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 7.02 - Definitions

Current through Register 1525, July 5, 2024
As used in 958 CMR 7.00, the following words mean:
Acquisition
. A purchase or takeover of one organization by another, including a license substitution, standard asset purchase, or troubled asset purchase, but not including employment of a single Health Care Professional.
Carrier
. An insurer licensed or otherwise authorized to transact accident or health insurance under M.G.L. c. 175; a nonprofit Hospital service corporation organized under M.G.L. c. 176A; a nonprofit medical service corporation organized under M.G.L. c. 176B; 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. 176I; provided, that this shall not include 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, the term
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 visions care services.
Center
. The Center for Health Information and Analysis.
Clinical Affiliation
. Any relationship between a Provider or Provider Organization and another organization for the purpose of increasing the level of collaboration in the provision of Health Care Services, including, but not limited to, sharing of physician resources in Hospital or other ambulatory settings, co-branding, expedited transfers to advanced care settings, provision of inpatient consultation coverage or call coverage, enhanced electronic access and communication, co-located services, provision of capital for service site development, joint training programs, video technology to increase access to expert resources and sharing of hospitalists or intensivists.
Commission
. The Health Policy Commission.
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.
Corporate Affiliation
. Any relationship between two organizations that reflects, directly or indirectly, a partial or complete controlling interest or partial or complete common control.
Cost and Market Impact Review
. A review conducted by the Commission pursuant to M.G.L. c. 6D, § 13 and 958 CMR 7.00.
Dispersed Service Area
. A geographic region in which a multi-Provider Provider Organization functions and in which its market presence is likely to be meaningful to purchasers and Payer networks, as determined by the Commission based on best available data in a methodology set forth in a Technical Bulletin.
Dominant Market Share
. A Provider's share of Health Care Services, including but not limited to inpatient services, outpatient services, or professional services, in such Provider's service area that is of significant importance to Payer networks. For inpatient general acute care services, a Provider or Provider Organization has Dominant Market Share if it has 40% of the commercial discharges in one or more of its hospitals' Primary Service Areas. For other services, thresholds for Dominant Market Share may be set forth in a Technical Bulletin, as determined by the Commission based on best available data.
Final Report
. A report issued by the Commission subsequent to a Preliminary Report on a Cost and Market Impact Review, pursuant to M.G.L. c. 6D, § 13 and 958 CMR 7.12.
Health Care Professional
. A physician or other health care practitioner licensed, accredited, or certified to perform specified Health Care Services consistent with law.
Health Care Services
. Supplies, care and services of medical, behavioral health, substance use disorder, mental health, 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 and services; 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.
Hospital
. Any hospital licensed under M.G.L. c. 111, § 51, the teaching hospital of the University of Massachusetts Medical School and any psychiatric facility licensed under M.G.L. c. 19, § 19.
Material Change
. The following types of proposed changes involving a Provider or Provider Organization:
(a) A Merger or affiliation with, or Acquisition of or by, a Carrier;
(b) A Merger with or Acquisition of or by a Hospital or hospital system;
(c) Any other Acquisition, Merger, or affiliation (such as a Corporate Affiliation, Contracting Affiliation, or employment of Health Care Professionals) of, by, or with another Provider, Providers (such as multiple Health Care Professionals from the same Provider or Provider Organization), or Provider Organization that would result in an increase in annual Net Patient Service Revenue of the Provider or Provider Organization of ten million dollars or more, or in the Provider or Provider Organization having a near-majority of market share in a given service or region;
(d) Any Clinical Affiliation between two or more Providers or Provider Organizations that each had annual Net Patient Service Revenue of $25 million or more in the preceding fiscal year; provided that this shall not include a Clinical Affiliation solely for the purpose of collaborating on clinical trials or graduate medical education programs; and
(e) Any formation of a partnership, joint venture, accountable care organization, parent corporation, management services organization, or other organization created for the purpose of administering contracts with Carriers or third-party administrators or current or future contracting on behalf of one or more Providers or Provider Organizations.
Materially Higher Price
. A Provider's price, as defined by the Center pursuant to M.G.L. c. 12C and 957 CMR 2.02:
Definitions
or as specified in a Technical Bulletin, for a Carrier or set of Carriers which constitute at least 1/3 of such Provider's total commercial revenue, which exceeds the weighted mean the price of the similar Providers or Provider type for the same Carrier or set of Carriers. The methodology for the calculation of Materially Higher Price is set forth in a Technical Bulletin.
Materially Higher Health Status Adjusted Total Medical Expenses
. A Provider's health status adjusted total medical expenses, as defined by the Center pursuant to M.G.L. c. 12C and 957 CMR 2.02:
Definitions
or as specified in a Technical Bulletin, for a Carrier or set of Carriers which constitute at least 1/3 of such Provider's total commercial revenue, which exceeds the weighted mean health status adjusted total medical expenses of the similar Providers or Provider type for the same Carrier or set of Carriers. The methodology for the calculation of Materially Higher Health Status Adjusted Total Medical Expenses is set forth in a Technical Bulletin.
Merger
. A consolidation or integration of two or more organizations, including two or more organizations joining through a common parent organization or two or more organizations forming a new organization, but not including the merger of a corporate affiliate into a sole member parent or a corporate re-organization within an existing Provider or Provider Organization.
Net Patient Service Revenue
. The total revenue received for patient care from any third party Payer net of any contractual adjustments. For Hospitals, Net Patient Service Revenue should be as reported to the Center under M.G.L. c. 12C, § 8. For other Providers or Provider Organizations, Net Patient Service Revenue shall include the total revenue received for patient care from any third Party payer net of any contractual adjustments, including:
(a) prior year third party settlements; and
(b) premium revenue, which means per-member-per-month amounts received from a third party Payer to provide comprehensive Health Care Services for that period, for all Providers represented by the Provider or Provider Organization in contracting with Carriers, for all Providers represented by the Provider or Provider Organization in contracting with third party Payers.
Non-material Change
: Any change to a Provider or Provider Organization's operations or governance structure which is not a Material Change.
Notice of Material Change
. Notification to the Commission by a Provider or Provider Organization prior to making a Material Change to its operations or governance structure, pursuant to M.G.L. c. 6D, § 13 and 958 CMR 7.00.
Payer
. An organization that pays Providers for the provision of Health Care Services; provided that
Payer
shall include both governmental and private organizations; provided further, that
Payer
shall not include excluded ERISA plans.
Preliminary Report
. A report issued by the Commission containing factual findings on a Cost and Market Impact Review, pursuant to M.G.L. c. 6D, § 13 and 958 CMR 7.10.
Primary Service Area
. A contiguous geographic area from which a Provider draws a significant proportion of its volume, as determined by the Commission based on best available data in a methodology set forth in a Technical Bulletin. For general acute care Hospitals, a Primary Service Area shall be the contiguous geographic area from which the Hospital draws 75% of its commercial discharges, as measured by zip codes closest to the Hospital by drive time, and for which the Hospital represents a minimum proportion of the total discharges in a zip code, as determined by the Commission based on best available data in a methodology set forth in a Technical Bulletin.
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 Carriers or third-party administrators for the payments of Health 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.
Technical Bulletin
. A sub-regulatory document containing methodological explanations and examples to facilitate understanding and compliance with the provisions contained in 958 CMR 7.00.