| | Sec. 5. 24-A MRSA §4302, sub-§2, as enacted by PL 1995, c. 673, Pt. C, | §1 and affected by §2, is amended to read: |
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| | 2. Plan complaint; adverse decisions; prior authorization | statistics. A carrier shall provide annually to the | superintendent information for each health plan that it offers on | plan complaints, adverse decisions and, prior authorization | statistics and uniform quality data. This statistical | information must contain, at a minimum: |
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| A. The ratio of the number of complaints received by the | plan to the total number of enrollees, reported by type of | complaint and category of enrollee; |
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| B. The ratio of the number of adverse decisions issued by | the plan to the number of complaints received, reported by | category; |
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| C. The ratio of the number of prior authorizations denied | by the plan to the number of prior authorizations requested, | reported by category; |
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| D. The ratio of the number of successful enrollee appeals | to the total number of appeals filed; |
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| E. The percentage of disenrollments by enrollees and | providers from the health plan within the previous 12 months | and the reasons for the disenrollments. With respect to | enrollees, the information provided in this paragraph must | differentiate between voluntary and involuntary | disenrollments; and |
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| F. Enrollee satisfaction statistics, including provider-to- | enrollee ratio by geographic region and medical specialty | and a report on what actions, if any, the carrier has taken | to improve complaint handling and eliminate the causes of | valid complaints.; |
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| G.__Data on aggregate utilization of health care services by | enrollees; |
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| H.__Data on the demographic characteristics of enrollees; |
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| I.__Data on disease-specific and age-specific mortality | rates and, to the extent feasible, disease-specific and age- | specific morbidity rates of enrollees; and |
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| J.__Data on quality indicators and health outcomes, | including, to the extent feasible and appropriate, data on | pediatric cases and on a gender-specific basis. |
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