MPA Advocates for REAL Health Plan Transparency
Wednesday, May 21, 2014
Posted by: Jonathan Brush
May 21, 2014
The Honorable Stephen Brewer
Chair, Senate Committee on Ways and Means
State House, Room 212
Boston, MA 02133
Re: Senate Fiscal Year 2015 Budget Amendment #764
Dear Chairman Brewer:
As organizations representing consumers, healthcare providers, and other healthcare
stakeholders, we are writing to oppose Amendment #764 to the Senate FY2015 state budget.
One of the major goals of Chapter 224 of the Acts of 2012 was to increase transparency within the
health care system and provide avenues for consumers to be informed about and engage in health
care decision-making. Specifically, several sections of Chapter 224 require health insurance carriers
and utilization review organizations to make utilization review criteria and other protocols available
to health plan members, providers and the public.
However, Senate budget amendment #764 seeks to restrict access to the criteria and protocols that
health plans use to make decisions about patient care. And, the amendment goes even further to
create a new exemption under the Public Records Law for utilization review criteria, thus further
obstructing health care transparency. This is in stark contrast to the goals of Chapter 224 and the
Commonwealth’s ongoing efforts to transition to a more transparent health care system.
Ensuring consumers and providers have broad access to utilization review and medical necessity
information is essential to achieving the goal of increased transparency under GL c. 6D, § 16 and c.
176O, §§ 12 and 16. Access to adequate information is a prerequisite to protecting patient rights –
unless a health plan member and provider can obtain and review a copy of utilization review policies
and procedures, it is impossible to determine whether those policies and procedures are being
applied in a way that complies with state and federal laws.
Furthermore, the disclosure requirements under current state law are critical to ensuring that health
plan members and providers are fully informed about health insurance benefits when planning care.
Patients and their providers should have a right to know what decision-making criteria are being
used to determine whether or not a service is considered medically necessary.
In addition, federal law supports advancing transparency of utilization review criteria and Senate
budget amendment #764 may be preempted by plans’ requirements under federal law. The final rule
implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity
Act (MHPAEA), issued November 13, 2013, requires transparency and disclosure of medical
necessity criteria upon request to any “current or potential participant, beneficiary, or contracting
provider upon request.” 78 FR at 68283. This heightened disclosure for behavioral health care
makes clear that federal law allows for access to medical necessity criteria by individual patients,
providers and the broader public upon request. This is largely consistent with federal guidance under
the Employee Retirement Income Security Act concerning the availability of health plan information
for those with employer-sponsored plans. See 29 CFR 2560.503-1(g)(v) (A) and (j)(5)(i); 65 FR at
By promoting transparency, patients and providers will be better informed about how
recommended care will be covered and will be better able to plan a course of treatment
together. Thank you for your consideration of this important issue. Please do not hesitate to
contact us with any questions. We look forward to continuing to work with the Massachusetts
Senate to increase transparency and consumer engagement in health care.
Association for Behavioral Healthcare
Health Care For All
Health Law Advocates
Mass. Association of Behavioral Health Systems, Inc.
Massachusetts Hospital Association
Massachusetts Medical Society
Massachusetts Psychological Association
Mental Health Legal Advisors Committee
National Association of Social Workers - MA Chapter
cc: Members of the Senate