02-031 C.M.R. ch. 835, § 6 - Dental Loss Ratio Calculation and Reporting

1. A carrier shall calculate the dental loss ratio for its Maine plans, excluding any experience from noncredible plans, as follows:

A. The numerator is the sum of:

(1) The amount expended for clinical dental services provided to enrollees;

(2) The amount expended on activities that improve dental care quality; and

(3) The amount of claims payments identified as having been avoided or recaptured through fraud reduction efforts; and

B. The denominator is the total amount of premium revenue, excluding federal and state taxes and licensing and regulatory fees paid. For nonprofit carriers that are exempt from Maine taxes, the pro rata share of the carrier's community benefit expenditures may be excluded, in the same proportion that the carrier's premium for fully and partially credible Maine dental plans bears to the carrier's total premium for all lines of business, up to a maximum of two percent of the gross premium, before exclusions, for fully and partially credible Maine dental plans.

C. The numerator described in Paragraph A may not include administrative cost expenditures.

2. In calculating its dental loss ratio, a carrier shall use clinical dental services and premium revenue solely attributable to its Maine risks, except that if the carrier's experience in Maine is not fully credible, the carrier may use nationwide experience to calculate its dental loss ratio. In considering its experience outside of Maine, the carrier must give appropriate weight to the credibility of its Maine experience.

3. Beginning on July 31, 2023, and annually thereafter, a carrier offering a dental plan or plans in Maine in effect during the preceding calendar year shall report on a form prescribed by the Superintendent the carrier's dental loss ratio for the preceding calendar year for each market segment in which the carrier participates. The Superintendent may require the carrier to submit detailed information on each plan that the carrier offered in order to determine the carrier's compliance with this rule.

Notes

02-031 C.M.R. ch. 835, § 6