By the Division of Insurance


Bulletin 2016-07

TO:                  Commercial Health Insurers; Blue Cross Blue Shield of Massachusetts, Inc.; and Health Maintenance Organizations Offering or Renewing Insured Health Products in Massachusetts (collectively, “Carriers”)

FROM:            Daniel R. Judson, Commissioner of Insurance

DATE:            July 6, 2016

RE:                  Membership, Utilization and Claims Reports

                                                                                                                                                           

The Division of Insurance (“Division”) sends this Bulletin regarding membership, utilization and claims reports that Carriers submit on a regular basis to the Division and a process that Carriers are to follow beginning in July 2016 so that the Division may replace certain reports with those generated from the Massachusetts All-Payer Claims Database (“MA APCD”) administered by the Center for Health Information and Analysis (“CHIA”).[1]

Reporting of Information

Carriers are required to submit to the Division certain membership, utilization and claims reports that are based upon statutory and regulatory requirements and are intended to assist the Division in its oversight of Carrier operations and its review of the functioning of health coverage markets.  These reports include, for example, the reports required under M.G.L. c. 176I, §7 and 211 CMR 51.06 for insured preferred provider plans.  Once information reports are forwarded to the Division, staff members develop aggregate information tables that are made available to the public on its website.

Over the years, the Division has established data reporting guidelines, data submission worksheets and administrative processes to be used when collecting, storing and aggregating reports.  The Division is aware that these reports entail the intensive use of Carrier and Division resources to ensure that the reports properly reflect membership, utilization or claims experience in Massachusetts’ market for health coverage.

Development of MA APCD

Carriers have been required to submit membership and claims data to CHIA since 2009, according to regulations and other guidelines established by that agency.  The MA APCD is a central database that is designed to be used by state agencies that need information to support their missions, as well as by researchers and other interested parties when evaluating trends in the delivery of health care. CHIA has established data release guidelines and regulations in order to protect the confidentiality of personal health information.

In the summer of 2012, CHIA released a “Preliminary Release,” the first MA APCD dataset based on private payer data from 2008-2010.  In 2015, CHIA made available MA APCD Release 4.0, which includes dates of service for 2010-2014.  Release 5.0, which will include dates of service for 2015 (with a three month run-out), is scheduled to be released in the summer of 2016.

Reports Generated from the MA APCD

The Division plans to transition during 2016 to a process where it receives membership, utilization and claims reports from the MA APCD.  Because the Division has for many years relied on Carriers to certify that their submitted membership, utilization and claims reports reflect their respective experience, a parallel certification process will be implemented with CHIA in connection with use of the MA APCD-generated reports.

During 2016, CHIA will develop membership, utilization and claims report specifications in consultation with Carriers CHIA will develop and forward MA APCD-generated membership, utilization and claims reports to Carriers and will make those datasets used to create the reports available to individual Carriers upon written request.  Carriers will be expected to designate–an actuary or other appropriate party with sufficient exposure to the Carrier’ membership, utilization or claims experience – to receive and review the reports on at least a quarterly basis to ascertain whether they reasonably reflect the carrier’s experience.  Within 45 days of the Carrier’s receipt of the MA APCD-generated reports, the designated person will be expected to review the reports in relation to the actual experience of the Carrier.

If the designated person finds that the MA APCD-generated reports reasonably reflect the actual experience of the Carrier, the designated person will be expected to sign and submit to CHIA a document certifying to this on at least a quarterly basis.  If the designated person is not able to certify that any MA APCD-generated report reasonably reflects the Carrier’s actual experience, the designated person will notify CHIA and the Division.  The designated person will be responsible for coordinating the Carrier’s efforts to investigate and correct any problems with the Carrier’s MA APCD submissions and review new MA APCD-generated reports based on any new information submitted by the Carrier.

The Division intends to end the requirement that a Carrier submit certain membership, utilization and/or claims reports to the Division beginning in 2017, provided that the Carrier has provided the appropriate certifications to CHIA on at least a quarterly basis.  Any Carrier that is not able to provide the necessary certification to CHIA on at least a quarterly basis will be required to continue to submit statutorily-required membership, utilization and claims reports to the Division until such time that the Carrier is able to demonstrate that it has been able to complete the certifications of the APCD-generated reports on a regular basis.

If you have any questions about this Bulletin, please contact Kevin Beagan, Deputy Commissioner of the Health Care Access Bureau at 617-521-7323 or Kevin.Beagan@state.ma.us


[1] With the passage of Chapter 224 of the Acts of 2012, the agency then known as the Division of Health Care Finance and Policy was restructured and renamed as the Center for Health Information and Analysis.  The responsibility to administer the All Payer Claims Database remained with CHIA.