An Act To Clarify Transparency of Medical Provider Profiling Programs Used by Insurance Companies and Other Providers of Health Insurance
Maine Legislature, Session 126, LD 1006
Committee Amendment CA_A_H502 (House)
Amends: 5 MRSA §285, 24-A MRSA §2694-A, 24-A MRSA §4301-A, 24-A MRSA §4303, 24-A MRSA §4303-A

COMMITTEE AMENDMENT ·:A" to H.P. 704, L.D. 1006, Bill, "An Act To 
Clarify Transparency of Medical Provider Profiling Programs Used by Insurance 
Companies and Other Providers of Health Insurance" 
Amend the bill by striking out everything after the enacting clause and before the 
summary and inserting the following: 
'Sec. 1. 5 MRSA §285, slllb-§15 is enacted to read: 
15. Provider profiling programs. Notwithstanding subsection 10, the requirements 
of Title 24-A, sections 2694-A and 4303-A apply to any provider profiling program, as 
defined in Title 24-A, section 42,01-A, subsection 16-A, developed by the commission. 
Sec. 2. 24-A MRSA §2694-A, sub-§l, as enacted by PL 2009, c. 350, Pt. B, § 1, 
is amended to read: 
1. 
Performance measurement, reporting and tiering programs. An insurer 
delivering or issuing for delivery within the State any individual health insurance policy 
or group health insurance policy or certificate shall annually file with the superintendent 
on or before October 1, 2010 and annually by October 1 st in subsequent years a full and 
true statement of its criteria, standards, practices, procedures and programs that measure 
pkysieiaa performaaee or tier physieiaa health care provider performance with respect to 
quality, cost or cost-efficiency. The statement must be on a form prepared by the 
superintendent and may be supplemented by additional information required by the 
superintendent. The statement must be verified by the oath of the insurer's president or 
vice-president, and secretary or ,;hief medical officer. A filing and supporting information 
are public records notwithstanding Title 1, section 402, subsection 3, paragraph B. 
Sec. 3. 24-A MRSA §4301-A, sub-§16-A, as enacted by PL 2009, c. 439, Pt. B, 
§ 1, is amended to read: 
16-A. Provider profiling program. "Provider profiling program" means a program 
that uses provider data in order to rate or rank provider quality, cost or efficiency of care 
by the use of a grade, star, tier, rating or any other form of designation that provides an 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT .. A 
.. to H.P. 704, L.D. 1006 
enrollee with an incentive to use a designated provider based OIll quality, cost or 
efficiency of care. 
Sec. 4. 24-A MRSA §4303, sub-§2, ~, as enacted by PL 2009, c. 439, Pt. B, 
§5, is repealed. 
Sec. 5. 24-A MRSA §4303-A is enacted to read: 
§4303-A. Provider profiling programs 
1. Disclosure. At least 60 days prior to using or publicly disclosing the results of the 
provider profiling program, a carrier with a provider profiling program shall disclose to 
providers the methodologies, criteria, data and analysis used to evaluate provider quality, 
performance and cost, including but not limited to unit cost, price and cost-efficiency 
ratings. For the pumoses of this subsection, the disclosure of data is satisfied by the 
provision by a carrier of a description of the data used in the evaluation, the source of the 
data, the time period subject to evaluation and, if applicable, the types of claims used in 
the evaluation including any adjustments to the data and exclusion from the data. 
2. Provider profile. A carrier shall create and share with providers their provider 
profile at least 60 days prior to using or publicly disclosing the results of the provider 
profiling program. 
3. Request for data. A provider may request a copy of its data within 30 days of the 
carrier's disclosure to a provider as required by subsection 2, and, upon request from a 
provider, a carrier shall provide to that provider the data associated with the requesting 
provider and all adjustments to the data used to evaluate that provider as part of the 
carrier's provider profiling program. 
The bureau shall adopt IUles to establish 
requirements for the disclosure of data by a carrier to a provider in accordance with this 
subsection. The bureau shall provide in the rules for a time and manner of disclosure 
consistent with a carrier's ability to adopt, revise and develop an effective provider 
profiling program. 
4. Appeals. A carrier shall establish a process that affords a provider the opportunity 
to review and dispute its provider profiling result within 30 days of being provided with 
its provider profile pursuant to subsection 2. The appeal process must: 
A. Afford the provider the opportunity to correct material errors, submit additional 
information for consideration and seek review of data and performance ratings; 
B. Afford the provider the opportunity to review any information or evaluation 
prepared by a 3rd party and used by the carrier as part of its provider profiling 
program; however, if the 3rd party provides the right to review and correct that data, 
any appeal pursuant to this paragraph is limited to whether the carrier accurately 
portrayed the information and not to the underlying determination made by the 3rd 
party; and 
C. Allow the provider to request reconsideration of its provider profiling result and 
submit supplemental information, including information demonstrating any 
computational or data errors. 
COMMITTEE AMENDMENT 
't-.. ~ ~. 
COMMIITEE AMENDMENT "A" to H.P. 704, L.D. 1006 
5. Out-of-network providers. If a carrier has a provider profiling program that 
includes out-of-network providers, a carrier must meet the requirements of this section 
with regard to an out-of-network provider as well as for a provider in a carrier's network. 
6. Rules. The bureau shall adopt rules necessary to implement this section. Rules 
adopted pursuant to this subs~:ction are routine technical rules as defined in Title 5, 
chapter 375, subchapter 2-A.' 
SUMMARY 
This amendment replaces the bill. The amendment requires that any cost metric used 
by insurance carriers in a provider profiling program be covered by the existing 
transparency provisions in the health plan improvement laws. The amendment also 
requires carriers to provide copies of the data and methodology used in the metric to 
affected providers. 
]<'ISCAL NOTE REQUIRED 
(See attached) 
COMM/~rTEE AMENDMENT 
Revised: 06/13/13 
~ac 
LD 1006 
LR 1402(02) 
An Act To Clarify Transparency of Medical Provider Profiling Programs Used by Insurance 
Fiscal Detail and Notes 
Companies and Other Providers of Health Insurance 
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Fiscal Note for Bill as Amended by Committee Amendment ~'CH -~~) 
Committee: Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Potential current biennium cost increase - Internal Service Fund 
Minor cost increase - Other Special Revenue Funds 
Assumes the potential cost to the State Employee Health Plan from the requirement to provide data if requested by 
providers will be absorbed within existing budgeted resources. Additional costs to the Department of Professional ana 
Financial Regulation are assumed to be minor and can be absorbed within existing budgeted resources. 
LR1402(02) - Fiscal Note - Page 1 of 1