An Act To Amend the Law Governing Provider Contracts with Insurance Companies
Maine Legislature, Session 126, LD 1466
Committee: Insurance and Financial Services
Sponsors: GOODALL, GRATWICK, PATRICK, WOODBURY, BECK, GRAHAM
Amends: 24-A MRSA §4303

Legislative Document 
No. 1466 
S.P. 540 
In Senate, April 25, 2013 
An Act To Amend the Law Governing Provider Contracts with 
Insurance Companies 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
DAREK M. GRANT 
Secretary of the Senate 
Presented by Senator GOODALL of Sagadahoc. 
Cosponsored by Senators: GRATWICK of Penobscot, PATRICK of Oxford, WOODBURY of 
Cumberland, Representatives: BECK of Waterville, GRAHAM of North Yarmouth. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  24-A MRSA §4303, sub-§18 is enacted to read: 
18.  Preferred provider arrangement contract requirements.  A contract offered 
by a carrier to a provider for a preferred provider arrangement, as defined in section 2671, 
subsection 7, must meet the requirements of this subsection. 
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 upon the 
provider's request at the time the contract is offered. 
B.  A preferred provider arrangement contract offered to a provider by a carrier must: 
(1) Include a fee schedule; and 
(2) Identify all health plans for which the provider is agreeing to provide services 
to health plan enrollees. 
C.  An amendment to the terms of an in-force preferred provider arrangement 
contract, including, but not limited to, changes to referenced policies and procedures, 
fee schedules and the identified health plans to which the contract applies, is subject 
to the notice requirements of subsection 9.  The carrier shall obtain the written 
agreement of a provider to any such amendment that adds to the health plans 
previously identified pursuant to paragraph B, subparagraph (2) or to a contract, 
policy or procedure a provision that may materially and adversely affect provider 
reimbursement, 
including, 
but 
not 
limited 
to, 
increased 
documentation, 
preauthorization and utilization review requirements.    
D.  A carrier may not retaliate in any way against a contracted provider, including, 
but not limited to, excluding a provider from participation in one or more health plans 
covered by the preferred provider arrangement contract, for the provider's refusal to 
accept a preferred provider arrangement contract amendment pursuant to paragraph 
C. 
E.  Except as otherwise required by law, a carrier may not disclose a contracted 
provider's fee schedule to any party other than the applicable payor under a health  
plan for which the provider has agreed to provide services to health plan enrollees. 
F.  A provider's contractual participation in a carrier's preferred provider arrangement 
may not subject the provider to health plan payor requirements or fee schedules that 
differ from the terms of the provider's contract with the carrier, nor may a carrier's 
subsequent contract with a health plan payor supersede the terms of the provider's 
existing preferred provider arrangement contract. 
G.  If a payor under a health plan for which a provider has contracted with a carrier to 
provide services to health plan enrollees fails to comply with the terms of the 
provider's underlying preferred provider arrangement contract, the provider, after 
notice to the carrier and opportunity to cure the noncompliance consistent with the 
provider's contract with the carrier, may terminate its agreement to provide services 
under that health plan.  The carrier may not terminate or otherwise retaliate against 
the provider for exercising this right of termination. 
H.  A provider providing a service to an enrollee under a health plan included in the 
provider's preferred provider arrangement contract may not be subject to 
preauthorization requirements if the enrollee's health plan does not require prior 
authorization as a condition of coverage for the applicable service. 
I.  A provider under a preferred provider arrangement contract that has in good faith 
provided services to a health plan enrollee in reliance upon coverage confirmation 
and coverage requirement advice obtained consistent with the terms of the provider's 
contract may not have payment for those services subsequently denied by the 
applicable health plan payor for any reason that conflicts with the advice earlier 
provided. 
J.  Explanation of benefits forms or comparable documents, whether in paper or 
electronic form, that accompany and identify payment of a provider's claims under a 
preferred provider arrangement contract must identify the administrator and payor of 
the provider's claims. 
K.  An identification card issued to a health plan enrollee on whose behalf a provider 
provides services under a preferred provider arrangement contract must identify the 
claims payor, the claims administrator and the contracting carrier if the contracting 
carrier is not the claims payor or administrator. 
L.  A contracting preferred provider arrangement carrier shall notify the 
superintendent if the termination of one or more contracting providers, whether 
initiated by the carrier or by the claims payor, adversely affects a health plan 
enrollee's access to covered services. 
M.  It is an unfair trade practice for a preferred provider arrangement contract to 
subject a provider or health plan enrollee to preauthorization or utilization review 
requirements designed in whole or in part to generate claims administration fees or to 
provide a barrier to the enrollee's right to services covered under a health plan or the 
provider's right to receive payment for those services. 
The requirements of this subsection must be included in all preferred provider 
arrangement contracts. 
SUMMARY 
This bill 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.  This 
bill 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 and adversely affects provider reimbursement, including, but not limited 
to, increased documentation, preauthorization or utilization review requirements; 
3.  Prohibiting a carrier from subjecting enrollees 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 for the applicable service; and 
4.  Requiring the provisions of law regarding these contracts to be included in each 
contract.