MA H4226

Dually eligible individuals (those with both Medicare and MassHealth) may receive care from any specialist or hospital enrolled in Medicare or MassHealth, regardless of health plan network restrictions

Out-of-network providers without existing contracts must be reimbursed by One Care or SCO plans at Medicare or MassHealth fee-for-service rates

When contracts between One Care/SCO plans and providers terminate, affected members may continue receiving services from their existing primary care, specialist, or hospital providers for 12 months beyond standard continuity of care periods

Plans must maintain all pre-termination contract terms, including reimbursement rates, during the extended continuity period unless both parties mutually agree to different terms

Plans and providers are prohibited from using these provisions to avoid good faith contract negotiations