Section 500.3569 - Assumption of financial risk; “requiring an affiliated provider to assume financial risk” defined.
THE INSURANCE CODE OF 1956 (EXCERPT)
Act 218 of 1956
500.3569 Assumption of financial risk; “requiring an affiliated provider to assume financial risk” defined.
Sec. 3569.
(1) Except as provided in section 3515(2), a health maintenance organization shall assume full financial risk on a prospective basis for the provision of health maintenance services. However, the organization may do any of the following:
(a) Require an affiliated provider to assume financial risk under the terms of its contract.
(b) Obtain insurance.
(c) Make other arrangements for the cost of providing to an enrollee health maintenance services the aggregate value of which is more than $5,000.00 in a year for that enrollee.
(2) If the health maintenance organization requires an affiliated provider to assume financial risk under the terms of its contract, the contract shall require both of the following:
(a) The health maintenance organization to pay the affiliated provider, including a subcontracted provider, directly or through a licensed third party administrator for health maintenance services provided to its enrollees.
(b) The health maintenance organization to keep all pooled funds and withhold amounts and account for them on its financial books and records and reconcile them at year end in accordance with the written agreement between the affiliated provider and the health maintenance organization.
(3) As used in this section, “requiring an affiliated provider to assume financial risk” means a transaction whereby a portion of the chance of loss, including expenses incurred, related to the delivery of health maintenance services is shared with an affiliated provider in return for a consideration. These transactions include, but are not limited to, full or partial capitation agreements, withholds, risk corridors, and indemnity agreements.
History: Add. 2000, Act 252, Imd. Eff. June 29, 2000
Popular Name: Act 218
Popular Name: HMO