02-031 C.M.R. ch. 840, § 6 - Participating Carriers

A. To be eligible as a participating carrier, a carrier must demonstrate the following operating characteristics to the alliance board's satisfaction:

(1) That the carrier is licensed and in good standing with the Superintendent. The board shall request certification from the Superintendent that all participating carriers are licensed carriers and that all carriers to be offered to small employers have filed forms and rates pursuant to 24-A M.R.S.A. §2808-B;

(2) The ability to administer health benefit plans, to provide adequate service, and to comply with all contractual requirements of the alliance;

(3) The ability to provide enrollees with reasonable access to covered services;

(4) The ability to provide coverage for enrollees in any service area in which the carrier plans to participate through the alliance;

(5) The ability to arrange and pay for the appropriate quality, level, and type of health care services;

(6) The ability to provide data required by the board, including information on enrollee satisfaction based on standard surveys and to meet reasonable satisfaction measures as the board may establish;

(7) Strong financial condition;

(8) Adequate administrative management;

(9) A procedure to address enrollee grievances and appeals;

(10) The ability to achieve satisfactory enrollment levels within the service area in which the carrier is licensed; and

(11) All other criteria established by the board.

B. In evaluating which carriers may participate in the alliance, the board shall consider:

(1) Minimum geographic service and participation requirements, maximum levels for premium rates, and standards for determining whether a carrier operates efficiently;

(2) Pricing and the competitiveness of each bid from a carrier; and

(3) The effect of contracting with additional carriers on the administrative costs of the alliance and its members, and the competitiveness of the premiums that will be paid to participating carriers.

C. Contracts between the board and participating carriers shall specify how all premiums will be transmitted, grace periods for payments, and penalties for late payments.

D. Nothing in this Rule prohibits a participating carrier from contracting with particular health care providers or types, classes, or categories of health care providers, or from setting reimbursement methodology.

E. When filing rates with the Superintendent for use with alliance products offered to individuals or small employers, the carrier shall include a comparison of the alliance rates to the carrier's rates for the same or similar product offered outside the alliance. The filing must demonstrate that all rate differences are attributable to differences in administrative costs, marketing costs, profit margins, economies of scale, product design, or other factors unrelated to health status or perceived health risk. Differences in product design may include differences in benefits, provider networks, provider contracts, or case management provisions.

Notes

02-031 C.M.R. ch. 840, § 6