Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 155.00 - Risk-bearing Provider Organizations
Section 155.02 - Definitions

As used in 211 CMR 155.00, the following words mean:

Alternative Payment Contract. Any contract between a Provider or Provider Organization and a Health Care Payer, Employer or individual, which utilizes Alternative Payment Methodologies.

Alternative Payment Methodologies or Methods. Methods of payment that are not solely based on fee for service reimbursements; provided, however, Alternative Payment Methodologies may include, but shall not be limited to, shared savings arrangements, bundled payments, and global payments; and further provided, Alternative Payment Methodologies may include fee for service payments, which are settled or reconciled with a bundled or global payment.

Carrier. An insurer licensed or otherwise authorized to transact accident and health insurance under M.G.L. c. 175; a nonprofit hospital service corporation organized under M.G.L. c. 176A; a non profit Medical Service Corporation organized under M.G.L. c. 176B; or 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. 1761, but not including 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, 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 vision care services.

Center. The Center for Health Information and Analysis established in M.G.L. c. 12C.

Commission. The Health Policy Commission established in M.G.L. c. 6D.

Commissioner. The Commissioner of Insurance appointed pursuant to M.G.L. c. 26, § 6, or his or her designee.

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.

Division. The Division of Insurance established pursuant to M.G.L. c. 26, § 1.

Downside Risk. The risk taken on by a Provider Organization as part of an Alternative Payment Contract with a Health Care Payer, Employer, or individual in which the Provider Organization is responsible for either the full or partial costs of treating a group of patients that may exceed the contracted budgeted payment arrangements.

Employer. An Employer as defined in M.G.L. c. 151 A, § 1.

Health Care Payer. A Carrier; a Public Health Care Payer; the federal Medicare Program, including any Carrier or other entity that contracts to pay for or arrange the purchase of benefits under any Medicare program, or a Carrier acting as a third party administrator, and includes, for the purposes of 211 CMR 155.00, those organizations who act as subcontractors of Health Care Payers to enter into Alternative Payment Contracts with Providers and Provider Organizations.

Health Care Services. Supplies, care and services of medical, 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; 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.

Health Maintenance Organization. A company licensed according to M.G.L. c. 176G.

Medical Service Corporation. A corporation established to operate a nonprofit medical service plan as provided in M.G.L. c. 176B.

Medicare Program. The medical insurance program established by Title XVIII of the Social Security Act.

Provider or Health Care 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 Health Care Payers for the payments of Health Care Services; provided, however, that the definition 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 Health Care Payers for payment for Health Care Services.

Public Health Care Payer. The Medicaid program established in M.G.L. c. 118E; any Carrier or other entity that contracts with the office of Medicaid or the commonwealth health insurance connector authority to pay for or arrange the purchase of Health Care Services on behalf of individuals enrolled in health coverage programs under Titles XIX or XXI, or under the Connector Care health insurance program, including prepaid health plans subject to the provisions of St. 1997, c. 47, § 28; the group insurance commission (GIC) established under M.G.L. c. 32A, and any Carrier or other entity that contracts with the GIC to pay for or arrange the purchase of Health Care Services; and any city or town with a population of more than 60,000 that has adopted M.G.L. c. 32B.

Registered Provider Organization. A Provider Organization that meets the criteria for registration pursuant to M.G.L. c. 6D, § 11 and 958 CMR 6.00: Registration of Provider Organizations and has registered with the Commission.

Reserves. The estimated liability for contract losses that have occurred as of a given evaluation date. This includes actual and potential contract losses and estimated costs incurred but not yet paid.

Risk-bearing Provider Organization. A Provider Organization that manages the treatment of a group of patients and bears Downside Risk according to the terms of an Alternative Payment Contract.

Risk Certificate. A certificate of solvency issued by the Division that demonstrates that a Risk-bearing Provider Organization has satisfied the certification requirements of M.G.L. c. 176T and 211 CMR 155.00.

Risk Certificate Waiver. A waiver granted by the Commissioner to a Risk-bearing Provider Organization from the requirement to obtain a Risk Certificate.

Title XIX. Title XIX of the Social Security Act, 42 U.S.C. 1396 etseq., or any successor statute enacted into federal law for the same purposes as Title XIX.