1. Disclosure to superintendent. Each carrier shall provide information concerning the carrier’s downstream risk arrangements as required or requested by the superintendent. The disclosure must contain the following information in sufficient detail to enable the superintendent to determine whether the risk arrangement complies with the following requirements:
A. Whether services not furnished by the downstream entity are covered by the risk arrangement. If the services furnished by the downstream entity are covered by the risk arrangement, disclosure of other aspects of the plan need not be made; [PL 1999, c. 609, §20 (NEW).]
B. The type of risk arrangement; for example, withhold, bonus, capitation; [PL 1999, c. 609, §20 (NEW).]
C. If the risk arrangement involves a withhold or bonus, the percent of the withhold or bonus; [PL 1999, c. 609, §20 (NEW).]
D. The panel size, the number of enrollees covered by the downstream entity and the total number of enrollees covered by the carrier in the State; and [PL 1999, c. 609, §20 (NEW).]
E. In the case of capitated downstream entities, capitation payments paid to primary care providers for the most recent year broken down by percent for primary care services, referral services to specialists, hospital services and other types of provider services, including, but not limited to, nursing home and home health agency services. [PL 1999, c. 609, §20 (NEW).]

[PL 1999, c. 609, §20 (NEW).]

Terms Used In Maine Revised Statutes Title 24-A Sec. 4336

  • 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
  • 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
  • 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
  • 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
  • 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. Annual disclosure. A carrier shall provide this information to the superintendent at least annually. A carrier shall provide the capitation data required under subsection 1 for the previous calendar year to the superintendent by April 1st of each year.

    [PL 1999, c. 609, §20 (NEW).]

    3. Disclosure to enrollees. A carrier shall provide the following information to any enrollee upon request:
    A. Whether the prepaid plan uses a downstream risk arrangement that affects the use of referral services; and [PL 1999, c. 609, §20 (NEW).]
    B. The type of risk arrangement. [PL 1999, c. 609, §20 (NEW).]

    [PL 1999, c. 609, §20 (NEW).]

    SECTION HISTORY

    PL 1999, c. 609, §20 (NEW).
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