An Act To Stabilize Funding and Enable DirigoChoice To Reach More Uninsured
Maine Legislature, Session 124, LD 1264
Committee: Insurance and Financial Services
Sponsors: TREAT, BOWMAN, PINGREE, MITCHELL
Amends: 24-A MRSA §6908, 24-A MRSA §6913, 24-A MRSA §6917, 24-A MRSA §6951

FIRST RF,(;ULAR SF,SSION-2009 
Legislative Document 
No. 1264 
H.P.883 
House of Representatives, March 31, 2009 
An Act To Stabilize Funding and Enable DirigoChoice To Reach 
More Uninsured 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
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1/1. 77!tJ£~{ 
MILLICENT M. MacFARLAND 
Clerk 
Presented by Representative TREAT of Hallowell. (GOVERNOR'S BILL)' 
Cosponsored by Senator BOWMAN of York and 
Representative: Speaker PINGREE of North Haven" Senator: President MITCHELL of 
'Kennebec. 
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Printed on recycled paper 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1. 24-A MRSA §6908, sub-.§2, ~, as amended by PL 2007, c~ 629, Pt. L, 
§ 1, is fUliher amended to read: 
B. Collect the savings offset payments provided in former section 6913 and the 
ftea.Itft access surcharge payment provided in section 6913 A6917; 
Sec. 2. 24-A MRSA §6913, as amended by PL 2007, c. 1, Pt. X, §§ 1 and 2 and 
affected by §3, is repealed. 
Sec. 3. 24-A MRS A §6915, as ·amended byPL 2005, c. 386, Pt. D, §3, .is further 
amended to read: 
§6915. Dirigo Health Enterprise Fund 
The Dirigo Health Enterprise Fund is created as an enterprise 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 former section 6913~· 
access payments made pursuant to section 6917 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. 
Sec. 4. 24-A MRSA §6917 is enacted to read: 
§6917. Access payment 
1.. 
Access payments required from health insurance carriers, 3rd-party 
administrators and employee benefit excess insurance carriers. All health insurance. 
carriers, 3rd-party administrators and employee benefit excess insurance carriers shall 
pay an access payment of 2.14% on all paid claims, except claims under accidental 
c,' 
injury, specified disease, hospital indemnity, dental, vision, disability income, long-term . 
care, Medicare supplement or other limited benefit health insurance.· The following 
provisions govern ·access payments. 
A. A health insurance carrier or employee benefit excess insurance carrier may not 
be required to pay an access payment on policies or contracts insuring federal 
employees. 
B. Access payments apply to claims paid beginning on or after the effective date of 
this section. 
C. Access payments must be made monthly to Dirigo Health and are due 15 days 
after the end of each month and must accrue interest at 12% per annum on or after the 
due date, except that access payments for 3rd-pai1y administrators for groups of 500 
or fewer members may be made anriually not less than 60 days after the close of the 
plan year. 
D; Access payments received by Dirigo Health must be pooled with other revenues 
of the agency in the Dirigo Health Enterprise Fund established in section 6915. 
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2. Failure to pay access payments., The superintendent may suspend or revoke, 
after notice and hearirig, 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 3rd-party administrator to operate in this State that fails to pay an access payment. In 
addition, the superint~ndent may assess civil penalties in accordance with section 12-A, 
'against any health insurance carrier, employee benefit excess insurance carrier or 3rd-
party administrator that fails to pay an access payment or may take any other enforcement 
action authorized under section 12-A to collect any unpaid access payments and may 
collect the cost of enforcement including attorney's fees from those who fail to pay an 
access payment. 
3. Definitions. As used in this section, the following terms have the following 
meanings. 
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A. "Claims-related expenses" includes: 
(1) Payments for utilization review, care management, disease management, risk 
assessment and similar administrative services intended to reduce the claims paid 
for health and medical services rendered to covered individuals, usually either by 
attempting to ensure that needed services are delivered in the most efficacious 
manner possible or by helping such covered individuals to maintain or improve 
their health; and 
(2) Payments that are made to or by organized groups of providers of health and 
medical services in accordance with managed care risk arrangements or network 
access agreements and that are unrelated to the provision of services-to specific 
covered individuals. 
B. 
"Health and medical services" includes, but is not limited to, any services 
included in the furnishing of medical care, dental care to the extent covered under a 
medical insurance policy; pharrriaceutical benefits or hospitalization, including but 
not limited to services provided in a hospital or other medical 'facility; ancillary 
services, including but not limited to ambulatorY services; physician' and other 
practitioner services, including but not limited to services provided by a physician's 
assistant, nurse practitioner or midwife; aild behavioral health services, including but 
not limited to mental health and substance abuse services. 
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C. "Paid claims" means all payments made by health insurance carriers, 3rd-party 
administrators and employee benefit excess insurance carriers for health and medical 
services provided under policies that insure residents of this State or, in the case of 
3rd-party administrators, for health care for residents of this State, except that "paid 
clainls" does not include: 
(1) Claims-related expenses and general administrative expenses; 
(2) Payments made to qualifying providers under a "pay for performance" or 
other incentive compensation arrangement if the payments are not reflected in the 
processing of claims submitted for' services rendered to specific covered 
individuals; 
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(3) 
Claims paid by carriers and 3rd-palty administrators with respect to 
accidental injury, ;pecified disease, hospital indemnity, dental, vision, disability 
8. 
income, long-term care, Medicare supplement or other limited benefit health 
insurance, except that claims paid for dental services covered under a medical 
policy are included; 
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(4) Claims paid for services rendered to nonresidents of this State; 
(5) Claims paid under retiree health benefit plans that are separate from and not 
included within benefit plans for existing employees; 
(6) Claims paid by an employee benefit excess insurance carrier that have been 
counted by a 3rd-palty administrator for determining its access payment; 
(7) Claims paid for services rendered to persons covered under a benefit plan for 
federal employees; and 
(8) Claims paid for services rendered outside of this State to a person who is a 
resident of this State. 
In those instances in which a health insurance carrier, employee benefit excess 
insurance carrier: or 3rd-party administrator is contractually entitled to withhold 
celiain amounts from payments due to providers of health and medical services in 
order to help ensure that the providers can fulfill any financial obligations they may 
have under a managed care risk arrangement, the full amounts due the providers 
before application of such withholds must be reflected in the calculation of paid 
claims. 
4. Rulemaking. The board may adopt any rules necessary to implement this section. 
Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, 
chapter 375, subchapter 2-A. 
Sec. 5. 24-A MRSA §6951, first~, as amended by PL 2007, c. 629, Pt. L, §5, is 
further amended to read: 
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The Maine Quality Forum, refen'ed to in this subchapter as "the forum," is 
established within Dirigo Health. The forum is governed by the board with advice from 
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the Maine Quality Forum Advisory Council pursuant to section 6952. The forum must be 
funded, at least in part, through the savings offset payments made pursuant to former 
section 6913 and theflealtfl access surcharge payment pursuant to section 6913 A 6917. 
Except as provided in section 6907, subsection 2, information obtained by the forum is a 
public record as provided by Title 1, chapter 13, subchapter I. The forum shall perform 
the following duties. 
·Sec. 6. Changes to Dirigo Health. The Board of Trustees of Dirigo Health,or 
"the board," shall: 
1. 
Develop· products, procedures. 
Develop more affordable products and 
procedures that can reach uninsured and underinsured r:esidents of the State to reduce 
uncompensated care; 
2. 
Maximize federal initiatives. Use subsidies to maximize federal initiatives, 
including Medicaid and any national health reform; 
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3. Asset tests. Determine the impact of asset tests on determining eligibility; 
4. Voucher program. Consider offering a voucher-bFlsed program to provide health 
insurance benefits based upon the experience in the Dirigo voucher program established 
in section 6; and 
5. Redesign. Redesign the DirigoChoice product or products. 
The board shall repOli to the Joint Standing Committ~e .on Insurance and 'Financial 
Services regarding changes that will be made to the Dirigo Health Program consistent 
with this section by January 1,2010. 
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Sec. 7. 
Savings offset payments calculated prior to effective date. 
Nop.vithstanding that section of this Act that repeals the Maine Revised Statutes, Title 
24-A, section 6913; the savings offset payments that have been calculated and required 
under former Title 24-A, section 6913 for claims paid prior "to the effective date of this 
Act are due and payable in the same manner and subject to the same procedures set forth 
in former Title 24-A, section 6913. 
SUMMARY 
This bill requires the Board of Trustees of Dirigo Health to reach more uninsured and 
lInderinsured individuals through a more affordable product and to report to the Joint 
- Standing Committee on Insurance and Financial Services regarding changes to the Dirigo 
Health Program by January 1, 2010. 
The bill replaces the savings offset payment, 
currently assessed at a variable rate up to 4% of paid claims determined each year 
depending on savings, with a fixed 2.14% access payment on paid claims paid monthly.