(1) Municipal Employers shall report all changes to an enrollee's coverage on forms designated by the Commission. Upon notification from the Commission, Municipal Employers shall be required to enter on the Commission's eligibility system (MAGIC system), an enrollee's coverage and/or coverage changes.
(2) The Commission determines the effective date of enrollees' coverage changes including, but not limited to: individual to family, family to individual, and cancellation of coverage and shall notify the Municipal Employer directly via the Premium Deduction Change Notice. The Municipal Employer shall accept this notice and update its records accordingly.
(3) Municipal Employers shall reconcile their entire insured membership on a monthly basis via the Statement of Verification that is included with the monthly bill and roster. Municipal Employers shall report any discrepancies to the Commission at a time determined by the Commission. Late notification of discrepancies to the Commission may result in a delay in the effective date of insurance coverage changes.
(4) Any Municipal Employer that transfers its insureds to the Commission with more than one enrollee percentage contribution towards a particular individual, family or Medicare health plan premium shall provide the Commission with enrollment data by enrollee percentage contribution for said health plan(s). Reporting shall be monthly, or less frequently as required by the Commission, on a form that will be provided by the Commission.
(5) A participating Municipal Employer or its Public Employee Committee may request data for the sole purpose of determining whether it will continue to participate after three years, as specified in its executed Public Employee Committee agreement or order from the three person arbitration panel. Requests for such data shall be made in the preceding or current fiscal year in which a given agreement is open to negotiation, and such requests shall be limited to one request in the preceding or current fiscal year in which a political subdivision is considering withdrawing from coverage.
(a) Entities requesting utilization data should assess the amount of time they will need to analyze data and conduct negotiations before making a decision about whether to remain in the Commission. Such entities must submit their requests to the Commission at least 45 days before the data are to be provided to them to use in their decision-making process. In a City, the request must be signed by the City Manager or the Mayor, in a Town by the Chairman of the Board of Selectmen, and in a regional school district, by the Chairman of the Regional School District Committee. For a Public Employee Committee, the request must be signed by a majority of the representatives of the Public Employee Committee, or by a weighted majority of representatives by membership in the Public Employee Committee. The Commission will notify the relevant Municipal Employer of a data request from a Public Employee Committee.
(b) The Commission will provide the following data to each requesting entity with more than 50 subscribers:
(i) A monthly claims report consisting of the following data elements:
a. the subscriber count;
b. the covered lives count;
c. the total paid medical claims;
d. the total paid prescription drug claims.
(ii) A yearly large loss report, i.e., for claimants who have incurred $25,000 or more paid claims in a given year consisting of the following elements:
a. the de-identified claimant ICD-9 or ICD-10 codes (diagnoses);
b. the de-identified claimant total paid claims (medical and prescription drug).
The Commission will provide Protected Health Information to requesting entities as the Commission's Business Associates subject to the HIPAA Privacy Rule after each signs the Commission's Business Associate Agreement (BAA). In the event that a Municipal Employer or a Public Employee Committee both request data in the same year, the Commission will supply data for the same time period to both entities.
Municipal Employers and Public Employee Committees that have requested these data will be required to designate a single person to handle these data, and such persons will be required to sign a BAA in which they agree not to share these data with other parties. Before receiving these data, the requesting entity agree to execute a BAA with the Commission in which they agree that only their single designated person shall handle these data, and that these data shall not be shared with anyone other than insurance brokers, benefits consultants, and health plans for the limited purpose of securing bids for the procurement of health insurance.
Requesting entities wanting Medicare HMO data or fully insured retiree dental coverage data should use the monthly premium as a substitute for actual cost. Administrative costs are not included in the data provided.
(6) On or before January 15, 2013 or any later year, at the request of a Municipal Employer, the Commission will make available to the Municipal Employer a list of that Municipal Employer’s current members. A Municipal Employer must make any such request by November 15th of the prior year. The purpose of this list is to assist the Municipal Employer in meeting its obligations under M.G.L. c. 32B, § 26.
This information provided by the Group Insurance Commission .