Group Insurance Commission
Administrative Bulletin 14-02:Guidance Regarding Municipal Requests for Utilization Data
April 13, 2010, Revised: November 29, 2010; Revised: February 4, 2014_______________________________________________________________
The purpose of this bulletin is to clarify and outline the parameters under which the Group Insurance Commission (GIC) will respond to written requests for enrollment and utilization data, pursuant to 805 CMR 8.06, from political subdivisions, as defined in M.G.L. c.32B s.2, that provide health insurance coverage through the GIC to its subscribers by acceptance of the Municipal Partnership Act, M.G.L. c.32B s. 19 and s. 21 and that are considering whether to remain inside the GIC. The parameters clarified and outlined herein also apply to requests for enrollment and utilization data made by Public Employee Committees (PEC) described in M.G.L. c. 32B, §§ 19(a) and 21(b). These data requests are for the sole purpose of determining whether a participating municipal employer and its subscribers in the GIC's health coverage program will continue to participate after their coverage interval of three or six years, as specified in their PEC agreement, expires. Requests for such data shall be made in the preceding or current fiscal year in which a given PEC agreement is open to negotiation, and such requests shall be limited to one request from a political subdivision and one request from a PEC in the preceding or current fiscal year in which a political subdivision is considering withdrawing from GIC coverage.
1) Political subdivisions and PECs requesting utilization data should assess the amount of time they will need to analyze data and conduct negotiations necessary before making a decision about whether to remain in the GIC. Such entities must submit their requests to the GIC at least 60 days before the data are to be provided to them to use in their decision-making process. In the event that a political subdivision and a PEC request data in the same year, the GIC will supply data for the same time period to both entities.
A request from a political subdivision for data must be made in writing and signed by the appropriate legal representative of the public authority, as defined in M.G.L. c.32B, § 2(a). 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. A request for data from a PEC must be made in writing, signed by a majority of representatives of the PEC, or by a weighted majority of representatives by membership in the PEC. The GIC will notify a political subdivision of a data request made by the associated PEC.
2) The GIC will provide three years of the following data to each requesting entity with more than 50 subscribers:
a. A monthly claims report consisting of the following data elements:
i. the subscriber count;
ii. the covered lives count;
iii. the total paid medical claims;
iv. the total paid prescription drug claims.
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:
- the de-identified claimant diagnosis codes;
- the de-identified claimant total paid claims (medical and prescription drug).
3) Entities that have requested these data will be required to designate a single person to handle said data. The GIC will provide the de-identified Protected Health Information to the person identified by the requesting entity as authorized to receive such data as the GIC's Business Associate under the HIPAA Privacy Rule after said person signs the GIC's Business Associate Agreement (BAA), as most recently amended. The designated person must agree not to share these data with other parties, including municipal employees, PEC members and union personnel. The data may be shared with insurance brokers, benefits consultants, and health plans for the limited purpose of securing bids for the procurement of health insurance to the extent allowed by the applicable BAA. The GIC encourages political subdivisions and PECs to designate consultants as persons authorized to receive the data.
Please note: Medicare HMO data may not be available if such data have not been submitted to the GIC’s data vendor by the plan. Communities wanting such data should use the monthly premium as a substitute for actual cost (administrative costs are also not included in the data provided).
This information provided by the Group Insurance Commission.