An Act To Promote Wellness and Prevention through Health Plans
Maine Legislature, Session 126, LD 0991
Committee: Insurance and Financial Services
Sponsors: WOODBURY, WHITTEMORE, MORRISON, WALLACE
Amends: 24-A MRSA §4320-I

Legislative Document 
No. 991 
S.P. 336 
In Senate, March 12, 2013 
An Act To Promote Wellness and Prevention through Health Plans 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
DAREK M. GRANT 
Secretary of the Senate 
Presented by Senator WOODBURY of Cumberland. 
Cosponsored by Senator: WHITTEMORE of Somerset, Representatives: MORRISON of 
South Portland, WALLACE of Dexter. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  24-A MRSA §4320-I is enacted to read: 
§4320-I.  Health plans promoting wellness and prevention 
1.  Heath plans authorized.  Beginning October 1, 2013, the superintendent shall 
authorize pilot projects that allow a carrier to offer health plans in this State that include 
premium credits and other incentives to encourage enrollees to participate in wellness and 
prevention programs to the extent permitted under federal law and as provided in this 
section. 
2.  Rates.  A carrier offering incentives pursuant to this section shall ensure that the 
carrier does not use wellness and prevention programs, or incentives under such 
programs, to increase rates or premiums for any enrollees covered by the carrier's health 
plans. 
3.  Permissible incentives.  A carrier may allow incentives that include, but are not 
limited to, premium discounts or rebates or modifications to copayments, deductibles or 
coinsurance amounts or a combination of these incentives in accordance with this 
subsection. The incentive for a wellness and prevention program, together with the 
incentive for other wellness and prevention programs, that requires satisfaction of a 
standard related to a health risk factor, must be reasonably related to the program and 
may not exceed the allowable percentage of the cost of enrollee-only coverage under the 
health plan as prescribed in federal regulations adopted under the federal Health 
Insurance Portability and Accountability Act of 1996. 
4.  Standards.  An incentive offered by a carrier for participation in a wellness and 
prevention program must be reasonably related to the program and may be: 
A.  Tied only to participation in the program rather than particular outcomes or 
results from such participation; or 
B.  Based on satisfaction of a standard related to a health risk factor. As used in this 
section, "health risk factor" includes, without limitation, health behaviors such as 
smoking, diet, alcohol consumption, exercise and exposure to ultraviolet radiation 
that are known to be associated with increased early mortality and morbidity for a 
number of conditions. 
5.  Incentive based on health risk factor.  A carrier offering an incentive pursuant 
to this section shall ensure that: 
A.  Participation in or satisfaction of a standard related to a health risk factor pursuant 
to a wellness and prevention program is not a condition of coverage under the health 
plan; and 
B.  Participation in a wellness and prevention program is voluntary and that a penalty 
may not be imposed on an enrollee for not participating in a wellness and prevention 
program or not satisfying a standard related to a health risk factor pursuant to the 
program. 
6.  Requirements for wellness and prevention programs.  An incentive may be 
offered or provided by a carrier only pursuant to a wellness and prevention program that: 
A.  Is consistent with evidence-based research and best practices and accredited by a 
nationally recognized nonprofit entity that accredits wellness programs; 
B.  Has a reasonable likelihood of improving the health of, or preventing disease in, 
participating enrollees; 
C.  Contains culturally and linguistically appropriate programs and materials; 
D.  Is not overly burdensome, a subterfuge for discrimination based on a health factor 
or highly suspect in the method chosen to promote health or prevent disease; 
E.  Gives enrollees eligible for the wellness and prevention program the opportunity 
to qualify for the incentive under the program upon enrollment in the health plan and 
at least once per year after enrollment; 
F.  Provides a reasonable alternative standard or waiver of the otherwise applicable 
standard for obtaining the incentive for the period under paragraph E if it is 
unreasonably difficult for the enrollee due to a medical condition to satisfy the 
otherwise applicable standard or if it is medically inadvisable for the enrollee to 
attempt to satisfy the otherwise applicable standard; and 
G.  Provides an incentive that is based on a program or activity that is scientifically 
proven to improve health and that is not based on an enrollee's actual health status. 
7.  Privacy.  A carrier offering a health plan as part of an authorized pilot project 
shall implement adequate measures to ensure the privacy of enrollees in the health plan 
and that individually identifiable health information is not shared or made available to an 
enrollee's employer or any other person not otherwise allowed access to the information 
under federal or state law.  A carrier may not disclose to any 3rd party, including an 
enrollee's employer, and the enrollee's employer may not disclose any information 
obtained from or about an enrollee in connection with the enrollee's participation in a 
wellness and prevention program that is reasonably attributable to the enrollee, unless the 
enrollee consents in writing to disclosure of such information. 
8.  Rules.  The superintendent shall establish by rule procedures and policies that 
facilitate the implementation of a pilot project pursuant to this section, including, but not 
limited to, a process for submitting a pilot project proposal, minimum requirements for 
approval of a pilot project and any requirements for incentives. Rules adopted pursuant to 
this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 
2-A and must be adopted no later than 90 days after the effective date of this subsection. 
9.  Report.  Beginning in 2014, the superintendent shall report by March 1st annually 
to the joint standing committee of the Legislature having jurisdiction over insurance and 
financial services matters on the status of any pilot project approved by the 
superintendent pursuant to this section. 
10.  Evaluation.  During the First Regular Session of the 130th Legislature, the joint 
standing committee of the Legislature having jurisdiction over insurance and financial 
services matters shall conduct an evaluation of the effectiveness of any pilot project 
approved by the superintendent pursuant to this section and make a determination 
whether to continue, amend or repeal the authorization for the pilot project.  The joint 
standing committee of the Legislature having jurisdiction over insurance and financial 
services matters may report out a bill based on the evaluation to the First Regular Session 
of the 130th Legislature. 
11.  Construction.  This section may not be construed to restrict or limit the right of 
a carrier to engage in activities expressly permitted by this Title or to require a carrier to 
obtain prior approval as a pilot project to engage in those activities. 
SUMMARY 
This bill provides authority to the Superintendent of Insurance, beginning October 1, 
2013, to approve pilot projects allowing health insurance carriers to offer health plans that 
include premium credits and other incentives to encourage enrollees to participate in 
wellness and prevention programs.