Massachusetts Health Care Affordability: A Closer Look

As of 2021, 51% of Massachusetts adults experienced some form of a healthcare affordability burden according to the Healthcare Value Hub’s CHESS survey. In addition, Massachusetts continues to have some of the highest healthcare spending per person out of all states, at $9,876 per person in 2021.¹

In the 2022 Healthcare Affordability State Policy Scorecard, Massachusetts scored only 61.9 out of 80 possible points, equivalent to a C+ letter grade. While Massachusetts has enacted many policies intended to contain healthcare costs, their outcomes continue to lag, especially in reducing low-value care and making out-of-pocket costs affordable. Ultimately, the execution and effectiveness of the state’s policies need significant improvement, alongside new interventions that will address the state’s unique healthcare landscape. Overall, Massachusetts has much work to do to improve healthcare affordability for its residents. This memo is intended to capture and critique Massachusetts’ current healthcare affordability policies and outcomes, with specific recommendations for how to improve execution.

Curb Excess Prices

Commercial healthcare spending growth in Massachusetts is primarily driven by increases in prices paid per service, not by utilization. Internal analyses showed that price increases accounted for more than half of overall commercial spending growth in Massachusetts from 2015 to 2018.² External analysis by the Health Care Cost institute found that commercial healthcare prices grew 15.6% from 2014 to 2018, accounting for two-thirds of total spending growth, compared to only a 7% increase in utilization.³

Notably, price growth was highest in hospital inpatient settings (9.1% increase from 2016 to 2018), followed by hospital outpatient services (6.6% increase) and office-based services (4.4% increase) (see Figure 1).⁴ Looking further at hospital inpatient prices, Massachusetts’ inpatient private payer prices were 200% of Medicare prices, on average, for a basket of the top 25 most frequent private inpatient Diagnostic Related Groups (DRGs), placing them in the upper middle range of all states (ranked 28 out of 48 states, plus D.C.).⁵

While is it debated whether Medicare prices are too low or too high for different services, high and growing private prices remain a significant driver of cost increases over time. Further analysis of revenues and costs of specific hospitals using the National Academy for State Health Policy (NASHP) Hospital Cost Tool shows that almost all Massachusetts hospitals receive prices paid by commercial payers that exceed the payment level required to cover their maximum expenses with no profit (i.e. commercial breakeven) (see Figure 1).⁶

The Massachusetts Health Policy Commission has also noted that some spending increases can be attributed to shifts away from lower-priced care settings (community hospitals, community high payer public hospitals and teaching hospitals) to higher-priced care settings (academic medical centers and specialty hospitals).⁷ Hospital upcoding also contributes to higher spending, with hospitals coding admissions at increasingly higher severity levels, which correspond to higher spending regardless of the type of care ultimately administered. Finally, increases in the average price per person have increased across inpatient, outpatient and professional services as well as prescription drugs since 2016, although it is worth noting that inpatient prices per person remain the highest by a substantial amount (see Figure 2).⁸

Figure 1. Hospital Commercial Breakeven Point to Private Payer Prices Charged for Select Massachusetts Hospitals

Source: Health Policy Commission, Meeting of the HPC’s Advisory Council (March 30, 2022)

Figure 2. Percent Change in Average Price per Person per Service from 2016 to 2020 in Massachusetts (Average Price in 2020)

Source: Hargraves, John, Biniek, Jean Fugelstein, and Jason Fehr, 2018 Health Care Cost and Utilization Report, State Spending Trends, Health Care Cost Institute, (Accessed on Oct. 31, 2022). https://healthcostinstitute.org/interactive/2018-healthcare-cost-and-utilization-report

Health Spending Oversight Entity and All-Payer Spending Benchmarks

Massachusetts’ Health Policy Commission (HPC) is a permanent health spending oversight entity— established in 2012—that targets all spending, using All-Payer Claims Database (APCD) data to review market transactions and to monitor healthcare cost growth. They conduct regulatory reviews of proposed mergers, acquisitions and affiliations and have the ability to recommend approval, denial or terms of agreement. They also conduct Annual Health Care Cost Trends Reports, examining state trends in healthcare spending and delivery to inform the next year’s statewide target for growth in Total Health Care Expenditures (THCE).

The HPC can then require individual health plans, hospitals and medical groups charging above the THCE benchmark to submit Performance Improvement Plans (PIP) and is authorized to levy penalties of up to $500,000 for noncompliance with PIPs.⁹ In February 2022, the Commission issued its first ever PIP request in its ten years of operation, requiring the Mass General Brigham health system to submit a PIP.^10,11,12 In September 2022, the HPC approved Mass General Brigham’s revised PIP, which cut around $128 million in annual costs, a nearly $60 million increase from their original plan submitted in May 2022. Spending reductions will be achieved primarily through price reductions accounting for a majority $90 million in spending cuts, including cutting outpatient rates charged to insurers and converting pricing at one facility to a community hospital rate schedule, as well as reducing utilization and moving care to lower-cost settings.¹³

In the field of prescription medications, the state can directly negotiate supplemental rebate agreements with manufacturers for MassHealth Medicaid, and the HPC can review manufacturer prices to determine whether they are unreasonably or excessively high.14 This process has reportedly saved the state’s Medicaid program $171 million since 2019.15 In 2021, Governor Baker’s office issued a fiscal 2022 budget proposal that would have penalized drug manufacturers who increase prices above the consumer price index plus 2 percent each year, but it did not pass.^16,17

Despite HPC advancements, total health care expenditures increased above the benchmark in 2018 and 2019. This may be due, in part, to providers becoming dismissive of the benchmarks, particularly in the wake of COVID-19 and the increased administrative and financial burdens it placed on some hospitals, as well as continued consolidation, despite the HPC’s regulatory efforts. Specifically, the HPC rejected Partners HealthCare’s proposed acquisition of community hospitals, and Partners then captured the same assets through other avenues and began investing in costly developments. In response, multiple Boston hospitals and health plans merged, furthering consolidating across Eastern Massachusetts and ostensibly driving up prices to fund revenues for expansions.¹⁸ In response to the shifting healthcare and hospital landscape, the HPC has affirmed its interest in new approaches to curbing healthcare spending and improving affordability, notably strengthening accountability for the cost growth benchmarks and increasing penalties for hospitals that are consistently over the benchmark.^19,20

Recommendations:

Improve PIP and Increase Penalties: Improve the Performance Improvement Process (PIP) by allowing the Center for Health Information and Analysis (CHIA) to (1) use stronger metrics beyond primary care spending alone to identify entities driving spending and (2) increase financial penalties for above benchmark spending or non-compliance, so that it will be impactful for hospitals of different sizes. Potential metric improvements include adding all-patient spending beyond primary care, hospitals and other provider types beyond primary care groups and robust medical coding analysis (see Massachusetts Health Policy Commission’s 2021 Cost Trends Report).²¹ Massachusetts might consider using the NASHP Hospital Cost Tool²² as a component of these stronger metrics by using the commercial breakeven point for hospitals with high spending as a reference point for setting new spending goals for individual hospitals or health systems during the PIP.

Constrain Excessive Provider Prices: Implement limits on excess prices by establishing price caps for the highest-priced providers, limiting facility fees, increasing monitoring of provider expansions and ambulatory care and adopting default out-of-network payment rates (see Massachusetts Health Policy Commission’s 2021 Cost Trends Report).

Investigate Medical Coding Changes and Improve Patient Risk Adjustment: The HPC encourages Massachusetts to further investigate high-intensity medical coding and take action to mitigate this practice, such as aligning payments with actual resource use rather than diagnosis exclusively and implementing mechanisms to offset coding-related spending impacts (see Massachusetts Health Policy Commission’s 2021 Cost Trends Report). Given that increased coding appears to be a deliberate, acknowledged strategy among some Massachusetts hospitals,²³ Massachusetts should carefully consider whether penalties or incentives will be more effective in addressing this issue.

Authorize the HPC to Prohibit or Penalize Private Insurer Excess Prices for Prescription Drugs: While Massachusetts’ Medicaid negotiation authority has accrued savings for the state, it has not directly addressed high prescription drug prices driving spending in the commercial market, which is critical to addressing affordability for residents who rely on private insurance. Since a negotiation model cannot be applied to private markets where the state is not a buyer, authorizing the HPC to prohibit or penalize payment for excess prescription drug prices among all payers could be a viable alternative. This approach could potentially serve to reduce hospital medication prices as well.

Lessons from Colorado:

While Colorado’s Prescription Drug Affordability Board is still in development (beginning April 2022), their Upper Payment Limit model²⁴ presents an opportunity to address prescription drug prices for commercial plans. The law achieves this by referring to all purchases of and payer reimbursements for drugs dispensed or administered to individuals in Colorado.²⁵ Massachusetts should watch the Colorado PDAB progress closely to assess how they establish their payment limits, any lawsuits they may face related to employer-sponsored insurance and whether the program yields the intended reductions in prescription drug payments and spending.

All-Payer Claims Database

Massachusetts’ All-Payer Claims Database (APCD) is comprised of medical, pharmacy and dental claims, as well as information about member eligibility, providers and insurance coverage.²⁶ Massachusetts also offers an Acute Hospital Case Mix Database for detailed inpatient, outpatient and emergency department data, cost reports for hospitals and other health providers such as nursing facilities, statewide payment/ expenditure data and insurance cost/coverage data. Information on the share of the state’s population captured in the APCD was not readily available.

However, Massachusetts has reported that around 75% of self-insured enrollees in the state, including enrollees in non-ERISA self-funded plans, were missing from the APCD as of 2017 after the Gobeille v. Liberty Mutual Supreme Court decision (previously 2.3 million self-insured beneficiaries before 2016 to 563,000 beneficiaries in 2018, with a 27% drop in medical claims volume). Post-Gobeille, the percent difference between the Massachusetts APCD and U.S. Census estimates was 24%.27,28 The Center for Health Information and Analysis (CHIA) is “actively working with payers and employers to maintain as much self insured data as possible.”²⁹

Recommendations:

Encourage Voluntary Data Submission from Employers/Self-Insured Plans: To further support CHIA’s efforts to encourage private employers and purchasing coalitions to submit self-insured data, Massachusetts might consider disseminating opt-in forms, educating employer groups on the value of participation and offering specific resources targeted toward employers.³⁰

Lessons from Colorado:

Colorado’s APCD offers pre-made reports for employers, including a “Cost Driver Analysis” report to determine which services are driving highest healthcare cost among employees, and design benefits that incentivize employees to use high-quality, low-cost facilities, as well as a report on “Medicare Reference-Based Pricing” to help negotiate lower rates with providers.³¹

Price Transparency Tool

Massachusetts’ Compare Care³² tool shows negotiated prices paid by insurers and consumers for nearly 300 unique procedures by provider. There are ten service categories, including colonoscopy/endoscopy, maternity and others. The tool consistently directs consumers to contact their individual insurance plan for personalized quotes. However, some procedures have limited data that reduce the tool’s usefulness. For example, the vaginal delivery childbirth page includes only professional fees, not hospital fees, which are often a substantial cost associated with childbirth.

Recommendations:

Provide Both Negotiated and Chargemaster Rates: Providing only the negotiated rates can be a disadvantage for the small number of Massachusetts residents without insurance, who are often responsible for paying the chargemaster rate. Therefore, including both the chargemaster rate and the negotiated rate would be helpful for the uninsured.

Display More Robust Data for Select Services: For pages where information is limited, such as the childbirth page, CompareCare might consider either displaying more robust data on procedures that accompany medical events like childbirth or providing sample itemized bills. This may further assist consumers trying to understand or estimate their costs, especially those who cannot get estimates from their insurer in advance or those trying to negotiate a fair price after they have received a bill. The state might start by estimating hospital fees in addition to the professional fees already captured and publishing them through the tool.

Reduce Low-Value Care

Low-value care is defined as patient care that does not provide a net health benefit in clinical scenarios. Low value care includes care that is clinically inappropriate for particular clinical cases, services that provide little to no clinical benefit and are against patient preferences, services that are done out of habit rather than scientific evidence and services that actively harm patients.³³

A groundbreaking 2019 study conducted by the Institute of Medicine and Berwick and Hackbarth found that approximately one-quarter of healthcare spending is wasted, or roughly 25% of healthcare spending does not result in better health. Researchers estimated that one category of healthcare waste—overtreatment and low-value care—drives $75.7 billion to $101.2 billion in health expenditures each year. The estimated annual savings from the implementation of measures to eliminate overtreatment/low-value care ranges from $12.8 billion to $28.6 billion. Failure to curtail this “waste” raises premiums and causes patients to endure unnecessary cost-sharing for services, inconvenience and, occasionally, medical harm.³⁴

Measure Low-Value Care in Claims and Electronic Health Records Data

In 2018, the Massachusetts Health Policy Commission released a report looking at 19 low- or no-value tests, imaging services and procedures. The report found that one in five people covered by three major health insurers received low-value service from 2013-2015, with costs totaling $80 million, including more than $12 million paid out-of-pocket by patients.^35,36

Recommendations:

Replicate Analysis with Larger Sample, More Low-Value Care Services and Recent Data: The HPC might replicate their study using a larger sample covering more low-value care services and using more recent data. To determine the list of low-value care services to evaluate, consider drawing from the Choosing Wisely Campaign Clinician List³⁷ or services evaluated in other state studies below.

Lessons from Other States:

Washington State: 36% of spending on the healthcare services examined went to low value treatments and procedures, totaling an estimated $282 million in wasteful spending.³⁸

Oregon: The top 15 most utilized services accounted for 97% of all low-value services identified, affecting 2.9 million people, with $293,561,410 spent.³⁹

Virginia: Found that 1,573,514 individuals received a low-value care service across a variety of service types with a total proxy cost of $706,504,304.⁴⁰

Recommendations, cont.:

Enact a Multi-Stakeholder Campaign to Reduce Low-Value Care: According to the Massachusetts HPC, “payers, providers, and purchasers should convene to develop strategies, incentives, and action steps to eliminate low-value care. Employers can also play a role in assisting employees and their families in accessing information useful in making high-value treatment decisions.”⁴¹ The HPC might draw on strategies implemented by Atrius Health, a network of primary and specialty care providers, such as continuous education for physicians and other clinicians about low-value care, decision-support tools built into electronic medical records⁴² and drawing on research about effective communication with physicians drawn from the Choosing Wisely campaign.⁴³

Lessons from Virginia:

After identifying low-value care services in a 2014 report, the nonprofit Virginia Center for Health Innovation (VCHI) received a $2.2 million grant from Arnold Ventures to create a statewide pilot, Smarter Care Virginia, aimed at reducing the provision of seven key low-value care services by creating a large-scale health system learning community and employer task force, as well as developing a set of consumer-driven low-value care measures.⁴⁴

Require Validated Patient Safety Reporting in Hospitals

One critical aspect of reducing spending on low-value care is reducing care that harms patients. Recent research found that nearly 62,000 incidents of medical error in inpatient facilities produced over $617 million in excess costs in a single year in Massachusetts.⁴⁵ Hospital/Healthcare-Acquired Infections (HAIs) are a prominent type of medical error, which include Central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). Nationwide, research shows that CLABSI and CAUTI are estimated to cost hospitals roughly $48,100 and $13,800 per case, respectively.⁴⁶ The costs of medical harm can also impact consumers, particularly if a medical error requires a patient to seek additional care to repair damage caused by the error.^47,48

In 2010, the Massachusetts Department of Public Health developed a comprehensive statewide plan to address HAIs.⁴⁹ Within that framework, Massachusetts mandated patient safety reporting and validation for CLABSIs and CAUTIs in acute care hospitals as of 2019 in an effort to reduce the prevalence of these costly incidents.⁵⁰ However, recent data showed that Massachusetts did not complete validation of CLABSIs or CAUTIs in acute care hospitals (ACH) in 2020, possibly as a result of strain on health systems during the COVID-19 pandemic.⁵¹ States are designated as performing validation if they performed regular data cleaning or quality checks on at least 6 months of 2020 data prior to June 1, 2021 and contacted hospitals if data errors, outliers or missing information were found. States that perform more vigorous data validation activities are more likely to find hospital records of infections, and therefore these states may have higher SIRs compared to states that do not perform validation.⁵²

Between 2019 and 2020, Massachusetts acute care hospitals reported an increase in CLABSIs, and 10% of the 49 ACHs with sufficient data have rates higher than the national infection ratio. While there was no notable change in CAUTIs, 17% of the 53 ACHs with sufficient data still had higher rates than the national infection ratio.^53,54 In addition to patient safety reporting, Massachusetts has also established the Betsy Lehman Center for Patient Safety⁵⁵ (launched 2004) and the Massachusetts Healthcare Safety and Quality Consortium⁵⁶ (launched in 2019), which are dedicated to improving patient safety reporting compliance, working with providers to implement patient safety programs and identifying policy strategies to incentivize best practices.

Recommendations:

Establish State-Based Patient Safety Authority: Massachusetts might consider establishing a state-based Patient Safety Authority modeled after the Pennsylvania Patient Safety Authority (PSA). The Pennsylvania PSA is an independent, non-regulatory entity that takes in information gathered by Department of Health and organizes liaisons to work directly with care providers to facilitate improvements in patient safety.

Establish State-Based Patient Safety Authority: Massachusetts might consider establishing a state-based Patient Safety Authority modeled after the Pennsylvania Patient Safety Authority (PSA). The Pennsylvania PSA is an independent, non-regulatory entity that takes in information gathered by Department of Health and organizes liaisons to work directly with care providers to facilitate improvements in patient safety.

Hospital Antibiotic Stewardship

Overuse of antibiotics contributes to the problem of healthcare-associated infections (HAIs), a form of medical harm, by encouraging antibiotic resistant organisms to thrive, thereby making HAIs more difficult to treat, limiting treatment options and potentially prolonging a patient’s length of stay in a healthcare facility. In turn, the CDC estimates that antibiotic resistant infections result in $20-35 billion in excess direct healthcare costs.⁵⁷

Ninety-nine percent of Massachusetts hospitals had adopted the CDC’s Core Elements of Antibiotic Stewardship—a set of key principles to guide providers’ efforts to improve antibiotic use and advance patient safety and improve outcomes—in 2019, but the share decreased to 93% in 2020. It is possible that some of this decrease may have come about due to the COVID-19 pandemic and the strain it put on the healthcare system. Among outpatient pharmacies, Massachusetts reported an all-antibiotic prescription rate of 696 prescriptions per 1,000 population in 2019 and 548 out of 1,000 in 2020. This places them in the middle 50% of states, suggesting that there are further stewardship opportunities for providers, facilities and other partners interested in improving how antibiotics are used.^58,59

Recommendations:

Increase Hospital Adoption of CDC Antibiotic Stewardship: Encourage universal adoption of the CDC’s 7 Core Elements by working with remaining hospitals to complete the Antibiotic Stewardship Program Assessment Tool. Identify senior hospital leaders to champion efforts and secure resources, particularly the chief medical officer, chief nursing officer and director of pharmacy.⁶⁰

Target Providers Outside of Hospitals: Consider promoting the CDC Antibiotic Stewardship model to additional providers beyond hospitals, such as nursing homes (which have their own CDC Antibiotic Stewardship model), retail health and urgent care settings, community clinic physicians, community pharmacists and public health clinics. This promotion may require modified campaigns based on the unique organizational structure and decision-makers of the target provider.

Extend Coverage to All Residents

Massachusetts has the lowest overall uninsurance rate of any state—roughly 3.0% to 3.6%, depending on the source.^61,62 However, state rates of uninsurance are higher among people of color and non-citizens. Black and Hispanic residents had uninsurance rates over 5%⁶³ and foreign-born non-citizens had an uninsurance rate of 8.6%, far higher than native-born and naturalized citizens (see Figure 3).⁶⁴ The uninsured population remains at risk for experiencing restricted access to crucial healthcare services and uncompensated care costs when using emergency services.

Figure 3. Massachusetts Uninsurance Rate by Race/Ethnicity, Citizenship Status, 2021

Sources: Kaiser Family Foundation, Uninsured Rates for the Nonelderly by Race/Ethnicity, Washington, D.C. (Accessed Nov. 1, 2022) and United States Census Bureau, B27020 Health Insurance Coverage Status and Type by Citizenship Status. 2021, 1-year estimate.

Roughly 15% of all uninsured Massachusetts residents are ineligible for Medicaid or ACA Marketplace health coverage due to their citizenship (see Figure 4).⁶⁵ An additional 18% of uninsured residents are ineligible for ACA Marketplace coverage due to an offer of ‘affordable’ employer coverage, and 9% are ineligible because the Marketplace calculates that, based on their income, they have access to an ‘affordable’ Marketplace plan without subsidies (the federal government defines ‘affordable’ as a plan with premiums costing up to 8.5% of household income). These data suggest that these employer or ACA Marketplace plans are, in reality, unaffordable or undesirable for this population.

In addition, over half of uninsured Massachusetts residents are eligible for subsidized coverage but remain uninsured. Roughly 29% are Medicaid-eligible and another 29% are tax credit eligible (including American Rescue Plan Subsidies), totaling roughly 114,000 residents as of 2021. While coverage may, in theory, be extended to this population, barriers remain that may have prevented them from getting coverage, including difficulty enrolling, healthcare plans being too expensive despite subsidies, lack of insurance carriers in rural areas and churn in and out of the program.

While a large share of Massachusetts’ total uninsured population is middle-income and white, economic and racial and ethnic disparities persist in the state. Slightly less than half of Massachusetts’ remaining uninsured population is white (48.4%),⁶⁶ but Hispanic and Black residents continue to face higher rates of uninsurance (5.1% and 5.3%, respectively) compared to white residents (2.0%) (see Figure 3). Low-income households earning less than 200% of the Federal Poverty Level (FPL) make up just 37% of the state’s uninsured population (see Figure 5)⁶⁷ but face higher rates of uninsurance (6.5%) compared to middle-income households making 200–399% FPL (5.2%) and high-income households making 400% FPL or more (1.9%) (see Figure 6).⁶⁸

Figure 4. Distribution of Eligibility for ACA Health Coverage Among the Remaining Uninsured, 2021

Sources: Kaiser Family Foundation, Distribution of Eligibility for ACA Health Coverage Among the Remaining Uninsured, Washington, D.C. (Accessed Nov. 1, 2022).

Figure 5. Distribution of Uninsured by Federal Poverty Level, 2021

Source: Kaiser Family Foundation, Distribution of the Nonelderly Uninsured by Federal Poverty Level (FPL), Washington, D.C. (Accessed on Nov. 29, 2022).

Figure 4. Massachusetts Uninsured Rate by Federal Poverty Level, 2021

Sources: Kaiser Family Foundation, Uninsured Rates for the Nonelderly by Federal Poverty Level (FPL), Washington, D.C. (Accessed Nov. 1, 2022).

Medicaid Expansion

Massachusetts adopted the ACA Medicaid expansion to cover low-income adults with incomes under 138% FPL in 2014. To reduce state budgets, Governor Baker and the Massachusetts Department of Health and Human Services (DHHS) advocated for moving people earning 100-138% FPL off of MassHealth Medicaid and onto ConnectorCare marketplace plans with subsidies in 2017. Governor Baker also proposed prohibiting people from enrolling in MassHealth if they had access to employer-sponsored insurance plans with premiums less than 5% of their income, but neither of these proposals moved forward. Instead, the state increased Employer Medical Assistance Contributions and started charging employers an additional assessment if employees received benefits through MassHealth or ConnectorCare.⁶⁹

While Medicaid expansion has certainly benefited Massachusetts residents, there are still those struggling to maintain their coverage. Notably, Massachusetts appears to have issues with churn (the process of enrollees repeatedly losing and regaining Medicaid coverage), which can disrupt care, resulting in unnecessary administrative costs for states and delays in care for beneficiaries, which may increase health costs in the long run.⁷⁰ It can also indirectly make Medicaid expansion less effective at providing stable coverage if low-income beneficiaries are churning in and out of the program and delaying or foregoing care during coverage disruptions. According to a 2021 MACPAC study, 12% of Massachusetts enrollees disenrolled and re-enrolled within 12 months (i.e., churn) in the Medicaid program, among the highest of the states studied.⁷¹ Notably, Massachusetts has not enacted 12-month continuous eligibility for children’s Medicaid and CHIP, which may contribute to churn.⁷² While the state has taken some steps to streamline eligibility determination, such as redetermining eligibility using electronic data matches before requiring enrollees to complete a renewal form, more improvements can be made.⁷³

Recommendations:

Maintain Medicaid Eligibility for Residents Under 138% FPL: Massachusetts should consider continuing to allow residents under 138% FPL to remain on Medicaid, rather than switching them to ConnectorCare. The default Medicaid expansion structure has many affordability benefits, such as protecting patients from the high cost-sharing and enrollment barriers of marketplace plans, such as complex cost-sharing structures and confusion about plan selection. In addition, residents face a shortage of affordable dental care within ConnectorCare compared to Medicaid.

Enact 12-month Continuous Medicaid Eligibility: Massachusetts should consider enacting continuous Medicaid eligibility for children through a state plan amendment and for adults through a 1115 waiver.⁷⁴ Although adopting continuous eligibility does come with increased costs from additional coverage months and initial implementation, reductions in healthcare costs over time and administrative savings can help offset these costs.⁷⁵ See this resource from Georgetown Center for Children and Families (CCF) for a comprehensive guide to improving Medicaid retention.

Expand Enrollment Assistance and Simplify Renewal Process: Massachusetts can consider a variety of strategies to keep Medicaid-eligible people from losing their coverage, including: policies that streamline enrollment (relying on client statements for certain eligibility factors; sending both paper AND digital renewal forms if electronic verification fails, rather than only paper mail;⁷⁶ post-enrollment verification; expanded presumptive eligibility) and improved communication strategies (through text or email outreach; updating enrollee contact information with data from Medicaid providers; giving enrollees 30 days to verify their new address).⁷⁷ These improvements require investments in health insurance navigator staffing, capacity and training. See this resource from Georgetown Center for Children and Families (CCF) for a comprehensive guide to improving Medicaid retention.

Additional Coverage for People Above the Medicaid Eligibility Threshold

The Massachusetts Health ConnectorCare Program provides additional state subsidies to individuals earning up to 300% FPL. Enrollees have access to zero- or low-dollar premium plans, zero-or low-dollar copays and do not have deductibles or coinsurance. In 2018, Massachusetts published a study assessing the feasibility of allowing small employers to share premiums with or “buy into” MassHealth Medicaid.⁷⁸ Public option legislation was introduced in 2019 and 2021 but all bills thus far have died in committee.⁷⁹

Recommendations:

Offer a Public Option Plan: To reach the remaining uninsured population and ensure access to affordable coverage, Massachusetts might consider exploring a publicly funded health insurance plan. A ‘public option’ policy may allow states more freedom to pursue tailored subsidies and payment rate limits for commercial plans available to residents ineligible for Medicaid, especially if the state allows employers to offer public insurance instead of private plans. Massachusetts might even consider building on its existing Employer Medical Assistance Contributions infrastructure to allow residents with an offer of employer-sponsored coverage to instead choose the state public plan option if it is more affordable for them, while off-setting the costs with the additional assessment fees levied on employers. As a first step, Massachusetts could fund a study on how such a program could be created, including assessing how different program structures would affect the number of residents served, gathering input from employer stakeholders and estimating affordability for those earning above the Medicaid eligibility threshold.⁸⁰

Lessons from Other States:

Lessons from Washington: Washington’s Cascade Care is a hybrid public-private plan whereby the state contracts with private insurers to provide the plans, rather than creating a state-run insurance company. While this method saves on costs, it limits the state’s control over plans. Legislation originally capped provider reimbursement at 100% of Medicare rates in an effort to keep premiums lower than other private coverage options, but pushback from industry stakeholders on rate setting caused legislators to increase the cap to 160%.⁸¹

Thus far, Washington public option plans are not as affordable as expected and have struggled with network adequacy. Cascade Care Bronze plan premiums are 2% more expensive than the lowest non-standard Bronze plan on the marketplace in plan year 2022, though many carriers report that the public option plan is their lowest priced plan in several counties. Although Cascade Care plans were more likely to be offered in counties where the marketplace was larger and more competitive, plan premiums were lower in smaller, less competitive counties.^82,83 In addition, public option plans were available in only 25 of Washington’s 39 counties, due, in part, to hospitals refusing to participate in public option plan networks. Washington has since passed legislation requiring hospitals in large healthcare systems to participate in at least one public option plan.⁸⁴

Lessons from Colorado: In 2021, Colorado passed legislation to establish a public option plan available for purchase on the marketplace by 2023 for individuals and small businesses with less than 100 employees. Similar to Washington, Colorado will contract with private issuers to provide public option plans, requiring it in counties where the issuers offer marketplace plans. Notably, the public option premiums offered must be 15% lower by 2025 than they were in 2021 for the same carrier and county. Colorado has also submitted a Section 1332 waiver to get federal passthrough funding. Colorado’s legislation also includes several health equity components, such as efforts to improve perinatal healthcare coverage and pre-deductible high-value services. Moreover, plans must offer a culturally responsive network of providers that reflects the diverse nature of its enrollees in an effort to address health equity and reduce health disparities.⁸⁵

Lessons from Nevada: In 2021, Nevada passed legislation to establish a public option plan available for purchase on the marketplace in 2026.86 While the full details of the program are still in development, notably, the “bidder” model will require that any insurers who bid on Managed Care Organization contracts and public employee insurance contracts are required to make a good faith bid on the public option plans. The state will also prioritize bids from plans that integrate reducing health disparities into their proposals.⁸⁷

Coverage for Immigrants

Massachusetts offers Medicaid coverage to lawfully residing immigrant pregnant women and children without a 5-year wait, and provides some services not covered through Emergency Medicaid for income-eligible pregnant or postpartum women who would otherwise be ineligible due to immigration status. Massachusetts also provides some coverage for undocumented children through the Children’s Medical Security Plan, but it is restricted to primary and preventive care and excludes behavioral health for those with disabilities, among other crucial services. Massachusetts does not offer any coverage options for undocumented adults, who make up over 77% of the state’s unauthorized population.⁸⁸

Recommendations:

Consider Expanding Coverage for Undocumented Children: Expanding coverage for undocumented children beyond basic primary/preventive care and including behavioral health services would drastically improve the policy’s effectiveness. This could be achieved in several ways, including: (1) expanding the Children’s Medical Security plan to include more comprehensive services such as behavioral health, pharmacy benefits, outpatient surgical services and treatment of chronic conditions; (2) allowing undocumented children to access MassHealth Medicaid/CHIP coverage; and/or (3) expanding MassHealth CommonHealth for people with disabilities to cover undocumented immigrant children.

Offer Coverage Options for Undocumented Adults: Offering comprehensive coverage options for undocumented adults will help Massachusetts achieve 100% insurance coverage among its residents. Because undocumented adults are not eligible for Medicaid and are not allowed to purchase plans on the exchange, Massachusetts would need to pursue strategies to provide affordable, off-exchange coverage for undocumented adults. See Table 1 for examples from other states.

Table 1. State Coverage Options for Undocumented Adults

Source: Authors analysis of state coverage options for undocumented adult residents (2021)

Rate Review

Rate review is the process by which insurance regulators review health carriers’ proposed insurance premiums to ensure they are based on accurate, verifiable data and realistic projections of healthcare costs and utilization. Using a rigorous, multidimensional review process with input from the public and consumer advocates has been shown to lower rates for consumers.

Massachusetts is an ‘active purchaser,’ which means that the state-run exchange sets criteria for participating health plans, negotiates with insurers and ultimately decides which health plans will be sold through the exchange.¹⁰¹ This has traditionally kept premiums on the exchange lower than those in other states.¹⁰² However, over the past few years, Massachusetts’s exchange premiums have increased relative to national trends, though they remain below the national average. For example, in 2018 Massachusetts’s average benchmark premium was $316 compared to $481 nationwide, and in 2022 Massachusetts’s average benchmark premium is $389 compared to $438 nationwide.¹⁰³

The Department of Insurance (DOI) conducts premium rate review for their merged market, which includes all plans sold to individuals and all small group plans sold to businesses with fewer than 50 employees,¹⁰⁴ both on and off the exchange. The merged market review has clear statutory and regulatory standards, including Medical Loss Ratio, administrative expenses and other factors. The DOI can require issuers to provide a detailed description of the basis on which they reimburse different rates to similarly situated providers and require them describe efforts to reduce such variation.

The DOI can also request descriptions of cost containment programs the carrier will use to address healthcare delivery costs, and the savings gained from such cost containment programs. If the DOI does decide to reject a rate increase, the process requires hearings on the rejected rate before the rates become effective.¹⁰⁵ The DOI also conducts a separate, less comprehensive rate review of all HMO plans and Blue Cross Blue Shield plans, which make up most of the employer-sponsored plans in the large group market. The DOI can disapprove these commercial plan rates, but they generally do not take that course of action, focusing instead on rate changes in the small group market to ensure they are comparable to the large group market and to identify discriminatory behavior.¹⁰⁶

Finally, Massachusetts’s Health Policy Commission can request and review issuer-provider contracts as part of its mandate to reduce healthcare cost growth. The rate review process is conducted privately between insurers and the DOI and happens four times a year with short review periods. The DOI has only fully rejected one rate increase in the last decade. In , they rejected most requests for higher rates from multiple carriers.¹⁰⁷ There were no additional rejections until 2021, when they rejected an average 15% rate increase request for Allways health plans, later approving an 11.5% increase after the required hearings and negotiations. The initial increase was rejected because Allways did not demonstrate adequate steps taken to renegotiate reimbursement rates to limit the grown in claims cost, especially with higher cost provider groups and inpatient hospitals (likely a reference to Mass General Brigham’s hospital network).¹⁰⁸

Beyond outright rejection, in 2020 the DOI negotiated rate increases down by one percent across the board, ultimately approving rates that increased by an average of 7.9% beginning in 2021, including a 12.2% increase for Tufts Health Plan, which provides low-cost healthcare on the Massachusetts Health Connector. These high rates were due, in part, to uncertainty in the market caused by the COVID-19 pandemic.¹⁰⁹ The DOI has acknowledged that they did not challenge the 2020 increase or hold a hearing because it would have prevented plans from being available in time for October’s open enrollment period.¹¹⁰

In May 2022, the DOI drafted regulations that would reduce the number of chances insurers have to file rate increases for small businesses and would require insurers to provide information to the public to support their rates for individuals and small businesses, including a public hearing as part of an annual review process.¹¹¹ Governor Baker also proposed healthcare legislation (S. 2774) that would enhance the DOI’s ability to modify and disapprove proposed rates that are unjustified.¹¹²

Recommendations:

Create Affordability Standards and Factor into Rate Review: Massachusetts might consider developing health plan affordability standards that prioritize consumers’ ability to afford proposed rates. These affordability standards could then be added to the factors that the DOI considers in reviewing and approving health plan rate filings (see Massachusetts Health Policy Commission’s 2021 Cost Trends Report for full recommendation).¹¹³ Massachusetts might also consider developing their own affordability standard. See the NASHP rate review toolkit for model legislation and examples of affordability standards, including specific calculations.¹¹⁴

Explore Robust Negotiation with Large Group Market Carriers: In order to reach a large share of the state’s population, Massachusetts might consider strengthening the DOI’s authority to include rate negotiation with HMOs and Blue Cross Blue Shield plans in the large group market so that it more closely resembles the rigorousness of the merged market review.

Explore Increasing Duration of the Rate Review Process: In order to accommodate more robust review of consumer affordability in rate review, Massachusetts might also consider lengthening the rate review process for both the merged market and the large group market to last more than 45 days. Massachusetts might also consider adjusting the timeline to allow for sufficient time for the rejection and re-negotiation process without jeopardizing the effective date for the eventual rate increase. At the same time, carriers have expressed that the quarterly review window allows them more flexibility to respond to market trends, suggesting a compromise between quarterly and annual review could be beneficial.

Lessons from Other States:

Lessons from Rhode Island: Rhode Island’s affordability standard requires a cap of inflation plus 1% in insurers’ negotiated prices with hospitals in order to have their premium rates approved.¹¹⁵ This rate review process applies to large group market plans as well as the individual and small group markets.¹¹⁶ See this report for an overview of RI affordability standards.¹¹⁷

Lessons from Connecticut: CT is had developed their own affordability standard called the CT Healthcare Affordability Index, which factors in cost of living alongside healthcare expenses, to identify affordable premium and cost-sharing rates.¹¹⁸

Make Out-of-Pocket Costs Affordable

Premiums and out-of-pocket costs for Massachusetts households are higher than those in most states and are rising faster than earnings. According to a Commonwealth Fund analysis, combined household premium contributions and out-of-pocket costs for those with employer-sponsored insurance totaled $4,578 per year from 2016 to 2017—11th highest of any state, and almost $1,000 more than the national median.¹¹⁹

Increasing out-of-pocket costs are an important driver of healthcare affordability burdens, with lower-income households facing higher burdens. The 2019 Massachusetts Health Insurance Survey (MHIS) found that 59.3% of households with incomes below 400% of FPL faced affordability burdens (defined as: medical bills being paid overtime; problems paying medical bills; high share of family income spent on out-of-pocket costs; any unmet healthcare needs), as well as 38.2% of households above 400% FPL (see Figure 7).¹²⁰

Figure 7. Affordability Burdens for Massachusetts Residents

Source: Figures taken from Massachusetts Health Policy Commission 2021 Health Care Cost Trends Report (September 2021)

In a separate analysis, the HPC estimated that 33% of middle-class families in Massachusetts saw more than a quarter of all earnings go to healthcare spending based on 2016-2018 data, up from 23% in their 2019 report using 2013-2015 data.¹²¹ High deductible health plans (HDHP) are a notable barrier to care for the states’ lower-income workers. The MHIS survey found that 29% of low-income adults with high deductible health plans went without care due to cost compared to 21% of low-income adults without high deductible plans. Among adults with low incomes in high-deductible plans, the percentage was still greater for people of color (33% among Black, Hispanic, or reported other or multiple races) compared to White adults (28%).¹²² High deductible plans are becoming more prevalent nationwide and in Massachusetts.

According to SHADAC, roughly 46% of Massachusetts households enrolled in an HDHP in 2020, and the average family deductible among employer insurance plans in Massachusetts rose 36% between 2013 and 2019, totaling $3,151 in 2019. This may place an even greater burden on Massachusetts low-income workers: a CHIA analysis found that HDHPs comprise more than 60 percent of plans held by employees of small- and mid-sized firms in Massachusetts, which tend to employ workers with lower incomes.¹²³

Standard Plan Design on State Exchange

Massachusetts has a state-based exchange, the Massachusetts Health Connector, where they offer both standardized and non-standardized plans. A standard plan design is where several features of the insurance plan design have been standardized, and typically affect cost-sharing requirements. Standardization enables consumers to make an “apples to apples” comparison amongst plans and simplifies plan shopping.

Massachusetts’s standardized plans have the same out-of-pocket costs (within each metal level) for various benefit categories (such as deductibles, out-of-pocket maximums, office visits and emergency room visits), but can vary in terms of premiums, provider networks and cost-sharing for benefits outside of the standardized categories. Massachusetts carriers also offer non-standardized plan designs on the Health Connector that have different cost-sharing requirements from the standardized plans.¹²⁴ Massachusetts should enact the following recommendations to build on their success with standardized plan design.

Lessons from California:

It is worth noting that some states have gone beyond offering standardized plans. For example, in California, insurers cannot offer non-standardized plans on the exchange.^125,126

Recommendations:

Develop Affordability Standards and Monitor Whether Exchange Plans Meet Standards: Massachusetts might consider developing affordability standards and ensure that all standard plans offered on the exchanges meet affordability standards (potentially consider extending to all plans). See Rate Review section recommendations for details on affordability standards.¹²⁷

Partner with Employers to Investigate Alternatives to High-Deductible Health Plans: While standard plan designs benefit consumers purchasing on the state exchange, the majority of residents get their insurance through employer-sponsored plans, many of which are increasingly relying on high-deductible structures that do not align with the values and benefits of standard plan design. The state exchange and/ or individual health plans could provide valuable insight by partnering with employers to study alternatives to HDHPs. One example of this could be structures that allow premium contributions based on different employee wage levels, as the exchange currently does with income-based subsidies (see Massachusetts Health Policy Commission’s 2021 Cost Trends Report for details).

Waive or Reduce Cost-Sharing for High Value Services

Failure to receive high-value care like flu vaccines, certain cancer screenings and other select services not only worsens health outcomes but can result in higher future medical spending.¹²⁸ Reducing financial barriers by waiving or reducing cost-sharing for specific high-value services is one-way states can encourage the utilization of high-value care.

Massachusetts’s standardized benefit plans offer some services pre-deductible for those purchasing Platinum, Gold, and certain Silver plans, including primary care, mental health visits, urgent care, and certain prescription drugs (see Figure 8). However, those purchasing Bronze plans and HSA-compatible Silver plans are required to first meet their deductibles for many high-value services apart from the lowest tier prescription medications, with deductibles ranging from $2,000 to $6,400.¹²⁹

In contrast, ConnectorCare plans (special state-based plans for individuals who earn up to 300% FPL and are ineligible for other government healthcare programs like Medicaid or Medicare) limit deductibles and include pre-deductible services with low to moderate copay amounts based on income tier, including non-preventive primary care, specialty care, mental health and substance use disorder treatment, urgent care and prescription drugs (see Figure 9).¹³⁰

Figure 8. Massachusetts Standard Qualified Health Plan

Source: Massachusetts Health Connector (October 2021)

Figure 9. Massachusetts ConnectorCare Fee Schedule, 2022

Source: Massachusetts Health Connector (Accessed November 1, 2022)

Of the 26 states that have passed policies to reduce financial barriers to high-value care as of Dec. 31, 2021, the most common area of action was capping costs for prescription drugs, particularly insulin.¹³¹ While the Massachusetts legislature has attempted to cap prices for specific drugs, such as insulin, in the wider market, these efforts have not yet succeeded. The most recent attempt took place in February 2022, with an insulin price cap that died in the state House.¹³²

Recommendations:

Waive or Reduce Cost-Sharing for High-Value Services Across all Plan Types: Massachusetts should consider a suite of measures to ease consumer burdens, including waiving or reducing cost-sharing for high-value services beyond prescription drugs and those services already offered pre-deductible. For example, for ConnectorCare plans, the state might aim to offer $0 copays for primary care, emergency room services and mental/behavioral health visits across all plan types (rather than $10 and $15 for Plan Types 2 and 3, respectively). For standard marketplace plans, the state might offer primary care and mental and behavioral health outpatient visits pre-deductible and with a reduced copay, rather than requiring enrollees in certain Silver and Bronze Plans to meet their deductible and then pay copays ranging from $60 to $150.

Investigate Tying Consumer Out-of-Pocket Costs Increases to Healthcare Spending: To directly address healthcare affordability burdens, Massachusetts might commission a study of potential methods to tie consumer out-of-pocket costs in standard Marketplace and ConnectorCare plans to the healthcare spending benchmark. For example, if annual healthcare spending totals 3%, the advisory board in charge of plan design might aim to keep the growth of deductibles and copays between years to 3%.

Explore Other Avenues to Subsidize High-Value Prescription Drugs for all Residents, Not Exclusively Through the Marketplace: While Massachusetts’s Marketplace prescription drug schedule is an excellent start, its benefits are limited to the small population purchasing on the exchange. For example, one estimate assessing state marketplace-level insulin price cap programs suggested that only roughly 25% of people with diabetes in the states with these programs would be able to take advantage of a $100 copay cap on insulin.¹³³ Massachusetts should pursue additional opportunities to improve prescription drug affordability for all residents, including those in the private market and the uninsured, by way of discounts or wholesale purchasing.

Lessons from Other States:

Utah’s Insulin Savings Program allows any resident to purchase insulin at wholesale prices through the state and public employee plan.^134,135

New Mexico passed legislation to cap copays and out-of-pocket expenses for insulin at $25 for a 30-day supply (the lowest price cap in the country) and established an advisory group to study the cost of prescription drugs for New Mexico consumers and make recommendations on increasing accessibility.¹³⁶

Texas passed a law in 2021 that caps the cost-sharing of a 30-day supply of insulin to $25, regardless of the amount or type of insulin needed to fill an enrollee of a state-regulated health plan’s prescription.¹³⁷ Another Texas law instructs state officials to develop a drug savings program that would give uninsured individuals a discounted rate on insulin purchases.¹³⁸

In 2021, Oregon passed a law to limit cost-sharing of insulin for health plans offered on the state exchange to $75 for a 30-day supply or $225 for a 90-day supply.139 The law further excludes such coverage from deductibles imposed by health plans.¹⁴⁰

Delaware, Louisiana and Maryland cap cost-sharing for specialty drugs—such as those to treat HIV and hepatitis—at $150 for a 30-day supply.¹⁴¹

Beginning in 2023, Massachusetts ConnectorCare plans (available to residents earning up to 300% FPL) will eliminate cost-sharing for medications used to treat conditions that disproportionately affect communities of color, including diabetes, asthma, coronary artery disease and hypertension.¹⁴²

Also beginning in 2023, the District of Columbia will eliminate cost-sharing for prescription drugs and other medical services required for the treatment and maintenance of conditions that disproportionately affect District residents of color in standard marketplace plans. Plan year 2023 will eliminate cost-sharing for diabetes services, with other conditions under consideration for future plan years.¹⁴³

Recommendations, cont..:

Consider Establishing Spending Targets for High-Value Care: In addition to improving the affordability of high-value care for patients, Massachusetts should also consider setting targets for spending on high-value care for service categories like primary care and behavioral healthcare. Research shows that primary care-oriented health systems produce better patient outcomes, lower costs and improve patient experience of care, compared to specialist-oriented care.¹⁴⁴ The HPC recommends payers and providers increase spending on primary and behavioral health and prioritize non-claims-based spending, such as capitation, infrastructure and workforce investments. Massachusetts can enact these spending targets either within their cost growth benchmark or as an independent program.

Lessons from Other States:

Part of Connecticut’s cost growth benchmark includes spending targets for increasing primary care spending to account for 10% of total healthcare expenditures by 2025.¹⁴⁵ The Office of Health Care Strategy develops these cost benchmarks, as well as quality benchmarks, across all public and private payers that include clinical quality, over/under utilization and patient safety measures. The 2022-2025 Quality Benchmark Measures can be found here.¹⁴⁶ Importantly, the Executive Order creating the benchmarks charges the technical team overseeing their development with prioritizing health equity in their recommendations.¹⁴⁷

Rhode Island’s affordability standards (enacted in 2010) require commercial insurers to invest more in primary care providers and services and encourage primary care practices to transform into patient-centered medical homes. A 2019 study found that quarterly primary care coordination spending increased by $21 per commercially insured enrollee, total spending growth decreased (the reduction in fee-for-service spending on patient care was greater than the increase in non-fee-for-service spending related to primary care) and that quality measures were either unaffected or improved.¹⁴⁸

Surprise Out-of-Network Medical Bill Protections

Surprise medical bills (SMB), also known as balance bills, include any medical bill for which a health insurer paid less than the patient expected. One form of SMB receiving a lot of attention is when a patient receives a bill from an out-of-network provider that would have been difficult for them to avoid; for example, in emergency situations or when care is provided by an out-of-network provider at an in-network hospital.

A 2020 report from the Massachusetts HPC observed the potential for balance billing in more than 90% of out-of-network claims for professional services, with claims ranging from $5 to $749 and an average of $167 per claim. In addition to consumer affordability burdens, surprise medical bills pose a real problem for controlling spending—across a range of procedures and ambulance services, the average spending on out-of-network claims far exceeded the average spending on in-network claims.¹⁴⁹

Massachusetts has partial state protections against surprise medical billing. The state requires insurers to hold enrollees harmless for amounts beyond in-network cost-sharing, specifically for HMO and PPO enrollees and services provided by out-of-network professionals at in-network facilities.¹⁵⁰ In 2021, Governor Baker signed legislation prohibiting providers from billing insured patients for more than the allowed in-network amount.¹⁵¹ However, Massachusetts protections do not apply to self-insured plans, which cover the majority of consumers.¹⁵²

The federal No Surprises Act is a landmark law intended to shield consumers from many aspects of SMBs. Beginning on Jan. 1, 2022, providers for most plan types, including self-insured plans, may not bill patients
for more than the in-network cost-sharing due under patients’ insurance for emergency services provided
at hospitals, free-standing emergency departments and urgent care centers that are licensed to provide
emergency care. The No Surprises Act also covers non-emergency services provided at certain in-network facilities, as well as air ambulance services, along with ancillary services for both emergency and nonemergency situations.^153,154

However, there are a few crucial elements that the No Surprises Act does not cover:

Ground Ambulances: The lack of coverage for ground ambulance services presents challenges for Massachusetts consumers. According to an estimate from Johns Hopkins University, 40% of ground ambulance rides in Massachusetts charged to commercial insurance plans had the potential for surprise medical billing, while a separate 2020 study cites a median cost of $450 nationwide per ground ambulance ride.¹⁵⁵

Emergency Services Provided at Urgent Care Centers Not Licensed for Emergency Care: The No Surprises Act does not cover emergency services provided at Urgent Care facilities that are not licensed to provide emergency care.¹⁵⁶

Non-Emergency Services Provided at Certain In-Network Facilities: The No Surprises Act covers nonemergency services received at specific types of in-network facilities, including hospitals, hospital outpatient departments and ambulatory surgical centers. However, it does NOT cover non-emergency care received at in-network urgent care centers, birthing centers, hospices, addiction treatment facilities and nursing homes.

Certain Laboratory Services: The No Surprises Act does not apply when an in-network provider sends a test to an out-of-network lab for a non-emergency service, such as a doctor requesting a blood test during an annual primary care visit. In this case, the lab can balance bill the patient.¹⁵⁷

Notably, if a hospital or an insurer declares that the care provided wasn’t an emergency, the No Surprises Act doesn’t necessarily apply. In addition, disputes over lack of documentation demonstrating that the services provided were emergency services can result in claims being rejected and costs passed on to consumers, who must either pay or go through a burdensome appeal process.¹⁵⁸

The No Surprises Act also allows certain out-of-network providers to give patients a form waiving their SMB protections. The provider can refuse to treat a patient if they refuse to waive the protections; however, certain providers are prohibited from giving this form to patients, including emergency room doctors, anesthesiologists, radiologists, assistant surgeons and hospitalists. There is a risk that some facilities (including prohibited ones) will simply include this waiver in their general admission paperwork, potentially violating federal law or at least making it difficult for patients to identify the protections they are waiving.¹⁵⁹

The No Surprises Act defers to state law when resolving payment disputes between insurers and out-of-network providers. For states without their own arbitration process, the No Surprises Act creates a federally operated Independent Dispute Resolution Process (IDRP) to determine how much a patient’s health plan must pay an out-of-network provider, primarily based on the insurer’s median in-network rate (Qualified Payment Amount), among some other factors. The IDRP must eventually select one party’s offer, called baseball-style arbitration, which is then binding for both parties.¹⁶⁰ However, if a state law already sets a payment amount for the out-of-network services covered by the federal law, the state’s law will govern.¹⁶¹

Massachusetts’s 2021 legislation does not create any dispute resolution process or similar mechanism for providers and insurers to determine what additional amount, if any, an out-of-network provider may be reimbursed for services rendered to an insured patient. Nor does the state have a process dictating that such patient’s financial responsibility is limited to the applicable in-network coinsurance amount. However, the 2021 state law directed multiple state agencies to collaborate and recommend a default rate for out-of-network billing, and they issued a report in September 2021.^162,163

Recommendations:

Enact Protections Filling in Gaps in the No Surprises Act for State-Regulated Plans: Massachusetts should consider enacting state-level SMB protections for services and situations not covered by the No Surprises Act outlined in the section above. It is important to note that additional state SMB protections cannot by default apply to self-insured, employer-sponsored health insurance plans, which are federally regulated.¹⁶⁴ However, Massachusetts can still enact additional protections for consumers with state regulated insurance plans and simultaneously allow self-funded plans to opt into the state surprise medical billing protections, a practice permitted under ERISA¹⁶⁵ and currently in practice in a handful of states (Maine, New Jersey, Nevada, Virginia and Washington). This document explores additional considerations for adopting state SMB protections beyond the No Surprises Act, while this Health Affairs report contains details on opt-in programs.¹⁶⁶

Enact an SMB protection for state-regulated plans prohibiting balance billing for ground ambulance services. Eight states currently offer some protection for out-of-network ambulance charges:
Colorado, Delaware, Maine, Maryland, New York, Ohio, Vermont and West Virginia.

Enact an SMB protection for state-regulated plans covering emergency services provided at all urgent care facilities, regardless of whether they’re licensed to provide emergency care.

Enact SMB protections for state-regulated plans covering non-emergency care received at in-network urgent care centers, birthing centers, hospices, addiction treatment facilities and nursing homes.

Enact a protection for state-regulated plans prohibiting balance billing by out-of-network laboratories for services requested by in-network providers.

Lessons from Other States:

Colorado law prohibits privately-owned ambulance services from billing insured patients for amounts other than for the in-network cost sharing rate. However, the law does not apply to publicly funded fire departments or county emergency medical services. In addition, Colorado requires state-regulated health plans to reimburse out-of-network private ground ambulances at 325% of Medicare payment rates and limits the amount patients pay out-of-pocket to the in-network rate.¹⁶⁷

Delaware has regulations on the out-of-network payment dispute resolution process for health plans and providers of emergency services, which specifically include ground ambulances.¹⁶⁸

New York prohibits ground ambulance service providers from billing enrollees in certain plan types (HMOs, PPOs, EPOs) more than the in-network cost sharing.¹⁶⁹

Recommendations, cont.:

Allow Self-Funded Plans to “Opt Into” State Balance Billing Protections: Massachusetts should consider allowing self-funded plans to opt into state balance billing protections to provide additional balance billing protections for those consumers.

Lessons from Other States:

Several states with surprise medical bill protections enable self-funded plans to opt into the protections. According to a 2021 publication from Health Affairs, 20 entities had opted into Nevada’s law (for emergency services only), 137 entities had opted into New Jersey’s law, 351 entities had opted into Virginia’s law and about 350 entities had opted into Washington’s law. Maine also allows self-funded entities to opt into their 2020 law (for emergency services only), though data on how many have chosen to do so is not yet available.¹⁷⁰

Recommendations, cont.:

Outline Dispute Resolution Process for Misidentified Emergency Services: Massachusetts might also consider outlining an additional dispute resolution process between insurers and hospitals when one or both entities miscodes or misidentifies emergency services as non-emergency services, or there is missing documentation causing the claim to be rejected. This process could be applied to both self-insured and fully insured plans, since the No Surprises Act defers to state laws on dispute resolution and arbitration. Such a resolution process should protect consumers from being charged and from the burden of managing the appeal process.¹⁷¹

Explore Regulating Waivers: Massachusetts might explore (1) prohibiting SMB protection waivers, (2) prohibiting providers from rejecting patients that refuse to waive their SMB rights or (3) requiring providers to present the waiver to patients as a separate document with clear language explaining the rights they are waiving. The first two options could likely only apply to state-regulated plans, since their application to federally-regulated plans would undermine the No Surprises Act. The third option, however, could likely be applied to all plan types, including federally-regulated plans, since additional notice requirements simply exceed the No Surprises Act and do not directly undermine it.¹⁷² Once enacted, these approaches could involve auditing provider intake forms, conducting a patient and provider education campaign on SMB protections and the No Surprises Act and designating an office responsible for receiving patient waiver violation complaints and resolving disputes.

Lessons from New York:

In New York, patients with fully-insured, state-regulated¹⁷³ health insurance coverage cannot give written consent to waive balance billing protections for certain services, including post-stabilization services after emergency care and services referred by an in-network doctor. In addition, if an in-network doctor refers a patient to an out-of-network provider without their consent (including lab and pathology services), the provider cannot balance bill the patient.^174,175

Recommendations, cont.:

Consider Enacting Recommended Payment Limits: Massachusetts should use data from the state’s APCD to calculate a median in-network rate for each individual payer in alignment with the federal Qualified Payment Amount (QPA) standard.¹⁷⁶ This would preemptively resolve any potential disputes of the QPA in the federal arbitration process.

Lessons from Other States:

Initial analysis suggests that California’s payment benchmark (greater of the average contracted rate or 135% of Medicare) protected patients, reduced spending and maintained or increased patient access.¹⁷⁷ In contrast, the baseball-style arbitration systems in New York and New Jersey base their determination on the 80th percentile of provider charges, which is much higher than in-network prices. This has led to prices higher than those that would have been paid without surprise billing legislation.^178,179

Recommendations, cont.:

State-Level Surprise Medical Billing Protections that Mirror the No Surprises Act: While it may seem unnecessary to enact state-level protections given the new federal law, the Act may be repealed in the future, especially if there is a desire to undo perceived ‘big government’ regulations enacted under the Biden Administration. While Massachusetts may not be able to enact protections for the large share of residents with self-insured employer-sponsored insurance, it can still insulate those who buy coverage on the state exchanges and who have fully-insured employer-sponsored insurance plans from this potential federal policy change.

Protections Against Short-Term, Limited Duration Health Plans

In response to rising insurance costs, some people turn to Short-Term, Limited-Duration (STLD) health plans, which offer lower monthly premiums compared to ACA-compliant plans. However, these policies offer poor coverage, can discriminate against people with pre-existing conditions and pose significant financial risks for consumers. Massachusetts laws are inhospitable to short-term plans, and as a result, no carriers sell STLD plans in the state. Massachusetts requires guaranteed issue (no rejections for pre-existing conditions), and short-term plans do not meet state-based individual health insurance mandate requirements, so individuals with short-term plans would be charged a penalty fee.¹⁸⁰

Recommendations:

While Massachusetts could enact an outright ban on STLD plans, the current level of regulation has achieved the goal of eliminating their impact on Massachusetts residents, suggesting further regulation is not needed.

Conclusion

Massachusetts has an evolving healthcare policy landscape and has pursued many innovative strategies to address healthcare spending and affordability. However, affordability challenges persist for residents of the state. Massachusetts should consider enacting many of the policy strategies outlined in this report to address serious healthcare affordability concerns.

1. Bureau of Economic Analysis, Personal Consumption Expenditures by State, 2021, (Oct. 6, 2022).
https://www.bea.gov/news/2022/personal-consumption-expenditures-state-2021

2. Health Policy Commission, “Hearing on the Potential Modification of the Health Care Cost Growth Benchmark,” Slide 17, (March 11, 2021)
https://www.mass.gov/doc/presentation-benchmark-hearing march-11-2020/download.

3. Hargraves, John, Biniek, Jean Fugelstein and Jason Fehr, 2018 Health Care Cost and Utilization Report, State Spending Trends, Health Care Cost Institute, (Accessed on Oct. 31, 2022). https://healthcostinstitute.org/interactive/2018-healthcare-cost-and-utilization-report

4. Health Policy Commission, Meeting of the HPC’s Advisory Council (March 30, 2022), 47 minutes, https://www.youtube. com/watch?v=S5mRX-HQn1M&t=1586s

5. Sen, Aditi, Jodi Segal and Yang Wang, John’s Hopkins University analysis of hospital pricing MarketScan data conducted for the Altarum Healthcare Value Hub (2021).

6. National Academy for State Health Policy’s (NASHP) Hospital Cost Tool (HCT), Massachusetts Comparison Among Hospitals, using 2021 data (Accessed Nov. 29, 2022).
https://d3g6lgu1zfs2l4.cloudfront.net/

7. Ibid. Meeting of the HPC’s Advisory Council (March 30, 2022).

8. Ibid. Hargraves, John, Biniek, Jean Fugelstein and Jason Fehr.

9. Waugh, Lisa, and Douglas McCarthy, How the Massachusetts Health Policy Commission Is Fostering a Statewide Commitment to Contain Health Care Spending Growth, The Commonwealth Fund (March 5, 2020). https://www.commonwealthfund.org/publications/case-study/2020/mar/massachusetts-health-policy-commission-spendinggrowth

10. Murray, et al., Report Card on State Price Transparency Laws, Catalyst for Payment Reform (May 2020). https://www.catalyze.org/wp-content/uploads/woocommerce_uploads/2020/05/2020-Report-Card-on-State-Price-TransparencyLaws_May-2020_Published-uttkwt.pdf

11. Massachusetts Health Policy Commission, HPC DataPoints, Issue 10: Health Care Cost Growth Benchmark (Accessed on Nov. 2, 2022). https://www.mass.gov/service-details/hpc-datapoints-issue-10-health-care-cost-growth-benchmark

12. Butler, Johanna, Massachusetts Health Policy Commission Takes Steps to Hold High-Cost Health System Accountable, National Academy of State Health Policy (February 14, 2022). https://www.nashp.org/massachusetts-health-policycommission-takes-steps-to-hold-high-cost-health system-accountable/

13. Liss, Samantha, “Mass General Brigham’s plan to slash millions in costs gets green light,” Healthcare Dive (Sept. 28, 2022). https://www.healthcaredive.com/news/mass-general-brighams-performance-improvement-planapproved/632851/

14. Massachusetts Health Policy Commission, Presentation to the Maryland Prescription Drug Affordability Board, (May 2021). https://pdab.maryland.gov/documents/presentations/Mass_Health_Policy_Commission_prst.pdf

15. Healthcare for All Massachusetts, Press Statement: MA Prescription Drug Affordability Coalition Commends Senate for Advancing Significant Rx Cost Reform, (Feb. 3, 2022). https://hcfama.org/press-statement-ma-prescription-drugaffordability-coalition-commends-senate-for-advancing-significant-rx-cost-reform/

16. The Commonwealth Fund, Profiles of Cost Containment Strategies, (February 2022). https://www.commonwealthfund.org/sites/default/files/2022-02/Hwang_health_care_cost_growth_10_profiles.pdf

17. Schoenberg, Shira, “Baker says proposed drug overcharging penalties would total $70m,” Commonwealth Magazine (Feb. 1, 2021). https://commonwealthmagazine.org/drug-addiction/drugs/baker-says-proposed-drug-overcharging-penaltieswould-total-70m/

18. Kingsdale, Jon M., “Whither Massachusetts Health Reform?” Health Affairs (Oct. 4, 2021). https://www.healthaffairs.org/do/10.1377/hblog20210930.371346/full/

19. Mohl, Bruce, “Devaux says Health Policy Commission needs more power,” Commonwealth Magazine (Oct. 24, 2022). https://commonwealthmagazine.org/podcast/devaux-says-health-policy-commission-needs-more-power/

20. Massachusetts Health Policy Commission, 2022 Health care Cost Trends Report and Policy Recommendations, (September 2022), https://www.mass.gov/doc/2022-health-care-cost-trends-report-and-policy-recommendations/download

21. Massachusetts Health Policy Commission, 2021 Annual Health Care Cost Trends Report (September 2021). https://www. mass.gov/doc/2021-health-care-cost-trends-report/download

22. National Academy for State Health Policy, Hospital Cost Tool (Accessed Nov. 2, 2022). https://d3g6lgu1zfs2l4.cloudfront.net/

23. Kacik, Alex, “Price hikes, upcoding drive Massachusetts inpatient spending,” Modern Healthcare (Sept. 12, 2019). https:// www.modernhealthcare.com/operations/price-hikes-upcoding-drive-massachusetts-inpatient-spending

24. National Academy for State Health Policy, Comparison of State Prescription Drug Affordability Board Bills (March 15, 202). https://www.nashp.org/comparison-of-state-prescription-drug-affordability-board-bills/

25. NASHP Conference, State Health Policy Unmuted, Presentation from Senator Sonya Jaquez Lewis, September 21-22, 2021.

26. Center for Health Information and Analysis, Hospital and Other Provider Data (Accessed Oct. 1, 2022). https://www.chiamass.gov/data-index/#insurance

27. Hobbs, Sylvia D. and Anne Medinus, Demographic Differences in Massachusetts All Payer Claims Data (MA APCD) Before and After Gobeille, Center for Health Information and Analysis, Boston, MA (August 2020). https://www.chiamass.gov/data-index/

28. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) at the U.S. Department of Health & Human Services, “Linking State Health Care Data to Inform Policymaking: Opportunities and Challenges,” (June 2022). https:// aspe.hhs.gov/sites/default/files/documents/96f34fd0474b3da4884836c4341f1bbe/Linking-State-Health-Care-Data.pdf

29. Center for Health Information and Analysis, Overview of the Massachusetts All-Payer Claims Database, Bocton, MA (September 2016). https://www.chiamass.gov/assets/docs/p/apcd/APCD-White-Paper-2016.pdf

30. McCarthy, Douglas, State All-Payer Claims Databases, Tools for Improving Health Care Value, Part 1: How States Establish an APCD and Make It Functional, The Commonwealth Fund (December 2022). https://www.commonwealthfund.org/sites/ default/files/2020 12/McCarthy_State_APCDs_Part1_Report_v2.pdf

31. Center for Improving Value in Health Care, Standard Reports, (Accessed Oct. 31, 2022). https://www.civhc.org/standard-reports/

32. Massachusetts CompareCare, https://www.masscomparecare.gov/cost

33. Beaudin-Seiler, Beth, and Quincy, Lynn, Reducing Low-Value Care: Saving Money and Improving Health, Altarum Healthcare Value Hub (November 2018). https://www.healthcarevaluehub.org/advocate resources/publications/reducing-low-valuecare-saving-money-and-improving-health

34. Hunt, Amanda, Six Categories of Healthcare Waste: Which Reign Supreme?, Healthcare Value Hub blog (October 2019). https://www.healthcarevaluehub.org/advocate-resources/publications/six-categories healthcare-waste-which-reignsupreme

35. Massachusetts Health Policy Commission, 2018 Annual Health Care Cost Trends Report (February 2019). https://www. mass.gov/doc/2018-report-on-health-care-cost-trends/download

36. According to a separate analysis conducted in 2021 by Johns Hopkins University for the Altarum Healthcare Value Hub using 2015-2018 Medicare claims data, MA’s overuse of low-value care is 0.1 standard deviations above the national average, which is undesirable.

37. Choosing Wisely, “Clinician Lists” (Accessed on Nov. 2, 2022). https://www.choosingwisely.org/clinician lists/

38. Washington Health Alliance, First, Do No Harm, Calculating Health Care Waste in Washington State (February 2018). https://www.wacommunitycheckup.org/media/47156/2018-first-do-no-harm.pdf

39. Oregon Health Leadership Council, Health for Oregonians: Opportunities to Reduce Low-Value Care, Richmond, VA (July 2020). http://www.orhealthleadershipcouncil.org/wp-content/uploads/2020/07/Oregon Low-Value-Care-Report-FinalJuly-2020.pdf

40. Virginia Health Information, 2016 Virginia Low Value Services Report, (February 2017). https://www.vhi.org/APCD/Virginia%20Low%20Value%20Services%20Report.pdf

41. Massachusetts Health Policy Commission, 2021 Annual Health Care Cost Trends Report, Boston, MA (September 2021). https://www.mass.gov/doc/2021-health-care-cost-trends-report/download

42. Schoenberg, Shira, “Massachusetts Residents Spent $80 Million on Low-Value Health Care, Report Finds,” MassLive (Dec. 13, 2018). https://www.masslive.com/news/2018/12/massachusetts-residents spent-80-million-on-low-valuehealth-care-report-finds.html

43. Zadro, Joshua, et al., “Do choosing wisely recommendations about low-value care target income-generating treatments provided by members? A content analysis of 1293 recommendations,” BMC Health Services Research (Nov. 11, 2019).https://doi.org/10.1186/s12913-019-4576-1

44. Virginia Center for Health Innovation, Smarter Care Virginia (Accessed on Nov. 2, 2022). https://www.vahealthinnovation.org/scv/

45. Betsy Lehman Center for Patient Safety, The financial and Human Cost of Medical Error and How Massachusetts Can Lead the Way on Patient Safety (June 2019). https://betsylehmancenterma.gov/assets/uploads/Cost-of-Medical-ErrorReport-2019.pdf

46. Agency for Healthcare Research and Quality, Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital-Acquired Conditions, Rockville, MD (Accessed Nov. 1, 2022). https://www.ahrq.gov/hai/pfp/haccost2017-results.html

47. Bernazzani, Sophia, Tallying the High Cost of Preventable Harm, Costs of Care (Accessed Nov. 1, 2022). https://costsofcare.org/tallying-the-high-cost-of-preventable-harm/

48. Betsy Lehman Center for Patient Center, The Financial and Human Cost of Medical Error… and How Massachusetts Can Lead the Way on Patient Safety, Boston, MA (June 2019). https://betsylehmancenterma.gov/assets/uploads/Cost-ofMedical-Error-Report-2019.pdf

49. Massachusetts HAI Plan, Massachusetts State Government (Accessed Nov. 1, 2022). https://www.mass.gov/doc/massachusetts-hai-plan-2016-2020/download

50. Centers for Disease Control and Prevention, Current HAI Progress Report, Atlanta, GA (Accessed Nov. 1, 2022). https://www.cdc.gov/hai/data/portal/progress-report.html#Data_tables

51. Weiner-Lastinger, Lindsey M., et al., “The Impact of Coronavirus Disease 2019 (COVID-19) on Healthcare Associated Infections in 2020: A Summary of Data Reported to the National Healthcare Safety Network,” Infection Control & Hospital Epidemiology, Vol. 43, No. 1 (Sept. 3, 2021). https://www.cambridge.org/core/ journals/infection-control-and-hospital-epidemiology/article/impact-of-coronavirus-disease-2019-covid19-on-healthcareassociated-infections-in-2020-a-summary-of-data-reported-to-the-national-healthcare-safety-network/8197F323F4840D233A0C62F4726287E1

52. Centers for Disease Control and Prevention, Current HAI Progress Report, Atlanta, GA (Accessed Nov. 1, 2022). https://www.cdc.gov/hai/data/portal/progress-report.html#Data_tables

53. Centers for Disease Control and Prevention, Central Line-Associated Bloodstream Infections, Atlanta, GA (Accessed Nov. 1, 2022). https://arpsp.cdc.gov/profile/nhsn/clabsi?state-select-report=state25

54. Centers for Disease Control and Prevention, Catheter-Associated Urinary Tract Infections, Atlanta, GA (Accessed Nov. 1, 2022). https://arpsp.cdc.gov/profile/nhsn/cauti?state-select-report=state25

55. Betsy Lehman Center for Patient Safety, Our Mandate, Boston, MA (Accessed Nov. 1, 2022). https:// betsylehmancenterma.gov/the-center/our-mandate

56. Betsy Lehman Center for Patient Safety, A Roadmap to Healthcare Safety for Massachusetts, Boston, MA (2020). https://betsylehmancenterma.gov/assets/uploads/Roadmap_report.pdf

57. Massachusetts HAI Plan, Massachusetts State Government (Accessed Nov. 1, 2022). https://www.mass.gov/doc/massachusetts-hai-plan-2016-2020/download

58. Centers for Disease Control and Prevention, Antibiotic Prescribing and Use: Current Stewardship Report, Atlanta, GA (Accessed Nov. 1, 2022). https://www.cdc.gov/antibiotic-use/stewardship-report/current.html

59. Centers for Disease Control and Prevention, Antibiotic Resistance & Patient Safety Portal – All Antibiotic Classes, Atlanta, GA (Accessed Nov. 1, 2022). https://arpsp.cdc.gov/profile/antibiotic-use/all-classes?year-select-rate-map=year2020

60. Centers for Disease Control and Prevention, Antibiotic Prescribing and Use – Hospital, Centers for Disease Control and Prevention, Atlanta, GA (Accessed Nov. 1, 2022). https://www.cdc.gov/antibiotic use/core-elements/hospital.html

61. Kaiser Family Foundation, Uninsured Rates for the Nonelderly by Race/Ethnicity, Washington, D.C. (Accessed Nov. 1, 2022). https://www.kff.org/uninsured/state-indicator/nonelderly-uninsured-rate-by-raceethnicity

62. Keisler-Starkey, Katherine, and Lisa N. Bunch, Health Insurance Coverage in the United States: 2019, United States Census Bureau, Suitland, MD. (September 2020). https://www.census.gov/content/dam/Census/library/publications/2020/demo/p60-271.pdf

63. Kaiser Family Foundation, Uninsured Rates for the Nonelderly by Race/Ethnicity, Washington, D.C. (Accessed Nov. 1, 2022). https://www.kff.org/uninsured/state-indicator/nonelderly-uninsured-rate-by-raceethnicity/

64. United States Census Bureau, B27020 Health Insurance Coverage Status and Type by Citizenship Status. 2021, 1-year estimate. https://censusreporter.org/tables/B27020/

65. Kaiser Family Foundation, Distribution of Eligibility for ACA Health Coverage Among the Remaining Uninsured, Washington, D.C. (Accessed Nov. 1, 2022). https://www.kff.org/health-reform/state-indicator/distribution-of-eligibility-for-acacoverage-among-the-remaining-uninsured/?currentTi

66. Kaiser Family Foundation, Distribution of the Nonelderly Uninsured by Race/Ethnicity (CPS), Washington, D.C. (Accessed Nov. 1, 2022). https://www.kff.org/other/state-indicator/distribution-of-the-nonelderly-uninsured-by-raceethnicity-cps/

67. Kaiser Family Foundation, Distribution of the Nonelderly Uninsured by Federal Poverty Level (FPL), Washington, D.C. (Accessed on Nov. 29, 2022). https://www.kff.org/uninsured/state-indicator/distribution-uninsured-nonelderly-federalpoverty-level-fpl/

68. Kaiser Family Foundation, Uninsured Rates for the Nonelderly by Federal Poverty Level (FPL), Washington, D.C. (Accessed Nov. 1, 2022). https://www.kff.org/uninsured/state-indicator/nonelderly-uninsured-rate-federal-poverty-level-fpl/

69. Norris, Louise, Massachusetts and the ACA’s Medicaid Expansion, HealthInsurance.org (Nov. 17, 2021). https://www.healthinsurance.org/medicaid/massachusetts/

70. MACPAC, An Updated Look at Rates of Churn and Continuous Coverage in Medicaid and CHIP, Washington, D.C. (October 2021). https://www.macpac.gov/wp-content/uploads/2021/10/An-Updated Look-at-Rates-of-Churn-and-ContinuousCoverage-in-Medicaid-and-CHIP.pdf

71. Ibid.

72. Kaiser Family Foundation, State Adoption of 12-Month Continuous Eligibility for Children’s Medicaid and CHIP, Washington, D.C. (Accessed Nov. 1, 2022). https://www.kff.org/health-reform/state-indicator/state-adoption-of-12-monthcontinuous-eligibility-for-childrens-medicaid-and-chip/

73. Kaiser Family Foundation, Medicaid and CHIP Eligibility and Enrollment Policies as of January 2021: Findings from a 50-State Survey – Table 6. Renewals, Changes in Circumstances, and Returned Mail, January 2021, Washington, D.C. (Accessed Nov. 1, 2022). https://files.kff.org/attachment/Table-6-Renewals-Changes-in-Circumstances-and-Returned-Mail-January-2021.pdf

74. Erzouki, Farah, and Jennifer Wagner, Unwinding the Medicaid Continuous Coverage Provision: What States Can Do Now to Keep Eligible People Covered, Center on Budget and Policy Priorities, Washington, D.C. (March 23, 2021). https://www.cbpp.org/research/health/unwinding-the-medicaid-continuous-coverage-provision-what-states-can-do-now-to-keep

75. Brooks, Tricia, and Allexa Gardner, Continuous Coverage in Medicaid and CHIP, Georgetown University Health Policy Institute, Center for Children and Families, Washington, D.C. (July 2021). https://ccf.georgetown.edu/wp-content/uploads/2012/03/CE-program-snapshot.pdf

76. Kaiser Family Foundation, Medicaid & CHIP Indicators, Washington, D.C. (Accessed Nov. 1, 2022). https://www.kff.org/state-category/medicaid-chip/streamlined-enrollment-renewal-practices/

77. Erzouki, Farah, and Jennifer Wagner, Unwinding the Medicaid Continuous Coverage Provision: What States Can Do Now to Keep Eligible People Covered, Center on Budget and Policy Priorities, Washington, D.C. (March 23, 2021). https://www.cbpp.org/research/health/unwinding-the-medicaid-continuous-coverage-provision-what-states-can-do-now-to-keep

78. Massachusetts Medicaid Buy-In, Massachusetts Health Connector (October 2018). https://archives.lib.state.ma.us/bitstream/handle/2452/822383/on1140075904.pdf

79. State Action, The Source on Healthcare Price & Competition, San Francisco, CA (Accessed Nov. 1, 2022). https://sourceonhealthcare.org/state-action/

80. See here for overview of commissioned studies in different states: Boozang, Patricia, and Kyla Ellis, The State of Play: Public Option at the Federal and State Level and What to Expect in 2021, State Health & Value Strategies, Princeton University, Princeton, NJ (Jan. 7, 2021). https://www.shvs.org/the-state-of play-public-option-at-the-federal-and-statelevel-and-what-to-expect-in-2021/

81. Kliff, Sarah, “The Lessons of Washington State’s Watered Down ‘Public Option,’” New York Times (June 27, 2019). https://www.nytimes.com/2019/06/27/upshot/washington-state-weakened-public-option-.html

82. Sen, Aditi P., et al., “Participation, Pricing, and Enrollment in a Health Insurance ‘Public Option:’ Evidence from Washington State’s Cascade Care Program,” The Milbank Quarterly (Nov. 23, 2021). https://www.milbank.org/quarterly/ articles/participation-pricing-and-enrollment-in-a-health-insurance-public-option-evidence-from-washingtonstates-cascade-care-program/

83. O’Brien, Madeline, Encouraging Signs for the Public Option in Washington State: Improved Availability and Affordability of Plans in 2022, Georgetown University Center on Health Insurance Reforms, Washington, D.C. (Dec. 3, 2021). http://chirblog.org/encouraging-signs-public-option-washington-state-improved-availability-affordability-plans-2022/

84. Washington Senate Bill 5377 – Health Insurance Individual Market—Premium Assistance—Standardized Plans, 2021 Regular Session (Accessed Nov. 1, 2022). https://lawfilesext.leg.wa.gov/biennium/2021 22/Pdf/Bills/Session%20Laws/Senate/5377-S2.SL.pdf#page=1

85. Hagan, Liz, and Rachel Bonesteel, Advancing Equity Through Public Options: How Colorado is Designing Culturally Responsive Networks, United States of Care (Oct. 12, 2021). https://unitedstatesofcare.org/advancing-equity-throughpublic-options-how-colorado-is-designing-culturally-responsive-networks/

86. Messerly, Megan, and Sean Golonka, “Sisolak Signs Bill Making Nevada the Second State to Adopt a Public Health Insurance Option,” Nevada Independent, (June 9, 2021). https://thenevadaindependent.com/article/sisolak-signs-billmaking-nevada-the-second-state-to-adopt-a-public-health-insurance-option

87. Nevada Department of Health and Human Services, Nevada Public Option (Accessed Nov. 1, 2022). https://dhhs.nv.gov/PublicOption/

88. Migration Policy Institute, Profile of the Unauthorized Population: Massachusetts, Washington, D.C. (Accessed Nov. 1, 2022). https://www.migrationpolicy.org/data/unauthorized-immigrant-population/state/MA

89. California, Illinois and DC data drawn from: State Health & Value Strategies, Supporting Health Equity and Affordable Health Coverage for Immigrant Populations: State-Funded Affordable Coverage Programs for Immigrants, Princeton University, Princeton, N.J. (October 2021). https://www.shvs.org/wp-content/uploads/2021/10/State-FundedAffordable-Coverage-Programs-for-Immigrants.pdf

90. Medi-Cal Expansion Provided 286,000 Undocumented Californians with Comprehensive Health Care, Office of California Governor Gavin Newsom (Oct. 19, 2022). https://www.gov.ca.gov/2022/10/19/medi-cal expansion-provided-286000-undocumented-californians-with-comprehensive-health-care/

91. State Health & Value Strategies (October 2021).

92. Illinois Department of Health and Family Services, Health Benefits For Immigrant Adults (Accessed Nov. 22, 2022). https://www2.illinois.gov/hfs/HealthBenefitsForImmigrants/Pages/default.aspx

93. State Health & Value Strategies (October 2021).

94. D.C. Department of Health Care Finance, Health Care Alliance, Washington, D.C. (Accessed Nov. 1, 2022). https://dhcf.dc.gov/service/health-care-alliance

95. Norris, Louise, District of Columbia and ACA Medicaid Expansion, HealthInsurance.org (April 22, 2022). https://www.healthinsurance.org/medicaid/dc/

96. Connect for Health Colorado, Get Started: OmniSalud (Accessed Nov. 1, 2022). https://connectforhealthco.com/getstarted/omnisalud/

97. Connect for Health Colorado, OmniSalud (Accessed on Nov. 22, 2022). https://connectforhealthco.com/getstarted/omnisalud/ See also: Colorado Consumer Health Initiative, Colorado Option Standardized Benefit Plan, https://cohealthinitiative.org/wp-content/uploads/2022/10/Co-Option-One-Pager-Bilingual-updated-2.pdf

98. Nathanson, Isabelle, Colorado’s Public Option Gets to the Root of the Problem, Colorado Consumer Health Initiative (Accessed Nov. 1, 2022). https://cohealthinitiative.org/articles/colorados-public-option-gets-to-the-root-of-theproblem/

99. Uphoff, Adrian, et al., State Success Story: The Colorado General Assembly Achieves a Big Victory for Expanding Access to Care, United States of Care, Washington, D.C. (July 9, 2020). https://unitedstatesofcare.org/colorado-general-assemblyachieves-big-victory/

100. Northwest Health Law Advocates, 2022 NoHLA Final Budget Analysis (as of April 4, 2022). https://docs.google.com/spreadsheets/d/14EWBtP3kH9aO0HDfd6vsB0ss6rhcXptdv9xUIUXgQOQ/

101. Massachusetts Health Insurance Marketplace 2023 Guide, HealthInsurance.org (Accessed Nov. 1, 2022). https://www.healthinsurance.org/health-insurance-marketplaces/massachusetts/

102. Morse Gasteier, Audrey, Emily Brice and Marissa Woltmann, “Why Massachusetts Stands Out in Marketplace Premium Affordability,” Health Affairs Forefront (Sept. 4, 2018). https://www.healthaffairs.org/do/10.1377/forefront.20180903.191590/full/

103. Kaiser Family Foundation, Average Marketplace Premiums by Metal Tier, 2018-2023, Washington, D.C. (Accessed Nov. 1, 2022). https://www.kff.org/health-reform/state-indicator/average-marketplace-premiums-by-metal-tier/

104. Massachusetts 211 CMR 66.00 – Small Group Health Insurance, Massachusetts State Government (Accessed Nov. 1, 2022). https://www.mass.gov/doc/211-cmr-66-small-group-health-insurance/download

105. Bartlett, Jessica, “State to Change Health Insurance Rate Setting Process for Individuals, Small Businesses,” Boston Globe (May 10, 2022). https://www.bostonglobe.com/2022/05/10/metro/state-looks change-health-insurance-rate-settingprocess-individuals-small-businesses/

106. Interview with Kevin Beagan, Deputy Commissioner of the Massachusetts Health Care Access Bureau within the Department of Insurance (May 23, 2022).

107. Sack, Kevin, “Massachusetts Insurance Regulators Reject Most Requests for Higher Insurance Rates,” The New York Times (April 2, 2010). https://www.nytimes.com/2010/04/02/health/policy/02rates.html

108. Hattis, Paul A., “Money-Losing Always is Drain on Mass General Brigham,” CommonWealth (Feb. 15, 2021). https://commonwealthmagazine.org/opinion/money-losing-allways-is-drain-on-mass-general-brigham/

109. Schachter, Aaron, “Do You Live in Massachusetts? You’ll Probably Pay More for Health Insurance Next Year,” GBH News, (Sept. 17, 2020). https://www.wgbh.org/news/local-news/2020/09/17/do-you-live-in-massachusetts-youll-probably-paymore-for-health-insurance-next-year

110. Rosenthal, Amy, “Health Insurance Rate Hike Should be Reviewed,” CommonWealth (Sept. 23, 2020). https://commonwealthmagazine.org/health-care/health-insurance-rate-hike-should-be-reviewed/

111. Bartlett, Jessica, “State Looks to Change Health Insurance Rate Setting Process for Individuals, Small Businesses,” The Boston Globe (May 10, 2022). https://www.bostonglobe.com/2022/05/10/metro/state-looks-change-health-insurancerate-setting-process-individuals-small-businesses/

112. Hurst, Jon, and Laura Glordano, Press Statement: Statement from Health Care For All and Retailers Association of Massachusetts on New Division of Insurance Regulations to Curb Health Insurance Premium Increases, Health Care For All Massachusetts, Boston, M.A. (April 13, 2022). https://hcfama.org/press-statement-statement-from-health-care-forall-and-retailers-association-of-massachusetts-on-new-division-of-insurance-regulations-to-curb-health-insurancepremium-increases/

113. Massachusetts Health Policy Commission, 2021 Annual Health Care Cost Trends Report, Boston, M.A. (September 2021). https://www.mass.gov/doc/2021-health-care-cost-trends-report/download

114. Fuse Brown, Erin, Toolkit: Health Insurance Rate Review Authority to Control Health Care Costs, Including Model Legislation and Regulatory Language, National Academy for State Health Policy, Washington, D.C. (June 29, 2021). https://www.nashp.org/nashp-toolkit-for-assessing-and-enacting-health-insurance-rate-review-authority-to-control-health-carecosts/#toggle-id-2

115. Butler, Johanna, Insurance Rate Review as a Hospital Cost Containment Tool: Rhode Island’s Experience, National Academy for State Health Policy, Washington, D.C. (Feb. 1, 2021). https://www.nashp.org/insurance-rate-review-as-a-hospitalcost-containment-tool-rhode-islands-experience/

116. Ibid.

117. Reger, Alex, Rhode Island’s Health Insurance “Affordability Standards,” Connecticut General Assembly, Office of Legislative Research, Hartford, C.T. (Aug. 22, 2016). https://www.cga.ct.gov/2016/rpt/pdf/2016-R-0146.pdf

118. Connecticut Office of Health Strategy, CT Healthcare Affordability Index (June 2021). https://portal.ct.gov/-/media/OHS/CT-Healthcare-Affordability-Index/CHAI/CT-Healthcare-Affordability-IndexJune-23-2021.pdf

119. Hayes, Susan L., Sara R. Collins and David C. Bradley, How Much U.S. Households with Employer Insurance Spend on Premiums and Out-of-Pocket Costs: A State-by-State Look, Commonwealth Fund, Washington, D.C. (May 23, 2019). https://www.commonwealthfund.org/publications/issue-briefs/2019/may/how-much-us-households-employerinsurance-spend-premiums-out-of-pocket

120. Massachusetts Health Policy Commission (September 2021). https://www.mass.gov/doc/2021-health care-cost-trendsreport/download

121. Ibid.

122. Ibid.

123. Ibid.

124. Norris, Louise, Massachusetts Health Insurance Marketplace 2023 Guide, HealthInsurance.org (Oct. 31, 2022). https://www.healthinsurance.org/health-insurance-marketplaces/massachusetts/

125. Corlette, Sabrina, Standardizing Health Plan Benefit Design: Opportunities and Implications for States, State Health & Value Strategies, Princeton University, Princeton, N.J. (Nov. 18, 2019).
https://www.shvs.org/standardizing-health-planbenefit-design-opportunities-and-implications-for-states/

126. Giovannelli, Justin, Rachel Schwab and Kevin Lucia, State Efforts to Standardize Marketplace Health Plans Show How the Biden Administration Could Improve Value and Reduce Disparities, Commonwealth Fund, Washington, D.C. (July 28, 2021). https://www.commonwealthfund.org/blog/2021/state-efforts-standardize-marketplace-health-plans

127. Massachusetts Health Policy Commission (September 2021).
https://www.mass.gov/doc/2021-health care-cost-trendsreport/download

128. Cooper, Rebecca, and Lynn Quincy, High-Value Care: Strategies to Address Underuse, Altarum’s Healthcare Value Hub, Ann Arbor, M.I. (November 2018).
https://www.healthcarevaluehub.org/advocate-resources/publications/high-valuecare-strategies-address-underuse

129. Health Connector Update: Open Enrollment 2022, Massachusetts Health Connector, (October 2021). https://www.masshealthmtf.org/sites/default/files/Oct_2021_MTF_HealthConnectorUpdates_updated_0.pdf

130. ConnectorCare Health Plans: Affordable, High-Quality Coverage from the Health Connector, Massachusetts Health Connector (Accessed Nov. 1, 2022). https://www.mahealthconnector.org/wp-content/uploads/Guide_to_ConnectorCare.pdf

131. Altarum’s Healthcare Value Hub, Healthcare Affordability State Policy Scorecard (Accessed Nov. 1, 2022). https://healthcarevaluehub.org/affordability-scorecard

132. Massachusetts Senate Bill 2695, An Act Relative to Pharmaceutical Access, Costs and Transparency, 2021-2022 Session, Massachusetts Legislature, (Accessed Nov. 1, 2022). https://malegislature.gov/Bills/192/S2695

133. Hoskins, Mike, “Why State-by-State Insulin Copay Caps Aren’t the Answer,” Healthline (March 19, 2021). https://www.healthline.com/diabetesmine/state-insulin-copay-caps-not-enough

134. Roe, Ginna, Utah Health Insurer to Launch State’s First-Ever Insulin Savings Program, KUTV (May 14, 2020). https://kutv.com/news/local/utah-health-insurer-to-launch-states-first-ever-insulin-savings-program

135. Utah House Bill 207, Insulin Access Amendments, 2020 General Session, Utah State Legislature, (Accessed Dec. 23, 2021). https://le.utah.gov/~2020/bills/static/HB0207.html

136. New Mexico House Bill 292, Prescription Drug Cost Sharing, 2020 Regular Session, New Mexico Legislature (Accessed Nov. 1, 2022). https://www.nmlegis.gov/Legislation/Legislation Chamber=H&LegType=B&LegNo=292&year=20

137. Texas Senate Bill 827, Relating to Health Benefit Plan Cost-Sharing Requirements for Prescription Insulin, 2021-2022 Session, LegiScan, (Accessed Nov. 1, 2022). https://legiscan.com/TX/text/SB827/2021

138. Texas House Bill 18, Relating to Establishment of the Prescription Drug Savings Program for Certain Uninsured Individuals, 2021 Regular Session, Texas Legislature, (Accessed Nov. 1, 2022).
https://capitol.texas.gov/BillLookup/History.aspx?LegSess=87R&Bill=HB18

139. Oregon House Bill 2623, Relating to the Cost of Insulin, 2021 Regular Session, Oregon Legislature (Accessed Nov. 1, 2022). https://olis.oregonlegislature.gov/liz/2021R1/Downloads/MeasureDocument/HB2623/Enrolled

140. Oregon Department of Consumer and Business Services, Temporary Administrative Order: ID 4-2021, Amendment to 2022 Standard Bronze and Silver Health Benefit Plans, Salem, O.R. (May 28, 2021).
https://dfr.oregon.gov/laws-rules/Documents/id04-2021_rule-order.pdf

141. Yeung, Kai, et al., “Patient and Plan Spending after State Specialty-Drug Out-of-Pocket Spending Caps,” New England Journal of Medicine, Vol. 383 (Aug. 6, 2020). https://www.nejm.org/doi/full/10.1056/NEJMsa1910366

142. Massachusetts Health Connector, Health Equity Initiatives in the 2023 Seal of Approval (Accessed Aug. 10, 2022). https://www.mahealthconnector.org/health-equity-initiatives-in-the-2023-seal-of-approval

143. DC Health Benefit Exchange Authority, Resolution, Washington, D.C. (July 14, 2021).

144. Connecticut Office of Health Strategy, Connecticut’s Cost and Quality Benchmarks Initiative: A Presentation to the Medical Assistance Program Oversight Council (MAPOC) (Aug. 14, 2020).

145. State of Connecticut Office of Health Strategy, Cost Growth/Quality Benchmarks/Primary Care Target (accessed Aug. 10, 2022). https://portal.ct.gov/OHS/Services/Cost-Growth-Quality-Benchmarks-Primary-Care-Target

146. Connecticut State Office of Health Strategy, Quality Council: Quality Benchmarks (Accessed Oct. 31, 2022). https://portal.ct.gov/OHS/Pages/Quality-Council/Quality-Benchmarks

147. Connecticut State Office of Health Strategy, Cost Growth/Quality Benchmarks/Primary Care Target (Accessed Oct. 31, 2022). https://portal.ct.gov/OHS/Services/Cost-Growth-Quality-Benchmarks-Primary-Care-Target

148. Barum, Aaron, et al., “Health Care Spending Slowed Following State Regulation of Commercial Insurers through Rhode Island’s Affordability Standards,” Health Affairs, Vol. 38, No. 2 (Feb. 1, 2020).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593124/

149. Massachusetts Health Policy Commission, Out-of-Network Billing in Massachusetts, Boston, M.A. (May 2020). https://www.mass.gov/doc/out-of-network-billing-in-massachusetts-chartpack/download

150. Kona, Maanasa, State Balance-Billing Protections, Commonwealth Fund, Washington, D.C. (Feb. 5, 2021). https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections

151. McCormick, Drew Elizabeth, and Joseph Parise, Massachusetts Enacts Legislation Promoting Access to Quality and Affordable Care, Telehealth, JD Supra (Feb. 9, 2021). https://www.jdsupra.com/legalnews/massachusettsenacts-legislation-6404557/

152. Evidence on Surprise Billing: Protecting Consumers with the No Surprises Act, U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Washington, D.C.(Nov. 22, 2021).

153. Glaser, Alex H., and Timothy P. Brechtel, “A Few Surprises for the No Surprises Act,” National Law Review, Vol. 12, No. 305 (May 12, 2022). https://www.natlawreview.com/article/few-surprises-no-surprises-act

154. Pollitz, Karen, No Surprises Act Implementation: What to Expect in 2022, Kaiser Family Foundation, Washington, D.C. (Dec. 10, 2021). https://www.kff.org/health-reform/issue-brief/no-surprises-act implementation-what-to-expect-in-2022/

155. Kalmar, Patricia, Ground Ambulances: The One Surprise Bill Not Covered by the ‘No Surprises Act,’ PIRG, Denver, C.O. (June 15, 2021).

156. Sullivan, Heather, Loopholes in No Surprises Act Can Leave Some Patients with High Bills, Fox 26 Houston, Houston, T.X. (April 13, 2022). https://www.fox26houston.com/news/loopholes-in-no-surprises-act-can-leave-patients-with-high-bills

157. Kaiser Family Foundation, No Surprises Act Quiz, Washington, D.C. (Accessed Nov. 1, 2022).
https://www.kff.org/quiz/nosurprises-act-quiz/

158. Hancock, Jay, “An $80,000 Tab for Newborns Lays Out a Loophole in the New Law to Curb Surprise Bills,” Kaiser Health News, (Feb. 23, 2022).
https://khn.org/news/article/nicu-surprise-bill-loophole-no-surprises-act/

159. Weissmann, Dan, “How to Avoid Surprise Medical Bills – and the Pitfalls in the New Law,” Health News Florida (March 16, 2022). https://health.wusf.usf.edu/health-news-florida/2022-03-16/how-to-avoid-surprise-medical-bills-and-thepitfalls-in-the-new-law

160. Volk, JoAnn, and Sabrina Corlette, The No Surprises Act: Implications for States, State Health & Value Strategies, Princeton University, Princeton, N.J., (Jan 12, 2021).
https://www.shvs.org/the-no-surprises-act-implications-for-states/

161. McCormick, Drew Elizabeth, and Joseph Parise (Feb. 9, 2021).
https://www.jdsupra.com/legalnews/massachusettsenacts-legislation-6404557/

162. Ibid.

163. Massachusetts Executive Office of Health and Human Services (Sept. 8, 2021).
https://www.mass.gov/doc/report-tothe-massachusetts-legislature-out-of-network-rate-recommendations/download

164. U.S. Department of Health and Human Services (Nov. 22, 2021). https://aspe.hhs.gov/sites/default/files/documents/acfa063998d25b3b4eb82ae159163575/no-surprises-act-brief.pdf

165. Adler, Loren, et al., State Approaches to Mitigating Surprise Out-of-Network Billing, USC-Brookings Schaeffer Initiative for Health Policy (February 2019).
https://www.brookings.edu/wp-content/uploads/2019/02/Adler_et-al_State-Approachesto-Mitigating-Surprise-Billing-2019.pdf

166. Georgetown University Health Policy Institute, Center on Health Insurance Reforms, The No Surprises Act and Preemption of State Balance Billing Protections, Washington, D.C. (April 1, 2021).
https://surprisemedicalbills.chir.georgetown.edu/wpcontent/uploads/Preemption-and-No-Surprises-Act_April-2021.pdf

167. Amin, Krutika, et al., Ground Ambulance Rides and Potential for Surprise Billing, Peterson-KFF Health System Tracker (June 24, 2021). https://www.healthsystemtracker.org/brief/ground-ambulance-rides-and-potential-for-surprise-billing/

168. Ibid.

169. Ibid.

170. Keith, Katie, et al., “Banning Surprise Bills: Biden Administration Issues First Rule on the No Surprises Act,” Health Affairs Forefront, Washington, D.C. (July 6, 2021).
https://www.healthaffairs.org/do/10.1377/forefront.20210706.903518/

171. Hancock, Jay (Feb. 23, 2022).
https://khn.org/news/article/nicu-surprise-bill-loophole-no-surprises-act/

172. Georgetown University Health Policy Institute, Center on Health Insurance Reforms (April 1, 2021). https://surprisemedicalbills.chir.georgetown.edu/wp-content/uploads/Preemption-and-No-Surprises-Act_April-2021.pdf

173. Adler, Loren, Experience with New York’s Arbitration Process for Surprise Out-of-Network Bills, USC-Brookings Schaeffer Initiative for Health Policy (Oct. 24, 2019).
https://www.brookings.edu/blog/usc-brookings-schaeffer-on-healthpolicy/2019/10/24/experience-with-new-yorks-arbitration-process-for-surprise-out-of-network-bills/

174. University of Vermont Health Network, Your Rights and Protections Against Surprise Medical Bills, Burlington, V.T., (Accessed Nov. 1, 2022). https://www.uvmhealth.org/balance-billing-notice

175. Hoadley, Jack, et al., State Efforts to Protect Consumers from Balance Billing, Commonwealth Fund, Washington, D.C. (Jan. 18, 2019). https://www.commonwealthfund.org/blog/2019/state-efforts-protect-consumers-balance-billing

176. Massachusetts Executive Office of Health and Human Services (Sept. 8, 2021).
https://www.mass.gov/doc/report-tothe-massachusetts-legislature-out-of-network-rate-recommendations/download

177. Ibid.

178. Ollove, Michael, Laws to Curb Surprise Medical Bills Might be Inflating Health Care Costs, Pew Charitable Trusts, Washington, D.C. (May 20, 2021).
https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2021/05/20/laws-to-curb-surprise-medical-bills-might-be-inflating-health-care-costs

179. Adler, Loren, et al., Understanding the No Surprises Act, USC-Brookings Schaeffer Initiative for Health Policy, (Feb. 4, 2021). https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2021/02/04/understanding-the-nosurprises-act/

180. Norris, Louise, Availability of Short-Term Health Insurance in Massachusetts, HealthInsurance.org, (Sept. 27, 2021). https://www.healthinsurance.org/short-term-health-insurance/massachusetts/