Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 155.00 - Risk-bearing Provider Organizations
Section 155.08 - Noncompliance with 211 CMR 155.00

(1) If the Commissioner determines that a Provider Organization qualifies as a Risk-bearing Provider Organization and is subject to 211 CMR 155.00, but has failed to submit an application for an initial Risk Certificate, or an initial Risk Certificate Waiver, as applicable, the Division shall provide written notice to the Provider Organization, as well as to the Commission and the Center. If a Risk-bearing Provider Organization fails to submit the annual renewal application for either a Risk Certificate or a Risk Certificate Waiver to the Division in the form and within the time provided, the Division shall provide written notice to the Commission and the Center.

(2) If the Commissioner determines that a Risk-bearing Provider Organization has entered into an arrangement to manage the treatment of a group of patients and bear Downside Risk according to the terms of an Alternative Payment Contract directly with any Employers or individuals, the Commissioner will contact the Risk-bearing Provider Organization or Provider Organization in writing and may require the Risk-bearing Provider Organization or Provider Organization to be otherwise licensed pursuant to the criteria set forth in M.G.L. c. 176T, § 2.

(3) If the Commissioner determines that a Risk-bearing Provider Organization's existing or proposed arrangement to manage the treatment of a group of patients and bear Downside Risk according to the terms of an Alternative Payment Contract is likely to threaten the financial solvency of the Risk-bearing Provider Organization, the Commissioner shall provide written notice to the Risk-bearing Provider Organization. A copy of such notice shall be provided to the Commission and the Center.

(4) The Commissioner shall not suspend or cancel a Risk Certificate unless the Commissioner has first afforded the Risk-bearing Provider Organization an opportunity for a hearing pursuant to M.G.L. c. 30A. After hearing, the Commissioner may suspend or cancel a Risk-bearing Provider Organization's Risk Certificate upon a determination that:

(5) Upon a ruling after hearing to suspend or revoke a Risk Certificate, the Commissioner shall notify the Risk-bearing Provider Organization, in writing, of the reason(s) for the suspension or cancellation of its Risk Certificate. A copy of such notice shall be provided to the Commission and Center.

(6) The Commissioner may take such other action as appropriate under law to enforce the requirements of M.G.L. c. 176T or 211 CMR 155.00.