Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 155.00 - Risk-bearing Provider Organizations
Section 155.04 - Risk Certificate Waivers

Universal Citation: 211 MA Code of Regs 211.155

Current through Register 1531, September 27, 2024

(1) A Risk-bearing Provider Organization may apply for an annual Risk Certificate Waiver if it wishes to demonstrate that its Alternative Payment Contracts do not contain significant downside risk.

(a) A Risk-bearing Provider Organization may apply for a new Risk Certificate Waiver at any time as specified by the Division.

(b) All Risk Certificate Waivers will be valid beginning no earlier than March 1st, for up to one year through the last calendar day of February.

Each Risk-bearing Provider Organization may apply to renew a current Risk Certificate Waiver for an additional annual term, provided that it submits materials in a form approved by the Commissioner by no later than August 31st in the year prior to the expiration date of the Risk Certificate Waiver.

(2) It shall be within the discretion of the Commissioner to issue or renew a Risk Certificate Waiver.

(3) An application and renewal for a Risk Certificate Waiver shall include the following information certified by an officer of the applicant Risk-bearing Provider Organization:

(a) the name of the Risk-bearing Provider Organization;

(b) the name and contact information for the person within the Risk-bearing Provider Organization designated to be the Division's primary contact;

(c) the official 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, and a statement describing the type(s) of payment arrangement entered into with each Health Care Payer and Employer;

(d) 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;

(e) a filing fee in the amount of $250.00 made payable to the "Commonwealth of Massachusetts"; and

(f) any other information deemed necessary by the Commissioner.

(4) Each Risk-bearing Provider Organization that applies for a Risk Certificate Waiver must submit sufficient information to the Division to demonstrate that its existing or proposed arrangements to manage the treatment of a group of patients according to the terms of one or more Alternative Payment Contracts do not contain significant Downside Risk. The submitted materials should project the proportion of organizational revenue that is subject to Downside Risk during the applicable period, the steps that the Risk-bearing Provider Organization has taken to prepare for the Downside Risk, and the reasons that the Risk-bearing Provider Organization believes that the contractual Downside Risk should not be considered significant.

(5) A Risk-bearing Provider Organization's application for an initial or renewal Risk Certificate Waiver shall not be considered complete until all materials and information required by M.G.L. c. 176T and 211 CMR 155.00 have been received by the Division. An applicant Risk-bearing Provider Organization shall respond to any request for additional information by the Division within 15 days of the date of the Division's request.

(6) If a Risk-bearing Provider Organization applicant is issued a Risk Certificate Waiver:

(a) the Division shall forward a copy of the Risk Certificate Waiver to the Risk-bearing Provider Organization, the Commission, and the Center; and

(b) the Division shall post the names of all Risk-bearing Provider Organizations who have been issued a Risk Certificate Waiver on the Division's website, www.mass.gov/doi/.

A Risk-bearing Provider Organization that has been issued a Risk Certificate Waiver shall report to the Division any material change to the information contained in its initial or renewal Risk Certificate Waiver application, in a document certified by an officer of the Risk-bearing Provider Organization, within 30 days of such change. Such material change would include, but is not limited to, the addition of new Alternative Payment Contracts, amendments to Downside Risk provisions in existing Alternative Payment Contracts, changes to the number or types of patients that are covered under existing Alternative Payment Contracts or changes to the organizational structure of any Provider Organization.

(7) If an applicant is not issued a Risk Certificate Waiver, the Division shall notify the Risk-bearing Provider Organization, the Commission, and the Center in writing that a Risk Certificate Waiver has not been issued, and the Risk-bearing Provider Organization must begin the process to apply for a Risk Certificate.

(8) It shall be within the discretion of the Commissioner to suspend or cancel an existing Risk Certificate Waiver. Such grounds for cancellation or suspension include, but are not limited to, a determination by the Commissioner that the combination of all of the Risk-bearing Provider Organization's existing or proposed arrangements to manage the treatment of a group of patients according to the terms of one or more Alternative Payment Contracts contains significant Downside Risk. Prior to suspending or cancelling a Risk Certificate Waiver, the Division shall provide written notice to the Risk-bearing Provider Organization holding the waiver, the Commission, and the Center, and provide the Risk-bearing Provider Organization 30 days to respond to such notice of suspension or cancellation with the filing of an application for a Risk Certificate.

Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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