Opinion ID: 2135222
Heading Depth: 1
Heading Rank: 5

Heading: Blue Cross's Authority to Contract for Payment for Physicians' Services.

Text: To respond to question No. 2 it will be helpful to recast the question into two questions: (a) Is Blue Cross empowered under G.L.c. 176A to cover physicians' services under the caption other health services as that phrase is used in G.L.c. 176A, § 1? (b) By what authority is Blue Cross authorized to contract directly with the Commonwealth to cover services of physicians? The first question (a) must be answered no. Blue Cross was permitted to provide benefits only for hospital services until 1953. In that year the Legislature amended G.L.c. 176A, § 1, to permit a hospital service corporation to provide reimbursement for other health services. St. 1953, c. 287, § 1. These other health services have included such nonhospital providers as visiting nurse associations, mental health clinics and home health agencies. Authorization for these contracts is found in the fourth paragraph of G.L.c. 176A, § 5. It has been stipulated that Blue Cross has never provided benefits for physicians' services except (1) covered services rendered by salaried staff physicians of hospitals and certain other institutional providers with which it has contracts; and (2) nonemergency, in State service rendered by participating and nonparticipating Blue Shield physicians under the State employees' contract. The Master Medical Certificate issued to subscribers provides that [b]enefits contained herein for all services and supplies other than those furnished by a physician, dentist, podiatrist, or psychologist shall be provided by Blue Cross, and that [b]enefits contained herein for services of a physician, dentist, podiatrist, or psychologist shall be provided by Blue Shield. It is highly unlikely that the Legislature would authorize Blue Cross and Blue Shield to sail on a collision course of competition for subscribers for coverage of physicians' services when Blue Cross's principal course is directed toward hospital services and Blue Shield's towards physicians' services. Equally improbable is a legislative intent to permit Blue Cross to provide the benefits of a full range of physicians' services on a nonparticipating basis and thereby escape the network of regulation found in G.L.c. 176B. In short, Blue Cross is not empowered to cover physicians' services except in those instances already noted. The answer to the second question (b) can be found in G.L.c. 32A, § 4. Blue Cross is authorized to contract with State employees because the Legislature vested it with such authority. Under this statute, [6] the Group Insurance Commission is authorized to enter into an agreement for insurance coverage for State employees with Blue Cross in the same manner as any other insurance company. The authority for contracts with State employees reposes in G.L.c. 32A in the first instance, and not in G.L.c. 176A. The express reference to G.L.c. 176A in G.L.c. 32A, § 4, encourages us to rule that such provision is special and thus, absent a contrary legislative intent, it must prevail over conflicting provisions, if any, in G.L.c. 176A and c. 176B. See Boston Teachers Local 66 v. School Comm. of Boston, 370 Mass. 455, 472 (1976). Accordingly, we respond to this question by recognizing that payments to physicians for medical services under the contract between Blue Cross and the Group Insurance Commission are authorized by the express language of G.L.c. 32A, § 4, and, as such, this coverage does not derogate from the exclusiveness of Blue Shield's coverage for physicians' services to subscribers who are not under the contract insuring State employees. In conclusion, we answer question 1(a), No, 1(b), Yes, 2, No.