reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 10.00 - Health Insurance Responsibility Disclosure › Section 10.05 - Other Provisions

Current through Register 1525, July 5, 2024
(1) Information
			 that identifies individual Employees by name or health insurance status shall
			 not be a public record, but such information may be exchanged with the
			 Department of Revenue, the Health Care Access Bureau of the Division of
			 Insurance, the Division of Unemployment Assistance, or the Commonwealth Health
			 Insurance Connector Authority to extent permitted by law under an Interagency
			 Service Agreement.
(2)
Penalties
. An Employer that knowingly falsifies or
			 fails to file any information required by the Connector shall be punished by a
			 fine of not less than $1,000 or more than $5,000.
(3)
Severability
.
			 The provisions of
			 956 CMR 10.00 are severable.
			 If any provision or the application of any provision is held to be invalid or
			 unconstitutional, and such invalidity shall not be construed to affect the
			 validity or constitutionality of any remaining provisions of
			 956 CMR 10.00 or the
			 application of such provisions.
(4)
Administrative Bulletins
. The Connector may issue
			 administrative bulletins to clarify policies, update administrative
			 requirements and specify information and documentation necessary to implement
			 956 CMR 10.00.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 11.00 - Employer Fair Share Contribution › Section 11.01 - General Provisions

Current through Register 1525, July 5, 2024
Scope and Purpose
.
				956 CMR 11.00 governs the
				determination of whether an Employer makes a Fair and Reasonable Premium
				Contribution to the health insurance cost of its Employees. Employers that make
				a Fair and Reasonable Premium Contribution are exempt from the Employer Fair
				Share Contribution under M.G.L. c. 149, § 188.
				956 CMR 11.00 also governs
				the determination of the annual Fair Share Contribution Amount. The Fair Share
				Contribution is collected by the Division of Unemployment Assistance from
				Employers of 11 or more full-time equivalent employees in accordance with 430
				CMR 15.00:
Fair Share Employer Contribution.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 11.00 - Employer Fair Share Contribution › Section 11.03 - Determination of Fair and Reasonable Premium Contribution

Current through Register 1525, July 5, 2024
(1)
General
. An
			 Employer that employs 11 or more full-time equivalent Employees in the
			 Commonwealth as determined under 956 CMR 11.03(2) and is not a Contributing
			 Employer as determined under 956 CMR 11.03(3) shall pay a per Employee
			 contribution in accordance with 430 CMR 15.00:
Fair Share Employer
			 Contribution.
(2)
Number of Employees
. An Employer has 11 or more
			 full-time equivalent Employees if the sum of total payroll hours for all
			 Employees for a calendar quarter, divided by 500, is greater than or equal to
			 11. In calculating total payroll hours:
(a)
			 For each Employee with more than 500 payroll hours, the Employer shall include
			 500 payroll hours.
(b) Payroll
			 hours include all hours for which an Employer paid wages to an Employee
			 including, but not limited to, regular, vacation, sick, Federal Medical Leave
			 of Absence, short term disability, long term disability, overtime and holiday
			 payroll hours.
(c) An Employer that
			 is determined to be a successor under M.G.L. c. 151A shall include the payroll
			 hours of the predecessor's Employees during the applicable period.
(d) Payroll hours include hours for which an
			 Employer paid wages to a temporary employee as defined in
			 430 CMR
			 4.04(8)(a):
Definitions
provided that the individual has worked for the
			 Employer for at least 150 payroll hours during the 12 month period ending with
			 the last day of the applicable reporting period.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 11.00 - Employer Fair Share Contribution › Section 11.04 - Determination of Annual Fair Share Employer Contribution

Current through Register 1525, July 5, 2024
(1)
Determination of Contribution
			 Amount
. The Annual Fair Share Employer Contribution Rate is the
			 lower of:
(a) $295 per employee; or
(b) the sum of the Fair Share Employer
			 Contribution and the Per Employee Cost of Unreimbursed Physician Care as
			 calculated in accordance with 956 CMR 11.04. The Fair Share Employer
			 Contribution Rate shall be determined annually by the Connector in consultation
			 with the Director of the Department of Workforce Development using the best
			 available data. The Annual Fair Share Employer Contribution Rate shall be
			 adjusted to reflect a quarterly rate based on 25% of the annual fair share
			 contribution rate applicable to that quarterly period.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 11.00 - Employer Fair Share Contribution › Section 11.05 - Other Provisions

Current through Register 1525, July 5, 2024
(1)
General
. Each Employer shall file or make available
			 information which is required or which the Connector deems reasonably necessary
			 for calculating the Employer Fair Share Contribution.
(2)
Severability
.
			 The provisions of
			 956 CMR 11.00 are severable.
			 If any provision or the application of any provision is held to be invalid or
			 unconstitutional, such invalidity shall not be construed to affect the validity
			 or constitutionality of any remaining provisions of
			 956 CMR 11.00 or the
			 application of such provisions.
(3)
Administrative Bulletins
. The Connector may issue
			 administrative bulletins to clarify policies, update administrative
			 requirements and specify information and documentation necessary to implement
			 956 CMR 11.00.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.01 - Purpose

Current through Register 1525, July 5, 2024
The purpose of
										956 CMR 12.00 is to implement the provisions of M.G.L. c.
										176Q and thereby facilitate the availability, choice and adoption of qualified health plans to eligible
										individuals, families and groups.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.02 - Scope

Current through Register 1525, July 5, 2024
956 CMR 12.00 governs eligibility
										for Connector Programs, Enrollment, responsibility of Enrollees, Enrollee Premiums, disenrollment, and the
										related appeal process under M.G.L. c. 176Q. The Connector also promulgates other regulations and publishes
										other documents affecting its programs, including statements of policy and procedure, conditions of
										participation, guidelines, billing instructions, administrative information bulletins and other documents as
										necessary.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.04 - Eligibility for ConnectorCare

Current through Register 1525, July 5, 2024
(1)
Eligibility for a Non-group Health Plan without Financial
								 Assistance
. To be eligible for a Non-group Health Plan without financial assistance, the
								 individual must:
(a) Be a citizen or national of the United States, or a
								 non-citizen who is lawfully present in the United States, as defined in
								 45 CFR
								 152.2, and is reasonably expected to be a citizen, national, or a
								 non-citizen who is lawfully present for the entire period for which enrollment is sought;
(b) Not be incarcerated, other than incarceration pending the disposition
								 of charges; and
(c) Be a Resident.
To be eligible for a Non-group Health Plan that is a catastrophic plan, as
										described at
										42 USC
										§
											18022(e), an individual must meet the above
										eligibility requirements and also not have reached 30 years of age before the beginning of the plan year or
										have a qualifying exemption from the requirement to maintain minimum essential coverage under the Internal
										Revenue Code, 45 CFR
										155.305(h)(2), §5000A.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.05 - Matching Information

Current through Register 1525, July 5, 2024
The Connector or its designee initiates information matches with other state
										and federal agencies and information sources when an Application is received, when eligibility is
										redetermined, or at other times in the Connector's administrative processes in order to verify eligibility or
										certain information. These agencies and information sources may include, but are not limited to, the
										following: the Massachusetts Department of Unemployment Assistance (DUA), MassHealth, Massachusetts
										Department of Public Health's Registry of Vital Records and Statistics (RVRS), Massachusetts Department of
										Industrial Accidents, Massachusetts Department of Veteran's Services, Massachusetts Department of Revenue
										(DOR), Massachusetts Bureau of Special Investigations, Internal Revenue Service, Social Security
										Administration (SSA), Systematic Alien Verification for Entitlements Program (SAVE), Department of Homeland
										Security, Massachusetts Department of Transitional Assistance (DTA), and Health Carriers.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.06 - Standards for an Eligibility Application

Current through Register 1525, July 5, 2024
In making an eligibility determination for Connector Programs, the Connector
										will require an Applicant to complete an Application and provide the information requested in that
										Application. Based on the information supplied in that Application, and, consistent with
										45 CFR 155.315 and
										155.320, matching
										information as described in 956
										CMR 12.05, additional information may be requested to determine eligibility
										status.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.07 - Eligibility Review Related to Connector Programs for Non-group Health Plans

Current through Register 1525, July 5, 2024
(1) The Connector or its designee may review
								 eligibility for Connector Programs for Non-Group Health Plans every 12 months, consistent with
								 45 CFR 155.335, or more
								 frequently as part of a mid-year redetermination, consistent with
								 45 CFR 155.330.
								 Eligibility may also be reviewed more frequently as a result of an Eligible Individual's change in
								 circumstances, or a change in Connector Program eligibility rules. The Connector or its designee updates the
								 case file based on information received as the result of such review. The Connector reviews eligibility:
(a) By information matching with other state and federal agencies, Health
								 Carriers, and information sources as set forth in
								 956 CMR
								 12.05;
(b) Based on information
								 obtained from an Applicant, Eligible Individual, or Enrollee, subject to verification.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.08 - Eligibility Effective Dates for Connector Programs for Non-group Health Plans

Current through Register 1525, July 5, 2024
(1) In general, any eligibility determination for
								 Non-group Health Plans, including a change in eligibility in accordance with
								 956 CMR
								 12.07, will be effective on the first day of the month following the month
								 in which the Connector notifies the Eligible Individual of the eligibility determination.
(2) The Connector shall provide in written policy a point during the month
								 after which, if an Eligible Individual's eligibility changes, and the Eligible Individual remains eligible
								 for a Connector Program, the effective date of that new eligibility determination will be the first day of
								 the month following the month specified in
								 956 CMR
								 12.08(1).
(3)
								 Notwithstanding the foregoing, any eligibility determination that results in an Eligible Individual no longer
								 being eligible for any Connector Program for Non-Group Health Plans will be effective on the first day of the
								 month after the month in which the Connector notifies the Eligible Individual of the eligibility
								 determination.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.09 - Responsibilities of Applicants, Eligible Individuals, Eligible Small Employers, and Enrollees

Current through Register 1525, July 5, 2024
(1)
Responsibility to
								 Cooperate
. The Applicant, Eligible Individual, Eligible Small Employer, or Enrollee must
								 cooperate with the Connector or its designee in providing information necessary to establish and maintain
								 eligibility and to bill and collect Premiums, and must comply with all the rules and regulations of the
								 Connector or its designee. An Applicant's failure to provide information requested during the eligibility
								 determination process may result in a delay in the eligibility determination, or a denial of
								 eligibility.
(2)
Responsibility to Report
								 Changes
. The Applicant, Eligible Individual, Eligible Small Employer, or Enrollee must report to
								 the Connector or its designee, within 30 days, changes that may affect eligibility or Premiums. Such changes
								 include, but are not limited to, residency, address, income, the availability of health insurance, household
								 composition changes, and immigration status.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.10 - Enrollment in, Open Enrollment and Special Enrollment Periods Applicable to, and Termination from Non-group Health Plans

Current through Register 1525, July 5, 2024
(1)
Open Enrollment and Special
			 Enrollment Periods for Non-group Health Plans
. Eligible
			 Individuals may enroll in a Non-group Health Plan, and Enrollees may transfer
			 from one Non-group Health Plan to a different Non-group Health Plan, as made
			 available to that Eligible Individual or Enrollee through the Health Connector,
			 during any open enrollment periods established by state or federal law.
			 Eligible Individuals may enroll in a Non-group Health Plan, and Enrollees may
			 transfer from one Non-group Health Plan to a different available Non-group
			 Health Plan, outside of the open enrollment period only during a special
			 enrollment period established by the Connector for one of the following
			 reasons:
(a) The Enrollee experiences a
			 triggering event, as set forth in
			 45 CFR
			 155.420 and applicable state law including,
			 but not limited to, enrollment waivers available under 958 CMR 4.00:
Health Insurance Open Enrollment Waivers
;
(b) An individual is determined newly
			 eligible for a ConnectorCare plan in accordance with
			 956 CMR
			 12.04(3);
(c) The Enrollee's eligibility changes Plan
			 Types in accordance with
			 956 CMR
			 12.04(3);
(d) The Enrollee's eligibility changes from
			 being eligible for ConnectorCare to being eligible for a Non-group Health Plan
			 with APTC Only;
(e) The Enrollee
			 has been approved for a hardship waiver in accordance with
			 956 CMR 12.12;
			 or
(f) The Enrollee's hardship
			 waiver period has ended.
Enrollees will have 60 days to enroll in a Health Plan from the
				date of one of the events in 956 CMR 12.10(1)(a) through
				(f).
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.13 - Right to Appeal

Current through Register 1525, July 5, 2024
Applicants, Eligible Individuals, Enrollees, and Employers are
				entitled to appeal the following Appealable Actions:
(1) Any eligibility determination based on
			 any eligibility factor in accordance with
			 956 CMR
			 12.04;
(2) Any determination of APTC amount, or of
			 ConnectorCare Plan Type;
(3) Any
			 determination regarding a Special Enrollment Period related to a Non-group
			 Health Plan based on the reasons listed at
			 956
			 CMR 12.10(4)(1) through (f);
			 or
(4) The Connector's denial of a
			 financial hardship waiver or reduction of premium, the renewal of a financial
			 hardship waiver or reduction of premium, or the period of time to which a
			 financial hardship waiver or reduction of premium applies, under
			 956 CMR
			 12.12.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.14 - Times and Methods for Filing Appeal Requests

Current through Register 1525, July 5, 2024
(1) The Applicant, Eligible Individual,
			 Enrollee, or Employer will receive a notice in writing of an Appealable Action
			 identified in
			 956 CMR
			 12.13 from either MassHealth or the Connector
			 or both. That notice will also include notice of the right to an appeal,
			 including to a hearing with an independent hearing officer, of the method by
			 which an appeal may be requested, and of the right to use an Appeal
			 Representative. The notice will also include a form for appealing the
			 action.
(2) The request for an
			 appeal must be received within the following time limits:
(a) For any Appealable Action regarding a
			 Connector Program for Non-group Health plans
1. 30 days after the receipt of the notice of
			 the Appealable Action. (In the absence of evidence to the contrary, it will be
			 presumed that the notice was received five days after the date on the notice);
			 or
2. 120 days from the date of an
			 Appealable Action if the Connector fails to send written notice of such action
			 or fails to act on a request for an eligibility determination.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.15 - Appeal Process

Current through Register 1525, July 5, 2024
(1) Appeal
			 requests will be processed and hearings will be conducted by the Connector
			 using the policies and procedures for informal hearings set forth in
			 801 CMR
			 1.02:
Informal/Fair Hearing
			 Rules
, as well as the procedures set forth in
			 956 CMR 12.00 or in any
			 administrative bulletins issued by the Connector. In addition, regarding
			 appeals of Connector Programs related to Non-group Health Plans, the Connector
			 will use the policies and procedures at
			 45
			 CFR 155.500 through
			 155.550, and
			 regarding appeals of Health Connector Programs related to Small Group Health
			 Plans, the Connector will use the policies and procedures at
			 45
			 CFR 155.741.
(2) The Connector may dismiss any appeal
			 request if:
(a) It is not received within the
			 time periods specified in
			 956 CMR
			 12.14;
(b) It does not state a valid ground for
			 appeal under
			 956 CMR
			 12.13;
(c) The appeal is withdrawn by the appellant
			 or Appeal Representative;
(d) The
			 appellant dies while the appeal is pending, except if the executor,
			 administrator, or other duly authorized representative of the estate requests
			 to continue the appeal; or
(e) For
			 any reason stated in
			 801 CMR
			 1.02:
Informal/Fair Hearing
			 Rules
.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.16 - Dental Plans

Current through Register 1525, July 5, 2024
(1)
Eligibility for Dental Plans
.
(a) Any individual who meets the eligibility
			 requirements for Non-group Health Plans without Financial Assistance, listed at
			 956 CMR 12.04(1)(a)
			 through (c), shall also be eligible to
			 purchase a Dental Plan; for purposes of clarity, an individual does not need to
			 be eligible for a Connector Program for Non-group Health Plans to be eligible
			 for Dental Plans. Any time an individual no longer meets the requirements
			 listed at
			 956 CMR 12.04(1)(a)
			 through (c), such individual shall no longer
			 be eligible for a Dental Plan.
(b)
			 Any Employer that is eligible to offer a Small Group Health Plan, in accordance
			 with
			 956 CMR
			 12.04(4)(a), shall be
			 eligible to offer a Dental Plan for its Employees. Any time an Employer loses
			 eligibility for Small Group Health Plan coverage through the Connector, such
			 Employer shall also lose eligibility for a Dental Plan.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.17 - Authorized Representatives

Current through Register 1525, July 5, 2024
The Connector shall recognize any person or organization
				identified as the authorized representative of an Applicant for a Connector
				Program for Non-Group Health Plans, an Eligible Individual, or Enrollee in a
				Non-Group Health Plan, consistent with the provisions of
				130 CMR
				501.001:
Definition of
				Terms
.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.18 - Administrative Information Bulletins

Current through Register 1525, July 5, 2024
(1) The Connector may issue administrative
			 information bulletins that set out policies that are consistent with the
			 substantive provisions of
			 956 CMR 12.00. In addition,
			 the Connector may issue administrative information bulletins, which specify the
			 information and documentation necessary to implement
			 956 CMR 12.00. The Connector
			 may also issue administrative bulletins containing interpretations of
			 956 CMR 12.00 and other
			 information to assist persons subject to
			 956 CMR 12.00 meet their
			 obligations under
			 956 CMR 12.00.
(2) The Connector may publish policies and
			 procedures describing the operationalization and implementation Connector
			 Programs to provide more detailed information and guidance, including
			 statements of policy and procedure, conditions of participation, guidelines,
			 billing instructions, Health Carrier bulletins, and other documents as
			 necessary.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 12.00 - Eligibility, Enrollment, and Hearing Process for Connector Programs › Section 12.19 - Severability of Provisions

Current through Register 1525, July 5, 2024
The provisions of
				956 CMR 12.00 are hereby
				declared to be severable. If any such provisions or the application of such
				provisions or circumstances shall be held invalid or unconstitutional, such
				invalidity shall not be construed to affect the validity or constitutionality
				of any remaining provisions of
				956 CMR 12.00 or the
				applications of such provisions or circumstances other than those held
				invalid.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market › Section 13.01 - Purpose and Scope

Current through Register 1525, July 5, 2024
The purpose of
				956 CMR 13.00 is to implement
				a Risk Adjustment Program as described in 42 U.S.C. § 18063, pursuant to
				M.G.L. c. 176Q, § 3(v). Risk Adjustment is a permanent risk mitigation
				provision under the federal Patient Protection and Affordable Care Act.
				956 CMR 13.00 applies to all
				Carriers that offer at least one Risk Adjustment Covered Plan in the
				Commonwealth.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market › Section 13.03 - Requirements for Data Submission

Current through Register 1525, July 5, 2024
(1)
			 The Connector will utilize the Risk Adjustment Data Extract provided by CHIA
			 for risk adjustment operations.
(2)
			 Each Carrier must comply with requirements for submitting enrollment, claims,
			 and other data to CHIA, in accordance with
			 957 CMR 8.00:
All
			 Payer Claims Database (APCD) and Case Mix and Charge Data Submission
and related regulations and guidance and any additional instructions
			 or guidance provided by the Connector. All applicable data for a Benefit Year
			 must be submitted by April 30th of the year
			 following the applicable Benefit Year.
(3) If a Carrier fails to submit data or
			 submits incomplete or inaccurate date to the MA APCD within the timeframe
			 required, the Connector may assess a default risk adjustment charge, as
			 described in
			 956 CMR
			 13.05.
(4) The Carrier must comply with all
			 applicable data privacy and security standards and requirements set forth by
			 CHIA, by the Connector, or by federal regulators, including standards and
			 requirements described in the applicable State Payment Notice.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market › Section 13.04 - Ongoing Discrepancy Resolution Process

Current through Register 1525, July 5, 2024
(1)
Reports provided to Carriers
. During the course of
			 each applicable Benefit Year, CHIA or the Connector will provide Carriers, at a
			 frequency specified by the Connector, with Member Month Tracker Reports and
			 Quarterly Simulation Reports.
(2)
Carrier Review of Reports
. Within 30 calendar days of
			 receiving either of the reports described in 956 CMR 13.04(1), a Carrier must
			 either:
(a) Confirm to the Connector that the
			 information in the report accurately reflects the data that the Carrier has
			 provided to CHIA for the timeframe specified in the report, or
(b) Identify and report to the Connector with
			 appropriate reporting detail any discrepancy it identifies in the report. The
			 Connector may through guidance provide the manner and format for reporting any
			 discrepancies.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market › Section 13.06 - Request for Reconsideration

Current through Register 1525, July 5, 2024
(1)
Grounds for Reconsideration Request
. A Carrier may
			 request reconsideration of the Final Risk Adjustment Payments and Charges
			 Report only with respect to the following:
(a)
			 An incorrect application by the Connector of the risk adjustment methodology,
			 including issues related to unresolved data discrepancies; or
(b) Mathematical error.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market › Section 13.07 - Reconsideration Procedures

Current through Register 1525, July 5, 2024
(1)
Scope of Reconsideration
. The Connector will not
			 consider any claim or issue raised in the request for reconsideration that
			 could have been raised in the ongoing discrepancy resolution process, but that
			 was not.
(2)
Burden of
			 Proof
. The burden of proving a ground for reconsideration will be
			 on the Carrier seeking reconsideration.
(3)
First-level
			 Review
. The Connector will review the request for reconsideration.
			 In conducting this review, the Connector will consider the Final Risk
			 Adjustment Payments and Charges Report, along with all the data, calculations,
			 and other evidence supporting that report. Additionally, the Connector will
			 consider any documentary evidence included by the Carrier in its request for
			 reconsideration. The Connector may consider other evidence that it considers to
			 be relevant, provided that it will provide such evidence to the Carrier with a
			 reasonable opportunity to review and comment on such evidence. The Connector
			 may conduct this first-level review based solely on documentary evidence. The
			 Connector will inform the Carrier of its reconsideration decision in
			 writing.
(4)
Request
			 for Hearing
. A Carrier that is aggrieved by the Connector's
			 decision after the first-level review may file a request for hearing. The
			 request must be in writing and must be submitted within ten calendar days after
			 issuance of the first-level reconsideration decision.
(5)
Hearing
. The
			 hearing will be conducted using the policies and procedures set forth for
			 informal hearings pursuant to
			 801 CMR
			 1.02:
Informal Fair Hearing Rules
or in any administrative bulletins issued by the Connector.
(6)
Conduct of
			 Hearing
. The hearing officer will not consider any issue or claim
			 that was not raised in the request for reconsideration. The hearing officer
			 will not accept any evidence that was not presented by the Carrier with the
			 reconsideration request or considered by the Connector in the first-level
			 review.
(7)
Decision
. The hearing officer will issue a final
			 decision in writing. The decision of the hearing officer will be the final
			 decision of the Connector.
(8)
Adjustment
. In the event the final decision would
			 cause a change in the relative risk adjustment payment and transfers among
			 Carriers that would have been made in a Benefit Year, the Connector will
			 determine the level of adjustment required to be applied to each Carrier's
			 transfer amounts, with the adjustment made to the next risk adjustment transfer
			 after the issuance of the final decision and the conclusion of any proceedings
			 for judicial review arising from that decision.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market › Section 13.08 - Risk Adjustment Data Validation

Current through Register 1525, July 5, 2024
(1)
			 The Connector will employ a Risk Adjustment Data Validation (RADV) program,
			 under which a statistically valid sample of risk adjustment data from each
			 Carrier will be validated. Each Carrier must comply with the Connector's RADV
			 procedures as laid out in applicable regulation, administrative bulletin, or
			 other guidance.
(2) A Carrier must
			 supply the Connector or the Connector's designee with all relevant source
			 enrollment documentation, all claims and encounter data, and medical record
			 documentation from providers of services to each enrollee in the applicable
			 sample without unreasonable delay and in a manner that reasonably assures
			 confidentiality and security in transmission.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market › Section 13.09 - Administrative Bulletins

Current through Register 1525, July 5, 2024
The Connector may issue administrative bulletins that contain
				interpretations of or policies and procedures consistent with
				956 CMR 13.00, or that
				contain such other information as may assist individuals subject to
				956 CMR 13.00 to meet their
				obligations under
				956 CMR
				13.00.
Code of Massachusetts Regulations › 956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY › Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market › Section 13.10 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				956 CMR 13.00 are severable.
				If any provisions or the application of any provision is held to be invalid or
				unconstitutional, such invalidity shall not be construed to affect the validity
				or constitutionality of any remaining provisions of
				956 CMR 13.00 or the
				application of such provisions.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.01 - General Provisions

Current through Register 1525, July 5, 2024
Scope and Purpose
.
				957 CMR 2.00 governs
				the methodology and filing requirements for Health Care Payers to
				calculate and report Health Status Adjusted Total Medical Expenses,
				Relative Prices, Alternative Payment Methods, Prescription Drug
				Rebate information, Primary Care and Behavioral Health Expenses, and
				other aggregate data as the Center for Health Information and
				Analysis may require to ensure the uniform reporting of information
				from Private and Public Health Care Payers, including Third Party
				Administrators.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.03 - General Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Annual Reports
.
(a) Each Payer shall file annually its TME by Physician Group, Physician Local Practice Group, and Member zip code; its Relative Prices for Hospitals, Physicians, and Other Providers; its APMs by Registered Provider Organization, Hospital, Physician Group, Physician Local Practice Group, Other Provider, and Member zip code, its Prescription Drug Rebate data, and its Primary Care and Behavioral Health Expenses by Physician Group in accordance with the requirements of 957 CMR 2.04, 2.05, 2.06, 2.07 and 2.08.
(b) A Private Health Care Payer is subject to the reporting requirements in 957 CMR 2.00 if:
1. The Payer is a Surcharge Payer and the Payer's surcharge payments made pursuant to M.G.L. c. 118E, § 68 placed the Payer at the company level within the top ten Surcharge Payers for the period October 1, 2009 through September 30, 2010 as determined by the Health Safety Net Office and posted on the Center's website; or
2. The Payer contracts with the office of Medicaid, the Massachusetts Health Connector, or the Group Insurance Commission to pay for or arrange for the purchase of Health Care Services on behalf of individuals enrolled in health coverage programs under Titles XVIII, XIX, or XXI, under the ConnectorCare Health Insurance program, Medicaid managed care organizations, or under the Group Insurance Commission.
3. If a Private Health Care Payer subject to the reporting requirements of 957 CMR 2.00 makes separate surcharge payments pursuant to M.G.L. c. 118E, § 68 for individual plans or clients the Payer shall file the required data for all of its plans or clients.
(c) Public Health Care Payers may provide data to the Center pursuant to an interagency service agreement.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.04 - Reporting Health Status Adjusted Total Medical Expenses

Current through Register 1525, July 5, 2024
(1)
TME by Physician Group and Physician Local Practice
			 Group.
(a)
Reporting Requirements
.
1. Payers shall report TME by
			 Physician Group and Physician Local Practice Group for Massachusetts
			 Members, separated into the following categories:
a. Members required to select a
			 primary care physician;
b. Members attributed to a primary
			 care provider pursuant to a contract between the Payer and Provider
			 for financial or quality performance;
c. All other Members who have been,
			 "to the maximum extent possible", attributed to a primary care
			 provider pursuant to M.G.L. c. 176J, § 16; and
d. Members not attributable to a
			 primary care provider.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.06 - Reporting Alternative Payment Methods

Current through Register 1525, July 5, 2024
(1)
APM for Registered
			 Provider Organizations, Physician Groups, and Physician Local
			 Practice Groups
.
(a)
Reporting Requirements
.
1. Payers must report APM data
			 separately by Medicare, Medicaid, commercial full-claim, and
			 commercial partial-claim plans, and any other insurance categories as
			 defined by the
Data Specification Manual
. Commercial
			 (self- and fully-insured) data for Registered Provider Organizations,
			 Physician Groups, and Physician Local Practice Groups for which the
			 payer is able to collect information on all direct medical claims and
			 subcarrier claims shall be reported in the full-claim category.
			 Commercial (self- and fully-insured) data for Registered Provider
			 Organizations, or Physician Groups, Physician Local Practice Groups
			 that do not include all medical and subcarrier claims shall be
			 reported in the partial-claim category. Payers must include the full
			 amount paid for medical claims, including amounts paid under
			 stop-loss or reinsurance agreements, even if the payer was not
			 directly providing payment for those services. Payers shall not
			 include data for which they are the secondary or tertiary payer such
			 as Medicare Supplement.
2. Payers must report APM data
			 separately by product type as defined by the
Data
			 Specification Manual
.
3. When reporting preliminary APM
			 data, Payers shall include IBNR estimates resulting in approximated
			 completed claims for periods that are not yet considered
			 complete.
4. Payers shall
			 report APM for Physician Groups and Physician Local Practice Groups
			 with at least 36,000 Member Months for the Calendar Year. Payers
			 shall report APM data in the aggregate for all Physician Groups and
			 Physician Local Practice Groups with fewer than 36,000 Member Months
			 for the Calendar Year.
5.
			 Payers shall attribute Non-claims Related Payments to a Provider at
			 the Local Practice Group Level and thereafter at the Physician Group
			 Level. If direct attribution is not possible, Payers shall allocate
			 Non-claims Related Payments by Member Months.
6. Payers must report the risk
			 adjustment tool and version used to report the Health Status
			 Adjustment Score. The Center may specify additional requirements for
			 reporting the Health Status Adjustment Score by Administrative
			 Bulletin or in the
Data Specification
			 Manual
.
7. When
			 reporting preliminary APM by Physician Group and Physician Local
			 Practice Group, Payers shall include IBNR estimates resulting in
			 approximated completed claims for periods that are not yet considered
			 complete.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.07 - Reporting Prescription Drug Rebates

Current through Register 1525, July 5, 2024
(1)
Prescription Drug
			 Rebate Reporting
.
(a)
Reporting Requirements
.
1. Payers must report rebate data
			 for all Massachusetts residents for whom the payer has complete
			 pharmacy claim and rebate data.
a.
			 If Payers are not able to report data solely for Massachusetts
			 residents, they must notify the Center in writing and propose a
			 different Member population definition for Center approval.
b. Any Members for which a Payer
			 has no pharmacy expenditure or prescription drug rebate data, or
			 partial pharmacy expenditure or prescription drug rebate data, should
			 be excluded from this data reporting.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.08 - Reporting Primary Care and Behavioral Health Expenses

Current through Register 1525, July 5, 2024
(1)
Primary Care and Behavioral Health Expenses Reporting by
			 Physician Group
.
(a)
Reporting Requirements
.
1. Payers shall report Primary Care
			 and Behavioral Health Expenses and Member Months information by
			 Physician Group for Massachusetts Members, separated into the
			 following categories:
a. Members
			 required to select a primary care physician;
b. Members attributed to a primary
			 care provider pursuant to a contract between the Payer and Provider
			 for financial or quality performance;
c. All other Members who have been,
			 "to the maximum extent possible", attributed to a primary care
			 provider pursuant to M.G.L. c. 176J, § 16; and
d. Members not attributable to a
			 primary care provider.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.09 - Compliance and Penalties

Current through Register 1525, July 5, 2024
The Center will provide written notice to Payers that
				fail to comply with the reporting deadlines established in
				957 CMR 2.00.
(1) The Center will notify Payers
			 that failure to respond within two weeks of the written notice,
			 without just cause, may result in penalties. In accordance with
			 M.G.L. c. 12C, § 11, Payers may be subject to a penalty of up to
			 $1,000 per week for each week that they fail to provide the required
			 health care data and information, up to an annual maximum of
			 $50,000.
(2) Any remedy
			 available under 957 CMR 2.09 is in addition to other sanctions and
			 penalties that may apply under the provisions of other statutes and
			 regulations.
(3) Payers
			 that fail to comply with the requirements of
			 957 CMR 2.00 will be
			 subject to all penalties and remedies allowed by law and the Center
			 will take all necessary steps to enforce 957 CMR 2.09, including a
			 petition to the Superior Court for an order enforcing the
			 same.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 2.00 - Payer Data Reporting › Section 2.11 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				957 CMR 2.00 are
				severable. If any provision or the application of any provision is
				held to be invalid or unconstitutional, such invalidity shall not be
				construed to affect the validity or constitutionality of any
				remaining provisions of
				957 CMR 2.00 or the
				application of such provisions.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 3.00 - Assessment on certain health care providers and surcharge payors › Section 3.01 - General Provisions

Current through Register 1525, July 5, 2024
Scope and Purpose
.
				957 CMR
				3.00 governs payments to the Center for Health
				Information and Analysis, for the period commencing November 5, 2012, from
				certain Acute Hospitals, Ambulatory Surgical Centers and Surcharge
				Payors.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 3.00 - Assessment on certain health care providers and surcharge payors › Section 3.02 - Definitions

Current through Register 1525, July 5, 2024
Meaning of Terms
. All defined terms in
				957 CMR
				3.00 are capitalized. As used in
				957 CMR
				3.00, unless the context otherwise requires, terms
				have the following meanings:
Ambulatory Surgical Center
. Any
				distinct entity that operates exclusively for the purpose of providing surgical
				services to patients not requiring hospitalization and meets the U.S. Centers
				for Medicare and Medicaid (CMS) requirements for participation in the Medicare
				program.
Center
. The Center for Health
				Information and Analysis as established under M.G.L. c. 12C.
Center Expenses
. The amount
				appropriated by the general court for the expenses of the Center minus amounts
				collected from:
(a) filing fees;
(b) fees and charges generated by the Center's publication or
				dissemination of reports and information; and
(c) federal matching revenues received for these expenses or
				received retroactively for expenses of predecessor agencies. Center expenses
				shall include an amount equal to the cost of fringe benefits and indirect
				expenses, as established by the comptroller.
Gross Patient Service Revenue (GPSR)
.
				The total dollar amount of a Hospital's or an Ambulatory Surgical Center's
				charges for services rendered in a fiscal year.
Hospital
. The teaching hospital of the
				University of Massachusetts Medical School and any acute hospital licensed
				under M.G.L. c. 111, § 51 that contains a majority of medical-surgical,
				pediatric, obstetric and maternity beds, as defined by the Department of Public
				Health.
MassHealth
. The medical assistance
				program administered by the Executive Office of Health and Human Services
				Office of Medicaid pursuant to M.G.L. c. 118E and in accordance with Titles XIX
				and XXI of the Federal Social Security Act, and a § 1115 Demonstration
				Waiver.
Medicare Program
. The medical
				insurance program established by Title XVIII of the Social Security Act.
Payment
. A check, draft or other paper
				instrument, an electronic fund transfer, or any order, instruction, or
				authorization to a financial institution to debit one account and credit
				another.
Surcharge Payor
. A Surcharge Payor is
				an individual or entity, including a Managed Care Organization, that pays for
				or arranges for the purchase of Health Services provided by Hospitals and
				Ambulatory Surgical Center Service provided by Ambulatory Surgical Centers;
				provided, however, that the term "Surcharge Payor" shall not include:
(a) Title XVIII and Title XIX programs and their beneficiaries
				or recipients;
(b) other governmental programs of public assistance and their
				beneficiaries or recipients; and
(c) the workers' compensation program established pursuant to
				M.G.L. c. 152.
Code of Massachusetts Regulations › 957 CMR - CENTER FOR HEALTH INFORMATION AND ANALYSIS › Title 957 CMR 3.00 - Assessment on certain health care providers and surcharge payors › Section 3.03 - Acute Hospital and Ambulatory Surgical Center Assessment

Current through Register 1525, July 5, 2024
(1)
General
. The Center shall establish an assessment on
			 all Hospitals and Ambulatory Surgical Centers.
(2)
Calculation of the Hospital
			 and Ambulatory Surgical Center Assessment Percentage
. Using the
			 best information available as determined by the Center, the Center shall
			 calculate an assessment percentage for each Hospital and Ambulatory Surgical
			 Center by dividing each entity's individual GPSR for the most recent fiscal
			 year for which complete data was reported to the Center by the total of all
			 such GPSR reported by all Hospitals and Ambulatory Surgical Centers.
(3)
Hospital and Ambulatory
			 Surgical Center Assessment Liability
. The assessment liability for
			 each Hospital and Ambulatory Surgical Center is the product of:
(a) the assessment percentage as defined in
			 957 CMR 3.03(2); and
(b)
									½
			 of Center Expenses.