For the first time, many low-income patients seeking free care at hospitals will face deductibles and copayments similar to those charged to insured patients, under proposed rules released yesterday that are designed to push more Massachusetts residents to get health insurance.
In addition, the state will no longer reimburse hospitals and community health centers for care they provide if the patients are eligible for insurance through the state Medicaid program, state-subsidized Commonwealth Care, or affordable coverage through their work. Hospital officials said that they would not turn away patients needing urgent care, but that they probably would be more aggressive in billing those patients.
The new provisions were required under the state law that mandates that all adults obtain insurance coverage this year, if the state deems it affordable for them. The state is drawing on funds previously used for free care to pay for insurance subsidies and is counting on weaning as many people as possible from free care.
The number of people using the pool already has dropped 20 percent this year compared with last year, according to state officials, in large part because 155,000 people now have insurance through the state's near-universal coverage initiative. But hundreds of thousands of patients are still using the pool.
The state allocated $605 million for free care this year, but the fiscal 2008 budget Governor Deval Patrick approved yesterday includes only $354 million for the pool's successor, the Health Safety Net Trust Fund.
"We did not want the trust fund to look more attractive to people than insurance," said Dr. JudyAnn Bigby , state secretary of Health and Human Services, as she explained the rules the administration issued yesterday .
Rather, she said, the rules are designed to make sure free care serves as a safety net for people without access to insurance, those whose insurance is inadequate, and those who face extraordinary medical expenses. The rules are subject to a public hearing, scheduled for Aug. 22, and may be revised before they are imposed on Oct. 1.
The proposals drew support from advocates and healthcare providers, but also concern that the new copayments would deter some people from seeking care and could leave hospitals with extra debt if patients get care but are unable to pay for it.
"We think the regulations are a great step forward and will ensure that most folks who can't find affordable coverage . . . will maintain access to critical life-saving services," said John McDonough, executive director of the advocacy group Health Care for All . "But we are concerned that for an individual making between $15,000 and $20,000, there will be a new deductible that accumulates on a monthly basis whether or not they actually use any medical services. That means that someone could get services in January, then go back in December and face a bill of about $385 before they could get served."
The proposed deductible is $35 a month for people earning between 150 percent and 200 percent of the federal poverty level -- roughly $15,000 to $20,000. Other copayments include $5 for office visits in a hospital and $50 for emergency room visits that don't result in an inpatient admission. These payments apply to patients between 100 percent and 200 percent of the poverty level. There are no copayments or deductibles for children or for care at community health centers, other than a $3 charge for each prescription filled.
Patients earning between 200 percent and 400 percent of the poverty level would face a larger deductible, based on their income.
State officials said they would try to ensure that the new rules do not cause major disruption. "We will be implementing this in a measured and phased way, so it doesn't create a hardship," said Sarah Iselin , state commissioner of healthcare finance and policy, whose office oversees free care.
Joe Kirkpatrick, vice president of the Massachusetts Hospital Association , said, "Patients should expect more rigorous collection and enforcement efforts" from hospitals if the new rules are imposed. Hospital officials also want the state to help medical facilities foot the bill, he said, if patients do not pay deductibles or if uninsured patients with access to insurance nonetheless seek emergency care at hospitals.
"We're not going to turn people away," said Ellen Murphy Meehan , a spokeswoman for the Alliance of Safety Net Hospitals . "But we believe there's a shared burden of responsibility."
Under the proposed rules, the state would pay for a broad range of medically-necessary care for the uninsured. In addition, the state would expand the amount it pays for people facing medical bills that pose an extreme hardship.
Jon Kingsdale , executive director of the Commonwealth Health Insurance Connector , said the rules probably would drive more people to get insurance. "It's like the second shoe dropping on health reform," he said.
Alice Dembner can be reached at Dembner@globe.com.