§4336. Disclosure requirements for organizations with downstream risk arrangements

1.  Disclosure to superintendent.  Each carrier shall provide information concerning the carrier's downstream risk arrangements as required or requested by the superintendent. The disclosure must contain the following information in sufficient detail to enable the superintendent to determine whether the risk arrangement complies with the following requirements:

A. Whether services not furnished by the downstream entity are covered by the risk arrangement. If the services furnished by the downstream entity are covered by the risk arrangement, disclosure of other aspects of the plan need not be made;   [PL 1999, c. 609, §20 (NEW).]

B. The type of risk arrangement; for example, withhold, bonus, capitation;   [PL 1999, c. 609, §20 (NEW).]

C. If the risk arrangement involves a withhold or bonus, the percent of the withhold or bonus;   [PL 1999, c. 609, §20 (NEW).]

D. The panel size, the number of enrollees covered by the downstream entity and the total number of enrollees covered by the carrier in the State; and   [PL 1999, c. 609, §20 (NEW).]

E. In the case of capitated downstream entities, capitation payments paid to primary care providers for the most recent year broken down by percent for primary care services, referral services to specialists, hospital services and other types of provider services, including, but not limited to, nursing home and home health agency services.   [PL 1999, c. 609, §20 (NEW).]

[PL 1999, c. 609, §20 (NEW).]

2.  Annual disclosure.  A carrier shall provide this information to the superintendent at least annually. A carrier shall provide the capitation data required under subsection 1 for the previous calendar year to the superintendent by April 1st of each year.

[PL 1999, c. 609, §20 (NEW).]

3.  Disclosure to enrollees.  A carrier shall provide the following information to any enrollee upon request:

A. Whether the prepaid plan uses a downstream risk arrangement that affects the use of referral services; and   [PL 1999, c. 609, §20 (NEW).]

B. The type of risk arrangement.   [PL 1999, c. 609, §20 (NEW).]

[PL 1999, c. 609, §20 (NEW).]

SECTION HISTORY

PL 1999, c. 609, §20 (NEW).