Code of Massachusetts Regulations
114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY
Title 114.5 CMR 23.00 - PAYER REPORTING OF TOTAL MEDICAL EXPENSES AND RELATIVE PRICES
Section 23.04 - Health Status Adjusted Total Medical Expenses
Universal Citation: 114.5 CMR 23.00 MA Code of Regs 23.04
Current through Register 1531, September 27, 2024
(1) TME by Physician Group and Physician Local Practice Group.
(a)
Reporting
Requirements.
1. Payers shall
report TME by Physician Group and Physician Local Practice Group for
Massachusetts Members required to select a primary care physician.
2. Payers shall report TME for Physician
Groups and Physician Local Practice Groups Physician Local Practice Groups with
at least 36,000 Member Months for the calendar year.
3. Payers shall report TME separately for
Medicaid and Commonwealth Care (combined), Medicare, commercial full-claim, and
commercial partial-claim plans. Commercial (self and fully insured) data for
physicians' groups or zip codes for which the Payer is able to collect
information on all direct medical claims and subcarrier claims shall be
reported in the full-claim category. Commercial (self and fully insured) data
for physicians' groups or zip codes that do not include all medical and
subcarrier claims shall be reported in the partial-claim category. Payers must
include the full amount paid for medical claims, including amounts paid under
stop-loss or reinsurance agreements, even if the Payer was not directly
providing payment for those services. Payers shall not include data for which
they are the secondary or tertiary payer such as Medicare Supplement.
4. Payers shall report TME data in the
aggregate for all Physician Groups and Physician Local Practice Groups with
fewer than 36,000 Member Months for the calendar year.
5. Payers shall attribute Non-claims Payments
to a Provider at the Local Practice Group Level and thereafter at the Physician
Group Level. If direct attribution is not possible, Payers shall allocate
Non-claims Payments by Member Months.
6. Payers must report the risk adjustment
tool and version used to report the Health Status Adjustment Score. The
Division may specify additional requirements for reporting the Health Status
Adjustment Score by Administrative Bulletin or in the Data Specification
Manual.
(b)
Required Data Elements.
1. DHCFP Provider Number
2. OrgID or Payer's Internal Provider
Number
3. Physician Group
Name
4. Local Practice Group
Name
5. Pediatric
Indicator
6. Member Months
(annual)
7. Health Status
Adjustment Score
8.
Normalized Health Status Adjustment Score: the Health
Status Adjustment Score divided by the Payer's average health status adjustment
score.
9.
Total Allowed
Medical Claims (annual): the medical claims expenses by the
following subcategories: hospital inpatient, hospital outpatient, professional
physician, other professional, pharmacy, and other.
10.
Total Non-claims Payments
(annual): the non-claims payments by the following subcategories:
incentive programs, risk settlements, care management expenses, and
other.
(c)
Calculation of TME by Physician Group and Physician Local Practice
Group. Based upon the data specified in 114. 5 CMR 23.04(1)(b) the
Division shall calculate TME by Physician Group and Physician Local Practice
Group by summing Total Medical Claims and Total Non-claims Payments to obtain
Total Payments. PMPM Unadjusted TME will be calculated by dividing Total
Payments by Member Months. PMPM Health Status Adjusted TME: will be calculated
by dividing PMPM Unadjusted TME by the Health Status Adjustment Score. PMPM
Normalized Health Status Adjusted TME will be calculated by dividing PMPM
Unadjusted TME by the Normalized Health Status Adjustment Score. Payers will be
provided a copy of the calculation.
(2) TME by Zip Code.
(a)
Reporting
Requirements.
1. Payers shall
report TME by zip code for all Massachusetts Members based on the zip code of
the Member. The Division shall not publicly report zip code TME data unless
aggregated to an amount appropriate to protect patient
confidentiality.
2. Payers shall
separately report TME for Members whose plans require the selection of a
primary care provider and TME for Members not required to select a primary care
provider.
3. Payers shall report
TME separately for Medicaid and Commonwealth Care (combined), Medicare,
commercial full-claim, and commercial partial-claim plans. Commercial (self and
fully insured) data for physicians' groups or zip codes for which the Payer is
able to collect information on all direct medical claims and subcarrier claims
shall be reported in the full-claim category. Commercial (self and fully
insured) data for physicians' groups or zip codes that do not include all
medical and subcarrier claims shall be reported in the partial-claim category.
Payers must include the full amount paid for medical claims, including amounts
paid under stop-loss or reinsurance agreements, even if the Payer was not
directly providing payment for those services. Payers shall not include data
for which they are the secondary or tertiary payer such as Medicare
Supplement.
4. Payers shall
allocate Non-claims Payments by Member Months.
5. Payers must report the risk adjustment
tool and version used to report the Health Status Adjustment Score. The
Division may specify additional requirements for reporting the Health Status
Adjustment Score by Administrative Bulletin or in the Data Specification
Manual.
(b)
Required Data Elements.
1. Member Zip Code
2. PCP/No PCP Member Designation
3. Member Months (annual)
4. Health Status Adjustment Score
5.
Normalized Health Status
Adjustment Score: the Health Status Adjustment Score divided by
the Payer's average health status adjustment score.
6.
Total Allowed Medical Claims
(annual): the sum of medical claims expenses designated into the
following subcategories: hospital inpatient, hospital outpatient, professional
physician, other professional, pharmacy, and other.
7.
Total Non-claims Payments
(annual): the sum of non-claims payments.
(c)
Calculation of TME by Zip
Code. Based upon the data specified in 114. 5 CMR 23.04(2)(b) the
Division shall calculate TME by Zip Code by summing Total Medical Claims and
Total Non-claims Payments to obtain Total Payments. PMPM Unadjusted TME will be
calculated by dividing Total Payments by Member Months. PMPM Health Status
Adjusted TME will be calculated by dividing PMPM Unadjusted TME by the Health
Status Adjustment Score. PMPM Normalized Health Status Adjusted TME will be
calculated by dividing PMPM Unadjusted TME by the Normalized Health Status
Adjustment Score. Payers will be provided a copy of the calculation.
(3) Due Dates.
(a)
Annual
Reports. Beginning in 2012, annually on June
1st Payers must submit preliminary TME reports for
the prior Calendar Year and final TME reports for the Calendar Year ending 17
months prior.
(b)
Initial Filing. For Calendar Year 2009, Payers must
submit the required reports by March 31, 2011. Payers must submit preliminary
Calendar Year 2010 TME data by June 1, 2011.
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