Reporting Requirements

Section 1: Monitoring of Existing Mandated Benefits

Directs the Division of Health Care Finance and Policy (DHCFP) to analyze the impact of existing mandated insurance benefits on public health and overall health care costs and issue a report to the legislature at least once every 4 years. DHCFP must consult with the Department of Public Health and UMass Medical School to ensure that all mandated benefits continue to meet clinical standards of care. DHCFP may file legislation to amend or repeal existing mandates.

Section 7: Quality Reporting

Requires every health care provider to track and report quality information at least annually according to Department of Public Health regulations.

Section 13: Reporting Requirements for Total Medical Expenses, Relative Prices, and Hospital Costs

Adds to existing Division of Health Care Finance and Policy (DHCFP) payer data submission requirements by including health status adjusted total medical expenses (TME) by provider group, relative prices paid to every health care provider in the payer’s network by type of provider, and hospital inpatient and outpatient costs. Payers must report each of the three new data categories according to a uniform methodology determined by DHCFP.  Hospitals must report to DHCFP inpatient and outpatient costs, including direct and indirect costs, according to a uniform methodology. 

Each year, DHCFP must annually report and post on its website information on TME, relative prices, and hospital inpatient and outpatient costs. Providers will have 10 days advance notice of the public release or posting to review the data.  DHCFP is required to request TME data for Medicare patients from the Centers for Medicare & Medicaid Services (CMS). The uniform reporting is intended to allow DHCFP to track statewide and regional trends in the cost, utilization, and availability of medical services.  

DHCFP is required to notify payers of any reporting deadlines and may penalize payers that fail to report by the deadlines.

Section 14: Employer Health Insurance Responsibility Disclosure Form

Requires that Health Insurance Responsibility Disclosure (HIRD) forms, which employers with 11 or more full time equivalent employees are required to submit to the Division of Health Care Finance and Policy (DHCFP) to verify that they provide section 125 plans and to verify that employees who declined employer sponsored insurance have alternative coverage, be shared with the Department of Revenue, the Commonwealth Health Insurance Connector Authority and the Health Care Access Bureau within the Division of Insurance for enforcement purposes.

Any individually identifiable information will not be public record.

Section 25: Small Group Insurance Rating Factor Review

Allows the Commissioner of the Division of Insurance to conduct a study to determine whether rating factors that an insurer may use to determine annual base premium rates or individual group premiums for plans offered in the small group health insurance market inappropriately increase costs in relation to the risks of a particular small group. The Commissioner may adopt changes to regulations as necessary each July 1 for rates effective the following January 1 to modify rate adjustment factors.

When determining annual base premium rates, an insurer may consider an individual’s or small group’s business industry, age of members in a particular class of business, participation rate of members, wellness program discount, and tobacco use of its participants. The maximum premium rate offered to members cannot exceed 2 times the lowest premium rate offered to members within a particular class of business.

In general, after a carrier considers all rate adjustment factors, the base rate of any plan an insurer offers to individuals and small groups must fall within rate bands ranging between 0.66 and 1.32.

A carrier, however, may also consider certain additional base rate adjustment factors that establish a base rate outside of the rate band. These factors include: geographic region, group size, the relative actuarial value of the available health plan compared to the value of other health plans offered within a particular class of business, and the average relative actuarial value of at least 4 different base rate categories, including: single, 2 adults, 1 adult and children, and family. The Commissioner will establish at least five distinct regions for the purposes of area rate adjustments. Any additional adjustment factors must apply uniformly to every eligible member of a particular group.

Section 51: Directs DHCFP To Create TME Regulations

Instructs the Division of Health Care Finance and Policy (DHCFP), in consultation with the Division of Insurance, to establish regulations directing health insurance carriers to calculate and report health status adjusted total medical expenses for provider groups determined by zip code. In the regulations, DHCFP must specify a uniform method for calculating total medical expenses among each provider group, determine which non-claim related payments must be included in the calculations, account for health status and number of patients within each group, and specify reporting requirements.

Section 52: Directs DHCFP To Create Relative Pricing Regulations

Instructs the Division of Health Care Finance and Policy (DHCFP), in consultation with the Division of Insurance, to establish regulations directing health insurance carriers to calculate and report relative prices paid to health care facilities and providers. In the regulations, DHCFP must specify a method to account for a uniform mix of products and services and all non-claims related payments to providers.

Section 53: Health Care Facility Total Cost Reporting Requirement

Instructs the Division of Health Care Finance and Policy (DHCFP), in consultation with the Division of Insurance, to establish regulations directing hospitals to calculate and report all costs, including inpatient and outpatient costs and direct and indirect costs. Calculations must include costs and cost trends for labor, debt-related expenses, advertising and marketing, insurance, health information technology, management, research, academic costs, contributions, and all business operation costs. Before adopting final regulations, DHCFP must consult with designated stakeholders.

Section 56: Encourages Administrative and Reporting Simplification Through All-Payer Database

Directs the Secretary of Health and Human Services to organize a working group consisting of many state agencies and health care community stakeholders to identify ways to streamline health care administration requirements and reduce reporting requirements through the use of a single all-payer database.

The group must issue a report to the legislature by April 1, 2011 identifying steps each agency will take to collectively simplify administrative and reporting requirements.

Section 57: Establishes Regulations To Simpify Payer Claims Processing

Directs the Division of Insurance (DOI), in consultation with the Executive Office of Health and Human Services, to establish regulations by December 1, 2011 to simplify health care facility and provider administrative duties of processing claims for health care services. At a minimum, the regulations must create a standard prior authorization form for providers and must specify uniform standards for determining member eligibility and processing provider appeals of denied claims. Establishes a new commission to study the feasibility and financial implications of mandating a single claims administration system that would require the participation of all public and private health insurance payers, other than Medicare, in the Commonwealth. DOI must consult with this commission before adopting regulations under this section.

Section 61: Community Hospital Study

Directs the Department of Public Health to conduct a study on the impact of expanding the availability of primary care health care services in community hospitals, including the number and types of procedures primary care providers perform, related changes in revenue, recruitment and retention of primary care providers, and changes in types of compensation for services. DPH must issue a report to the legislature by April 1, 2011 summarizing its findings and making recommendations to strengthen community hospitals.

Section 62: Public Health Access Beneficiary Employer Reporting Requirement

Directs the Division of Health Care Finance and Policy to continue submitting to the legislature an annual public health access beneficiary employer report that must include names and addresses of employers whose employees and/or their dependents receive public medical assistance or medical benefits, the number of employees and/or dependents receiving public benefits, the cost to the Commonwealth for providing the benefits, and whether the employer offers health benefits to its employees.

Section 64: Encourages Adoption of Bundled Payment Programs

Requires that the Division of Health Care Finance and Policy (DHCFP) encourage providers and payers to adopt a payment system on a bundled payment, rather than fee-for-service, basis to reduce costs and improve quality and coordination of health care services. DHCFP must assist providers and payers to adopt such a payment system by making technical support available to them. DHCFP must also examine existing and proposed bundled payment models and publish results of research, study the effects of federal programs that promote bundled payment systems, and identify financial resources that may become available to providers while they implement bundled payment systems. The statute encourages DHCFP to implement pilot bundled payment programs before April 1, 2011 for at least 2 acute conditions or procedures where health benefit payers will reimburse health care providers for inpatient services, as well as certain pre- and post-inpatient stay, on a bundled payment basis. DHCFP is also encouraged to implement additional pilot bundled payment programs for at least 2 chronic conditions by July 1, 2011. DHCFP must file reports with the legislature detailing the efforts it undertakes to support providers and payers to implement bundled payment programs and the progress it makes toward implement the encouraged pilot programs.

Section 65: Proposed Plan Change Reporting

Directs the Division of Insurance (DOI) to complete a study by July 31, 2011 to determine whether the 90 day reporting requirement established in Section 31 of this Act gives health insurance carriers a sufficient amount of lead time to make accurate proposals of plan changes to DOI. DOI may recommend a more appropriate length of time if necessary.

Section 66A: Supplemental Reimbursement to Individuals and Small Groups

Provides that a health care provider may contract to provide supplemental funding to a health insurance carrier to be used to issue a premium reimbursement or other form of refund for eligible individuals and small groups currently enrolled in all health benefit plans under the carrier. The Division of Insurance (DOI) must issue a public report listing participating providers and the estimated refunds for individuals and small groups.