As used in 105 CMR 100.000, the following terms have the following meanings unless otherwise interpreted by the Department:

Addition means:

1. (1) The initial provision of a DoN-required Service or procedure, or acquisition of medical equipment defined as DoN-required Equipment; or

   (MA REG. # 1381, Dated 12-28-18)

2. (2) The initial provision of any services that may be provided by a Health Care Facility, including, but not limited to, a change from a single specialty to a multi-specialty Freestanding Ambulatory Surgery Center.

Affiliate. Any relationship between two organizations that reflects, directly or indirectly, a partial or complete controlling interest or partial or complete common control.

Ambulatory Surgery. Health care services restricted to those defined by the Department as surgical services, not requiring overnight stay, typically provided to ambulatory patients on an elective, urgent, or emergency basis, wherever provided.

Applicant. The Provider Organization that files the Application for Determination of Need with the Department for, or on behalf of, the Entity seeking a Notice of Determination of Need for a Proposed Project pursuant to 105 CMR 100.000. In instances where there is no Provider Organization, Applicant shall mean the Entity which files the Application for Determination of Need with the Department for itself or, on behalf of, an Affiliate seeking a Notice of Determination of Need for a Proposed Project pursuant to 105 CMR 100.000.

Application. A formal written request for a Determination of Need, submitted to the Department pursuant to 105 CMR 100.405.

Attorney General or AGO. The Massachusetts Attorney General or his or her designee. For the purposes of 105 CMR 100.000, the Attorney General may intervene in any hearing regarding an Application for Determination of Need, whether or not the Attorney General requested the hearing, by providing written notification of such intervention to the Department.

Bed Capacity. The capacity of a Health Care Facility to accommodate a bed and the necessary physical plant requirements, in accordance with all applicable standards, imposed as a condition of operation pursuant to all federal and state laws and regulations.

Capital Expenditure means:

1. (1) Any expenditure, or obligation to make an expenditure, past, present or future, which, under generally accepted accounting principles, is not properly chargeable as a cost of operation and maintenance, and which includes any fee(s) for architectural, engineering, legal, accounting, or any other professional services, any interest charges, and any other financing cost capitalized throughout the Construction period of the project, and any Site acquisition cost(s); or

2. (2) Any expenditure or obligation to make an expenditure, past, present, or future, for obtaining by lease, or comparable arrangement, capital equipment, or a building or part thereof; provided, that in both cases, such expenditure or obligation is incurred, or will be incurred, as an incident to Construction as defined in 105 CMR 100.100. Every calculation of a Capital Expenditure must take into account all expenditures related to a Proposed Project. All calculations shall be based on costs as of the Application Filing Date, assuming Construction commenced on that date, with no inclusion of estimates regarding inflation. Calculations shall be subject, but are not limited, to the following parameters:

   1. (a) In calculating a Capital Expenditure, Applicants shall account for all expected future expenditures in connection with a Proposed Project, as well as any past or present expenditures necessary for a Proposed Project's completion including, but not limited to: the purchase price of an earlier acquired Site; expenses related to completion of feasibility or other planning studies used in developing a project or preparing an Application; expenses incurred in seeking grants, loans, or other financing; legal or consultant fees; and, any other such expenditures which can be reasonably attributed to the completion of a Proposed Project.
   2. (b) Where Construction is to be undertaken on leased property, or where leased equipment is to be installed, the fair market value of such property or equipment, as appropriate and in conformance with the terms of M.G.L. c. 111, § 25B, shall be used in calculating the proposed Capital Expenditure attributed to such property or equipment. See 105 CMR 100.100: Substantial Capital Expenditure.

Center for Health Information and Analysis or CHIA. The Government Agency established pursuant to M.G.L. c. 12C.

Certified ACO. An Entity which is certified by the HPC as an accountable care organization pursuant to M.G.L. c. 6D, § 15 and which meets the HPC's Final Accountable Care Organization (ACO) Certification Standards.

Clinic. An Entity licensed by the Department pursuant to 105 CMR 140.000: Licensure of Clinics.

Commissioner. The Commissioner of Public Health or his or her designee.

Conditions. All terms and Conditions, both Standard and Other, included in a Notice of Determination of Need issued by the Department.

Conservation Project. Construction that consists solely of a project(s) that would Sustain or Restore a Health Care Facility or service for its designated purpose, and to its original functionality, without Modernization, Addition, or Expansion. For the purposes of Conservation Project, the following words shall mean:

1. (1) Sustain. The maintenance and repair activities necessary to keep a Health Care Facility or service in good working order. It includes regularly scheduled adjustments and inspections, preventive maintenance tasks, and emergency response and service calls for minor repairs. It also includes major repairs or replacement of facility components that are expected to occur periodically throughout the life cycle of said Health Care Facility or service. This work includes, but is not limited to, regular roof replacement, refinishing of wall surfaces, repairing and replacement of heating and cooling systems, replacing tile and carpeting, and similar types of work. It does not include environmental compliance costs, facility leases, or other tasks associated with facilities operations, such as custodial services, grounds services, waste disposal, and the provision of central utilities.
2. (2) Restore. To return a Health Care Facility or service to such a condition that it may be used for its designated purpose or to, but not beyond, restore the Health Care Facility or service's original functionality. This may include coming into compliance with all applicable federal, state, and local licensure, safety, and building requirements including nationally recognized Health Care facility construction guidelines and accreditation standards, such as those issued by the Facility Guidelines Institute, the American Institute of Architects, or the Joint Commission.
3. (3) Modernization. The alteration, Addition, Expansion, or replacement of all, or part, of a Health Care Facility or service to accommodate new or increased functionality, or to replace components of a Health Care Facility or service beyond that necessary to Sustain or Restore said facility or service.

Construction. The Construction of a new Health Care Facility; the alteration of, Expansion of, making of major repairs to, remodeling of, renovation of, or replacement of an existing Health Care Facility; the initial, additional, or replacement equipping of any Health Care Facility; and the acquisition of consulting, architectural, engineering, legal, accounting, or any other professional services, and of a Site, when such acquisition is directed toward an undertaking sufficiently specific to constitute part of the subject matter of an Application for Determination of Need pursuant to 105 CMR 100.000.

Conversion. The substitution of a service or equipment that is defined as a Substantial Change in Service by the Department, in place of a current service or equipment.

Department. The Department of Public Health, which shall include the Public Health Council, pursuant to M.G.L. c. 17, § 1, except as otherwise specified.

Department Staff. Employees or agents acting on behalf of the Commissioner or the Department including, but not limited to, consultants hired to support staff review and staff report development of an Application for Determination of Need.

Determination of Need Process. The process by which the Department reviews and evaluates the need for a Proposed Project pursuant to M.G.L. c. 111, §§ 25B through 25G, §§ 51 through 53, and § 71, or any applicable Government Agency requirement.

DoN-required Service. A service or procedure that for reasons of quality, access, cost, or health systems sustainability is determined by the Commissioner to require a Notice of Determination of Need. At a minimum, DoN-required Services shall include services or procedures for which the Commissioner has determined that there is evidence that the service(s) or procedure(s) do not lead to one or more of the following: improved Patient Panel health outcomes; increased access including, but not limited to, a decrease in price; or, a reduction in the Commonwealth's Total Health Care Expenditure. The Commissioner shall issue a list of DoN-required Services in the form of Guidelines. Said Guidelines shall be reviewed and evaluated annually. Persons may submit to the Commissioner requests that a certain service(s) or procedure(s) be considered for inclusion or exclusion from said Guidelines.

DoN-required Equipment. Equipment or services that for reasons of quality, access, cost, or health systems sustainability is determined by the Commissioner to require a Notice of Determination of Need. At a minimum, DoN-required Equipment shall include magnetic resonance imagers and linear accelerators, as well as any equipment and services for which the Commissioner has determined that there is evidence that the equipment or service(s) do not lead to one or more of the following: improved Patient Panel health outcomes; increased access including, but not limited to, a decrease in price; or, a reduction in the Commonwealth's Total Health Care Expenditure. The Commissioner shall issue a list of DoN-required Equipment in the form of Guidelines. Said Guidelines shall be reviewed and evaluated annually. Persons may submit to the Commissioner, requests that certain equipment or service(s) be considered for inclusion or exclusion from said Guidelines.

Emergency Situation. A situation involving either:

1. (1) a Government Declaration of emergency or a Catastrophic Event; or

2. (2) an existing Health Care Facility which the Commissioner determines has been destroyed, or otherwise substantially damaged, or where there is a clear and present danger of such damage, such that the damage could substantially impact public health. For the purposes of Emergency Situation, the following words shall mean:

   1. (a) Government Declaration. A federal, state, municipal, or local declaration of emergency that takes effect pursuant to applicable federal or state law.
   2. (b) Catastrophic Event. An unforeseen event that substantially affects or increases the need for health care services, such as a natural disaster, an act of terrorism, or an extended power outage. Examples of Catastrophic Events include, but are not limited to, events involving numerous serious injuries, such as fires or building collapse, a chemical spill or release, or widespread outbreak of disease or illness requiring emergency treatment or hospitalization.

Entity or Person. An individual or his or her estate upon his or her death, or a corporation, a Government Agency, a partnership, a trust, an association, or an organized group of Persons, whether incorporated or not, or any receiver, trustee, or other liquidating agent of any of the foregoing while acting in such capacity.

Expansion. Any increase or upgrade by a Health Care Facility to the existing functionality of a DoN-required Service or DoN-required Equipment; any increase or upgrade to the total number of beds, services, or stations; or any other change as further defined by the Department.

Expenditure Minimum.

1. (1) Expenditure Minimum with Respect to Substantial Capital Expenditures. Expenditure Minimum with Respect to Substantial Capital Expenditures as defined in M.G.L. c. 111, § 25B, and that is adjusted annually by the Commissioner after consideration of any inflation index established by the U.S. Department of Health and Human Services or similarly reliable national index, and set forth by the Commissioner in a Guideline.
2. (2) Expenditure Minimum with Regard to Substantial Change in Service or Increase in Staff. Expenditure Minimum with Regard to Substantial Change in Service or Increase in Staff as defined in M.G.L. c. 111, § 25B, and that is adjusted annually by the Commissioner after consideration of any inflation index established by the U.S. Department of Health and Human Services or similarly reliable national index, and set forth by the Commissioner in a Guideline. Notwithstanding 105 CMR 100.100: Expenditure Minimum(1) and (2), a Proposed Project

concerned solely with outpatient services other than Ambulatory Surgery, which are not otherwise defined as DoN-required Service or DoN-required Equipment, shall not require a Notice of Determination of Need, unless the expenditures and acquisitions are at least the amount that is adjusted annually by the Department after consideration of any inflation index established by the U.S. Department of Health and Human Services or similarly reliable national index, in which case, a Notice of Determination of Need shall be required. Notwithstanding 105 CMR 100.100: Expenditure Minimum(1) and (2), expenditures for, or the acquisition of, any replacement of medical, diagnostic, or therapeutic equipment defined as a DoN-required Service or DoN-required Equipment for which a Notice of Determination of Need was previously issued, or for which the DoN-required Service or DoN-required Equipment was exempt from Determination of Need, shall not require an additional Notice of Determination of Need, and shall not be included in the calculation of the Expenditure Minimum, so long as the project(s) falls within the definition of a Conservation Project as determined by the Department.

Factor or Determination of Need Factor. Each of the standard requirements for evaluation of an Application for Determination of Need as established within 105 CMR 100.000.

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Federal Fiscal Year. A 12-month period that starts on October 1 and ends on September 30 .

Filing Date. The date at which an Application for Determination of Need is deemed, by Department Staff, to be substantially complete and thus filed with the Department by an Applicant. The Filing and Submission Dates may be the same.

Final Action. Unless otherwise specified, the issuance of a Notice of Determination of Need, approval, disapproval or dismissal of an Application or request to amend a previously issued Notice of Determination of Need, or revocation of a Notice of Determination of Need by the Department or Commissioner.

Freestanding Ambulatory Surgery Center. An ambulatory surgery center licensed as a Clinic.

Good Cause Related to Project Implementation. The Applicant is unable to make Substantial and Continuing Progress within the period of the Notice of Determination of Need authorization due to:

1. (1) Unreasonably excessive delay on the part of the Department in processing any Application or request;
2. (2) Force majeure (e.g., a government declaration, catastrophic event, labor strike, or other cause beyond the control of the Applicant and/or the Department that could not be reasonably avoided by the Applicant's exercise of due care);
3. (3) Action of general application by any branch of federal, state, or local government;
4. (4) Winter conditions that preclude making Substantial and Continuing Progress toward completion, provided that the Applicant would have made such Substantial and Continuing Progress within the period of authorization, but for such winter conditions;
5. (5) Failure to obtain a financing commitment, provided that, within the period of the Notice of Determination of Need authorization, the Applicant has filed a firm commitment application with the United States Department of Housing and Urban Development or successor agency, in which case, the period of the Notice of Determination of Need authorization shall be extended for a period of not more than four months beyond the period authorized; or
6. (6) Any other condition that may be specified by the Department; and The Applicant is able to demonstrate to the Department that the project is diligently

proceeding with the completion of all prerequisites to making Substantial and Continuing Progress within the period of the Notice of Determination of Need authorization.

Good Cause Related to Project Implementation shall exclude Transfer of Ownership; transfer of Site; failure to obtain financing commitments under circumstances other than those described within 105 CMR 100.100: Good Cause Related to Project Implementation(5); an action taken by a Person related to zoning that has, or may have, the effect of limiting the Applicant's development rights with respect to a Site(s) in one city or town; and, any other reason deemed as applicable by the Department.

Government Agency. Any agency of the Commonwealth of Massachusetts or of any political subdivision of the Commonwealth of Massachusetts therein, including a city or a town, but does not mean an agency of the United States, even if such agency maintains a medical institution within Massachusetts.

Guideline. An enforceable sub-regulatory requirement that has been issued by the Commissioner pursuant to 105 CMR 100.000, but not promulgated as regulation. The Commissioner shall ensure that prior to issuance, all Guidelines have been put forth for public comment. The Commissioner shall notify the Public Health Council of any Guideline issued by the Department within 60 days of issuance.

Health Care Facility. A Hospital or a Clinic; a Long-term Care Facility; a clinical laboratory subject to licensure under M.G.L. c. 111D; a Public Medical Institution as defined in 105 CMR 100.100; or any other facility licensed by a Government Agency which requires a Notice of Determination of Need as a condition of licensure or other Government Agency requirement.

Health Policy Commission or HPC. The Government Agency established pursuant to M.G.L. c. 6D.

Health Priorities. Services or population health strategies that address identified regional, or statewide public health needs. Health Priorities shall be defined by the Commissioner in Guidelines and developed in consultation with relevant Government Agencies, community-based organizations, stakeholders, and the Public Health Council, may be guided by the state health plan pursuant to M.G.L. c. 6A, §16T and relevant community health needs assessments, and shall encourage the appropriate allocation of private and public health care resources consistent with M.G.L. c. 111, § 25C.

Holder. The Provider Organization which has been issued a Notice of Determination of Need by the Department pursuant to 105 CMR 100.000. In instances where there is no Provider Organization, Holder shall mean the Entity which has been issued a Notice of Determination of Need by the Department pursuant to 105 CMR 100.000.

Hospital. Any hospital licensed pursuant to M.G.L. c. 111, § 51.

Immaterial Change means:

1. (1) An increase or decrease in cost allocation among or between architectural costs, Construction contract, fixed equipment, and Site services that does not result in any increase in the maximum Capital Expenditure;
2. (2) A change in the proposed method of financing that does not result in any increase in the maximum Capital Expenditure or operating costs for interest in any year;
3. (3) A change in the maximum Capital Expenditure to the extent of the inflation adjustment provided for within 105 CMR 100.310(A)(9);
4. (4) For all Health Care Facilities other than Hospitals, a single increase, or cumulative series of increases, in Bed Capacity totaling not more than 12 beds to the licensed Bed Capacity of the entire Health Care Facility;
5. (5) A change in the architectural design that does not result in any changes in the spatial allocation among different components of the project, aggregate gross square footage, Bed Capacity, or maximum Capital Expenditure. Any such change in the architectural design shall be subject to the Department's architectural plan approval as provided for within 105 CMR 100.310(A)(6);
6. (6) An increase or decrease in the spatial allocation among different components of the project or the aggregate gross square footage of the project, provided that any such change does not result in any change in the Bed Capacity or any increase or decrease in the maximum Capital Expenditure over 10% of the inflation adjusted originally approved total expenditure, unless otherwise approved hereunder. Any such increase or decrease in the spatial allocation of the project's components or aggregate gross square footage of the project shall be subject to the Department's architectural plan approval as provided for in 105 CMR 100.310(6);
7. (7) Any increase or decrease in the maximum Capital Expenditure less than or equal to 10% of the inflation adjusted originally approved total expenditure. An increase shall be allowed only for contingencies that could not have been reasonably foreseen, that are not reasonably within the control of the Holder, as determined by the Commissioner, and for which the inflationary adjustment contained within 105 CMR 100.310(A)(9) is not appropriate;
8. (8) Any change in the type of equipment which the Commissioner determines not to be technologically different from that which received Notice of Determination of Need, provided that such a change does not result in any increase in the maximum Capital Expenditure, unless otherwise approved hereunder, or any increase in the likely operating costs; or
9. (9) Any alteration from the previously issued Notice of Determination of Need that the Commissioner determines to be an Immaterial Change in nature.

Location or Premises means:

1. (1) The street address(es) of the Health Care Facility; and
2. (2) In the case of a Health Care Facility located within a physically contiguous campus of an institution such as a school, university or Hospital, Location or Premises shall mean the campus.

Long-term Care Facility. A long-term care facility, including a convalescent or nursing home, or a rest home as defined in M.G.L. c. 111, § 71.

Notice of Determination of Need or Notice. A Final Action that represents the formal approval of the Department issued pursuant to 105 CMR 100.000. A Notice of Determination of Need shall include all applicable terms and Conditions, Standard or Other, as directed and attached to the Notice of Determination of Need by the Department.

Original License. The license issued to a Person for the Premises named therein, and is granted either upon initial licensure of a facility, change of Location, or Transfer of Ownership of a Health Care Facility.

Patient Panel. The total of the individual patients regardless of payer, including those patients seen within an emergency department(s) if applicable, seen over the course of the most recent complete 36-month period by the Applicant or Holder. Patient Panel also means:

1. (1) If the Applicant or Holder has no patient panel itself, the Patient Panel includes the Patient Panel of the health care facilities affiliated with the Applicant; or
2. (2) If the Proposed Project is for a new facility and there is no existing patient panel, Patient Panel means the anticipated patients; or
3. (3) In the case of a Transfer of Ownership, Patient Panel also includes the Patient Panel of the Entity to be acquired.

Party of Record. During the pendency of an Application for a Determination of Need, the Applicant or Holder, the Attorney General, CHIA, HPC, all Government Agencies with relevant oversight or licensure authority over the Proposed Project or components therein, and any Ten Taxpayer Groups duly registered. A Party of Record may review the Application for Determination of Need for which it is appropriately registered, as well as provide written comment for consideration by the Department, including written comment by the Attorney General, CHIA, and HPC as it relates to any independent cost-analyses made pursuant to 105 CMR 100.405.

Primary Service Area. The geographic area in which a majority of patients who receive care at a Health Care Facility reside. The percentage of patients who are counted in determining the Primary Service Area will be set out in Guideline.

Proposed Project. Any Substantial Capital Expenditure, Substantial Change in Service including, but not limited to, DoN-required Service, DoN-required Equipment, Ambulatory Surgery, or any combination thereof; or Any Original License or Transfer of Ownership that is proposed within an Application for Determination of Need and filed with the Department pursuant to 105 CMR 100.000. A Proposed Project may include an Applicant’s institutional master plan.

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 and is the sole corporate member or sole shareholder of one or more Health Care Facilities.

Public Medical Institution. Any medical institution, including an institution for the mentally ill or for individuals with intellectual disabilities, supported in whole or in part by public funds, either federal, state, or municipal, and staffed by professional medical and nursing personnel and providing medical care in accordance with standards established through licensure, approval, or certification by the Department for participation in programs administered under Titles XVIII or XIX of the Federal Social Security Act.

Significant Change means:

1. (1) Any change, modification, or deletion of components within a previously issued Notice of Determination of Need that is not an Immaterial Change, as determined by the Commissioner;
2. (2) Any increase or decrease in the maximum Capital Expenditure over 10% of the inflation adjusted originally approved total expenditure. An increase shall be allowed only for contingencies that could not have been reasonably foreseen, that are not reasonably within the control of the Holder, as determined by the Commissioner, and for which the inflationary adjustment contained within 105 CMR 100.310(A)(9) is not appropriate;
3. (3) Any request for modification or deletion of any Standard or Other condition set forth within a Notice of Determination of Need that is determined to be material by the Department;
4. (4) Unless otherwise approved by the Department, any extension of the authorization period of an approved project as specified in a Notice of Determination of Need; or
5. (5) Any build-out of shell space that was subject to a Notice of Determination of Need. Any change to a project the Commissioner deems to be so significant that it alters the

previously issued Notice of Determination of Need to a degree that it constitutes a new project will require the issuance of a new Notice of Determination of Need.

Site. Land and any building or part thereof.

Solicitation of Funding. The act of approaching any member of the general public with a request or plea for a donation of funds to be used for a Proposed Project. For such purposes, Solicitation of Funding shall exclude ongoing Solicitation of Funding conducted on behalf of the Applicant and not directly related to the Proposed Project.

Submission Date. The date at which an Application is for Determination of Need is first submitted to the Department Staff. The Filing and Submission Dates may be the same.

Substantial Capital Expenditure. Capital Expenditures that exceed, or may reasonably be regarded as likely to exceed, the Expenditure Minimum. Substantial Capital Expenditure shall also mean the obtaining of capital equipment or a building, or part thereof, by lease or comparable arrangement, by donation, or by transfer for less than fair market value in excess of the Expenditure Minimum. The fair market value of a lease of equipment or a building, or part thereof, shall be equal to its fair market value were it to be purchased. See 105 CMR 100.100: Capital Expenditure and Expenditure Minimum.

Substantial Change in Services means:

1. (1) With regard to Hospitals only, the Addition or Expansion of, or Conversion to:

   1. (a) A DoN-required Service, DoN-required Equipment, or Ambulatory Surgery, regardless of whether an Expenditure Minimum is exceeded; or
   2. (b) Any services that may be provided by facilities that are not Hospitals.

2. (2) For any Health Care Facility other than a Hospital:

   1. (a) The Addition of a service or increase in staff that entails annual operating costs in excess of the Expenditure Minimum;
   2. (b) Any increase in Bed Capacity, other than a single increase, or cumulative series of increases, totaling not more than 12 beds to the licensed Bed Capacity of the entire Health Care Facility;
   3. (c) The Addition or Expansion of, or Conversion to, a DoN-required Service or DoN-required Equipment regardless of whether an Expenditure Minimum is exceeded;
   4. (d) The Addition or Expansion of, or Conversion to, Ambulatory Surgery; or
   5. (e) Upgrading Level IV beds to skilled nursing and intermediate care beds (Level II and III).
3. (3) A transfer of Site of any Health Care Facility, DoN-required Service, DoN-required Equipment, or a project which has been previously issued a Notice of Determination of Need but is not yet licensed, or not yet operational if no Government Agency license, that is determined by the Department to result in a Substantial Change in Service.

Substantial and Continuing Progress means:

1. (1) In the case of a project involving equipping of a Health Care Facility, such equipment shall have been installed and shall be operational;

2. (2) In the case of a project involving the provision of a DoN-required Service or DoN-required Equipment, either:

   1. (a) provision of such service or use of such equipment shall have commenced; or
   2. (b) demonstration of a binding contract for the purchase or lease of the equipment with a party unrelated to the Holder or ultimate provider of the DoN-required Service or DoN-required Equipment;
3. (3) In the case of a project involving the provision of a DoN-required Service or DoN-required Equipment subject to Department licensure, the project shall have received written, final plan approval from the Department;
4. (4) In the case of a project involving an increase in the Bed Capacity, or licensed Bed Capacity of a Health Care Facility, or a service or unit thereof, but involving no Construction or renovation, a request for an increase in the Health Care Facility's licensed capacity for such beds shall have been submitted to the Department; however, if not required to be so licensed, such beds shall be in operation;

5. (5) In the case of a project involving Construction, the following shall have occurred:

   1. (a) commencement of demolition and the physical assembly of the foundation of the project for Construction and ground floor Addition projects when a foundation is part of the project;
   2. (b) commencement of the physical assembly of the additional structure; or
6. (6) In the case of a project involving renovation, progress beyond the removal and demolition of an existing facility, or of the component structures of an existing facility.

Sufficient Interest means one of the following:

1. (1) Clear legal title to the proposed Site, or a legally enforceable agreement to give such title;
2. (2) In the case of a Hospital or Long-term Care Facility, a lease for at least five years with options to renew for not less than a total of 15 additional years, or a legally enforceable agreement to give such lease;
3. (3) In the case of an Ambulatory Surgery center, a lease for at least one year with options to renew for not less than one additional year, or a legally enforceable agreement to give such lease;
4. (4) In the case of a Clinic organized as a non-profit corporation under M.G.L. c. 180, permission to use the Premises for a period of at least two years; or
5. (5) In the case of a Government Agency, recommendation of not more than four alternative Sites by an official Site selection committee and acceptance of that recommendation by the duly elected or appointed chief officer of that Government Agency and, in the case of a Government Agency within an executive office, acceptance of that recommendation by the Secretary of that executive office.

Taxpayer. Any individual residing within the Commonwealth of Massachusetts and who is subject to any Massachusetts state income, excise, or property tax during the calendar year in which he or she signs a written request for a public hearing, a statement of registration, or comments with respect to an Application filed pursuant to 105 CMR 100.000.

Ten Taxpayer Group. Any ten Taxpayers, organized as a group, which may participate in the review of an Application for Determination of Need or request to amend a previously issued Notice of Determination of Need. Said group must register with the Department at any time during the first 30 days following the Filing Date of an Application, or during the first ten days after a public hearing held pursuant to 105 CMR 100.445. Any such registration shall be signed by each Taxpayer and shall, in clearly legible print:

1. (1) List each Taxpayer by name and resident address;
2. (2) State whether or not each Taxpayer is acting as an agent for another party. If a Taxpayer is acting as an agent for another party, the Taxpayer must list that party's full name and address;
3. (3) Identify the Application in which the Taxpayers are interested; and
4. (4) Specify which Taxpayer is to be the recipient of all written communications concerning the Application on behalf of the Ten Taxpayer Group. Upon receipt of any such registration, Department Staff shall promptly send a copy to each

Party of Record. The Commissioner may revoke the Ten Taxpayer Group status of any group that has failed to comply with the requirements of 105 CMR 100.000.

Total Value. The sum of the total Capital Expenditure of a Proposed Project; or in the case of a Transfer of Ownership pursuant to 105 CMR 100.735, the total capital value or the last full year of reported net patient service revenue, whichever is greater, of the proposed facility or facilities to be acquired at the time of the Filing Date.

Transfer of Ownership shall include, but shall not be limited to, the following:

1. (1) A transfer of a majority interest in the ownership of a Hospital or Clinic;
2. (2) In the case of a privately-held for-profit corporation, transfer of a majority of any class of the stock thereof;
3. (3) In the case of a partnership, transfer of a majority of trustees;
4. (4) In the case of a trust, change of the trustee or a majority of trustees;
5. (5) In the case of a nonprofit corporation, such changes in the corporate membership and/or trustees to constitute a shift in control of the Hospital or Clinic as determined by the Commissioner; or
6. (6) In the case where foreclosure proceedings have been instituted by a mortgagee in possession of a Hospital or Clinic. For the purposes of 105 CMR 100.000, Transfer of Ownership may also mean any change

in the ownership interest or structure of the Hospital or Clinic, or of the Hospital or Clinic's organization or parent organization(s), such that the change results in a shift in control of the operation of the Hospital or Clinic, as determined by the Commissioner. The Commissioner may, based upon a review of the organizational structure and proposed change, determine that a proposed transaction does not rise to the level of a Transfer of Ownership.