Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 155.00 - Risk-bearing Provider Organizations › Section 155.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				211 CMR 155.00, the
				following words mean:
Alternative Payment Contract
. Any
				contract between a Provider or Provider Organization and a Health Care Payer,
				Employer or individual, which utilizes Alternative Payment
				Methodologies.
Alternative Payment Methodologies or
				Methods
. Methods of payment that are not solely based on fee for
				service reimbursements; provided, however,
Alternative Payment
				Methodologies
may include, but shall not be limited to, shared
				savings arrangements, bundled payments, and global payments; and further
				provided,
Alternative Payment Methodologies
may
				include fee for service payments, which are settled or reconciled with a
				bundled or global payment.
Carrier
. An insurer licensed or
				otherwise authorized to transact accident and health insurance under M.G.L. c.
				175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a
				non profit Medical Service Corporation organized under M.G.L. c. 176B; or a
				Health Maintenance Organization organized under M.G.L. c. 176G; and an
				organization entering into a preferred provider arrangement under M.G.L. c.
				1761, but not including an Employer purchasing coverage or acting on behalf of
				its employees or the employees of one or more subsidiaries or affiliated
				corporations of the Employer; provided that, unless otherwise noted,
Carrier
shall not include any entity to the extent it
				offers a policy, certificate or contract that provides coverage solely for
				dental care services or vision care services.
Center
. The Center for Health
				Information and Analysis established in M.G.L. c. 12C.
Commission
. The Health Policy
				Commission established in M.G.L. c. 6D.
Commissioner
. The Commissioner of
				Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her
				designee.
Contracting Affiliation
. Any
				relationship between a Provider Organization and another Provider or Provider
				Organization for the purposes of negotiating, representing, or otherwise acting
				to establish contracts for the payment of Health Care Services including for
				payment rates, incentives, and operating terms, with a Carrier or third-party
				administrator.
Division
. The Division of Insurance
				established pursuant to M.G.L. c. 26, § 1.
Downside Risk
. The risk taken on by a
				Provider Organization as part of an Alternative Payment Contract with a Health
				Care Payer, Employer, or individual in which the Provider Organization is
				responsible for either the full or partial costs of treating a group of
				patients that may exceed the contracted budgeted payment arrangements.
Employer
. An Employer as defined in
				M.G.L. c. 151 A, § 1.
Health Care Payer
. A Carrier; a Public
				Health Care Payer; the federal Medicare Program, including any Carrier or other
				entity that contracts to pay for or arrange the purchase of benefits under any
				Medicare program, or a Carrier acting as a third party administrator, and
				includes, for the purposes of
				211 CMR 155.00, those
				organizations who act as subcontractors of Health Care Payers to enter into
				Alternative Payment Contracts with Providers and Provider Organizations.
Health Care Services
. Supplies, care
				and services of medical, surgical, optometric, dental, podiatric, chiropractic,
				psychiatric, therapeutic, diagnostic, preventative, rehabilitative, supportive
				or geriatric nature including, but not limited to, inpatient and outpatient
				acute hospital care; services provided by a community health center, home
				health and hospice care Provider or by a sanatorium, as included in the
				definition of
Hospital
in Title XVIII of the federal
				Social Security Act; and treatment and care compatible with such services or by
				a Health Maintenance Organization.
Health Maintenance Organization
. A
				company licensed according to M.G.L. c. 176G.
Medical Service Corporation
. A
				corporation established to operate a nonprofit medical service plan as provided
				in M.G.L. c. 176B.
Medicare Program
. The medical
				insurance program established by Title XVIII of the Social Security Act.
Provider
or
Health Care
				Provider
. Any person, corporation, partnership, governmental unit,
				state institution or any other entity qualified under the laws of the
				commonwealth to perform or provide Health Care Services.
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 Health Care Payers for the payments of Health Care
				Services; provided, however, that the definition 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 Health Care Payers
				for payment for Health Care Services.
Public Health Care Payer
. The Medicaid
				program established in M.G.L. c. 118E; any Carrier or other entity that
				contracts with the office of Medicaid or the commonwealth health insurance
				connector authority to pay for or arrange the purchase of Health Care Services
				on behalf of individuals enrolled in health coverage programs under Titles XIX
				or XXI, or under the Connector Care health insurance program, including prepaid
				health plans subject to the provisions of St. 1997, c. 47, § 28; the group
				insurance commission (GIC) established under M.G.L. c. 32A, and any Carrier or
				other entity that contracts with the GIC to pay for or arrange the purchase of
				Health Care Services; and any city or town with a population of more than
				60,000 that has adopted M.G.L. c. 32B.
Registered Provider Organization
. A
				Provider Organization that meets the criteria for registration pursuant to
				M.G.L. c. 6D, § 11 and
				958 CMR 6.00:
Registration of Provider Organizations
and has registered with
				the Commission.
Reserves
. The estimated liability for
				contract losses that have occurred as of a given evaluation date. This includes
				actual and potential contract losses and estimated costs incurred but not yet
				paid.
Risk-bearing Provider Organization
. A
				Provider Organization that manages the treatment of a group of patients and
				bears Downside Risk according to the terms of an Alternative Payment
				Contract.
Risk Certificate
. A certificate of
				solvency issued by the Division that demonstrates that a Risk-bearing Provider
				Organization has satisfied the certification requirements of M.G.L. c. 176T and
				211 CMR 155.00.
Risk Certificate Waiver
. A waiver
				granted by the Commissioner to a Risk-bearing Provider Organization from the
				requirement to obtain a Risk Certificate.
Title XIX
. Title XIX of the Social
				Security Act,
				42 U.S.C.
				1396
etseq.,
or any
				successor statute enacted into federal law for the same purposes as Title
				XIX.