An Act To
Maine Legislature, Session 126, LD 1466
Committee Amendment CA_A_S284 (Senate)
Amends: 24-A MRSA §430

COMMITTEE AMENDMENT "A, " to S.P. 540, L.D. 1466, Bill, "An Act To 
Amend the Law Governing Provider cfoJtracts with Insurance Companies" 
II 
Amend the bill by striking out everything after the enacting clause and before the 
summary and inserting the following: 
'Sec. 1. 24-A MRSA §430:3, sub-§18 is enacted to read: 
18. Provider contract requirements. A carrier offering a health plan must meet the 
requirements of this subsection with respect to a contract offered by the carrier to a 
provider, including a contract offered through a preferred provider arrangement, as 
defined in section 2671, subsection 7. This subsection does not apply to dental or vision 
plans. 
A. 
If the contract for a preferred provider arrangement includes a reference to 
policies or procedures to which a contracting provider would be bound, all such 
policies and procedures must be provided to the provider for review in an easily 
accessible manner upon the provider's request at the time the contract is offered. 
B. 
Upon the provider's request at the time a contract for a preferred provider 
arrangement is offered, the following must be provided to a provider for review: 
(1) The fee schedule or, if there is not a fee schedule for one or more of the 
services covered under the contract, the terms under which payment is 
determined. 
A carrier may require a provider to execute a nondisclosure 
agreement covering the infonnation provided under this subparagraph; and 
(2) The identity of all carriers for which the provider is agreeing to provide 
services to health plan enrollees. 
C. 
As a condition of participation in one of the carrier's preferred provider 
arrangements, a contract offered by a carrier may not require a provider to participate 
in any other carrier's network subsequently offered by the carrier or by a carrier's 
preferred provider arrangement. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to S.P. 540, L.D. 1466 
D. Without the provider's prior written consent, a provider's contractual participation 
in a carrier's preferred provider arrangement may not: 
(1) Subject the provider to health plan payor requirements or fee schedules that 
materially differ from the terms of the provider's contract with the carrier, unless 
those materially different terms are set out in writing in a separate section of the 
contract, such as an exhibit or amendment; or 
(2) Permit the terms of the provider's existing preferred provider arrangement 
contract to be superseded by a carrier's subsequent contract with a health plan 
pgyQL, 
E. A preferred provider arrangement contract may not require a provider providing a 
service to an enrollee under a health plan included in the provider's contract to obtain 
preauthorization if the enrollee's health plan does not require prior authorization as a 
condition of coverage. 
F. Explanation of remittance advices or comparable documents, whether in paper or 
electronic form, that accompany and identify payment of a provider's claims under a 
carrier's contract, including contracts offered through a preferred provider 
arrangement, must identify the administrator and payor of the provider's claims and 
include contact information. 
The requirements of this subsection do not apply to a carrier offering a health plan with 
respect to preferred provider arrangement contracts with a hospital or pharmacy. ' 
SUMMARY 
This amendment replaces the bill. The amendment places certain requirements on 
contracts for preferred provider arrangements, which are contracts between a health 
insurance carrier and a health care provider in which the provider agrees to provide 
services to a health plan enrollee whose plan benefits include incentives for the enrollee 
to use the services of that provider. The amendment imposes requirements and 
restrictions on these contracts, including: 
1. Requiring a carrier who offers the contract to a health care provider to include in 
the contract a fee schedule and to provide any policies or procedures referred to in the 
contract to the provider, upon request by the provider; 
2. Requiring the approval of a provider, in writing, of an amendment to the contract 
that materially differs from the terms of the provider's contract and of any provision that 
would permit the provider's existing contract to be superseded by a carrier's subsequent 
contract with a health plan payor; 
3. Prohibiting a carrier from requiring a provider, as a condition of participation in 
one of the carrier's preferred provider arrangements, to participate in any other carrier's 
network subsequently offered by the carrier or by a carrier's preferred provider 
arrangement; 
4. Prohibiting a carrier from subjecting providers under health plans included in the 
contract to preauthorization requirements if the enrollee's health plan does not require 
prior authorization as a condition of coverage; and 
COMMITTEE AMENDMENT 
'-
COMMITTEE AMENDMENT 'f\" to S.P. 540, L.D. 1466 
5. Requiring remittance advices that identify payment of a provider's claims under a 
carrier's contract to identify the administrator and payor of the provider's claims and 
include contact information. 
The amendment provides that the requirements do not apply to dental or vision plans 
or to a carrier offering a health plan with respect to preferred provider arrangement 
contracts with a hospital or pharmacy. 
COMMITTEE AMENDMENT