reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 8.00 - Patient Assignment Limits For Registered Nurses In Intensive Care Units In Acute Hospitals › Section 8.07 - Required Elements of the Acuity Tool

Current through Register 1525, July 5, 2024
Each Acute Hospital shall develop or select an Acuity Tool that meets the following minimum requirements:
(1) The Acuity Tool shall be in writing either in electronic or hardcopy format;
(2) The Acuity Tool shall be tailored to the unique care needs and circumstances of the patient population in the ICU in which the Acuity Tool is deployed;
(3) The Acuity Tool shall include a method for scoring a defined set of indicators, which shall include Clinical Indicators of Patient Stability and other Indicators of Staff Nurse Workload; and
(4) Other requirements as may be specified in guidance of the Commission.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 8.00 - Patient Assignment Limits For Registered Nurses In Intensive Care Units In Acute Hospitals › Section 8.08 - Records of Compliance

Current through Register 1525, July 5, 2024
(1)
Development or Selection of Acuity Tool(s)
. Each Acute Hospital shall document, retain for a minimum period of ten years and provide to the Department and the Commission upon request, the following records related to the development or selection of the Acuity Tool required by 958 CMR 8.06(2):
(a) Membership of the advisory committee including name and title of members;
(b) Minutes from meetings of the advisory committee; and
(c) The Acute Hospital's rationale for selection or development of the Acuity Tool including how the Acute Hospital addressed recommendations of the advisory committee and the decision to include or exclude certain Clinical Indicators of Patient Stability and other related Indicators of Staff Nurse Workload, and how Critical Environmental Factors in 958 CMR 8.06(2)(b)3. were taken into account in the selection and the method for scoring of the indicators.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 8.00 - Patient Assignment Limits For Registered Nurses In Intensive Care Units In Acute Hospitals › Section 8.09 - Acuity Tool Certification and Compliance

Current through Register 1525, July 5, 2024
Acute Hospitals shall comply with the requirements for certification of an Acuity Tool and compliance with M.G.L. c. 111, § 231 and 958 CMR 8.00, as established by the Department.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 8.00 - Patient Assignment Limits For Registered Nurses In Intensive Care Units In Acute Hospitals › Section 8.10 - Public Reporting on Nurse Staffing Compliance

Current through Register 1525, July 5, 2024
(1) Each Acute Hospital shall report to the Department, in the form and manner specified by the Department, reports of Staff Nurse-to-patient ratios by ICU; and
(2) Each Acute Hospital shall post the reports provided to the Department pursuant to 958 CMR 8.10(1) on the Acute Hospital's website, or as may be specified in guidance of the Commission.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 8.00 - Patient Assignment Limits For Registered Nurses In Intensive Care Units In Acute Hospitals › Section 8.11 - Collection and Reporting of Quality Measures

Current through Register 1525, July 5, 2024
Each Acute Hospital shall:
(1) Report the ICU-related quality measures specified in guidance of the Commission;
(2) Report the quality measures for each ICU to the Department in the form and manner specified by the Department; and
(3) Post the reports provided to the Department pursuant to 958 CMR 8.11(2) on the Acute Hospital's website, or as may be specified in guidance of the Commission.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 8.00 - Patient Assignment Limits For Registered Nurses In Intensive Care Units In Acute Hospitals › Section 8.12 - Certification Timeline

Current through Register 1525, July 5, 2024
Each Acute Hospital shall comply with the requirements of the Department for certification of an Acuity Tool for each ICU by the dates in 958 CMR 8.12(1) and (2), or as may be otherwise specified in the Department's requirements for certification:
(1) Each Acute Hospital that is an academic medical center, as the term is used by the Center for Health Information and Analysis, shall comply with the requirements of the Department for certification of an Acuity Tool for each neonatal intensive care unit no later than January 31, 2017, and for all other ICUs no later than March 31, 2016.
(2) All other Acute Hospitals shall comply with the requirements of the Department for certification of an Acuity Tool for each ICU no later than January 31, 2017.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 8.00 - Patient Assignment Limits For Registered Nurses In Intensive Care Units In Acute Hospitals › Section 8.13 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of 958 CMR 8.00 or the applicability thereof is held invalid or unconstitutional by any court of competent jurisdiction, the remainder of 958 CMR 8.00 or applicability thereof to other persons, entities, or circumstances shall not thereby be affected.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 9.00 - Assessment on Certain Health Care Providers And Surcharge Payors › Section 9.01 - General Provisions

Current through Register 1525, July 5, 2024
958 CMR 9.00 governs payments to the Health Policy Commission, for the period commencing October 1, 2016, from Acute Hospitals, Ambulatory Surgical Centers and Surcharge Payors.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 9.00 - Assessment on Certain Health Care Providers And Surcharge Payors › Section 9.02 - Definitions

Current through Register 1525, July 5, 2024
All defined terms in 958 CMR 9.00 are capitalized. As used in 958 CMR 9.00, these terms have the following meaning:
Acute Hospital
. The teaching hospital of the University of Massachusetts Medical School and any 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.
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.
Commission
. The Health Policy Commission established under M.G.L. c. 6D.
Commission Expenses
. The amount appropriated by the General Court for the expenses of the Commission minus amounts collected from:
(1) filing fees;
(2) fees and charges generated by the Commission; and
(3) federal matching revenues received for these expenses or received retroactively for expenses of predecessor agencies. Commission Expenses shall include an amount equal to the cost of fringe benefits and indirect expenses, as established by the comptroller.
Fiscal Year (FY)
. The time period of 12 months beginning on October 1st of any calendar year and ending on September 30th of the following calendar year.
Gross Patient Service Revenue (GPSR)
. The total dollar amount of an Acute Hospital's or an Ambulatory Surgical Center's charges for services rendered in a Fiscal Year.
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 that pays for or arranges for the purchase of health care services provided by provided by Acute Hospitals and Ambulatory Surgical Centers, including a managed care organization; provided, however,
Surcharge Payor
shall not include:
(1) Title XVIII and Title XIX programs and their beneficiaries or recipients; and
(2) other governmental programs of public assistance and their beneficiaries or recipients; and
(3) the workers' compensation program established pursuant to M.G.L. c. 152.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 9.00 - Assessment on Certain Health Care Providers And Surcharge Payors › Section 9.03 - Acute Hospital and Ambulatory Surgical Center Assessment

Current through Register 1525, July 5, 2024
(1)
General
. The Commission shall establish an assessment on all Acute Hospitals and Ambulatory Surgical Centers; provided, however, that the Commission shall not assess any Acute Hospital operated by a city or town.
(2)
Calculation of the Acute Hospital and Ambulatory Surgical Center Assessment Percentage
. Using the best information available as determined by the Commission, the Commission shall calculate an Assessment Percentage for each Acute 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 pursuant to 957 CMR 3.05:
Reporting Requirements
by the total of all such GPSR reported by all Acute Hospitals and Ambulatory Surgical Centers.
(3)
Acute Hospital and Ambulatory Surgical Center Assessment Liability
. The assessment liability for each Acute Hospital and Ambulatory Surgical Center is the product of:
(a) the Assessment Percentage as defined in 958 CMR 9.03(2); and
(b)
									½ of Commission Expenses.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 9.00 - Assessment on Certain Health Care Providers And Surcharge Payors › Section 9.04 - Surcharge Payor Assessment

Current through Register 1525, July 5, 2024
(1)
General
. The Commission shall establish an assessment on all Qualifying Surcharge Payors.
(2)
Qualifying Surcharge Payor
. A Surcharge Payor is subject to assessment if the Surcharge Payor's Payments Subject to Assessment, as defined in 958 CMR 9.04(3), were at least $1 million during the last 12-month period for which complete data was received by the Center pursuant to 957 CMR 3.05:
Reporting Requirements
. A Surcharge Payor that administers health payments for health care services on behalf of a client plan in exchange for an administrative fee will be deemed to use the client plan's funds to pay for health care services whether the Surcharge Payor pays providers with funds from the client plan, with funds advanced by the Surcharge Payor subject to reimbursement by the client plan, or with funds deposited with the Surcharge Payor by the client plan.
(3)
Payments Subject to Assessment
. Payments that are made by Surcharge Payors to Acute Hospitals and Ambulatory Surgical Centers pursuant to M.G.L. c. 118E, § 68 are subject to assessment.
(4)
Calculation of the Surcharge Payor Assessment Percentage
. Using the best information available as determined by the Commission, the Commission shall calculate each Qualifying Surcharge Payor's Assessment Percentage by dividing an individual Surcharge Payor's Payments Subject to Assessment during the last Fiscal Year for which complete data was received by the Center pursuant to 957 CMR 3.05:
Reporting Requirements
by the total of all such payments by all Qualifying Surcharge Payors.
(5)
Surcharge Payor Liability
. The assessment liability for each Qualifying Surcharge Payor is the product of:
(a) the Surcharge Payor's Assessment Percentage, as defined in 958 CMR 9.04(4); and
(b)
									½ of Commission Expenses.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 9.00 - Assessment on Certain Health Care Providers And Surcharge Payors › Section 9.05 - Special Provisions

Current through Register 1525, July 5, 2024
(1)
Transfer of Ownership
. All liabilities to the Commission by an Acute Hospital, Ambulatory Surgical Center or Surcharge Payor shall, in the case of a transfer of ownership, be assumed by the successor.
(2)
Severability
. The provisions of 958 CMR 9.00 are severable. If any provision or the application of any provision to any Acute Hospital, Ambulatory Surgical Center or Surcharge Payor is held to be invalid or unconstitutional, any such invalidity shall not be construed to affect the validity or constitutionality of any remaining provisions of 958 CMR 9.00 or the application of such provisions to any Acute Hospital, Ambulatory Surgical Center or Surcharge Payor in circumstances other than those held invalid.
(3)
Administrative Bulletins
. The Commission may issue administrative bulletins to clarify policies and understanding of substantive provisions of 958 CMR 9.00 and specify information and documentation necessary to implement 958 CMR 9.00.
(4)
Debt Collection
. If an Acute Hospital, Ambulatory Surgical Center or Surcharge Payor has maintained an outstanding liability to the Commission for a period longer than 120 days, the Commission will pursue all legal remedies available to it, including those available under M.G.L. c. 7A, § 3.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 958 CMR 10.00 governs the process and criteria used to require Performance Improvement Plans as authorized in M.G.L. c. 6D, § 10. 958 CMR 10.00 specifies the process for submission, approval, and amendment of Performance Improvement Plans pursuant to M.G.L. c. 6D, § 10, as well as the process for conducting Cost and Market Impact Reviews of Provider Organizations pursuant to M.G.L. c. 6D, § 13(b).
(2)
Effect on Other Law
. Neither 958 CMR 10.00 nor any Performance Improvement Plan required by 958 CMR 10.00 shall be construed to relieve any entity of obligations or requirements imposed on it by other state or federal law.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.02 - Definitions

Current through Register 1525, July 5, 2024
All defined terms in 958 CMR 10.00 are capitalized. As used in 958 CMR 10.00, these terms have the following meaning:
Board
. The governing board of the Commission established in M.G.L. c. 6D, § 2(b).
Center
or
CHIA
. The Center for Health Information and Analysis established in M.G.L. c. 12C.
CHIA-identified Entity
. Any Health Care Entity that is identified by the Center under M.G.L. c. 12C, § 18 as an entity whose increase in health status adjusted total medical expense is considered excessive and who threatens the ability of the state to meet the health care cost growth benchmark established under M.G.L. c. 6D, § 9.
Commission
. The Health Policy Commission established in M.G.L. c. 6D.
Cost and Market Impact Review
. A review conducted by the Commission pursuant to M.G.L. c. 6D § 13 and 958 CMR 7.00:
Notices of Material Change and Cost and Market Impact Reviews
and 10.00.
Executive Director
. The Executive Director of the Commission.
Health Care Entity
. A clinic, hospital, ambulatory surgical center, physician organization, accountable care organization or payer; provided, however, that physician contracting units with a patient panel of 15,000 or fewer, or which represents providers who collectively receive less than $25,000,000 in annual net patient service revenue from carriers shall be exempt.
Performance Improvement Plan
or
PIP
. A plan submitted to the Commission by a PIP Entity pursuant to M.G.L. c. 6D, § 10 and 958 CMR 10.00.
PIP Entity
. Any CHIA-identified Entity from which the Commission has voted to require a Performance Improvement Plan, but which has neither successfully completed the Performance Improvement Plan nor obtained a waiver from the requirement to implement a Performance Improvement Plan.
PIP Notice
. Written notice issued by the Commission pursuant to 958 CMR 10.05 informing a CHIA-identified Entity that the Commission is requiring it to submit a Performance Improvement Plan.
Provider Organization
. Any corporation, partnership, business trust, association or organized group of persons, which is in the business of health care delivery or management, whether incorporated or not, that represents one or more health care providers in contracting with carriers or third-party administrators for the payments of heath care services; provided, that a Provider Organization shall include, but not be limited to, physician organizations, physician-hospital organizations, independent practice associations, provider networks, accountable care organizations and any other organization that contracts with carriers for payment for health care services.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.03 - Notice of Identification by the Center for Health Information and Analysis

Current through Register 1525, July 5, 2024
(1) The Commission shall provide written notice to each CHIA-identified Entity. Such notice shall state, at a minimum:
(a) That the Commission has received notice from CHIA identifying the Health Care Entity under M.G.L. c. 12C, § 18 as an entity whose increase in health status adjusted total medical expense is considered excessive and who threatens the ability of the state to meet the health care cost growth benchmark established under M.G.L. c. 6D, § 9;
(b) The data relied upon by CHIA to identify the Health Care Entity under M.G.L. c. 12C, § 18;
(c) hat the Commission may require a Performance Improvement Plan if, after a review of the factors described in 958 CMR 10.04(2), the Commission identifies significant concerns about the CHIA-identified Entity's costs and determines that a Performance Improvement Plan could result in meaningful, cost-saving reforms; and
(d) If the CHIA-identified Entity is a Provider Organization, that when total health care expenditures exceed the health care cost growth benchmark established under M.G.L. c. 6D, § 9 in the previous calendar year, the Commission may conduct a Cost and Market Impact Review of the CHIA-identified Entity if the Commission determines that its performance has significantly impacted or is likely to significantly impact market functioning or the state's ability to meet the benchmark established under M.G.L. c. 6D, § 9.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.04 - Requirement to File a Performance Improvement Plan

Current through Register 1525, July 5, 2024
(1) The Commission may require any CHIA-identified Entity to file a Performance Improvement Plan with the Commission if, after a review of the factors described in 958 CMR 10.04(2), the Commission identifies significant concerns about the CHIA-identified Entity's costs and determines that a Performance Improvement Plan could result in meaningful, cost-saving reforms.
(2) The Commission shall base its determination whether to require a Performance Improvement Plan on a review of the following factors:
(a) Baseline spending and spending trends over time, including by service category;
(b) Pricing patterns and trends over time;
(c) Utilization patterns and trends over time;
(d) Population(s) served, payer mix, product lines, and services provided;
(e) Size and market share;
(f) Financial condition, including administrative spending and cost structure;
(g) Ongoing strategies or investments to improve efficiency or reduce spending growth over time;
(h) Factors leading to increased costs that are outside the CHIA-identified Entity's control; and
(i) Any other factors the Commission considers relevant.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.05 - Notice of Requirement to File a Performance Improvement Plan and Public Identification

Current through Register 1525, July 5, 2024
(1) The Commission shall provide a PIP Notice to any PIP Entity subsequent to an affirmative vote as described in 958 CMR 10.04(4).
(2) The PIP Notice shall include, at a minimum:
(a) The Commission's basis for requiring a Performance Improvement Plan;
(b) The timing and process for filing a Performance Improvement Plan under 958 CMR 10.09;
(c) The timing and process for filing a request to extend the timing for filing a Performance Improvement Plan under 958 CMR 10.08; and
(d) The timing and process for filing a request to waive the requirement to file a Performance Improvement Plan under 958 CMR 10.07.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.06 - Timing of Submission

Current through Register 1525, July 5, 2024
Within 45 days of receiving a PIP Notice, a PIP Entity shall file:
(1) A proposed Performance Improvement Plan with the Commission pursuant to 958 CMR 10.09; or
(2) A request for a waiver from the requirement to file a Performance Improvement Plan pursuant to 958 CMR 10.07; or
(3) A request to extend the timeline for filing a proposed Performance Improvement Plan pursuant to 958 CMR 10.08.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.07 - Waiver from Requirement to File a Performance Improvement Plan

Current through Register 1525, July 5, 2024
(1) Requests for a waiver from the requirement to file a Performance Improvement Plan shall be filed in a manner and form prescribed by the Commission.
(2) The PIP Entity shall submit documentation or supporting evidence to the Commission to support the PIP Entity's request for waiver.
(3) The Commission may require the PIP Entity to submit any other relevant information it deems necessary in considering the waiver request.
(4) The Commission may waive the requirement for a PIP Entity to file a Performance Improvement Plan in response to a waiver request in light of all information received from the PIP Entity under 958 CMR 10.04, any additional information submitted under 958 CMR 10.07(2) and (3), and information received or obtained by the Commission, based on a consideration of the following factors:
(a) The costs, price, and utilization trends of the PIP Entity over time, and any demonstrated improvement to reduce health status adjusted total medical expenses;
(b) Any ongoing strategies or investments that the PIP Entity is implementing to improve future long-term efficiency and reduce cost growth;
(c) Whether the factors that led to increased costs for the PIP Entity can reasonably be considered to be unanticipated and outside of the control of the PIP Entity;
(d) The overall financial condition of the PIP Entity;
(e) A significant difference between the growth rate of potential gross state product and the growth rate of actual gross state product, as determined under section M.G.L. c. 29, § 7H½; and
(f) Any other factors the Commission considers relevant.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.08 - Extension to File a Performance Improvement Plan

Current through Register 1525, July 5, 2024
(1) Requests for an extension to file a Performance Improvement Plan shall be filed in a manner and form prescribed by the Commission.
(2) When filing a request for an extension, the PIP Entity shall indicate the requested submission deadline for the proposed Performance Improvement Plan.
(3) The PIP Entity may submit any documentation or supporting evidence to the Commission to support the PIP Entity's request for extension.
(4) The Commission may require the PIP Entity to submit any other relevant information it deems necessary in considering the extension request.
(5) The Executive Director may grant an extension of time, up to 45 days, to file a Performance Improvement Plan to provide sufficient time for the creation and submission of a plan that will be reasonably likely to successfully address the underlying cause(s) of the PIP Entity's cost growth.
(6) Any extension of more than 45 days shall be granted by vote of the Board.
(7) The Executive Director or Board may deny any extension request or grant an extension, as applicable, for a period of time less than the period requested.
(8) If the Executive Director or Board declines to extend the timeline for the PIP Entity to file a Performance Improvement Plan, the Commission shall provide written notice to the PIP Entity stating that its request for extension was denied, the reason for the denial, and that the PIP Entity shall file a proposed Performance Improvement Plan within 45 days of receipt of the notice of denial.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.09 - Performance Improvement Plan Proposal

Current through Register 1525, July 5, 2024
(1) Proposed Performance Improvement Plans shall be filed in a manner and form prescribed by the Commission.
(2) Any proposed Performance Improvement Plan shall be developed by the PIP Entity and shall include, at a minimum:
(a) Identification of the cause(s) of the PIP Entity's cost growth, with supporting analytic materials as applicable;
(b) Specific strategies, adjustments, and action steps the PIP Entity proposes to implement to improve health care spending performance without compromising quality of or access to needed services;
(c) A proposed timetable for implementing each strategy, adjustment or action step proposed in 958 CMR 10.09(2)(b), with an overall timetable for implementation of 18 months or less;
(d) Specific identifiable and measurable expected outcomes, with a timetable for measurement, achievement, and reporting of such outcomes;
(e) Proposed process and outcome metrics for evaluating the progress and success or failure of the Performance Improvement Plan;
(f) Any requests by the PIP Entity for implementation assistance from the Commission;
(g) Any documentation necessary to support any claims or assertions contained in the proposed Performance Improvement Plan;
(h) A list of any regulatory reviews or filings that would be necessary to implement components of the Performance Improvement Plan; and
(i) Other items as may be identified by the Commission from time to time.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.10 - Performance Improvement Plan Approval

Current through Register 1525, July 5, 2024
(1) The Commission shall approve a proposed Performance Improvement Plan by vote of the Board if it determines that the proposed Performance Improvement Plan meets the criteria described in 958 CMR 10.09(2), is reasonably likely to successfully address the underlying cause(s) of the PIP Entity's cost growth, and has a reasonable expectation that the PIP Entity will be capable of successfully implementing the proposed Performance Improvement Plan.
(2) Examples of factors the Commission may consider in determining whether to approve a Performance Improvement Plan include:
(a) Whether the proposed Performance Improvement Plan proposes a strategy or activity that has a reasonable economic, business, or medical rationale with a sufficient evidence base;
(b) The scope and likelihood of potential savings and the potential impact on the Commonwealth's ability to meet the health care cost growth benchmark established under M.G.L. c. 6D, § 9;
(c) Whether savings and efficiencies associated with the proposed Performance Improvement Plan are likely to continue after the implementation of the Performance Improvement Plan;
(d) The extent to which a proposed Performance Improvement Plan carries a risk of negative consequences that would be inconsistent with other policy goals of the Commonwealth (
e.g
., negative impacts on the quality of care or access to needed services); and
(e) Any other factors the Commission determines to be in the public interest.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.11 - Performance Improvement Plan Implementation, Reporting and Monitoring

Current through Register 1525, July 5, 2024
(1) Upon notice of approval of a proposed Performance Improvement Plan, the PIP Entity shall begin immediate implementation of the Performance Improvement Plan.
(2) Each PIP Entity implementing a Performance Improvement Plan shall be subject to compliance monitoring and regularly provide both public and confidential reports upon progress as specified in the approved Performance Improvement Plan and as may be otherwise specified by the Commission.
(3) The Commission shall provide assistance to the PIP Entity in the successful implementation of the performance improvement plan, subject to available capacity and expertise.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.12 - Amendments During Implementation

Current through Register 1525, July 5, 2024
(1) The PIP Entity may file proposed amendments to the approved Performance Improvement Plan at any point during implementation. Amendment requests shall be submitted in a manner and form prescribed by the Commission.
(2) The Commission shall approve significant proposed amendments by vote of the Board. Minor amendments may be approved by the Executive Director with notice to the Commission. The Commission shall provide written notice to the PIP Entity indicating whether a proposed amendment is approved or denied.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.13 - Conclusion of Implementation Period

Current through Register 1525, July 5, 2024
(1) Upon conclusion of the implementation period, the PIP Entity shall report to the Commission on the outcome of the Performance Improvement Plan.
(2) The Commission shall determine whether the Performance Improvement Plan was successful by vote of the Board.
(3) The Commission may consider the following factors when determining whether a Performance Improvement Plan was successful:
(a) Whether and to what extent the PIP Entity has addressed significant concerns about its costs,
i.e
., by achieving the target outcomes as specified in the Performance Improvement Plan, in accordance with the Commonwealth's policy goals, including those concerning the cost, quality and accessibility of care;
(b) Whether the PIP Entity has fully implemented, in good faith, the strategies, adjustments and action steps of the Performance Improvement Plan;
(c) The sustainability of the efficiencies and cost savings of the Performance Improvement Plan;
(d) The impact of events outside of the PIP Entity's control on implementation or cost growth; and
(e) Other factors the Commission determines to be relevant.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.14 - Confidentiality

Current through Register 1525, July 5, 2024
Pursuant to M.G.L. c. 6D, § 2A, the Commission shall keep confidential all nonpublic clinical, financial, strategic or operational documents or information provided or reported to the Commission in connection with any Performance Improvement Plan activities authorized under M.G.L. c. 6D, § 10 and 958 CMR 10.00 and shall not disclose the information or documents to any person without the consent of the payer or provider providing or reporting the information or documents, except in summary form in evaluative reports of such activities or when the Commission believes that such disclosure should be made in the public interest after taking into account any privacy, trade secret or anticompetitive considerations. Such confidential information and documents shall not be public records and shall be exempt from disclosure under M.G.L. c. 66, § 10 and c. 4, § 7(26).
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.15 - Penalties

Current through Register 1525, July 5, 2024
(1) The Commission may assess a civil penalty to a PIP Entity of not more than $500,000 if it finds that the PIP Entity has:
(a) Willfully neglected to file a Performance Improvement Plan, or a request for waiver, within 45 days of the PIP Notice, or within a time period approved through an extension request;
(b) Failed to file an acceptable Performance Improvement Plan in good faith with the Commission;
(c) Failed to implement an approved Performance Improvement Plan in good faith; or
(d) Knowingly failed to provide information to the Commission as required by M.G.L. c. 6D, § 10.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.16 - Initiation of a Cost and Market Impact Review; Notice

Current through Register 1525, July 5, 2024
(1) If the Commission determines that the performance of a Provider Organization identified by the Center under M.G.L. c. 12C, § 18 has significantly impacted or is likely to significantly impact the state's ability to meet the health care cost growth benchmark established under M.G.L. c. 6D, § 9 or market functioning, the Commission may conduct a Cost and Market Impact Review of that Provider Organization when total health care expenditures exceed the health care cost growth benchmark established under M.G.L. c. 6D, § 9 in the calendar year for which the Provider Organization was identified by the Center.
(2) To make the determination described in 958 CMR 10.16(1), the Commission may request additional information from the Provider Organization identified by the Center under M.G.L. c. 12C, § 18. Prior to any Board vote to determine whether to initiate a Cost and Market Impact Review pursuant to 958 CMR 10.16(1), the Commission shall provide written notice to the Provider Organization, an opportunity to review information used by the Commission relative to 958 CMR 10.16(1), and an opportunity to meet with the Executive Director.
(3) The Commission shall determine whether to initiate a Cost and Market Impact Review by vote of the Board.
(4) The Commission shall provide written notice to any Provider Organization for which it will conduct a Cost and Market Impact Review under 958 CMR 10.16(1).
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.17 - Cost and Market Impact Review Process for CHIA-identified Provider Organizations

Current through Register 1525, July 5, 2024
The process for a Cost and Market Impact Review under 958 CMR 10.16 shall be governed by M.G.L. c. 6D, § 13, and 958 CMR 7.05 through 7.12; and 7.14.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 10.00 - Performance Improvement Plans › Section 10.18 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of 958 CMR 10.00 or the applicability thereof is held invalid or unconstitutional by any court of competent jurisdiction, the remainder of 958 CMR 10.00 or the applicability thereof to other persons, entities, or circumstances shall not thereby be affected.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.01 - Scope and Purpose

Current through Register 1525, July 5, 2024
958 CMR 11.00 applies to all Risk-bearing Provider Organizations and Accountable Care Organizations subject to the requirements of M.G.L. c. 176O, § 24, M.G.L. c. 6D, §§ 15 and 16.  958 CMR 11.00 establishes requirements for administering internal appeals processes and establishes the requirements for external review of appeals submitted by or on behalf of Patients of Risk-bearing Provider Organizations and Accountable Care Organizations.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.03 - Right to an Internal Appeal

Current through Register 1525, July 5, 2024
(1) Risk-bearing Provider Organizations or Accountable Care Organizations shall maintain an internal appeal process that provides for adequate consideration and timely resolution of Patient concerns about denials, restrictions, or limitations of care.
(2) The internal appeals processes shall apply to decisions of the RBPO, ACO or the ACO or RBPO Participants relating to denials, restrictions or limitations of care regarding:
(a) Referrals to Providers not affiliated with the RBPO or ACO;
(b) The type or intensity of treatment or services;
(c) Timely access to treatment or services; and
(d) Other concerns related to the Patient's care provided by an RBPO or ACO or RBPO or ACO Participant that are related to Provider participation in an Alternative Payment Contract.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.04 - Information on Internal Appeals

Current through Register 1525, July 5, 2024
(1) The RBPO or ACO shall make information about its internal appeals process available to Patients and the public through the following means:
(a) Notice available in writing at all locations where Patients regularly seek care; and
(b) Hard copy or electronic copy of the notice to Patients upon request.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.05 - Form and Manner of Request for Internals Appeals

Current through Register 1525, July 5, 2024
(1) The RBPO or ACO shall adopt a process to accept appeals by telephone, in person, by mail, or by electronic means, provided that an oral appeal made by the Patient or the Patient's Authorized Representative shall be reduced to writing by the RBPO or ACO and a copy forwarded to the Patient or the Patient's Authorized Representative.
(2) Where an appeal requires review of a Patient's medical records such appeal shall include, if necessary, a form signed by the Patient or the Patient's Authorized Representative authorizing the release of medical and treatment information relevant to the appeal.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.06 - Risk-bearing Provider Organization and Accountable Care Organization Records of Appeals

Current through Register 1525, July 5, 2024
Each RBPO or ACO shall establish a system for maintaining records of each appeal made by a Patient or on his or her behalf, and response thereto, for a period of seven years, which records shall be subject to inspection by the Commissioner of Insurance and the Office of Patient Protection.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.07 - Time Limits for Resolution of Internal Appeals

Current through Register 1525, July 5, 2024
(1) The RBPO or ACO shall provide the Patient, or the Patient's Authorized Representative, with a written resolution of the appeal within 14 calendar days of receipt of the original appeal.
(2) The RBPO or ACO shall provide the Patient, or the Patient's Authorized Representative, with a written resolution of the expedited internal appeal concerning an Urgent Medical Need within three business days.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.08 - Internal Reviewers

Current through Register 1525, July 5, 2024
(1) The RBPO or ACO shall ensure that an Internal Reviewer determines the resolution of the internal appeal.
(2) An Internal Reviewer shall determine whether the Patient has an Urgent Medical Need that warrants an expedited internal appeal. The Internal Reviewer determining Urgent Medical Need and the Internal Reviewer determining the resolution of the internal appeal may be the same individual.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.09 - Form of Written Resolution of the Internal Appeal

Current through Register 1525, July 5, 2024
(1) Each written resolution of an internal appeal shall include a clear summary explanation of the basis for the decision, including a substantive clinical justification for the decision, and identification of the specific information considered.
(2) The written resolution on the Patient's appeal shall prominently provide information on the Patient's right to appeal the decision to the Office of Patient Protection and information on how to file a request for external review including, but not limited to:
(a) A paper copy of the form prescribed by the Office of Patient Protection for the request for external review, as well as instructions for locating the form on the Office of Patient Protection's website;
(b) The toll-free number, website, and email address maintained by the Office of Patient Protection; and
(c) A list of documents and information available to the Patient from the RBPO or ACO, including a list of the Patient's medical records and other documents and information relied upon by the RBPO or ACO in the internal appeal. The RBPO or ACO shall include instructions for obtaining these documents.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.10 - External Review

Current through Register 1525, July 5, 2024
A Patient or a Patient's Authorized Representative who seeks further review of a denial or restriction by an RBPO or ACO and whose concerns were not resolved through the internal appeals process may request an external review of the internal appeal decision by filing a request in writing with the Office of Patient Protection within 30 calendar days of the Patient's receipt of the written resolution of the internal appeal decision.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.11 - Expedited External Review

Current through Register 1525, July 5, 2024
(1) The Patient or Patient's Authorized Representative may request an expedited external review, which shall be determined by the External Review Agency.
(2) A request for expedited external review by a Patient or the Patient's Authorized Representative shall be included in the external review request, on the external review request form issued by the Office of Patient Protection. Each request for an expedited review shall contain a description, in writing, from the Patient or Patient's Authorized Representative demonstrating the Patient's Urgent Medical Need and may include other information, including medical records, from the Patient or the Patient's Authorized Representative.
(3) The External Review Agency shall order the external review to be expedited where it determines that there is an Urgent Medical Need.
(4) The External Review Agency shall order that the external review be expedited within 24 hours of receiving the request for expedited external review from the Office of Patient Protection.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.12 - Fees

Current through Register 1525, July 5, 2024
(1) The cost for an external review shall be borne by the involved RBPO or ACO. Upon completion of the external review, the Office of Patient Protection or the External Review Agency shall bill the involved RBPO or ACO the amount established pursuant to contract between the Commission and the assigned External Review Agency.
(2) There shall be no cost borne by the Patient requesting an external review.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.13 - Consent to Release of Medical Information

Current through Register 1525, July 5, 2024
(1) Any request for external review pursuant to  958 CMR 11.10 shall include the signature of the Patient or the Patient's Authorized Representative authorizing the release and forwarding of medical information and records relevant to the subject matter of the external review to the External Review Agency, in a matter consistent with state and federal law.
(2) In connection with any request for an external review, the RBPO or ACO shall ensure that the Patient, and where applicable the Patient's Authorized Representative, has timely access to any relevant medical information and records relating to the Patient in the possession of the RBPO or ACO, in accordance with applicable state and federal law.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.14 - Form and Manner of Request for External Review

Current through Register 1525, July 5, 2024
(1) Requests for external review submitted by the Patient or the Patient's Authorized Representative shall:
(a) Be on a form prescribed by the Office of Patient Protection;
(b) Include the signature of the Patient or the Patient's Authorized Representative consenting to the release of medical information; and
(c) Include a copy of the written resolution of the internal appeal issued by the RBPO or ACO.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.15 - Screening of Requests for External Review

Current through Register 1525, July 5, 2024
(1) The Office of Patient Protection shall screen all Patient requests for external reviews to determine if they:
(a) Comply with the requirements of  958 CMR 11.00;
(b) Do not involve an issue within the purview of the Patient's Carrier; and
(c) Result from an RBPO's or ACO's written resolution of the internal appeal upholding the decision that is the subject of the appeal; provided, however, that no written resolution is necessary where the RBPO or ACO has failed to comply with timelines for the internal appeals process.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 11.00 - Internal Appeals Process and External Review Process for Risk-bearing Provider Organizations and Accountable Care Organizations › Section 11.16 - Requests Ineligible for External Review - Notification

Current through Register 1525, July 5, 2024
Notification of the rejection of a request for external review for failure to meet requirements in  958 CMR 11.15 shall be issued by the Office of Patient Protection to the Patient or the Patient's Authorized Representative within 72 hours of a receipt of a request for an expedited review and within six business days of a receipt of a request for all other reviews. The notification shall set forth the specific reason why the request has been determined ineligible for an external review.