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: Insurance and Financial Services
Sponsors: TREAT, BEAUDOIN, GRAHAM, ROTUNDO, STANLEY, GRATWICK, WOODBURY
Amends: 24-A MRSA §2694-A, 24-A MRSA §4301-A, 24-A MRSA §4303

Legislative Document 
No. 1006 
H.P. 704 
House of Representatives, March 12, 2013 
An Act To Clarify Transparency of Medical Provider Profiling 
Programs Used by Insurance Companies and Other Providers of 
Health Insurance 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
MILLICENT M. MacFARLAND 
Clerk 
Presented by Representative TREAT of Hallowell. 
Cosponsored by Representatives: BEAUDOIN of Biddeford, GRAHAM of North Yarmouth, 
McCABE of Skowhegan, ROTUNDO of Lewiston, STANLEY of Medway, Senators: 
GRATWICK of Penobscot, WOODBURY of Cumberland. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  24-A MRSA §2694-A, sub-§1, 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 1st in subsequent years a full and 
true statement of its criteria, standards, practices, procedures and programs that measure 
physician performance or tier physician 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 
chief medical officer. A filing and supporting information are public records 
notwithstanding Title 1, section 402, subsection 3, paragraph B. 
Sec. 2.  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, including 
designations made pursuant to section 4303, subsection 1. 
Sec. 3.  24-A MRSA §4303, sub-§2, ¶E, as enacted by PL 2009, c. 439, Pt. B, 
§5, is amended to read: 
E.  A carrier with a provider profiling program shall: 
(1)  Disclose to providers the methodologies, criteria, data and analysis used to 
evaluate provider quality, performance, cost, including but not limited to unit 
cost, price and cost-efficiency ratings and, upon request from a provider 
evaluated on these bases, provide to that provider electronic copies of the data 
associated with the requesting provider and all adjustments to that data; 
(2)  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)  Afford providers the opportunity to correct errors, submit additional 
information for consideration and seek review of data and performance ratings; 
and 
(4)  Afford providers due process appeal rights to challenge the profiling 
determination described in this subsection and by Bureau of Insurance Rule 
Chapter 850, Health Plan Accountability. 
If a carrier has a provider profiling program that includes out-of-network providers, a 
carrier must meet the requirements of this paragraph with regard to an out-of-network 
provider as well as for a provider in a carrier's network. 
SUMMARY 
This bill requires that any cost metric used by insurance providers in a provider 
profiling program is covered by the existing transparency provisions in the health plan 
improvement laws.  The bill also requires carriers to provide copies of the data 
methodology used in the metric to affected providers.  The purpose of this bill is to 
require all insurance providers, including the state health plan and other government 
insurance programs, to be included in this transparency obligation.