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MPA Testifies in Support of Allowing Clinicians to Determine Medical Necessity

Thursday, September 7, 2017   (0 Comments)
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MPA Testifies in Support of Allowing Clinicians to Determine Medical Necessity


The Joint Committee on Children, Families and Persons with Disabilities heard testimony on H.1070 and S.1093, An Act to further define the medical necessity determinations on June 5, 2017.  Current law allows health plans to restrict approvals and create their own narrow definitions of medical necessity criteria.  As a result, health plans can refuse to cover any treatment, or cover only a reduced form of treatment, which is different from what the patient and clinician believe is necessary.  This medical necessity criteria, which may have no basis in clinical research or standards for care, creates an unnecessary barrier to Massachusetts citizens accessing behavioral health care.

An Act to further define the medical necessity determinations resolves this issue by placing treatment decisions where they belong- with the trained and licensed behavioral health providers.  In July 2014, the Massachusetts Legislature enacted Chapter 258 of the Acts of 2014, which provided that for substance abuse acute treatment and clinical stabilization services, medical necessity criteria would be determined by the treating clinician, in consultation with the patient.  H. 1070 and S. 1093 would extend that practice standard to all mental health services, thereby increasing access to care and reducing unnecessary delays in treatment while awaiting health plan authorization.

MPA’s Executive Director, Mr. Brian Doherty, provided oral testimony to the committee in support of the bill, where he highlighted an MPA member’s experience with a health plan using it’s medical necessity criteria to discourage necessary treatment.  He emphasized that if this bill were to pass, such barriers to treatment based on a health plan’s particular medical necessity criteria would be prevented.  State House News Service reported on the medical necessity bill hearing, and it’s article was published by other news entities, including the Lowell Sun.  Click here to read Mr. Doherty’s complete official testimony on behalf of MPA.

The next step in the process is that MPA will advocate in meetings with legislative committee members and staff that the committee recommend the bill favorably to advance it to the next level of the process.  Members who live in the districts represented by Committee Chairs Sen. Jennifer Flanagan (D) of the Worcester and Middlesex District (representing part of Northern Central Massachusetts) and Rep. Denise Garlick (D) of the 13th Norfolk District (representing part of Northern Suffolk County) are encouraged to communicate their support for this bill directly to their legislator.  Not sure who represents you? Find your legislators.

For members that do not live in one of these districts but who want to support our efforts on this vital legislation, keep your eyes out for updates.  If and when the bill is advanced to another committee or brought to the full House or Senate for a vote, we’ll send out notifications with suggestions for how you can help.

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