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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XXII CORPORATIONS
  • CHAPTER 176T RISK-BEARING PROVIDER ORGANIZATIONS
  • Section 1 Definitions

  Section 1. As used in this chapter the following words shall, unless the context clearly requires otherwise, have the following meanings:--

  "Alternative payment contract'', any contract between a provider or provider organization and a health care payer payer which utilizes alternative payment methodologies.

  "Alternative payment methodologies or methods'', methods of payment that are not solely based on fee-for-service reimbursements; provided, however, that "alternative payment methodologies'' may include, but shall not be limited to, shared savings arrangement, bundled payments, and global payments; and further provided, that "alternative payment methodologies'' may include fee-for-service payments, which are settled or reconciled with a bundled or global payment.

  "Carrier,'' an insurer licensed or otherwise authorized to transact accident or health insurance under chapter 175; a nonprofit hospital service corporation organized under chapter 176A; a nonprofit medical service corporation organized under chapter 176B; a health maintenance organization organized under chapter 176G; and an organization entering into a preferred provider arrangement under chapter 176I, but not including an employer purchasing coverage or acting on behalf of its employees or the employees of or more subsidiaries or affiliated corporations of the employer; provided, however, that, unless otherwise noted, the term "carrier'' shall not include any entity to the extent it offers a policy, certificate or contract that provides coverage solely for dental care services or vision care services.

  "Center'', the center for health information and analysis established in chapter 12C.

  "Commission'', the health policy commission established in chapter 6D.

  "Commissioner'', the commissioner of insurance.

  "Division'', the division of insurance.

  "Downside risk'', the risk taken on by a provider organization as part of an alternate payment contract with a carrier or other payer in which the provider organization is responsible for either the full or partial costs of treating a group of patients that may exceed the contracted budgeted payment arrangements.

  "Employer'', an employer as defined in section 1 of chapter 151A.

  "Health care services'', supplies, care and services of medical, surgical, optometric, dental, podiatric, chiropractic, psychiatric, therapeutic, diagnostic, preventative, rehabilitative, supportive or geriatric nature including, but not limited to, inpatient and outpatient acute hospital care and services, provided by a community health center, home health and hospice care provider, or by a sanatorium, as included in the definition of "hospital'' in Title XVIII of the federal Social Security Act, and treatment and care compatible with such services or by a health maintenance organization.

  "Medicaid program'', the medical assistance program administered by the office of Medicaid under chapter 118E and in accordance with Title XIX of the Federal Social Security Act or any successor statute.

  "Medical assistance program'', the medicaid program, the Veterans Administration health and hospital programs and any other medical assistance program operated by a governmental unit for persons categorically eligible for such program.

  "Medical service corporation'', a corporation established to operate a nonprofit medical service plan as provided in chapter 176B.

  "Medicare program'', the medical insurance program established by Title XVIII of the Social Security Act.

  "Provider'' or "health care provider'', any person, corporation, partnership, governmental unit, state institution or any other entity qualified under the laws of the commonwealth to perform or provide health care services.

  "Provider organization'', any corporation, partnership, business trust, association or organized group of persons in the business of health care delivery or management whether incorporated or not that represents 1 or more health care providers in contracting with carriers for the payments of heath care services; provided, however, that "provider organization'' shall include, but not be limited to, physician organizations, physician-hospital organizations, independent practice associations, provider networks, accountable care organizations and any other organization that contracts with carriers for payment for health care services.

[ Definition of "Public health care payer'' effective until January 1, 2014. For text effective January 1, 2014, see below.]

  "Public health care payer'', the Medicaid program established in chapter 118E; any carrier or other entity that contracts with the office of Medicaid or the commonwealth health insurance connector to pay for or arrange the purchase of health care services on behalf of individuals enrolled in health coverage programs under Titles XIX or XXI, or under the commonwealth care health insurance program, including prepaid health plans subject to the provisions of section 28 of chapter 47 of the acts of 1997; the group insurance commission established under chapter 32A; and any city or town with a population of more than 60,000 that has adopted chapter 32B.

[ Definition of "Public health care payer'' as amended by 2013, 35, Sec. 96 effective January 1, 2014. See 2013, 35, Sec. 104. For text effective until January 1, 2014, see above.]

  "Public health care payer'', the Medicaid program established in chapter 118E; any carrier or other entity that contracts with the office of Medicaid to pay for or arrange the purchase of health care services on behalf of individuals enrolled in health coverage programs under Titles XIX or XXI of the Social Security Act, including prepaid health plans subject to section 28 of chapter 47 of the acts of 1997; the group insurance commission established pursuant to chapter 32A; and any city or town with a population of more than 60,000 that has adopted chapter 32B.

  "Registered provider organization'', a provider organization that has been registered in accordance with chapter 6D.

  "Risk-bearing provider organization'', a provider organization that manages the treatment of a group of patients and bears the downside risk according to the terms of an alternate payment contract.

  "Risk certificate'', a certificate of solvency issued by the division of insurance.

  "Self-insurance health plan'', a plan which provides health benefits to the employees of a business, which is not a health insurance plan, and in which the business is liable for the actual costs of the health care services provided by the plan and administrative costs.

  "Title XIX,'' Title XIX of the Social Security Act, 42 USC 1396 et seq., or any successor statute enacted for the same purposes as Title XIX.