Mass. Gen. Laws ch. 118E § 10N

Current through Chapters 1 to 249 and Chapters 253 to 255 of the 2024 Legislative Session

Section 118E:10N - Enrollees not required to obtain referral from primary care provider prior to obtaining health care services from urgent care facility

(a) For the purposes of this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:-

"Division", the division of medical assistance within the executive office of health and human services.

"Urgent care facility", any entity, however organized, whether conducted for profit or not for profit, which is advertised, announced, established or maintained for the purpose of providing urgent care services in an office or a group of offices, or any portion thereof, or an entity which is advertised, announced, established or maintained under a name which includes the words "urgent care" or which suggests that urgent care services are provided therein; provided, however, that an urgent care facility shall not serve as a patient's primary care provider.

"Urgent care services", delivery of episodic care for the diagnosis, treatment, management or monitoring of acute and chronic disease or injury that is:

(i) for the treatment of illness or injury that is immediate in nature but does not require emergency services;

(ii) generally provided on a walk-in basis without a prior appointment;

(iii) available to the general public; and

(iv) not intended as the patient's primary care provider.

(b) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall not require an enrollee to obtain a referral from a primary care provider prior to obtaining health care services from an urgent care facility; provided, however, that any urgent care facility providing health care services to an enrollee shall provide the enrollee with names of primary care providers contracted with MassHealth and practicing in the municipality of residence of the enrollee or an adjacent municipality.

Any urgent care facility that provides health care services to an enrollee shall notify the division, in a manner to be determined by the division, that the urgent care facility provided such services to the enrollee. The urgent care facility shall also notify the division, in a manner to be determined by the division, if the enrollee does not have a designated primary care provider, and the division shall send a notice to the enrollee that shall contain guidance on how to choose a primary care provider.

The division may promulgate regulations to implement this section.

Mass. Gen. Laws ch. 118E, § 10N

Added by Acts 2020, c. 260,§ 39, eff. 1/1/2021.