Current through Register 1531, September 27, 2024
(1) EOHHS will collect a surcharge on certain
payments to hospitals and ambulatory surgical centers. The surcharge amount
equals the product of:
(a) payments subject
to the surcharge as defined in
101
CMR 516.03(3); and
(b) the assessment percentage as defined in
101
CMR 516.03(4).
(2) Payers subject to surcharge:
(a) Payers are subject to the surcharge if:
1. the payer is a surcharge payer;
and
2. the payer's payments subject
to surcharge were $1,000,000 or more during the previous state fiscal year or
the most recent state fiscal year for which data is available.
(b) The same entity that pays the
hospital or ambulatory surgical center for services must pay the
surcharge.
(c) A payer that pays
for hospital or ambulatory surgical center services on behalf of a client plan
must pay the surcharge on those services. A payer that administers payments for
health care services on behalf of a client plan in exchange for an
administrative fee will be deemed to use the client plan's funds to pay for
health care services whether the payer pays providers with funds from the
client plan, with funds advanced by the payer subject to reimbursement by the
client plan, or with funds deposited with the payer by the client
plan.
(d) In the case of a transfer
of ownership, a surcharge payer's liability to the Fund must be assumed by the
successor in interest to the surcharge payer.
(3) Payments subject to the surcharge include
direct and indirect payments made by surcharge payers in a time period as
determined by EOHHS and released annually, to hospitals for the purchase of
hospital services; and to ambulatory surgical centers for the purchase of
ambulatory surgical center services.
(4) EOHHS will determine the surcharge
percentage as follows:
(a) EOHHS will, on an
annual basis, collect the Total Behavioral Health Surcharge Amount by
collecting a portion of the total amount from all payers.
(b) EOHHS will require each payer to pay a
portion of the total behavioral health surcharge amount proportional to their
payments subject to surcharge during the most recent period for which data is
available.
(c) The surcharge
percentage is determined by dividing the total amount to be collected
determined under
101
CMR 516.03(4)(a) by total
payments subject to surcharge determined under
101
CMR 516.03(4)(b).
(d) EOHHS may establish the surcharge
percentage by administrative bulletin. EOHHS may adjust the surcharge
percentage by Administrative Bulletin if an adjustment is necessary to collect
the revenue required to be collected.
(5) Each payer must determine its surcharge
liability in accordance with guidance issued by EOHHS in administrative
bulletins. The surcharge liability is the product of the payer's payments
subject to the surcharge, as defined in
101
CMR 516.03(3) and the
surcharge percentage as defined in
101
CMR 516.03(4)(c). The total
amount to be collected may vary depending on the outcome of any administrative
review of payments pursuant to
101
CMR 516.04.
(6) Payers that pay a global fee or
capitation for services that include hospital or ambulatory surgical center
services, as well as other services not subject to the surcharge, must develop
a reasonable method for allocating the portion of the payment intended to be
used for services provided by hospitals or ambulatory surgical centers. Such
payers must file this allocation with EOHHS by February
1st of each year. If there is a significant change
in the global fee or capitation payment arrangement that necessitates a change
in the allocation method, the payer must notify EOHHS and file a new allocation
method at least 45 days before the new payment arrangement takes effect. Payers
may not change the allocation method later in the year unless there is a
significant change in the payment arrangement.
(a) EOHHS will review allocation plans within
90 days of receipt. During this review period, EOHHS may require a payer to
submit supporting documentation or to make changes in this allocation method if
it finds that the method does not reasonably allocate the portion of the global
payment or capitation intended to be used for services provided by hospitals or
ambulatory surgical centers.
(b) A
payer must include the portion of the global payment or capitation intended to
be used for services provided by hospitals or ambulatory surgical centers, as
determined by this allocation method, in its determination of payments subject
to the surcharge.
(7) A
payer must include all payments made as a result of settlements, judgments or
audits in its determination of payments subject to the surcharge. A payer may
include payments made by Massachusetts hospitals or ambulatory surgical centers
to the payer as a result of settlements, judgments or audits as a credit in its
determination of payments subject to the surcharge.
(8) Each payer must pay its surcharge
liability in the first quarter of each calendar year in accordance with a
schedule developed and released by the EOHHS through administrative
bulletin.
(9)
Penalties
for Non-payment.
(a) If a payer
does not pay the amount calculated pursuant to
101
CMR 516.03(4)(c), or a
specified portion thereof, by the due date established by EOHHS, EOHHS may
assess up to a 3% penalty on the outstanding balance. EOHHS will calculate the
penalty on the outstanding balance as of the due date. EOHHS may assess up to
an additional 3% penalty against the outstanding balance and prior penalties
for each month that a payer remains delinquent. EOHHS will credit partial
payments from delinquent payers to the current outstanding liability. If any
amount remains from the partial payment, EOHHS will then credit such amount to
the penalty amount.
(b) In
determining the penalty amount, EOHHS may consider factors including, but not
be limited to, the payer's payment history, financial situation, and relative
share of the payments.
