An Act To Amend the Laws Governing Financial Incentives and Geographic Accessibility of Services Covered by Health Insurance Providers
Maine Legislature, Session 125, LD 0496
Committee: Insurance and Financial Services
Sponsors: McKANE, THOMAS, MALABY, PICCHIOTTI, RICHARDSON, WEAVER, HASTINGS, SNOWE-MELLO
Amends: 24-A MRSA §2673-A, 24-A MRSA §4203, 24-A MRSA §4303

Legislative Document 
No. 496 
H.P. 389 
House of Representatives, February 10, 2011 
An Act To Amend the Laws Governing Financial Incentives and 
Geographic Accessibility of Services Covered by Health Insurance 
Providers 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
HEATHER J.R. PRIEST 
Clerk 
Presented by Representative McKANE of Newcastle. 
Cosponsored by Senator THOMAS of Somerset and 
Representatives: MALABY of Hancock, PICCHIOTTI of Fairfield, RICHARDSON of 
Warren, WEAVER of York, Senators: HASTINGS of Oxford, McCORMICK of Kennebec, 
SNOWE-MELLO of Androscoggin. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  24-A MRSA §2673-A, sub-§3, as enacted by PL 1999, c. 609, §8, is 
amended to read: 
3.  Rules.  Preferred provider arrangements offered by carriers that are subject to 
chapter 56-A must be in compliance with applicable provisions of that chapter and any 
rules adopted under that chapter.  Employer-sponsored plans that are exempt from this 
chapter pursuant to federal law and administrators offering preferred provider 
arrangements to employer-sponsored plans are not subject to the provisions of chapter 
56-A or rules adopted under that chapter, provided either the administrator or any other 
participating entity, other than the self-insured employer, does not undertake insurance 
risk.  The superintendent may adopt rules establishing procedures for filing and approval 
of preferred provider arrangements, including the time period within which the 
superintendent must act on a completed application; specific criteria for determining 
when a term or condition is unjust, unfair or inequitable or has the effect of unreasonably 
restricting access and availability to health care services; and standards consistent with 
this chapter and chapter 56-A for the ongoing operation and oversight of approved 
provider arrangements.  The rules may prohibit the carrier from applying a benefit level 
differential to enrollees who must travel an unreasonable distance to obtain the service.  
Rules adopted pursuant to this subsection are routine technical rules pursuant to Title 5, 
chapter 375, subchapter II-A 2-A. 
Sec. 2.  24-A MRSA §4203, sub-§3, ¶S, as amended by PL 2003, c. 469, Pt. E, 
§18, 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 D. 
Sec. 3.  24-A MRSA §4303, sub-§1, as amended by PL 2009, c. 652, Pt. A, §33, 
is further amended to read: 
1.  Demonstration of adequate access to providers.  Except as provided in 
paragraphs B and C paragraph D, a carrier offering or renewing a managed care plan shall 
provide to its members reasonable access to health care services in accordance with 
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. 
B.  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, but only if the health plan is offered by a health 
maintenance organization; 
(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 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 of this 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.  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 
subsection 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 
committee 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. 
D.  In addition to a managed care plan offered by a carrier in accordance with this 
subsection and standards developed by rule by the superintendent, a carrier shall offer 
a health plan with financial provisions to encourage use of designated providers that 
is exempt from geographic access requirements set forth in this subsection or in rules 
adopted by the superintendent. 
SUMMARY 
This bill removes provisions in current law prohibiting health insurance carriers from 
applying benefit differentials based on travel and repeals the provision authorizing pilot 
projects that are exempt from geographic access requirements. In its place, the bill 
requires health insurance carriers to offer a health plan with financial provisions to 
encourage use of designated providers that is exempt from geographic access 
requirements established in current law and in rules adopted by the Department of 
Professional and Financial Regulation, Bureau of Insurance.