§ 24-A §4319-B — Medical loss ratio reporting for dental insurance plans

Maine § 24-A §4319-B

• Jurisdiction: Maine
• Title 24-A: MAINE INSURANCE CODE
• Ch. 56-A: HEALTH PLAN IMPROVEMENT ACT

Text

1.
Definitions.
As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
2.
Dental loss ratio defined.
For purposes of this section, the dental loss ratio is the ratio of the numerator to the denominator as described in paragraphs A and B, respectively. For purposes of this subsection:
3.
Expenditures for clinical dental services.
The superintendent shall define "clinical dental services" in rule to be consistent with similar expenditures for clinical services used for reporting of medical loss ratio by carriers offering health plans in the State.
4.
Activities that improve dental care quality.
The superintendent shall define "activities that improve dental care quality" in rule to be consistent with similar activities related to quality that are permitted for reporting of medical loss ratio by carriers offering health plans in this State such as case management; oral health assessments; identifying and addressing ethnic, cultural or racial disparities in effectiveness of best clinical practices and evidence-based medicine; quality reporting; and health information technology.
5.
Administrative cost expenditures.
The superintendent shall define "administrative cost expenditures" in rule to be consistent with similar cost expenditures used for reporting of medical loss ratio by carriers offering health plans in the State such as financial administrative expenses, marketing and sales expenses, commissions, distribution expenses, claims operations expenses, utilization review expenses, network operations expenses, charitable expenses, board, bureau or association fees and payroll expenses.
6.
Dental loss ratio reporting.
Beginning in 2023, on or before July 31st annually, a carrier offering a dental plan in effect during the preceding calendar year shall file a report with the bureau of the carrier's dental loss ratio for the preceding calendar year organized by market segment according to guidance issued by the superintendent.
7.
Average dental loss ratio; identifying dental plans with dental loss ratio deviating from average.
The superintendent shall aggregate the dental loss ratio reports filed by each carrier pursuant to subsection 6 by market segment. The superintendent shall calculate an average dental loss ratio for each market segment using aggregate data for a 3-year period, including data for the dental loss ratio reporting year that is being reported and the data for the 2 prior dental loss ratio reporting years, and identify as outliers dental plans that fall outside 2 standard deviations of the average dental loss ratio. If the average dental loss ratio in a market segment declines over time, the superintendent may identify as outliers dental plans that fall outside one standard deviation of the average dental loss ratio or establish by rule a minimum average dental loss ratio for use in calculating outliers.
8.
Authority for review.
For those dental plans identified as outliers in accordance with subsection 7, the superintendent shall conduct a review and require the carrier of a dental plan identified as an outlier to submit additional relevant financial information as requested by the superintendent. The superintendent may require the carrier to submit a remediation plan including but not limited to measures such as rate revisions or benefit modifications. Any action taken by the superintendent pursuant to this subsection is limited to the dental plans identified as outliers.
9.
Rules.
The superintendent may adopt rules to implement this section, including development of a common reporting form. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.

Legislative History

PL 2021, c. 529, §1 (NEW). PL 2021, c. 529, §2 (AFF).