An Act To Provide Affordable Health Insurance to Small Businesses and Individuals and To Control Health Care Costs LR2137(02)
Maine Legislature, Session 121, LD 1611
Committee Amendment CA_A_H565 (House)
Amends: 5 MRSA §934-B, 5 MRSA §12004-G, 24-A MRSA §6904, 5 MRSA §12004-I, 24-A MRSA §6952, 22 MRSA §3174, 22 MRSA §3174-D, 22 MRSA §3174-V, 2 MRSA §104, 22 MRSA §1709, 22 MRSA §328, 22 MRSA §329, 22 MRSA §335, 22 MRSA §338, 22 MRSA §1718, 22 MRSA §2061, 22 MRSA §8702, 22 MRSA §8703, 22 MRSA §8704, 22 MRSA §8707, 22 MRSA §8708-A, 22 MRSA §8712, 24 MRSA §2987, 24 MRSA §2332, 24-A MRSA §1912, 24-A MRSA §2436, 24-A MRSA §2680, 24-A MRSA §2823, 24 MRSA §2327, 24-A MRSA §423, 24-A MRSA §1902, 24-A MRSA §1903, 24-A MRSA §1905, 24-A MRSA §2736, 24-A MRSA §2736-A, 24-A MRSA §2736-C, 24-A MRSA §2, 24-A MRSA §4203, 24-A MRSA §4207, 24-A MRSA §4303

12lST LEGISLATURE 
COMMITTEE AMENDMENT itA It to H.P. 1187, L.D. 1611, Bill, "An 
Act To Provide Affordable Health Insurance to Small Businesses 
and Individuals and To Control Health Care Costs" 
Amend the bill by inserting after the title and before the 
enacting clause the following: 
'Emergency preamble. Whereas, Acts of the Legislature do not 
become effective until 90 days after adjournment unless enacted 
as emergencies; and 
Whereas, Maine needs a comprehensive state health plan to 
ensure access to and quality and affordability of health care 
statewide; and 
Whereas, 
health 
care 
costs 
are 
rising 
rapidly 
and 
challenging Maine's capacity to provide accessible, high-quality 
health care; and 
Whereas, 
small 
businesses 
and 
individuals 
do 
not 
have 
adequate access to affordable health insurance coverage in this 
State: and 
Whereas, this legislation establishes Dirigo Health, which 
will 
provide 
access 
to 
coverage 
for 
small 
businesses 
and 
individuals: and 
Whereas, this legislation needs 
to 
allow 
Dirigo 
Health 
to 
begin 
beginning on July 1, 2004; and 
to be enacted immediately 
offering 
health 
coverage 
Page l-LR2137 (3) 
COMMITTEE AMENDMENT 
~s· 
~.() 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Whereas, in the judgment of the Legislature, these facts 
create an emergency within the meaning of the Constitution of 
Maine 
and 
require 
the 
following 
legislation 
as 
immediately 
necessary for the preservation of the public peace, health and 
safety; now, therefore,' 
Further amend the bill by striking out everything after the 
enacting clause and before the summary and inserting in its place 
the following: 
· PART A 
Sec. A-t. 2 MRS A §6, sub-§l, as amended by PL 1997, c. 643, 
Pt. Q, §l and by PL 2001, c. 354, §3, is further amended to read: 
1. 
Range 91. 
The salaries of the following state officials 
and employees are within salary range 91: 
Commissioner of Transportation; 
Commissioner of Conservation; 
Commissioner of Administrative and Financial Services; 
Commissioner of Education; 
Commissioner of Environmental Protection; 
Executiye Director of Dirigo Health; 
Commissioner of Human Services; 
Commissioner of Behavioral and Developmental Services; 
Commissioner of Public Safety; 
Commissioner of Professional and Financial Regulation; 
Commissioner of Labor; 
Commissioner of Agriculture, Food and Rural Resources; 
Commissioner of Inland Fisheries and Wildlife; 
Commissioner of Marine Resources; 
Commissioner of Corrections; 
Commissioner of Economic and Community Development; and 
COMMITTEE AMENDMENT 
~. ()\ s· 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Commissioner of Defense, Veterans and Emergency Management. 
Sec. A-2. 5 MRSA §934-B is enacted to read: 
§934-B. 
Dirigo Health 
The 
position 
of 
executive 
director 
is 
a 
major 
pOlicy-influencing 
position within 
Dirigo 
Health 
established 
pursuant to Title 24 A, 
chapter 87. 
Notwithstanding any other 
provision of law, this position and any successor position are 
subject to this chapter. 
Sec. A-3. 5 MRSA §12004-G, sub-§14-D is enacted to read: 
l4-D. 
Health Care 
Board of 
Directors 
of Dirigo 
Health 
$100 
per diem 
and expenses 
24-A MRSA 
§6904 
Sec. A-4. 5 MRSA §12004-I, sub-§30-A is enacted to read: 
30-A. 
Health Care 
Maine 
Quality 
Forum 
Advisory 
Council 
Expenses 
Only 
24-A MRSA 
§6952 
Sec. A·5. 22 MRSA §3174·G, sub·§l, as amended by PL 2001, c. 
450, Pt. A, §§1 and 2, is further amended to read: 
1. 
Delivery of services. 
The department shall provide for 
the delivery of federally approved Medicaid services to the 
following persons: 
A. A qualified woman during her pregnancy and up to 60 days 
following delivery when the woman's family income is equal 
to or below 200% of the nonfarm income official poverty line; 
B. 
An infant under one year of age when the infant's family 
income is equal to or below ~8§% 200% of the nonfarm income 
official poverty line; 
C. 
A qualified elderly 9F-eisa9±ea person when the person's 
family income is equal to or below 100°-& of the nonfarm 
income official poverty line and a gualified disabled person 
when that person's family income is egual to or below 125""0 
of the nonfarm income official poverty line; 
COMMITTEE AMENDMENT 
R. 0/ S. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
D. 
A child one year of age or older and under 19 years of 
age when the child's family income is equal to or below 199% 
200% of the nonfarm income official poverty line; 
E. 
The parent or caretaker relative of a child described in 
paragraph B or D when the child's family income is equal to 
or below 199% 200% of the nonfarm income official poverty 
line, subject to adjustment by the commissioner under this 
paragraph. 
Medicaid services provided under this paragraph 
must be provided within the limits of the program budget. 
Funds appropriated for services under this paragraph must 
include an annual inflationary adjustment equivalent to the 
rate of inflation in the Medicaid program. 
On a quarterly 
basis, the commissioner shall determine the fiscal status of 
program 
expenditures 
under 
this 
paragraph. 
If 
the 
commissioner determines that expenditures will exceed the 
funds available to provide Medicaid coverage pursuant to 
this paragraph, 
the 
commissioner must adjust the 
income 
eligibility limit for new applicants to the extent necessary 
to operate the program within the program budget. 
If, after 
an 
adjustment 
has 
occurred pursuant to this paragraph, 
expenditures fall below the program budget, the commissioner 
must 
raise 
the 
income eligibility limit to 
the 
extent 
necessary to provide services to as many eligible persons as 
possible 
within 
the 
fiscal 
constraints 
of 
the 
program 
budget, as long as the income limit does not exceed 199% 
200% of the nonfarm income official poverty line; and 
F. 
A person 20 to 64 years of age who is not otherwise 
covered under paragraphs A to E when the person's family 
income is below or equal to 199% 125% of the nonfarm income 
official poverty line, provided that the commissioner shall 
adjust the maximum eligibility level in accordance with the 
requirements of the paragraph. 
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p~e~~am--~~--~~--eemmissieRe~--~£~~~---r~~--tHe 
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pessigle-~1~1&-~~-~i6eal--eeR&tra1Rt&-~--~~-Ma~Re 
Hea~tH-Aeeess-~~Ba-aese~igee-iR-seetieR-6e9T 
(2) 
If tRe-.ffiaK~mmn-~1-1g-ib-11-j,.t~-level--i~--ra-i 
.. sed--ageve 
199%-~--tRe-~~~-level-~~--te-~~~-pa~a~~apR 
aBa----s~a6e~~eBtly 
the 
commissioner 
reasonably 
anticipates the cost of the program to exceed the 
budget of the population described in this paragraph, 
COMMITTEE AMENDMENT 
R. 0\ S. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
the commissioner shall lower the maximum eligibility 
level to the extent necessary to provide coverage to as 
many persons as possible within the program budget. 
(3) 
The 
commissioner shall give at least 30 days' 
notice of the proposed change in maximum eligibility 
level 
to 
the 
joint 
standing 
committee 
of 
the 
Legislature having jurisdiction over appropriations and 
financial affairs and the joint standing committee of 
the Legislature having jurisdiction over health and 
human services matters. 
f4*---~he-~Ft~-~-~~-~~~~£~--€e¥e~a§e--~ 
meR~Rs-af~e~-~~i£i£~-~~-~-~~~¥&r-e~-ee¥e~a§e 
{~em-~~~a~&&G-S~a~e6-~~~-e~-R€~~~h-~-HWffiaR 
Se~v~ees-eF-eR-Qe~eseF-IT-6GG6T-wh~eheveF-~s-la~eFT 
For the purposes of this subsection, the "nonfarm income official 
poverty 
line" 
is that applicable 
to 
a 
family 
of 
the 
size 
involved, 
as defined by the federal Department of Health and 
Human Services and updated annually in the Federal Register under 
authority 
of 
United 
States 
Code, 
Section 
9902(2). 
For 
purposes of this subsection, "program budget" means the amounts 
available 
from 
both 
federal 
and 
state 
sources 
to 
provide 
federally approved Medicaid services. 
Sec. A-6. 22 MRSA §3174-DD is enacted to read: 
§3174-DD. 
Dirigo health coverage 
The 
department 
may 
contract 
with 
one 
or 
more 
health 
insurance 
carriers 
to 
purchase 
Dirigo 
Health 
Insurance 
for 
MaineCare members 
who 
seek to enroll through their employers 
pursuant to Title 24-A, section 6910, subsection 4, paragraph B. 
A MaineCare member who enrolls in a Dirigo Health Insurance plan 
as a member of an employer group receives full MaineCare benefits 
through Dirigo Health Insurance. 
The benefits are delivered 
through the employer-based health plan, subject to nominal cost 
sharing 
as 
permitted 
by 
United 
States 
Code, 
Section 
1396o( 2003) 
and additional coverage provided under contract by 
the department. 
Sec. A-7. 22 MRSA §3174-V, sub-§2, as amended by PL 2003, c. 
20, Part K, §ll is further amended to read: 
2. 
Contracted services. 
When a federally qualified health 
center 
otherwise 
meeting 
the 
requirements 
of 
subsection 
contracts with a managed care plan or Dirigo Health Insurance for 
the 
prov~s~on of 
Mea~ea~a MaineCare services, 
the department 
shall reimburse that center the difference between the payment 
COMMITTEE AMENDMENT 
R. o~ S. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
received by the center from the managed care plan or Dirigo 
Health Insurance and 100% of the reasonable cost, reduced by the 
total copayments for which members are responsible, incurred in 
providing services within the scope of service approved by the 
federal 
Health Resources 
and 
Services Administration or 
the 
commissioner. 
Any 
such 
managed 
care 
contract 
must 
provide 
payments for the services of a center that are not less than the 
level and amount of payment that the managed care plan or Dirigo 
Heal th Insurance would make for services provided by an entity 
not defined as a federally qualified health center. 
Sec. A-8. 24-A MRSA c. 87 is enacted to read: 
CHAPTER 87 
DIRIGO HEALTH 
SUBCHAPTER 1 
GENERAL PROVISIONS 
§6901. 
Short title 
This chapter may be known and cited as "the Dirigo Health 
Act." 
§6902. 
Dirigo Health established: declaration of necessity 
Dirigo Health is established as an independent executive 
agency to arrange for the provision of comprehensive, affordable 
health care coverage to eligible small employers. including the 
self-employed. their employees and dependents. and individuals on 
a 
voluntary basis. 
Dirigo 
Health 
is 
also 
responsible 
for 
monitoring and improving the guality of health care in this 
State. 
The exercise by Dirigo Health of the powers conferred by 
this chapter must be deemed and held to be the performance of 
essential governmental functions. 
§6903. 
Definitions 
As 
used in this 
chapter. 
unless 
the 
context 
otherwise 
indicates, the following terms have the following meanings. 
1. 
Board. 
"Board" means the Board of Directors of Dirigo 
Health, as established in section 6904. 
2. Child. 
"Child" means a natural child. stepchild. adopted 
child or child placed for adoption with a plan enrollee. 
COMMITTEE AMENDMENT 
R. 0\ S. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
3. 
Dependent. 
"Dependent" means 
a 
spouse, 
an unmarried 
child under 19 years of age, a child who is a student under 23 
years of age and is financially dependent upon a plan enrollee or 
a person of any age who is the child of a plan enrollee and is 
disabled and dependent upon that plan enrollee. "Dependent" may 
include 
a 
domestic 
partner consistent with sections 
2741-A, 
2832-A and 4249 and Title 24, section 2319-A. 
4. 
Dirigo 
Health 
Insurance. 
"Dirigo 
Health 
Insurance" 
means the health' insurance product established by Dirigo Health 
that is offered by a private health insurance carrier or carriers. 
5. 
Eligible business. 
"Eligible business" means a business 
that employs at least 2 but not more than 50 eligible employees, 
the majority of whom are employed in the State, 
including a 
municipality that has 50 or fewer employees. 
After one year of operation of Dirigo Health, the board may, by 
rule, define "eligible business" to include larger public or 
private employers. 
6. 
Eligible 
employee. 
"Eligible 
employee" 
means 
an 
employee of an eligible business who works at least 20 hours per 
week for that eligible business. 
"Eligible employee" does not 
include an employee who works on a temporary or substitute basis 
or who does not work more than 26 weeks annually. 
7. 
Eligible individual. 
"Eligible individual" means: 
A. 
A self-employed individual who: 
(1) 
Works and resides in the State; and 
(2) 
Is organized as a sole proprietorship or in any 
other 
legally 
recognized 
manner 
in 
which 
a 
self-employed individual may organize, 
a 
substantial 
part of whose income derives from a trade or business 
through which the individual has 
attempted to earn 
taxable income; 
B. 
An unemployed individual who resides in this State; or 
C. 
An individual employed in an eligible business that does 
not offer health insurance. 
8. 
Employer. 
"Employer" means the owner or responsible 
agent of a business authorized to sign contracts on behalf of the 
business. 
COMM/rrEE AMENDMENT 
?,. 0\ S. 
COMMITTEE AMENDMENT "A" to H.P. 1187. L.D. 1611 
9. 
Executive director. 
"Executive director" 
means 
the 
Executive Director of Dirigo Health. 
10. 
Health insurance carrier. 
"Health insurance carrier" 
means: 
A. 
An insurance company licensed in accordance with this 
Title to provide health insurance: 
B. 
A health maintenance organization licensed pursuant to 
chapter 56: 
C. 
A 
preferred 
provider 
arrangement 
administrator 
registered pursuant to chapter 32: 
D. 
A nonprofit hospital or medical service organization or 
health plan licensed pursuant to Title 24: or 
E. An employee benefit excess insurance company licensed in 
accordance with this Title to provide property and casualty 
insurance that provides employee benefit excess insurance 
pursuant to section 707, subsection 1, paragraph C-l. 
11. 
Health plan in Medicaid. 
"Health plan in Medicaid" 
means a health insurance carrier that meets the requirements of 
Code 
of Federal Regulations, 
Part 438 
(2002) 
and has 
a 
contract 
with 
the 
Department 
of 
Human 
Services 
to 
provide 
MaineCare covered services to individuals enrolled in MaineCare. 
12. 
Participating employer. "Participating employer" means 
an eligible business that contracts with Dirigo Health pursuant 
to section 6910. subsection 4. paragraph B and that has employees 
enrolled in Dirigo Health Insurance. 
13. 
Plan enrollee. 
"Plan enrollee" 
means 
an eligible 
individual or eligible employee who enrolls in Dirigo Health 
Insurance through Dirigo Health. 
"Plan enrollee" includes an 
eligible employee who is eligible to enroll in MaineCare. 
14. 
Provider. 
"Provider" means any person, organization, 
corporation or association that provides health care services and 
products and is authorized to provide those services and products 
under the laws of this State. 
15. 
Reinsurance 
or 
reinsurer. 
"Reinsurance" 
and 
"reinsurer" have the same meanings as in section 741. 
16. 
Resident. 
"Resident" 
has 
the 
same 
meaning 
as 
in 
section 2736-C, subsection 1, paragraph C-2. 
COMMITTEE AMENDMENT 
R.o(S. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
• 
Subsidy. 
"Subsidy" means a subsidy as described in 
section 6912. 
18. 
Third-party administrator. 
"Third-party administrator" 
means any person who, on behalf of any person who establishes a 
health insurance plan covering residents, receives or collects 
charges, 
contributions or 
premiums for 
or settles claims 
on 
residents in connection with any type of health benefit provided 
in or as an alternative to insurance as defined by section 704, 
other than: 
A. 
Any 
person 
listed 
in 
section 
1901, 
subsection 
L 
paragraphs A to C and paragraphs E to 0: or 
B. Any person who provides those services in connection with 
a group health plan sponsored by an agricultural cooperative 
association located outside of this State that provides 
heath 
insurance 
coverage 
to 
members 
and 
employees 
of 
agricultural cooperative associations located within this 
State. 
19. 
Unemployed individual. 
"Unemployed individual" means 
an individual who does not work more than 20 hours a week for any 
single employer. 
§6904. 
Board of Directors of Dirigo Health 
Dirigo Health operates under the supervision of a Board of 
Directors established in accordance with this section. 
1. 
Appointments. 
The board consists of 5 voting members 
and 3 ex officio, nonvoting members as follows. 
A. 
The 5 voting members of the board must be appointed by 
the 
Governor, 
subject 
to 
review 
by 
the 
joint standing 
committee of the Legislature having jurisdiction over health 
insurance matters and confirmation by the Senate. 
B. 
The 3 ex officio, nonvoting members of the board are: 
(1) 
The 
Commissioner 
of Professional 
and Financial 
Regulation or the commissioner's designee: 
(2) 
The director of the Governor's Office of Health 
Policy and Finance or the director of 
a 
successor 
agency; and 
( 3 ) 
The Commissioner of Administrative and Financial 
Services or the commissioner's designee. 
COMMITTEE AMENDMENT 
R.OfS. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
2. 
Qualifications of voting members. 
Voting members of the 
board: 
A. 
Must have knowledge of and experience in one or more of 
the following areas: 
(1) 
Health care purchasing: 
(2) 
Health insurance: 
(3) 
MaineCare: 
(4) 
Health policy and law: 
(5) 
State management and budget: or 
(6) 
Health care financing: and 
B. 
Except as provided in this paragraph, may not be: 
(1) 
A representative 
or 
employee 
of 
an 
insurance 
carrier authorized to do business in this State: 
(2) 
A representative or employee of a health care 
provider operating in this State: or 
(3) 
Affiliated 
with 
a 
health 
or 
health-related 
organization regulated by State Government. 
A nonpracticing health care practitioner, retired or former 
health care administrator or retired or former employee of a 
health 
insurance 
carrier 
is 
not 
prohibited 
from 
being 
considered for board membership as long as that person is 
not currently affiliated with a health or health-related 
organization. 
3. 
Terms of office. 
Voting members serve 3-year terms. 
Voting members may serve up to 2 consecutive terms. 
Of the 
initial appointees, 
one member serves an initial term of one 
year, 
members serve initial terms of 2 years and 2 members 
serve initial terms of 3 years. 
The Governor shall fill any 
vacancy for an unexpired term in accordance with subsections 1 
and 2. 
Members reaching the end of their terms may serve until 
replacements are named. 
4. 
Chair. 
The Governor shall appoint one of the voting 
members as the chair of the board. 
5. 
Quorum. 
Three voting members of the board constitute a 
quorum. 
COMMITTEE AMENDMENT 
R. of S. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
6. 
Affirmative vote. 
An affirmative vote of 3 members is 
reguired for any action taken by the board. 
7. 
Compensation. 
A member of the board must be compensated 
according 
to 
the 
provJ.sJ.ons 
of 
Title 
5, 
section 
12004-G, 
subsection 14-Di a member must receive compensation whenever that 
member fulfills any board duties in accordance with board bylaws. 
8. 
Meetings. 
The board shall meet at least 4 times a year 
at regular intervals and may also meet at other times at the call 
of the chair or the executive director. 
All meetings of the 
board are public proceedings within the meaning of Title 1, 
chapter 13, subchapter 1. 
§6905. 
Limitation on liability 
A member of the board or an employee of Dirigo Health is not 
subject to any personal liability for having acted within the 
course and scope of membership or employment to carry out any 
power or duty under this chapter. 
Dirigo Health shall indemnify 
any member of the board and any employee of Dirigo Health against 
expenses actually and necessarily incurred by that member or 
employee 
in 
connection with 
the 
defense 
of 
any 
action 
or 
proceeding in which that member or employee is made a party by 
reason of past or present authority with Dirigo Health. 
§6906. 
Prohibited interests of board members and employees 
Board members 
and 
employees of Dirigo Health and their 
spouses 
and 
dependent 
children 
may 
not 
receive 
any 
direct 
personal 
benefit 
from 
the 
activities 
of 
Dirigo 
Health 
in 
assisting any private entity, except that they may participate in 
Dirigo Health Insurance on the same terms as others may under 
this chapter. This section does not prohibit corporations or 
other entities with which board members are associated by reason 
of ownership or employment from participating in activities of 
Dirigo Health or receiving services offered by Dirigo Health as 
long as the ownership or employment is made known to the board 
and, if applicable, 
the board members abstain from voting on 
matters relating to that participation. 
§6907. 
Confidential records 
Except as provided in subsections 
and 
2, 
information 
obtained by Dirigo Health under this chapter is a public record 
within the meaning of Title 1, chapter 13, subchapter 1. 
1. 
Financial 
information. 
Any 
personally 
identifiable 
financial 
information, 
supporting data or tax return of any 
Page II-LR2137(3) 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
person 
obtained 
by 
Dirigo 
Health 
under 
this 
chapter 
is 
confidential and not open to public inspection. 
2. 
Health 
infoDmation. 
Health 
information 
obtained by 
Dirigo Health under this chapter that is covered by the federal 
Health 
Insurance Portability and Accountability Act of 1996, 
Public Law 104-191, 
Stat. 1936 or information covered by 
chapter 24 or Title 22, section 17l1-C is confidential and not 
open to public inspection. 
§6908. 
Powers and duties of Dirigo Health 
1. 
Powers. 
Subject to any limitations contained in this 
chapter or in any other law, Dirigo Health may: 
A. 
Take any legal actions necessary or proper to recover or 
collect savings offset payments due Dirigo Health or that 
are necessary for the proper administration of Dirigo Health: 
B. 
Make 
and alter bylaws, 
not 
inconsistent with this 
chapter 
or 
with 
the 
laws 
of 
this 
State, 
for 
the 
administration and regulation of the activities of Dirigo 
Health: 
C. 
Have and exercise all powers necessary or convenient to 
effect the purposes for which Dirigo Health is organized or 
to 
furtber 
the 
activities 
in 
which 
Dirigo 
Health 
may 
lawfully be engaged, including the establishment of Dirigo 
Health Insurance: 
D. 
Engage 
in legislative liaison activities, 
including 
gathering information regarding legislation, analyzing the 
effect of legislation, communicating with Legislators and 
attending 
and giving testimony at legislative sessions, 
public hearings or committee bearings; 
E. 
Take any legal actions necessary to avoid the payment of 
improper 
claims 
against 
Dirigo 
Health 
or 
the 
coverage 
provided by or through Dirigo Health, to recover any amounts 
erroneously or improperly paid by Dirigo Health, to recover 
any amounts paid by Dirigo Health as a result of mistake of 
fact or law and to recover other amounts due Dirigo Health; 
F. 
Enter into contracts with gualified 3rd parties both 
private and public for any service necessary to carry out 
the purposes of this chapter: 
G. 
Conduct studies and analyses related to the provision of 
health care, health care costs and gualitYi 
COMMITTEE AMENDMENT 
~.o\S' 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
H. 
Establish and administer a reyo1ving loan fund to assist 
health care practitioners and health care providers in the 
purchase of hardware and software necessary to implement the 
reguirements for electronic submission of claims. 
Dirigo 
Health may solicit matching contributions to the fund from 
each health insurance carrier licensed to do business in 
this State; 
I. 
Apply for and receive funds, grants or contracts from 
public and private sources; 
J. Contract with the Maine Health Data Organization and 
other organizations with expertise in health care data, 
including a nonprofit health data processing entity in this 
State, to assist the Maine Quality Forum established in 
section 6951 in the performance of its responsibilities; 
K. Provide staff support and other assistance to the Maine 
Quality 
Forum 
established 
in 
section 
6951, 
including 
assigning a director and other staff as needed to conduct 
the work of the Maine Quality Forum: and 
L. 
In accordance with the limitations and restrictions of 
this chapter, 
cause any of its powers or duties to be 
carried out by one or more organizations organized, created 
or operated under the laws of this State. 
2. 
Duties. 
Dirigo Health shall: 
A. 
Establish administrative and accounting procedures as 
recommended by the State Controller for the operation of 
Dirigo Health in accordance with Title 5: 
B. 
Collect the savings offset payments provided in section 
6913 : 
C. 
Determine the comprehensive services and benefits to be 
included 
in 
Dirigo 
Health 
Insurance 
and 
develop 
the 
specifications for Dirigo Health Insurance in accordance 
with the provisions in section 6910. Within 30 days of its 
determination of the benefit package to be offered through 
Dirigo Health Insurance, 
the board shall report 
on 
the 
benefit 
package, 
including 
the 
estimated 
premium 
and 
applicable 
coinsurance, 
deductibles, 
copayments 
and 
out-of-pocket maximums, to the joint standing committee of 
the Legislature having jurisdiction over appropriations and 
financial 
affairs, 
the 
joint standing 
committee 
of 
the 
Legislature having jurisdiction over insurance and financial 
services matters and the joint standing committee of the 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Legislature 
having 
jurisdiction 
over 
health 
and 
human 
services matters; 
D. 
Develop 
and 
implement 
a 
program 
to 
publicize 
the 
existence of Dirigo Health and Dirigo Health Insurance and 
the eligibility requirements and the enrollment procedures 
for Dirigo Health Insurance and to maintain public awareness 
of Dirigo Health and Dirigo Health Insurance; 
E. 
Arrange the provision of Dirigo Health Insurance benefit 
coverage 
to eligible individuals 
and eligible 
employees 
through contracts with one or more qualified bidders; 
F. Develop a high-risk pool for plan enrollees in Dirigo 
Health 
Insurance 
in 
accordance 
with 
the 
provisions 
of 
section 6971; and 
G. 
Establish 
and 
operate 
the 
Maine 
Quality 
Forum 
in 
accordance with the provisions of section 6951. 
3. Budget. The revenues and expenditures of Dirigo Health 
are 
subject to 
legislative 
approval 
in the biennial 
budget 
process. At the direction of the board, the executive director 
shall prepare the budget for the administration and operation of 
Dirigo Health in accordance with the provisions of law that apply 
to departments of State Government. 
4. 
Audit. 
Dirigo Health must be audited annually by the 
State Auditor. The board may, in its discretion, arrange for an 
independent audit to be conducted. A copy of the audit must be 
provided to the State Controller, to the superintendent, to the 
joint standing committee of the Legislature having jurisdiction 
over appropriations and financial affairs, to the joint standing 
committee of the Legislature having jurisdiction over insurance 
and 
financial 
services 
matters 
and 
to 
the 
joint 
standing 
committee of the Legislature having jurisdiction over health and 
human services matters. 
5. 
RUlemaking. 
Dirigo Health may adopt rules as necessary 
for the proper administration and enforcement of this chapter, 
pursuant 
to 
the 
Maine 
Administrative 
Procedure 
Act. 
Unless 
otherwise specified, rules adopted pursuant to this chapter are 
routine technical rules as defined in Title 5, 
chapter 375, 
subchapter 2-A. 
6. Annual report. 
Beginning September 1, 2004, and annually 
thereafter, the board shall report on the impact of Dirigo Health 
on the small group and individual health insurance markets in 
this 
State 
and 
any 
reduction 
in 
the 
number 
of 
uninsured 
individuals 
in 
the 
State. 
The 
board 
shall 
also 
report 
on 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
membership 
in Dirigo 
Health, 
the 
administrative 
expenses 
of 
Dirigo Health, the extent of coverage, the effect on premiums, 
the 
number 
of 
covered 
lives, 
the 
number 
of 
Dirigo 
Health 
Insurance policies issued or renewed and Dirigo Health Insurance 
premiums earned and claims incurred by health insurance carriers 
offering Dir igo Health Insurance. 
The board shall submit the 
report to the Governor, 
the joint standing committee of the 
Legislature having jurisdiction over appropriations and financial 
affairs, the joint standing committee of the Legislature having 
jurisdiction over health insurance and financial services matters 
and 
the 
joint standing 
committee 
of 
the 
Legislature having 
jurisdiction over health and human services matters. 
7. 
Technical assistance from other state agencies. 
Other 
state agencies, including, but not limited to, the bureau, the 
Department of Human Services, 
Maine Revenue Services and the 
Maine 
Health 
Data 
Organization, 
shall 
provide 
technical 
assistance and expertise to Dirigo Health upon request. 
8. 
Legal counsel. 
The Attorney General, 
when requested, 
shall furnish any legal assistance, 
counsel or advice Dirigo 
Health requires in the discharge of its duties. 
9. 
Coordination with federal« state and local health care 
systems. 
Dirigo Health shall institute a system to coordinate 
the activities of Dirigo Health with the health care programs of 
the Federal Government and state and municipal governments. 
10. 
Initial staffing. 
Upon request from the board, 
the 
Governor shall provide staffing assistance to Dirigo Health in 
the initial phases of its operation. 
11. 
Advisory 
committees. 
Dirigo 
Health 
may 
appoint 
advisory committees to advise and assist Dirigo Health. 
Members 
of an advisory committee serve without compensation but may be 
reimbursed by Dirigo Health for necessary expenses while 
on 
official business of the advisory committee. 
§6909. 
Executive director 
1. 
Appointed position. 
The executive director is appointed 
by the board and serves at the pleasure of the board. 
The 
position of executive director is a 
major policy-influencing 
position as designated in Title 5, section 934-B. 
2. 
Duties of executive director. 
The executive director 
shall: 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
A. 
Serve as the liaison between the board of directors and 
Dirigo Health and serve as secretary and treasurer to the 
board: 
B. 
Manage Dirigo Health's programs and services, including 
the Maine Quality Forum established under section 6951; 
C. 
Employ or contract on behalf of Dirigo Health for 
professional 
and 
nonprofessional 
personnel 
or 
service. 
Employees of Dirigo Health are subject to the Civil Service 
Law, 
except that the position of Director of the Maine 
Ouality Forum is not subject to the Civil Service Law: 
D. 
Approve all accounts for salaries, per diems, allowable 
expenses of Dirigo Health or of any employee or consultant 
and expenses incidental to the operation of Dirigo Health; 
and 
E. 
Perform other duties prescribed by the board to carry 
out the functions of this chapter. 
§6910. 
Dirigo Health Insurance 
1. 
Dirigo Health Insurance. 
Dirigo Health shall arrange 
for the provision of health benefits coverage through Dirigo 
Health Insurance not later than October 1. 2004. 
Dirigo Health 
Insurance must comply with all relevant requirements of this 
Title. 
Dirigo 
Health 
Insurance 
may 
be 
offered 
by 
health 
insurance 
carriers 
that 
apply 
to 
the 
board 
and 
meet 
qualifications described in this 
section 
and 
any 
additional 
qualifications set by the board. 
2. 
Legislative approval of nonprofit health care plan or 
expansion of public plan. 
If health insurance carriers do not 
apply to offer and deliver Diri90 Health Insurance, the board may 
have 
Dirigo 
Health 
provide 
access 
to 
health 
insurance 
by 
proposing the establishment of 
a 
nonprofit health care plan 
organized under Title 13-B and authorized pursuant to Title 24, 
chapter 19 or by proposing the expansion of an existing public 
plan. If the board proposes the establishment of a nonprofit 
health care plan or the expansion of an existing public plan, the 
board shall submit its proposal, including, but not limited to, a 
funding mechanism to capitalize a nonprofit health care plan and 
any recommended legislation to the joint standing committee of 
the 
Legislature 
having 
jurisdiction 
over 
health 
insurance 
matters. Dirigo Health may not provide access to health insurance 
by establishing a 
nonprofit health care plan or through 
an 
existing public plan without specific legislative approval. 
Page l6-LR2l37(3) 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
3. 
Carrier participation requirements. 
To 
qualify 
as 
a 
carrier of Dirigo Health Insurance, a health insurance carrier 
must: 
A. 
Provide the comprehensive health services and benefits 
as determined by the board, 
including a standard benefit 
package that meets the requirements for mandated coverage 
for 
specific health services, 
specific diseases 
and for 
certain providers of health services under Title 24 and this 
Title and any supplemental benefits the board wishes to make 
available; and 
B. 
Ensure that: 
(1) 
Providers contracting with a carrier contracted to 
provide coverage to plan enrollees do not charge plan 
enrollees 
or 
3rd parties 
for 
covered 
health 
care 
services in excess of the amount allowed by the carrier 
the provider has contracted with, except for applicable 
copayments, deductibles or coinsurance or as provided 
in section 4204, subsection 6; 
(2) 
Providers contracting with a carrier contracted to 
provide coverage to plan enrollees do not refuse to 
provide services to a plan enrollee on the basis of 
health status, medical condition, 
previous insurance 
status, 
race, 
color. 
creed, 
age, 
national 
origin, 
citizenship 
status, 
gender, 
sexual 
orientation, 
disability or marital status. 
This subparagraph may 
not be construed to require 
a 
provider to furnish 
medical services that are not within the scope of that 
provider's license; and 
(3) 
Providers contracting with a carrier contracted to 
provide coverage to plan enrollees are reimbursed at 
the negotiated reimbursement rates between the carrier 
and its provider network. 
Health insurance carriers that seek to qualify to provide 
Dirigo Health Insurance must also qualify as health plans in 
Medicaid. 
4. 
Contracting authority. 
Dirigo Health has contracting 
authority and powers to administer Dirigo Health Insurance as set 
out in this subsection. 
A. 
Dirigo 
Health 
may 
contract 
with 
health 
insurance 
carriers licensed to sell health insurance in this State or 
other 
private 
or 
public 
third-party 
administrators 
to 
provide Dirigo Health Insurance. 
In addition: 
COMMITTEE AMENDMENT 
\\; 0\ s· 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
(1) 
Dirigo Health shall issue requests for proposals 
from health insurance carriers; 
(2) 
Dirigo Health may 
include quality improvement, 
disease 
prevention, 
disease 
management 
and 
cost-containment 
prOV1Slons 
in 
the 
contracts 
with 
participating health insurance carriers or may arrange 
fQr the provision of such services through contracts 
with other entities; 
(3) 
Dirigo Health shall require participating health 
insurance carriers to offer a benefit plan identical to 
Dirigo Health Insurance, 
for which 
nQ 
Dirigo Health 
subsidies are available, in the general small grQup 
market; 
(4) 
Dirigo Health shall make payments tQ participating 
health 
insurance 
carriers 
under 
a 
DirigQ 
Health 
Insurance contract to provide DirigQ Health Insurance 
benefits to plan enrollees nQt enrQlled in MaineCare; 
(5) 
Dirigo 
Health 
may 
set 
allowable 
rates 
for 
administration and underwriting gains fQr Dirigo Health 
Insurance; 
(6) 
DirigQ Health may administer cQntinuatiQn benefits 
fQr eligible individuals frQm emplQyers with 20 or more 
emplQyees who have purchased health insurance CQverage 
thrQugh 
Dirigo 
Health 
fQr 
the 
duration 
Qf 
their 
eligibility periods for continuation benefits pursuant 
tQ 
the 
federal 
CQnsolidated 
Omnibus 
Budget 
Reconciliation Act, Public Law 99-272, Title X, Private 
Health Insurance Coverage, Sections 10001 to 10003; and 
(7) 
Dirigo 
Health 
may 
administer 
Qr 
contract 
to 
administer the United States Internal Revenue Code of 
1986, 
Section 125 plans for employers and employees 
participating 
in 
Dirigo 
Health, 
including 
medical 
expense 
reimbursement 
accounts 
and 
dependent 
care 
reimbursement accounts. 
B. 
Dirigo Health shall contract with eligible businesses 
seeking assistance 
from 
Dirigo 
Health 
in 
arranging for 
health benefits coverage by DirigQ Health Insurance for 
their emplQyees and dependents as set out in this paragraph. 
(1) 
Dirigo Heath may establish contract and other 
repQrting 
forms 
and 
procedures 
necessary 
for 
the 
efficient administration of contracts. 
Page l8-LR2137(3) 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
(2) 
Dirigo 
Health 
shall 
collect 
payments 
from 
participating employers and plan enrollees to cover the 
cost of: 
( a) 
Dirigo 
Health 
Insurance 
for 
enrolled 
employees and dependents in contribution amounts 
determined by the board: 
(b) 
Dirigo Health's quality assurance, 
disease 
prevention, 
disease 
management 
and 
cost-containment programs: 
(c) 
Dirigo Health's administrative services: and 
(d) 
Other health promotion costs. 
(3) 
Dirigo Health shall establish the minimum required 
contribution levels, not to exceed 60°1>, to be paid by 
employers toward the aggregate payment in subparagraph 
(2) and establish an equivalent minimum amount to be 
paid 
by 
employers 
or 
plan 
enrollees 
and 
their 
dependents who are enrolled in MaineCare. 
The minimum 
required contribution level to be paid by employers 
must be prorated for employees that work less than the 
number of hours of a full-time equivalent employee as 
determined 
by 
the 
employer. 
Dirigo 
Health 
may 
establish a separate minimum contribution level to be 
paid by employers toward coverage for dependents of the 
employers' enrolled employees. 
(4) 
Dirigo 
Health 
shall 
require 
participating 
employers 
to 
certify that 
at 
least 
75% 
of 
their 
employees that work 30 hours or more per week and who 
do not have other creditable coverage are enrolled in 
Dirigo Health Insurance and that the employer group 
otherwise meets the minimum participation requirements 
specified by section 2808-B, subsection 4, paragraph A. 
(5) 
Dirigo Health shall reduce the payment amounts for 
plan enrollees eligible for 
a 
subsigy unger section 
6912 
accordingly. 
Dirigo 
Health 
shall 
return 
any 
payments 
mage 
by 
plan enrollees 
also 
enrolled 
in 
MaineCare to those enrollees. 
(6) 
Dirigo 
Health 
shall 
require 
participating 
employers to pass on any subsidy in section 6912 to the 
plan enrollee qualifying for the subsidy, 
up to the 
amount of payments made by the plan enrollee. 
COMMITTEE AMENDMENT 
.()\ s· 
~. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
(7} 
Dirigo 
H~alth mal': establish other criteria for 
participation. 
(8} 
Dirigo 
Health 
mal': 
limit 
the 
number 
of 
2articipating emplol':ers. 
C. 
Dirigo 
Health 
mal': 
2ermit 
eligible 
individuals 
to 
purchase Dirigo Health Insurance for themselves and their 
de2endents as set out in this 2aragraph. 
(I} 
Dirigo Health mal': establish contract and other 
re20rting 
forms 
and 
procedures 
necessarl': 
for 
the 
efficient administration of contracts. 
(2} 
Dirigo Health mal': collect payments from eligible 
individuals participating in Dirigo Health Insurance to 
cover the cost of: 
(a} 
Enrollment in Dirigo Health Insurance 
for 
eligible individuals and dependents: 
(b} 
Dirigo Health's gualitl': assurance, 
disease 
prevention, 
disease 
management 
and 
cost-containment programs: 
(c) 
Dirigo Health's administrative services: and 
(d} 
Other health promotion costs. 
(3} 
Dirigo Health shall reduce the pal':ment amounts for 
individuals eligible for a subsidl': under section 6912 
accordingll':. 
(4} 
Dirigo 
Health 
mal': 
reguire 
that 
eligible 
individuals 
certifl': 
that all their 
dependents 
are 
enrolled in Dirigo Health Insurance or are covered bl': 
another creditable plan. 
(5) 
Dirigo Health mal': reguire an eligible individual 
who is currentll': emplol':ed bl': an eligible employer that 
does not offer health insurance to certify that the 
current 
employer 
did 
not 
provide 
access 
to 
an 
employer-sponsored benefits plan in the 12-month period 
immediatell': 
preceding 
the 
eligible 
individual's 
application. 
(6) 
Dirigo 
Health 
mal': 
limit 
the 
number 
of 
plan 
enrollees. 
COMMITTEE AMENDMENT 
~.Q\S. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
(7) 
Dirigo Health may establish other criteria for 
participation. 
5. 
Enrollment in Dirigo Health Insurance. 
Dirigo Health 
shall 
perform, 
at 
a 
m~n~mum, 
the 
following 
functions 
to 
facilitate enrollment in Dirigo Health Insurance. 
A. 
Dirigo Health shall publicize the availability of Dirigo 
Health Insurapce to businesses, 
self-employed individuals 
and others eligible to enroll in Dirigo Health Insurance. 
B. 
Dirigo Health shall screen all eligible individuals and 
employees for eligibility for subsidies under section 6912 
and eligibility for MaineCare. 
To facilitate the screening 
and referral process, Dirigo Health shall provide a single 
application 
form 
for 
Dirigo 
Health 
and 
MaineCare. 
The 
application materials must inform applicants of subsidies 
available 
through 
Dirigo 
Health 
and 
of 
the 
additional 
coverage available through MaineCare. 
It must 
allow an 
applicant to choose on the application form to apply or not 
to apply for MaineCare or for a subsid,y. It must allow an 
applicant 
to 
provide 
household 
financial 
information 
necessary 
to 
determine 
eligibility for 
MaineCare 
or 
a 
subsidy. 
Except when the applicant has declined to apply 
for MaineCare or a subsidy, an application must be treated 
as an application for Dirigo Health, for a subsidy and for 
MaineCare. 
MaineCare must make the final determination of 
eligibility for MaineCare. 
C. 
Except as provided in this paragraph, the effective date 
of coverage for a new enrollee in Dirigo Health Insurance is 
the first day of the month following receipt of the fully 
completed 
application for 
that enrollee 
by 
the carrier 
contracting with Dirigo Health or the first day of the next 
month if the fully completed application is received by the 
carrier within 10 calendar days of the end of the month. If 
a new enrollee in Dirigo Health Insurance had prior coverage 
through an individual or small group policy, coverage under 
Dirigo Health Insurance must take effect the day following 
termination of that enrollee's prior coverage. 
6. 
Quality 
improvement. 
disease 
management 
and 
cost 
containment. 
Dirigo Health shall promote quality improvement, 
disease 
prevention, 
disease 
management 
and 
cost-containment 
programs as part of its administration of Dirigo Health Insurance. 
§6911. 
Coordination with MaineCare 
The 
Department 
of 
Human 
Services 
is 
the 
state 
agency 
responsible for the financing and administration of MaineCare. It 
COMMITTEE AMENDMENT 
~s· 
\\. () 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
shall 
pay 
for 
MaineCare 
benefits 
for 
MaineCare-eligible 
individuals, 
including 
those 
enrolled 
in 
health 
plans 
in 
MaineCare 
that 
are 
providing 
coverage 
under 
Dirigo 
Health 
Insurance. 
§69l2. 
Subsidies 
Dirigo Health may establish sliding-scale subsidies for the 
purchase 
of Dirigo 
Health 
Insurance paid by individuals 
or 
employees whose income is under 300% of the federal poverty level 
and who are not eligible for MaineCare. 
Dirigo Health may also 
establish 
sliding-scale 
subsidies 
for 
the 
purchase 
of 
employer-sponsored 
health 
coverage 
paid 
by 
employees 
of 
businesses with more than 50 employees, whose income is under 
300% of the federal poverty level and who are not eligible for 
MaineCare. 
1. 
Administration. 
Dirigo Health shall, by rule, establish 
procedures to administer this section. 
2. 
Individuals eligible for subsidy. 
Indiyiduals eligible 
for a subsidy must: 
A. 
Have an income under 300% of the federal poverty level, 
be 
a 
resident of the State, be ineligible for MaineCare 
coverage and be enrolled in Dirigo Health Insurance: or 
B. 
Be enrolled in a health plan of an employer with more 
than 50 employees. 
The health plan must meet any criteria 
established by Dirigo Health. 
The 
individual must meet 
other eligibility criteria established by Dirigo Health. 
3. 
Limitation of subsidies. 
Dirigo Health shall limit the 
availability of subsidies to reflect limitations of available 
funds. 
4. 
Limitation on amount subsidized. 
Dirigo Health may 
limit the amount subsidized of the payment made by individual 
plan enrollees under section 6910, subsection 4, paragraph C to 
40% of the payment to more closely parallel the subsidy received 
by employees. 
In no case may the subsidy granted to eligible 
indi viduals in accordance wi th subsection 2, paragraph A exceed 
the maximum subsidy level available to other eligible individuals. 
5. 
Notification of subsidy. 
Dirigo Health shall notify 
applicants and their employers in writing of their eligibility 
and approved level of subsidy. 
6. 
Report. 
Within 
days 
after 
any 
subsidies 
are 
established pursuant to this section, the board shall report on 
COMMITTEE AMENDMENT 
.. 11. Of S. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
the 
amount 
of 
the 
subsidies, 
the 
funding 
reguired 
for 
the 
subsidies and the estimated number of Dirigo Health enrollees 
eligible for the subsidies and submit the report to 
the joint 
standing committee of the Legislature having jurisdiction over 
appropriations 
and 
financial 
affairs, 
the 
joint 
standing 
committee of the Legislature having jurisdiction over insurance 
and financial services matters and the joint standing committee 
of the Legislature having juriSdiction over health and human 
services matters. 
§6913. 
Savings offset paJments against health insurance 
carriers. employee benefit excess insurance carriers and 
third-party administrators 
1. 
Determination of cost savings. 
After an opportunity for 
a hearing conducted pursuant to Title 5, chapter 375, subchapter 
4, the board shall determine annually not later than April the 
aggregate measurable cost savings, 
including any reduction or 
avoidance of bad debt and charity care costs to health care 
providers in this State as a result of the operation of Dirigo 
Health and 
any 
increased enrollment due 
to 
an expansion in 
MaineCare eligibility occurring after June 30, 2004. 
2. 
Sayings offset payments. 
For the purpose of providing 
the funds necessary to provide subsidies pursuant to section 6912 
and support 
the Maine Quality Forum established pursuant to 
subchapter 2, the board shall establish a savings offset amount 
to be paid by health insurance carriers, employee benefit excess 
insurance carriers and third-party administrators, not including 
carriers 
and 
third-party 
administrators 
with 
respect 
to 
accidental injury, specified disease, hospital indemnity, dental, 
vision, disability, income, long-term care, Medicare supplement 
or other limited benefit health insurance, annually at a rate 
that may not exceed savings resulting from decreasing rates of 
growth in the State's health care spending and in bad debt and 
charity care costs. 
Payment of the savings offset amount must 
begin 
months after Dirigo Health begins providing health 
insurance 
coverage. 
The 
savings 
offset 
payment 
amount, 
as 
determined by the board, is the determining factor for inclusion 
of savings offset payments in premiums 
through rate setting 
review by 
the bureau. 
Savings offset payments 
must be 
made 
guarterly and are due not less than 30 days after written notice 
to 
the 
health 
insurance 
carriers, 
employee 
benefit 
excess 
insurance carriers and third-party administrators and must accrue 
interest at 12% per annum on or after the due date. 
3. 
Maximum 
savings offset payments 
on health insurance 
carriers and employee benefit excess insurance carriers. 
Each 
health insurance carrier and employee benefit excess insurance 
carrier must pay a savings offset in an amount not to exceed 4.0% 
COMMITTEE AMENDMENT 
~s· 
~~c;) 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
of annual health insurance premiums and employee benefit excess 
insurance premiums on policies issued pursuant to the laws of 
this State that insure residents of this State. 
The savings 
offset payment may not exceed savings resulting from decreasing 
rates of growth in the State's health care spending and bad debt 
and charity care costs. The savings offset payment applies to 
premiums paid on or after July 1, 2005. Savings offset payments 
must reflect aggregate measurable cost savings, 
including any 
reduction or avoidance of bad debt and charity care costs to 
health care providers in this State, as a result of the operation 
of Dirigo Health and any increased enrollment due to an expansion 
in MaineCare eligibility occurring after 
June 
30, 
2004, 
as 
determined by the board consistent with subsection 1. A health 
insurance carrier and employee benefit excess insurance carrier 
may not be required to pay a savings offset payment on policies 
or contracts insuring federal employees. 
4. 
Deterntination of savings offset payments. 
The board 
shall make reasonable efforts to ensure that premium revenue, or 
claims plus any administrative expenses and fees with respect to 
third-party administrators, is counted only once with respect to 
any savings offset payment. 
For that purpose, the board shall 
reguire each health insurance carrier to include in its premium 
revenue gross of reinsurance ceded. 
The board shall allow a 
health insurance carrier to 
exclude 
from 
its gross 
premium 
revenue 
reinsurance 
premiums 
that have 
been 
counted 
by 
the 
primary insurer for the purpose of determining its savings offset 
payment 
under 
this 
subsection. 
The 
board 
shall 
allow 
each 
employee benefit excess insurance carrier to exclude from its 
gross premium revenue the amount of claims that have been counted 
by a third-party administrator for the purpose of determining its 
savings offset payment 
under this subsection. 
The 
board may 
verify each health insurance carrier, 
employee benefit excess 
insurance carrier and third-party administrator's savings offset 
payment based on annual statements and other reports determined 
to be necessary by the board. 
5. 
Failure 
to 
pay 
savings 
offset 
payments. 
The 
superintendent may suspend or revoke, after notice and hearing, 
the certificate of authority to transact insurance in this State 
of 
any health 
insurance carrier or 
employee benefit 
excess 
insurance carrier or the license of any third-party administrator 
to operate in this State that fails to pay a savings offset 
payment. 
In 
addition, 
the 
superintendent 
may 
assess 
civil 
penalties against any health insurance carrier, employee benefit 
excess insurance carrier or third-party administrator that fails 
to pay a savings offset payment or may take any other enforcement 
action authorized 
under 
section 
12-A 
to collect 
any 
unpaid 
savings offset payments. 
COMMITTEE AMENDMENT 
~'O. 
~5~ 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
6. 
Savings offset payments through reductions in growth in 
State's health care spending and bad debt and charity care. On an 
annual basis no later than April of each year, the board shall 
prospectively determine the savings offset to be applied during 
each 12 month period. 
To make its determination, the board shall 
use the criteria and reports described in subsections 7 and 8. 
Annual offset payments must be reconciled to determine whether 
unused payments may be returned to health insurance carriers, 
employee 
benefit 
excess 
insurance 
carriers 
and 
third-party 
administrators according to a formula developed by the board. 
Savings offset payments must be used solely to fund the subsidies 
authorized by section 6912 and to support the Maine Ouality Forum 
established in subchapter 
and may not exceed savings 
from 
reductions in growth of the State's health care spending and bad 
debt and charity care. 
7. 
Demonstration of recovery of savings offset payments 
through reduction in rate of growth in State's health spending 
and 
bad 
debt 
and 
charity 
care. 
In 
accordance 
with 
the 
requirements of this subsection, every health insurance carrier 
and health care provider shall demonstrate that best efforts have 
been made to ensure that a carrier has recovered savings offset 
payments 
made 
pursuant 
to 
this 
section 
through 
negotiated 
reimbursement 
rates 
that 
reflect 
health 
care 
providers' 
reductions or stabilization in the cost of bad debt and charity 
care as 
a 
result of the operation of Dirigo Health and any 
increased enrollment due to an expansion in MaineCare eligibility 
occurring after June 30, 2004. 
A. 
A health insurance carrier shall use best efforts to 
ensure health insurance premiums reflect any such recovery 
of savings offset payments as those savings offset payments 
are 
reflected 
through 
incurred 
claims 
experience 
in 
accordance with subsection 9. 
B. 
During any negotiation with a health insurance carrier 
relating to a health care provider's reimbursement agreement 
with that carrier, a health care provider shall provide data 
relating to any reduction or avoidance of bad debt and 
charity care costs to health care providers in this State, 
as a result of the operation of Dirigo Health and as a 
result of any increased enrollment due to an expansion in 
MaineCare eligibility occurring after June 30, 2004. 
8. 
Rgports. 
The 
following 
reports 
are 
required 
in 
accordance with this subsection. 
A. 
On a quarterly basis beginning with the first quarter 
after Dirigo Health Insurance begins offering coverage, the 
board shall collect and report on the following: 
COMMITTEE AMENDMENT 
~<::>. 
~.~ 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
(1) 
The total enrollment in Dirigo Health Insurance, 
including 
the 
number 
of 
enrollees 
previously 
under insured or 
uninsured, 
the 
number 
of 
enrollees 
previously insured, the number of individual enrollees 
and the 
number of enrollees enrolled through small 
employers: 
( 2 ) 
The total number of enrollees covered in health 
plans 
through 
large 
employers 
and 
self-insured 
employers: 
(3) 
The number of employers, both small employers and 
large 
employers, 
who 
have 
ceased 
offering 
health 
insurance 
or 
contributing 
to 
the 
cost 
of 
health 
insurance for 
employees or who 
have 
begun offering 
coverage on a self-insured basis; 
(4) 
The number of employers, both small employers and 
large 
employers, 
who 
have 
begun 
to 
offer 
health 
insurance or contribute to the cost of health insurance 
premiums for their employees. 
(5) 
The 
number 
of 
new participating 
employers 
in 
Dirigo Health Insurance; 
(6) 
The number of employers ceasing to offer coverage 
through Dirigo Health Insurance; 
(7) 
The duration of employers participating in Dirigo 
Health Insurance; and 
(8) 
A comparison of actual enrollees in Dirigo Health 
Insurance to the projected enrollees. 
B. 
The board shall establish the total health care spending 
in the State for the base year of 2002 and shall annually 
determine, 
in 
collaboration 
with 
the 
superintendent, 
appropriate actuarially supported trend factors that reflect 
savings consistent wi th subsection 1 and compare rates of 
spending growth to the base year of 2002. 
The board shall 
collect 
on 
an 
annual 
basis, 
in consultation 
with 
the 
superintendent, the total cost to the State's health care 
providers of bad debt and charity care beginning with the 
base year of 2002. 
This information may be compiled through 
mechanisms, 
including, 
but 
not 
limited 
to, 
standard 
reporting or statistically accurate surveys of providers and 
practitioners. The board shall utilize existing data on file 
with state agencies 
or other organizations 
to minimize 
COMMITTEE AMENDMENT 
~<o. 
~.~ 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
duplication. 
The 
comparisons 
to 
the 
base 
year 
must 
be 
reported beginning March 1, 2004 and annually thereafter. 
C. 
Health insurance carriers and health care providers 
shall 
report 
annually, 
beginning 
March 
1, 
2005 
and 
thereafter, information regarding the experience of a prior 
12-month period on the efforts undertaken by the carrier and 
provider to recover sayings offset payments, as reflected in 
reimbursement rates. through a reduction or stabilization in 
bad debt and charity care costs as a result of the operation 
of Dirigo Health and any increased enrollment due to an 
expansion in MaineCare eligibility occurring after June 30, 
2004. 
The board shall determine the appropriate format for 
the report and utilize existing data on file with state 
agencies or other organizations to minimize duplication. The 
report must be submitted to the board. Using the information 
submitted by carriers and providers, the board shall submit 
a 
summary of that 
information 
by 
October 
1, 
2005 
and 
annually thereafter. 
D. 
The quarterly reports required to be submitted by the 
board pursuant 
to 
paragraph 
A 
and 
the 
annual 
reports 
required to be submitted by the board pursuant to paragraphs 
Band C must be submitted to the superintendent, to the 
joint 
standing 
committee 
of 
the 
Legislature 
having 
jurisdiction over appropriations and financial affairs, to 
the 
joint standing 
committee 
of 
the 
Legislature having 
jurisdiction over insurance and financial services matters, 
and to the joint standing committee 
of 
the Legislature 
having jurisdiction over health and human services matters. 
10. 
Demonstration of offset. 
As 
provided in sections 
2736-C, 
2808-B 
and 
2839-B, 
the 
claims 
experience 
used 
to 
determine any filed premiums or rating formula must reasonably 
reflect, in accordance with accepted actuarial standards, known 
changes and offsets in payments by the carrier to health care 
providers in this State. including any reduction or avoidance of 
bad debt and charity care costs to health care providers in this 
State as a result of the operation of Dirigo Health and any 
increased enrollment due to an expansion in MaineCare eligibility 
occurring after 
June 
30, 
2004 
as 
determined 
by 
the 
board 
consistent with subsection 1. 
§6914. 
Intragovernmenta1 transfer 
Starting July L 
2004, Dirigo Health shall transfer funds, 
as necessary, to a special dedicated, nonlapsing revenue account 
administered by the agency of State Government that administers 
MaineCare for the purpose of providing a state match for federal 
Medicaid dollars. Dirigo Health shall annually set the amount of 
COMMITTEE AMENDMENT 
~<,:>. 
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COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
contribution. 
The transfer may not include money collected as a 
savings payment offset pursuant to section 6913. 
§6915. 
Dirigo Health Fund 
The Dirigo Health Fund is created as a dedicated fund for 
the deposit of any funds advanced for initial operating expenses, 
payments made by employers and individuals, any savings offset 
payments made pursuant to section 6913 and any funds received 
from any public or private source. 
The fund may not lapse, but 
must be carried forward to carry out the purposes of this chapter. 
SUBCHAPTER 2 
HEALTH CARE QUALITY 
§6951. 
Maine Quality Forum 
The Maine Ouality Forum, referred to in this subchapter as 
"the forum, II is established within Dirigo Health. 
The forum is 
governed by the board with advice from the Maine Ouality Forum 
Advisory Council pursuant to section 6952. 
The forum must be 
funded, at least in part. through the savings offset payments 
made pursuant to section 6913. 
Except as provided in section 
6907, subsection 2, information obtained by the forum is a public 
record as provided by Title L 
chapter 13 , 
subchapter 1. 
The 
forum shall perform the following duties. 
1. 
Research dissemination. 
The 
forum shall collect and 
disseminate 
research 
regarding 
health 
care 
quality, 
evidence-based medicine 
and 
patient 
safety 
to 
promote 
best 
practices. 
2. 
Quality and performance measures. 
The forum shall adopt 
a set of measures to evaluate and compare health care quality and 
provider performance. The measures must be adopted with guidance 
from the advisory council pursuant to section 6952. The quality 
measures adopted by the forum must be the basis for the rules for 
the collection of quaE ty data adopted by the Maine Health Data 
Organization pursuant to Title 22, section 8708-A. 
3. 
Data coordination. 
The 
forum 
shall 
coordinate 
the 
collection of health care quality data in the State. The forum 
shall work with the Maine Health Data Organization and other 
entities that collect health care data to minimize duplication 
and to minimize the burden on providers of data. 
4. 
Reporting. 
The forum shall work collaboratively with 
the 
Maine 
Health 
Data 
Organization, 
health 
care 
providers, 
COMMITTEE AMENDMENT 
~~. 
~.~ 
COMMITTEE AMENDMENT "A" to H.P. 1181, L.D. 1611 
health insurance carriers and others to report in useable formats 
comparative 
health 
care 
quality 
information 
to 
consumers, 
purchasers, 
providers, 
insurers 
and policy makers. 
The 
forum 
shall produce annual quality reports in conjunction with the 
Maine Health Data Organization pursuant to Title 22, section 8112. 
5. 
Consumer education. 
The forum shall conduct education 
campaigns to help health care consumers make informed decisions 
and engage in healthy lifestyles. 
6. 
Technology 
assessment. 
The 
forum 
shall 
conduct 
technology assessment reviews to guide the use and distribution 
of 
new 
technologies 
in 
this 
State. 
The 
forum 
shall 
make 
recommendations to the certificate of need program under Title 
22, chapter 103-A. 
7. 
Electronic data. 
The forum shall encourage the adoption 
of electronic technology and assist health care practitioners to 
implement electronic systems for medical records and submission 
of claims. The assistance may include, but is not limited to, 
practitioner 
education, 
identification 
or 
establishment 
of 
low interest financing options for hardware 
and software 
and 
system implementation sypport. 
8. 
State health plan. 
The forwm shall make recommendations 
for inclusion in the State Health Plan described under Title 2 , 
chapter 5, 
including 
recommendations based on the 
technology 
assessment reviews under subsection 6. 
9. 
Annual report. 
The forum shall make an annual report to 
the public. 
The 
forum shall provide the report to the joint 
standing committees of the Legislature having jurisdiction over 
appropr iations and financial affairs, health and human services 
matters and insurance and financial services matters. 
§6952. 
Maine Quality Forum Advisory Council 
The Maine Ouality Forum Advisory Council, referred to in 
this sybchapter as "the advisory council." is a l1-member body 
established by Title 5, 
section 12004-1, 
subsection 30-A, 
to 
advise the forum. Except as provided in section 6901, subsection 
2, 
information obtained by the advisory council is a 
public 
record as provided by Title 1, chapter 13, subchapter 1. 
1. 
Appointment; 
composition. 
The Governor shall appoint 
the following members with the approval of the joint standing 
~ommittee of the Legislature having jurisdiction over health and 
human services matters: 
A. 
Seven 
members 
representing 
providers, 
including 
physicians, 
one 
registered nurse, 
one 
representative 
of 
COMMITTEE AMENDMENT 
~s· 
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COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
hospitals, one mental health provider and one health care 
practitioner who 
is not 
a 
physician. 
The 
physician 
members must represent allopathic physicians, osteopathic 
physicians, 
primary 
care 
physicians 
and 
specialist 
physicians: 
B. 
Four 
members 
representing 
consumers, 
including 
one 
employee who 
receives health care through a commercially 
insured product, one representative of organized labor, one 
representative of a consumer health advocacy group and one 
representative of the uninsured or MaineCare recipients: 
C. 
Four 
members 
representing 
employers, 
including 
one 
member 
of 
the 
State 
Employee 
Health 
Commission. 
one 
representative of a private employer with more than 1, 000 
full-time equivalent employees, 
one 
representative of 
a 
private employer with 50 to 1, 000 full-time employees and 
one representative of a private employer with fewer than 50 
employees: 
D. 
One representative of a private health plan; and 
E. 
One representative of the MaineCare program. 
Prior 
to 
making 
appointments 
to 
the 
advisory 
council, 
the 
Governor 
shall 
seek nominations 
from 
the public 
and 
from 
a 
statewide 
allopathic 
association, 
a 
statewide 
osteopathic 
associatiop. a statewide hospital association, a statewide nurses 
association, 
a 
statewide 
health 
purchasing 
collaborative, 
a 
statewide 
health 
management 
coalition. 
organized 
labor, 
a 
statewide 
organization 
representing 
consumers 
advocating 
for 
affordable health care, 
a 
statewide 
association representing 
consumers of mental health services, a national association of 
retired persons, 
a 
statewide citizen action organization, 
a 
statewide 
organization advocating 
equal 
justice, 
a 
statewide 
organization representing local chambers of commerce, a statewide 
organization representing businesses for social responsibility, a 
statewide 
small 
business alliance, 
a 
national 
federation of 
independent businesses, a statewide association of health plans 
and other entities as appropriate. 
2. 
Terms. 
Members of the advisory council serve 5-year 
terms except for initial appointments. 
Initial appointments must 
include 5 members appointed to 3-year terms, 6 members appointed 
to 4-year terms and 6 members appointed to 5-year terms. 
A 
member may not serve more than 2 consecutive terms. 
3. 
Compensation. 
Members 
of 
the 
advisory 
council 
are 
eligible for compensation according to the provisions of Title 5, 
chapter 379. 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
4. 
Ouorum. 
A <Iuorum is a majority of the members of the 
advisory council. 
5. 
Chair and officers. 
The advisory council shall annually 
choose one of its members to serve as chair for a one-year term. 
The advisory council may select other officers and designate 
their duties. 
6. 
Meetings. 
The advisory council shall meet at least 4 
times a year at regular intervals and may meet at other times at 
the call of the chair or the executive director of Dirigo Health. 
Meetings of the council are public proceedings as provided by 
Title 1, chapter 13, subchapter 1. 
7. 
Duties. 
The advisory council shall: 
A. 
Convene 
a group of health care providers to provide 
input and advice to the council. The council shall invite 
members broadly representing health care practitioners as 
defined in Title 24, section 2502, subsection I-A, health 
care 
providers 
as 
defined 
in Title 
24, 
section 
2502, 
subsection 
2, 
federally 
qualified 
health 
centers 
and 
pharmacists. 
Members 
serve 
as 
volunteers 
and 
without 
compensation or reimbursement for expenses: 
B. 
Provide expertise in health care quality to assist the 
board: 
C. 
Advise and support the forum by: 
(1) 
Establishing and monitoring, with Dirigo Health, 
an annual work plan for the forum: 
(2) 
Providing guidance in the adoption of <Iual i ty and 
performance measures: 
(3) 
Serving as a liaison between the provider group 
established in paragraph A and the forum: 
(4) 
Conducting public hearings and meetings; and 
(5) 
Reviewing consumer education materials developed 
by the forum: 
D. 
Make 
recommendations 
regarding <Iuality assurance 
and 
quality improvement priorities for inclusion in the State 
Health Plan described in Title 2, chapter 5: and 
COMMITTEE AMENDMENT 
~s· 
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COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
E. 
Serve 
as 
a 
liaison 
between 
the 
forum 
and 
other 
organizations working in the field of health care quality. 
SUBCHAPTER 3 
DIRIGQ HEALTH HIGH-RISK POOL 
§6971. 
Dirigo Health High-risk Pool 
Dirigo Health shall establish the Dirigo Health High-risk 
Pool, referred to in this section as "the high-risk pool" for 
plan enrollees in accordance with this section. 
1. 
Eligible enrollees for high risk pool. 
A plan enrollee 
must be included in the high-risk pool if: 
A. 
The total cost of health care services for the enrollee 
exceeds $100,000 in any 12-month period: or 
B. 
The enrollee has been diagnosed with one or more of the 
follQwing conditiQns: 
acquired 
immune deficiency syndrome 
(HIV/AIDS), 
angina 
pectQris, 
cirrhosis 
Qf 
the 
liver, 
cQronary occlusion, 
cystic fibrQsis, 
Friedreich's ataxia, 
hemQphilia, HQdgkin's disease, Huntington's chorea, juvenile 
diabetes, 
leukemia, 
metastatic 
cancer, 
mQtor 
or 
sensory 
aphasia, multiple sclerosis, muscular dystrophy, myasthenia 
gravis, 
mYQtQnia, 
heart 
disease 
regu1r1ng 
Qpen-heart 
surgery, 
Parkinson's 
disease, 
PQlcystic 
kidney 
disease, 
psychotic disQrders, 
quadriplegia, 
stroke, 
syringQmyelia, 
and Wilson's disease. 
2. 
Disease 
management. 
DirigQ 
Health 
shall 
develop 
appropriate disease management protocQls, develop procedures for 
implementing those protocols and determine the manner in which 
disease management must be provided to plan enrollees in the 
high-risk pool. Dirigo Health may include disease management in 
its 
cQntract with participating carriers 
for 
Dirigo 
Health 
Insurance pursuant to section 6910. 
contract separately with 
another entity fQr disease management services Qr provide disease 
management services directly through Dirigo Health. 
3. 
Report. 
Dirigo Health shall submit a report. no later 
than January 1, 2006, outlining the disease management protocols, 
procedures and delivery mechanisms used to provide services to 
plan enrollees. 
The report must also include the number of plan 
enrollees in the high risk pool, the types of diagnoses managed 
within the high risk pool, 
the 
claims experience within the 
high-risk pool 
and the 
number 
and 
type of claims exceeding 
$100,000 
for 
enrollees 
in 
the 
high-risk 
pool 
and 
for 
all 
enrollees 
in Dirigo 
Health 
Insurance. 
The 
report 
must 
be 
COMMITTEE AMENDMENT 
~s· 
~.~ 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
submitted to the joint standing committee of the Legislature 
having jurisdiction over health insurance matters. 
The committee 
may make recommendations on the operation of the high-risk pool 
and may report out legislation to the Second Regular Session of 
the 122nd Legislature relating to the high-risk pool. 
4. 
Establishment of statewide high risk pool. 
After 
years of operation, but no later than October L 
2007, Dirigo 
Health shall evaluate the impact of Dirigo Health on average 
premium 
rates in this State 
and 
on 
the 
rate of 
uninsured 
individuals in this State and compare the trends in those rates 
to the trends in the average premium rates and average rates of 
uninsured individuals for the 31 states that have established a 
statewide high-risk pool as of July L 
2003. 
The board shall 
submit the evaluation of the impact of Dirigo Health in this 
State in comparison to states with high-risk pools to the joint 
standing committee of the Legislature having jurisdiction over 
health insurance matters by January L 
2008. If the trend in 
average 
premium 
rates 
in this 
State 
and 
rate 
of 
uninsured 
individuals exceed the trend for the average among the 31 states 
with high-risk pools, 
the board shall submit legislation on 
January 1, 
2008 to the Second Regular Session of the 123rd 
Legislature that proposes to establish a statewide high-risk pool 
in this State consistent with the characteristics of high-risk 
pools operating in other states. 
Sec. A-9. Monthly report. 
The Department of Human Services 
shall provide a monthly report of enrollment and expenditures for 
the noncategorical adults enrolled in the MaineCare program under 
the Maine Revised Statutes, Title 22, section 3174-G, subsection 
1, paragraph F. 
The report must include the number of members, 
expenses and projections for expenses in the state fiscal year 
for members enrolled under the expansion of income eligibility 
from 100% of the nonfarm income official poverty line to 125% of 
the nonfarm income official poverty line. 
Sec. A-tO. Determination of savings offset payments for third-party 
administrators. 
The 
Governor I s 
Office 
of 
Health 
Policy 
and 
Finance and the Board of Directors of Dirigo Health, established 
pursuant to the Maine Revised Statutes, Title 24, chapter 87, 
shall develop a methodology to determine an appropriate savings 
offset payment 
to 
be 
paid 
by 
third-party administrators 
as 
required 
by 
Title 
24-A, 
section 
6913, 
subsection 
2. 
In 
developing the methodology, the Governor I s office and the board 
shall 
consult 
with 
and 
reach 
consensus 
among 
self-insured 
employers, multiple-employer welfare arrangements and third-party 
administrators. 
The methodology must take into account both the 
similarities and the differences that exist between self-insured 
plans, 
multiple-employer 
welfare 
arrangements 
and 
health 
COMMITTEE AMENDMENT 
~s· 
~;() 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
insurance. 
No 
later than February 1, 
2004, 
the board shall 
report on the methodology, including recommended legislation to 
implement the savings offset payments, 
to the Joint Standing 
Committee 
on 
Insurance 
and 
Financial 
Services. 
The 
Joint 
Standing Committee on Insurance and Financial Services may report 
out legislation to the 
Second Regular 
Session of 
the 121st 
Legislature to implement the savings offset payments. 
Sec. A-II. Effective date. 
That section of this Part that 
amends 
the Maine Revised Statutes, Title 22, 
section 3174-G, 
subsection 1 takes effect on the date that coverage is first 
provided to eligible employees 
and eligible individuals under 
Dirigo Health Insurance as established in Title 24-11., 
section 
6910. 
PARTB 
Sec. B-1. 2 MRSA c. 5 is enacted to read: 
CHAPTER 5 
STATE HEALTH PLANNING 
§lQl. 
Duties of Goyernor 
1. 
Governor. 
The Governor or the Governor's designee shall: 
A. 
Develop 
and 
issue 
the biennial 
State Health Plan, 
referred to in this chapter as "the plan," pursuant to 
section 103. 
The first plan must be issued by May 2004; 
B. 
Make 
an annual 
report to 
the public assessing the 
progress toward meeting goals of the plan and provide any 
needed updates to the plan; 
C. 
Issue 
an annual 
statewide health expenditure budget 
report 
that 
must 
serve 
as 
the 
basis 
for 
establishing 
priorities within the plan; and 
D. 
Establish a limit, called the capital investment fund. 
for eaQh year of the plan pursuant to section 102. 
The Governor shall provide the reports specified in paragraphs B 
and C to the joint standing committee of the Legislature having 
jurisdiction over appropriations and financial affairs, the joint 
standing committee of the Legislature having jurisdiction over 
health 
and 
human 
services 
matters 
and 
the 
joint 
standing 
committee of the Legislature having jurisdiction over insurance 
and financial services matters. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
SI02. 
Capital investment fund 
1. 
Purpose. 
The capital investment fund is a limit for 
resources 
allocated 
annually 
under 
the 
certificate of 
need 
program described in Title 22, chapter 103-A. 
2. 
Process: criteria. 
The process for 
determining the 
capital investment fund amount must be set forth in rules and may 
include the formation of an ad hoc expert panel to advise the 
Governor. 
The process must include the division of the total 
capital investment 
fund 
amount 
into nonhospital 
and hospital 
components, 
must establish large and small capital investment 
fund amounts within each component and must be based on 3rd-year 
capital and operating expenses of projects under the certificate 
of 
need 
program. 
The 
process 
must 
take 
into 
account 
the 
following: 
A. 
The plan; 
B. 
The opportunity for improved operational efficiencies in 
the State's health care system; 
C. 
The average age of the infrastructure of the State's 
health care system; and 
D. 
Technological 
developments 
and 
the 
dissemination of 
technology in health care. 
3. 
HOnhospital capital expenditures. 
For the first 3 years 
of the plan, the nonhospital component of the capital investment 
fund must be at least 12.5~ of the total. 
This subsection is repealed July 1, 2007. 
SI03. 
State Health Plan 
1. 
Purpose. 
The plan issued pursuant to section 101, 
subsection 
1, 
paragraph 
A 
must 
set 
forth 
a 
comprehensive, 
coordinated approach to the development of health care facilities 
and resources in the State based on statewide cost, quality and 
access goals and strategies to ensure access to affordable health 
care, maintain a rational system of health care and promote the 
development of the health care workforce. 
2. 
Input. 
In developing the plan, the Governor shall, at a 
m~n1mum, seek input from the Advisory Council on Health Systems 
Development, pursu2nt to section 104; the Maine Quality Forum and 
the Maine Quality Forum Advisory Council, pursuant to Title 24-A, 
chapter 87, subchapter 2; a statewide health performance council; 
and other agencies and organizations. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.n. 1611 
3. 
Requirements. 
The plan must: 
A. 
Assess health care cost. quality and access in the State: 
B. 
Develop benchmarks to measure cost, quality and access 
goals and report on progress toward meeting those goals: 
C. 
Establish and set annual priorities among health care 
cQst, qugiity and access gQals; 
D. 
Prioritize the cgpital investment needs of the health 
care system in the Stgte within the capitgl investment fund, 
estgblished under sectiQn 102; 
E. 
Outline strategies tQ: 
(1) 
Promote health systems change; 
(2) 
Address the factors influencing health care cost 
increases; gnd 
(3) 
Address the majQr threats to public health and 
safety in the State, including. but not limited to, 
lung disegse, diabetes, cgncer gnd heart disease: and 
F. 
Provide recommendations tQ help purchgsers and providers 
make 
decisions thgt improve public heglth 
gnd build an 
affordgble, high-quality health care system. 
3. 
Uses of plan. 
The plan must be used in determining the 
cgpital investment fund amount pursuant to sectiQn 102 and must 
guide the issugnce Qf certificgtes Qf need by the State and the 
heglth Cgre lending decisions of the Maine Health gnd Higher 
Education Facilities Authority. 
A certificate of need or public 
fingncing thgt gffects heglth Cgre costs may not be provided 
unless it meets gQals gnd budgets explicitly outlined in the plan. 
§l04. 
Advisory COuncil on Health Systems Development 
1. 
Appointment: 
composition. 
The 
Adyisory 
Council 
on 
Heglth 
Systems 
Development, 
established in Title 
5, 
section 
12004-1, subsection 3l-A and referred to in this section as "the 
council," cQnsists of the following 11 members appointed by the 
Governor with approval of the joint standing committee of the 
Legislature having jurisdiction over health and human services 
matters: 
A. 
TWQ individugls with expertise in health care delivery: 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
B. 
One individual with expertise in long term care: 
C. 
One individual with expertise in mental health; 
D. 
One individual with expertise in public health care 
financing: 
E. 
One individual with expertise in private health care 
financing: 
F. 
One individual with expertise in health care quality; 
G. 
One individual with expertise in public health; 
H. 
Two representatives of consumers: and 
I. 
One representative of the Department of Human Services, 
Bureau of Health program that works collaboratively with 
other organizations to improve the health of the citizens of 
this State. 
Prior to making appointments to the council, the Governor shall 
seek nominations 
from the public, 
from statewide associations 
representing 
hospitals, 
physicians 
and 
consumers 
and 
from 
individuals 
and 
organizations with expertise in health care 
delivery systems, health care financing, health care quality and 
public health. 
2. 
Term. 
Members of the council serve 5 year terms except 
for 
initial 
appointees. 
Initial 
appointees 
must 
include 
members appointed to 3-year terms, 4 members appointed to 4-year 
terms and 4 members appointed to 5-year terms. 
A member may not 
serve more than 2 consecutive terms. 
3. 
Compensation. 
Members of the council are entitled to 
compensation according to the provisions of Title 5, chapter 379. 
4. 
Quorum. 
A quorum is a majority of the members of the 
council. 
5. 
Chair. 
The council shall annually choose one of its 
members to serve as chair for a one-year term. 
6. 
Meetings. 
The council shall meet at least 4 times a 
year at regular intervals and may meet at other times at the call 
of the chair or the Governor. Meetings of the council are public 
proceedings as provided by Title 1, chapter 13, subchapter 1. 
7. 
Duties. 
The 
council 
shall 
advise 
the 
Governor 
in 
developing the plan by: 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
A. 
Collecting 
and 
coordinating data 
on health 
systems 
development in this State: 
B. 
Synthesizing relevant research: and 
C. 
Conducting at least 2 public hearings on the plan and 
the capital investment fund each biennium. 
8. 
Staff support. 
The Governor's office shall provide 
staff support to the council. 
The Department of Human Services, 
Bureau of Health, the Maine Health Data Organization and other 
agendes of State Government as necessary and appropriate shall 
provide additional staff support or assistance to the council. 
9. 
Data. 
The council shall solicit data and information 
from both the public and private sectors to help inform the 
council's work. 
A. 
The 
following organizations 
shall 
forward 
data that 
documents key public health needs, organized by region of 
the State, to the council annually: 
(1) 
The Department of Human Services, Bureau of Health: 
(2) 
The 
Maine 
Center 
for 
Public 
Health 
Practice 
established pursuant to Title 22, section 3-D: and 
(3) 
A statewide public health association. 
B. 
Public purchasers using state or municipal funds to 
purchase health care services or health insurance shall, 
beginning 
January 
1. 
2004, 
submit 
to 
the 
council 
a 
consolidated public purchasers expenditure report outlining 
all funds expended in the most recently completed state 
fiscal year for hospital inpatient and outpatient care, 
physician 
services, 
prescription 
drugs, 
long-term 
care, 
mental 
health 
and 
other 
services 
and 
administration, 
organized by agency. 
C. 
The 
council 
shall 
encourage 
private 
purchasers 
established under Title 13, Title 13 -B and Title 13-C to 
develop 
and 
submit to the council 
a 
health expenditure 
report similar to that described in paragraph B. 
§l05. 
Rulemaking 
The Governor shall adopt rules for the implementation of 
this chapter. Rules adopted pursuant to this chapter are major 
COMMITTEE AMENDMENT 
~s. 
~~~ 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
substantive rules as defined in Title 5, chapter 375, subchapter 
2-A. 
Sec. B-2. 5 MRSA §12004-I, sub-§31-A is enacted to read: 
31-A. 
Health Care 
Advisory 
Council on 
Health 
Systems 
Development 
Expenses 
Only 
MRSA 
§104 
Sec. B-3. 22MRSA§253, as amended by PL 2001, c. 354, §3, is 
repealed. 
Sec. B-4. 22 MRSA §1709, as enacted by PL 1965, c. 231, §3, 
is repealed. 
PARTe 
Sec. e-l. 5 MRSA §l2004-I, sub-§38, as amended by PL 1997, c. 
689, Pt. A, §l and affected by Pt. c, §2, is repealed. 
Sec. C-2. 22 MRSA §328, sub-§3-A is enacted to read: 
3-A. 
Capital investment fund. 
"Capital investment fund" 
means that fund established by the Goyernor pursuant to Title 2, 
section 101, subsection 1, paragraph D. 
Sec. C-3. 22 MRSA §328, sub-§8, as enacted by PL 2001, c. 664, 
§2, is amended to read: 
8. 
Health care facility. 
"Health care facility" means a 
hospital, psychiatric hospital, nursing facility, kidney disease 
treatment center including a freestanding hemodialysis facility, 
rehabilitation 
facility, 
ambulatory 
surgical 
facility, 
independent 
radiological 
service 
center, 
independent 
cardiac 
catheterization center or cancer treatment center. 
"Health care 
facility" does not include the office of a private pbysieia:&-EH' 
pbysieiaBs-e£-~~~~r-QeB~is~s health care practitioner, as 
defined in Title 24, section 2502, subsection I-A, whether in 
individual or group practice. 
In an ambulatory surgical facility 
that functions also as the office of a health care practitioner, 
the following portions of the ambulatory surgical facility are 
considered to be a health care facility: 
A. 
Operating rooms; 
B. 
Recovery rooms; 
COMMITTEE AMENDMENT 
~. 0\<0· 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.n. 1611 
C. 
Waiting areas for ambulatory surgical facility patients: 
and 
D. 
Any other space used primarily to support the activities 
of the ambulatory surgical facility. 
Sec. C-4. 22 MRSA §328, sub-§16, as enacted by PL 2001, c. 
664, §2, is amended to read: 
16. 
Major medical equipment. 
"Major medical 
equipment" 
means a single unit of medical equipment or a single system of 
components with related functions used to provide medical and 
other heal th services that costs $1,200,000 or more. 
"Maj or 
medical equipment" does not include medical equipment acquired by 
or 
on 
behalf 
of 
a 
clinical laboratory to 
provide clinical 
laboratory services if the clinical laboratory is independent of 
a physician I s office and a hospital and has been determined to 
meet the requirements of the United States Social Security Act, 
Title 
XVIII, 
Section 
1861(s), 
paragraphs 
and 
11. 
In 
determining whether medical equipment costs more than $lr699r1:HHI 
the threshold provided in this subsection, the cost of studies, 
surveys, 
designs, 
plans, 
working drawings, 
specifications and 
other activities essential to acquiring the equipment must be 
included. 
If the equipment is acquired for less than fair market 
value, the term "cost" includes the fair market value. 
Beginning 
September 30, 2004 and annually thereafter, the threshold amount 
for review must be updated by the commissioner to reflect the 
change in the Consumer Price Index, medical index. 
Sec. C-S. 22 MRSA §328, sub-§17-A is enacted to read: 
17-A. 
New health service. 
"New health service" means: 
1. 
Capital elGtenditure. 
The obligation of 
any capital 
expenditures 
by or 
on behalf of 
a 
health care facility of 
$110,000 or more that is associated with the addition of a health 
service that was not offered on a regular basis by or on behalf 
of the health care facility within the 12-month period prior to 
the time the services would be offered: 
2. 
Addition of health service. 
The addition of a health 
service that is to be offered by or on behalf of a health care 
facility that was not offered on a regular basis by or on behalf 
of the health care facility within the l2-month period prior to 
the time the services would be offered and that, for the 3rd 
fiscal 
year 
of 
operation, 
including 
a 
partial 
first 
year 
following 
addition of that service, 
is projected 
to entail 
incremental annual operating costs directly attributable to the 
addition of that health service of at least $400,000; or 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
3. 
Addition of health care practitioner. 
The addition in 
the private office of a health care practitioner, as defined in 
Ti tIe 24, section 2502, subsection I-A, of new technology that 
costs $L200,000 or more. The department shall consult with the 
Maine Quality Forum Advisory Council established pursuant to 
Title 24-A, section 6952, prior to determining whether a project 
qualifies 
as 
a 
new 
technology 
in the office of 
a 
private 
practitioner. 
Beginning 
September 
30, 
2004 
and 
annually 
thereafter, the threshold amount for review must be updated by 
the commissioner to reflect the change in the Consumer Price 
Index medical index. 
With regard to the private office of a 
health care practitioner, "new health service" does not include 
the location of a new practitioner in a geographic area. 
"New health service" does not include a health care facility 
that extends a current service within the defined primary service 
area of the health care facility by purchasing within a l2-month 
time period new equipment costing in the aggregate less than the 
threshold provided in section 328, subsection 16: 
Sec. C-6. 22 MRSA §328, sub-§27 is enacted to read: 
27. 
State Health Plan. 
"State Health Plan" means the plan 
developed in accordance with Title 2, chapter 5. 
Sec. C-7. 22 MRSA §329, sub-§§2 to 4, as enacted by PL 2001, c. 
664, §2, are amended to read: 
2. 
Acquisitions of major medical equipment. 
Acquisitions 
of major medical equipment 
wi~h--a-~-~~-~~-a~~~e~a~e--9E 
$lrd-GG r Gg.g.--&.r--fR9£e. 
The use of major medical equipment on a 
temporary basis in the case of a natural disaster, major accident 
or equipment failure and the use of replacement equipment do not 
require a certificate of need. 
Beginning September 30, 2004 and 
annually thereafter, 
the threshold amount for 
review must be 
updated by the commissioner to reflect the change in the Consumer 
Price Index medical index; 
3. 
Capital expenditures. 
Except as provided in subsection 
6, the obligation by or on behalf of a health care facility of 
any 
capital 
expenditure 
of 
$2,400,000 
or 
more. 
Capital 
expenditures in the case of a natural disaster, major accident or 
equipment failure for replacement equipment or for parking lots 
and garages, information and communications systems and physician 
office space do not require a certificate of need. 
Beginning 
September 30, 2004 and annually thereafter, the threshold amount 
for review must be updated by the commissioner to reflect the 
change in the Consumer Price Index medical index; 
COMMITTEE AMENDMENT 
~. o\s. 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
4. 
Hew health service. 
The offering or development of any 
new heal th 
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ea~e-~~~~~~~~~~~-t;:ae-~~~~~~~-pEieE-~~~~-t;ime 
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BY-~~-~--Beaa~~-~--a--hett~~a-~~-faeilit;y--~-~-Ret; 
9fEeEea-~-a-~~~--&asis-~-~r-eB-~~~-9f-~~-:aealt;:a 
eaEe-~~~~~~~-~it~~-t;:ae-~~-ment~~r~-pEieE-~~~~-t;ime 
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Ur6QQ r QQQ; 
Sec. e-s. 22 MRSA §335, sub-§l, as enacted by PL 2001, c. 664, 
§2, is repealed and the following enacted in its place: 
1. 
Basis for decision. 
Based solely on a review of the 
record maintained under 
subsection 6, 
the commissioner shall 
approve 
an 
application 
for 
a 
certificate 
of 
need 
if 
the 
commissioner determines that the project: 
A. 
Meets the conditions set forth in subsection 7; 
B. 
Is consistent with the State Health Plan; 
C. 
Ensures high-guality outcomes and does not negatively 
affect the quality of care delivered by existing service 
providers; 
D. 
Does not result in inappropriate increases in service 
utilization, according to the principles of evidence-based 
medicine adopted by the Maine Quality Forum, as established 
in Title 24-A, section 6951; and 
E. 
Can be funded within the capital investment fund. 
COMMITTEE AMENDMENT 
"'; 0\ S· 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Sec. C-9. 22 MRSA §335, sub-§l-A is enacted to read: 
I A. 
Review 
cycle. 
The 
commissioner 
shall 
review 
applications periodically on a competitive basis. 
Sec. C-IO. 22 MRSA §335, sub-§5, as enacted by PL 2001, c. 
664, §2, is amended to read: 
5. 
Record. 
The record created by the department in the 
course of its review of an application must contain the following: 
A. 
The application and all other 
applicant 
for 
the 
purpose 
of 
documents part of the record; 
materials submitted by the 
Be~a~--maee making 
those 
B. 
All information generated by or for the department in 
the course of gathering material to assist the commissioner 
in 
determining 
whether 
the 
conditions 
for 
granting 
an 
application for a certificate of need have or have not been 
met. 
This information may include, without limitation, the 
report 
of 
consultants, 
including 
reports 
by 
panels 
of 
experts assembled by the department to advise it on the 
application, memoranda of meetings or conversations with any 
person interested in commenting on the application, letters, 
memoranda and documents from other interested agencies of 
State Government and memoranda describing officially noticed 
facts; 
C. 
Stenographic 
hearing held 
by 
department at the 
the application; 
or electronic recordings of 
any public 
the 
commissioner 
or 
the staff of 
the 
direction of the commissioner regarding 
D. 
Stenographic or electronic 
recording 
of 
informational meeting held by the department 
section 337, subsection 5; 
any 
public 
pursuant to 
E. 
Any documents submitted by any person for the purpose of 
Beia~--maee making 
those 
documents 
part 
of 
the 
record 
regarding any application for a certificate of need or for 
the purpose of influencing the outcome of any analyses or 
decisions regarding an application for certificate of need, 
except documents that have been submitted anonymously. Such 
source-identified documents automatically become part of the 
record upon receipt by the department; ase 
F. 
Preliminary and final analyses of the record prepared by 
the staff ... ; and 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
G. 
Written assessments by the Director of the Bureau of 
Health and the Superintendent of Insurance assessing the 
impact of the application on the health care system or cost 
of health insurance in the State. 
Sec. C-ll. 22 MRSA §335, sub-§7, ttC and D, as enacted by PL 
2001, c. 664, §2, are amended to read: 
C. 
There is a public need for the proposed services as 
demonstrated by certain factors, including, but not limited 
to: 
(1) 
Whether, and the extent to which, the project will 
substantially 
address 
specific 
health 
problems 
as 
measured by health needs in the area to be served by 
the project; 
(2) 
Whether the project will have a positive impact on 
the health status indicators of the population to be 
served; 
(3) 
Whether the services affected by the project will 
be accessible to all residents of the area proposed to 
be served; and 
(4) 
Whether 
the project will provide 
demonstrable 
improvements in quality and outcome measures applicable 
to the services proposed in the project; aae 
D. 
The proposed services are consistent with the orderly 
and economic development of health facilities and health 
resources for the State as demonstrated by: 
(1) 
The impact of the project on total health care 
expenditures after taking into account, to the extent 
practical, both the costs and benefits of the project 
and the competing demands in the local service area and 
statewide for available resources for health care; 
(2) 
The availability of state funds 
to 
cover 
any 
increase in state costs associated with utilization of 
the project's services; and 
(3) 
The 
likelihood 
that 
more 
effective, 
more 
accessible or less costly alternative technologies or 
methods of service delivery may become availableT: and 
Sec. C-12. 22 MRSA §335, sub-§7, tE is enacted to read: 
E. 
The project meets the criteria set forth in subsection 1. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Sec. C-13. 22 MRSA §338, sub-§l, ~~A and B, as enacted by PL 
2001, c. 664, §2, are amended to read: 
A. 
New 
medical 
technologies 
and 
the 
impact 
of 
technologies 
on 
the health care delivery system 
State; ane 
those 
in the 
B. 
Unmet need for health care services in the StateT~ 
Sec. C-14. 22 MRSA §338, sub-§l, ~C is enacted to read: 
C. 
The quality of health care. 
Sec. C-lS. 22 MRSA §1718 is enacted to read: 
§1718. 
Consumer information 
Each hoRpital or ambulatory surgical center licensed under 
chapter 405 shall maintain a price list of the most 
common 
inpatient services 
and outpatient procedureR 
provided by the 
licensee. 
A. 
For inpatient services, the price list must include a 
per diem bed charge and an average charge for all ancillary 
charges 
for 
the 
most 
common 
nonemergent 
services 
involving inpatient stays. 
If the per 
diem bed charge 
includes all ancillary charges for a procedure, no further 
information is required. 
B. 
For outpatient 
nonemergent procedures 
for 
which 
an 
individual would not incur a bed charge, the price list must 
include average charges for the 20 most common surgical and 
diagnostic procedures. excluding laboratory services. 
C. 
For emergency services, 
the price list must include 
average 
charges 
for 
facility 
and 
physician 
services 
according to the level of emergency services provided by the 
hospital and b1;l.sed on the time and intensity of services 
provided. 
The hORpital or ambul1;l.tory surgical center licensed under chapter 
shall post in 
1;1. 
conspicuous place 
1;1. 
statement 1;I.bout the 
availability of the price list 
1;I.S 
required by this section. 
Posting of the price list is not required. 
The hospital or ambul1;l.tory surgical center licensed under chapter 
sh1;l.11 provide its price list upon request of a consumer. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
The price list may include a statement that actual charges may 
vary depending on individual need and other factors. 
Sec. C-16. 22 MRSA §2061, sub-§2, as amended by PL 1993, c. 
390, §24, is further amended to read: 
2. 
Review. 
Each project for a health care facility has 
been reviewed and approved to the extent required by the agency 
of the State that serves as the Designated Planning Agency of the 
State or by the Department of Human Services in accordance with 
the provisions of the Maine Certificate of Need Act of 1918 2002, 
as amended, eFT-4R-~Qe-~~~~-~~~~-~-~-~&~i&&~r-aa&-SeeR 
Feviewee-aRe-~~e¥eQ-~-~~~~~~~~~-~iaaaee-GemmissieB 
~9-~he-~~~-~~~~~~-eaap&e~-197 and is consistent with the 
cost containment provisions for health care and health coverage 
of the State Health Plan adopted pursuant to Title 2, section 
101, paragraph A; 
Sec. C-17. 22 MRS A §8702, sub-§4, as amended by PL 2001, c. 
596, Pt. B, §2l and affected by §25, is further amended to read: 
4. 
Health care facility. 
"Health care facility" means a 
public 
or private, 
proprietary 
or 
not-for-profit entity 
or 
institution providing health services, including, but not limited 
to, a radiological facility licensed under chapter 160, a health 
care facility licensed under 
chapter 405 or certified under 
chapter 405-0, 
an 
independent radiological service center, 
a 
federally qualified health center eF.L rural health clinic QI 
rehabilitation agency certified or otherwise approved by the 
Division of Licensing and Certification within the Department of 
Human 
Services, 
a 
home 
health care provider 
licensed under 
chapter 419, a residential care facility licensed under chapter 
1664, a hospice provider licensed under chapter 1681, 
a-eemmaBi~y 
FeBasilitatieB-~~~-lieea&ee-~--~i~~-~G-A7-~~-191 ~ 
retail store drug outlet licensed under Title 32, chapter 117, a 
state institution as defined under Title 34-B, chapter 1 and a 
mental health facility licensed under Title 34-B, chapter 1. 
Sec. C-18. 22 MRSA §8702, sub-§4-A is enacted to read: 
4-A. 
Health care practitioner. 
"Health care practitioner" 
has the meaning provided in Title 24, section 2502, subsection 
I-A. 
Sec. C-19. 22 MRSA §8702, sub-§8, as enacted by PL 1995, c. 
653, Pt. A, §2 and affected by §7, is amended to read: 
8. 
Payor. 
administrator. 
"Payor" means a 
3rd-party payor or 3rd-party 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Sec. C-20. 22 MRSA §8702, sub-§9-A is enacted to read: 
9-A. 
Quality data_ 
"Ouality data" means 
information on 
health care guality required to be submitted pursuant to section 
8708-A. 
Sec. C-21. 22 MRSA §8702, sub-§l1, as amended by PL 2001, c. 
677, §2, is further amended to read: 
11. 
Third-party payor. 
"Third-party payor" means a health 
insurer, 
nonprofit hospital, 
medical services organization or 
managed care organization licensed in the State or the plan 
established in chapter 854. 
~Third-party payor~ does not include 
carriers licensed to issue limited benefit health policies or 
accident, specified disease, vision, disability, long-term carer 
QK nursing home care er-MeQieare-s~ppleffieB~ pOlicies. 
Sec. C-22. 22 MRSA §8703, sub-§l, as amended by PL 2001, c. 
457, §4, is further amended to read: 
1. 
Objective. 
The 
p~rpese purposes of the organization is 
~ to create and maintain a 
useful, objective, reliable and 
comprehensive health information database that is used to improve 
the health of Maine citizens and to issue reports. as provided in 
section 8712. 
This database must be publicly accessible while 
protecting patient confidentiality and respecting providers of 
care. 
The organization shall collect, process aBe..L analyze and 
report clinical aBe..L financial. quality and restructuring data as 
defined in this chapter. 
Sec. C-23. 22 MRS A §8704, sub-§l, 1fA, as amended by PL 2001, 
c. 457, §7, is further amended to read: 
A. 
The board shall develop and implement 
e.a~a---G-G-1-1e-e-~i-eB 
policies 
and procedures 
for 
the 
collection, 
processing, 
storage and analysis of clinical, financial, quality and 
restructuring data in accordance with this subsection for 
the following purposes: 
(1) 
To 
use, 
build and improve upon and coordinate 
existing data sources and measurement efforts through 
the integration of data systems and standardization of 
concepts; 
(2) 
To coordinate the development of a linked public 
and private sector information system; 
(3) 
To emphasize data that is useful, relevant and is 
not duplicative of existing data; 
COMMITTEE AMENDMENT 
~. ()\ s· 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
(4) 
To minimize the burden on those providing data; and 
(5) 
To 
preserve 
the 
reliability, 
accuracy 
and 
integrity of collected data while ensuring that the 
data is available in the public domainf-aBa~ 
t9t---~-~~~--iB~e£ma~4eB--~Fem-~~id&r~-w~-weFe 
Fe~QiFea--te--~i~e--aata--witR--tRe--MaiBe--Hea~tR--GaFe 
iiBaBee--~~~----~B&--e£~aB4~a~ieB--~--eelleet 
iR~eFmatieB--~£em--~~~~--~~~~-~~--WB&B--a 
~iRkeQ---~~~~~~---&y&~---~e£---~~---e~eetFeBie 
tFaRsmissieBT--~~~~~--aRa--~~~--e~--~~--is 
FeaseBaB~y-availaBle-te-pFeviQeFsT 
Sec. C-24. 22 MRSA §8704, sub-§l, ~C, as enacted by PL 1995, c. 
653, Pt. A, §2 and affected by §7, is amended to read: 
C. 
The 
organization 
may 
modify 
the 
uniform 
reporting 
systems for clinical, financiaL quality and restructuring 
data to allow for differences in the scope or type of 
services 
and 
in 
financial 
structure 
among 
health 
care 
facilities, providers or payors subject to this chapter. 
Sec. C-2S. 22 MRSA §8704, sub-§7, as amended by PL 2001, c. 
457, §9, is further amended to read: 
7. 
Annual report. 
The board shall prepare and submit an 
annual report on the operation of the organization and the Maine 
Health Data Processing Center as authQrized in Title 10, section 
681, including any activity contracted for by the organization, 
and on health care trends to the Governor and the joint standing 
committee of the Legislature having jurisdiction over health and 
human services matters no later than February 1st of each year. 
The report must include an annual accounting of all revenue 
received and expenditures incurred in the previous year and all 
revenue and expenditures planned for the next year. 
The report 
must include a list of persons or entities that requested data 
from the organization in the preceding year with a brief summary 
of the stated purpose of the request. 
Sec. C-26. 22 MRSA §8704, sub-§10, as amended by PL 2001, c. 
457, §10, is repealed. 
Sec. C-27. 22 MRSA §8707, sub-§2, as enacted by PL 1995, c. 
653, Pt. A, §2 and affected by §7, is amended to read: 
2. 
Notice and conunent period. 
The rules must establish 
criteria for 
determining 
whether 
information is confidential 
~c~l~i~n~i~c~a~l~~d~a~t~a~, 
confidential 
eemmeFeial 
financial 
data 
or 
privileged medical 
information 
and 
adopt procedures 
to give 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
affected health care providersT-.f-a€-i~i~ie6 and payors notice and 
opportunity to comment in response to requests for information 
that may be considered confidential or privileged. 
Sec. C-28. 22 MRSA §8708-A is enacted to read: 
§S70S-A. Quality data 
The board shall adopt rules regarding the collection of 
quality data. 
The board shall work with the Maine Ouality Forum 
and the Maine Quality Forum Advisory Council established in Title 
A, chapter 87, subchapter 2 to develop the rules. The rules 
must be based on the quality measures adopted by the Maine 
Quality Forum pursuant to Title 24-A, section 6951, subsection 
2. 
The 
rules 
must 
specify 
the 
content, 
form, 
medium 
and 
frequency of quality data to be submitted to the organization. 
In the collection of quality data, the organization must minimize 
duplication of effort, minimize the burden on those required to 
provide 
data 
and 
focus 
on 
data that 
may 
be 
retrieved 
in 
electronic format from within a health care practitioner's office 
or health care facility. 
As specified by the rules, health care 
practitioners and health care facilities shall submit quality 
data to the organization. 
Rules adopted pursuant to this section 
are major substantive rules as defined in Title 5, chapter 375, 
subchapter 2-A. 
Sec. C-29. 22 MRSA §8712 is enacted to read: 
§S712. 
Reports 
The 
organization 
shall 
produce 
clearly 
labeled 
and 
easy-to-understand 
reports 
as 
follows. 
Unless 
otherwise 
specified, the organization shall distribute the reports on a 
publicly accessible site on the Internet or via mail or e-mail, 
through the creation of 
a 
list of interested parties. 
The 
organization shall publish a notice of the availability of these 
reports at least once per year in the 3 daily newspapers of the 
greatest 
general 
circulation 
published 
in 
the 
State. 
The 
organization shall make 
reports available to members 
of the 
public upon request. 
1. Quality. 
At a 
m~n~mum, the organization, in conjunction 
with the Maine Quality Forum, established in Title 24-A, section 
6951, shall develop and produce annual quality reports. 
2. Price. 
At a minimum, the organization, with advice from 
the Maine Health Data Processing Center as authorized in Title 
10, section 681, shall develop and produce annual reports on 
prices charged for the 15 most common services provided by health 
care 
facilities 
and 
health 
care 
practitioners. 
excluding 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
emergency services. For health care facilities, the reports must 
include, but are not limited to, the average price charged per 
service per facility and total number of services per facility. 
3. 
Comparison report. At a minimum, the organization shall 
develop and produce an annual report that compares the 15 most 
common diagnosis-related groups and the 15 most common outpatient 
procedures for all hospitals in the State and the 15 most common 
procedures for nonhospital health care facilities in the State to 
similar data for medical care rendered in other states, when such 
data are available. 
4. 
Physician services. The organization shall provide an 
annual 
report of the 
services 
and procedures 
most often 
provided by osteopathic and allopathic physicians in the private 
office setting in this State. 
The organization shall distribute 
this report to all physician practices in the State. 
The first 
report must be produced by July I, 2004. 
Sec. C·30. 24 MRSA §2987 is enacted to read: 
§2987. 
Consumer information 
A health care practitioner shall notify patients in writing 
of 
the 
health care 
practitioner's 
charges 
for 
health 
care 
services commonly offered by the practitioner. 
Upon request of a 
patient. a health care practitioner shall assist the patient in 
determining the actual payment 
from 
a 
3rd-party payor for 
a 
health care service commonly offered by the practitioner. 
A 
patient may file a complaint with the appropriate licensing board 
regarding a health care practitioner who fails to provide the 
consumer information required by this section. 
PARTD 
Sec. D·l. 24 MRSA §2332.E, as amended by PL 2003, c. 218, §l, 
is further amended to read: 
§2332-E. Standardized claim forms 
All nonprofit hospital or medical service organizations and 
nonprofit health care plans providing payment or reimbursement 
for diagnosis or treatment of a condition or a complaint by a 
licensed !'Rys4e4aR--o-r--eh1r:-e!'Fae1::eF health care practitioner must 
accept 
the 
current 
standardized 
claim 
form 
for 
professional 
services 
approved 
by 
the 
Federal 
Government 
and 
submitted 
electronically. 
All 
nonprofit 
hospital 
or 
medical 
service 
organizations and nonprofit health care plans providing payment 
or reimbursement for diagnosis or treatment of a condition or a 
COMMITTEE AMENDMENT 
",." 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
complaint 
by 
a 
licensed 
hospital 
must 
accept 
the 
current 
standardized claim form for professional or facility services, as 
applicable, 
approved by the Federal 
Government 
and submitted 
electronically. 
A 
nonprofit 
hospital 
or 
medical 
service 
organization or nonprofit health care plan may not be required to 
accept a claim submitted on a form other than the applicable form 
specified in this section and may not be required to accept a 
claim that is not submitted electronically, except from a health 
care practitioner who is exempt pursuant to section 2985. 
Sec. D-2. 24 MRS A §2985, as enacted by PL 1993, c. 477, Pt. 
D, §7 and affected by Pt. F, §1, is repealed and the following 
enacted in its place: 
§2985. 
Billing for health care services 
A health care practitioner. 
as defined in section 2502. 
subsectiQn I-A, 
who directly bills for health care services must 
use the current standardized claim form for professional services 
approved by the Federal Government and, after October 16, 2003, 
must submit claims in electronic data format to a carrier, as 
defined in Title 24-A, section 4301-A. subsection 3, that accepts 
claims in an electronic format. 
A health care practitioner or 
group 
of 
health 
care 
practitioners 
with 
fewer 
than 
full-time-equivalent 
health 
care 
practitioners 
and 
other 
employees is exempt from the requirement to submit claims in 
electronic data format until October 16. 2005. 
Beginning October 
16. 
2005. 
a health care practitioner or group of health care 
practitioners with fewer than 10 full-time-equivalent health care 
practitioners and other employees may apply to the Superintendent 
of Insurance for a continued exemption from the requirement to 
submit claims in electronic data format based upon hardship. 
The 
Superintendent of Insurance shall adopt rules relating to the 
process for a hardship exemption and the standard for determining 
whether a practitioner has demonstrated hardship. Rules adopted 
pursuant to this section are routine technical rules as defined 
in Title 5, chapter 375. subchapter 2-A. 
Sec. D-3. 24-A MRSA §1912, as am"ended by PL 2003, c. 218, 
§2, is further amended to read: 
§1912. 
Standardized claim forms 
All administrators who administer claims and who 
provide 
payment 
or 
reimbursement 
for 
diagnosis 
or 
treatment 
of 
a 
condition or a complaint by a licensed ~aysieiaR-e~-€£4~e~~ae~e~ 
health care practitioner must accept the current standardized 
claim form for professional services approved by the Federal 
Government and submitted electronically. 
All administrators who 
administer claims and who provide payment or reimbursement for 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
diagnosis or treatment of 
a 
condition or 
a 
complaint by 
a 
licensed hospital must accept the current standardized claim form 
for professional or facility services, as applicable, approved by 
the 
Federal 
Government 
and 
submitted 
electronically. 
An 
administrator may not be required to accept a claim submitted on 
a form other than the applicable form specified in this section 
and may not be required to accept a claim that is not submitted 
electronically, except from a health care practitioner who is 
exempt pursuant to Title 24, section 2985. 
Sec. D-4. 24-A MRSA §2436, sub-§2-A, as amended by PL 2003, c. 
218, §3, is further amended to read: 
2-A. 
Except as provided in this subsection, for purposes of 
this section, 
an "undisputed claim" means 
a timely claim for 
payment 
of 
covered health care 
expenses 
under 
a 
policy or 
certificate providing health care coverage that is submitted to 
an insurer on the insurer's standard claim form using the most 
current published procedural codes with all the required fields 
completed with correct and complete information in accordance 
wi th the insurer's published claims filing requirements. After 
JaRyaEy-1T-~GG§ October 16, 2003 and until October 16, 2005, for 
a provider with 10 or more full-time-equiva1ent employees, an 
"undisputed claim" means a timely claim for payment of covered 
health care expenses under 
a 
policy or certificate providing 
health care coverage that is submitted to an insurer in the 
insurer's standard electronic data format using the most current 
published procedural codes with all the required fields completed 
with correct and complete information in accordance with the 
insurer's published claims filing requirements. 
This subsection 
applies only to a policy or certificate of a health plan as 
defined in section 4301-A, subsection 7. 
Sec. D-S. 24-A MRSA §2680, as amended by PL 2003, c. 218, 
§s, is further amended to read: 
§2680. 
Standardized claim form 
Administrators 
providing 
payment 
or 
reimbursement 
for 
diagnosis 
or 
treatment of 
a 
condition or 
a 
complaint by 
a 
licensed 
physieiaBT--ehiFepFae~eF health care practitioner or 
licensed hospital shall accept the current standardized claim 
form 
for 
professional 
or 
facility 
services, 
as 
applicable, 
approved by the Federal Government and submitted electronically. 
An administrator may not be required to accept a claim submitted 
on 
a 
form other than the applicable form specified in this 
section and may not be required to accept a claim that is not 
submitted electronically, except from a health care practitioner 
who is exempt pursuant to Title 24, section 2985. 
COMMITTEE AMENDMENT 
(;~ 
~\ .. 
~ 
9.:~ 
.' 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Sec. D-6. 24·A MRSA §2753, as amended by PL 2003, c. 218, 
§6, is further amended to read: 
§2753. 
Standardized claim forms 
All insurers providing individual medical expense insurance 
on an expense-incurred basis providing payment or reimbursement 
for diagnosis or treatment of a condition or a complaint by a 
*ieeasea-~~~~~~~~-eaiFeFFae~eF health care practitioner must 
accept 
the 
current 
standardized claim 
form 
for 
professional 
services 
approved 
by 
the 
Federal 
Government 
and 
submitted 
electronically. 
All 
insurers 
providing 
individual 
medical 
expense insurance on an expense-incurred basis providing payment 
or reimbursement for diagnosis or treatment of a condition or a 
complaint 
by 
a 
licensed 
hospital 
must 
accept 
the 
current 
standardized claim form for professional or facility services, as 
applicable, 
approved 
by the Federal 
Government 
and submitted 
electronically. 
An insurer may not be required to accept a claim 
submi tted on a form other than the applicable form specified in 
this section and may not be reguired to accept a claim that is 
not 
submitted 
electronically, 
except 
from 
a 
health 
care 
practitioner who is exempt pursuant to Title 24, section 2985. 
Sec. D-7. 24-A MRSA §2823·B, as amended by PL 2003, c. 218, 
§7, is further amended to read: 
§2823-B. 
Standardized claim forms 
All insurers providing group medical expense insurance on an 
expense-incurred basis providing payment or reimbursement for 
diagnosis or treatment of 
a 
condition or 
a 
complaint by 
a 
licensed Fays:i:eiaR--&r---Ghi-FGFFae~eF health care practitioner must 
accept 
the 
current 
standardized 
claim 
form 
for 
professional 
services 
approved 
by 
the 
Federal 
Government 
and 
submitted 
electronically. 
All insurers providing group medical expense 
insurance 
on 
an 
expense-incurred basis 
providing payment 
or 
reimbursement for diagnosis or treatment of a 
condition or a 
complaint 
by 
a 
licensed 
hospital 
must 
accept 
the 
current 
standardized claim form for professional or facility services, as 
applicable, 
approved 
by the Federal 
Government 
and submitted 
electronically. 
An insurer may not be required to accept a claim 
submitted on a form other than the applicable form specified in 
this section and may not be reguired to accept a claim that is 
not 
submitted 
electronically, 
except 
from 
a 
health 
care 
practitioner who is exempt pursuant to Title 24, section 2985. 
Sec. D·8. 24·A MRSA §4235, as amended by PL 2003, c. 218, 
§8, is further amended to read: 
§4235. 
Standardized claim forms 
COMMITTEE AMENDMENT 
(~ 
.~~:' 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
All health maintenance organizations providing payment or 
reimbursement for diagnosis or treatment of a 
condition or a 
complaint by a 
licensed physieiaB--o-r--€aiE9FEaee9r health care 
practitioner must accept the current standardized claim form for 
professional services 
approved by the Federal 
Government 
and 
submitted electronically. 
All health maintenance organizations 
providing payment or reimbursement for diagnosis or treatment of 
a condition or a complaint by a licensed hospital must accept the 
current standardized claim form for professional or facility 
services, as applicable, approved by the Federal Government and 
submitted electronically. 
A health maintenance organization may 
not be required to accept a claim submitted on a form other than 
the applicable form specified in this section and may not be 
required to accept a claim that is not submitted electronically, 
except from a health care practitioner who is exempt pursuant to 
Title 24, section 2985. 
Sec. D-9. Effective date. 
This Part takes effect October 16, 
2003. 
PARTE 
Sec. E-l. 24 MRSA §2327, as amended by PL 2003, c. 428, Pt. 
E, §1, is further amended to read: 
§2327. 
Group rates 
A 
group 
health care contract may 
not 
be 
issued by 
a 
nonprofit hospital or medical service organization in this State 
until a copy of the group rates to be used in calculating the 
premium for 
these contracts has been filed for 
informational 
purposes with the superintendent. 
The filing must include the 
base rates and a description of any procedures to be used to 
adjust the 
base rates 
to reflect factors 
including but not 
limited to age, gender, health status, claims experience, group 
size and coverage of dependents. 
Notwithstanding this section, 
rates 
for 
group 
Medicare 
supplement, 
nursing 
home 
care 
or 
long-term care contracts and for certain group contracts included 
within the definition of "individual health plan" in Title 24-A, 
section 
2736-C, 
subsection 1, 
paragraph 
C must 
be filed in 
accordance with section 2321 and rates for small group health 
plans as defined by Title 24-A, section 2808-B must be filed in 
accordance with that section. 
Sec. E-2. 24-A MRSA §423·D is enacted to read: 
§423-D. 
Annual report supplement 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
1. 
Annual report supplement required. 
Each health insurer 
and health maintenance organization shall file an annual report 
supplement on or before March 1st of each year, or within any 
reasonable extension of time that the superintendent for good 
cause 
may 
have 
granted 
on 
or 
before 
March 
1st. 
The 
§uperintendent shall adopt rules regarding specifications for the 
annual 
report supplement. 
The 
annual report §upp1ements must 
provide the public with general, under§tandable and comparable 
financial information relative to the in state operations and 
results 
of 
authorized 
insurer§ 
and 
health 
maintenance 
organization§. 
Such information must include, but is not limited 
to, 
medical 
claims 
expense, 
administrative 
expense 
and 
underwriting gain for each line segment of the market in this 
State in which the in§urer participate§. 
The 
annual 
report 
supplements must contain sufficient detail for the public to 
understand the component§ of cost incurred by authorized health 
insurer§ and health maintenance organizations as well as the 
annual cost trends of these carriers. The superintendent shall 
develop standardized definitions of each reported measure. Rules 
adopted pursuant to this section are routine technical rules as 
defined in Title 5, chapter 375, subchapter 2-A. 
2. 
Exemption. 
If an in§urer is engaged in the type of 
health insurance bu§iness identified as 
an exception to the 
definit~on of health insurance in section 704, subsection 2 and 
i§ not engaged in health in§urance in thi§ State as defined in 
that section, then the insurer i§ not subject to the requirements 
of this section for the filing of annual report supplements. 
Sec. E-3. 24-A MRSA §1902, as enacted by PL 1989, c. 846, Pt. 
D, §2 and affected by Pt. E, §4, is amended to read: 
§1902. License required 
A person may not act as or profess to be an administrator 
after August 1, 1990, unless licensed under this chapter. 
An 
administrator doing business in this State on August 1, 1990, 
shall apply for a license by November 1, 1990. 
In addition to 
any other penalty that may be imposed for violation of this 
Title, any person violating this section shall, upon conviction, 
be punished by a fine of not less than $100 nor more than $1,000 
or by imprisonment for less than one year, or both. 
An admini§trator licensed under this chapter on or before 
December 31, 2003 shall submit information by March 21, 2004 as 
to the types of busines§ conducted by that administrator in this 
State on a form prescribed by the superintendent. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Sec. E-4. 24-A MRSA §1903, sub-§§l and 2, as enacted by PL 
1989, c. 846, Pt. D, §2 and affected by Pt. E, §4, are amended to 
read: 
1. 
The 
names, 
addresses 
and official positions of the 
individuals who are responsible for the conduct of the affairs of 
the administrator, including, but not limited to, all members of 
the board of directors, board of trustees, executive committee, 
or other governing board or committee, the principal officers in 
the case of a corporation or the partners in the case of a 
partnership: aRe 
2. 
An application fee, as specified 
the superintendent shall apply toward the 
annual 
fee if an administrator's 
license 
applicantT ; and 
in section 601, that 
initial administrator 
is granted to 
the 
Sec. E-5. 24-A MRSA §1903, sub-§3 is enacted to read: 
3. 
The specific type of business in which the 3rd-party 
administrator will or intends to engage. 
Sec. E-6. 24-A MRSA §1905, sub-§2, as enacted by PL 1989, c. 
846, Pt. D, §2 and affected by Pt. E, §4, is amended to read: 
2. 
If the 
superintendent 
finds 
that 
the 
applicant is 
qualified for an administrator license, the superintendent shall 
promptly 
issue 
the 
license, 
which 
identifies 
the 
types 
of 
business 
in 
which 
the 
applicant 
may 
engage; 
otherwise 
the 
superintendent shall refuse to issue the license and promptly 
notify the applicant. 
Sec. E-7. 24-A MRSA §1905, sub-§5 is enacted to read: 
5. 
An administrator shall submit an application to amend 
its license if the administrator desires to amend the types of 
business on its then-current license. 
Sec. E·8. 24·A MRSA §1952, as amended by PL 2003, c. 428, Pt. 
H, §2, is further amended to read: 
§195Z. Licensure 
A private purchasing alliance may not market, sell, offer or 
arrange 
for 
a 
package of 
one 
or 
more 
health benefit plans 
underwritten by one or more carriers without first being licensed 
by the superintendent. 
The superintendent shall specify by rule 
standards and procedures for the issuance and renewal of licenses 
for 
private 
purchasing 
alliances. 
A 
rule 
may 
require 
an 
application fee of not more than $400 and an annual license fee 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
of not more than $100. 
A license may not be issued until the 
rulemaking required by this chapter has been undertaken and all 
required rules are in effect. 
Dirigo Health, as established in 
chapter 87, is exempt from the licensure reguirements of this 
section as an independent executive agency of the State. 
Sec. E-9. 24-A MRS A §2736, sub-§3, 1[B, as enacted by PL 1997, 
c. 344, §8, is amended to read: 
B. 
The 
insurer 
must 
demonstrate 
in 
accordance 
with 
generally 
accepted 
actuarial 
principles 
and 
practices 
consistently applied that, as of a date no more than 210 
days prior to the filing, the ratios of benefits incurred to 
premiums earned for those products average no less than 80% 
for the previous 12-month period. 
For the purposes of this 
calculation, any savings offset payments paid pursuant to 
section 6913 must be treated as incurred claims. 
Sec. E-IO. 24-A MRSA §2736, sub-§4, 1[C, as enacted by PL 1997, 
c. 344, §8, is amended to read: 
C. 
In any hearing conducted under this subsection, 
the 
Bureau of Insurance and any party asserting that the rates 
are excessive have the burden of establishing that the rates 
are 
excessive. 
The 
burden 
of 
proving 
that 
rates 
are 
adequate 
aBa~ not unfairly discriminatory and in compliance 
with the 
requirements of section 6913 
remains with the 
insurer. 
Sec. E-ll. 24-A MRSA §2736-A, as repealed and replaced by PL 
1979, c. 558, §8, is amended to read: 
§2736-A. Hearinq 
If at any time the superintendent has reason to believe that 
a filing does not meet the requirements that rates shall not be 
excessive, 
inadequate 
eF~ unfairly discriminatory or 
not 
in 
compliance with section 6913 or that the filing violates any of 
the provisions of chapter 23, he the superintendent shall cause a 
hearing to be held. 
Hearings held under this section shall !!lY§..t. conform to the 
procedural requirements set forth in the Maine Administrative 
Procedure Act, Title 5, chapter 375, subchapter IV 1. 
Sec. E-12. 24-A MRSA §2736-C, sub-§2, 1JF is enacted to read: 
F. 
A carrier that adjusts its rate shall account for the 
savings offset payment or 
any 
recovery in that offset 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT itA" to H.P. 1187, L.D. 1611 
~ent in its experience consistent with this section and 
section 6913. 
Sec. E-13. 24-A MRSA §2736-C, sub-§5, as amended by PL 2003, 
c. 428, Pte H, .§3, is further amended to read: 
5. 
Loss ratios. 
For all policies and certificates issued 
on 
or 
after 
the 
effective 
date 
of 
this 
section, 
the 
superintendent shall disapprove any premium rates filed by any 
carrier, whether initial or revised, for an individual health 
policy unless it is anticipated that the aggregate benefits 
estimated to be paid under all the individual health policies 
maintained in force by the carrier for the period for which 
coverage is to be provided will return to policyholders at least 
65% of the aggregate premiums collected for those policies, as 
determined in accordance with accepted actuarial principles and 
practices and on the basis of incurred claims experience and 
earned premiums. 
For the purposes 
of this calculation, 
any 
savings offset payments paid pursuant to section 6913 must be 
treated as incurred claims. 
Sec. E-14. 24-A MRSA §2S0S-B, sub-§2, tA, as amended by PL 
2003, c. 313, §l, is repealed. 
Sec. E-15. 24-A MRSA §2S0S-B, sub-§2, tG, as enacted by PL 
2003, c. 313, §2, is repealed. 
Sec. E-16. 24-A MRSA §2S0S-B, sub-§§2-A to 2-C are enacted to 
read: 
2-A. 
Rate filings. 
A carrier offering small group health 
plans shall file with the superintendent the community rates for 
each plan and every rate, rating formula and classification of 
risks and every modification of any formula or classification 
that it proposes to use. 
A. 
Every filing must state the effective date of the 
filing. 
Every filing must be made not less than 60 days in 
advance of the stated effective date, 
unless the 60-day 
requirement is waived by the superintendent. 
The effective 
date may be suspended by the superintendent for a period of 
time not to exceed 30 days. In the case of a filing that 
meets 
the criteria in subsection 2-B, 
paragraph E, 
the 
superintendent may suspend the effective date for a longer 
period not to exceed 30 days 
from the date the carrier 
satisfactorily responds to any reasonable discovery requests. 
B. 
A filing and supporting information are public records 
except as provided by Title 1, section 402, subsection 3 and 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
become part of the official record of 
any hearing held 
pursuant to subsection 2-B, paragraphs B or F. 
C. 
Rates for small group health plans must be filed in 
accordance with this section and subsections 2-B and 2-C for 
premium rates effective on or after July 1, 
2004, except 
that the filing of rates for small group health plans are 
not required to account for any savings offset payment or 
any recovery of that offset payment pursuant to subsection 
2-B, paragraph D and section 6913 for rates effective before 
July 1, 2005. 
2-D. 
Rate 
review and hearings. 
Except 
as provided in 
subsection 2-C, rate filings are subject to this subsection. 
A. 
The superintendent shall disapprove any premium rates 
filed by any carrier, whether initial or revised, 
for 
a 
small group health plan unless it is anticipated that the 
aggregate benefits estimated to be paid under all the small 
groyp health plans maintained in force by the carrier for 
the period for which coverage is to be provided will return 
to policyholders at least 75% of the aggregate premiums 
collected for those policies, as determined in accordance 
with accepted actuarial principles and practices and on the 
basis of incurred claims experience and earned premiums. For 
the 
purposes 
of 
this 
calculation, 
any 
savings 
offset 
payments paid pursuant to section 6913 must be treated as 
incurred claims. 
B. 
If at any time the superintendent has reason to believe 
that a filing does not meet the reqyirements that rates not 
be excessive, inadequate or ynfairly discriminatory or that 
the filing violates any of the provisions of chapter 23, the 
superintendent shall cause a hearing to be held. 
Hearings 
held under this subsection must conform to the procedural 
requirements set forth in Title 5, chapter 375, subchapter 
4. 
The superintendent shall issue an order or decision 
within 30 days after the close of the hearing or of any 
rehearing or reargument or within such other period as the 
superintendent for good cause may require, but not to exceed 
an additional 
days. 
In the order or decision, 
the 
superintendent shall either approve or disapprove the rate 
filing. 
If the superintendent disapproves the rate filing, 
the syperintendent shall establish the date on which the 
filing 
is 
no 
longer effective, 
specify 
the 
filing 
the 
superintendent would approve and authorize the insurer to 
submit a 
new filing in accordance with the terms of the 
order or decision. 
COMMITTEE AMENDMENT 
of> 
~\-
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
c. When a filing is not accompanied by the information upon 
which the carrier supports the filing or the superintendent 
does not have sufficient information to determine whether 
the 
filing 
meets 
the 
requirements 
that 
rates 
not 
be 
excessive, 
inadequate, 
unfairly discriminatory or not in 
compliance 
with 
section 
6913, 
the 
superintendent 
shall 
require the carrier to furnish the information upon which it 
supports the filing. 
D. 
A carrier that adjusts its rate shall account for the 
savings offset payment or any recovery of that savings 
offset 
payment 
in 
its 
experience 
consistent 
with 
this 
section and section 6913. 
E. 
Any filing of rates, rating formulas and modifications 
that satisfies the criteria set forth in this paragraph is 
subject to the provisions of paragraph F: 
(1) 
The proposed rate for any group or subgroup does 
not include a unit cost change that exceeds the index 
of inflation multiplied by 1.5, excluding any approved 
rate differential based on age. For the purposes of 
this subparagraph, "index of inflation" means the rate 
of increase in medical costs for a 
section of the 
United 
States 
selected 
by 
the 
superintendent 
that 
includes this State for the most recent 12-month period 
immediately preceding the date of the filing for which 
data are available; and 
(2) 
The 
carrier 
demonstrates 
in 
accordance 
with 
generally accepted actuarial principles and practices 
consistently applied that. as of a date no more than 
days prior to the filing, the ratio of benefits 
incurred to premiums earned averages no less than 78°1) 
for the previous 36-month period. 
F. 
Any rate hearing conducted with respect to filings that 
meet 
the 
criteria in 
paragraph 
E is 
subject 
to 
this 
paragraph. 
(1) 
A person requesting a hearing shall provide the 
superintendent with a written statement detailing the 
circumstances that justify a hearing, notwithstanding 
the satisfaction of the criteria in paragraph E. 
(2) 
If the superintendent decides to hold a hearing, 
the 
superintendent shall issue 
a 
written statement 
detailing the circumstances that justify a 
hearing, 
notwithstanding the satisfaction of the criteria in 
paragraph E. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
(3) 
In any hearing conducted under this paragraph, the 
bureau and 
any party asserting that the 
rates are 
excessive have 
the burden of establishing that the 
rates are excessive. 
The burden of proving that rates 
are 
adequate, 
not 
unfairly 
discriminatory 
and 
in 
compliance 
with 
the 
requirements 
of 
section 
6913 
remains with the carrier. 
C. 
Qptional 
guaranteed 
loss 
ratio. 
Notwithstanding 
subsection 2-B, 
at the carrier's option, 
rate filings for 
a 
credible block of small group health plans may be filed in 
accordance with this subsection instead of subsection 2-B. 
Rates 
filed 
in 
accordance 
with 
this 
subsection 
are 
filed 
for 
inform9tional purposes. 
A. 
A block of 
small group health p19ns 
is considered 
credible if the 9nticip9ted number of member months for 
which the r9tes will be in effect is 9t least 1,000 or if it 
meets credibility standards adopted by the superintendent by 
rule. The r9te filing must state the anticipated number of 
member months for which the rates will be in effect and the 
b9sis for the estimate. 
If the superintendent determines 
th9t the number of member months is likely to be less than 
1,000 
9nd 
the 
block 
does 
not 
satisfy 
9ny 
9lternative 
credibility st9ndards adopted by rule, the filing is subject 
to subsection 2-B. 
B. 
On 
an 
annual 
schedule 
as 
determined 
by 
the 
superintendent. 
the carrier shall file 9 report with the 
superintendent 
showing 
9ggregate 
e9rned 
premiums 
and 
incurred cl9ims for the period the rates were in effect. 
Incurred cl9ims must include claims paid to 9 d9te 6 months 
after the end of the 9nnual reporting period determined by 
the superintendent and an estimate of unpaid c19ims. 
The 
report 
must 
state 
how 
the 
unpaid 
c19ims 
estimate 
was 
determined. 
C. 
If incurred cl9ims were less than 
78~ of aggregate 
earned 
premiums 
over 
a 
continuous 
36-month period, 
the 
c9rrier sh911 refund a percentage of the premium to the 
current 
in-force 
policyholder. 
For 
the 
purposes 
of 
calculating this loss-ratio percentage, 
9ny savings offset 
payments paid pursuant to section 6913 must be treated as 
incurred claims. The excess premium is the amount of premium 
above that amount necessary to achieve a 
78~ loss ratio for 
all of the carrier's small group policies during the same 
36-month 
period. 
The 
refund 
must 
be 
distributed 
to 
policyholders 
in 
9n 
amount 
reasonably 
calculated 
to 
correspond to the aggregate experience of all policyholders 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
holding policies having similar benefits. The total of all 
refunds must equal the excess premiums. 
(1) 
For determination of loss-ratio percentages in 
2005, actual aggregate incurred claims expenses include 
expenses incurred in 2005 and projected expenses for 
2006 
and 
2007. 
For 
determination 
of 
loss 
ratio 
percentages in 2006, actual incurred claims expenses 
include 
expenses 
in 
2005 
and 
2006 
and 
projected 
expenses for 2007. 
(2) 
The superintendent may waive the requirement for 
refunds during the first 3 years after the effective 
date of this subsection. 
D. 
The superintendent may require further support for the 
unpaid 
claims 
estimate 
and 
may 
require 
refunds 
to 
be 
recalculated if the estimate is found to be unreasonably 
large. 
E. 
The 
superintendent 
may 
adopt 
rules 
setting 
forth 
appropriate methodologies 
regarding reports, 
refunds 
and 
credibility standards pursuant to this subsection. 
Rules 
aQopted pursuant to this subsection are routine technical 
ryles as Qefined in Title 5, chapter 375, subchapter 2-A. 
Sec. E·17. 24·A MRSA §2839·B is enacted to read: 
§2839-B. 
Large group rates 
1. 
Application. 
This 
section applies 
to 
group health 
insurance offered in the large group market as defined in section 
2850-B, 
except 
insurance 
covering 
only 
accidental 
~nJyry, 
specified Qisease, hospital indemnity, dental, vision, disability 
income, 
long-term care, 
Medicare 
supplement or other limited 
benefit health insurance. 
2. 
Annual filing. 
Every carrier offering group health 
insurance specified in subsection 1 shall annually file with the 
superintendent on or before April 30th a certification signed by 
a member in good standing of the American Academy of Actuaries or 
a successor organization that the carrier' s rating methods and 
practices are in accordance with generally accepted actuarial 
principles 
and 
with 
the 
applicable 
actuarial 
standards 
of 
practice as promylgated by an actuarial standards board. 
The 
filing must also certify that the carrier has included in its 
experience any savings offset payments or 
recovery of those 
savings offset payments consistent with section 6913. The filing 
also must state the number of policyholders, certificate holders 
and dependents, as of the close of the preceding calendar year, 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
enrolled in large group health insurance plans offered by the 
carrier. A filing and supporting information are public records 
except as provided by Title 1, section 402, subsection 3. 
3. 
Documentation. 
Every carrier shall maintain at its 
principal place of business a complete and detailed description 
of its rating practices, including information and documentation 
that demonstrates that its rating methods and practices are in 
accordance wi th generally accepted actuarial pr inciples and with 
the applicable actuarial standards of practice as promulgated by 
an actuarial standards board. 
Sec. E-18. 24-A MRSA §4203, sub-§3, 1(S, as amended by PL 1997, 
c. 370, Pt. F, §l, is further amended to read: 
S. 
A list of the names and addresses of all physicians and 
facilities with which the health maintenance organization 
has or will have agreements. 
If products are offered that 
pay full benefits only when providers within a subset of the 
contracted physicians or facilities are utilized, a list of 
the providers in that limited network must be included, as 
well as a list of the geographic areas where the products 
are 
offered. 
This 
paragraph 
may 
not 
be 
construed 
to 
prohibit a health maintenance organization from offering a 
health plan that includes financial provisions designed to 
encourage members to use designated providers in a network 
in accordance with section 4303, subsection 1, paragraph A. 
Sec. E-19. 24-A MRSA §4207, sub-§S, as repealed and replaced 
by PL 1993, c. 645, Pt. A, §6, is amended to read: 
5. 
A schedule or an amendment to a schedule of charge for 
enrollee health coverage for health care services may not be used 
by any health maintenance organization unless it complies with 
section 2736, 2808-B or 2839, whichever is applicable. 
Sec. E-20. 24-A MRSA §4303, sub-§l, as amended by PL 1999, c. 
742, §6, is further amended to read: 
1. 
Demonstration of adequate access to providers. --A-
Except as provided in paragraph A, 
a carrier offering a managed 
care plan shall provide to its members 
reasonable access to 
heal th care services in accordance wi th standards developed by 
rule by the superintendent. 
These standards must consider the 
geographical and transportational problems in rural areas. 
All 
managed care plans covering residents of this State must provide 
reasonable 
access 
to 
providers 
consistent 
with 
the 
access-to-services requirements of any applicable bureau rule. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
A. Upon approval of the superintendent, a carrier may offer 
a health plan that includes financial provisions designed to 
encourage members to use designated providers in a network 
if: 
(1) 
The entire network meets overall access standards 
pursuant to Bureau of Insurance Rule Chapter 850; 
(2) 
The health plan is consistent with product design 
guidelines for Bureau of Insurance Rule Chapter 750; 
(3) 
The 
health 
plan 
does 
not 
include 
financial 
provisions 
designed 
to 
encourage 
members 
to 
use 
designated providers of primary, preventive, maternity, 
obstetricaL ancillary or emergency care services, as 
defined in Bureau of Insurance Rule Chapter 850; 
(4) 
The financial provisions may apply to all of the 
enrollees covered under the carrier's health plan; 
(5) 
The carrier establishes to the satisfaction of the 
superintendent that the financial provisions permit the 
provision of better guality services and the guali ty 
improvements 
either 
significantly 
outweigh 
any 
detrimental impact to covered persons forced to travel 
longer distances to access services, or the carrier has 
taken steps to effectively mitigate any detrimental 
impact associated with reguiring covered persons to 
travel 
longer 
distances 
to 
access 
services. 
The 
superintendent may consult with other state entities < 
including the Department of Human Services, Bureau of 
Health 
and 
the 
Maine 
Quality 
Forum 
established in 
section 6951. to determine whether the carrier has met 
the 
reguirements 
of 
this 
subparagraph. 
The 
superintendent 
shall 
provisionally 
adopt 
rules 
by 
January 1, 
2004 
regarding the criteria used by the 
superintendent to determine whether the carrier meets 
the 
guality 
reguirements 
of 
this 
subparagraph 
and 
present those rules for legislative review during the 
(6) 
The financial provisions may not permit travel at 
a distance that exceeds the standards established in 
Bureau of Insurance Rule Chapter 850 for mileage and 
travel time by 100%. 
This paragraph takes effect January 1, 2004 and is repealeq 
July 1, 2007. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Sec. 
E-21. 
Report 
by 
Superintendent 
of 
Insurance. 
The 
Superintendent of Insurance shall submit a report no later than 
January 
1, 
2007 
to 
the 
joint 
standing 
committee 
of 
the 
Legislature having 
jurisdiction over 
insurance 
and 
financial 
services matters on any decisions by the superintendent to allow 
health insurance carriers to offer health plans in accordance 
with 
the 
Maine 
Revised Statutes, Title 
24-A, 
section 4303, 
subsection 1, paragraph A. The report must include information on 
the number of enrollees covered under these plans, the financial 
prov~s~ons used in the plans and the designated providers that 
enrollees are encouraged to use under the plans, including their 
locations. The joint standing committee of the Legislature having 
jurisdiction over insurance and financial services matters may 
report out legislation to the First Regular Session of the 123rd 
Legislature to remove the repeal date of Title 24-A, 
section 
4303, subsection 1, paragraph A. 
Sec. 
E-22. 
Report 
on 
medical 
malpractice 
awards. 
The 
Superintendent of Insurance shall submit a report, no later than 
January 
1, 
2005, 
to 
the 
joint 
standing 
committee 
of 
the 
Legislature having 
jurisdiction over 
insurance 
and 
financial 
services matters regarding medical malpractice lawsuits, damage 
awards for noneconomic damages in those lawsuits and the cost and 
availabili ty of medical malpractice insurance in this State. 
As 
part 
of its 
review, 
the 
superintendent 
shall 
consult 
with 
representatives of the medical community, 
legal community and 
medical malpractice insurance industry regarding these issues. 
At a minimum, the report must address the impact on the cost of 
malpractice insurance of a cap on noneconomic damages of $250,000 
in malpractice lawsuits. 
The joint standing committee of the 
Legislature having 
jurisdiction over 
insurance 
and 
financial 
services matters may report out legislation to the First Regular 
Session of the 122nd Legislature in response to the report. 
PARTF 
Sec. F -1. Voluntary limits to control growth of insurance and health 
care costs; report. 
1. 
Voluntary restraint. 
In order to control the rate of 
growth 
of 
costs 
of 
health 
care 
and 
health 
coverage, 
the 
Legislature asks the cooperation of health care practitioners, 
hospitals and health insurance carriers. 
A. 
Each health care practitioner, as defined in the Maine 
Revised Statutes, Title 24, section 2502, subsection I-A, is 
asked 
to 
limit 
the 
growth 
of 
net 
revenue 
of 
the 
practitioner's practice to 3% for the practitioner's fiscal 
year beginning July 1, 2003 and ending June 30, 2004. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
B. 
Each hospital licensed under Title 22, chapter 405 is 
asked to voluntarily restrain cost increases, measured as 
expenses per case mix adjusted discharge, to no more than 
3.5% for the hospital fiscal year beginning July 1, 2003 and 
ending June 30, 2004. 
Each hospital is asked to voluntarily 
hold hospital consolidated operating margins to no more than 
3% for the hospital's fiscal year beginning July 1, 2003 and 
ending June 30, 2004. 
C. 
Each health insurance carrier licensed in this State is 
asked to voluntarily limit the pricing of products it sells 
in this State to the level that supports no more than 3'l-o 
underwriting gain less 
federal 
taxes 
for 
the carrier's 
fiscal year beginning July 1, 2003 and ending June 30, 2004. 
2. 
Report. 
By 
January 
1, 
2004, 
the 
Maine 
Hospital 
Association 
and 
the 
Governor's 
Office 
of Health Policy and 
Finance shall agree on a timetable, format and methodology for 
the hospital association to report on hospital charges, 
cost 
efficiency and consolidated operating margins. 
In accordance 
with the agreement, the Maine Hospital Association shall report 
to 
the 
Governor 
and 
the 
joint 
standing 
committee 
having 
jurisdiction over health and human services matters. 
F-2. MaineCare report. 
The 
Department of Human 
Services 
shall conduct a comprehensive review of reimbursement rates in 
the MaineCare program and shall report the results of that review 
to 
the 
joint 
standing 
committee 
of 
the 
Legislature 
having 
jurisdiction over health and human services matters by January 
15, 2005. 
The review must provide opportunity for input from 
health care consumers, 
providers, 
practitioners and insurance 
carriers and must include consideration of the costs of providing 
health care in different settings, reflecting the recovery offset 
in bad debt and charity care, and a review of rates paid in other 
states and by insurance carriers and the Medicare program. 
The 
review must also identify options and costs for increasing rates 
and must propose strategies for achieving stated priorities. 
The 
joint standing committee having jurisdiction over health and 
human services matters may report out legislation on MaineCare 
provider 
rates 
to 
the 
First 
Regular 
Session of 
the 
l22nd 
Legislature. 
F-3. Commission to Study Maine's Community Hospitals. 
1. 
Commission established. 
The Commission to Study Maine's 
Communi ty 
Hospitals, 
referred 
to 
in 
this 
section 
as 
"the 
commission," is established for the following purposes: 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
A. 
To study the roles of community hospitals in the 21st 
century, including services provided, primary care, medical 
centers, rural hospitals, teaching hospitals, public health, 
prevention and education services, relationships wi th other 
health 
care 
providers, 
physician 
recruitment, 
physician 
training, and continuing care and to evaluate those roles 
based on the priorities in the State Health Plan; 
B. To study the economic impact of hospitals on the state 
and local economies; 
C. 
To 
study 
funding 
mechanisms 
and 
reimbursement, 
the role of insurance 
and the effect of unreimbursed care; 
levels, 
methods 
of 
and 3rd-party payors 
D. 
To study facility and equipment needs, financing options 
and capital needs; 
E. To study opportunities for hospitals to cooperate through: 
( 1) 
Adopting 
common 
technologies, 
record 
shar ing 
systems and quality control techniques; 
(2) 
Purchas ing 
common 
services, 
supplies 
and 
pharmaceuticals and selecting and servicing equipment; 
(3) 
Recruiting and training staff; 
(4) 
Managing 
malpractice, 
workers' 
compensation, 
health care and casualty risks; and 
(5) 
Planning, 
improvements; 
designing 
and 
constructing 
capital 
F. 
To explore public policy regarding community 
including 
incentives 
and barriers 
to 
change, 
health care for 
consumers 
and the challenges 
transitions to new community roles; 
hospitals, 
access 
to 
of making 
G. 
To 
collect 
and 
evaluate 
data 
regarding 
statewide 
hospital 
expenditures 
to 
assess 
cost efficiencies, 
cost 
effectiveness and overall affordability of available health 
care services while preserving geographic access to care; and 
H. 
To 
make 
recommendations 
regarding 
public 
policy 
initiatives to better define the roles of the community 
hospitals and to strengthen the hospitals and equip them to 
serve the residents of the State through the 21st century. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
2. 
Membership. 
The 
commission 
consists 
of 
members 
appointed by the Governor. 
The membership of the commission must 
reflect the geographic diversity of the State. 
The Governor 
shall appoint the chair from among the membership. 
Members serve 
as 
volunteers 
and without 
compensation or 
reimbursement 
for 
expenses. 
The membership consists of the following persons: 
A. 
Two persons representing community hospitals chosen from 
a list submitted by a statewide association representing 
hospitals; 
B. 
One 
person 
representing 
consumers 
of 
health 
care 
services; 
C. 
Two persons representing physicians chosen from lists 
submitted by statewide associations representing allopathic 
and osteopathic physicians; 
D. 
One person representing employers; 
E. 
One 
person representing 
insurers or 
other 
3rd-party 
payors of health care services; 
F. 
One 
economist familiar with econometric modeling of 
health care systems and the analysis and forecasting of 
health care costs; and 
G. 
One person who has expertise in public health issues. 
3. 
Duties. 
The commission shall consider the challenges of 
community hospitals and must be guided by the purposes outlined 
in subsection 1. 
The commission may: 
A. 
Hold at least 2 public hearings to collect 
from 
individuals, 
hospitals, 
health 
care 
insurers, 3rd-party payors, government-sponsored 
programs and interested organizations; 
information 
providers, 
health care 
B. 
Consult with experts in the fields of health care and 
hospitals and public policy; and 
C. 
Examine any other issues to further the purposes of the 
study. 
4. 
Staff assistance. 
The Executive Department shall staff 
the commission through the Governor's Office of Health Policy and 
Finance with assistance from the State Planning Office and the 
Department of Human Services. 
The Attorney General shall provide 
all necessary cooperation and assistance to the commission. 
The 
COMMITTEE AMENDMENT 
.j"' 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
commission shall work in cooperation with the Maine Hospital 
Association. 
5. 
Report. 
The commission shall submit a report and any 
suggested legislation to the joint standing committee of the 
Legislature 
having jurisdiction over health and human services 
matters 
and the joint standing committee of the Legislature 
having jurisdiction over insurance and financial services matters 
no later than November 1, 2004. 
PARTG 
Sec. G·l. Medicare and veterans' health care. The Governor shall 
engage in active negotiations with the Federal Government to 
increase 
access 
to 
federally 
sponsored 
health 
services 
for 
veterans in this State and to increase the rates of Medicare 
reimbursement for the State's health care providers. 
Sec. G·2. Task Force on Veterans' Health Services. 
1. Task force estab1ished. 
The 
Task 
Force 
on Veterans' 
Health Services, referred to in this section as "the task force," 
is established and consists of 13 members as follows: 
A. One member of the Senate appointed by the President of 
the Senate; 
B. 
One member of the House of Representatives appointed by 
the Speaker of the House of the Representatives; 
C. Nine members appointed by the Governor: 
(1) 
Three members who are military veterans, including 
one military veteran representing the Maine Veterans 
Coordinating 
Committee, 
one 
military 
veteran 
representing the Department of Defense, Veterans and 
Emergency 
Management 
Services, 
Bureau 
of 
Maine 
Veterans' 
Services 
and 
one 
military 
veteran 
representing the Maine Veterans' Homes; 
(2) 
Two 
members 
representing 
state 
agencies 
that 
provide health care services; and 
(3) 
Four members representing health care providers, 
including one 
allopathic physician, 
one 
osteopathic 
physician, 
one 
representative of hospitals 
and 
one 
provider of mental health services; 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
D. 
A representative of the federal Department of Veterans 
Affairs; and 
E. 
The Director of Maine Veterans' Homes or the director's 
designee. 
2. Chairs. 
The Senate member and the House member serve as 
cochairs of the task force. 
3. 
Appointments; conveninq of task force. 
All appointments 
must be made no later than 30 days following the effective date 
of this Part. 
The 
appointing authorities shall notify the 
Executive 
Director 
of 
the 
Legislative 
Council 
once 
all 
appointments 
have 
been 
completed. 
Within 
days 
after 
appointment of all members, the chairs shall call and convene the 
first meeting of the task force. 
4. 
Duties. 
The task force shall review and assess the 
needs of the State's veterans for health care services and the 
availability, accessibility and quality of public and private 
health care services for veterans. 
Based on its review and 
assessment, 
the task force shall make recommendations for the 
reorganization of those services to more effectively meet the 
needs of the State's veterans for health care services. 
5. 
Staff assistance. 
and 
Emergency 
Management 
services to the task force. 
The Department of Defense, 
shall 
provide 
necessary 
Veterans 
staffing 
6. Compensation. The legislative members of the task force 
are entitled to the legislative per diem, as defined in the Maine 
Revised Statutes, Title 
3, 
section 2, 
and 
reimbursement for 
travel and other necessary expenses related to their attendance 
at authorized meetings of the task force. 
Public members not 
otherwise compensated by their employers or other entities that 
they represent are entitled to receive reimbursement of necessary 
expenses and, upon a demonstration of financial hardship, a per 
diem equal to the legislative per diem for their attendance at 
authorized meetings of the task force. 
7. Report. 
The task force shall submit a report, no later 
than 
January 
1, 
2005, 
that 
includes 
its 
findings 
and 
recommendations, 
including suggested legislation, to the joint 
standing committees of the Legislature having jurisdiction over 
veterans affairs matters and health and human services matters 
for consideration in the First Regular Session of the 122nd 
Legislature. 
COMMITTEE AMENDMENT 
" 
~) 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
PARTH 
Sec. H-l. Transfer. 
Notwithstanding any other provision of 
law, 
the State Controller shall transfer $53, 000, 000 from the 
unappropriated surplus of the General Fund to the Dirigo Health 
Fund in a 
manner to be determined in consultation with the 
Executive Director of Dirigo Health but in no case later than 
June 30, 2004. 
Sec. 
H-2. 
Appropriations 
and 
allocations. 
appropriations and allocations are made. 
DIRIGO HEALTH 
Dirigo Health Fund 
9999 
The 
following 
Initiative: 
Allocates funds for the operating expenses of Dirigo 
Health, including: premium and subsidy payments under the Dirigo 
Health 
Plan, 
the operation of 
the 
Maine 
Quality 
Forum 
and 
administrative 
costs, 
including 
the 
establishment 
of 
the 
Executive Director of Dirigo Health position. 
Sources of funding 
for the fund include payments made by employers and individuals, 
savings offset payments and any other funds received from public 
or private sources. 
Other Special Revenue Funds 
Positions - Legislative Count 
Personal Services 
Unallocated 
Other Special Revenue Funds Total 
DIRIGO HEALTH 
DEPARTMENT TOTALS 
OTHER SPECIAL REVENUE FONDS 
DEPARTMENT TOTAL -
ALL FONDS 
HUMAN SERVICES, DEPARTMENT OF 
2003-04 
(1. 000) 
$103,901 
1,246,099 
$1,350,000 
2003-04 
$1,350,000 
$1,350,000 
Medical Care -
Payments to Providers 
0147 
Initiative: 
Allocates 
funds 
for 
eligibility under the Dirigo Health 
Federal Expenditures Fund 
All Other 
Federal Expenditures Fund Total 
the 
Plan. 
expansion 
2003-04 
$0 
$0 
2004-05 
(1.000) 
$103,901 
76,437,106 
$76,541,007 
2004-05 
$76,541,007 
$76,541,007 
of 
MaineCare 
2004-05 
$46,516,263 
$46,516,263 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Other Special Revenue Funds 
All Other 
Other Special Revenue Funds Total 
BOMAN SERVICES, DEPARTMENT OF 
DEPARTMENT 1.'O'I'ALS 
FEDERAL EXPENDITURES FUND 
O'llIER SPECIAL REVENUE FUNDS 
DEPAR"J.'MENT TOTAL -
ALL FUNDS 
PROFESSIONAL AND FINANCIAL REGULATION, 
DEPARTMENT OF 
Bureau of Insurance 0092 
2003-04 
$0 
$0 
2003-04 
$0 
$0 
2004-05 
$23,952,246 
$23,952,246 
2004-05 
$46,516,263 
23,952,246 
$70,468,509 
Initiative: 
Allocates 
funds 
Assistant 
position 
and 
one 
temporary 
employment 
services 
services to enable the bureau 
Dirigo Health Act. 
for 
one 
Insurance 
Actuarial 
Statistician 
III 
position, 
for 
and 
for 
contracted 
consultant 
to meet the requirements of the 
Other Special Revenue Funds 
positions - Legislative Count 
Personal Services 
All Other 
Other Special Revenue Funds Total 
PROFESSIONAL AND FINANCIAL 
REGULATION, DEPARTMENT OF 
DEPARTMENT TOTALS 
OTHER SPECIAL REVENUE FUNDS 
DEPARTMENT '1'OTAL -
ALL FUNDS 
HEALTH DATA ORGANIZATION, MAINE 
Maine Health Data Orqanization 
2003-04 
(2.000) 
$131,265 
514,970 
$646,235 
2003-04 
$646,235 
$646,235 
2004-05 
(2.000) 
$133,357 
500,000 
$633,357 
2004-05 
$633,357 
$633,357 
Initiative: 
Allocates funds for one new Epidemiologist position 
and the reclassification of one Comprehensive Health Planner I 
position to a Comprehensive Health Planner II position to enable 
the Maine Health Data Organization to meet the requirements of 
the Dirigo Health Act. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Other Special Revenue Funds 
Positions - Legislative Count 
Personal Services 
All Other 
Other Special Revenue Funds Total 
HEALTH DATA ORGANIZATION, MAINE 
DEPARTMENT "l'O'rALS 
OTHER SPECIAL REVENUE FUNDS 
DEPARTMENT 'l'O'.rAL -
ALL FUNDS 
SECTION "l'O'rALS 
FEDERAL EXPENDITURES FUND 
OTHER SPECIAL REVENUE FUNDS 
SECTION 'l'O'.rAL -
ALL FUNDS 
2003-04 
(1.000) 
$64,271 
6,250 
$70,521 
2003-04 
$70,521 
$70,521 
2003-04 
$0 
2,066,756 
$2,066,756 
Sec. 
H-3. 
Appropriations 
and 
allocations. 
appropriations and allocations are made. 
DUMAN SERVICES, DEPARTMENT OF 
Medical Care -
Payments to Providers 
0147 
2004-05 
(1. 000) 
$65,119 
a 
$65,119 
2004-05 
$65,119 
$65,119 
2004-05 
$46,516,263 
101,191,729 
$147,707,992 
The 
following 
Initiative: 
Appropriates and allocates funds to restore funding 
for the MaineCare Physician Incentive Program (PIP). 
General Fund 
All Other 
General Fund Total 
Federal Expenditures Fund 
All Other 
Federal Expenditures Fund Total 
DUMAN SERVICES, DEPARTMENT OF 
DEPARTMENT "l'O'rALS 
GENERAL FUND 
FEDERAL EXPENDITURES FUND 
DEPARTMENT TOTAL -
ALL FUNDS 
2003-04 
$500,000 
$500,000 
2003-04 
$973,188 
$973,188 
2003-04 
$500,000 
973,188 
$1,473,188 
2004-05 
$500,000 
$500,000 
2004-05 
$971,021 
$971,021 
2004-05 
$500,000 
971,021 
$1,471,021 
COMMITTEE AMENDMENT 
<'" 
":>~:f?~" 
t, 
COMMITTEE AMENDMENT .A" to H.P. 1187, L.D. 1611 
Emergency clause. 
In view of the emergency cited in the 
preamble, this Act takes effect when approved •• 
SUMMARY 
This amendment replaces the bill. In Part A, the amendment 
establishes Dirigo Health as an independent executive agency to 
arrange for the provision of health coverage to small employers 
and their employees 
and dependents 
and to 
individuals 
on 
a 
voluntary basis. 
Dirigo Health is also required to monitor and 
improve the quality of health care in this State. 
Dirigo Health 
is governed by a board of directors. 
Five voting members must be 
appointed by the Governor and confirmed by the Legislature. 
Under 
Part 
A, 
Dirigo 
Health 
must 
contract with health 
insurance carriers to offer health insurance to eligible small 
businesses and individuals through Dirigo Health Insurance. 
The 
health insurance benefits must be determined by the board and 
must 
comply 
with 
all 
statutory 
requirements 
of 
the 
Maine 
Insurance Code, including mandated benefits. 
The amendment also 
provides 
additional assistance through subsidies, 
based on 
a 
sliding scale, to employees and individuals with earnings below 
300°1> of the federal poverty level who are enrolled in Dirigo 
Health. 
Employers who participate in Dirigo Health Insurance may 
be required to contribute up to 60°1> toward the cost of coverage 
for employees who work at least 20 hours per week and their 
dependents. 
The employer contribution rate for employees who 
work less than full time must be prorated. 
In the first year of operation, funding for Dirigo Health is 
provided through the General Fund. 
After July 1, 2005, funding 
for 
subsidies 
and 
the Maine Quality Forum 
must 
be provided 
through 
savings 
offset 
payments 
paid 
by 
health 
insurance 
carriers, 
employee 
benefit 
excess 
insurance 
carriers 
and 
third-party administrators. 
The board of directors is required 
to establish the savings offset amount, 
not to exceed 
4'l-o 
of 
annual premium revenue or its equivalent, on an annual basis and 
those savings offset payments may not exceed the aggregate cost 
savings attributable to reductions in bad debt and charity care 
costs as a 
result of the operation of Dirigo Health and the 
expansion in MaineCare. 
Part A expands MaineCare coverage for children and adults 
and 
provides 
coverage 
for 
expansion 
enrollees 
who 
enroll 
individually and who enroll through Dirigo Health as part of an 
employer group. 
The expansion 
~f MaineCare eligibility may not 
become effective until Dirigo Health becomes operational. 
The 
amendment also requires monthly reporting of the noncategorical 
adult MaineCare expansion. 
COMMITTEE AMENDMENT 
,:', 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Wi thin Dirigo Health, the amendment establishes a high-risk 
pool for persons whose care costs are over $100,000 per year and 
for 
those with certain named diagnoses. 
It requires Dirigo 
Health to develop disease management protocols for persons in the 
high-risk pool. 
If after 3 years Dirigo Health underperforms 
relative to the trends in average premium rates and average rates 
of uninsured individuals compared to those trends in states with 
high-risk 
pools, 
Dirigo 
Health 
is 
charged 
with 
submitting 
legislation to create a high-risk pool on January 1, 2008. 
Part A establishes the Maine Quality Forum within Dirigo 
Health to collect and disseminate research, adopt quality and 
performance 
measures, 
coordinate quality data, 
issue quality 
reports in conjunction with the Maine Health Data Organization, 
conduct 
consumer education and technology assessment reviews, 
encourage 
the 
adoption 
of 
electronic 
technology, 
make 
recommendations for the biennial State Health Plan and issue an 
annual report. 
To assist the board and the forum, the amendment 
establishes the Maine Quality Forum Advisory Council. 
Part B requires the Governor to issue a 
biennial State 
Health Plan and establishes an advisory council to assist in the 
development of the plan. 
Part B also establishes the capital 
investment fund, 
an annual limit for resources allocated under 
the certificate of need program. 
Within the capital investment 
fund, 
12.5% of 
the total is required to 
be designated for 
nonhospital projects for a period of 
years. 
The amendment 
specifies that a certificate of need or public financing that 
affects health care costs may not be provided unless it meets the 
goals and budgets in the State Health Plan. 
Part C applies certificate of need (CON) requirements to the 
portions of an ambulatory surgical facility used by patients or 
to support ambulatory surgical care and to new technology that 
costs over $1,200,000 in the office of a private practitioner. 
It establishes an automatic adjustment to the 
CON 
thresholds 
based on the Consumer Price Index, medical index. 
It expands the 
bases on which the Commissioner of Human Services makes 
CON 
decisions, 
adding 
consistency 
with 
the 
State 
Health 
Plan, 
reference 
to 
quality 
outcomes, 
reference 
to 
inappropriate 
increases in service utilization and the limits of the capital 
investment fund. 
It allows the Commissioner of Human Services to 
receive reports from a panel of experts on CON applications and 
requires 
evaluations 
from 
the Department 
of 
Human 
Services, 
Bureau 
of 
Health 
and 
the 
Superintendent 
of 
Insurance. 
It 
requires 
hospitals 
and 
health 
care 
practitioners 
to 
make 
information on the charges for 
commonly offered health care 
services available to the public. 
Part C requires the Maine Health Data Organization to adopt 
rules to collect data on health care quality based on the quality 
COMMITTEE AMENDMENT 
~:::, \':: 
"". -, 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
measures adopted by the Maine Quality Forum. 
It requires the 
Maine Health Data Organization to issue reports on health care 
services, costs and quality. 
Part D requires health care practitioners to submit claims 
to health insurance 
carriers in electronic 
format 
beginning 
October 
16, 
2003. 
Until 
October 
16, 
2005, 
health 
care 
practitioners with fewer than 10 full-time equivalent employees 
are not required to submit claims electronically. 
After that 
date, 
those practitioners may apply to the Superintendent of 
Insurance for an exemption from the electronic claims filing 
requirement. 
Part E requires the Superintendent of Insurance to adopt 
rules for the filing of annual report supplements by health 
insurers and health maintenance organizations. 
It requires small 
group health plans to submit rate filings to the Superintendent 
of Insurance and imposes rate hearings and rate reviews on those 
filings unless a carrier opts to guarantee a 
78<>.0 loss ratio or 
refund excess premiums. 
It requires individual and small group 
health insurance rates to reflect savings offset payments and any 
recovery of those offsets in premium rates. 
It requires large 
group health carriers to file annually certification that rating 
practices and methods meet actuarial principles and that savings 
offset payments and recovery offsets have been properly included 
in the filing. 
It allows managed care health plans to apply to 
the Superintendent of Insurance for permission to offer health 
plans with financial incentive provisions to encourage the use of 
designated providers of specialty and hospital care if the plan 
does not exceed the Bureau of Insurance Rule Chapter 850 travel 
standards by 100% and meets quality criteria. 
The Superintendent 
of Insurance is required to adopt rules relating to quality 
criteria 
by 
January 
1, 
2004 
and 
submit 
those 
rules 
for 
legislative 
review 
before 
final 
adoption. 
The 
provision 
regarding managed care plans offering health plans with financial 
incentive provisions is repealed on July 1, 2007 unless continued 
by the Legislature. 
It requires the Superintendent of Insurance 
to conduct a 
study of the impact of 
a 
cap of 
$250,000 
on 
noneconomic damages in medical malpractice lawsuits on the cost 
of medical malpractice insurance. 
Part F sets voluntary constraints on financial growth for a 
period of one year by health care practitioners, hospitals and 
health 
insurance 
carriers. 
It also 
requires 
the 
Governor's 
Office of Health Policy and Finance 
and the Maine Hospital 
Association to agree on a timetable, format and methodology for 
reporting on hospital charges, cost efficiency and consolidated 
operating margins. 
It requires the Department of Human Services 
to conduct a comprehensive study of MaineCare reimbursement rates 
and to report by January 15, 2005. 
It establishes the Commission 
to Study Maine's Hospitals and requires that commission to report 
by November 1, 2004. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to H.P. 1187, L.D. 1611 
Part G requires the Governor to work to improve access to 
care for veterans and to improve Medicare reimbursements for 
Maine providers and establishes a task force to study health care 
services provided to Maine veterans. 
Part H restores $500,000 in General Fund money to restore 
the physician incentive payment program within the MaineCare 
program. 
Part 
H 
authorizes 
the 
State 
Controller 
to 
transfer 
$53,000,000 from the General Fund to Dirigo Health to support its 
operation in the first year. 
Part H also adds appropriations and allocations sections to 
the bill, as 
amended, 
as well as 
an emergency preamble and 
emergency clause. 
FISCAL NOTE REQIDRED 
(See attached) 
COMMITTEE AMENDMENT 
Net Cost (Savings) 
General Fund 
Appropriations/Allocations 
General Fund 
Federal Expenditures Fund 
Other Special Revenue Funds 
Revenue 
Federal Expenditures Fund 
Other Special Revenue Funds 
Transfers 
General Fund 
Other Special Revenue Funds 
Fiscal Detail and Notes 
Approved: 06111103 frac 
st Maine Legislature 
Office of Fiscal and Program Review 
LD 1611 
An Act To Provide Affordable Health Insurance to Small Businesses and 
Individuals and To Control Health Care Costs 
LR2137(02) 
Fiscal Note for Bill as Amended by Committee Amendment" " 
Committee: Joint Select Committee on Health Care Reform 
Fiscal Note Required: Yes 
Fiscal Note 
2003-04 
2004-05 
$53,500,000 
$500,000 
$500,000 
$500,000 
$973,188 
$47,487,284 
$2,066,756 
$101,191,729 
$973,188 
$0 
($53,000,000) 
$53,000,000 
$47,487,284 
$62,457,480 
$0 
$0 
Projections 
2005-06 
$500,000 
$500,000 
$111 ,313,873 
$260,850,284 
$111,313,873 
$251,537,581 
$0 
$0 
Projections 
2006-07 
$500,000 
$500,01lv 
$161,845,977 
$327,250,067 
$161,845,977 
$326,551,591 
$0 
$0 
After the initial transfer from the General Fund of $53 million from the funding provided under the federal Jobs and 
Growth Tax Relief Reconciliation Act of2003 PL 108-27, the additional costs resulting from this bill are intended to be 
offset by dedicated revenue generated in the bill. The bill assumes the operational costs of Dirigo Health -- the premium 
subsidy payments, the MaineCare eligibility expansions, the new Maine Quality Forum, and necessary administrative 
costs -- will be offset by dedicated revenue generated from employee and employer contributions, the one-time General 
fund transfer, ongoing federal Medicaid matching funds, and beginning July 1,2005, a new assessment to be paid by 
health carriers, 3rd party administrators and employee benefit excess insurance carriers (referred to in the bill as a 
"savings offset payment"). 
LR2137(2) - Fiscal Note - Page 1 of3 
The ability of Dirigo Health to remain financially sound within these funding resources will depend on Dirigo 
aggressively managing the start up and phase-in of the program to ensure employer participation is maximized. Without 
continued employer participation, Dirigo Health would increasingly be forced to rely on the health insurance assessment 
to fund the MaineCare eligibility expansions. 
The specifics -- both costs and financing -- of the biIl will depend on actions taken by the new Dirigo Health Board and 
Dirigo Health Plan over the coming year, with program services not assumed to begin until the first quarter of state 
fiscal year 2004-05. For the purposes of this fiscal note, it is assumed that approximately 30,000 enrollees will 
participate in the first year of the plan beginning July 1, 2004, however there is no specific cap on the enrollment 
specified in the bill so this should be viewed as more of a management target than a cap. As provided in the bill, 
eligible enrollees will be a mix of MaineCare and non-MaineCare eligibles and will participate either as individuals or 
through employer group plans. This mix of MaineCare vs. non-MaineCare and individual vs. group is critically 
important to the costs of this program and its financial viability. 
Because of the importance of the employer contribution as the financing mechanism for both the MaineCare and non-
MaineCare enrollees, any reduction in employer participation from assumed levels could also threaten the financial 
viability of the plan and may require a reduction in coverage -- both in eligibility levels and the benefit plan. For 
example, the Administration's pricing model assumes slightly more than 80% of MaineCare participants must enroll 
through their employers for the plan to be financially viable. In addition, failure of insurance carriers to participate in 
Dirigo would trigger the bill's provisions regarding creation of a public alternative -- this would require additional 
approval by the Legislature. 
The assumption that the bill will not have a General Fund impact beyond the initial transfer of $53 million, assumes the 
Department of Human Services will have in place the ability to uniquely identify the three MaineCare expansion 
populations in the bill-- childless adults from 100% to 125% of poverty, disabled persons from 100% to 125% of 
poverty, and parents of "CubCare" children from 150% to 200% of poverty -- and allocate these costs to Dirigo 
dedicated revenue. In addition, the ability of the Department to control and appropriately allocate the costs of the 
current population (up to 100% of poverty) participating in the MaineCare childless adult federal waiver, will be a 
critical factor in the Administration's assumption that the expanded childless adult population (to 125%) can be included 
in Dirigo as MaineCare eligible. 
On the administrative cost side, the bill creates Dirigo Health as an independent executive agency and provides for the 
creation of an "Executive Director of Dirigo Health" position. The Executive Director is tasked with the responsibility 
of employing or contracting on behalf of Dirigo Health for professional and non professional personnel or services. The 
bill requires that employees of Dirigo Health be subject to the State Civil Service Law. This fiscal note assumes that 
other than the Executive Director position, no positions are created at this time. It is assumed the Executive Director 
will work with the State Budget Officer to create limited period positions as appropriate, and that any request for 
permanent positions will be subject to further Legislative approval. It is assumed funding for all administrative costs of 
Dirigo will come from Dirigo dedicated revenue -- with one exception, the $374,368 in fiscal year 2003-04 and 
$374,630 in fiscal year 2004-05 that would be appropriated in Committee Amendment A to the Part 2 budget (LD 
1614). 
This estimate assumes the Bureau of Insurance will require additional Other Special Revenue Funds allocations for two 
new positions and for contracted services to enable it to meet the bill's requirement regarding review of small group 
health insurance filings, review of Certificate of Need (CON) applications and review of large group rate certifications. 
The bill makes no provision for revenue for this purpose, therefore, it is assumed that existing fees and assessments will 
need to be adjusted to cover these costs. 
LR2137(2) - Fiscal Note - Page 2 of 3 
The estimate also assumes the Maine Health Data Organization will require additional Other Special Revenue Funds 
allocations for one new position and the reclass of an existing position to meet its responsibilities under the bill. The 
bill makes no provision for revenue for this purpose, therefore, it is assumed that existing fees and assessments may 
need to be adjusted to cover these costs. 
The bill does not include additional resources for the Department of Human Services for costs it will incur in 
coordinating the implementation ofDirigo Health. It is assumed these can be absorbed by the Department utilizing 
existing resources. 
Any additional costs to the Department of Audit to audit Dirigo Health on an annual basis can be absorbed by the 
Department of Audit. 
The additional cost to the Legislature in Part G will need to be funded through the Legislature's study budget of $30,000 
as funds permit. Any additional costs to the Department of Defense, Veterans, and Emergency Management resulting 
from Part G can be absorbed within existing resources. 
The bill also includes a General Fund appropriation of $500,000 in state fiscal year 2003-04 and $500,000 in state fiscal 
year 2004-05 to restore funding for the MaineCare Physician Incentive Program (PIP). 
LR2137(2) - Fiscal Note - Page 3 of3