As used in this subchapter, unless the context otherwise indicates, the following terms have the following meanings. [PL 1999, c. 609, §20 (NEW).]
1. Bonus. “Bonus” means a payment a carrier makes to a downstream entity beyond any salary, fee-for-service payment, capitation or returned withhold.

[PL 1999, c. 609, §20 (NEW).]

Terms Used In Maine Revised Statutes Title 24-A Sec. 4331

  • Bonus: means a payment a carrier makes to a downstream entity beyond any salary, fee-for-service payment, capitation or returned withhold. See Maine Revised Statutes Title 24-A Sec. 4331
  • Capitation: means a set dollar payment per patient per unit of time, usually per month, that a carrier pays a health care practitioner, institutional provider or downstream entity to cover a specified set of services and administrative costs without regard to the actual number or nature of services provided. See Maine Revised Statutes Title 24-A Sec. 4331
  • Carrier: means :
A. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Downstream 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
  • Downstream risk arrangement: means an arrangement that transfers insurance risk from a carrier to a downstream entity. See Maine Revised Statutes Title 24-A Sec. 4331
  • Month: means a calendar month. See Maine Revised Statutes Title 1 Sec. 72
  • Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
  • 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
  • Physician group: means a partnership, association, corporation, individual practice association or other group of physicians that distributes income from the practice among members. See Maine Revised Statutes Title 24-A Sec. 4331
  • Potential payments: means the maximum anticipated total amount, based on the most recent year's utilization and experience and any current or anticipated factors that may affect costs, to be paid for a defined set of referral services for the carrier's subscribers and for which the downstream entity assumes by contract financial risk, to some extent, for the costs of such services. See Maine Revised Statutes Title 24-A Sec. 4331
  • Provider: means a practitioner or facility licensed, accredited or certified to perform specified health care services consistent with state law. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Referral services: means any specialty, inpatient, outpatient or laboratory services that a downstream entity orders or arranges, but does not furnish directly. See Maine Revised Statutes Title 24-A Sec. 4331
  • Risk threshold: means the maximum risk, if the risk is based on referral services, to which a downstream entity may be exposed under a downstream risk arrangement without being at substantial financial risk. See Maine Revised Statutes Title 24-A Sec. 4331
  • Risk-sharing arrangement: means an arrangement between a carrier and a downstream entity in which the carrier continues to pay providers for a defined set of services subject to an annual reconciliation process in which costs incurred by the carrier are compared with budgeted or targeted amounts for such services and that may, if payments are different than the budgeted amount, create financial liability of the downstream entity to the carrier or the carrier to the downstream entity provided the carrier holds or retains control of any funds in excess of those required to satisfy current claims obligations or direct payment to providers for services rendered pending reconciliation. See Maine Revised Statutes Title 24-A Sec. 4331
  • United States: includes territories and the District of Columbia. See Maine Revised Statutes Title 1 Sec. 72
  • Withhold: means a percentage of payments or set dollar amounts that a carrier deducts from a downstream entity's service fee, capitation or salary payment and that may or may not be returned to the downstream entity, depending on specific predetermined factors. See Maine Revised Statutes Title 24-A Sec. 4331
  • Year: means a calendar year, unless otherwise expressed. See Maine Revised Statutes Title 1 Sec. 72
  • 2. Capitation. “Capitation” means a set dollar payment per patient per unit of time, usually per month, that a carrier pays a health care practitioner, institutional provider or downstream entity to cover a specified set of services and administrative costs without regard to the actual number or nature of services provided. The services covered may include the downstream entity’s own services, referral services or all medical services.

    [PL 1999, c. 609, §20 (NEW).]

    3. Downstream entity. “Downstream 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. An employer exempt from the applicability of this chapter under the federal Employee Retirement Income Security Act of 1974, 29 United States Code §§ 1001 to 1461 (1988) is not considered a downstream entity.

    [PL 1999, c. 609, §20 (NEW).]

    4. Downstream risk arrangement. “Downstream risk arrangement” means an arrangement that transfers insurance risk from a carrier to a downstream entity.

    [PL 2003, c. 428, Pt. H, §6 (AMD).]

    5. Payments. “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. Bonuses and other compensation that are not based on referral levels, such as bonuses based solely on quality of care furnished, patient satisfaction and participation on committees, are not considered payments for purposes of this subchapter.

    [PL 1999, c. 609, §20 (NEW).]

    6. Physician group. “Physician group” means a partnership, association, corporation, individual practice association or other group of physicians that distributes income from the practice among members. An individual practice association is a physician group only if the association is composed of individual physicians and has no subcontracts with physician groups.

    [PL 1999, c. 609, §20 (NEW).]

    7. Potential payments. “Potential payments” means the maximum anticipated total amount, based on the most recent year‘s utilization and experience and any current or anticipated factors that may affect costs, to be paid for a defined set of referral services for the carrier’s subscribers and for which the downstream entity assumes by contract financial risk, to some extent, for the costs of such services. The methodology for determining potential payments must be filed by the carrier with the bureau.

    [PL 1999, c. 609, §20 (NEW).]

    8. Referral services. “Referral services” means any specialty, inpatient, outpatient or laboratory services that a downstream entity orders or arranges, but does not furnish directly.

    [PL 1999, c. 609, §20 (NEW).]

    9. Risk-sharing arrangement. “Risk-sharing arrangement” means an arrangement between a carrier and a downstream entity in which the carrier continues to pay providers for a defined set of services subject to an annual reconciliation process in which costs incurred by the carrier are compared with budgeted or targeted amounts for such services and that may, if payments are different than the budgeted amount, create financial liability of the downstream entity to the carrier or the carrier to the downstream entity provided the carrier holds or retains control of any funds in excess of those required to satisfy current claims obligations or direct payment to providers for services rendered pending reconciliation.

    [PL 1999, c. 609, §20 (NEW).]

    10. Risk threshold. “Risk threshold” means the maximum risk, if the risk is based on referral services, to which a downstream entity may be exposed under a downstream risk arrangement without being at substantial financial risk.

    [PL 1999, c. 609, §20 (NEW).]

    11. Withhold. “Withhold” means a percentage of payments or set dollar amounts that a carrier deducts from a downstream entity’s service fee, capitation or salary payment and that may or may not be returned to the downstream entity, depending on specific predetermined factors.

    [PL 1999, c. 609, §20 (NEW).]

    SECTION HISTORY

    PL 1999, c. 609, §20 (NEW). PL 2003, c. 428, §H6 (AMD).