reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.504 - Carrier's Coverage Conditions

Current through Register 1525, July 5, 2024
(1) A carrier may
			 condition coverage of continued treatment by a provider under
			 958
			 CMR 3.500 through
			 3.502, upon the provider's
			 agreeing:
(a) to accept reimbursement from the
			 carrier at the rates applicable prior to the notice of disenrollment as payment
			 in full;
(b) to not impose cost
			 sharing with respect to the insured in an amount that would exceed the cost
			 sharing that could have been imposed if the provider had not been
			 disenrolled;
(c) to adhere to the
			 quality assurance standards of the carrier and to provide the carrier with
			 necessary medical information related to the care provided; and,
(d) to adhere to such carrier's policies and
			 procedures, including procedures regarding referrals, obtaining prior
			 authorization and providing treatment pursuant to a treatment plan, if any,
			 approved by the carrier.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.505 - Standing Referrals

Current through Register 1525, July 5, 2024
(1) A carrier that
			 requires an insured to designate a primary care provider shall allow such a
			 primary care provider to authorize a standing referral for specialty health
			 care, including mental health care, provided by a health care provider
			 participating in such carrier's network when:
(a) the primary care provider determines that
			 such referrals are appropriate;
(b)
			 the provider of specialty health care agrees to a treatment plan for the
			 insured and provides the primary care provider with all necessary clinical and
			 administrative information on a regular basis; and
(c) the health care services to be provided
			 are consistent with the terms of the carrier's evidence of coverage.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.506 - Specialty Care Not Requiring Prior Authorization

Current through Register 1525, July 5, 2024
(1) No
			 carrier that requires an insured to obtain referrals or prior authorizations
			 from a primary care provider for specialty care shall require an insured to
			 obtain a referral or prior authorization from a primary care provider for the
			 following specialty care provided by an obstetrician, gynecologist, certified
			 nurse-midwife or family practitioner participating in such carrier's health
			 care provider network:
(a) annual preventive
			 gynecologic health examinations, including any subsequent obstetric or
			 gynecological services determined by such obstetrician, gynecologist, certified
			 nurse-midwife or family practitioner to be medically necessary as a result of
			 such examination;
(b) maternity
			 care; and
(c) medically necessary
			 evaluations and resultant health care services for acute or emergency
			 gynecological conditions.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.507 - Coverage of Pediatric Specialty Care

Current through Register 1525, July 5, 2024
Carriers shall provide coverage of pediatric specialty care,
				including mental health care, by persons with recognized expertise in providing
				specialty pediatric care to insureds requiring such services.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.508 - Denial of Provider Application

Current through Register 1525, July 5, 2024
Carriers shall provide health care providers who are applying
				to be participating providers and who are denied such status with a written
				reason or reasons for the denial of such application.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.509 - Provider Termination Without Cause Provisions

Current through Register 1525, July 5, 2024
(1)
			 Contracts between carriers and health care providers shall state that neither
			 the carrier nor the provider has the right to terminate the contract without
			 cause.
(2) Carriers shall provide a
			 written statement to a provider of the reason or reasons for such provider's
			 involuntary disenrollment.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 3.000 - Health Insurance Consumer Protection › Section 3.700 - Required Oral Interpretation and Written Translation Services

Current through Register 1525, July 5, 2024
(1) Each carrier shall provide to the insured
			 or the insured's authorized representative, upon request, oral interpretation
			 and written translation services related to all procedures under
			 958 CMR
			 3.000, as required by M.G.L. 1760, § 15(k),
			 including, but not limited to, notices of adverse determinations and final
			 adverse determinations. Oral interpretation services shall include, but not be
			 limited to, oral interpretations of documents, answering questions and
			 providing information and assistance with filing grievances or external review
			 requests.
(2) A carrier must
			 include in the English version of all notices required by
			 958 CMR
			 3.000 and provided to the insured or the insured's
			 authorized representative, a statement describing how the insured or the
			 insured's authorized representative can request oral interpretation and written
			 translation services from the carrier. At a minimum the statement must be
			 prominently displayed within the notice in English, Arabic, Khmer (Cambodian),
			 Chinese, French, Greek, Haitian-Creole, Italian, Lao, Portuguese, Russian and
			 Spanish, and in any non-English language in which 10% or more of the population
			 residing in any Massachusetts county served by the carrier is only literate in
			 the same non-English language, as determined by the Office of Patient
			 Protection, or as otherwise specified by the Office of Patient Protection in
			 consultation with the Division of Insurance.
(3) Effective July 1, 2014, once an insured
			 or insured's authorized representative has requested written translation of
			 documents into Spanish, the carrier must provide all subsequent written notices
			 required by
			 958 CMR
			 3.000 to the insured or the insured's authorized
			 representative in Spanish along with the English version.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 4.000 - Health Insurance Open Enrollment Waivers › Section 4.001 - Scope and Purpose

Current through Register 1525, July 5, 2024
958 CMR 4.000 establishes the requirements for requests by consumers who wish to enroll in a nongroup health plan outside of the open enrollment periods established by M.G.L. c. 176J. 958 CMR 4.000 applies to all carriers subject to the requirements of M.G.L. c. 176J.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 4.000 - Health Insurance Open Enrollment Waivers › Section 4.030 - Eligibility for Enrollment Waivers

Current through Register 1525, July 5, 2024
(1) An eligible individual may apply for an enrollment waiver within 30 calendar days of receipt of notice by a carrier in accordance with regulatory guidance issued by the Division of Insurance that such individual is not eligible to enroll in a health benefit plan outside of open enrollment pursuant to 211 CMR 66.00:
Small Group Health Insurance
, or pursuant to applicable federal law including the Patient Protection and Affordable Care Act, Public Law 111-148, and any rules, regulations or guidance issued thereunder.
(2) The following individuals are not eligible to apply for an enrollment waiver:
(a) A person who does not meet the definition of "eligible individual" set forth in 958 CMR 4.020.
(b) An individual who has not first applied to a carrier for enrollment in a health plan and been notified that he or she is not eligible to enroll outside of the open enrollment period.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 4.000 - Health Insurance Open Enrollment Waivers › Section 4.040 - Procedure for Submission of Request for Enrollment Waiver

Current through Register 1525, July 5, 2024
(1) An eligible person shall submit a request for an enrollment waiver on a form specified by the Office of Patient Protection and shall include a copy of the notice from the carrier that denied enrollment to the eligible person.
(2) The Office of Patient Protection shall not charge a fee to any person who requests an enrollment waiver.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 4.000 - Health Insurance Open Enrollment Waivers › Section 4.050 - Review of Applications for Enrollment Waivers

Current through Register 1525, July 5, 2024
(1) The review of enrollment waiver requests is not an adjudicatory proceeding. The Office of Patient Protection shall not be required to conduct a hearing or hold a face-to-face meeting with any applicant.
(2) The Office of Patient Protection may grant an enrollment waiver to an eligible individual who certifies, under penalty of perjury, that such individual did not intentionally forgo enrollment into coverage that is at least actuarially equivalent to minimum creditable coverage and for which the individual is or was eligible during a period of open enrollment.
(3) The Office of Patient Protection may use the following criteria in determining whether to grant an enrollment waiver to an eligible individual.
(a) Evidence of extenuating circumstances that prevented an individual from enrolling in a health benefit plan during the previous open enrollment period or during an applicable special enrollment period, including but not limited to lack of accessibility to minimum creditable coverage;
(b) The similarity of the circumstances to the qualifying events set forth in regulations or guidance issued by the Division of Insurance, the Health Connector, or applicable federal law including the Patient Protection and Affordable Care Act, Public Law 111-148, and any rules, regulations or guidance issued thereunder, that permit an individual to enroll in a nongroup health benefit plan outside of the open enrollment period. The Office of Patient Protection may confer with the Division of Insurance, the Health Connector, or other state or federal agency in order to make such determination.
(c) The credibility of the evidence presented in the enrollment waiver request.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 4.000 - Health Insurance Open Enrollment Waivers › Section 4.060 - Effect of Decision on a Request for an Enrollment Waiver

Current through Register 1525, July 5, 2024
(1) The applicant for the request for the enrollment waiver is responsible for notifying the carrier that issued the denial notice of an approval of an enrollment waiver request by the Office of Patient Protection within 30 calendar days of the receipt of the approval.
(2) The carrier shall enroll the eligible individual in accordance with regulations or guidance issued by the Division of Insurance.
(3) An applicant whose request for an enrollment waiver is denied must wait until the next open enrollment period to apply to a carrier for enrollment in a nongroup health benefit plan.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 4.000 - Health Insurance Open Enrollment Waivers › Section 4.070 - Reporting to Office of Patient Protection

Current through Register 1525, July 5, 2024
Each carrier shall provide to the Office of Patient Protection no later than April 1st of each year, the following information to assist the Office of Patient Protection in resolving enrollment waiver requests.
(1) Each carrier shall provide the name, telephone number and e-mail address of the person or persons within its organization who will serve as the general contact for the Office of Patient Protection for enrollment waivers.
(2) Each carrier shall provide the name, telephone number and e-mail address of the person or persons who have the authority to approve enrollment applications.
(3) Each carrier shall provide the name, telephone number and e-mail address of the person or persons to whom the Office of Patient Protection can direct a specific caller with a particular enrollment problem. This information shall include the name and contact information for a specific individual or individuals and shall not be a general customer service number.
(4) If any of this contact information changes, the carrier shall provide the new information in writing to the Office of Patient Protection within ten business days following the change.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 5.00 - Administration Of The Distressed Hospital Trust Fund › Section 5.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 958 CMR 5.00 governs the procedures and criteria used to award grants to certain qualifying acute hospitals as authorized in M.G.L. c. 29, § 2GGGG. 958 CMR 5.00 specifies how the Commission will administer the grant program in compliance with the Office of the Comptroller's regulation 815 CMR 2.00:
Grants and Subsidies.
(2)
Authority
. 958 CMR 5.00 is adopted pursuant to M.G.L. c. 29, § 2GGGG.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 5.00 - Administration Of The Distressed Hospital Trust Fund › Section 5.02 - Definitions

Current through Register 1525, July 5, 2024
Acute Hospital
. The teaching hospital of the University of Massachusetts Medical School and any hospital licensed under M.G.L. c. 111, § 51 and which contains a majority of medical-surgical, pediatric, obstetric and maternity beds as defined by the department of public health.
Applicant
. An acute hospital submitting an application for funding in response to a Commission-issued RFP.
Center
. The Center for Health Information and Analysis or CHIA.
Chair
. The Chairperson of the Health Policy Commission.
Commission
. The Health Policy Commission.
Commissioner
. A member of the governing board of the Health Policy Commission pursuant to M.G.L. c. 6D, § 2(b).
Executive Director
. The Executive Director of the Health Policy Commission.
For Profit Hospital or For Profit Hospital System
. A hospital or hospital system that is not exempt from Federal income tax or is not incorporated under M.G.L. c. 180, § 3.
Fund
. The Distressed Hospital Trust Fund established in M.G.L. c. 29, § 2GGGG.
Grant Program or Grant
. The Grant program authorized under M.G.L. c. 29, § 2GGGG.
Non-profit
. An organization exempt from Federal income tax; and/or an organization incorporated under M.G.L. c. 180, § 3.
Qualified Acute Hospital
. A hospital eligible to receive a grant from the Fund. A qualified acute hospital shall not include:
(a) a hospital that is a teaching hospital;
(b) a hospital whose relative prices are determined by the Commission to be above the statewide median relative price; or
(c) a for-profit hospital or a hospital that is part of a for-profit system.
Relative Prices
. The contractually negotiated amounts paid to providers by each private and public carrier for health care services, including non-claims related payments and expressed in the aggregate relative to the payer's network-wide average amount paid to providers, as calculated by the Center under M.G.L. c. 12C, § 10 and 958 CMR 5.00.
Request for Proposals or RFP
. The Request for Proposals or RFP issued by the Commission pursuant to 958 CMR 5.04.
Statewide Median Relative Price
. The benchmark established by the Center by comparing relative price levels across payers' networks for all acute hospitals. The statewide median relative price is used by the Commission to determine eligibility for the Fund.
Teaching Hospital
. An acute hospital that has at least 25 full-time equivalent interns or residents per 100 inpatient beds, as determined by the center.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 5.00 - Administration Of The Distressed Hospital Trust Fund › Section 5.03 - Grant Application Requirements

Current through Register 1525, July 5, 2024
(1) An eligible Applicant is a qualified acute hospital, as determined by the Commission at the time of issuance of an RFP, using the best available data from the Center.
(2) All requests for grant funding must support the Commonwealth's goals to improve the health of its residents, improve the access and quality of care, including patient experience, and reduce health care cost growth. All requests should further support one or more of the following purposes:
(a) to improve and enhance the ability of community hospitals to serve populations effectively, including but not limited to enhancing care coordination, advancing integration of behavioral and physical health services, promoting evidence-based care practices and efficient care delivery, and providing culturally and linguistically appropriate services;
(b) to advance the adoption of health information technology, including interoperable electronic health records systems and clinical support tools;
(c) to accelerate the ability to electronically exchange information with other providers to ensure continuity of care and enhanced coordination across the continuum of providers and organizations in the community served by the Applicant;
(d) to support infrastructure investments necessary for the transition to alternative payment methodologies, including investments in data analysis functions and performance management programs, including systems to promote provider price transparency, necessary to aggregate and analyze clinical data on a population level to facilitate appropriate and evidence-based interventions and care management practices, especially for vulnerable populations and those with complex health care needs;
(e) to aid in the development of care practices and other operational standards necessary for certification as an accountable care organization or patient centered medical home under M.G.L. c. 6D, §§ 14 and 15;
(f) to improve the affordability and quality of care, including but not limited to increasing access to behavioral health services, and coordination between hospitals and community based providers and organizations; or
(g) to plan or develop grant proposals supporting one or more of the purposes in 958 CMR 5.03(2)(a) through (f).
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 5.00 - Administration Of The Distressed Hospital Trust Fund › Section 5.04 - Request for Proposals

Current through Register 1525, July 5, 2024
(1) The Executive Director, upon approval of the Commission, shall issue one or more Requests for Proposals, each addressing one or more goals as specified in 958 CMR 5.03(2). The RFP shall specify the information Applicants shall be required to submit in connection with the application.
(2) Applications must be submitted to the Commission in the form and manner specified in the RFP and by the date specified in the RFP.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 5.00 - Administration Of The Distressed Hospital Trust Fund › Section 5.05 - Materials to be Submitted by Applicants

Current through Register 1525, July 5, 2024
The RFP shall require each Applicant to submit the following
(1) Applicant contact information;
(2) Narrative description of the Applicant;
(3) Narrative summary of request for grant funding, including the total amount of grant funding requested, justification for the amount requested and a timetable for expenditure of funds;
(4) A plan that defines specific goals for improving the efficiency and effectiveness of the hospital's care over a multi-year period;
(5) The programs the Applicant shall use to meet the goals, and the evidence-base for these programs where applicable;
(6) A budget necessary to implement the plan, including a detailed description of any funding or in-kind contributions the Applicant will be providing in support of the proposal;
(7) A plan for sustaining any investments after the expiration of grant funds;
(8) Any other private funding or private sector participation the Applicant anticipates in support of the proposal; and
(9) Any other information as specified in the RFP.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 5.00 - Administration Of The Distressed Hospital Trust Fund › Section 5.06 - Criteria for Awarding Grants

Current through Register 1525, July 5, 2024
The Executive Director shall evaluate all applications that meet all of the minimum requirements listed in 958 CMR 5.03 using the following criteria:
(1) The financial health of the qualified acute hospital and the demonstrated need for investment, taking into account all resources available to the particular provider including the relationship or affiliation of the particular provider to a health care delivery system and the capacity of the system to provide financial support for the acute hospital; provided that, in assessing financial health, the commission shall take into account days cash on hand, net working capital and earnings before income tax, payer mix, uncompensated care, and depreciation and amortization, and access to working capital, using data reported to the Center.
(2) The anticipated return on investment, as measured by improved health care coordination and a reduction in health care costs;
(3) Whether the investment will support innovative health care delivery and payment models as identified by the health care policy commission;
(4) Geographic need and population need;
(5) Demonstrated ability to implement the operational changes described in the application in response to requirements set forth in 958 CMR 5.03(2); and
(6) Any other criteria specified in the RFP.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 5.00 - Administration Of The Distressed Hospital Trust Fund › Section 5.07 - Review and Selection Procedure

Current through Register 1525, July 5, 2024
(1) The Executive Director shall review all applications to determine if they have fulfilled all the application requirements and submitted all materials required in the RFP issued pursuant to 958 CMR 5.05. Applications that do not meet all the requirements and/or have not submitted all required materials in the RFP shall not be further reviewed and shall not be approved for funding.
(2) The Executive Director, and any Commissioner designated by the Chair, shall further review applications that meet all required application requirements and have submitted all required materials in accordance with the criteria set forth in 958 CMR 5.05 and 5.06. The Executive Director may request an Applicant to submit any additional information it deems necessary to complete its review, including an oral presentation or interview. The Commission must receive all requested additional materials within five business days of a request or the Executive Director may determine the application to be incomplete.
(3) The Executive Director shall recommend to the Commission Applicants to receive grants and the amounts to be awarded, which may be an amount higher or lower than that requested by the Applicant. Recommendations for awards shall be made based on the availability of funds, the degree to which an Applicant meets the criteria and the degree to which the grant meets the Applicant's need for such funding.
(4) The Commission shall make the final award decisions based on the recommendations of the Executive Director and criteria in 958 CMR 5.06. The Commission's decisions are final and not subject to appeal.
(5) The Commission shall notify all Applicants of their selection or non-selection for a grant.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 5.00 - Administration Of The Distressed Hospital Trust Fund › Section 5.08 - Grant Contract

Current through Register 1525, July 5, 2024
(1) All Applicants selected to receive a grant must execute contracts with the Commission, as required by 815 CMR 2.05:
Contractual Requirementsfor Grants and Grant Payments,
in order to receive payment.
(2) The Executive Director shall develop and execute grant contracts consistent with 958 CMR 5.08.
(3) The grant contract shall specify, as applicable:
(a) any financial, programmatic, technical or other reporting appropriate to monitor and evaluate the funded activities, including ongoing milestones, an annual progress review as applicable for multi-year grants, and an evaluation process;
(b) any conditions or restrictions on the funding, including any monitoring of the grantee's operations, including where appropriate, an independent financial and operational audit to recommend steps to increase sustainability and efficiency of the hospital;
(c) any additional means the Commission will use to hold the grantee accountable for proper performance under the grant;
(d) a limit on the amount each hospital may spend on administrative or overhead spending related to the approved project;
(e) any deadlines for completing components of the project; and
(f) provisions for repayment of all or a portion of funds to the Commission if the Commission determines that the funds were not used consistent with the approved grant application and contract.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 5.00 - Administration Of The Distressed Hospital Trust Fund › Section 5.09 - Severability

Current through Register 1525, July 5, 2024
The provisions of 958 CMR 5.00 are severable. If any provisions or the application of any provision is held invalid or unconstitutional, such invalidity shall not be construed to affect the validity or constitutionality of any remaining provisions of 958 CMR 5.00.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 6.00 - Registration Of Provider Organizations › Section 6.01 - General Provisions

Current through Register 1525, July 5, 2024
Scope and Purpose
. 958 CMR 6.00 governs the procedures and criteria used to administer the provider organization registration program as required by M.G.L. c. 6D, § 11 and 12. 958 CMR 6.00 specifies the criteria that determine which Provider Organizations must register with the Health Policy Commission and what information must be submitted by each Provider Organization to complete Registration.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 6.00 - Registration Of Provider Organizations › Section 6.03 - Applicability

Current through Register 1525, July 5, 2024
(1)
								958 CMR 6.00 applies to a Provider Organization that negotiates, represents, or otherwise acts on behalf of one or more Providers or Provider Organizations, which may include itself, in establishing contracts for the payment of Health Care Services with Carriers or Third-party Administrators, that collectively received $25,000,000 or more in Net Patient Service Revenue from Carriers or Third-party Administrators in the prior Fiscal Year.
(2)
								958 CMR 6.00 also applies to a Risk-bearing Provider Organization subject to the requirements of the Division pursuant to M.G.L. c. 176T and any regulations promulgated thereunder.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 6.00 - Registration Of Provider Organizations › Section 6.04 - Requirement to Register

Current through Register 1525, July 5, 2024
(1) The following Provider Organizations shall register with the Commission pursuant to 958 CMR 6.00:
(a) a Provider Organization that negotiates, represents, or otherwise acts on behalf of one or more Providers or Provider Organizations, which may include itself, in establishing contracts for the payment of Health Care Services with Carriers or Third-party Administrators, that collectively:
1.received $25,000,000 or more in Net Patient Service Revenue from Carriers or Third-party Administrators in the prior Fiscal Year; and
2.had a Patient Panel of more than 15,000 as of the end of the Provider Organization's prior Fiscal Year; and
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 6.00 - Registration Of Provider Organizations › Section 6.05 - Registration

Current through Register 1525, July 5, 2024
(1) A Provider Organization that meets the criteria set forth in 958 CMR 6.04(1)  as of July 18, 2014 shall file an application for Registration with the Commission as specified in the Data Submission Manual, subject to the provisions of 958 CMR 6.04(2) and (3).
(2) The following Provider Organizations that meet the criteria set forth in 958 CMR 6.04(1)  shall begin and complete Initial Registration by no later than the dates specified in the Data Submission Manual:
(a) A Provider Organization that negotiates, represents, or otherwise acts on behalf of one or more Providers or Provider Organizations, which may include itself, that is a physician group, Acute Hospital, rehabilitation hospital, long term acute care hospital, or that provides inpatient or outpatient Behavioral Health Services, to establish contracts for the payment of Health Care Services with Carriers or Third-party Administrators; and
(b) A Risk-bearing Provider Organization.
A Provider Organization specified in 958 CMR 6.05(2) that does not meet the criteria set forth in 958 CMR 6.04(1)  as of July 18, 2014, but that meets these criteria at any time after July 18, 2014 shall complete Initial Registration not later than 180 calendar days after meeting the criteria set forth in 958 CMR 6.04(1), subject to the provisions of 958 CMR 6.04(2) and (3), unless otherwise authorized by the Commission in writing.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 6.00 - Registration Of Provider Organizations › Section 6.06 - Non-compliance

Current through Register 1525, July 5, 2024
(1) If the Commission determines that a Provider or Provider Organization that has not registered with the Commission pursuant to 958 CMR 6.00 might meet the eligibility criteria set forth in 958 CMR 6.04(1), the Commission may send written notice to the Provider or Provider Organization. Within 30 calendar days of the date of the notice, a Provider or Provider Organization that receives such a notice from the Commission shall:
(a) Submit an application for Registration in compliance with 958 CMR 6.05; or
(b) Submit adequate supporting documentation to demonstrate that the Provider or Provider Organization does not meet the eligibility criteria set forth in 958 CMR 6.04(1). The documentation must demonstrate to the satisfaction of the Commission that the Provider or Provider Organization does not meet the criteria established in 958 CMR 6.04(1).
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 6.00 - Registration Of Provider Organizations › Section 6.07 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of 958 CMR 6.00 or the applicability thereof is held invalid or unconstitutional by any court of competent jurisdiction, the remainder of 958 CMR 6.00 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 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.01 - General Provisions

Current through Register 1525, July 5, 2024
Scope and Purpose
. 958 CMR 7.00 governs certain procedures for filing of Notices of Material Change with the Commission by Providers and Provider Organizations, as required by M.G.L. c. 6D, § 13. 958 CMR 7.00 specifies the procedures by which the Commission shall review Notices of Material Change and conduct Cost and Market Impact Reviews.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.03 - Requirement to File a Notice of Material Change; Timing of Filing

Current through Register 1525, July 5, 2024
(1)
Requirement for Filing
. Any Provider or Provider Organization with $25 million or more in Net Patient Service Revenue in the preceding fiscal year shall provide the Commission, the Center, and the Office of the Attorney General with a Notice of Material Change not fewer than 60 days before the proposed effective date of the proposed Material Change. For purposes of 958 CMR 7.00, the effective date of a Material Change is the date when the proposed transaction will be consummated or closed. If the Commission determines that a Provider or Provider Organization has failed to file a Notice of Material Change pursuant to 958 CMR 7.03(1), the Commission may refer the Provider or Provider Organization to the Office of the Attorney General.
(2)
Timing of Filing
. A Provider or Provider Organization may file a Notice of Material Change earlier than 60 days before the effective date of the proposed Material Change; provided that if the Commission considers the Notice of Material Change to be incomplete, or if the Commission requires clarification of any information to make its determination, the Commission may, within 30 days of receipt of the Notice of Material Change, notify the Provider or Provider Organization of the information or clarification necessary to complete the notice.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.04 - Filing a Notice of Material Change; Completed Notice

Current through Register 1525, July 5, 2024
(1) A Notice of Material Change shall be filed in a manner and form prescribed by the Commission and shall identify any changes in Health Care Services anticipated in connection with the proposed Material Change.
(2) A Notice of Material Change shall be complete upon filing of the Notice of Material Change form and any information requested by the Commission pursuant to M.G.L. c. 6D, § 13(c) and 958 CMR 7.03.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.05 - Notice of Cost and Market Impact Review

Current through Register 1525, July 5, 2024
The Commission shall inform each notifying Provider or Provider Organization of any determination to initiate a Cost and Market Impact Review within 30 days of its receipt of a completed Notice of Material Change, including all required information pursuant to 958 CMR 7.03(2), or by a later date set by mutual agreement of the Provider or Provider Organization and the Commission.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.06 - Factors Considered in a Cost and Market Impact Review

Current through Register 1525, July 5, 2024
A Cost and Market Impact Review may examine factors relating to the Provider or Provider Organization's business and its relative market position, including, but not limited to:
(1) The Provider or Provider Organization's size and market share within its Primary Service Areas by major service category, and within its Dispersed Service Areas;
(2) The Provider or Provider Organization's prices for services, including its relative price compared to other Providers for the same services in the same market;
(3) The Provider or Provider Organization's health status adjusted total medical expense, including its health status adjusted total medical expense compared to similar Providers;
(4) The quality of the services it provides, including patient experience;
(5) Provider cost and cost trends in comparison to total health care expenditures statewide;
(6) The availability and accessibility of services similar to those provided, or proposed to be provided, through the Provider or Provider Organization within its Primary Service Areas and Dispersed Service Areas;
(7) The Provider or Provider Organization's impact on competing options for the delivery of Health Care Services within its Primary Service Areas and Dispersed Service Areas including, if applicable, the impact on existing service Providers of a Provider or Provider Organization's expansion, affiliation, Merger or Acquisition, to enter a Primary or Dispersed Service Area in which it did not previously operate;
(8) The methods used by the Provider or Provider Organization to attract patient volume and to recruit or acquire health care professionals or facilities;
(9) The role of the Provider or Provider Organization in serving at-risk, underserved and government payer patient populations, including those with behavioral, substance use disorder and mental health conditions, within its Primary Service Areas and Dispersed Service Areas;
(10) The role of the Provider or Provider Organization in providing low margin or negative margin services within its Primary Service Areas and Dispersed Service Areas;
(11) Consumer concerns, including but not limited to, complaints or other allegations that the Provider or Provider Organization has engaged in any unfair method of competition or any unfair or deceptive act or practice; and
(12) Any other factors that the Commission determines to be in the public interest.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.07 - Information Requests to Providers and Provider Organizations; Timing

Current through Register 1525, July 5, 2024
(1) Within 21 days of issuance of a notice of Cost and Market Impact Review by the Commission, a Provider or Provider Organization shall submit a written response to the notice. The written response shall include the information requested by the Commission pursuant to such notice and may include additional information.
(2) The Provider or Provider Organization may request additional time to provide its written response or requested information; provided that any additional time granted by the Commission to submit information may be added to the time for completion of the Final Report, pursuant to M.G.L. c. 6D, § 13 and 958 CMR 7.12.
(3) The Provider or Provider Organization shall certify substantial compliance with the Commission's requests for information on the date determined by the Commission.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.08 - Information Requests to Other Market Participants; Timing

Current through Register 1525, July 5, 2024
In connection with its review of a Notice of Material Change filed pursuant to M.G.L. c. 6D, § 13 and 958 CMR 7.03 or a Cost and Market Impact Review initiated pursuant to M.G.L. c. 6D, § 13 and 958 CMR 7.05, the Commission may request information of other Providers, Provider Organizations, or Payers, which shall be provided within 21 days of a request by the Commission.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.09 - Confidentiality

Current through Register 1525, July 5, 2024
The Commission shall keep confidential all nonpublic information and documents obtained in connection with a Notice of Material Change or a Cost and Market Impact Review and shall not disclose the information or documents to any person without the consent of the Provider or Payer that produced the information or documents, except in a Preliminary Report or Final Report if the Commission believes that such disclosure should be made in the public interest after taking into account any privacy, trade secret or anti-competitive considerations. The confidential information and documents shall not be public records and shall be exempt from disclosure under M.G.L. c. 4, § 7 cl. 26 or M.G.L. c. 66, § 10. Nonpublic information and documents shall not include information included on the Notice of Material Change form itself, prescribed by and filed with the Commission.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.10 - Preliminary Report

Current through Register 1525, July 5, 2024
The Commission shall issue a Preliminary Report containing factual findings on a Cost and Market Impact Review, pursuant to M.G.L. c. 6D, § 13(e).
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.11 - Written Response by Provider or Provider Organization; Certification of Truth

Current through Register 1525, July 5, 2024
(1)
Written Response
. Within 30 days after the Commission issues a Preliminary Report, the Provider or Provider Organization may respond in writing to the findings in the Preliminary Report.
(2)
Certification of Truth
. In submitting a written response to the Preliminary Report, the Provider or Provider Organization shall certify that all information set forth in the written response is true and accurate to the best knowledge of the Provider or Provider Organization's chief executive officer. Further, the Provider or Provider Organization shall certify that none of the information included in the written response, or any information referred to therein, is responsive to the Commission's requests for information in connection with the notice of Cost and Market Impact Review and was previously available but not provided.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.12 - Final Report

Current through Register 1525, July 5, 2024
The Commission shall issue a Final Report on a Cost and Market Impact Review subsequent to the issuance of a Preliminary Report and any written response timely submitted by the Provider or Provider Organization, which shall be within 185 days from the date that the Provider or Provider Organization filed a completed Notice of Material Change with the Commission; provided that the Provider or Provider Organization has certified substantial compliance with the Commission's requests for information within 21 days pursuant to M.G.L. c. 6D, § 13 and 958 CMR 7.07. If the Provider or Provider Organization has not certified substantial compliance within 21 days of the Commission's requests for information as provided in 958 CMR 7.07, the Commission may set a later date for the issuance of the Final Report that is commensurate with any additional time granted pursuant to 958 CMR 7.07.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.13 - Completion of Proposed Material Change

Current through Register 1525, July 5, 2024
Any proposed Material Change shall not be completed until the Commission has informed the Provider or Provider Organization of any determination not to initiate a Cost and Market Impact Review pursuant to 958 CMR 7.05, or until at least 30 days after the Commission has issued its Final Report on a Cost and Market Impact Review.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.14 - Referral to the Office of the Attorney General

Current through Register 1525, July 5, 2024
The Commission shall refer a Final Report issued pursuant to 958 CMR 7.12 to the Office of the Attorney General pursuant to M.G.L. c. 6D, § 13(f) on any Provider Organization that has Dominant Market Share, Materially Higher Price, and Materially Higher Health Status Adjusted Total Medical Expenses, as defined in 958 CMR 7.02. The Commission may also refer a Final Report to the Office of the Attorney General in other circumstances as appropriate.
Code of Massachusetts Regulations › 958 CMR - HEALTH POLICY COMMISSION › Title 958 CMR 7.00 - Notices Of Material Change And Cost And Market Impact Reviews › Section 7.15 - Severability

Current through Register 1525, July 5, 2024
If any section or portion of a section of 958 CMR 7.00 or the applicability thereof is held invalid or unconstitutional by any court of competent jurisdiction, the remainder of 958 CMR 7.00 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 8.00 - Patient Assignment Limits For Registered Nurses In Intensive Care Units In Acute Hospitals › Section 8.01 - General Provisions

Current through Register 1525, July 5, 2024
Scope and Purpose
. 958 CMR 8.00 governs the implementation of M.G.L. c. 111, § 231, which establishes Patient Assignment limits for Registered Nurses in Intensive Care Units in Acute Hospitals licensed by the Massachusetts Department of Public Health and in hospitals operated by the Commonwealth of Massachusetts, including the process for selecting or developing the Acuity Tool and required elements of the Acuity Tool.
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 8.03 - Applicability

Current through Register 1525, July 5, 2024
958 CMR 8.00 applies to Acute Hospitals licensed by the Department to provide service(s) in ICUs, as defined in 958 CMR 8.02, and to hospitals operated by the Commonwealth and authorized to provide ICU service(s).
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 8.04 - Staff Nurse Patient Assignment in Intensive Care Units

Current through Register 1525, July 5, 2024
(1) In all ICUs, the Patient Assignment for each Staff Nurse shall be one or two ICU Patients depending on the stability of the ICU Patient as assessed pursuant to 958 CMR 8.05.
(2) The maximum Patient Assignment for each Staff Nurse may not exceed two ICU Patients.
(3) Nothing in 958 CMR 8.00 prohibits the assignment of more than one Staff Nurse to an ICU Patient.
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 8.05 - Assessment of Patient Stability

Current through Register 1525, July 5, 2024
(1) For purposes of implementing 958 CMR 8.04, the Staff Nurse assessing the ICU Patient shall assess the stability of the ICU Patient utilizing:
(a) The exercise of sound nursing assessment and judgment within the parameters of the Staff Nurse's continuing education and experience; and
(b) The Acuity Tool developed or selected by the Acute Hospital and certified by the Department, pursuant to 958 CMR 8.00.
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 8.06 - Development or Selection and Implementation of the Acuity Tool

Current through Register 1525, July 5, 2024
(1) Each Acute Hospital shall develop or select an Acuity Tool for each ICU that meets the requirements of 958 CMR 8.00, in order to:
(a) Support the determination of whether each ICU Patient requires care by one or more Staff Nurses, or by a Staff Nurse assigned to care for no more than two ICU Patients; and
(b) Address the unique care needs and circumstances of the patient population in and physical environment of each ICU at the Acute Hospital.