Code of Maine Rules › 95 - INDEPENDENT AGENCIES › 629 - DIRIGO HEALTH AGENCY › Chapter 2 - PAID CLAIMS DEFINITION

Current through 2024-29, July 17, 2024
PRINCIPAL REASON OR PURPOSE FOR PROPOSING THIS RULE:
PL 2005, Chapter 400, Part B, section B-2, 1 states:
1. Definition of paid claims; first
			 assessment year. The Board of Directors of Dirigo Health shall adopt rules
			 regarding the definition of paid claims under section 1 of this Part for the
			 calculation of savings offset payments for the first 12-month calendar year
			 period of savings offset payments, referred to in this section as "the first
			 assessment year," due from health insurance carriers, 3rdparty administrators
			 and employee benefit excess insurance carriers pursuant to the Maine Revised
			 Statutes, Title 24-A, section 6913. In adopting these rules, the board shall
			 take into account the recommendations of the working group established under
			 section 1 with respect to the definition of paid claims and the methodology for
			 calculating and invoicing savings offset payment assessments based on paid
			 claims. Rules adopted pursuant to this section are routine technical rules as
			 defined in Title 5, chapter 375, subchapter 2-A.
RECOMMENDED DEFINITION OF PAID CLAIMS
For the purpose of calculating savings offset payment
				assessments for health insurance carriers, third-party administrators and
				employee benefit excess insurance carriers, the term "paid claims" shall be
				defined as:
All payments made by health insurance carriers, third-party
				administrators and employee benefit excess carriers for health and medical
				services provided under policies issued pursuant to the laws of this State that
				insure residents of this State or, in the case of third-party administrators,
				for health care for residents of this State except that paid claims shall not
				include:
1. claims related expenses as
			 defined in this section and general administrative expenses;
2. payments made to qualifying providers
			 under a "pay for performance" or other incentive compensation arrangement if
			 the payments are not reflected in the processing of claims submitted for
			 services rendered to specific covered individuals;
3. claims paid by carriers and third-party
			 administrators with respect to accidental injury, specified disease, hospital
			 indemnity, dental, vision, disability income, long-term care, Medicare
			 supplement or other limited benefit health insurance, except that claims paid
			 for dental services covered under a medical policy shall be included;
4. claims paid for services rendered to
			 non-residents of this State;
5.
			 claims paid under retiree health benefit plans that are separate from and not
			 included within benefit plans for existing employees;
6. claims paid by an employee benefit excess
			 carrier which have been counted by a third-party administrator for determining
			 its savings offset payment;
7.
			 claims paid for services rendered to persons covered under a benefit plan for
			 federal employees; and,
8. claims
			 paid for services rendered outside of this State to persons resident of this
			 State.
For the purposes of this definition of "paid claims" claims
				related expenses shall include:
1.
			 payments for utilization review, care management, disease management, risk
			 assessment, and similar administrative services intended to reduce the claims
			 paid for health and medical services rendered to covered individuals, usually
			 either by attempting to assure that needed services are delivered in the most
			 efficacious manner possible or by helping such covered individuals to maintain
			 or improve their health; and
2.
			 payments made to or by organized groups of providers of health and medical
			 services in accordance with managed care risk arrangements or network access
			 agreements, which payments are unrelated to the provision of services to
			 specific covered individuals.
In those instances in which a health insurance carrier,
				employee benefit excess insurance carrier, or third party administrator is
				contractually entitled to withhold certain amounts from payments due to
				providers of health and medical services in order to help assure that the
				providers can fulfill any financial obligations they may have under a managed
				care risk arrangement, the full amounts due the providers before application of
				such withholds shall be reflected in the calculation of "paid claims."
For the purposes of this definition of "paid claims" the phrase
				"health and medical services" shall include but not be limited to any services
				included in the furnishing of medical care, dental care to the extent covered
				under a medical insurance policy, pharmaceutical benefits, hospitalization
				including but not limited to services provided in a hospital or other medical
				facilities; ancillary services, including but not limited to ambulatory
				services; physician and other practitioner services including but not limited
				to services provided by a physician's assistant, nurse practitioner or midwife;
				and behavioral health services including but not limited to mental health and
				substance abuse services.