Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 155.00 - Risk-bearing Provider Organizations
Section 155.03 - Applicability

(1)211 CMR 155.00 applies to a Provider Organization that negotiates, represents, or otherwise acts on behalf of one or more Providers or Provider Organizations, which may include itself, in establishing Alternate Payment Contracts in which:

(2) A Risk-bearing Provider Organization shall annually submit materials to apply for a Risk Certificate or a Risk Certificate Waiver, as applicable.

(3) A Provider Organization shall not be permitted to enter into an arrangement with either a Carrier or a Public Health Care Payer whereby the Provider Organization or any entity with which the Provider Organization has a Contracting Affiliation manages the treatment of a group of patients and bears Downside Risk according to the terms of an Alternative Payment Contract, or other alternative payment arrangement as part of an insured health benefit plan network, unless the Provider Organization obtains a Risk Certificate or a Risk Certificate Waiver, as applicable.

(4) A Provider Organization that is seeking to enter or has entered into an Alternative Payment Contract with an Employer or an individual under which the Provider Organization or any entity with which the Provider Organization has a Contracting Affiliation would assume a significant portion of Downside Risk may be required to be licensed as a Carrier in accordance with M.G.L. c. 176T,§2. For purposes of 211 CMR 155.03(4), a Public Health Care Payer shall not be considered to be an Employer.

(5) A Provider Organization that is seeking to enter into an arrangement to manage the treatment of a group of patients and bears Downside Risk according to the terms of an Alternative Payment Contract shall be subject to the requirements of 211 CMR 155.00 unless the Provider Organization's only Downside Risk arrangement is an Alternative Payment Contract(s) exclusively involving Medicare Program risk. Any Provider Organization that is subject to the requirements of 211 CMR 155.00 shall be subject to the same extent and degree that a Risk-bearing Provider Organization is subject to 211 CMR 155.00, and any reference to a Risk-bearing Provider Organization shall be deemed to include any Provider Organization that has entered or is seeking to enter into an arrangement to manage the treatment of a group of patients and bears Downside Risk according to the terms of an Alternative Payment Contract, as appropriate unless the Provider Organization's only Downside Risk arrangement is an Alternative Payment Contract(s) exclusively involving Medicare Program risk.