Maine Revised Statutes

§4319. Rebates

1. Rebates required.  Carriers must provide rebates in the large group, small group and individual markets to the extent required by the federal Affordable Care Act and federal regulations adopted pursuant thereto if the medical loss ratio under subsection 2 is less than the minimum medical loss ratio under subsection 3.
[ 2011, c. 90, Pt. D, §5 (NEW) .]
2. Medical loss ratio.  For purposes of this section, the medical loss ratio is the ratio of the numerator to the denominator as described in paragraphs A and B, respectively, plus any credibility adjustment. The period for which the medical loss ratio is determined and the meaning of all terms used in this subsection must be in accordance with the federal Affordable Care Act and federal regulations adopted pursuant thereto. For the purposes of this subsection:
A. The numerator is the amount expended on reimbursement for clinical services provided to enrollees and activities that improve health care quality; and [2011, c. 90, Pt. D, §5 (NEW).]
B. The denominator is the total amount of premium revenue excluding federal and state taxes and licensing and regulatory fees paid and after accounting for payments or receipts for risk adjustment, risk corridors and reinsurance pursuant to federal law. [2011, c. 90, Pt. D, §5 (NEW).]
[ 2011, c. 90, Pt. D, §5 (NEW) .]
3. Minimum medical loss ratio.  The minimum medical loss ratio is:
A. In the large group market, 85%; [2011, c. 90, Pt. D, §5 (NEW).]
B. In the small group market, 80%; and [2011, c. 90, Pt. D, §5 (NEW).]
C. In the individual market, 80% or such lower minimum medical loss ratio as the Secretary of the United States Department of Health and Human Services determines based on a finding, pursuant to the federal Affordable Care Act and federal regulations adopted pursuant thereto, that an 80% minimum medical loss ratio might destabilize the individual market in this State. [2011, c. 90, Pt. D, §5 (NEW).]
[ 2011, c. 90, Pt. D, §5 (NEW) .]
SECTION HISTORY
2011, c. 90, Pt. D, §5 (NEW).

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