(2)
Definitions.
Ambulatory Surgical Center. 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.
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. The Massachusetts
Department of Mental Health.
Department of Public Health. The
Massachusetts Department of Public Health.
General Appropriations Act. The act of
the General Court, or any subsequent amendment or supplemental act enacting the
Commonwealth's fiscal year budget.
Hospital. 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 of Public
Health.
Hospital Services. Services listed on
an acute hospital's license issued by the Department of Public Health.
Indirect Payment. 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. A managed
care organization as defined in M.G.L. c. 118E, § 64.
Medicaid. 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. The medical
insurance program established by Title XVIII of the Social Security Act.
Payer. A surcharge payer that meets
the criteria set forth in
104
CMR 30.08(4)(b).
Payment. 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. 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 younger than 65
years old; 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. The surcharge on payments
made to hospitals and ambulatory surgical centers established by M.G.L. c.
118E, § 68.
Surcharge Payer. 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. 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.
(3)
Determination of Assessment Liability and Payment.
(a) The Department shall collect an
assessment on certain payments to hospitals and ambulatory surgical centers.
The assessment amount equals the product of:
1. payments subject to the assessment as
defined in
104
CMR
30.08(3)(c);
and
2. the assessment percentage as
defined in
104
CMR
30.08(3)(d).
(b) Payers subject to assessment:
1. Payers are subject to the assessment if:
a. the payer is a surcharge payer;
and
b. the payer's payments subject
to surcharge were $1,000,000 or more during the previous state fiscal year or
the most recent state fiscal year for which data is
available.
2. The same
entity that pays the hospital or ambulatory surgical center for services must
pay the assessment.
3. A payer that
pays for hospital or ambulatory surgical center services on behalf of a client
plan must pay the assessment on those services. A payer that administers
payments for health care services on behalf of a client plan in exchange for an
administrative fee will be deemed to use the client plan's funds to pay for
health care services whether the payer pays providers with funds from the
client plan, with funds advanced by the payer subject to reimbursement by the
client plan, or with funds deposited with the payer by the client
plan.
(c) Payments
subject to the assessment include direct and indirect payments made by payers
in a time period as determined by the Department and released annually, to
hospitals for the purchase of hospital services; and to ambulatory surgical
centers for the purchase of ambulatory surgical center services.
(d) The Department will determine the
assessment percentage as follows:
1. The
Department will, on an annual basis, determine the total amount expended on the
MCPAP from the Commonwealth's General Appropriations Act, Line Item 5042-5000
on behalf of commercial clients of Surcharge Payers in the previous fiscal
year.
2. The Department will
utilize the projected aggregate payments subject to the assessment based on
payers' historical data related to the surcharge, adjusted as the Department
deems necessary to create an accurate projection.
3. The assessment percentage is determined by
dividing the total amount to be collected determined under
104
CMR
30.08(3)(d)1. by total
projected aggregate payments determined under
104
CMR
30.08(3)(d)2.
4. The Department may establish the
assessment percentage by Administrative Bulletin. The Department may adjust the
assessment percentage by Administrative Bulletin if an adjustment is necessary
to collect the revenue required to be collected.
(e) Each payer shall determine its assessment
liability in accordance with guidance issued by the Department in
Administrative Bulletins. The assessment liability is the product of the
payer's payments subject to the assessment, as defined in
104
CMR
30.08(3)(c) and the
assessment percentage as defined in
104
CMR
30.08(3)(d)3.
(f) Payers that pay a global fee or
capitation for services that include hospital or ambulatory surgical center
services, as well as other services not subject to the assessment, shall
utilize the same reasonable method for allocating the portion of the payment
intended to be used for services provided by hospitals or ambulatory surgical
centers as the payer utilizes for such allocation pursuant to 105 CMR
223.00:
Pediatric Immunization Program Assessment. A payer must
include the portion of the global payment or capitation intended to be used for
services provided by hospitals or ambulatory surgical centers, as determined by
this allocation method, in its determination of payments subject to the
assessment.
(g) A payer must
include all payments made as a result of settlements, judgments or audits in
its determination of payments subject to the assessment. A payer may include
payments made by Massachusetts hospitals or ambulatory surgical centers to the
payer as a result of settlements, judgments or audits as a credit in its
determination of payments subject to the assessment.
(h) Each payer shall pay its assessment
liability in accordance with a schedule developed and released by the
Department through Administrative Bulletin.
(4)
Administrative
Review.
(a) The Department may
conduct an administrative review of assessment liability payments at any
time.
(b) In conducting such
review, the Department will review data submitted by hospitals, ambulatory
surgical centers, and any other relevant data, including surcharge data. All
information provided by, or required from, any payer, pursuant to
104
CMR
30.08 shall be subject to audit by the
Department. For assessment liability payments based upon a global fee or
capitation payment allocated according to an allocation method accepted by the
Department pursuant to
104
CMR
30.08(3)(d)2., the
Department's review will be limited to determining whether this method was
followed accurately and whether the amounts reported were accurate.
1. The Department may require the payer to
submit additional documentation reconciling the data it submitted with data
received from hospitals and ambulatory surgical centers.
2. If the Department determines through its
review that a payer's assessment liability payment was materially incorrect,
the Department will require a payment adjustment.
(c)
Notification.
The Department shall notify the payer in writing if it determines there should
be a payment adjustment. The notification will include a detailed explanation
of the proposed adjustment.
(d)
Objection Process. A payer may object to proposed
adjustment in writing, within 15 business days of the mailing of the
notification letter. The payer may request an extension of this period for
cause. The written objection must, at a minimum, contain:
1. the specific reason(s) for each of the
payer's objections; and
2. all
documentation that supports the payer's position.
(e)
Written
Determination. Following review of the payer's objection, the
Department will notify the payer of its determination in writing, with an
explanation of its reasoning.
(f)
Payment of Adjustment Amounts. Payment of adjustment
amounts are due within 30 days following the mailing of the determination
letter.
