Maine Revised Statutes Title 24-A Sec. 4334 – Substantial insurance risk; substantial enrollment risk
Current as of: 2023 | Check for updates
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1. Substantial insurance risk. Substantial insurance risk is risk based on the use or costs of referral services only, when the downstream entity is at risk for more than 25% of potential payments by the carrier to the downstream entity.
[PL 1999, c. 609, §20 (NEW).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 4334
- 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 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-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
2. Substantial enrollment risk. Substantial enrollment risk exists when a carrier enters into a risk arrangement with a downstream entity involving more than 25% of the enrollees served by the carrier in the State unless the risk arrangement is a risk-sharing arrangement.
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).