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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XXII CORPORATIONS
  • CHAPTER 176T RISK-BEARING PROVIDER ORGANIZATIONS
  • Section 3 Risk certificate application; waiver; form; fee

Section 3. (a) Each registered provider organization that enters into or renews an alternative payment contract with a carrier or public health care payer in which the provider organization accepts downside risk shall file an application for a risk certificate with the division; provided, however, that integrated care organizations or senior care organizations contracted under section 9D or 9E of chapter 118E which have undergone a financial solvency certification shall be deemed to be to have satisfied the risk certificate requirements for purposes of this chapter.

(b) A risk-bearing provider organization may apply for a risk certificate waiver if it wishes to demonstrate that its alternative payment contracts do not contain significant downside risk. A risk-bearing provider organization may be deemed to be in compliance with the division’s standards if the division determines that the provider organization’s alternative payment contracts do not contain significant downside risk. The division shall forward such waiver in writing to the commission and the center.

(c) The applicant for a risk certificate shall file such information as the commissioner shall by regulation require, in a form approved by the commissioner. A risk-bearing provider organization shall make an annual filing to renew its risk certificate. Such information shall include, but not be limited to:

(1) the filing materials submitted to be registered as a provider organization, pursuant to chapter 6D;

(2) a list of all carriers and public health payers with which the provider organization has entered into alternative payment contracts with downside risk;

(3) financial statements showing the 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 3 years;

(4) a financial plan, including a statement indicating the anticipated timing for receipt of income from alternative payment contracts with downside risk versus the incurrence of expenses, a statement of the applicant’s plan to establish and maintain sufficient reserves or other resources that will protect the risk-bearing provider organization from the potential losses from downside risk, copies of insurance or other agreements which protect the risk-bearing provider organization from potential losses from downside risk, and a detailed description of mechanisms to monitor the financial solvency of any provider organization subcontracting with the applicant that assumes downside risk in its alternative payment arrangement with the risk-bearing provider organization;

(5) a utilization plan describing the methods by which the risk-bearing provider organization will monitor inpatient and outpatient utilization under the alternative payment contracts with downside risk;

(6) an actuarial certification that, after examining the terms of all the risk-bearing provider organization’s alternative payment contracts with downside risk that the alternate payment contracts are not expected to threaten the financial solvency of the risk-bearing provider organization; and

(7) such other information as the division may specify through regulation.

(d) There shall be a fee for such application or renewal, in an amount determined by the commissioner.

(e) A risk-bearing provider organization shall notify the commissioner of any material change to the information submitted in its initial or renewal application, in a form approved by the commissioner.