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Nonpayment for Serious Preventable Adverse Health Care Events

The Plan implemented a policy in October 2008 to no longer pay for hospital-based costs associated with 29 serious preventable adverse health care events. This nonpayment policy is in line with Massachusetts legislation enacted in the fall of 2008. These adverse events are based upon the work done by the National Quality Forum, a nonprofit coalition of physicians, hospitals, businesses and policy-makers. Some of these events include:

For a complete list of the 29 serious preventable health care events for which the Plan will not pay benefits, visit the website for the National Quality Forum.

In accordance with the current Department of Public Health (DPH) regulations, Massachusetts providers are not permitted to bill members for designated serious reportable health care events. Therefore, members will not be responsible for paying any charges in connection with events that the Plan will not cover.

DPH has established requirements indicating that providers must report the occurrence of these serious preventable events as defined by this new legislation. DPH has also provided guidance to providers on what they are allowed to bill for regarding these events. The Plan will follow the guidance of DPH in administering its nonpayment policy.

For Medicare Members

The Centers for Medicare and Medicaid Services (CMS) established a similar policy regarding the nonpayment of serious preventable health care events in October 2008. For information on this policy, contact CMS at 1-800-633-4227 (TTY: 1-877-486-2048).

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