§ 9505. Insurer eligibility and duties.

270 words·~1 min read·/pa/title-40/chapter-95/9505

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(a)Eligibility for payment.-- An insurer shall be eligible for a reinsurance payment if:

(1)The claims costs for a reinsurance-eligible enrollee's covered benefits in a benefit year exceed the attachment point.

(2)The eligible insurer has implemented and documented reasonable care management practices for enrollees who are the subject of reinsurance claims through the reinsurance program.

(3)The eligible insurer makes its requests for reinsurance payments in accordance with any requirements established by the department, including requirements related to the format, structure and timing for submission of claims for reinsurance payments.

(4)The eligible insurer participated in the exchange, or is affiliated with an entity that participated in the exchange, in the benefit year in which the claims costs for which a reinsurance payment is sought were incurred.

(b)Reporting requirement.-- An insurer that seeks reinsurance payments under this chapter must report to the department, in the form and manner prescribed by the department, information about reinsurance-eligible enrollees insured by the insurer as necessary for the department to calculate reinsurance payments.

(c)Confidentiality.-- Reinsurance claims submitted under this section are confidential and are not subject to public disclosure, except as provided under section 9514 (relating to immunity).

(d)Consideration for rate filings.-- In a rate filing for a health insurance policy to be offered through the exchange, the impact of reinsurance payments under this chapter shall be identified.

(e)Limitation.-- The calculation of reinsurance payments due to an eligible insurer shall be net of all other available insurance payments applicable to a claim, including insurance accessible through subrogation or coordination of benefits.

40c9506s