24-A §4342. Related provisions - Maine Statutes

Title 24-A: MAINE INSURANCE CODE

Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT HEADING: PL 1997, C. 792, §2 (RPR)

Subchapter 3: DOWNSTREAM RISK HEADING: PL 1999, C. 609, §20 (NEW)

§4342. Related provisions

The superintendent may deny a request for waiver based on any of the following characteristics: [1999, c. 609, §20 (NEW).]

1. Carrier controlled. An arrangement with a downstream entity that has control of the carrier. "Control" has the same meaning as defined in section 222, subsection 2, paragraph B;

[ 1999, c. 609, §20 (NEW) .]

2. Transfer of claims processing, payment or adjudication. An arrangement by which the claims processing, claims payment or claims adjudication functions are transferred to the downstream entity from the carrier. This section may not be construed to authorize the superintendent to deny a request based on the transfer of utilization review functions from the carrier to the downstream entity;

[ 1999, c. 609, §20 (NEW) .]

3. Transfer of managerial control. An arrangement by which managerial control of the carrier's information system is transferred to the downstream entity;

[ 1999, c. 609, §20 (NEW) .]

4. Overlap between officers or directors. An arrangement in which there is overlap between the officers or directors of the downstream entity and the carrier; or

[ 1999, c. 609, §20 (NEW) .]

5. Transfer of more than 1/12 of annual capitated payments. An arrangement that transfers more than 1/12 of the annual capitated payments at one time to the downstream entity.

[ 1999, c. 609, §20 (NEW) .]

SECTION HISTORY

1999, c. 609, §20 (NEW).