Definitions

Ambulatory Surgical Center means any distinct entity located in Massachusetts that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and meets the U.S. Centers for Medicare and Medicaid (CMS) requirements for participation in the Medicare program. Ambulatory Surgical Center Services means services described for purposes of the Medicare program pursuant to 42 U.S.C. § 1395k(a)(2)(F)(i). These services include only facility services and do not include physician fees. Department means the Massachusetts Department of Public Health. Hospital means an acute hospital licensed under M.G.L. c. 111, § 51, that contains a majority of medical-surgical, pediatric, obstetric and maternity beds, as defined by the Department. Hospital Services means services listed on an acute hospital's license issued by the Department. Indirect Payment means a payment made by a payer to a group of providers, including one or more Massachusetts acute care hospitals or ambulatory surgical centers, that then forward the payment to member hospitals or ambulatory surgical centers; or a payment made to an individual to reimburse him or her for a payment made to a hospital or ambulatory surgical center. Managed Care Organization means a managed care organization as defined in M.G.L. c. 118E, § 64. Medicaid means the medical assistance program administered by the Executive Office of Health and Human Services Office of Medicaid pursuant to M.G.L. c. 118E and in accordance with Titles XIX and XXI of the Federal Social Security Act, and a Section 1115 Demonstration Waiver. Medicare Program means the medical insurance program established by Title XVIII of the Social Security Act. Payer means a surcharge payer that meets the criteria set forth in 105 CMR 223.100(B). Payment means a check, draft, or other paper instrument, an electronic fund transfer, or any order, instruction, or authorization to a financial institution to debit one account and credit another. Payments Subject to Surcharge means all amounts paid, directly or indirectly, by surcharge payers to acute hospitals for health services and ambulatory surgical centers for ambulatory surgical center services; provided, however, that it shall not include: (a) payments, settlements and judgments arising out of third party liability claims for bodily injury which are paid under the terms of property or casualty insurance policies; and (b) payments made on behalf of Medicaid recipients, Medicare beneficiaries or persons enrolled in policies issued under M.G.L. c. 176K or similar policies issued on a group basis; provided further, that it shall include payments made by a managed care organization on behalf of: 1. Medicaid recipients under age 65; and 2. enrollees in the commonwealth care health insurance program; and provided further, that it may exclude amounts established under regulations promulgated by the department for which the costs and efficiency of billing a surcharge payer or enforcing collection of the surcharge from a surcharge payer would not be cost effective. Surcharge means the surcharge on payments made to hospitals and ambulatory surgical centers established by M.G.L. c. 118E, § 68. Surcharge Payer means an individual or entity that pays for or arranges for the purchase of health care services provided by acute hospitals and ambulatory surgical center services provided by ambulatory surgical centers; provided, however, that it shall include a managed care organization; and provided further, that it shall not include Title XVIII and Title XIX programs and their beneficiaries or recipients, other governmental programs of public assistance and their beneficiaries or recipients and the workers' compensation program established under M.G.L. c. 152. Third Party Administrator means an entity that administers payments for health care services on behalf of a client plan in exchange for an administrative fee. A third party administrator may provide client services for a self-insured plan or an insurance carrier's plan. A third party administrator will be deemed to use a client plan's funds to pay for health care services whether the third party administrator pays providers with funds from a client plan, with funds advanced by the third party administrator subject to reimbursement by the client plan, or with funds deposited with the third party administrator by a client plan.