Maine Revised Statutes Title 24-A Sec. 2677-A – Payment for nonpreferred providers
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1. Nonpreferred providers. A carrier incorporating a preferred provider arrangement into a health plan shall provide for payment of covered health care services rendered by providers that are not preferred providers.
[PL 1999, c. 609, §14 (NEW).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 2677-A
- Carrier: means an insurance company licensed in accordance with this Title, a fraternal benefit society authorized pursuant to chapter 55 or a nonprofit hospital or medical service organization licensed pursuant to Title 24. See Maine Revised Statutes Title 24-A Sec. 2671
- Health care services: means health care services or products rendered or sold by a provider within the scope of the provider's legal authorization. See Maine Revised Statutes Title 24-A Sec. 2671
- Health plan: means a plan offered or administered by a carrier that provides for the financing or delivery of health care services to persons enrolled in the plan. See Maine Revised Statutes Title 24-A Sec. 2671
- Preferred provider: means a provider who enters into a preferred provider arrangement with an administrator or carrier. See Maine Revised Statutes Title 24-A Sec. 2671
- Preferred provider arrangement: means a contract, agreement or arrangement between a carrier or administrator and a provider in which the provider agrees to provide services to a health plan enrollee whose plan benefits include incentives for the enrollee to use the services of that provider. See Maine Revised Statutes Title 24-A Sec. 2671
- Provider: means an individual or entity duly licensed or otherwise legally authorized to provide health care services, including, but not limited to, the treatment of physical health and mental health and provision for medical supplies and pharmaceutical supplies. See Maine Revised Statutes Title 24-A Sec. 2671
- Superintendent: means the Superintendent of Insurance. See Maine Revised Statutes Title 24-A Sec. 2671
2. Benefit level. The benefit level differential between services rendered by preferred providers and nonpreferred providers may not exceed 20% of the allowable charge for the service rendered, except that the superintendent may waive this requirement for a given benefit plan. Compliance with this requirement for a given benefit plan may be demonstrated on an aggregate basis. This demonstration of compliance must be based on a reasonably anticipated mix of claims certified by a qualified actuary who is a member of the American Academy of Actuaries or a successor organization. As used in this subsection, “allowable charge” means the amount that would be payable for services under the preferred provider arrangement including deductible and coinsurance amounts.
[PL 2001, c. 369, §3 (AMD).]
SECTION HISTORY
PL 1999, c. 609, §14 (NEW). PL 2001, c. 369, §3 (AMD).