An Act To Establish a Health Care Bill of Rights
Maine Legislature, Session 124, LD 1205
Committee Amendment CA_A_H446 (House)
Amends: 24-A MRSA §4303, 24-A MRSA §2736, 24-A MRSA §2736-A, 24-A MRSA §2808-B, 24-A MRSA §2, 24-A MRSA §280, 24-A MRSA §221

FmST REGULAR SESSION 
COMMITTEE AMENDMENT "R " 
to H.P. 830, L.D. 1205, Bill, "An Act To 
Establish a Health Care Bill of Rights" 
Amend the bill in Part A in section 4 in subsection 13 in the last paragraph in the 
second line (page 2, line 18 in L.D.) by inserting after the following: "carriers" the 
following: " taking into consideration any national standards for explanation of benefits 
forms' 
Amend the bill in Part A by inserting after section 4 the following: 
'Sec. A-5. 24-A MRSA §4303, sub-§14 is enacted to read: 
14. Policy terms. The superintendent may by rule defme standard policy terms that 
must be used in all policies issued by carriers offering health plans in the State. Rules 
adopted pursuant to this subsection are routine technical rules as defined in Title 5, 
chapter 375, subchapter 2-A. 
Sec.,A-6. Appropriations and allocations. The following appropriations and 
allocations are made. 
PROFESSIONAL AND FINANCIAL REGULATION, DEPARTMENT OF 
Insurance - Bureau of 0092 
Initiative: Allocates funds for the one-time costs of required rule-making proceedings. 
OTHER SPECIAL REVENUE FUNDS 
All Other 
OTHER SPECIAL REVENUE FUNDS TOTAL 
2009-10 
$2,100 
$2,100 
2010-11 
$0 
$0 
Amend the bill in Part B in section 5 in paragraph E by inserting at the end a new 
blocked paragraph to read: 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" ~"to H.P, 830, L.D, 1205 
'If a carrier has a provider profiling program that includes out-of-network providers, a') 
carrier must meet the requirements ofthis paragraph with regard to an out-of-network 
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provider as well as for a provider in a carrier's network.' 
Amend the bill by striking out all of Parts C, D, E, F and G and inserting the 
following: 
'PARTe 
Sec. C-l. 24-A MRSA §2736, sulb-§JI., as amended by PL 2009, c. 14, §4, is 
further amended to read: 
1. Filing of rate inform.ation. Every insurer shall file with the superintendent every 
rate, rating formula, classification of risks and every modification of any formula or 
classification that it proposes to use in connection with individual health insurance 
policies and certain group policies specified in section 270l. If the filing applies to 
individual health plans as dermed in section 2736-C, the insurer shall simultaneously file 
a copy with the Attorney General. Every such filing must state the effective date of the 
filing. Every such 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, and the 
effective date may be suspended by the superintendent for a period of time not to exceed 
days. In the case of a filing that meets the criteria in subsection 3, the superintendent 
may suspend the effective date for a longer period not to exceed 30 days from the date the 
organization satisfactorily responds to any reasonable discovery requests. 
A filing 
required under this section must be made electronically in a format required by the 
superintendent unless exempted by rule adopted by the superintendent. Rules adopted 
pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, 
subchapter 2-A. 
Sec. C-2. 24-A MRSA §2736, sub-§2, as amended by PL 1997, c. 344, §8, is 
further amended to read: 
2. Filing; information. When a filing is not accompanied by the information upon 
which the insurer supports such filing, or the superintendent does not have sufficient 
information to determine whether such filing meets the requirements that rates not be 
excessive, inadequate or unfairly discriminatory, the superintendent shall require the 
insurer to furnish the information upon which it supports the filing. A filing and all 
supporting information, except for protected health information required to be kept 
confidential by state or federal statute and descriptions of the amount and terms or 
conditions or reimbursement in a contract between an insurer and a 3rd party, are public 
records within the meaning of notwithstanding Title 1, section 402, subsection 3~ 
paragraph B and become part of the official record of any hearing held pursuant to 
section 2736-A. 
Sec. C-3. 24-A MRSA §2736-A, first~, as amended by PL 2007, c. 629, Pt. M, 
§3, is further amended to read: 
If at any time the superintendent has reason to believe that a filing does not meet the 
requirements that rates not be excessive, inadequate, unfairly discriminatory or not in 
compliance with fermeF section 6913 or that the filing violates any of the provisions of 
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COMMITIEE AMENDMENT "A "to H.P. 830, L.D. 1205 
chapter 23, the superintendent shall cause a hearing to be held. If a filing proposes an 
increase in rates in an individual health plan as defined in section 2736-C, the 
superintendent shall cause a hearing to be held at the request of the Attorney General. In 
any hearing conducted under this section, the insurer has the burden of proving rates are 
not excessive, inadequate or unfairly discriminatory and in compliance with section 6913. 
PARTD 
Sec. D-l. 24-A MRSA §2808-B, sub-§2-A, 4TH, as enacted by PL 2003, c. 469, 
Pt. E, § 16, is amended to read: 
B. 
A filing and all supporting information, except for protected health information 
required to be kept confidential by state or federal statute and except for descriptions 
of the amount and terms or conditions or reimbursement in a contract between an 
insurer and a 3rd party, are public records except as provided by notwithstanding 
Title 1, section 402, subsection 3, paragraph B and become part of the official record 
of any hearing held pursuant to subsection 2-B, paragraphs paragraph B or F. 
Sec. D-2. 24-A MRSA §2S0S-B, sub-§2-B, -,rA, as amended by PL 2007, c. 
629, Pt. M, §7, is further amended to read: 
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 group health plans 
maintained in force by the carrier for the period for which coverage is to be provided 
will return to policyholders at least ~ 
78% 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 payments paid pursuant to fermer section 6913 
must be treated as incurred claims. 
Sec. D-3. 24-A MRSA §2S0S-B, sub-§2-C, -,rC, as amended by PL 2007, c. 
629, Pt. M, § 10, is further amended to read: 
C. If incurred claims were less than 18% 80% of aggregate earned premiums over a 
continuous 36-month period, the carrier shall refund a percentage of the premium to 
the current in-force policyholder. 
For the purposes of calculating this loss-ratio 
percentage, any payments paid pursuant to fermer section 6913 must be treated as 
incurred claims. The excess premium is the amount of premium above that amount 
necessary to achieve a----+8% an 80% 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 an amount reasonably calculated to correspond to the aggregate 
experience of all policyholders holding policies having similar benefits. The total of 
all refunds must equal the excess premiums. 
(1) For determination ofloss-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. 
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COMMITIEE AMENDMENT "~,, to H.P. 830, L.D. 1205 
(2) The superintendent may waive the requirement for refunds during the first 3,., 
years after the effective date of this subsection. 
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Sec. D-4. 24-A MRSA §2S0S-B, sub-§6, ~A, as amended by PL 2001, <to 410, 
Pt. A, §6, is further amended to read: 
A. 
Each carrier must actively market small group health plan coverage, including 
any standardized plans required to be offered pursuant to subsection 8-A. to eligible 
groups in this State. 
Sec. D-5. 24-A MRSA §280S-B, sub-§8-A is enacted to read: 
8-A. Authority of the superintendent. The superintendent may by rule define one 
or more standardized small group health plans that must be offered by all carriers offering 
small group' health plans in the State. Rules adopted pursuant to this subsection are 
routine technical rules as defined in Title 5, chapter 375, subchapter 2-A. 
Sec. D-6. 
Superintendent of Insurance report. 
The Superintendent of 
Insurance shall review possible ways to improve the availability and affordability of the 
State's individual health insurance market, including, but not limited to, increases in the 
minimum loss-ratio standards applicable to that market and consideration of an insurer's 
loss experience in all lines of insurance marketed by a carrier in this State when 
reviewing health insurance rate filings. The superintendent shall report the results of the 
review, including any recommendations for legislation, to the Joint Standing Committee 
on Insurance and Financial Services no later than February 1, 2010. The joint standing 
committee may report out a bill based on the report to the Second Regular Session of the 
124th Legislature. 
PARTE 
Sec. E-l. 24-A MRSA §221, suh-§5 is enacted to read: 
5. Examination of health carriers. The superintendent shall examine the market 
conduct of each domestic health carrier, as defined in section 4301-A, subsection 3, and 
each foreign health carrier with at least 1,000 covered lives in this State, offering a health 
plan as defmed in section 4301-A, subsection 7, no less frequently than once every 5 
years. An examination under this subsection may be comprehensive or may target 
specific issues of concern observed in the State's health insurance market or in the 
company under examination. In lieu of an examination conducted by the superintendent, 
the superintendent may participate in a multi state examination, or, in the case of a foreign 
company, approve an examination by the company's domiciliary regulator upon a finding 
that the examination and report adequately address relevant aspects of the company's 
market conduct within this State. 
Sec. E-2. Transition. The Superintendent of Insurance shall begin conducting the 
market conduct examinations required by the Maine Revised Statutes, Title 24-A, section 
221, subsection 5 during calendar year 2010, and all health carriers subject to the 
examination requirement must be examined at least once before January 1,2015. 
COMMI 
EE AMENDMENT 
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COM1v1ITIEE AMENDMENT"~ "to H.P. 830, L.D. 1205 
PARTF 
Sec. F-1. 24-A MRSA §4303, sub-§7-A is enacted to read: 
7-A. Continuity of prescriptions. If an enrollee has been undergoing a course of 
treatment with a prescription drug by prior authorization of a carrier and the enrollee's 
coverage with one carrier is replaced with coverage from another carrier pursuant to 
section 2849-B, the replacement carrier shall honor the prior authorization for that 
prescription drug and provide coverage in the same manner as the previous carrier until 
the replacement carrier conducts a review of the prior authorization for that prescription 
drug with the enrollee's prescribing provider. Policies must include a notice of the right 
to request a review with the enrollee's provider, and the replacing carrier must honor the 
prior carrier's authorization if the enrollee's provider participates in the review and 
requests the prior authorization be continued. The replacing carrier is not required to 
provide benefits for conditions or services not otherwise covered under the replacement 
policy, and cost sharing may be based on the copayments and coinsurance requirements 
of the replacement policy.' 
SUMMARY 
This amendment does the following. 
1. It amends Part A to require the Superintendent of Insurance, when making rules, to 
take into consideration national standards and to give the superintendent authority to 
define standard policy terms by rulemaking. It provides a one-time allocation to cover 
the costs of rulemaking. 
2. It amends Part B to establish standards for provider profiling programs used by 
carriers for out-of-network providers. 
3. It removes Part C, which requires carriers and health maintenance organizations to 
include certain information about product offerings in the annual report supplement to the 
Department of Professional and Financial Regulation, Bureau ofInsurance. 
4. Part C in this amendment permits the Attorney General to request a rate hearing 
regarding proposed rate increases for individual health plans. It removes the provisions in 
the bill that extended the notice period for carriers to notify policyholders of proposed 
rate increases. 
5. Part D in this amendment requires a benefits-incurred-to-premiums-earned loss 
ratio of 78% for one year or 80% over a 3-year average in the small group insurance 
market. Part D authorizes the Superintendent of Insurance to adopt rules requiring small 
group health carriers to offer standardized small group health plans. Part D also 
authorizes the superintendent to study the impact of increases in the loss ratio in the 
individual market and the consideration of losses in all health insurance markets as part of 
rate filings. 
6. Part E in this amendment requires the Superintendent of Insurance to undertake 
market conduct examinations of health insurance companies no less frequently than once 
every 5 years, beginning in 2010. Part E requires all health insurance carriers to be 
examined at least once by 2015. 
COMMITTEE AMENDMENT 
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COMMITIEE AMENDMENT "~ " to H.P. 830, L.D. 1205 
7. Part F in this amendment requires a carrier replacing a previous carrier to honor" 
any prior authorizations for prescription drugs for an enrollee undergoing a course of 
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treatment until the replacement carrier conducts a review of that prior authorization with 
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the enrollee's prescribing provider. 
FISCAL NOTE REQUIRED 
(See attached) 
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COMMITTEE AMENDMENT 
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Approved: 05/24/09 ;'!;pac 
LD 1205 
LR 1504(02) 
An Act To Establish a Health Care Bill of Rights 
Fiscal Note for Bill as Amended by Committee Amendment '~" 
Committee: Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
2009-10 
2010-11 
Projections 
2011-12 
Appropriations/Allocations 
Other Special Revenue Funds 
Fiscal Detail and Notes 
$2,100 
$0 
$0 
Projections 
2012-13 
$0 
Allocates $2,100 in Fiscal Year 2009-10 to the Bureau of Insurance in the Department of Professional and Financial 
Regulation for the one-time costs of required rulemaking proceedings. Additional costs to other state agencies and 
programs are expected to be minor and can be absorbed utilizing existing budgeted resources. 
LR1504(02) - Fiscal Note - Page 1 of 1