| (a) An HMO must provide to each delegated entity with
which the HMO has a delegation agreement, at least monthly unless
otherwise stated in the agreement and provided in standard electronic
format agreed to by the parties, the following information:
(1) the name and either the date of birth or social
security number of each enrollee of the HMO who is eligible or assigned
to receive health care from the delegated entity, including the enrollees
added and terminated since the previous reporting period;
(2) the age, sex, evidence of coverage, and any riders
to that evidence of coverage, and, if applicable, the name of the
employer, for the enrollees of the HMO who are eligible or assigned
to receive health care from the delegated entity;
(3) a summary of the number and amount of claims paid
by the HMO on behalf of the delegated entity during the previous reporting
period; provided that an HMO is not prevented from providing, on request,
additional nonproprietary information regarding the claims if the
HMO pays any claims for the delegated entity;
(4) a summary of the number and amount of pharmacy
prescriptions paid for each enrollee for which the delegated entity
has taken partial risk during the previous reporting period, provided
that an HMO is not prevented from providing, on request, additional
nonproprietary information regarding the claims, if the HMO pays any
claims for the delegated entity;
(5) information that is needed by the delegated entity
to file claims for reinsurance, coordination of benefits, and subrogation;
and
(6) patient complaint data that relates to the delegated
entity.
(b) An HMO must provide to each delegated entity with
which the HMO has a delegation agreement the following information,
as applicable, provided in standard electronic format agreed to by
the parties at least quarterly unless otherwise stated in the agreement:
(1) detailed risk-pool data, reported quarterly and
on settlement, sufficient to allow the delegated entity to adequately
monitor its position in the risk pool; and
(2) the percent of premium attributable to hospital
or facility costs, if hospital or facility costs impact the delegated
entity's costs and, if there are changes in hospital or facility contracts
with the HMO, the projected impact of those changes on the percent
of premium attributable to hospital and facility costs within 30 days
of the changes.
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