Maine Revised Statutes Title 24-A Sec. 4342 – Related provisions
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The superintendent may deny a request for waiver based on any of the following characteristics: [PL 1999, c. 609, §20 (NEW).]
1. Carrier controlled. An arrangement with a downstream entity that has control of the carrier. “Control” has the same meaning as defined in section 222, subsection 2, paragraph B;
[PL 1999, c. 609, §20 (NEW).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 4342
- Carrier: means :
A. See Maine Revised Statutes Title 24-A Sec. 4301-ADownstream entity: means a person other than a carrier that has assumed all or part of the insurance risk of one or more health plans under a contractual relationship with a carrier or another downstream entity. See Maine Revised Statutes Title 24-A Sec. 4331 Payments: means any amounts the carrier pays the downstream entity for services the downstream entity furnishes directly, plus amounts paid for administration and amounts paid in whole or in part based on use and costs of referral services such as withhold amounts, bonuses based on referral levels and any other compensation to the downstream entity to influence the use of referral services. See Maine Revised Statutes Title 24-A Sec. 4331
2. Transfer of claims processing, payment or adjudication. An arrangement by which the claims processing, claims payment or claims adjudication functions are transferred to the downstream entity from the carrier. This section may not be construed to authorize the superintendent to deny a request based on the transfer of utilization review functions from the carrier to the downstream entity;
[PL 1999, c. 609, §20 (NEW).]
3. Transfer of managerial control. An arrangement by which managerial control of the carrier’s information system is transferred to the downstream entity;
[PL 1999, c. 609, §20 (NEW).]
4. Overlap between officers or directors. An arrangement in which there is overlap between the officers or directors of the downstream entity and the carrier; or
[PL 1999, c. 609, §20 (NEW).]
5. Transfer of more than 1/12 of annual capitated payments. An arrangement that transfers more than 1/12 of the annual capitated payments at one time to the downstream entity.
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).