Exhibit ES-A

PSO Regulatory Features of the Nine States Reviewed

State

Standards for PSOs Assuming Direct Risk

Standards for PSOs Assuming Downstream Risk

Positions on Regulatory Authority over Direct Contracting with Employers
California HMO licensure required Restricted HMO license required to accept global capitation Assumes authority to regulate risk contracting with employers
Colorado HMO or limited service licensure required HMO regulations apply to PSOs globally capitated downstream from HMOs. Assumes authority to regulate risk contracting with employers
Illinois Insurance or HMO license required if PSO is ultimate bearer of risk No regulation Direct contracting with ERISA-exempt employers allowed if employer is ultimate bearer of risk
Iowa Organized Delivery System (ODS) licensure required No regulation Assumes authority to regulate risk contracting with employers
Minnesota Community Integrated Service Network (CISN) licensure required No regulation Generally assumes authority to regulate risk contracting with employers
Ohio Insurance or HMO license required if PSO is ultimate bearer of risk HMOs, but not indemnity insurers, permitted to offer global capitation to PSOs Direct contracting with ERISA-exempt employers allowed if employer is ultimate bearer of risk
Pennsylvania Licensure as health insurance carrier required Statements of Policy outline standards for risk sharing arrangements between HMOs and PSOs Assumes authority to regulate risk contracting with employers
Texas Approved Nonprofit Health Corporation (ANHC) licensure required ANHC licensure required to accept global capitation Assumes authority to regulate risk contracting with employers
Washington Licensure as health insurance carrier required Providers can only accept risk for services they are licensed to provide themselves. Assumes authority to regulate risk contracting with employers

 

 

Exhibit 1

PSO Regulatory Features of the Nine States Reviewed

State

Standards for PSOs Assuming

Direct Risk

Standards for PSOs Assuming

Downstream Risk

Positions on Regulatory Authority over Direct Contracting with Employers
California HMO licensure required Restricted HMO license required to accept global capitation Assumes authority to regulate risk contracting with employers
Colorado HMO or limited service licensure required HMO regulations apply to PSOs globally capitated downstream from HMOs. Assumes authority to regulate risk contracting with employers
Illinois Insurance or HMO license required if PSO is ultimate bearer of risk No regulation Direct contracting with ERISA-exempt employers allowed if employer is ultimate bearer of risk
Iowa Organized Delivery System (ODS) licensure required No regulation Assumes authority to regulate risk contracting with employers
Minnesota Community Integrated Service Network (CISN) licensure required No regulation Generally assumes authority to regulate risk contracting with employers
Ohio Insurance or HMO license required if PSO is ultimate bearer of risk HMOs, but not indemnity insurers, permitted to offer global capitation to PSOs Direct contracting with ERISA-exempt employers allowed if employer is ultimate bearer of risk
Pennsylvania Licensure as health insurance carrier required Statements of Policy outline standards for risk sharing arrangements between HMOs and PSOs Assumes authority to regulate risk contracting with employers
Texas Approved Nonprofit Health Corporation (ANHC) licensure required ANHC licensure required to accept global capitation Assumes authority to regulate risk contracting with employers
Washington Licensure as health insurance carrier required Providers can only accept risk for services they are licensed to provide themselves. Assumes authority to regulate risk contracting with employers