02- 031 C.M.R. ch. 360, § 11 - Marketing

A. An administrator may market and otherwise make available preferred provider arrangements to licensed health maintenance organizations, carriers, fraternal benefit societies, or self-insuring employers or health and welfare trust funds, and to their subscribers, provided that, in performing these functions, the administrator shall provide administrative services only and shall not accept underwriting risk in the form of a premium or capitation payment for its services except as provided for in 24-A M.R.S.A. Chapter 56-A Subchapter III.

B. In those cases where an administrator makes a preferred provider arrangement available to a health maintenance organization, the health maintenance organization shall continue to market and offer health care services, including at a minimum basic health care services as defined at 24-A M.R.S.A. §4202-A(1). All such services, to the extent otherwise consistent with this Rule and other applicable law, may be offered through a preferred provider arrangement, or through a combination of arrangements including a preferred provider arrangement.

(1) No schedule of charges, including an amended schedule, for enrollee coverage for health care services, including services provided through a preferred provider arrangement, may be used by a health maintenance organization until a copy of the schedule, or amended schedule, has been filed with and approved by the Superintendent.

(2) The charges for the enrollee coverage for health care services including services provided through a preferred provider arrangement will be subject to the review required by 24-A M.R.S.A. §4207.

C. In those cases where an administrator makes a preferred provider arrangement available to a fraternal benefit society which provides for payment of hospital, medical, or nursing benefits due to sickness or bodily infirmity or accident, the fraternal benefit society must comply with all provisions of 24-A M.R.S.A. Chapter 55 (§§ 4101-4143 ) prior to marketing and offering the preferred provider arrangement to its members and their beneficiaries.

Notes

02- 031 C.M.R. ch. 360, § 11