Maine Revised Statutes > Title 24-A > Chapter 56-A > Subchapter 3 – Downstream Risk
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Terms Used In Maine Revised Statutes > Title 24-A > Chapter 56-A > Subchapter 3 - Downstream Risk
- 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-AContract: 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 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 in writing: include printing and other modes of making legible words. See Maine Revised Statutes Title 1 Sec. 72 Month: means a calendar month. See Maine Revised Statutes Title 1 Sec. 72 Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period. Participating provider: means a licensed or certified provider of health care services, including mental health services, or health care supplies that has entered into an agreement with a carrier to provide those services or supplies to an individual enrolled in a managed care plan. See Maine Revised Statutes Title 24-A Sec. 4301-A 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