Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 223.000 - Pediatric Immunization Program Assessment › Section 223.003 - Definitions

Current through Register 1525, July 5, 2024
Ambulatory Surgical Center
means any
				distinct entity located in Massachusetts 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.
Ambulatory Surgical Center Services
means services described for purposes of the Medicare program pursuant to
				42 U.S.C. §
									1395k(a)(2)(F)(i). These
				services include only facility services and do not include physician
				fees.
Department
means the Massachusetts
				Department of Public Health.
Hospital
means an 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.
Hospital Services
means services
				listed on an acute hospital's license issued by the Department.
Indirect Payment
means a payment made
				by a payer to a group of providers, including one or more Massachusetts acute
				care hospitals or ambulatory surgical centers, that then forward the payment to
				member hospitals or ambulatory surgical centers; or a payment made to an
				individual to reimburse him or her for a payment made to a hospital or
				ambulatory surgical center.
Managed Care Organization
means a
				managed care organization as defined in M.G.L. c. 118E, § 64.
Medicaid
means 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 Section 1115 Demonstration
				Waiver.
Medicare Program
means the medical
				insurance program established by Title XVIII of the Social Security Act.
Payer
means a surcharge payer that
				meets the criteria set forth in
				105 CMR
				223.100(B).
Payment
means 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.
Payments Subject to Surcharge
means
				all amounts paid, directly or indirectly, by surcharge payers to acute
				hospitals for health services and ambulatory surgical centers for ambulatory
				surgical center services; provided, however, that it shall not include:
(a) payments, settlements and judgments arising out of third
				party liability claims for bodily injury which are paid under the terms of
				property or casualty insurance policies; and
(b) payments made on behalf of Medicaid recipients, Medicare
				beneficiaries or persons enrolled in policies issued under M.G.L. c. 176K or
				similar policies issued on a group basis; provided further, that it shall
				include payments made by a managed care organization on behalf of:
1. Medicaid recipients under age 65; and
2. enrollees in the commonwealth care health insurance program;
				and provided further, that it may exclude amounts established under regulations
				promulgated by the department for which the costs and efficiency of billing a
				surcharge payer or enforcing collection of the surcharge from a surcharge payer
				would not be cost effective.
Surcharge
means the surcharge on
				payments made to hospitals and ambulatory surgical centers established by
				M.G.L. c. 118E, § 68.
Surcharge Payer
means an individual or
				entity that pays for or arranges for the purchase of health care services
				provided by acute hospitals and ambulatory surgical center services provided by
				ambulatory surgical centers; provided, however, that it shall include a managed
				care organization; and provided further, that it shall not include Title XVIII
				and Title XIX programs and their beneficiaries or recipients, other
				governmental programs of public assistance and their beneficiaries or
				recipients and the workers' compensation program established under M.G.L. c.
				152.
Third Party Administrator
means an
				entity that administers payments for health care services on behalf of a client
				plan in exchange for an administrative fee. A third party administrator may
				provide client services for a self-insured plan or an insurance carrier's plan.
				A third party administrator will be deemed to use a client plan's funds to pay
				for health care services whether the third party administrator pays providers
				with funds from a client plan, with funds advanced by the third party
				administrator subject to reimbursement by the client plan, or with funds
				deposited with the third party administrator by a client
				plan.