CENTER FOR HEALTH INFORMATION AND ANALYSIS

M.G.L. pt. Part I, tit. Title II, ch. c. 12C

in effect

M.G.L. c. 12C, § 1 Definitions

c. 12C, § 1. Definitions Section 1. As used in this chapter the following words shall, unless the context clearly requires otherwise, have the following meanings:— ''Accountable care organization'', or ''ACO'', a provider organization certified under section 15 of chapter 6D. ''Actual costs'', all direct and indirect costs incurred by a hospital or a community health center in providing medically necessary care and treatment to its patients, determined in accordance with generally accepted accounting principles. ''Acute hospital'', the teaching hospital of the University of Massachusetts Medical School and any hospital licensed under section 51 of chapter 111 and which contains a majority of medical-surgical, pediatric, obstetric and maternity beds, as defined by the department of public health. ''Alternative payment contract'', any contract between a provider or provider organization and a public health care payer or a private health care 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, that ''alternative payment methodologies'' may include, but not be limited to, shared savings arrangement, bundled payments, and global payments; provided further, that ''alternative payment methodologies'' may include fee-for-service payments, which are settled or reconciled with a bundled or global payment. ''Ambulatory surgical center'', any distinct entity that operates exclusively to provide surgical services to patients not requiring hospitalization and meets the requirements of the federal Health Care Financing Administration for participation in the Medicare program. ''Ambulatory surgical center services'', services described for purposes of the Medicare program under 42 USC § 1395k(a)(2)(F)(I); provided, that ''ambulatory surgical center services'' shall include facility services only and shall not include surgical procedures. ''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 1 or more subsidiaries or affiliated corporations of the employer; provided 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. ''Case mix'', the description and categorization of a hospital's patient population according to criteria approved by the center including, but not limited to, primary and secondary diagnoses, primary and secondary procedures, illness severity, patient age and source of payment. ''Center'', the center for health information and analysis. ''Charge'', the uniform price for specific services within a revenue center of a hospital. ''Child'', a person who is under 18 years of age. ''Clinical affiliation'', any relationship between a provider organization and another entity for the purpose of increasing the level of collaboration in the provision of health care services, including, but not limited to, sharing of physician resources in hospital or other ambulatory settings, co-branding, expedited transfers to advanced care settings, provision of inpatient consultation coverage or call coverage, enhanced electronic access and communication, co-located services, provision of capital for service site development, joint training programs, video technology to increase access to expert resources and sharing of hospitalists or intensivists. ''Commission'', the health policy commission established in chapter 6D. ''Community health centers'', health centers operating in conformance with Section 330 of United States Public Law 95–626 and shall include all community health centers which file cost reports as requested by the center. ''Dependent'', the spouse and children of any employee if such persons would qualify for dependent status under the Internal Revenue Code or for whom a support order could be granted under chapters 208, 209 or 209C. ''Dispersed service area,'' a geographic area of the commonwealth in which a provider organization delivers health care services; provided, however, that the center may by regulation establish standards to determine dispersed service areas based on the number of zip codes, towns, counties or primary service areas, which standards may vary based upon the population density of various regions of the commonwealth. ''Eligible person'', a person who qualifies for financial assistance from a governmental unit in meeting all or part of the cost of general health supplies, care or rehabilitative services and accommodations. ''Employee'', a person who performs services primarily in the commonwealth for remuneration for a commonwealth employer; provided, that ''employee'' shall not include a person who is self-employed. ''Employer'', an employer as defined in section 1 of chapter 151A. ''Executive director'', the executive director of the center. ''Facility'', a licensed institution providing health care services or a health care setting, including, but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings. ''Fee-for-service'', a payment mechanism in which all reimbursable health care activity is described and categorized into discreet and separate units of service and each provider is separately reimbursed for each discrete service rendered to a patient. ''Fiscal year'', the 12 month period during which a hospital keeps its accounts and which ends in the calendar year by which it is identified. ''General health supplies, care or rehabilitative services and accommodations'', all supplies, care and services of medical, behavioral health, substance use disorder, mental health, optometric, dental, surgical, chiropractic, podiatric, psychiatric, therapeutic, diagnostic, rehabilitative, supportive or geriatric nature, including inpatient and outpatient hospital care and services, and accommodations in hospitals, sanatoria, infirmaries, convalescent and nursing homes, retirement homes, facilities established, licensed or approved under chapter 111B and providing services of a medical or health-related nature, and similar institutions including those providing treatment, training, instruction and care of children and adults; provided, however, that rehabilitative service shall include only rehabilitative services of a medical or health-related nature which are eligible for reimbursement under Title XIX of the Social Security Act. ''Governmental unit'', the commonwealth, any department, agency board or commission of the commonwealth and any political subdivision of the commonwealth. ''Gross patient service revenue'', the total dollar amount of a hospital's charges for services rendered in a fiscal year. ''Health care professional'', a physician or other health care practitioner licensed, accredited, or certified to perform specified health services consistent with law. ''Health care cost growth benchmark'', the projected annual percentage change in total health care expenditures in the commonwealth, as established in section 9 of chapter 6D. ''Health care real estate investment trust'', a real estate investment trust, as defined by 26 U.S.C section 856, whose assets consist of real property held in connection with the use or operations of a provider or provider organization. ''Health care services'', supplies, care and services of medical, behavioral health, substance use disorder, mental health, surgical, 1 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; services provided by a community health center 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 1 services or by a health maintenance organization. ''Health disparities'', preventable differences in the burden of disease, injury, violence or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. ''Health equity'', the state in which a health system offers the infrastructure, facilities, services, geographic coverage, affordability and all other relevant features, conditions and capabilities that will provide all people with the opportunity and reasonable expectation that they can reach their full health potential and well-being and are not disadvantaged in access to health care by their race, ethnicity, language, disability, age, gender, gender identity, sexual orientation, social class, intersections among these communities or identities or their socially determined circumstances. ''Health insurance company'', a company as defined in section 1 of chapter 175 which engages in the business of health insurance. ''Health insurance plan'', the medicare program or an individual or group contract or other plan providing coverage of health care services and which is issued by a health insurance company, a hospital service corporation, a medical service corporation or a health maintenance organization. ''Health maintenance organization'', a company which provides or arranges for the provision of health care services to enrolled members in exchange primarily for a prepaid per capita or aggregate fixed sum as further defined in section 1 of chapter 176G. ''Health status adjusted total medical expenses'', the total cost of care for the patient population associated with a provider group based on allowed claims for all categories of medical expenses and all non-claims related payments to providers, adjusted by health status, and expressed on a per member per month basis, as calculated under section 9 and the regulations promulgated by the center. ''Hospital'', any hospital licensed under section 51 of chapter 111, the teaching hospital of the University of Massachusetts Medical School and any psychiatric facility licensed under section 19 of chapter 19. ''Hospital service corporation'', a corporation established to operate a nonprofit hospital service plan as provided in chapter 176A. ''Major service category,'' a set of service categories to be established by regulation, which may include: (i) acute hospital inpatient services, by major diagnostic category; (ii) outpatient and ambulatory services, by categories as defined by the Centers for Medicare and Medicaid, or as established by regulation, not to exceed 15, including a residual category for ''all other'' outpatient and ambulatory services that do not fall within a defined category; (iii) behavioral, substance use disorder and mental health services by categories as defined by the Centers for Medicare and Medicaid, or as established by regulation; (iv) professional services, by categories as defined by the Centers for Medicare and Medicaid, or as established by regulation; and (v) sub-acute services, by major service line or clinical offering, as defined by regulation. ''Management services organization'', a corporation that provides management or administrative services to a provider or provider organization for compensation. ''Medicaid program'', the medical assistance program administered by the division of medical assistance 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. ''Net cost of private health insurance'', the difference between health premiums earned and benefits incurred, which shall consist of: (i) all categories of administrative expenditures, as included in medical loss ratio regulations promulgated by the division of insurance; (ii) net additions to reserves; (iii) rate credits and dividends; and (iv) profits or losses, or as otherwise defined by regulations promulgate by the center. ''Network contract'', a contract entered between a provider or provider organization and a carrier or third-party administrator concerning payment for the provision of heath care services. ''Non-acute hospital'', any hospital which is not an acute hospital. ''Patient'', any natural person receiving health care services. ''Patient-centered medical home'', a model of health care delivery designed to provide a patient with a single point of coordination for all their health care, including primary, specialty, post-acute and chronic care, which is (i) patient-centered; (ii) comprehensive, integrated and continuous; and (iii) delivered by a team of health care professionals to manage a patient's care, reduce fragmentation, and improve patient outcomes. ''Payer'', any entity, other than an individual, that pays providers for the provision of health care services; provided, however, that ''payer'' shall include both governmental and private entities; and provided further, that ''payer'' shall include self-insured plans to the extent allowed under the Employee Retirement Income Security Act of 1974. ''Pharmaceutical manufacturing company'', an entity engaged in the: (i) production, preparation, propagation, compounding, conversion or processing of prescription drugs, directly or indirectly, by extraction from substances of natural origin, independently by means of chemical synthesis or by a combination of extraction and chemical synthesis; or (ii) packaging, repackaging, labeling, relabeling or distribution of prescription drugs; provided, however, that ''pharmaceutical manufacturing company'' shall not include a hospital licensed under section 51 of chapter 111, a wholesale drug distributor licensed under section 36B of chapter 112 or a retail pharmacist registered under section 39 of said chapter 112. ''Pharmacy benefit manager'', as defined in section 1 of chapter 176Y. ''Primary service area'', a geographic area of the commonwealth in which consumers are likely to travel to obtain health services; provided, however, that the center may by regulation establish standards to determine primary service areas by major service category, which standards may vary based upon the population density of various regions of the commonwealth. ''Private equity company'', any company that collects capital investments from individuals or entities and purchases, as a parent company or through another entity that the company completely or partially owns or controls, a direct or indirect ownership share of a provider, provider organization or management services organization; provided, however, that ''private equity company'' shall not include venture capital firms exclusively funding startups or other early-stage businesses. ''Private health care payer'', a carrier authorized to transact accident and health insurance under chapter 175, a nonprofit hospital service corporation licensed under chapter 176A, a nonprofit medical service corporation licensed under chapter 176B, a dental service corporation organized under chapter 176E, an optometric service corporation organized under chapter 176F, a self-insured plan, to the extent allowable under federal law governing health care provided by employers to employees, or a health maintenance organization licensed under chapter 176G. ''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, which is 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, including but not 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. ''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 under chapter 32A; and any city or town with a population of more than 60,000 that has adopted chapter 32B. ''Purchaser'', a natural person responsible for payment for health care services rendered by a hospital. ''Quality measures'', the standard quality measure set as defined by the center in section 14. ''Registered provider organization,'' a provider organization that has been registered in accordance with section 11 of chapter 6D. ''Relative prices'', the contractually negotiated amounts paid to providers by each private and public carrier for health care services, including non-claims related payments and expressed in the aggregate relative to the payer's network-wide average amount paid to providers, as calculated under section 9 and regulations promulgated by the center. ''Revenue center'', a functioning unit of a hospital which provides distinctive services to a patient for a charge. ''Resident'', a person living in the commonwealth, as defined by the center by regulation; provided, however, that such regulation shall not define a resident as a person who moved into the commonwealth for the sole purpose of securing health insurance under this chapter; and provided, further that confinement of a person in a nursing home, hospital or other medical institution shall not, in and of itself, suffice to qualify such person as a resident. ''Secretary'', the secretary of health and human services. ''Self-employed'', a person who, at common law, is not considered to be an employee and whose primary source of income is derived from the pursuit of a bona fide business. ''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. ''Self-insured group'', a self-insured or self-funded employer group health plan. ''Significant equity investor'', (i) any private equity company with a financial interest in a provider, provider organization or management services organization; or (ii) an investor, group of investors or other entity with a direct or indirect possession of equity in the capital, stock or profits totaling more than 10 per cent of a provider, provider organization or management services organization; provided, however, that ''significant equity investor'' shall not include venture capital firms exclusively funding startups or other early-stage businesses. ''Specialty hospital'', an acute hospital which qualifies for an exemption from the medicare prospective payment system regulations or any acute hospital which limits its admissions to patients under active diagnosis and treatment of eyes, ears, nose and throat or to children or patients under obstetrical care. ''State institution'', any hospital, sanatorium, infirmary, clinic and other such facility owned, operated or administered by the commonwealth, which furnishes general health supplies, care or rehabilitative services and accommodations. ''Surcharge payor'', 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 the term ''surcharge payor'' shall include a managed care organization; and provided further, that ''surcharge payor'' 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 chapter 152. ''Third party administrator'', an entity that administers payments for health care services on behalf of a client in exchange for an administrative fee. ''Third party payer'', an entity including, but not limited to, Title XVIII and Title XIX programs, other governmental payers, insurance companies, health maintenance organizations and nonprofit hospital service corporations; provided, that, ''third party payer'' shall not include a purchaser responsible for payment for health care services rendered by a hospital, either to the purchaser or to the hospital. ''Title XIX'', Title XIX of the Social Security Act, 42 USC 1396 et seq., or any successor statute enacted into federal law for the same purposes as Title XIX. ''Total health care expenditures'', the annual per capita sum of all health care expenditures in the commonwealth from public and private sources, including: (i) all categories of medical expenses and all non-claims related payments to providers, as included in the health status adjusted total medical expenses reported by the center under subsection (d) of section 8; (ii) all patient cost-sharing amounts, such as deductibles and copayments; and (iii) the net cost of private health insurance, or as otherwise defined in regulations promulgated by the center. ''Wholesale acquisition cost'', the cost of a prescription drug as defined in 42 U.S.C. 1395w–3a(c)(6)(B).

M.G.L. c. 12C, § 2 Center for health information and analysis; executive director; term; removal

c. 12C, § 2. Center for health information and analysis; executive director; term; removal Section 2. There is hereby established a center for health information and analysis. There shall be in the center an executive director, who shall be the administrative head of the center and who shall be appointed by a majority vote of the attorney general, the state auditor and the governor for a term of 5 years. The person so appointed shall be selected without regard to political affiliation and solely on the basis of expertise in health care policy, expertise in health care finance and such other educational requirements and experience that the attorney general, state auditor and governor determine are necessary. In the case of a vacancy in the position of executive director, a successor shall be appointed in the same manner as the original appointment for the unexpired term. No person shall be appointed for more than 2 consecutive 5–year terms. The person so appointed may be removed from office, for cause, by a majority vote of the attorney general, the state auditor and the governor. Such cause may include substantial neglect of duty, gross misconduct or conviction of a crime. The reasons for removal of the executive director shall 1 be stated in writing and shall include the basis for such removal. The writing shall be sent to the clerk of the senate, the clerk of the house of representative and to the governor at the time of the removal and shall be a public record.

M.G.L. c. 12C, § 2A Health information and analysis oversight council; members; meetings; powers and duties

c. 12C, § 2A. Health information and analysis oversight council; members; meetings; powers and duties Section 2A. (a) There shall be a health information and analysis oversight council which shall oversee the center; provided, however, that the council shall not oversee the Betsy Lehman center for patient safety and medical error reduction established in section 15. The council shall consist of: the secretary of health and human services; the secretary of administration and finance; the commissioner of insurance; the executive director of the health policy commission; 2 members who shall be appointed by the attorney general, 1 of whom shall have experience in cybersecurity and 1 of whom shall have experience in health equity advocacy; 2 members who shall be appointed by the state auditor, 1 of whom shall be a health care economist; and 3 members who shall be appointed by the governor, 1 of whom shall have experience in health care delivery or health care management, 1 of whom shall have experience with the use of big data, open data and analytics and 1 of whom shall have experience in finance and budgeting. Appointments shall be made without regard to political affiliation. Members of the council shall serve for terms of 5 years. In the case of a vacancy, a successor shall be appointed for the remainder of the unexpired term in the same manner as the original appointment. Members of the council shall be eligible for reappointment. Members of the council shall not be employed by, a consultant to, a member of the board of directors of, affiliated with, have a financial stake in or otherwise be a representative of: (i) an acute hospital; (ii) an ambulatory surgical center; or (iii) a surcharge payor. The council shall annually elect 1 of its members to serve as chair and 1 to serve as vice-chair. Members of the council shall be residents of the commonwealth. (b) The council shall meet on a quarterly basis. Meetings of the council shall be subject to sections 18 to 25, inclusive, of chapter 30A. Six members of the council shall constitute a quorum and the council may take any action based on the affirmative vote of 6 members. No vacancy in the membership of the council shall impair the right of a quorum to exercise all the rights and duties of the commission. Members shall serve without pay, but shall be reimbursed for actual expenses necessarily incurred in the performance of their duties. (c) The council shall: (1) prepare an annual operating budget for the center following at least 1 public hearing; (2) review and manage the administrative expenses of the center; (3) implement procedures for communications with the executive director; (4) develop annual research and analysis priorities for the center; provided, however, that the council shall not require approval of the center's actions under section 16 of this chapter, section 38C of chapter 3 or section 17 of chapter 176A; (5) develop guidelines for uniform reporting and data preparation pursuant to sections 8 to 10, inclusive; and (6) develop guidelines for the collection, storage and maintenance of the payer and provider claims database established pursuant to section 12. (d) Chapter 268A shall apply to all council members except that the center may purchase from, sell to, borrow from, contract with or otherwise deal with any organization in which any council member is in anyway interested or involved; provided, however, that such interest or involvement shall be disclosed in advance to the council and recorded in the minutes of the proceedings of the council; and provided further, that no member shall be deemed to have violated section 4 of said chapter 268A because of the member's receipt of that member's usual and regular compensation from the member's employer during the time in which the member participates in the activities of the council.

M.G.L. c. 12C, § 3 Agents, officers and employees; appointment; powers and duties

c. 12C, § 3. Agents, officers and employees; appointment; powers and duties Section 3. The executive director may appoint and remove, subject to appropriation, such agents and subordinate officers and employees as the executive director may consider necessary and may establish such subdivisions within the center as the executive director considers appropriate to fulfill the following duties: (i) to collect, analyze and disseminate health care information to assist in the formulation of health care policy and in the provision and purchase of health care services including, but not limited to, collecting, storing and maintaining data in a payer and provider claims database; (ii) to provide an analysis of health care spending trends as compared to the health care cost growth benchmark established by the health policy commission under section 9 of chapter 6D; (iii) to collect, analyze and disseminate information regarding providers, provider organizations, pharmaceutical manufacturing companies, pharmacy benefit managers and payers to increase the transparency and improve the functioning of the health care system; (iv) to provide information to, and work with, the general court and other state agencies including, but not limited to, the executive office of health and human services, the department of public health, the department of mental health, the health care policy commission, the office of Medicaid and the division of insurance to collect and disseminate data concerning the cost, price and functioning of the health care system in the commonwealth and the health status of individuals; (v) to participate in and provide data and data analysis for annual hearings conducted by the health policy commission concerning health care provider, payer, pharmaceutical manufacturing company and pharmacy benefit manager costs, prices and cost trends; and (vi) report to consumers comparative health care cost and quality information through the consumer health information website established under section 20. The center shall make available actual costs and prices of health care services, as supplied by each provider, to the general public in a conspicuous manner on the consumer health information website.

M.G.L. c. 12C, § 4 Salaries; personnel regulations

c. 12C, § 4. Salaries; personnel regulations Section 4. The position of executive director shall be classified under section 45 of chapter 30 and the salary shall be determined under section 46C of said chapter 30. The total amount of all appointee salaries shall not exceed the sum appropriated therefor by the general court. Sections 9A, 45, 46, and 46C of chapter 30, chapter 31 and chapter 150E shall not apply to the executive director of the center. Sections 45, 46 and 46C of chapter 30 shall not apply to any employee of the center. The executive director may establish personnel regulations for the officers and employees of the center. The executive director shall file an annual personnel report not later than the first Wednesday in February with the senate and house committees on ways and means containing the job classifications, duties and salary of each officer and employee within the center together with personnel regulations applicable to said officers and employees. The executive director shall file amendments to such report with the senate and house committees on ways and means whenever any changes become effective.

M.G.L. c. 12C, § 5 Adoption of rules and regulations

c. 12C, § 5. Adoption of rules and regulations Section 5. The center shall adopt and amend rules and regulations, in accordance with chapter 30A, for the administration of its duties and powers and necessary to effectuate this chapter; provided, however, that the rules or regulations shall not be construed to impair or in any way modify the authority of the executive office of health and human services to act, pursuant to section 16 of chapter 6A of the General Laws, as the single state agency authorized to supervise and administer the state programs under titles XIX and XXI of the Social Security Act. The regulations shall be adopted, after notice and hearing, only upon consultation with representatives of providers, provider organizations, pharmacy benefit managers, pharmaceutical manufacturing companies, private health care payers and public health care payers. The center shall, before adopting regulations under this chapter, consult with other agencies of the commonwealth and the federal government, affected providers, affected payers, affected pharmaceutical manufacturing companies and affected pharmacy benefit managers, as applicable, to ensure that the reporting requirements imposed under the regulations are not duplicative or excessive. If reporting requirements imposed by the center result in additional costs for the reporting providers, these costs may be included in any rates promulgated by the executive office of health and human services or a governmental unit designated by the executive office for these providers. The center may specify categories of information which may be furnished under an assurance of confidentiality to the provider; provided, however, that such assurance shall only be furnished if the information is not to be used for setting rates.

M.G.L. c. 12C, § 6 Powers

c. 12C, § 6. Powers Section 6. In addition to the powers conferred on state agencies, the center shall have the following powers: (1) to make, amend and repeal rules and regulations for the management of its affairs; (2) to make contracts and execute all instruments necessary or convenient for the carrying on of its business; (3) to acquire, own, hold, dispose of and encumber personal property and to lease real property in the exercise of its powers and the performance of its duties; and (4) to enter into agreements or transactions with any federal, state or municipal agency or other public institution or with any private individual, partnership, firm, corporation, association or other entity.

M.G.L. c. 12C, § 7 Payment by acute hospital or ambulatory surgical center for estimated expenses of center and other purposes under this chapter

c. 12C, § 7. Payment by acute hospital or ambulatory surgical center for estimated expenses of center and other purposes under this chapter Section 7. (a) For the purposes of this section, ''non-hospital provider organization'' shall mean a provider organization required to register under section 11 under chapter 6D that is: (i) a non-hospital-based physician practice with not less than $500,000,000 in annual gross patient service revenue; (ii) a clinical laboratory; (iii) an imaging facility; or (iv) a network of affiliated urgent care centers. (b) Each acute hospital, ambulatory surgical center, non-hospital provider organization, pharmaceutical manufacturing company and pharmacy benefit manager, shall pay to the commonwealth an amount for the estimated expenses of the center and for the other purposes described in this chapter which shall include any transfer made to the Community Hospital Reinvestment Trust Fund established in section 2TTTT of chapter 29. (c) The assessed amount for acute hospitals, ambulatory surgical centers and non-hospital provider organizations shall be not less than 30 per cent nor more than 40 per cent of the amount appropriated by the general court for the expenses of the center and for the other purposes described in this chapter which shall include any transfer made to the Community Hospital Reinvestment Trust Fund established in section 2TTTT of chapter 29 minus amounts collected from: (i) filing fees; (ii) fees and charges generated by the center's publication or dissemination of reports and information; and (iii) federal matching revenues received for these expenses or received retroactively for expenses of predecessor agencies; provided, however, that, to the maximum extent permissible under federal law, non-hospital provider organizations shall be assessed not less than 3 per cent nor more than 8 per cent of the total assessed amount for acute hospitals, ambulatory surgical centers and non-hospital provider organizations. Each acute hospital, ambulatory surgical center and non-hospital provider organization shall pay such assessed amount multiplied by the ratio of the acute hospital's, ambulatory surgical center's or non-hospital provider organization's gross patient service revenues to the total gross patient services revenues of all such hospitals, ambulatory surgical centers and non-hospital provider organizations. Each acute hospital, ambulatory surgical center and non-hospital provider organization shall make a preliminary payment to the center on October 1 of each year in an amount equal to 1/2 of the previous year's total assessment. Thereafter, each acute hospital, ambulatory surgical center and non-hospital provider organization shall pay, within 30 days' notice from the center, the balance of the total assessment for the current year based upon its most current projected gross patient service revenue. The center shall subsequently adjust the assessment for any variation in actual and estimated expenses of the center and for changes in acute hospital, ambulatory surgical center and non-hospital provider organization gross patient service revenue. Such estimated and actual expenses shall include an amount equal to the cost of fringe benefits and indirect expenses, as established by the comptroller under section 5D of chapter 29. In the event of late payment by any such acute hospital, ambulatory surgical center or non-hospital provider organization, the treasurer shall advance the amount of due and unpaid funds to the center prior to the receipt of such monies in anticipation of such revenues up to the amount authorized in the then current budget attributable to such assessments and the center shall reimburse the treasurer for such advances upon receipt of such revenues. This section shall not apply to any state institution or to any acute hospital which is operated by a city or town. (d) To the maximum extent permissible under federal law, and provided that such assessment will not result in any reduction of federal financial participation in Medicaid, the assessed amount for pharmaceutical manufacturing companies shall be not less than 5 per cent nor more than 10 per cent of the amount appropriated by the general court for the expenses of the center minus amounts collected from: (i) filing fees; (ii) fees and charges generated by the center's publication or dissemination of reports and information; and (iii) federal matching revenues received for these expenses or received retroactively for expenses of predecessor agencies. Each pharmaceutical manufacturing company shall pay such assessed amount multiplied by the ratio of MassHealth's net spending for the manufacturer's prescription drugs used in the MassHealth rebate program to MassHealth's total pharmacy spending. (e) To the maximum extent permissible under federal law, and provided that such assessment will not result in any reduction of federal financial participation in Medicaid, the assessed amount for pharmacy benefit managers shall be not less than 5 per cent nor more than 10 per cent of the amount appropriated by the general court for the expenses of the center minus amounts collected from: (i) filing fees; (ii) fees and charges generated by the center's publication or dissemination of reports and information; and (iii) federal matching revenues received for these expenses or received retroactively for expenses of predecessor agencies. Each pharmacy benefit manager shall pay such assessed amount multiplied by the ratio of the claims paid by the pharmacy benefit manager attributed to residents of the commonwealth for whom it manages pharmaceutical benefits on behalf of carriers to the total of all such claims paid by all pharmacy benefit managers attributed to residents of the commonwealth for whom they manage pharmaceutical benefits on behalf of carriers. (f) Each pharmaceutical manufacturing company and each pharmacy benefit manager shall make a preliminary payment to the center annually on October 1 in an amount equal to 1/2 of the previous year's total assessment. Thereafter, each pharmaceutical manufacturing company and each pharmacy benefit manager shall pay, within 30 days' notice from the center, the balance of the total assessment for the current year as determined by the center.

M.G.L. c. 12C, § 7A Center for health information and analysis fund

c. 12C, § 7A. Center for health information and analysis fund Section 7A. There shall be a Center for Health Information and Analysis Fund which shall be a separate, nonbudgeted special revenue fund to be administered by the executive director. The fund shall be credited with: (i) any transfers from the Health Safety Net Trust Fund established in section 66 of chapter 118E; (ii) appropriations or other money authorized or transferred by the general court and specifically designated to be credited to the fund; (iii) funds from public and private sources, including, but not limited to, gifts, federal financial participation, grants and donations; and (iv) any interest earned on the assets of the fund. Amounts credited to the fund shall be expended, without further appropriation, for the expenses of the center and for the other purposes described in this chapter. For the purpose of accommodating timing discrepancies between the receipt of revenues and related expenditures, the fund may incur expenses and the comptroller may certify for payment amounts not to exceed the lower of amounts credited to the fund during the period of the timing discrepancy or the most recent revenue estimate as reported in the state accounting system. Any balance in the fund at the close of a fiscal year shall be available for expenditure in subsequent fiscal years and shall not be transferred to any other fund or revert to the General Fund.

M.G.L. c. 12C, § 8 Reporting requirements for institutional providers and their parent organization and other affiliates

c. 12C, § 8. Reporting requirements for institutional providers and their parent organization and other affiliates Section 8. (a) The center shall promulgate such regulations as necessary to ensure the uniform reporting of revenues, charges, costs, prices, and utilization of health care services and other such data as the center may require of institutional providers and their parent organizations and any other affiliated entities including significant equity investors, health care real estate investment trusts and management services organizations, non-institutional providers and provider organizations; provided, however, that the center may establish reporting thresholds through regulation. Such uniform reporting shall enable the center to identify, on a patient-centered and provider-specific basis, statewide and regional trends in the cost, price, availability and utilization of medical, surgical, diagnostic and ancillary services provided by acute hospitals, nursing homes, chronic care and rehabilitation hospitals, other specialty hospitals, clinics, including mental health clinics and the ambulatory care providers as the center may specify. The center shall also promulgate regulations to require providers to report any agreements through which provider agrees to furnish another provider with a discount, rebate or any other type of refund or remuneration in exchange for, or in any way related to, the provision of heath care services. (b) With respect to any acute or non-acute hospital, the center shall, by regulation, designate information necessary to effectuate this chapter including, but not be limited to, the filing of a charge book, the filing of cost data and audited financial statements, including the audited financial statements of the parent organization's out-of-state operations, significant equity investors, health care real estate investment trusts and management services organizations, and the submission of merged billing and discharge data. The center shall, by regulation, designate standard systems for determining, reporting and auditing volume, case-mix, proportion of low-income patients and any other information necessary to effectuate this chapter and to prepare reports comparing acute and non-acute care hospitals by cost, utilization and outcome. The regulations may require the hospitals to file required information and data by electronic means; provided, however, that the center shall allow reasonable waivers from the requirement. The center shall, at least annually, publish a report analyzing the comparative information to assist third-party payers and other purchasers of health services in making informed decisions. The report shall include comparative price and service information relative to outpatient mental health services. (c) The center shall also collect and analyze such data as it considers necessary in order to better protect the public's interest in monitoring the financial conditions of acute hospitals. The information shall be analyzed on an industry-wide and hospital-specific basis and shall include, but not be limited to: (1) gross and net patient service revenues; (2) sources of hospital revenue, including revenue excluded from consideration in the establishment of hospital rates and charges under section 13G of chapter 118E; (3) private sector charges; (4) trends in inpatient and outpatient case mix, payer mix, hospital volume and length of stay; (5) total payroll as a per cent of operating expenses, as well as the salary and benefits of the top 10 highest compensated employees, identified by position description and specialty; (6) margins, including margins by payer type; (7) investments; (8) information on any relationships with significant equity investors, health care real estate investment trusts and management service organizations; and (9) other relevant measures of financial health or distress. The center shall publish annual reports and establish a continuing program of investigation and study of financial trends in the acute hospital industry, including an analysis of systemic instabilities or inefficiencies that contribute to financial distress in the acute hospital industry. The reports shall include an identification and examination of hospitals that the center considers to be in financial distress, including any hospitals at risk of closing or discontinuing essential health services, as defined by the department of public health under section 51G of chapter 111, as a result of financial distress. The center may modify uniform reporting requirements established under subsections (a) and (b) and may require hospitals to report required information quarterly to effectuate this subsection. (d) The center shall publicly report and place on its website information on health status adjusted total medical expenses including a breakdown of the health status adjusted total medical expenses by major service category and by payment methodology, relative prices and hospital inpatient and outpatient costs, including direct and indirect costs under this chapter on an annual basis; provided, however, that at least 10 days before the public posting or reporting of provider specific information the affected provider shall be provided the information for review. The center shall request from the federal Centers for Medicare and Medicaid Services the health status adjusted total medical expenses of provider groups that serve Medicare patients. (e) When collecting information or compiling reports intended to compare individual health care providers, the center shall require that: (1) providers which are representative of the target group for profiling shall be meaningfully involved in the development of all aspects of the profile methodology, including collection methods, formatting and methods and means for release and dissemination; (2) the entire methodology for collecting and analyzing the data shall be disclosed to all relevant provider organizations and to all providers under review; (3) data collection and analytical methodologies shall be used that meet accepted standards of validity and reliability; (4) the limitations of the data sources and analytic methodologies used to develop provider profiles shall be clearly identified and acknowledged, including, but not limited to, the appropriate and inappropriate uses of the data; (5) to the greatest extent possible, provider profiling initiatives shall use standard-based norms derived from widely accepted, provider-developed practice guidelines; (6) provider profiles and other information that have been compiled regarding provider performance shall be shared with providers under review prior to dissemination; provided, however, that opportunity for corrections and additions of helpful explanatory comments shall be provided prior to publication; and, provided, further, that such profiles shall only include data which reflect care under the control of the provider for whom such profile is prepared; (7) comparisons among provider profiles shall adjust for patient case-mix and other relevant risk factors and control for provider peer groups, when appropriate; (8) effective safeguards to protect against the unauthorized use or disclosure of provider profiles shall be developed and implemented; (9) effective safeguards to protect against the dissemination of inconsistent, incomplete, invalid, inaccurate or subjective profile data shall be developed and implemented; and (10) the quality and accuracy of provider profiles, data sources and methodologies shall be evaluated regularly.

M.G.L. c. 12C, § 9 Reporting requirements for registered provider organizations

c. 12C, § 9. Reporting requirements for registered provider organizations Section 9. (a) The center, in consultation with the commission, shall promulgate regulations to require that provider organizations registered under section 11 of chapter 6D shall annually report the data as the center considers necessary to better protect the public interest in monitoring the financial conditions, organizational structure, business practices, clinical services and market share of each registered provider organization. The center may assess administrative fees on provider organizations in an amount to help defray the center's costs in complying with this section. The center may specify, by regulation, uniform reporting standards and reporting thresholds as it determines necessary. (b) The center shall require registered provider organizations to annually report information necessary to achieve the goals described in subsection (a) which shall include, but shall not be limited to: (i) organizational charts showing the ownership, governance and operational structure of the provider organization, including any clinical affiliations and community advisory boards; (ii) the number of affiliated health care professional full-time equivalents by license type, specialty, name and address of practice locations and whether the professional is employed by the organization; (iii) the name and address of licensed facilities by license number, license type and capacity in each major service category; (iv) the name, address and capacity of all other locations where the provider organization, or any of its affiliates, delivers health care services, including those services listed in subsection (a) of section 22 of chapter 6D; (v) a comprehensive financial statement, including information on parent entities, including their out-of-state operations, and corporate affiliates, including significant equity investors, health care real estate investment trusts and management services organizations as applicable, and including details regarding annual costs, annual receipts, realized capital gains and losses, accumulated surplus and accumulated reserves; (vi) information on stop-loss insurance and any non-fee-for-service payment arrangements; (vii) information on clinical quality, care coordination and patient referral practices; (viii) information regarding expenditures and funding sources for payroll, teaching, research, advertising, taxes or payments-in-lieu-of-taxes and other non-clinical functions; (ix) information regarding charitable care and community benefit programs; (x) for any risk-bearing provider organization, a certificate from the division of insurance under chapter 176U; (xi) information regarding other assets and liabilities that may affect the financial condition of the provider organization or the provider organization's facilities including, but not limited to, real estate sale-leaseback arrangements with health care real estate investment trusts; and (xii) such other information as the center considers appropriate as set forth in the center's regulations; provided, however, that the center shall coordinate with the commission and the division of insurance to obtain information directly from the commission or division; and provided further, that the center shall consider the administrative burden of reporting when developing reporting requirements. The center may, in consultation with the division of insurance and the commission, merge similar reporting requirements where appropriate. (c) Annual reporting shall be in a form provided by the center. The center shall promulgate regulations that define criteria for waivers from certain annual reporting requirements under this section. Criteria for waivers may include operational size of the provider organization, the provider organization's annual net patient service revenue, the degree of risk assumed by the provider organization and other criteria as the center considers appropriate. (d) Notwithstanding the annual reporting requirements under this section, the center may require in writing, at any time, such additional information as it deems reasonable and necessary to determine the organizational structure, business practices, clinical services, market share or financial condition of a registered provider organization, including information related to its total adjusted debt and total adjusted earnings. The center may: (i) modify uniform reporting requirements; (ii) require registered provider organizations with private equity investment to report required information quarterly; or (iii) require the disclosure of relevant information from any significant equity investor associated with a registered provider organization. (e) The center may enter into interagency agreements with the commission and other state agencies to effectuate the goals of this section.

M.G.L. c. 12C, § 10 Reporting requirements for private and public health care payers and third-party administrators

c. 12C, § 10. Reporting requirements for private and public health care payers and third-party administrators Section 10. (a) The center shall promulgate regulations necessary to ensure the uniform reporting of information from private and public health care payers, including third-party administrators, that enables the center to analyze: (1) changes over time in health insurance premium levels; (2) changes in the benefit and cost-sharing design of plans offered by these payers; (3) changes in measures of plan cost and utilization; provided that this analysis shall facilitate comparison among plans and between public and private payers; and (4) changes in type of payment methods implemented by payers and the number of members covered by alternative payment methodologies; provided, however, that this analysis shall facilitate comparison among plans and plan types, including the self-insured. The center shall adopt regulations to require private and public health care payers to submit claims data, member data and provider data to develop and maintain a database of health care claims data under this chapter. [Subsection (b) applicable to all dental benefit plans issued, made effective, delivered or renewed on or after January 1, 2024.] (b) The center shall require the submission of data and other information from each private health care payer offering small or large group health plans including, but not limited to: (1) average annual individual and family plan premiums for each payer's most popular plans for a representative range of group sizes, as further determined in regulations, and average annual individual and family plan premiums for the lowest cost plan in each group size that meets the minimum standards and guidelines established by the division of insurance under section 8H of chapter 26; (2) information concerning the actuarial assumptions that underlie the premiums for each plan; (3) summaries of the plan and network designs for each plan, including whether behavioral, substance use disorder and mental health or other specific services are carved-out from any plans; (4) information concerning the medical and administrative expenses, including medical loss ratios for each plan, using a uniform methodology and collected under section 21 of chapter 176O or section 3 of chapter 176X; (5) information concerning the payer's current level of reserves and surpluses; (6) information on provider payment methods and levels; (7) health status adjusted total medical expenses by registered provider organization, provider group and local practice group and zip code calculated according to the method established under section 51 of chapter 288 of the acts of 2010; (8) relative prices paid to every hospital, registered provider organization, physician group, ambulatory surgical center, freestanding imaging center, mental health facility, rehabilitation facility, skilled nursing facility and home health provider in the payer's network, by type of provider, with hospital inpatient and outpatient prices listed separately and product type, including health maintenance organization and preferred provider organization products and determined using the method established under section 52 of chapter 288 of the acts of 2010; (9) hospital inpatient and outpatient costs, including direct and indirect costs, according to a uniform methodology; (10) the annual rate of growth, stated as a percentage, of the average relative price by provider type and product type for the payer's participating health care providers, whether that rate exceeds the rate of growth of the applicable producer price index as reported by the United States Bureau of Labor Statistics and identified by the commissioner of insurance and whether that rate exceeds the rate of growth in projected economic growth benchmark established under section 7H1/2 of chapter 29; and (11) a comparison of relative prices for the payer's participating health care providers by provider type which shows the average relative price, the extent of variation in price, stated as a percentage, and identifies providers who are paid more than 10 per cent, 15 per cent and 20 per cent above and more than 10 per cent, 15 per cent and 20 per cent below the average relative price. (c) The center shall require the submission of data and other information from public health care payers including, but not limited to: (1) average premium rates for health insurance plans offered by public payers and information concerning the actuarial assumptions that underlie these premiums; (2) average annual per-member per-month payments for enrollees in MassHealth primary care clinician and fee for service programs; (3) summaries of plan and network designs for each plan or program, including whether behavioral, substance use disorder and mental health or other specific services are carved-out from any plans; (4) information concerning the medical and administrative expenses, including medical loss ratios for each plan or program; (5) where appropriate, information concerning the payer's current level of reserves and surpluses; (6) information on provider payment methods and levels, including information concerning payment levels to each hospital for the 25 most common medical procedures provided to enrollees in these programs, in a form that allows payment comparisons between Medicaid programs and managed care organizations under contract to the office of Medicaid; (7) health status adjusted total medical expenses by registered provider organization, provider group and local practice group and zip code calculated according to the method established under section 51 of chapter 288 of the acts of 2010; and (8) relative prices paid to every hospital, registered provider organization, physician group, ambulatory surgical center, freestanding imaging center, mental health facility, rehabilitation facility, skilled nursing facility and home health provider in the payer's network, by type of provider, with hospital inpatient and outpatient prices listed separately, and product type and determined using the method established under section 52 of chapter 288 of the acts of 2010; (9) hospital inpatient and outpatient costs, including direct and indirect costs, according to a uniform methodology; () the annual rate of growth, stated as a percentage, of the average relative price by provider type and product type for the payer's participating health care providers, whether that rate exceeds the rate of growth of the applicable producer price index as reported by the United States Bureau of Labor Statistics and identified by the commissioner of insurance and whether that rate exceeds the rate of growth in projected economic growth benchmark established under section 7H1/2 of chapter 29; and (11) a comparison of relative prices for the payer's participating health care providers by provider type which shows the average relative price, the extent of variation in price, stated as a percentage and identifies providers who are paid more than 10 per cent, 15 per cent and 20 per cent above and more than 10 per cent, 15 per cent and 20 per cent below the average relative price. (d) The center shall require the submission of data and other information from public and private health care payers which utilize alternative payment contracts, including, but not limited to: (1) if applicable, the negotiated monthly or yearly budget for each alternative payment contract in the current contract year; (2) any applicable measures of provider performance in such alternative payment contracts; and (3) if applicable, the average negotiated monthly or yearly budget weighted by member months for each geographic region of the commonwealth as further defined in regulations promulgated by the center. For purposes of this subsection, payers shall report the negotiated budget assuming a neutral health status score of 1.0 using an industry accepted health status adjustment tool and shall, if applicable, separately report the budget allowances for: all medical and behavioral, substance use disorder and mental health care at both in and out-of-network providers; pharmacy coverage allowance; administrative expenses such as data analytics, health information technology, clinical program development and other program management fees; the purchase of reinsurance or stop-loss; and quality bonus monies, unit cost adjustments or other special allowances as may be required in regulations promulgated by the center. If out-of-network care, behavioral, substance use disorder and mental health, stop-loss insurance or any other clinical services are carved out of any global budget, bundled payments or other alternative payment methodologies such that there is no allowance included in the budget for those services, payers shall report actual claims costs of these items on a per member per month basis for the year immediately prior to the current contract year. (e) Except as specifically provided otherwise by the center or under this chapter, insurer data collected by the center under this section shall not be a public record under clause Twenty-sixth of section 7 of chapter 4 or under chapter 66.

M.G.L. c. 12C, § 10A Reporting requirements for pharmacy benefit managers

c. 12C, § 10A. Reporting requirements for pharmacy benefit managers Section 10A. (a) The center shall promulgate regulations necessary to ensure the uniform reporting of information from pharmacy benefit managers to enable the center to analyze: (i) year-over-year changes in wholesale acquisition cost; (ii) year-over-year trends in formulary, maximum allowable cost lists and cost-sharing design, including the establishment and management of specialty product lists; (iii) aggregate information regarding discounts, utilization limits, rebates, administrative fees charged to pharmaceutical manufacturing companies and other financial incentives or concessions related to pharmaceutical products or formulary programs; (iv) trends in estimated aggregate drug rebates and other aggregate drug price reductions, if any, provided by a pharmacy benefit manager to a carrier client or health plan sponsor or passed through from a pharmacy benefit manager to a carrier client or health plan sponsor in connection with utilization of drugs in the commonwealth offered through the pharmacy benefit manager and a measure of lives covered by each carrier client or health plan sponsor in the commonwealth; and (v) any other information deemed reasonably necessary by the center by regulation. (b) The center shall require the submission of available data and other information from pharmacy benefit managers including, but not limited to: (i) the aggregate amount of all rebates that the pharmacy benefit manager received from all pharmaceutical manufacturing companies and for all carrier clients or health plan sponsors; (ii) the administrative fees that the pharmacy benefit manager received from all carrier clients or health plan sponsors in the aggregate and for each carrier client or health plan sponsor individually; (iii) the aggregate amount of rebates a pharmacy benefit manager: (A) retains based on its contractual arrangement with each carrier client or health plan sponsor individually; and (B) passes through to each carrier client or health plan sponsor individually; (iv) the aggregate amount of all retained rebates that the pharmacy benefit manager received from all pharmaceutical manufacturing companies and did not pass through to each pharmacy benefit manager's carrier client or health plan sponsor individually; (v) the percentage of contracts that a pharmacy benefit manager holds where the pharmacy benefit manager: (A) retains all rebates; (B) passes all rebates through to the carrier client or health plan sponsor; and (C) shares rebates with the carrier client or health plan sponsor; and (vi) information related to the pharmacy benefit manager practices of spread pricing, administrative fees, claw backs and formulary placement. (c) Except as specifically provided otherwise under this chapter, data collected by the center pursuant to this section shall not be a public record under clause Twenty-sixth of section 7 of chapter 4 and section 10 of chapter 66. No such data shall be disclosed in a manner that is likely to compromise the financial, competitive or proprietary nature of such data and other information, or that may identify specific prices charged for drugs, the value of any rebate amounts, individual drugs, or any pharmaceutical manufacturing company.

M.G.L. c. 12C, § 11 Timely reporting of information required under Secs. 8 to 10A

c. 12C, § 11. Timely reporting of information required under Secs. 8 to 10A Section 11. The center shall ensure the timely reporting of information required under sections 8 to 10A, inclusive. The center shall notify entities required to submit data under this chapter of any applicable reporting deadlines. The center shall notify, in writing, an entity required to submit data under this chapter that has failed to meet a reporting deadline and shall notify such entity that failure to respond within 2 weeks of the receipt of the notice may result in penalties. The center may assess a penalty against an entity required to submit data under this chapter that fails, without just cause, to provide the requested information within 2 weeks following receipt of the written notice required under this paragraph, of not more than $25,000 per week for each week of delay after the 2–week period following the reporting entity's receipt of the written notice. Amounts collected under this section shall be deposited in the Healthcare Payment Reform Fund established in section 100 of chapter 194 of the acts of 2011. The center shall notify the commission and the department of public health if a provider or provider organization fails to timely report in accordance with this section or if the center has assessed a penalty under this section. Such notification shall be considered by the commission in a cost and market impact review under section 13 of chapter 6D, and by the department in determining licensure and suitability in accordance with section 51 of chapter 111 and for a determination of need under section 25C of chapter 111.

M.G.L. c. 12C, § 12 Collection, storage and maintenance of data collected under Secs. 8 to 10A; payer and provider claims database; access to data; reasons for access; disclosure of identifiable information for research; disclosure of de-identified information; prohibited uses of health information; compliance with chapter 66A; violations

c. 12C, § 12. Collection, storage and maintenance of data collected under Secs. 8 to 10A; payer and provider claims database; access to data; reasons for access; disclosure of identifiable information for research; disclosure of de-identified information; prohibited uses of health information; compliance with chapter 66A; violations Section 12. (a) The center shall be the sole repository for health care data collected under sections 8 to 10A, inclusive. The center shall collect, store and maintain such data in a payer and provider claims database. The center shall acquire, retain and oversee all information technology, infrastructure, hardware, components, servers and employees necessary to carry out this section. All other agencies, authorities, councils, boards and commissions of the commonwealth seeking health care data that is collected under this section shall, whenever feasible, utilize the data before requesting data directly from health care providers and payers. In order to ensure patient data confidentiality, the center shall not contract or transfer the operation of the database or its functions to a third-party entity, nonprofit organization or governmental entity; provided, however, that the center may enter into interagency services agreements for transfer and use of the data. The center shall, to the extent feasible, make data in the payer and provider claims database available to payers and providers in real-time; provided, however, that all data-sharing complies with applicable state and federal privacy laws The center may charge a fee for access to the data. To the maximum extent feasible, the center shall also make data available to health care consumers, on a timely basis and in an easily readable and understandable format, data on health care services they have personally received. [ Subsection (b) effective until November 5, 2025. For text effective November 5, 2025, see below.] (b) The center shall permit providers, provider organizations, public and private health care payers, government agencies and authorities and researchers access to de-identified data collected by the center for the purposes of lowering total medical expenses, coordinating care, benchmarking, quality analysis and other research, administrative or planning purposes, provided, however, that the data shall not include information that would allow the identification of the health information of an individual patient, except to the extent necessary for a government agency or authority to accomplish the public purposes for which access was given. The center shall also permit providers, provider organizations, and public and private health care payers access to data with patient identifiers solely for the purpose of carrying out treatment and coordinating care among providers. Access to data authorized under this section shall be deemed to comply with the requirements of chapter 66A. The center shall charge user fees sufficient to defray the center's cost of providing such access to non-governmental entities. [ Subsection (b) as amended by 2025, 16, Sec. 3 effective November 5, 2025. For text effective until August 5, 2025, see above.] (b) The center shall permit a government agency or authority to access identifiable health information of an individual only to the extent necessary for such government agency or authority to accomplish the public purposes for which access was given, subject to subsection (f). Except as required by federal law, the center shall not provide access to any data, including de-identified data or any other data that would allow the identification of a patient or provider in response to an out-of-state or federal inquiry or investigation into services constituting legally-protected health care activity, as defined in section 11I1/2 of chapter 12. [ Subsections (c) to (h) added by 2025, 16, Sec. 3 effective November 5, 2025.] (c) The center shall permit providers, provider organizations and public and private health care payers access to identifiable health information of an individual solely for the purposes of carrying out treatment, payment or health care operations. (d) The center may disclose identifiable health information of an individual for research, regardless of the source of funding of the research; provided, however, that: (i) the center obtains documentation of authorization from the individual patient; or (ii) waiver of individual authorization has been approved by either an institutional review board or privacy board. (e) The center may disclose de-identified health information of an individual for the purposes of lowering total medical expenses, coordinating care, benchmarking, quality analysis, research, administrative or planning purposes, informing consumer health care decisions or other purposes that aim to improve healthcare or public health outcomes for commonwealth residents that are consistent with the goals of this chapter. A recipient of de-identified health information of an individual shall not use such information or data to identify any person for any purpose. (f) A recipient of de-identified or identifiable health information of an individual patient shall not use such information to: (i) conduct a criminal, civil or administrative investigation into any individual patient; or (ii) impose criminal, civil or administrative liability on any individual patient. (g) Access to identifiable health information of an individual, including personal data as defined in section 1 of chapter 66A, authorized under this section shall be deemed to comply with the requirements of chapter 66A. (h) The center may charge an application fee or other fees sufficient to process and provide such access to non-governmental entities. (i) A violation of subsection (f), or any rule or regulation issued thereunder, shall constitute a violation of chapter 93A.

M.G.L. c. 12C, § 13 Uniform provider licensure reporting system

c. 12C, § 13. Uniform provider licensure reporting system Section 13. The center shall coordinate with the public health council and the boards of registration for health care providers to develop a uniform and interoperable electronic system of public reporting for providers as a condition of licensure. The uniform provider licensure reporting system shall include information designed for health resource planning and for analysis of market share by provider organization by primary service areas and dispersed service areas, including, but not limited to, reporting for each licensed provider its principal business locations; the categories of services provided; the provider organization with which the provider is affiliated for contracting purposes, or by which the provider is employed, if any; whether and to what extent the provider is practicing on license; and other factors as the center considers appropriate. The center may centralize the uniform provider licensure reporting system or create a central portal for public access to the uniform provider licensure information. The uniform provider licensure reporting system shall be accessible to other state agencies and authorities including, but not limited to, the commission, the executive office of health and human services, the department of public health and the office of Medicaid.

M.G.L. c. 12C, § 14 Standard quality measure set

c. 12C, § 14. Standard quality measure set Section 14. (a)(1) The center, in consultation with the statewide advisory committee established pursuant to subsection (c), shall, not later than March 1 in each even-numbered year, establish a standard set of measures of health care provider quality and health system performance, hereinafter referred to as the ''standard quality measure set'', for use in: (i) contracts between payers, including the commonwealth and carriers, and health care providers, provider organizations and accountable care organizations, which incorporate quality measures into payment terms, including the designation of a set of core measures and a set of non-core measures; (ii) assigning tiers to health care providers in the design of any health plan; (iii) consumer transparency websites and other methods of providing consumer information; and (iv) monitoring systemwide performance. (2) The standard quality measure set shall designate: (i) core measures that shall be used in contracts that incorporate quality measures into payment terms between payers, including the commonwealth and carriers, and health care providers, including provider organizations and accountable care organizations, and shall meet the core criteria set by the statewide advisory committee pursuant to paragraph (3) of subsection (c); and (ii) a menu of non-core measures that may be used in such contracts. The standard quality measure set shall allow for innovation and the development of outcome measures for quality and safety. If the standard quality measure set established by the center differs from the recommendations of the statewide advisory committee, the center shall issue a written report detailing each area of disagreement and the rationale for the center's decision. (b) The center shall develop uniform reporting requirements for the standard quality measure set for each health care provider facility, medical group or provider group in the commonwealth. (c)(1) The center shall convene a statewide advisory committee which shall make recommendations for the standard quality measure set to: (i) ensure consistency in the use of quality and safety measures in contracts between payers, including the commonwealth and carriers, and health care providers in the commonwealth; (ii) ensure consistency in methods for the assignment of tiers to providers in the design of any health plan; (iii) improve quality and safety of care; (iv) improve transparency for consumers and employers; (v) improve health system monitoring and oversight by relevant state agencies; and (vi) reduce administrative burden. (2) The statewide advisory committee shall consist of commissioner of insurance and the executive director of the health policy commission, or their designees, who shall serve as co-chairs, and shall include the following members or their designees: the executive director of the center; the executive director of the Betsy Lehman center for patient safety and medical error reduction; the executive director of the group insurance commission; the secretary of elder affairs; the assistant secretary for MassHealth; the commissioner of public health; the commissioner of mental health; and 11 members to be appointed by the governor, 1 of whom shall be a representative of the Massachusetts Health and Hospital Association, Inc., 1 of whom shall be a representative of the Massachusetts League of Community Health Centers, Inc., 1 of whom shall be a representative the Massachusetts Medical Society, 1 of whom shall be a registered nurse licensed to practice in the commonwealth who practices in a patient care setting, 1 of whom shall be a representative of a labor organization representing health care workers, 1 of whom shall be a behavioral health provider, 1 of whom shall be a long-term supports and services provider, 1 of whom shall be a representative of Blue Cross and Blue Shield of Massachusetts, Inc., 1 of whom shall be a representative of the Massachusetts Association of Health Plans, Inc., 1 of whom shall be a representative of a specialty pediatric provider and 1 of whom shall be a representative for consumers. Members appointed to the statewide advisory committee shall have experience with and expertise in health care quality measurement. (3) The statewide advisory committee shall meet quarterly to develop recommendations for the core measure and non-core measures to be adopted in the standard quality measure set for use in: (i) contracts between payers, including the commonwealth and carriers, and health care providers, provider organizations and accountable care organizations, including the designation of a set of core measures and a set of non-core measures; (ii) assigning tiers to health care providers in the design of any health plan; (iii) consumer transparency websites and other methods of providing consumer information; and (iv) monitoring systemwide performance. (4) In developing its recommendations for the standard quality measure set, the statewide advisory committee shall incorporate recognized quality and safety measures including, but not limited to, measures used by the Centers for Medicare and Medicaid Services, the group insurance commission, carriers and providers and provider organizations in the commonwealth and other states, as well as other valid measures of health care provider performance and outcomes, including patient-reported outcomes and functional status, patient experience, health disparities and population health. The statewide advisory committee shall consider measures applicable to primary care providers, specialists, hospitals, provider organizations, accountable care organizations, oral health providers and other types of providers and measures applicable to different patient populations. (5) The statewide advisory committee shall, not later than January 1 in each even-numbered year, submit to the center its recommendations on the core measures and non-core measures to be adopted, changed or updated by the center in the standard quality measure set, along with a report in support of its recommendations.

M.G.L. c. 12C, § 15 Betsy Lehman center for patient safety and medical error reduction; board; education and research program; transmission of information

c. 12C, § 15. Betsy Lehman center for patient safety and medical error reduction; board; education and research program; transmission of information Section 15. (a) For the purposes of this section, the following words shall, unless the context clearly requires otherwise, have the following meanings: ''Adverse event'', harm to a patient resulting from a medical intervention and not to the underlying condition of the patient. ''Agency'', any agency of the executive branch of the commonwealth, including, but not limited to, any constitutional or other office, executive office, department, division, bureau, board, commission or committee thereof, or any authority created by the general court to serve a public purpose, having either statewide or local jurisdiction. ''Board'', the patient safety and medical errors reduction board. ''Healthcare-associated infection'', an infection that a patient acquires during the course of receiving treatment for other conditions within a health care setting. ''Lehman center'', the Betsy Lehman center for patient safety and medical error reduction. ''Incident'', an incident which, if left undetected or uncorrected, might have resulted in an adverse event. ''Medical error'', the failure of medical management of a planned action to be completed as intended or the use of a wrong plan to achieve an outcome. ''Patient safety'', freedom from accidental injury. ''Patient safety information'', data and information related to patient safety, including adverse events, incidents, medical errors or health care-associated infections, that is collected or maintained by agencies. (b) There shall be established within the center the Betsy Lehman center for patient safety and medical error reduction. The purpose of the Lehman center shall be to serve as a clearinghouse for the development, evaluation and dissemination, including, but not limited to, the sponsorship of training and education programs, of best practices for patient safety and medical error reduction. The Lehman center shall: (1) coordinate the efforts of state agencies engaged in the regulation, contracting or delivery of health care and those individuals or institutions licensed by the commonwealth to provide health care to meet their responsibilities for patient safety and medical error reduction; (2) assist all such entities to work as part of a total system of patient safety; and (3) develop appropriate mechanisms for consumers to be included in a statewide program for improving patient safety. The Lehman center shall coordinate state participation in any appropriate state or federal reports or data collection efforts relative to patient safety and medical error reduction. The Lehman center shall analyze available data, research and reports for information that would improve education and training programs that promote patient safety. (c) Within the Lehman center, there shall be established a patient safety and medical errors reduction board. The board shall consist of the secretary of health and human services, the executive director of the center, the director of consumer affairs and business regulations and the attorney general. The board shall appoint, in consultation with the advisory committee, the director of the Lehman center by a unanimous vote and the director shall, under the general supervision of the board, have general oversight of the operation of the Lehman center. The director may appoint or retain and remove expert, clerical or other assistants as the work of the Lehman center may require. The coalition for the prevention of medical errors shall serve as the advisory committee to the board. The advisory committee shall, at the request of the director, provide advice and counsel as it considers appropriate including, but not limited to, serving as a resource for studies and projects undertaken or sponsored by the Lehman center. The advisory committee may also review and comment on regulations and standards proposed or promulgated by the Lehman center, but the review and comment shall be advisory in nature and shall not be considered binding on the Lehman center. (d) The Lehman center shall develop and administer a patient safety and medical error reduction education and research program to assist health care professionals, health care facilities and agencies and the general public regarding issues related to the causes and consequences of medical error and practices and procedures to promote the highest standard for patient safety in the commonwealth. The Lehman center shall annually report to the governor and the general court relative to the feasibility of developing standards for patient safety and medical error reduction programs for any state department, agency, commission or board to reduce medical errors, and the statutory responsibilities of the commonwealth, for the protection of patients and consumers of health care together with recommendations to improve coordination and effectiveness of the programs and activities. (e) The Lehman center shall (1) identify and disseminate information about evidence-based best practices to reduce medical errors and enhance patient safety; (2) develop a process for determining which evidence-based best practices should be considered for adoption; (3) serve as a central clearinghouse for the collection and analysis of existing information on the causes of medical errors and strategies for prevention; and (4) increase awareness of error prevention strategies through public and professional education. The information collected by the Lehman center or reported to the Lehman center shall not be a public record as defined in section 7 of chapter 4, shall be confidential and shall not be subject to subpoena or discovery or introduced into evidence in any judicial or administrative proceeding, except as otherwise specifically provided by law. (f) Notwithstanding any general or special law to the contrary, the Lehman center and any agency, provider organization, department, division, commission, board, authority or other public or quasi-public entity in the commonwealth that collects or maintains patient safety information may transmit such information, including personal data as defined in section 1 of chapter 66A, and shall transmit such information to the Lehman center upon request from the Lehman center; provided, however, that transmission of such information shall be governed by an agreement, which may be an interagency service agreement, between the party transmitting the information and the Lehman center; provided further, that such agreement shall provide for any safeguards necessary to protect the privacy and security of the information; and provided further, that the transmission of such information shall be consistent with federal law. (g) The Lehman center may adopt rules and regulations necessary to carry out the purpose of this section. The Lehman center may contract with any federal, state or municipal entity or other public institution or with any private individual, partnership, firm, corporation, association or other entity to manage its affairs or carry out the purpose of this section. (h) The Lehman center shall report annually to the joint committee on health care financing regarding the progress made in improving patient safety and medical error reduction. The Lehman center shall seek federal and foundation support to supplement state resources to carry out the Lehman center's patient safety and medical error reduction goals.

M.G.L. c. 12C, § 16 Annual report based on the information submitted under Secs. 8 to 10A and 15, and Sec. 13 of chapter 6D; hearing

c. 12C, § 16. Annual report based on the information submitted under Secs. 8 to 10A and 15, and Sec. 13 of chapter 6D; hearing Section 16. (a) The center shall publish an annual report based on the information submitted under: (i) sections 8 to 10A, inclusive, concerning health care provider, provider organization, private and public health care payer, pharmaceutical manufacturing company and pharmacy benefit manager costs and cost and price trends; (ii) section 13 of chapter 6D relative to cost and market impact reviews; and (iii) section 15 relative to quality data. The center shall compare the costs and cost trends with the health care cost growth benchmark established by the health policy commission under section 9 of chapter 6D, analyzed by regions of the commonwealth, and shall detail: (1) baseline information about cost, price, quality, utilization and market power in the commonwealth's health care system; (2) cost growth trends for care provided within and outside of accountable care organizations and patient-centered medical homes; (3) cost growth trends by provider sector, including but not limited to, hospitals, hospital systems, non-acute providers, pharmaceuticals, medical devices and durable medical equipment; provided, however, that any detailed cost growth trend in the pharmaceutical sector shall consider the effect of drug rebates and other price concessions in the aggregate without disclosure of any product or manufacturer-specific rebate or price concession information, and without limiting or otherwise affecting the confidential or proprietary nature of any rebate or price concession agreement; (4) factors that contribute to cost growth within the commonwealth's health care system and to the relationship between provider costs and payer premium rates; (5) the proportion of health care expenditures reimbursed under fee-for-service and alternative payment methodologies; (6) the impact of health care payment and delivery reform efforts on health care costs including, but not limited to, the development of limited and tiered networks, increased price transparency, increased utilization of electronic medical records and other health technology; (7) the impact of any assessments including, but not limited to, the health system benefit surcharge collected under section 68 of chapter 118E, on health insurance premiums; (8) trends in utilization of unnecessary or duplicative services, with particular emphasis on imaging and other high-cost services; (9) the prevalence and trends in adoption of alternative payment methodologies and impact of alternative payment methodologies on overall health care spending, insurance premiums and provider rates; (10) the development and status of provider organizations in the commonwealth including, but not limited to, acquisitions, mergers, consolidations and any evidence of excess consolidation or anti-competitive behavior by provider organizations; (11) the impact of health care payment and delivery reform on the quality of care delivered in the commonwealth; and (12) costs, cost trends, price, quality, utilization and patient outcomes related to behavioral health service subcategories described in section 21A. As part of its annual report, the center shall report on price variation between health care providers, by payer and provider type. The center's report shall include: (1) baseline information about price variation between health care providers by payer including, but not limited to, identifying providers or provider organizations that are paid more than 10 per cent above or more than 10 per cent below the average relative price and identifying payers which have entered into alternative payment contracts that vary by more than 10 per cent; (2) the annual change in price variation, by payer, among the payer's participating providers; (3) factors that contribute to price variation in the commonwealth's health care system; (4) the impact of price variations on disproportionate share hospitals and other safety net providers; and (5) the impact of health reform efforts on price variation including, but not limited to, the impact of increased price transparency, increased prevalence of alternative payment contracts and increased prevalence of accountable care organizations and patient centered medical homes. The center shall publish and provide the report to health policy commission at least 30 days before any hearing required under section 8 of chapter 6D. The center may contract with an outside organization with expertise in issues related to the topics of the hearings to produce this report. (b) The center shall participate in the annual hearing required by section 8 of chapter 6D and advise and assist the health policy commission in conducting such hearing including, but not limited to, identifying witnesses and examining and cross-examining providers, provider organizations and payers regarding any issues material to the subject of such hearings. (c) The center shall provide technical assistance to the health policy commission in compiling the annual report required by section 8 of chapter 6D including, but not limited to, providing access to any data collected by the center under section 8, 9 and 10 and providing analysis regarding spending trends and factors underlying the spending trends.

M.G.L. c. 12C, § 17 Attorney general review and analysis of information submitted pursuant to Secs. 8, 9 and 10 and under Sec. 8 of chapter 6D; authority to compel production of documents, answers to interrogatories and testimony; confidentiality

c. 12C, § 17. Attorney general review and analysis of information submitted pursuant to Secs. 8, 9 and 10 and under Sec. 8 of chapter 6D; authority to compel production of documents, answers to interrogatories and testimony; confidentiality Section 17. The attorney general may review and analyze any information submitted to the center by a provider, provider organization, significant equity investor, health care real estate investment trust, management services organization or payer pursuant to sections 8, 9 and 10 and to the health policy commission under section 8 of chapter 6D. The attorney general may require that such entities produce documents, answer interrogatories and provide testimony under oath related to health care costs and cost trends, factors that contribute to cost growth within the commonwealth's health care system and the relationship between provider costs and payer premium rates. The attorney general shall keep confidential all nonpublic information and documents obtained under this section and shall not disclose the information or documents to any person without the consent of the entity that produced the information or documents; provided, however that the attorney general may disclose such information or documents during: (i) the annual hearing conducted under section 8 of chapter 6D; (ii) a rate hearing before the division of insurance; or (iii) in a case brought by the attorney general, if the attorney general believes that such disclosure will promote the health care cost containment goals of the commonwealth and that the disclosure would be in the public interest after taking into account any privacy, trade secret or anti-competitive considerations. The confidential information and documents shall not be public records and shall be exempt from disclosure under clause Twenty-sixth of section 7 of chapter 4 and section 10 of chapter 66.

M.G.L. c. 12C, § 18 Analysis of data received under Secs. 6, 9 and 10 to identify excessive increases in health status adjusted total medical expense

c. 12C, § 18. Analysis of data received under Secs. 6, 9 and 10 to identify excessive increases in health status adjusted total medical expense Section 18. The center shall perform ongoing analysis of data it receives under sections 6, 9 and 10 to identify any payers, providers or provider organizations whose increase in health status adjusted total medical expense is considered excessive and who threaten the ability of the state to meet the health care cost growth benchmark established by the health care finance and policy commission under section 10 of chapter 6D. The center shall confidentially provide a list of the payers, providers and provider organizations to the health policy commission such that the authority may pursue further action under section 10 of chapter 6D.

M.G.L. c. 12C, § 19 Review and comment upon capital expenditure projects requiring determination of need under Sec. 25C of chapter 111

c. 12C, § 19. Review and comment upon capital expenditure projects requiring determination of need under Sec. 25C of chapter 111 Section 19. The center shall review and comment upon all capital expenditure projects requiring a determination of need under section 25C of chapter 111, including, but not limited to, the availability and accessibility of services similar to those provided, or proposed to be provided, through the provider organization within its primary service areas and dispersed service areas; the provider organization's impact on competing options for the delivery of health care services within its primary service areas and dispersed service areas; less costly or more effective alternative financing methods for the projects; the immediate and long-term financial feasibility of the projects; the probable impact of the project on costs of and charges for services; and the availability of funds for capital and operating needs. The center may transmit to the department of public health its written recommendations on each project. The center shall appear and comment on any application for a determination of need where a public hearing is required under said section 25C of said chapter 111.

M.G.L. c. 12C, § 20 Consumer health information website

c. 12C, § 20. Consumer health information website Section 20. (a) The center, in consultation with commission, the executive office of health and human services, the department of public health and such other agencies or authorities as it deems appropriate, shall maintain a consumer health information website. The website shall contain information comparing the quality, price and cost of health care services. The website shall also provide information about provider and payer achievement of cost benchmarks and growth goals. The website may also contain general health care information as the center considers appropriate. The website shall be designed to assist consumers in making informed decisions regarding their medical care and informed choices among health care providers. Information shall be presented in a format that is understandable to the average consumer. The center shall publicize the availability of its website. (b) The website shall provide updated information on a regular basis, at least annually, and additional comparative quality, price and cost information shall be published as determined by the center. To the extent possible, the website shall include: (1) comparative price and cost information for the most common referral or prescribed services, as determined by the center, categorized by payer and listed by facility, provider, and provider organization or other groupings, as determined by the center; (2) comparative quality information, as determined by the center, available by facility, provider, provider organization or any other provider grouping, as determined by the center, for each such service or category of service for which comparative price and cost information is provided; (3) general information related to each service or category of service for which comparative information is provided; (4) comparative quality information, as determined by the center, available by facility, provider, provider organization or other groupings, as determined by the center, that is not service-specific, including information related to patient safety and satisfaction; (5) data concerning healthcare-associated infections and serious reportable events reported under section 51H of chapter 111; (6) definitions of common health insurance and medical terms, including, but not limited to, those determined under sections 2715(g) (2) and (3) of the Public Health Service Act, so that consumers may compare health coverage and understand the terms of their coverage; (7) a list of health care provider types, including but not limited to primary care physicians, nurse practitioners and physician assistants, and what types of services they are authorized to perform in the commonwealth under applicable state and federal scope of practice laws; (8) factors consumers should consider when choosing an insurance product or provider group, including, but not limited to, provider network, premium, cost-sharing, covered services, and tiering; (9) patient decision aids, which are interactive, written or audio-visual tools that provide a balanced presentation of the condition and treatment or screening options, benefits and harms, with attention to the patient's preferences and values, and which may facilitate conversations between patients and their health care providers about preference-sensitive conditions or diseases such as chronic back pain, early stage of breast and prostate cancers, hip osteoarthritis, and cataracts; provided, however, that decision aids shall be made available on, but not be limited to, long-term care and supports and palliative care; (10) a list of provider services that are physically and programmatically accessible for people with disabilities; and (11) descriptions of standard quality measures, as determined by the center. (c) The center shall develop and adopt, on an annual basis, a reporting plan specifying the quality and cost measures to be included on the consumer health information website and the security measures used to maintain confidentiality and preserve the integrity of the data. In developing the reporting plan, the center, to the extent possible, shall collaborate with other organizations or state or federal agencies that develop, collect and publicly report health care quality and cost measures and the center shall give priority to those measures that are already available in the public domain. As part of the reporting plan, the center shall determine for each service the comparative information to be included on the consumer health information website. (d) In designing and maintaining the website, the center may conduct research regarding ease of use of the website by health care consumers, consult with organizations that represent health care consumers, and conduct focus groups that represent a cross section of health care consumers in the commonwealth, including low income consumers and consumers with limited literacy. The website shall comply with the Americans with Disabilities Act.

M.G.L. c. 12C, § 21 Continuing program of investigation and study of the uninsured and underinsured

c. 12C, § 21. Continuing program of investigation and study of the uninsured and underinsured Section 21. The center shall establish a continuing program of investigation and study of the uninsured and underinsured in the commonwealth, including the health insurance needs of the residents of the geographically isolated or rural areas of the commonwealth. Said continuing investigation and study shall examine the overall impact of programs developed by the center and the division of medical assistance on the uninsured, the underinsured and the role of employers in assisting their employees in affording health insurance.

M.G.L. c. 12C, § 21A Continuing program of investigation and study of mental health, chronic pain and substance use disorders; development of criteria for behavioral health services

c. 12C, § 21A. Continuing program of investigation and study of mental health, chronic pain and substance use disorders; development of criteria for behavioral health services Section 21A. The center shall establish a continuing program of investigation and study of mental health, chronic pain and substance use disorders in the commonwealth. The investigation and study shall also include developing and defining criteria for health care services to be categorized as behavioral health services, with subcategories including, but not limited to: (i) mental health; (ii) substance use disorder; (iii) outpatient; (iv) inpatient; (v) services for children; (vi) services for adults; and (vii) provider type.

M.G.L. c. 12C, § 22 Conditions for reimbursement or payment for treatment of injured workers under chapter 152 or from governmental unit; penalty for noncompliance

c. 12C, § 22. Conditions for reimbursement or payment for treatment of injured workers under chapter 152 or from governmental unit; penalty for noncompliance Section 22. (a) Any provider of health care services that receives reimbursement or payment for treatment of injured workers under chapter 152 and any provider of health care services other than an acute or non-acute hospital that receives reimbursement or payment from any governmental unit for general health supplies, care and rehabilitative services and accommodations, shall, as a condition of such reimbursement or payment: (1) permit the executive director, or the executive director's designated representative and the attorney general or a designee, to examine such books and accounts as may reasonably be required for the center to perform its duties; (2) file with the executive director from time to time or on request, such data, statistics, schedules or other information as the center may reasonably require, including outcome data and such information regarding the costs, if any, of the provider for research in the basic biomedical or health delivery areas or for the training of health care personnel which are included in the provider's charges to the public for health care services, supplies and accommodations; and (3) accept reimbursement or payment at the rates established by the secretary of health and human services or a governmental unit designated by the executive office, subject to a right of appeal under section 13E of chapter 118E, as discharging in full any and all obligations of an eligible person and the governmental unit to pay, reimburse or compensate the provider of health care services in any way for general health supplies, care and rehabilitative services or accommodations provided. (b) Any provider of health care services that knowingly fails to file with the center data, statistics, schedules or other information required under this section or by any regulation promulgated by the center or knowingly falsifies the same shall be punished by a fine of not less than $100 nor more than $500. (c) If, upon application by the center or its designated representative, the superior court upon summary hearing determines that a provider of health care services has, without justifiable cause, refused to permit any examination or to furnish information, as required in this section; it shall issue an order directing all governmental units to withhold payment for general health supplies, care and rehabilitative services and accommodations to such provider of services until further order of the court. (d) In addition, the appropriate licensing authority may suspend or revoke, after an adjudicatory proceeding under chapter 30A, the license of any provider of health care services that knowingly fails to file with the center data, statistics, schedules or other information required by this section or by any regulation of the center or that knowingly falsifies the same.

M.G.L. c. 12C, § 24 Report on the provision of continuous skilled nursing care

c. 12C, § 24. Report on the provision of continuous skilled nursing care Section 24. The center, in conjunction with MassHealth, shall prepare a biennial report on the provision of continuous skilled nursing care as defined in 101 CMR 361 and 130 CMR 403.402. The report shall include, but not be limited to: (i) the number of pediatric patients and the number of adult patients requiring continuous skilled nursing care; (ii) the average and median number of continuous skilled nursing hours authorized by MassHealth per day, week, month and year for pediatric patients and for adult patients; (iii) the average and median number of authorized continuous skilled nursing hours actually delivered per day, week, month and year for pediatric patients and for adult patients; (iv) the total number of continuous skilled nursing hours authorized and actually delivered by MassHealth per month and year for pediatric patients and for adult patients; (v) the number of nurses providing continuous skilled nursing care to more than 1 patient at a time and, for the patients cared for by those nurses, the aggregate proportion of authorized continuous skilled nursing hours to utilized continuous skilled nursing hours; (vi) the number of nurses who contract with MassHealth to provide continuous skilled nursing care, the number of nurses who provide continuous skilled nursing care through a home health agency that contracts with MassHealth and whether the total number of nurses providing such care is sufficient to fill all authorized continuous skilled nursing hours; (vii) a description of the training, experience and education levels of the nurses who contract with MassHealth to provide continuous skilled nursing care; and (viii) an evaluation of the adequacy of the reimbursement rates for continuous skilled nursing care as established in 101 CMR 350.04(2) and a comparison of those rates against: (A) the rate paid to nurses who contract directly with MassHealth to provide continuous skilled nursing care; (B) the portion of the reimbursement rate paid directly as wages to nurses providing continuous skilled nursing care through a home health agency that contracts with MassHealth; and (C) the median wage rate paid to all nurses in the commonwealth. Not later than January 1 of each even-numbered year, the report shall be filed with the secretary of health and human services, the clerks of the senate and the house of representatives, the joint committee on health care financing, the joint committee on public health and the senate and house committees on ways and means. The center shall make the report publicly available on its website.

Source: Massachusetts General Court (malegislature.gov)URL: https://malegislature.gov/Laws/GeneralLaws/PartI/TitleII/Chapter12CFetched: 10/20/2026