An Act To Allow Efficient Health Insurance Coverage
Maine Legislature, Session 124, LD 1397
Committee: Insurance and Financial Services
Sponsors: PRIEST, BOWMAN, FOSSEL, GOODE
Amends: 24-A MRSA §4303

Legislative Document 
No. 1397 
H.P.976 
HOllse of Representatives, April 2, 2009 
An Act To Allow Efficient Health Insurance Coverage 
Reference to the Committee on Insurance and Financial Services suggested anq ordered 
printed. 
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MILLICENT M. MacFARLAND 
Clerk 
Presented by Representative PRIEST of Brunswick. (GOVERNOR'S BILL) 
Cosponsored by Senator BOWMAN of York and 
Representatives: B~AUDOIN of Biddeford, FOSSEL of Alna, GOODE of Bangor, 
RICHARDSON ofWan"en. 
PrirnctJ 011 rcc.:yclL'd p>lpcr 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1. 24-A MRSA §4303, sub-§l, as amended by PL 2007, c. 199, Pt. B,§5, is 
further amended to read: 
1. 
Demonstration of adequate access to providers. 
Except as provided in 
paragraph paragraphs A, Band C, a carrier offering or renewing a managed care plan 
shall provide to its members reasonable access to health care services in accordance with 
7. 
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 j'easonable access to providers consi~tent 
with the access-to-services requirements of any applicable bureau rule. 
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; 
2J 
(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 
can'ier's health plan; 
. 
(5) 
The carrier establishes to the satisfaction of the superintendent that the 
financial provisions permit the provision of better quality services and the quality 
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 
requiring covered persons to travel longer distances to access services. The· 
superintendent may consult with other state entities, including the Department of 
Health and Human Servi~es, Bureau of Health and the Maine Quality Forum 
established in' section 6951, to detennine whether the carrier has met the 
requirements of this subparagraph. The super.intendent shall provisionally adopt 
rules by January 1,2004 regarding the criteria used by the superintendent to 
determine whether the carrier meets the quality requirements of this subparagraph 
and present those rules for legislative review during the Second Regular Session 
of the 121 st Legislature; and 
(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 b-y 100%. 
This paragraph takes effect January 1, 2004and is repealed July 1, 2009. 
Page I - 124LR1907(0l)-1 
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B. 
Upon approval of the superintendent, a carrier may offel; 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 primalY, 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 quality services and the quality 
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 
requiring covered persons to travel longer distances to access services. The 
superintendent may consult with other state entities, including the Department of 
Health and Human Services, Bureau of Health and the Maine Quality Forum 
established in section 6951, to determine whether the carrier has met the 
requirements of this subparagraph. The superintendent shall adopt rules regarding 
the criteria used by the superintendent to determine whether the carrier meets the 
quality requirements ofthis subparagraph; and 
(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%. 
C. 
Notwithstanding paragraph B, a carrier may develop and file with the 
superintendent for approval a pilot program that allows carriers to reward providers 
for quality and efficiency through tiered benefit networks and providing incentives to 
members.· The upper tier, or the upper tiers if there are 3 or more tiers, under a pilot 
program approved pursuant to this paragraph is exempt from geographic access 
requirements set forth in this Title or in rules adopted by the superintendent. Any 
carrier offering a health plan under the pilot program must collect data: on the impact . 
of the pilot program on premiums paid by enrollees, payments made to providers, 
quality of care received and access to health care services by individuals enrolled in 
health plans under the pilot program and must submit that data annually to the 
superintendent. The superintendent shall report annually beginning January 15, 2010 
to the joint standing comm ittee of the Legislature having jurisdiction over insurance 
and financial services matters on any approval of a pilot program pursuant to this 
paragraph. 
The basis for tiering benefits under a pilot program must be to provide incentives for 
higher-quality care, improved patient safety or improved efficiency or a combination 
of those factors. The superintendent shall consult with the Maine Quality Forum 
under section 6951 in assessing quality. 
The superintendent shall· disapprove or 
withdraw approval of a pilot program if the superintendent finds that approval or 
·continued operation would cause undue hardship to enrollees in the pilot program or 
reduce their quality of care. 
The superintendent shall consider the experience of approved pilot programs, 
including consumer complaints and examinations, provider behavior and efficiency, 
in determining whether or not to reapprove subsequent pilot program applications. 
SUMMARY 
This bill allows carriers to include financial incentives to members to use designated 
providers and gives the Superintendent of Insurance the authority to approve a financial 
incentive pilot program similar to the pilot program used by the State Employee He~lth 
Plan that allows companies to offer products in which consumers can choose to travel 
further for improved quality, patient safety and efficiency without adversely affecting 
quality of care: This bill also enacts again language that is scheduled to be repealed July 
1, 2009 regarding limits, including geographic access requirements, on the inc~ntives 
,used by health plans to encourage in-network designated providers. 
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