Maine Revised Statutes Title 24-A Sec. 2673-A – Preferred provider arrangements
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1. Filing with superintendent; disapproval. A carrier or administrator who proposes to offer a preferred provider arrangement shall file with the superintendent proposed agreements, rates, geographic service areas, provider networks and other materials relevant to the proposed arrangement. The superintendent shall disapprove any preferred provider arrangement if the arrangement contains any unjust, unfair or inequitable provisions; unreasonably restricts access and availability of health care services; or fails to comply with other requirements of this chapter, chapter 56?A or rules adopted by the superintendent.
[PL 1999, c. 609, §8 (NEW).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 2673-A
- Administrator: means any person, other than a carrier, that administers a preferred provider arrangement. See Maine Revised Statutes Title 24-A Sec. 2671
- 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
- Oversight: Committee review of the activities of a Federal agency or program.
- 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. Considered separate preferred provider arrangements. If health plans offered by the same carrier have different geographic service areas, or if there are preferred providers in one health plan who are nonpreferred providers in another health plan offered by the same carrier or administered by the same administrator or who are in a different preference tier if the plan is a multitier plan, then the plans represent different preferred provider arrangements and must be separately filed and approved.
[PL 1999, c. 609, §8 (NEW).]
3. Rules. Preferred provider arrangements offered by carriers that are subject to chapter 56?A must be in compliance with applicable provisions of that chapter and any rules adopted under that chapter. Employer-sponsored plans that are exempt from this chapter pursuant to federal law and administrators offering preferred provider arrangements to employer-sponsored plans are not subject to the provisions of chapter 56?A or rules adopted under that chapter, provided either the administrator or any other participating entity, other than the self-insured employer, does not undertake insurance risk. The superintendent may adopt rules establishing procedures for filing and approval of preferred provider arrangements, including the time period within which the superintendent must act on a completed application; specific criteria for determining when a term or condition is unjust, unfair or inequitable or has the effect of unreasonably restricting access and availability to health care services; and standards consistent with this chapter and chapter 56?A for the ongoing operation and oversight of approved provider arrangements. The rules may prohibit the carrier from applying a benefit level differential to enrollees who must travel an unreasonable distance to obtain the service. Rules adopted pursuant to this subsection are routine technical rules pursuant to Title 5, chapter 375, subchapter II?A.
[PL 1999, c. 609, §8 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §8 (NEW).