Definitions

As used in 101 CMR 515.00, unless the context requires otherwise, terms have the meanings in 101 CMR 515.02. Assessed Services. Services rendered by a managed care organization for which a premium or membership payment is made by or on behalf of the member; provided, however, that assessed services do not include services which are (a) rendered to members enrolled per month in Medicare managed care organizations; (b) rendered to members dually enrolled per month in both Medicaid and Medicare; (c) rendered to members in a Medicaid managed care organization who are 65 or older; (d) rendered to members through a limited benefit plan; (e) rendered to members through an indemnity plan; (f) preempted from taxation by 5 U.S.C. section 8909(f); (g) paid directly by a member as out of pocket costs that are not reimbursable by the managed care organization; or (h) paid directly by a member through a health savings account or other similar account; and provided further, that assessed services are identified and assessed through claims covered by managed care organizations and paid to health care providers, whether directly or through one or more subcontractors, third party administrators, or other such entities on behalf of the managed care organizations, for health care services rendered in Massachusetts. Assessment. The total payment due by each managed care organization each month, as set forth in 101 CMR 515.00. Assessment Year. The calendar year, from January 1 through December 31 of each year. Center for Health Information and Analysis (CHIA). An agency of the Commonwealth of Massachusetts, established under M.G.L. c. 12C. Center for Health Information and Analysis Revenue Amount. An amount equal to the sum of the amount collected by CHIA from acute hospitals and ambulatory surgical centers under M.G.L. c. 12C, § 7. Centers for Medicare & Medicaid Services (CMS). The federal agency under the US Department of Health and Human Services that is responsible for administering the Medicare and Medicaid programs. Division of Insurance. An agency of the Commonwealth of Massachusetts, established under M.G.L. c. 26. Entity. A natural person, corporation, partnership, trust, estate, or other legal entity operating as a managed care organization rendering managed care organization services in Massachusetts; and, in the case of an entity that is not a natural person, includes (a) any shareholder owning no less than 5%, any officer, and any director of any corporate entity; (b) any limited partner owning no less than 5% and any general partner of a partnership entity; (c) any trustee of any trust entity; (d) any sole proprietor of any entity that is a sole proprietorship; or (e) any mortgagee in possession and any executor or administrator of any entity that is an estate. Executive Office of Health and Human Services (EOHHS). The executive department of the Commonwealth of Massachusetts established under M.G.L. c. 6A, § 2. Through the Executive Office of Aging & Independence and other agencies within EOHHS, the department operates and administers the programs of medical assistance and medical benefits, as appropriate under M.G.L. c. 118E, and serves as the single state agency under section 1902(a)(5) of the Social Security Act. Health Policy Commission. An agency of the Commonwealth of Massachusetts, established under M.G.L. c. 6D. Health Policy Commission Revenue Amount. An amount equal to the sum of the amount collected by the health policy commission from hospitals and ambulatory surgical centers under M.G.L. c. 6D. Health Safety Net. The payment program established and administered in accordance with M.G.L. c. 118E, §§ 8A, and 64 through 69; regulations promulgated thereunder; and other applicable legislation. Health Safety Net Managed Care Organization Revenue Amount. An amount equal to $160,000,000 plus 50% of the estimated cost, as determined by the secretary for administration and finance, of administering the Health Safety Net and related assessments in accordance with M.G.L. c. 118E, §§ 65 through 69. Health Safety Net Office. The office within the Office of Medicaid established under M.G.L. c. 118E, § 65. Health Safety Net Trust Fund. The fund established under M.G.L. c. 118E, § 66. Immunization Revenue Amount. The estimated costs to purchase, store, and distribute vaccines for routine immunizations and to administer trust funds established for such purpose under M.G.L. c. 111, and to operate the computerized immunization registry, established in M.G.L. c. 111, § 24M, taking into consideration the limitations on expenditures described in M.G.L. c. 111, as well as any anticipated surplus or deficit in said trust funds, but excluding any costs anticipated to be covered by federal contribution. Indemnity Plan. A plan that does not offer benefits through a restricted or preferred network of health care providers, whether directly or through a third party. Limited Benefit Plan. A plan for stand-alone coverage of dental, vision, pharmacy, or long-term- care services. Managed Care Organization. An entity that (a) is accredited under M.G.L. c. 176O and that is 1. licensed or otherwise authorized to transact accident or health insurance under M.G.L. c. 175; 2. a nonprofit hospital service corporation organized under M.G.L. c. 176A; 3. a nonprofit medical service corporation organized under M.G.L. c. 176B; 4. a health maintenance organization organized under M.G.L. c. 176G; or 5. an organization entering into a preferred provider arrangement under M.G.L. c. 176I; (b) is a Medicaid managed care organization; (c) is a health care organization, as defined in M.G.L. c. 32A, § 2; (d) is a self-insured group for which one or more entities provide administrative services under M.G.L. c. 176O, § 21, whether directly or through one or more third parties; (e) is a health insurance plan that contracts with the commonwealth health insurance connector authority; or (f) otherwise provides health care coverage to individuals who receive health care services through a restricted or preferred network of health care providers, whether directly or through one or more third parties, whether or not as a self-insured group, and whether or not the entity is an out-of-state entity. Managed Care Organization Reinvestment Revenue Amount. A fixed amount equal to $246,000,000. Massachusetts Child Psychiatry Access Project Revenue Amount. The amount equal to the amounts expended annually for the Massachusetts Child Psychiatry Access Project that are related to services provided on behalf of commercially insured clients. MassHealth Program (MassHealth). The medical assistance benefits plans (Medicaid) operated and administered by EOHHS under M.G.L. c. 118E, § 1 and 42 U.S.C. § 1396, Title XXI of the Social Security Act (42 U.S.C. 1397), and other applicable laws and waivers to provide and pay for medical services to eligible members. Medicare. The federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant) established by Title XVIII of the Social Security Act. Total Assessment Amount. An amount to be determined annually by MassHealth, and noticed to managed care organizations annually via administrative bulletin or other written issuance prior to the start of the assessment year, which equals the total of (a) the Managed Care Organization Reinvestment Revenue Amount; (b) the Health Safety Net Managed Care Organization Revenue Amount; (c) the Massachusetts Child Psychiatry Access Project Revenue Amount; (d) the Immunization Revenue Amount; (e) the Health Policy Commission Revenue Amount; (f) the Center for Health Information and Analysis Revenue Amount; (g) the amount transferred, under M.G.L. c. 118E, § 66, to the Behavioral Health Access and Crisis Intervention Trust Fund established in M.G.L. c. 29, § 2WWWWW; and (h) the amounts necessary to prospectively incorporate all adjustments or reconciliations to account for under-assessments in the prior assessment year.