Section 155.05 - Risk Certificates(1) Each Risk-bearing Provider Organization that has not been granted a Risk Certificate Waiver shall be required to file an application for an annual Risk Certificate. Integrated care organizations or senior care organizations contracted under M.G.L. c. 118E, § 9D or 9F that have been certified in accordance with M.G.L. c. 118E, § 9D(q) or 9F(b) shall be deemed to have satisfied the Risk Certificate requirements for purposes of 211 CMR 155.00 and M.G.L. c. 176T. All Risk Certificates will be valid beginning no earlier than March 1st, for a term of up to one year through the last calendar day of February
(2) The application shall be certified by at least two officers of the Risk-bearing Provider Organization, including a senior executive officer or partner, and either the treasurer or an assistant treasurer. The application shall include the following: (a) the most recent materials submitted by the applicant Risk-bearing Provider Organization to the Commission pursuant to M.G.L. c. 6D, § 12 as a Registered Provider Organization, unless such materials are already on file with the Division, or unless such registration has not yet occurred;(b) the names of the Health Care Payers and Employers with which the applicant is seeking to enter into an arrangement, or has already entered into an arrangement to manage the treatment of a group of patients;(c) whether the applicant is seeking to enter into an arrangement, or has already entered into an arrangement directly with individuals to manage the treatment of a group of patients;(d) audited financial statements, where available, or other financial statements and/or documents that show the assets, liabilities, Reserves and sources of working capital and other sources of financial support and projections of the results of operations for the succeeding three years for the applicant Risk-bearing Provider Organization and each entity: 1. with whom the Risk-bearing Provider Organization has a Contracting Affiliation; and2. assumes Downside Risk in its arrangement with the Risk-bearing Provider Organization.(e) a financial plan, including the following: 1. a statement indicating the anticipated timing for receipt of income from Alternative Payment Contracts with Downside Risk versus the anticipated timing of the incurrence of expenses associated with those Alternative Payment Contracts with Downside Risk;2. a statement of the applicant Risk-bearing Provider Organization's plan to establish and maintain sufficient financial resources that will protect the applicant Risk-bearing Provider Organization and those entities with which it has a Contracting Affiliation from the potential losses from Downside Risk;3. evidence of any insurance coverage or other agreements that protects the applicant Risk-bearing Provider Organization from potential losses from Downside Risk; and4. a detailed description of mechanisms put in place by the applicant Risk-bearing Provider Organization to monitor the financial solvency of any subcontracting Provider(s) or Provider Organization(s) where the subcontracting entity assumes Downside Risk in its arrangement with the applicant Risk-bearing Provider Organization or Provider Organization.(f) a utilization plan describing the methods by which the applicant Risk-bearing Provider Organization will monitor inpatient and outpatient utilization under the Alternative Payment Contracts with Downside Risk;(g) an actuarial certification, consistent with 211 CMR 155.06, that provides a statement that, after examining the terms of all the applicant Risk-bearing Provider Organization's intended or existing Alternative Payment Contracts with Downside Risk, the actuary concludes that such Alternative Payment Contracts are not expected to threaten the financial solvency of the applicant Risk-bearing Provider Organization;(h) demonstrations that contracts between the applicant Risk-bearing Provider Organization and other Provider(s) or Provider Organizations include provisions that conspicuously prohibit Health Care Providers from collecting or attempting to collect from a patient money that is owed to the Health Care Provider by the applicant Risk-bearing Provider Organization, or other Provider Organization;(i) a description of the level and nature of risk assumed across all of the Provider Organization's Alternative Payment Contracts, including details about the aggregate number of members that are covered under Alternative Payment Contracts; and details with respect to the risk contracts of each entity: 1. with whom the Risk-bearing Provider Organization has a Contracting Affiliation; and2. which assumes Downside Risk in its arrangement with the Risk-bearing Provider Organization.(j) a certification that the applicant has established an internal appeals process pursuant to M.G.L. c. 1760, § 24; (k) a statement that indicates whether or not the applicant Risk-bearing Provider Organization has entered into any Alternative Payment Contracts with Downside Risk with any Employers or individuals, and if the applicant Risk-bearing Provider Organization has entered into any such Alternative Payment Contracts with Downside Risk, a detailed description of the number of contracts the applicant Risk-bearing Provider Organization has entered into with Employers or individuals; (l) a filing fee in the amount of $500.00 made payable to the "Commonwealth of Massachusetts"; and(m) any additional information deemed necessary by the Commissioner.(3) Each Risk-bearing Provider Organization may apply to renew a current Risk Certificate for an additional annual term, provided that it submits materials in a form approved by the Commissioner by no later than November 15th. The renewed Risk Certificate will be valid for a term of one year, beginning on March 1st of the following year. The information contained in the renewal application shall be certified by at least two officers of the Risk-bearing Provider Organization and include the following information: (a) the most recent materials submitted by the applicant Risk-bearing Provider Organization to the Commission pursuant to M.G.L. c. 6D, § 12 as a Registered Provider Organization, unless such materials are already on file with the Division, or unless such registration has not yet occurred;(b) any material changes to the applicant Risk-bearing Provider Organization's prior application for a Risk Certificate that were not submitted to the Division during the course of the previous year;(c) any new or modified arrangements to manage the treatment of a group of patients, whereby the applicant bears Downside Risk according to the terms of an Alternative Payment directly with individuals;(d) an updated list of the names of the Health Care Payers and Employers with which the applicant has entered into an arrangement to manage the treatment of a group of patients, whereby the applicant bears Downside Risk according to the terms of an Alternative Payment Contract, and a list of those arrangements with Health Care Payers and Employers that have ended during the previous year;(e) updated financial statements showing the applicant Risk-bearing Provider Organization's assets, liabilities, Reserves and sources of working capital and other sources of financial support and projections of the results of operations for the succeeding three years.(f) all changes to the previous year's filed financials;(g) all changes to the previous year's filed utilization plan;(h) an actuarial certification, consistent with 211 CMR 155.06, that provides a statement that, after examining the terms of all the applicant Risk-bearing Provider Organization's Alternative Payment Contracts with Downside Risk, the actuary concludes that such Alternative Payment Contracts are not expected to threaten the financial solvency of the applicant Risk-bearing Provider Organization or the financial solvency of any entity with which the Risk-bearing Provider Organization has a Contracting Affiliation during the period of the renewing Risk Certificate;(i) a filing fee in the amount of $500.00 made payable to the "Commonwealth of Massachusetts"; and(j) any other information deemed necessary by the Commissioner.(4) A Risk-bearing Provider Organization's application for an initial or renewal Risk Certificate shall not be considered complete until all required materials and information required by M.G.L. c. 176T and 211 CMR 155.00 have been received by the Division. An applicant Risk-bearing Provider Organization shall respond to any request for additional information by the Division within 15 days of the date of the Division's request.(5) A Risk-bearing Provider Organization that has been issued a Risk Certificate shall report to the Division any material change to the information contained in its initial or renewal Risk Certificate application, in a document certified by an officer of the Risk-bearing Provider Organization, within 30 days of such change. Such material change would include, but is not limited to, the addition of new Alternative Payment Contacts, amendments to Downside Risk provisions in existing Alternative Payment Contracts, changes to the number or types of patients that are covered under existing Alternative Payment Contracts, or changes to the organizational structure of any Provider Organization.(6) If a Risk-bearing Provider Organization is issued a Risk Certificate: (a) the Division shall forward a copy of the Risk Certificate to the applicant, the Commission, and the Center; and(b) the Division shall post the names of all Risk-bearing Provider Organizations who have been issued a Risk Certificate on the Division's website, www.mass.gov/doi/.(7) If an applicant Risk-bearing Provider Organization is denied an initial Risk Certificate, or an applicant's Risk Certificate renewal request is denied: (a) the Division shall initially notify the applicant in writing, and advise the applicant of the reason for any refusal to issue or renew a Risk Certificate;(b) the Division shall also outline in the initial notice the steps the applicant must take in order to meet the standards to obtain or renew the Risk Certificate, and if the applicant does not take the steps identified in the initial notice within 30 days, the Division will provide a final notification to the applicant that its request for an initial Risk Certificate is denied, or the applicant's Risk Certificate renewal request is denied; and(c) the Division will forward a copy of the final notice to the Commission and Center.(8) An applicant that has been denied an initial Risk Certificate, or an applicant's Risk Certificate renewal request has been denied, may make written demand upon the Commissioner within 30 days of receipt of such final notification for a hearing before the Commissioner to determine the reasonableness of the denial. The hearing shall be held pursuant to M.G.L. c. 30A.Adopted by Mass Register Issue 1268, eff. 8/29/2014.Amended by Mass Register Issue 1323, eff. 10/7/2016.