958 C.M.R. 10.04 – Requirement to File a Performance Improvement Plan

(1) The Commission may require any CHIA-identified Entity to file a Performance Improvement Plan with the Commission if, after a review of the factors described in 958 CMR 10.04(2), the Commission identifies significant concerns about the CHIA-identified Entity's costs and determines that a Performance Improvement Plan could result in meaningful, cost-saving reforms.
(2) The Commission shall base its determination whether to require a Performance Improvement Plan on a review of the following factors:
1. (a) Baseline spending and spending trends over time, including by service category;
2. (b) Pricing patterns and trends over time;
3. (c) Utilization patterns and trends over time;
4. (d) Population(s) served, payer mix, product lines, and services provided;
5. (e) Size and market share;
6. (f) Financial condition, including administrative spending and cost structure;
7. (g) Ongoing strategies or investments to improve efficiency or reduce spending growth over time;
8. (h) Factors leading to increased costs that are outside the CHIA-identified Entity's control; and
9. (i) Any other factors the Commission considers relevant.
(3) To evaluate the factors described in 958 CMR 10.04(2), the Commission may request additional information from the CHIA-identified Entity. Prior to any Board vote to determine whether to require a Performance Improvement Plan, the Commission shall provide written notice to the CHIA-identified Entity, an opportunity to review information used by the Commission relative to 958 CMR 10.04(2), and an opportunity to meet with the Executive Director.
(4) The Commission shall determine whether to require a Performance Improvement Plan by vote of the Board.