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MPA Advocates for REAL Health Plan Transparency

Wednesday, May 21, 2014   (0 Comments)
Posted by: Jonathan Brush
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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 

NAMI Massachusetts 

National Association of Social Workers - MA Chapter 



cc: Members of the Senate

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