Maine Revised Statutes Title 24-A Sec. 4333 – Requirements for downstream risk arrangements
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1. Permissible downstream risk arrangements. Downstream entities that do not exceed the risk threshold described in section 4334 may enter into downstream risk arrangements only if:
A. The requirements of section 4332, subsection 1 and sections 4335 and 4336 are met; and [PL 1999, c. 609, §20 (NEW).]
B. No specific payment is made directly or indirectly under the plan to a provider as an inducement to reduce or limit medically necessary services furnished to an enrollee. [PL 1999, c. 609, §20 (NEW).]
[PL 1999, c. 609, §20 (NEW).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 4333
- Carrier: means :
A. See Maine Revised Statutes Title 24-A Sec. 4301-AContract: A legal written agreement that becomes binding when signed. 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 Enrollee: means an individual who is enrolled in a health plan or a managed care plan. See Maine Revised Statutes Title 24-A Sec. 4301-A 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 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 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
2. Prohibited downstream risk payments. A specific payment of any kind may not be made directly or indirectly under the incentive plan to a downstream entity as an inducement to reduce or limit covered medically necessary services under the carrier‘s contract furnished to an enrollee. Indirect payments include offerings of monetary value such as stock options or waivers of debt measured in the present or future.
[PL 1999, c. 609, §20 (NEW).]
3. Applicability. This section applies to risk arrangements between carriers and downstream entities with which they contract to provide medical services to enrollees. This section also applies to subcontracting arrangements.
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).