Current through Register 1531, September 27, 2024
(1) Each
Risk-bearing Provider Organization that has not been granted a Risk Certificate
Waiver shall be required to file an application for an annual Risk Certificate.
Integrated care organizations or senior care organizations contracted under
M.G.L. c. 118E, § 9D or 9F that have been certified in accordance with
M.G.L. c. 118E, § 9D(q) or 9F(b) shall be deemed to have satisfied the
Risk Certificate requirements for purposes of
211 CMR 155.00 and M.G.L. c.
176T.
All Risk Certificates will be valid beginning no earlier than
March 1st, for a term of up to one year through the
last calendar day of February
(2) The application shall be certified by at
least two officers of the Risk-bearing Provider Organization, including a
senior executive officer or partner, and either the treasurer or an assistant
treasurer. The application shall include the following:
(a) the most recent materials submitted by
the applicant Risk-bearing Provider Organization to the Commission pursuant to
M.G.L. c. 6D, § 12 as a Registered Provider Organization, unless such
materials are already on file with the Division, or unless such registration
has not yet occurred;
(b) the 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;
(c) 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;
(d) audited financial statements, where
available, or other financial statements and/or documents that show the assets,
liabilities, Reserves and sources of working capital and other sources of
financial support and projections of the results of operations for the
succeeding three years for the applicant Risk-bearing Provider Organization and
each entity:
1. with whom the Risk-bearing
Provider Organization has a Contracting Affiliation; and
2. assumes Downside Risk in its arrangement
with the Risk-bearing Provider Organization.
(e) a financial plan, including the
following:
1. a statement indicating the
anticipated timing for receipt of income from Alternative Payment Contracts
with Downside Risk versus the anticipated timing of the incurrence of expenses
associated with those Alternative Payment Contracts with Downside
Risk;
2. a statement of the
applicant Risk-bearing Provider Organization's plan to establish and maintain
sufficient financial resources that will protect the applicant Risk-bearing
Provider Organization and those entities with which it has a Contracting
Affiliation from the potential losses from Downside Risk;
3. evidence of any insurance coverage or
other agreements that protects the applicant Risk-bearing Provider Organization
from potential losses from Downside Risk; and
4. a detailed description of mechanisms put
in place by the applicant Risk-bearing Provider Organization to monitor the
financial solvency of any subcontracting Provider(s) or Provider
Organization(s) where the subcontracting entity assumes Downside Risk in its
arrangement with the applicant Risk-bearing Provider Organization or Provider
Organization.
(f) a
utilization plan describing the methods by which the applicant Risk-bearing
Provider Organization will monitor inpatient and outpatient utilization under
the Alternative Payment Contracts with Downside Risk;
(g) an actuarial certification, consistent
with
211 CMR
155.06, that provides a statement that, after
examining the terms of all the applicant Risk-bearing Provider Organization's
intended or existing Alternative Payment Contracts with Downside Risk, the
actuary concludes that such Alternative Payment Contracts are not expected to
threaten the financial solvency of the applicant Risk-bearing Provider
Organization;
(h) demonstrations
that contracts between the applicant Risk-bearing Provider Organization and
other Provider(s) or Provider Organizations include provisions that
conspicuously prohibit Health Care Providers from collecting or attempting to
collect from a patient money that is owed to the Health Care Provider by the
applicant Risk-bearing Provider Organization, or other Provider
Organization;
(i) a description of
the level and nature of risk assumed across all of the Provider Organization's
Alternative Payment Contracts, including details about the aggregate number of
members that are covered under Alternative Payment Contracts; and details with
respect to the risk contracts of each entity:
1. with whom the Risk-bearing Provider
Organization has a Contracting Affiliation; and
2. which assumes Downside Risk in its
arrangement with the Risk-bearing Provider Organization.
(j) a certification that the applicant has
established an internal appeals process pursuant to M.G.L. c. 1760, § 24;
(k) a statement that indicates
whether or not the applicant Risk-bearing Provider Organization has entered
into any Alternative Payment Contracts with Downside Risk with any Employers or
individuals, and if the applicant Risk-bearing Provider Organization has
entered into any such Alternative Payment Contracts with Downside Risk, a
detailed description of the number of contracts the applicant Risk-bearing
Provider Organization has entered into with Employers or individuals;
(l) a filing fee in the amount of
$500.00 made payable to the "Commonwealth of Massachusetts"; and
(m) any additional information deemed
necessary by the Commissioner.
(3) Each Risk-bearing Provider Organization
may apply to renew a current Risk Certificate for an additional annual term,
provided that it submits materials in a form approved by the Commissioner by no
later than November 15th. The renewed Risk
Certificate will be valid for a term of one year, beginning on March
1st of the following year. The information contained
in the renewal application shall be certified by at least two officers of the
Risk-bearing Provider Organization and include the following information:
(a) the most recent materials submitted by
the applicant Risk-bearing Provider Organization to the Commission pursuant to
M.G.L. c. 6D, § 12 as a Registered Provider Organization, unless such
materials are already on file with the Division, or unless such registration
has not yet occurred;
(b) any
material changes to the applicant Risk-bearing Provider Organization's prior
application for a Risk Certificate that were not submitted to the Division
during the course of the previous year;
(c) any new or modified arrangements to
manage the treatment of a group of patients, whereby the applicant bears
Downside Risk according to the terms of an Alternative Payment directly with
individuals;
(d) an updated list of
the names of the Health Care Payers and Employers with which the applicant has
entered into an arrangement to manage the treatment of a group of patients,
whereby the applicant bears Downside Risk according to the terms of an
Alternative Payment Contract, and a list of those arrangements with Health Care
Payers and Employers that have ended during the previous year;
(e) updated financial statements showing the
applicant Risk-bearing Provider Organization's assets, liabilities, Reserves
and sources of working capital and other sources of financial support and
projections of the results of operations for the succeeding three
years.
(f) all changes to the
previous year's filed financials;
(g) all changes to the previous year's filed
utilization plan;
(h) an actuarial
certification, consistent with
211 CMR
155.06, that provides a statement that, after
examining the terms of all the applicant Risk-bearing Provider Organization's
Alternative Payment Contracts with Downside Risk, the actuary concludes that
such Alternative Payment Contracts are not expected to threaten the financial
solvency of the applicant Risk-bearing Provider Organization or the financial
solvency of any entity with which the Risk-bearing Provider Organization has a
Contracting Affiliation during the period of the renewing Risk
Certificate;
(i) a filing fee in
the amount of $500.00 made payable to the "Commonwealth of Massachusetts";
and
(j) any other information
deemed necessary by the Commissioner.
(4) A Risk-bearing Provider Organization's
application for an initial or renewal Risk Certificate shall not be considered
complete until all required 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.
(5) A Risk-bearing Provider Organization that
has been issued a Risk Certificate shall report to the Division any material
change to the information contained in its initial or renewal Risk Certificate
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
Contacts, 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.
(6) If a Risk-bearing Provider Organization
is issued a Risk Certificate:
(a) the
Division shall forward a copy of the Risk Certificate to the applicant, 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 on the Division's website,
www.mass.gov/doi/.
(7) If an applicant Risk-bearing Provider
Organization is denied an initial Risk Certificate, or an applicant's Risk
Certificate renewal request is denied:
(a)
the Division shall initially notify the applicant in writing, and advise the
applicant of the reason for any refusal to issue or renew a Risk
Certificate;
(b) the Division shall
also outline in the initial notice the steps the applicant must take in order
to meet the standards to obtain or renew the Risk Certificate, and if the
applicant does not take the steps identified in the initial notice within 30
days, the Division will provide a final notification to the applicant that its
request for an initial Risk Certificate is denied, or the applicant's Risk
Certificate renewal request is denied; and
(c) the Division will forward a copy of the
final notice to the Commission and Center.
(8) An applicant that has been denied an
initial Risk Certificate, or an applicant's Risk Certificate renewal request
has been denied, may make written demand upon the Commissioner within 30 days
of receipt of such final notification for a hearing before the Commissioner to
determine the reasonableness of the denial. The hearing shall be held pursuant
to M.G.L. c. 30A.
