Code of Massachusetts Regulations › 211 CMR - DIVISION OF INSURANCE › Title 211 CMR 155.00 - Risk-bearing Provider Organizations › Section 155.05 - Risk Certificates

Current through Register 1525, July 5, 2024
(1) Each
			 Risk-bearing Provider Organization that has not been granted a Risk Certificate
			 Waiver shall be required to file an application for an annual Risk Certificate.
			 Integrated care organizations or senior care organizations contracted under
			 M.G.L. c. 118E, § 9D or 9F that have been certified in accordance with
			 M.G.L. c. 118E, § 9D(q) or 9F(b) shall be deemed to have satisfied the
			 Risk Certificate requirements for purposes of
			 211 CMR 155.00 and M.G.L. c.
			 176T.
All Risk Certificates will be valid beginning no earlier than
				March 1st, for a term of up to one year through the
				last calendar day of February
(2) The application shall be certified by at
			 least two officers of the Risk-bearing Provider Organization, including a
			 senior executive officer or partner, and either the treasurer or an assistant
			 treasurer. The application shall include the following:
(a) the most recent materials submitted by
			 the applicant Risk-bearing Provider Organization to the Commission pursuant to
			 M.G.L. c. 6D, § 12 as a Registered Provider Organization, unless such
			 materials are already on file with the Division, or unless such registration
			 has not yet occurred;
(b) the names
			 of the Health Care Payers and Employers with which the applicant is seeking to
			 enter into an arrangement, or has already entered into an arrangement to manage
			 the treatment of a group of patients;
(c) whether the applicant is seeking to enter
			 into an arrangement, or has already entered into an arrangement directly with
			 individuals to manage the treatment of a group of patients;
(d) audited financial statements, where
			 available, or other financial statements and/or documents that show the assets,
			 liabilities, Reserves and sources of working capital and other sources of
			 financial support and projections of the results of operations for the
			 succeeding three years for the applicant Risk-bearing Provider Organization and
			 each entity:
1. with whom the Risk-bearing
			 Provider Organization has a Contracting Affiliation; and
2. assumes Downside Risk in its arrangement
			 with the Risk-bearing Provider Organization.
(e) a financial plan, including the
			 following:
1. a statement indicating the
			 anticipated timing for receipt of income from Alternative Payment Contracts
			 with Downside Risk versus the anticipated timing of the incurrence of expenses
			 associated with those Alternative Payment Contracts with Downside
			 Risk;
2. a statement of the
			 applicant Risk-bearing Provider Organization's plan to establish and maintain
			 sufficient financial resources that will protect the applicant Risk-bearing
			 Provider Organization and those entities with which it has a Contracting
			 Affiliation from the potential losses from Downside Risk;
3. evidence of any insurance coverage or
			 other agreements that protects the applicant Risk-bearing Provider Organization
			 from potential losses from Downside Risk; and
4. a detailed description of mechanisms put
			 in place by the applicant Risk-bearing Provider Organization to monitor the
			 financial solvency of any subcontracting Provider(s) or Provider
			 Organization(s) where the subcontracting entity assumes Downside Risk in its
			 arrangement with the applicant Risk-bearing Provider Organization or Provider
			 Organization.
(f) a
			 utilization plan describing the methods by which the applicant Risk-bearing
			 Provider Organization will monitor inpatient and outpatient utilization under
			 the Alternative Payment Contracts with Downside Risk;
(g) an actuarial certification, consistent
			 with
			 211 CMR
			 155.06, that provides a statement that, after
			 examining the terms of all the applicant Risk-bearing Provider Organization's
			 intended or existing Alternative Payment Contracts with Downside Risk, the
			 actuary concludes that such Alternative Payment Contracts are not expected to
			 threaten the financial solvency of the applicant Risk-bearing Provider
			 Organization;
(h) demonstrations
			 that contracts between the applicant Risk-bearing Provider Organization and
			 other Provider(s) or Provider Organizations include provisions that
			 conspicuously prohibit Health Care Providers from collecting or attempting to
			 collect from a patient money that is owed to the Health Care Provider by the
			 applicant Risk-bearing Provider Organization, or other Provider
			 Organization;
(i) a description of
			 the level and nature of risk assumed across all of the Provider Organization's
			 Alternative Payment Contracts, including details about the aggregate number of
			 members that are covered under Alternative Payment Contracts; and details with
			 respect to the risk contracts of each entity:
1. with whom the Risk-bearing Provider
			 Organization has a Contracting Affiliation; and
2. which assumes Downside Risk in its
			 arrangement with the Risk-bearing Provider Organization.
(j) a certification that the applicant has
			 established an internal appeals process pursuant to M.G.L. c. 1760, § 24;
(k) a statement that indicates
			 whether or not the applicant Risk-bearing Provider Organization has entered
			 into any Alternative Payment Contracts with Downside Risk with any Employers or
			 individuals, and if the applicant Risk-bearing Provider Organization has
			 entered into any such Alternative Payment Contracts with Downside Risk, a
			 detailed description of the number of contracts the applicant Risk-bearing
			 Provider Organization has entered into with Employers or individuals;
(l) a filing fee in the amount of
			 $500.00 made payable to the "Commonwealth of Massachusetts"; and
(m) any additional information deemed
			 necessary by the Commissioner.