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 13.02 - Definitions

Current through Register 1525, July 5, 2024
Benefit Year
. A calendar year or the
				applicable portion of a calendar year during which the Risk Adjustment Program
				is operated.
Carrier
. A Carrier, as defined in
				M.G.L. c. 176M, § 1, that offers at least one Risk Adjustment Covered Plan
				in the Commonwealth.
CHIA.
The Center for Health
				Information and Analysis established in M.G.L. c. 12C.
Commonwealth.
The Commonwealth of
				Massachusetts.
The Connector
. The Commonwealth Health
				Insurance Connector Authority.
Massachusetts All Payer Claims Database or MA
				APCD
. The All Payer Claims Database maintained by CHIA to which
				payers are required to submit data under
				957 CMR 8.00:
All
				Payer Claims Database (APCD) and Case Mix and Charge Data
				Submission
.
Member Month Tracker Report
. A report
				provided by the Connector to each Carrier including calculations of the total
				member months of enrollment subject to risk adjustment and collected premiums,
				based on the data submitted to the MA APCD by Carriers for the applicable
				reporting period.
Final Risk Adjustment Payments and Charges
				Report
. The annual report to be sent by the Connector to Carriers,
				by June 30th of the year following the applicable
				Benefit Year, describing charges owed by or payments owed to the Carrier under
				the Risk Adjustment program, as well as the list of data elements used in
				creating the risk adjustment data extract, the data extracts themselves,
				algorithms used to calculate payments and charges, and the output datasets from
				the algorithms.
Quarterly Simulation Reports
. A set of
				reports provided to each Carrier on a quarterly basis, providing preliminary
				calculations and data regarding the Carrier's risk adjustment experience. These
				shall include data quality assessment reports, as well as reports from the
				Connector regarding the data elements and algorithms used in developing the
				Risk Adjustment Data Extract and in calculating risk scores and preliminary
				transfer amounts, based on the data available for the applicable reporting
				period, and other data relevant to discrepancy resolution.
Risk Adjustment Covered Plan
. Any
				health insurance coverage offered in the individual or small group market in
				Massachusetts, as well as any other coverage specified as being subject to the
				Risk Adjustment Program in the applicable State Payment Notice, with the
				exception of: grandfathered health plans; coverage that is considered "excepted
				benefits" under 45 CFR § 146.145(c) or 45 CFR § 148.220; and any plan
				determined not to be a risk adjustment covered plan in the applicable State
				Payment Notice.
Risk Adjustment Data Extract
. An
				extract of health plan data reported to CHIA under
				957 CMR 8.00:
All
				Payer Claims Database (APCD) and Case Mix and Charge Data Submission
,
				containing only data elements that are necessary for risk adjustment, provided
				by CHIA to the Connector to conduct risk adjustment operations.
Risk Adjustment Methodology
. The
				federally certified risk adjustment methodology that will be implemented in the
				Commonwealth for a particular Benefit Year.
Risk Adjustment Program
. The risk
				mitigation program operated by the Connector, pursuant to the authority granted
				M.G.L. c. 176Q, § 3(v), as described in 42 U.S.C. § 18063, and as
				implemented in
				956 CMR 13.00.
State Payment Notice
. The
				Massachusetts Notice of Benefit and Payment Parameters, released by the
				Connector, describing the parameters, procedures, and methodology for Risk
				Adjustment for a given Benefit Year.