§6917. Access payment








1. Access payments required from health insurance carriers, 3rd-party administrators
and employee benefit excess insurance carriers. 
All health insurance carriers, 3rd-party administrators and employee benefit excess
insurance carriers shall pay an access payment on all paid claims, except claims under accidental injury, specified disease, hospital
indemnity, dental, vision, disability income, long-term care, Medicare supplement
or other limited benefit health insurance. The amount of the access payment is 2.14% on claims for services provided through
June 30, 2011, 1.87% on claims for services provided from July 1, 2011 to June 30,
2012, 1.64% on claims for services provided from July 1, 2012 to June 30, 2013 and
1.14% on claims for services provided from July 1, 2013 to December 31, 2013. No
access payment may be charged for any claims for services provided on January 1, 2014
or thereafter. The following provisions govern access payments.





A. A health insurance carrier or employee benefit excess insurance carrier may not be
required to pay an access payment on policies or contracts insuring federal employees. [2009, c. 359, §4 (NEW); 2009, c. 359, §8 (AFF).]











B. Access payments apply to claims paid beginning on or after September 1, 2009. [2009, c. 359, §4 (NEW); 2009, c. 359, §8 (AFF).]











C. Access payments must be made monthly to Dirigo Health and are due 30 days after the
end of each month and must accrue interest at 12% per annum on or after the due date,
except that access payments for 3rd-party administrators for groups of 500 or fewer
members may be made annually not less than 60 days after the close of the plan year. [2009, c. 359, §4 (NEW); 2009, c. 359, §8 (AFF).]











D. Access payments received by Dirigo Health must be pooled with other revenues of the
agency in the Dirigo Health Enterprise Fund established in section 6915. [2009, c. 359, §4 (NEW); 2009, c. 359, §8 (AFF).]








[
2011, c. 380, Pt. BBB, §2 (AMD)
.]








2. Failure to pay access payments. 
The superintendent may suspend or revoke, after notice and hearing, the certificate
of authority to transact insurance in this State of any health insurance carrier or
employee benefit excess insurance carrier or the license of any 3rd-party administrator
to operate in this State that fails to pay an access payment. In addition, the superintendent
may assess civil penalties in accordance with section 12-A against any health insurance
carrier, employee benefit excess insurance carrier or 3rd-party administrator that
fails to pay an access payment or may take any other enforcement action authorized
under section 12-A to collect any unpaid access payments and may collect the cost
of enforcement including attorney’s fees from those who fail to pay an access payment.


[
2009, c. 359, §4 (NEW);
2009, c. 359, §8 (AFF)
.]








3. Definitions. 
As used in this section, the following terms have the following meanings.





A. "Claims-related expenses" includes:



(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 ensure 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 that are made to or by organized groups of providers of health and medical
services in accordance with managed care risk arrangements or network access agreements
and that are unrelated to the provision of services to specific covered individuals. [2009, c. 359, §4 (NEW); 2009, c. 359, §8 (AFF).]












B. "Health and medical services" includes, but is not limited to, any services included
in the furnishing of medical care, dental care to the extent covered under a medical
insurance policy, pharmaceutical benefits or hospitalization, including but not limited
to services provided in a hospital or other medical facility; 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. [2009, c. 359, §4 (NEW); 2009, c. 359, §8 (AFF).]











C. "Paid claims" means all payments made by health insurance carriers, 3rd-party administrators
and employee benefit excess insurance carriers for health and medical services provided
under policies that insure residents of this State or, in the case of 3rd-party administrators,
for health care for residents of this State, except that "paid claims" does not include:



(1) Claims-related expenses 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 3rd-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 are included;




(4) Claims paid for services rendered to nonresidents 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 insurance carrier that have been counted
by a 3rd-party administrator for determining its access 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 a person who is a
resident of this State.



In those instances in which a health insurance carrier, employee benefit excess insurance
carrier or 3rd-party administrator is contractually entitled to withhold certain amounts
from payments due to providers of health and medical services in order to help ensure
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 must be reflected in the calculation of paid claims. [2009, c. 359, §4 (NEW); 2009, c. 359, §8 (AFF).]








[
2009, c. 359, §4 (NEW);
2009, c. 359, §8 (AFF)
.]








4. Rulemaking. 
The board may adopt any rules necessary to implement this section. Rules adopted
pursuant to this subsection are routine technical rules as defined in Title 5, chapter
375, subchapter 2-A.


[
2009, c. 359, §4 (NEW);
2009, c. 359, §8 (AFF)
.]





SECTION HISTORY

2009, c. 359, §4 (NEW).
2009, c. 359, §8 (AFF).
2011, c. 380, Pt. BBB, §2 (AMD).