evidence-based clinical practice
1302   guidelines developed by independent organizations or medical professional societies utilizing a
1303   transparent methodology and reporting structure and with a conflict of interest policy, including,
1304   but not limited to those of the National Comprehensive Cancer Network or the American Society
1305   of Clinical Oncology.
1306  (b) A health maintenance organization organized pursuant to this chapter shall provide to
1307   any active or retired employee of the commonwealth who is insured under the group insurance
1308   commission coverage for biomarker testing, pursuant to criteria established under subsection (c);
1309   provided, that coverage shall be applied in a manner that limits disruptions in care including the
1310   need for multiple biopsies or biospecimen samples.
1311  (c) Biomarker testing shall be covered when the test: (i) is conducted at either a CLIA-
1312   certified or CLIA-waived laboratory; and (ii) provides clinical utility to the enrollee, as
1313   demonstrated by medical and scientific evidence establishing that the result will be used to
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1314   select, initiate, exclude or discontinue a specific therapy, or to determine appropriate dosing of a
1315   specific therapy.
1316  (d) In the case of coverage that requires prior authorization, a carrier or a utilization
1317   review organization subject to this section shall approve or deny a prior authorization request and
1318   notify the enrollee, the enrollee’s health care provider and any entity requesting authorization of
1319   the service within 5 business days. If additional delay would result in significant risk to the
1320   insured’s health or well-being, a carrier or a utilization review organization shall approve or deny
1321   the request within 48 hours. If a response by a carrier or utilization review organization is not
1322   received within the time required under this subsection, said request or appeal shall be deemed
1323   granted.
1324  (e) The patient and prescribing practitioner shall have access to a clear, readily accessible
1325   and convenient processes to request an exception to a coverage policy or an adverse utilization
1326   review determination. The process shall be made readily accessible on the carrier’s website.
1327  SECTION 33A. Section 1 of chapter 176J of the General Laws, as appearing in the 2024
1328   Official Edition, is hereby amended by inserting after the definition of “Health benefit plan” the
1329   following definition:-
1330  “Health screening benefits”, a fixed dollar amount payable to an insured, without regard
1331   to the amount of any expenses incurred and without regard to benefits payable under any other
1332   coverage, upon proof that a test or diagnostic procedure, including a laboratory or radiological
1333   service, was performed in connection with a routine physical examination or preventive care
1334   visit.
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1335  SECTION 33B. Said section 1 of said chapter 176J, as so appearing, is hereby further
1336   amended by inserting after the word “plans”, in line 206, the second time it appears, the
1337   following words:- ; provided, however, that accident only, hospital indemnity insurance policies,
1338   disability income insurance and specified disease insurance may also offer health screening
1339   benefits.
1340  SECTION 33C. Section 1 of chapter 176M of the General Laws, as so appearing, is
1341   hereby amended by inserting after the definition of “Health plan” the following definition:-
1342  “Health screening benefits”, a fixed dollar amount payable to an insured, without regard
1343   to the amount of any expenses incurred and without regard to benefits payable under any other
1344   coverage, upon proof that a test or diagnostic procedure, including a laboratory or radiological
1345   service, was performed in connection with a routine physical examination or preventive care
1346   visit.
1347  SECTION 33D. Said section 1 of said chapter 176M, as so appearing, is hereby further
1348   amended by inserting after the figure “176K”, in line 218, the following words:- ; provided,
1349   however, that accident only, hospital indemnity insurance policies, disability income insurance
1350   and specified disease may also offer health screening benefits.
1351  SECTION 33E. Section 1 of chapter 176N of the General Laws, as so appearing, is
1352   hereby amended by inserting after the definition of “Health plan” the following definition:-
1353  “Health screening benefits”, a fixed dollar amount payable to an insured, without regard
1354   to the amount of any expenses incurred and without regard to benefits payable under any other
1355   coverage, upon proof that a test or diagnostic procedure, including a laboratory or radiological
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1356   service, was performed in connection with a routine physical examination or preventive care
1357   visit.
1358  SECTION 33F. Said section 1 of said chapter 176N, as so appearing, is hereby further
1359   amended by inserting after the figure “176K”, in line 42, the following words:- ; provided,
1360   however, that accident only, hospital indemnity insurance policies, disability income insurance
1361   and specified disease insurance may also offer health screening benefits.
1362  SECTION 34. Chapter 176O of the General Laws is hereby amended by inserting after
1363   section 12B the following section:-
1364  Section 12C. (a) As used in this section, the following words shall, unless the context
1365   clearly requires otherwise, have the following meanings:
1366  “Artificial intelligence”, an engineered or machine-based system that varies in its level of
1367   autonomy and that can, for a given set of human-defined explicit or implicit objectives, make
1368   predictions, recommendations or decisions influencing real or virtual environments.
1369  “Automated utilization review tool”, artificial intelligence, an algorithm or other software
1370   tool used to conduct, or to generate information relied upon in, utilization review based in whole
1371   or in part on medical necessity.
1372  (b) This section shall apply to a carrier or utilization review organization that uses an
1373   automated utilization review tool, or that contracts with or otherwise acts through an entity that
1374   uses an automated utilization review tool in connection with a prospective, concurrent or
1375   retrospective review of a request for a covered benefit. A carrier shall remain responsible for
1376   compliance with this section by any entity acting on its behalf.
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1377  (c) An automated utilization review tool shall base its output on the enrollee’s medical
1378   and other relevant clinical information, the individual clinical circumstances presented by the
1379   requesting provider and other relevant clinical information contained in the enrollee’s medical or
1380   other clinical record, and shall not base its output solely on a group dataset. An automated
1381   utilization review tool shall comply with all applicable provisions of this chapter and applicable
1382   state and federal law.
1383  (d) An automated utilization review tool shall not be the sole basis for an adverse
1384   determination, and shall not supplant the decision-making of a health care provider. An adverse
1385   determination shall be made only by a licensed physician or other licensed health care
1386   professional, who shall review the requesting provider’s recommendation, the enrollee’s medical
1387   or other clinical history and the enrollee’s individual clinical circumstances.
1388  (e) A carrier or utilization review organization that uses an automated utilization review
1389   tool shall: (i) disclose the use of such tool, in plain language, on its public website and to each
1390   health care provider in the carrier’s network; and (ii) state in each written notice of an adverse
1391   determination whether a utilization review tool was used in connection with the determination
1392   and describe the role the tool played.
1393  (f) A carrier or utilization review organization shall periodically evaluate the
1394   performance, use and outcomes of an automated utilization review tool and modify or
1395   discontinue use as necessary to improve accuracy and reliability. A carrier or utilization review
1396   organization shall use enrollee data only for purposes consistent with applicable state and federal
1397   privacy laws, and shall not use patient data beyond the data’s intended and stated purpose,
1398   consistent with the federal Health Insurance Portability and Accountability Act of 1996.
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1399  (g) A carrier or utilization review organization shall, upon request, make available to the
1400   division for audit or compliance review the criteria and guidelines applied by an automated
1401   utilization review tool, a description of the categories of data used to develop and train the tool,
1402   the tool’s intended use and the outcomes of its use, and shall retain records sufficient to permit
1403   such review for not less than 6 years. Information provided to the division under this subsection
1404   that constitutes a trade secret or proprietary information shall not be a public record as defined in
1405   clause Twenty-sixth of section 7 of chapter 4 or section 10 of chapter 66.
1406  (h) An automated utilization review tool shall not be designed or used in a manner that
1407   discriminates, directly or indirectly, against an enrollee in violation of state or federal law, and
1408   shall be fairly and equitably applied, including in accordance with any applicable regulations and
1409   guidance issued by the United States Department of Health and Human Services.
1410  (i) A carrier shall report annually to the division, in a form prescribed by the
1411   commissioner, the number of requests for coverage reviewed with the assistance of an automated
1412   utilization review tool, the number and percentage of adverse determinations issued in
1413   connection with such review and the number and percentage of such adverse determinations
1414   reversed on internal grievance or external review.
1415  (j) A violation of this section shall constitute an unfair method of competition or an unfair
1416   or deceptive act or practice in the business of insurance under section 3 of chapter 176D. If the
1417   commissioner determines that a carrier or utilization review organization is not in compliance
1418   with this section, the commissioner shall notify it of the violation and impose a corrective action
1419   plan. A carrier or utilization review organization that fails to come into compliance within the
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1420   period established by the commissioner shall be subject to a fine of not more than $5,000 for
1421   each day the violation continues.
1422  (k) The commissioner shall promulgate regulations to implement this section.
1423  SECTION 35. Said chapter 176O is hereby further amended by adding the following 2
1424   sections:-
1425  Section 31. (a) As used in this section, “primary care expenditures” and “provider
1426   organization” shall have the same meanings as in section 1 of chapter 6D.
1427  (b) There shall be an advanced primary care payment program administered by the
1428   commissioner. The commissioner shall: (i) approve 1 or more standard advanced primary care
1429   payment models developed pursuant to subsection (c); (ii) establish, in consultation with the
1430   primary care payment collaborative established in subsection (c), minimum standards and
1431   requirements for qualifying advanced primary care payment models; (iii) approve any alternative
1432   advanced primary care payment model submitted by a carrier that meets the minimum standards
1433   and requirements established pursuant to clause (ii); and (iv) monitor and evaluate the
1434   implementation of the program.
1435  (c) (1) There shall be a primary care payment collaborative to advise the commissioner in
1436   the development and administration of the advanced primary care payment program established
1437   under this section. The collaborative shall develop 1 or more standard advanced primary care
1438   payment models for approval by the commissioner and shall advise the commissioner regarding
1439   minimum standards and requirements for qualifying advanced primary care payment models,
1440   best practices in primary care payment reform and the implementation and evaluation of the
1441   program.
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1442  (2) The collaborative shall consist of the executive director of the health policy
1443   commission or their designee; the executive director of the center for health information and
1444   analysis, or their designee; and members appointed by the commissioner representing carriers,
1445   primary care providers, provider organizations, employers, consumer organizations, health
1446   equity organizations and such other entities as the commissioner deems appropriate.
1447  (d) A qualifying advanced primary care payment model shall be designed to support
1448   value-based, patient-centered primary care and shall include, at a minimum:
1449  (i) capitation paid on a prospective, per-member per-month basis for primary care
1450   services furnished to members attributed to a participating provider;
1451  (ii) a methodology for attributing members to a participating provider, which shall take
1452   into account a member’s established primary care relationship and utilization over a period of not
1453   less than 24 months;
1454  (iii) a risk adjustment for the clinical and social acuity and complexity of a participating
1455   provider’s attributed member population and accounting for differences between adult and
1456   pediatric primary care;
1457  (iv) the incentive payment required by subsection (f);
1458  (v) support for chronic disease management and preventive care;
1459  (vi) integration of behavioral health services within the primary care setting;
1460  (vii) medication management and care coordination activities;
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1461  (viii) expanded access to primary care services, including same-day or urgent
1462   appointments and after-hours access;
1463  (ix) timely provision by the carrier to the participating provider of data necessary to
1464   manage the care of attributed members;
1465  (x) standards governing the exchange of data between a participating provider and carrier
1466   for purposes of the carrier’s reporting obligations under subsection (i), including the form and
1467   frequency of such exchange; and
1468  (xi) such additional elements as the commissioner considers necessary to advance high-
1469   quality, coordinated and cost-effective primary care.
1470  (e) To reduce unnecessary administrative burden on participating providers, the
1471   commissioner shall, to the maximum extent practicable, require consistency and alignment
1472   among qualifying advanced primary care payment models with respect to reporting
1473   requirements, quality measures, data submission standards, administrative forms and processes,
1474   and any other common administrative function. Nothing in this section shall be construed to
1475   require uniformity in the amount of any base per-member per-month payment, incentive
1476   payment, risk adjustment methodology or other payment design feature.
1477  (f) A qualifying advanced primary care payment model shall provide for an incentive
1478   payment, in addition to the base per-member per-month payment, to a participating provider that
1479   demonstrates meaningful improvement in or performance exceeding a standard established by
1480   the commissioner with respect to: (i) the time within which an established patient may obtain an
1481   appointment with the provider; (ii) the time within which a new patient may obtain an
1482   appointment with the provider; (iii) the growth in members attributed to the provider under the
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1483   model; (iv) any growth in serving patient populations and communities with identified shortages
1484   in primary care accessibility; and (v) such measures of clinical quality and patient experience as
1485   the commissioner shall establish; provided, that the commissioner shall select such measures
1486   applicable to primary care from the standard quality measure set established under section 14 of
1487   chapter 12C.
1488  (g) A qualifying advanced primary care payment model shall provide that a participating
1489   provider receiving only the base per-member per-month payment shall receive, for its attributed
1490   members, aggregate reimbursement for primary care services not less than the amount the
1491   provider would have received for such services under the carrier’s applicable fee-for-service
1492   payment methodology.
1493  (h) Each carrier shall adopt not less than 1 qualifying advanced primary care payment
1494   model approved by the commissioner and shall offer such model to each primary care provider
1495   and provider organization with which it contracts. A carrier may satisfy this subsection by
1496   adopting a standard advanced primary care payment model approved under clause (ii) of
1497   subsection (b) or by submitting an alternative model for approval under clause (iii) of said
1498   subsection (b). Participation shall be at the election of the primary care provider or provider
1499   organization.
1500  (i) Annually, each carrier shall submit to the commissioner, in a form and manner
1501   prescribed by the commissioner: (i) an attestation demonstrating compliance with this section;
1502   (ii) the number of primary care providers and provider organizations that have elected to
1503   participate in the model and the number that have declined; (iii) information regarding
1504   implementation of its approved model and its required elements; (iv) data necessary to evaluate
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1505   quality, utilization, member outcomes, primary care expenditures and other performance
1506   measures identified by the commissioner, including performance on the measures described in
1507   subsection (f) and the incentive payments earned under the model, which the carrier shall obtain
1508   from participating providers pursuant to its contracts with them; and (v) any additional
1509   information the commissioner determines necessary to monitor implementation and evaluate the
1510   effectiveness of the program.
1511  (j) The commissioner may promulgate regulations pursuant to chapter 30A, issue
1512   bulletins and guidance and establish reporting requirements as necessary to implement,
1513   administer and enforce this section, including establishing reporting requirements, attestation
1514   forms and corrective action processes, and may suspend or withdraw approval of an advanced
1515   primary care payment model that no longer meets the minimum standards and requirements
1516   established pursuant to this section.
1517  (k) A carrier shall make its approved advanced primary care payment model available to
1518   the sponsor of a self-insured health benefit plan it administers. If such a sponsor elects in writing
1519   to adopt the model, the carrier shall administer it on the same terms as apply to the health benefit
1520   plans the carrier issues. Nothing in this subsection shall require a sponsor of a self-insured health
1521   benefit plan to adopt such a model.
1522  Section 32. (a) As used in this section, the following words shall, unless the context
1523   clearly requires otherwise, have the following meanings:
1524  “Affiliated entity”, as defined in section 1 of chapter 176Y.
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1525  “Base price concession”, a price concession provided by a pharmaceutical manufacturer
1526   that is tied to formulary placement or utilization of a prescription drug and that is not contingent
1527   on price protection, inflation or the achievement of specified performance criteria
1528  “Cost-sharing”, as defined in section 1 of chapter 176Y.
1529  “Estimated rebate”, any: (i) negotiated price concessions, whether described as a rebate
1530   or otherwise, including, but not limited to, base price concessions, and reasonable estimates of
1531   any price protection rebates and performance-based price concessions that may accrue, directly
1532   or indirectly, to a carrier, pharmacy benefit manager, affiliated entity or other party on a carrier’s
1533   behalf during a carrier’s plan year from a pharmaceutical manufacturing company, dispensing
1534   pharmacy or other party to the transaction based on the amounts the carrier received in the prior
1535   quarter or reasonably expects to receive in the current quarter; and (ii) reasonable estimates of
1536   any price concessions, fees and other administrative costs that are passed through, or are
1537   reasonably anticipated to be passed through to the carrier, pharmacy benefit manager, affiliated
1538   entity or other party on the carrier’s behalf and that serve to reduce the carrier’s prescription drug
1539   liabilities for the plan year based on the amounts the carrier received in the prior quarter or
1540   reasonably expects to receive in the current quarter.
1541  “Performance-based price concession”, a price concession, or portion thereof, that is
1542   contingent on achieving specified performance criteria, including but not limited, to clinical
1543   outcomes, specified utilization thresholds or market-share targets; provided, however, that a
1544   price concession, or portion thereof, shall not be considered a performance-based price
1545   concession to the extent it is based on a prescription drug’s formulary placement, tier status or
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1546   continued formulary coverage, or on utilization of such drug that is not subject to a specified
1547   utilization threshold.
1548  “Pharmacy benefit manager”, as defined in section 1 of chapter 176Y.
1549  “Price protection rebate”, a negotiated price concession that accrues directly or indirectly
1550   to the carrier, or other party on behalf of the carrier, including a pharmacy benefit manager or
1551   affiliated entity, in the event of an increase in the wholesale acquisition cost of a drug that is
1552   greater than a specified threshold.
1553  “Third-party administrator”, as defined in section 1 of chapter 176Y.
1554  (b) A carrier, pharmacy benefit manager or affiliated entity shall make available to an
1555   insured not less than 80 per cent of the estimated rebates received by or reasonably expected to
1556   be received by such carrier, or any pharmacy benefit manager or affiliated entity, by reducing the
1557   amount of defined cost-sharing that the carrier would otherwise charge at the point of sale,
1558   except that the reduction amount shall not result in a credit at the point of sale. Neither the
1559   insured nor the carrier shall be responsible for any difference between the estimated rebate
1560   amount and the actual rebate amount the carrier receives; provided, that such estimates were
1561   calculated in good faith.
1562  (c) Nothing in this section shall preclude a pharmacy benefit manager or affiliated entity
1563   from decreasing an insured’s defined cost-sharing by an amount equal to or greater than that
1564   required under subsection (b).
1565  (d) Annually, not later than April 1, a carrier shall file with the division a report in the
1566   manner and form determined by the commissioner demonstrating the manner in which the carrier
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1567   has complied with this section. If the commissioner determines that a carrier has not complied
1568   with this section, the commissioner shall notify the carrier of such noncompliance and a date by
1569   which the carrier must demonstrate compliance. If the carrier does not come into compliance by
1570   such date, the division shall impose a fine not to exceed $5,000 for each day during which such
1571   noncompliance continues.
1572  (e) In implementing the requirements of this section, the division shall only regulate a
1573   carrier or pharmacy benefit manager or affiliated entity to the extent permissible under
1574   applicable federal law.
1575  (f) A pharmacy benefit manager, affiliated entity or any third-party administrator shall
1576   not publish or otherwise disclose information regarding the actual amount of rebates a carrier
1577   receives on a specific product or therapeutic class of products, or on a manufacturer or
1578   pharmacy-specific basis. Such information shall be considered to be a trade secret and
1579   confidential commercial information, shall not be a public record as defined by clause Twenty-
1580   sixth of section 7 of chapter 4 or section 10 of chapter 66 and shall not be disclosed directly or
1581   indirectly, or in a manner that would allow for the identification of an individual product,
1582   therapeutic class of products or manufacturer, or in a manner that would have the potential to
1583   compromise the financial, competitive or proprietary nature of the information. A pharmacy
1584   benefit manager or affiliated entity shall impose the confidentiality protections and requirements
1585   of this section on any agent or third-party administrator that performs health care or
1586   administrative services on behalf of the pharmacy benefit manager that may receive or have
1587   access to rebate related information.
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1588  SECTION 36. Section 1 of chapter 176Y of the General Laws, as appearing in the 2024
1589   Official Edition, is hereby amended by inserting before the definition of “Carrier” the following
1590   definition:-
1591  “Affiliated entity”, an entity that directly or indirectly owns, is owned by, is under
1592   common ownership with, is vertically integrated with, has an investment interest in or is
1593   otherwise affiliated with a pharmacy benefit manager and that has a material financial interest in,
1594   or exercises operational control over, 1 or more stages of the prescription drug supply chain
1595   including, but not limited to, pharmacy services, claims adjudication, rebate administration,
1596   third-party administrator services, data aggregation or prescription drug reimbursement;
1597   provided, however, that “affiliated entity” shall not include a pharmaceutical manufacturing
1598   company, or an entity providing patient support or copayment assistance services on behalf of
1599   such a company, unless the company or entity directly or indirectly owns, is owned by, or is
1600   under common ownership with a pharmacy benefit manager.
1601  SECTION 37. Said section 1 of said chapter 176Y, as so appearing, is hereby further
1602   amended by inserting after the definition of “Commissioner” the following definition:-
1603  “Cost-sharing”, any copayment, coinsurance, deductible or any other amount owed by an
1604   insured under the terms of the insured’s health benefit plan, or as required by a pharmacy benefit
1605   manager or affiliated entity.
1606  SECTION 38. Said section 1 of said chapter 176Y, as so appearing, is hereby further
1607   amended by inserting after the definition of “Pharmacy benefit manager” the following
1608   definition:-
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1609  “Third-party administrator”, any person that directly or indirectly solicits or effects
1610   coverage of, underwrites, collects charges or premiums from, arranges alternative access to or
1611   funding for prescription drugs, or adjusts or settles claims on behalf of residents of the
1612   commonwealth or residents of another state from offices in this commonwealth, in connection
1613   with health insurance coverage.
1614  SECTION 39. Said chapter 176Y is hereby further amended by adding the following
1615   section:-
1616  Section 5. (a) When calculating an insured’s contribution to any applicable cost-sharing
1617   requirement, a carrier shall include any cost-sharing amounts paid by the insured or on behalf of
1618   the insured by another person. If under federal law application of this requirement would result
1619   in health savings account ineligibility under section 223 of the federal Internal Revenue Code,
1620   this requirement shall apply for health savings account-qualified high deductible health plans
1621   with respect to the deductible of such a plan after the insured has satisfied the minimum
1622   deductible under section 223 of the federal Internal Revenue Code, except for with respect to
1623   items or services that are preventive care pursuant to section 223(c)(2)(C) of the federal Internal
1624   Revenue Code, in which case the requirements of this paragraph shall apply regardless of
1625   whether the minimum deductible under section 223 has been satisfied.
1626  (b) A carrier, pharmacy benefit manager, affiliated entity or third-party administrator
1627   shall not directly or indirectly set, alter, implement or condition the terms of health benefit plan
1628   coverage, including the benefit design, based in whole or in part on information about the
1629   availability or amount of financial or product assistance available for a prescription drug.
1630  (c) The division shall promulgate regulations as necessary to implement this section.
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1631  SECTION 39A. Section 75 of chapter 260 of the acts of 2020 is hereby amended by
1632   striking out the figure “2027”, inserted by section 31 of chapter 248 of the acts of 2024, and
1633   inserting in place thereof the following figure:- 2029.
1634  SECTION 40. Notwithstanding any general or special law to the contrary, the
1635   comptroller, at the direction of the secretary of administration and finance, shall transfer
1636   $25,000,000 from the Commonwealth Federal Matching and Debt Reduction Fund established in
1637   section 2EEEEEE of chapter 29 of the General Laws, inserted by section 2 of chapter 214 of the
1638   acts of 2024, to the Health Care Workforce Transformation Fund established in section 2FFFF of
1639   chapter 29 of the General Laws.
1640  SECTION 40A. The office for health resource planning shall conduct a focused
1641   assessment of pharmacy deserts required under section 22A of chapter 6D, inserted by section
1642   22A, and submit its first report to the health policy commission by not later than September 1,
1643   2027.
1644  SECTION 40B. Section 26A shall go into effect on October 1, 2027.
1645  SECTION 41. The center for health information and analysis shall promulgate
1646   regulations pursuant to section 15A of chapter 12C of the General Laws, inserted by section 15,
1647   not later than January 1, 2027.
1648  SECTION 42. The health policy commission shall promulgate regulations pursuant to
1649   subsection (e) of section 9A of chapter 6D of the General Laws, inserted by section 6, and
1650   subsection (g) of section 10A of said chapter 6D, inserted by section 10, not later than April 1,
1651   2027.
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1652  SECTION 43. The center for health information and analysis shall promulgate
1653   regulations pursuant to subsection (g) of section 18A of said chapter 12C, inserted by section 18,
1654   not later than July 1, 2027.
1655  SECTION 44. Section 17BB of chapter 32A of the General Laws, inserted by section 22;
1656   section 47EEE of chapter 175, inserted by section 29; section 8FFF of chapter 176A of the
1657   General Laws, inserted by section 30; section 4FFF of chapter 176B of the General Laws,
1658   inserted by section 31; section 15B of chapter 176E of the General Laws, inserted by section 32;
1659   and section 4XX of chapter 176G of the General Laws, inserted by section 33, shall apply to
1660   health benefit plans delivered, issued for delivery or renewed on or after January 1, 2027.
1661  SECTION 45. Section 17CC of chapter 32A of the General Laws, inserted by section 22;
1662   section 10BB of chapter 118E of the General Laws, inserted by section 27; section 47FFF of
1663   chapter 175 of the General Laws, inserted by section 29; section 8GGG of chapter 176A of the
1664   General Laws, inserted by section 30; section 4GGG of chapter 176B of the General Laws,
1665   inserted by section 31; and section 4YY of chapter 176G of the General Laws, inserted by
1666   section 33, shall apply to health benefit plans delivered, issued for delivery or renewed on or
1667   after January 1, 2027.
1668  SECTION 46. Section 5 of chapter 176Y of the General Laws, inserted by section 39,
1669   shall apply to health benefit plans delivered, issued for delivery or renewed on or after January 1,
1670   2028.
1671  SECTION 47. Every carrier, as defined in section 1 of chapter 176O of the General
1672   Laws, shall offer at least 1 qualifying advanced primary care payment model approved pursuant
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1673   to section 31 of said chapter 176O, inserted by section 35, to each contracting primary care
1674   provider or provider organization by not later than January 1, 2028.
1675  SECTION 48. Section 32 of chapter 176O of the General Laws, inserted by section 35,
1676   and section 36 of chapter 32A of the General Laws, inserted by section 23, shall apply to health
1677   benefit plans delivered, issued for delivery or renewed on or after January 1, 2029.
1678  SECTION 49. Section 34 of this act shall take effect on January 1, 2027.
1679  SECTION 50. Section 4C of chapter 260 of the General Laws, as appearing in the 2022
1680   Official Edition, is hereby amended by striking out the first paragraph and inserting in place
1681   thereof the following paragraph:-
1682  Civil actions alleging a defendant sexually abused a minor may be commenced at any
1683   time after the acts alleged to have caused an injury or condition occurred.
1684  SECTION 51. Said chapter 260 is hereby amended by striking out section 4C 1/2 and
1685   inserting in place thereof the following section:-
1686  Section 4C½. Civil actions alleging that a defendant negligently supervised a person who
1687   sexually abused a minor or that a defendant’s conduct caused or contributed to the sexual abuse
1688   of a minor by another person may be commenced at any time after the acts alleged to have
1689   caused an injury or condition occurred. For the purposes of this section, “sexual abuse” shall
1690   have the same meaning as in section 4C.
1691  SECTION 52. Said chapter 260 is hereby further amended by inserting after section 4C ½
1692   the following section:
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1693  Section 4C ¾. Notwithstanding any provision of law which imposes a period of
1694   limitations to the contrary and the provisions of any other law pertaining to the filing of a notice
1695   of claim or a notice of intention to file a claim as a condition precedent to commencement of an
1696   action or special proceeding, every civil claim or cause of action brought against a party alleging
1697   sexual abuse of a minor, as that term is defined in section 4C, or negligent supervision
1698   contributing to the sexual abuse of a minor under section 4C ½, or a predecessor statute that
1699   prohibited such conduct at the time of the act, which is barred as of the effective date of this
1700   section because the applicable period of limitations has expired or the plaintiff previously failed
1701   to file a notice of claim or a notice of intention to file a claim, is hereby revived, and action
1702   thereon may be commenced no later than 2 years after the effective date of this section. In any
1703   such claim or action, dismissal of a previous action, ordered before the effective date of this
1704   section, on grounds that such previous claim was time barred or for failure of a party to file a
1705   notice of claim or a notice of intention to file a claim, shall not be grounds for dismissal of a
1706   revival action pursuant to this section.
1707  Notwithstanding any provision of law which limits the liability or damages for any
1708   organization or employer or their officers, directors, trustees, employees or volunteers, every
1709   civil claim or cause of action brought against a party alleging sexual abuse of a minor, as that
1710   term is defined in section 4C, or negligent supervision contributing to the sexual abuse of a
1711   minor under section 4C ½, or a predecessor statute that prohibited such conduct at the time of the
1712   act, which was subject to limits on liability or damages at the time of the act, shall not be subject
1713   to any limitations for revived actions brought pursuant to this section.
1714  SECTION 53. Section 5B of said chapter 260 is hereby amended by striking out, in lines
1715   5 and 6, inclusive, the words “three years next after the cause of action accrues” and inserting in
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1716   place thereof the following words:- 3 years next after the cause of action accrues; provided,
1717   however, that an action commenced under 20 U.S.C. §§1681-1688 for sexual abuse of a minor,
1718   as that term is defined in section 4C, or negligent supervision contributing to the sexual abuse of
1719   a minor under section 4C ½, shall be governed by the provisions of sections 4C and 4C½.
1720  SECTION 54. Section 85K of chapter 231 of the General Laws, as so appearing, is
1721   hereby amended by inserting, in line 12, after the word “costs” the following words:- provided,
1722   however, that claims of sexual abuse of a minor, as that term is defined in section 4C of chapter
1723   260, and claims of negligent supervision contributing to the sexual abuse of a minor under
1724   section 4C ½ of chapter 260, shall not be subject to a limitation on damages.
1725  SECTION 55. Section 85V of said chapter 231 is hereby amended by inserting after
1726   clause (iii) the following clause:-
1727  (iv) claims of sexual abuse of a minor as the term is defined in section 4C of chapter 260
1728   and claims of negligent supervision contributing to the sexual abuse of a minor under section 4C
1729   ½ of chapter 260.
1730  SECTION 56. Section 85W of said chapter 231 is hereby amended by inserting, in line
1731   11, after the word “person” the following language:-
1732  ; provided further, however, that the immunity conferred in this section shall not apply to
1733   claims related to child sexual abuse, as defined in section 4C of chapter 260, and claims of
1734   negligent supervision contributing to the sexual abuse of a minor under section 4C ½ of chapter
1735   260.
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1736  SECTION 57. Section 2 of chapter 258 of the General Laws, as so appearing, is hereby
1737   amended by inserting, in line 12, after the word “damages” the following words:- provided
1738   further, however, that claims of sexual abuse of a minor, as that term is defined in section 4C of
1739   chapter 260, and claims of negligent supervision contributing to the sexual abuse of a minor
1740   under section 4C ½ of chapter 260, shall not be subject to a limitation on damages.
1741  SECTION 58. Subsection (j) of section 10 of said chapter 258 is hereby amended by
1742   inserting after paragraph (4) the following paragraph:- (5) any claim by or on behalf of a person
1743   who alleges they were sexually abused as a minor, as that term is defined in section 4C of
1744   chapter 260 and claims of negligent supervision contributing to the sexual abuse of a minor
1745   under section 4C ½ of chapter 260.
1746  SECTION 59. Section 63 of chapter 277 of the General Laws, as so appearing, is hereby
1747   amended by inserting, in line 13, as amended by sections 9 and 10 of chapter 277 of the acts of
1748   2024, after the word “sections” the following number:- 13H,.
1749  SECTION 60. Said section 63 of said chapter 277 is hereby further amended by inserting,
1750   in line 27, as amended by sections 9 and 10 of chapter 277 of the Acts of 2024, after the number
1751   “23,” the following number:- 24,.
1752  ; and by striking out the title and inserting in place thereof the following title: “An Act
1753   strengthening primary care and advancing health care affordability”.
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