Code of Massachusetts Regulations
956 CMR - COMMONWEALTH HEALTH INSURANCE CONNECTOR AUTHORITY
Title 956 CMR 13.00 - Risk Adjustment Procedures For Small And Non-group Market
Section 13.02 - Definitions
Benefit Year. A calendar year or the applicable portion of a calendar year during which the Risk Adjustment Program is operated.
Carrier. A Carrier, as defined in M.G.L. c. 176M, § 1, that offers at least one Risk Adjustment Covered Plan in the Commonwealth.
CHIA. The Center for Health Information and Analysis established in M.G.L. c. 12C.
Commonwealth. The Commonwealth of Massachusetts.
The Connector. The Commonwealth Health Insurance Connector Authority.
Massachusetts All Payer Claims Database or MA APCD. The All Payer Claims Database maintained by CHIA to which payers are required to submit data under 957 CMR 8.00: All Payer Claims Database (APCD) and Case Mix and Charge Data Submission.
Member Month Tracker Report. A report provided by the Connector to each Carrier including calculations of the total member months of enrollment subject to risk adjustment and collected premiums, based on the data submitted to the MA APCD by Carriers for the applicable reporting period.
Final Risk Adjustment Payments and Charges Report. The annual report to be sent by the Connector to Carriers, by June 30th of the year following the applicable Benefit Year, describing charges owed by or payments owed to the Carrier under the Risk Adjustment program, as well as the list of data elements used in creating the risk adjustment data extract, the data extracts themselves, algorithms used to calculate payments and charges, and the output datasets from the algorithms.
Quarterly Simulation Reports. A set of reports provided to each Carrier on a quarterly basis, providing preliminary calculations and data regarding the Carrier's risk adjustment experience. These shall include data quality assessment reports, as well as reports from the Connector regarding the data elements and algorithms used in developing the Risk Adjustment Data Extract and in calculating risk scores and preliminary transfer amounts, based on the data available for the applicable reporting period, and other data relevant to discrepancy resolution.
Risk Adjustment Covered Plan. Any health insurance coverage offered in the individual or small group market in Massachusetts, as well as any other coverage specified as being subject to the Risk Adjustment Program in the applicable State Payment Notice, with the exception of: grandfathered health plans; coverage that is considered "excepted benefits" under 45 CFR § 146.145(c) or 45 CFR § 148.220; and any plan determined not to be a risk adjustment covered plan in the applicable State Payment Notice.
Risk Adjustment Data Extract. An extract of health plan data reported to CHIA under 957 CMR 8.00: All Payer Claims Database (APCD) and Case Mix and Charge Data Submission, containing only data elements that are necessary for risk adjustment, provided by CHIA to the Connector to conduct risk adjustment operations.
Risk Adjustment Methodology. The federally certified risk adjustment methodology that will be implemented in the Commonwealth for a particular Benefit Year.
Risk Adjustment Program. The risk mitigation program operated by the Connector, pursuant to the authority granted M.G.L. c. 176Q, § 3(v), as described in 42 U.S.C. § 18063, and as implemented in 956 CMR 13.00.
State Payment Notice. The Massachusetts Notice of Benefit and Payment Parameters, released by the Connector, describing the parameters, procedures, and methodology for Risk Adjustment for a given Benefit Year.
