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Bulletin 237

Educational and training standards in preferred provider arrangements

March 31, 1995

Title 24 M.R.S.A. Section 2336(B)(2) and Title 24-A M.R.S.A. Section 2673(B)(2) state:

Policies, agreements or arrangements issued under this chapter may not contain terms or conditions that will operate unreasonably to restrict the access and availability of health care services.

It is the Bureau's interpretation of the law that an arrangement unreasonably restricts access and availability if it requires
appropriately licensed providers, in order to be considered as preferred providers, to have education and training other than the following:

1. The arrangement may require a specialist provider to be certified or otherwise recognized as qualified to practice in that specialty area, according to professional standards adopted by the national organization representing that profession.

2. The arrangement may require a provider to have other education or training qualifications if the sponsor of the preferred provider arrangement demonstrates to the satisfaction of the Superintendent that its education and training requirements are uniformly applied, are not unfairly discriminatory, and are reasonably related to quality of service.

3. Nothing in this bulletin is intended to prohibit the use of reasonable standards other than education or training in the
credentialing of the preferred providers.

Insurers, nonprofit service organizations, and administrators operating preferred provider arrangements are hereby reminded that a description of the method by which providers will be selected must be filed as part of their registration application [Rule 360, Section 4(G)] and any changes made subsequent to approval must also be filed [Rule 360, Section 4]. Administrators must report any material changes within 30 days [Rule 360, Section 8(A)(1)].

Brian K. Atchinson
Superintendent of Insurance

NOTE: This bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties or privileges nor is it intended to provide legal advice. Readers are encouraged to consult applicable statutes and regulations and to contact the Bureau of Insurance if additional information is needed.

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Last Updated: September 27, 2010