LD 1619
pg. 2
Page 1 of 11 An Act to Create a Patients' Bill of Rights Page 3 of 11
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LR 251
Item 1

 
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:

 
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:

 
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;

 
B. The ratio of the number of adverse decisions issued by
the plan to the number of complaints received, reported by
category;

 
C. The ratio of the number of prior authorizations denied
by the plan to the number of prior authorizations requested,
reported by category;

 
D. The ratio of the number of successful enrollee appeals
to the total number of appeals filed;

 
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

 
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.;

 
G.__Data on aggregate utilization of health care services by
enrollees;

 
H.__Data on the demographic characteristics of enrollees;

 
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

 
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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