An Act To Encourage Health Insurance Consumers To Comparison Shop for Health Care Procedures and Treatment
Maine Legislature, Session 127, LD 1305
Committee Amendment CA_B_S407 (Senate)
Amends: 24-A MRSA §4318-A

COMMITTEE AMENDMENT " ~" to S.P. 470, L.D. 1305, Bill, "An Act To 
Encourage Health Insurance Consumers To Comparison Shop for Health Care Procedures 
and Treatment" 
Amend the bill by striking out the title and substituting the following: 
'An Act To Help Maine Consumers Comparison Shop for Certain Health Care 
Procedures and Lower Health Care Costs' 
Amend the bill by striking out everything after the enacting clause and before the 
summary and inserting the following: 
'Sec. 1. 24-A MRSA §4318-A is enacted to read: 
§4318-A. Shared savings incentive program 
Beginning January 1, 2018, a carrier offering a health plan in this State shall provide 
a shared savings incentive program that, at a minimum, meets the requirements of this 
section. 
1. Definitions. As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings. 
A. "Comparable health care service" means a health care service for which a carrier 
offers a shared savings incentive payment under a program established by the carrier 
pursuant to this section. "Comparable health care service" includes, at a minimum, a 
health care service in the following categories: 
(1) Physical and occupational therapy services: 
(2) Obstetrical and gynecological services; 
(3) Radiology and imaging services: and 
(4) Laboratory services. 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" B" to S.P. 470, L.D. 1305 
B. "Program" means the shared savings incentive program established by a carrier 
pursuant to this section. 
2. Filing with superintendent. Prior to offering the program to any enrollee, a 
carrier shall file a description of the program established by the carrier pursuant to this 
section with the superintendent in the manner determined by the superintendent. The 
superintendent may review the filing made by the carrier to determine if the carrier's 
program complies with the requirements of this section. Upon request by a carrier before 
January I, 2018, the superintendent may grant a waiver from the requirement in 
subsection 3 that the program be made available as a component of all health plans if the 
superintendent determines that a waiver is justified on the basis of criteria specified in 
rules adopted pursuant to subsection 8. Filings and waiver requests, and any supporting 
documentation, made pursuant to this subsection are confidential until the filing has been 
reviewed or the waiver request has been granted or denied by the superintendent in the 
same manner as are form filings under section 2412, subsection 8. 
3. Availability of program; notice to enrollees. Except for a health plan offered 
through the federally facilitated marketplace established pursuant to the federal 
Affordable Care Act, a carrier shall make the program available as a component of all 
health plans offered by the carrier in this State unless a waiver has been granted by the 
superintendent in accordance with subsection 2. 
A carrier may make the program 
available as a component of any health plans offered by the carrier through the federally 
facilitated marketplace. Annually at enrollment or renewal, a carrier shall provide notice 
about the availability of the program to any enrollee who is enrolled in a health plan 
eligible for the program. 
4. Incentive program required. A carrier shall develop and implement a program 
that provides incentives for an enrollee in a health plan who elects to receive a 
comparable health care service that is covered by the plan from a provider that charges 
less than the average price paid by that carrier for that comparable health care service. 
A. Incentives may be calculated as a percentage of the difference in price, as a flat 
dollar amount or by some other reasonable methodology approved by the 
superintendent. The carrier may provide the incentive as a cash payment to the 
enrollee or as a reduction in the enrollee's cost sharing or premium payment. For 
services that are paid for by the enrollee under the plan's deductible provision, the 
carrier may provide the incentive by crediting a higher amount than the provider's 
actual charge toward the enrollee's deductible. 
B. The shared savings incentive program must provide enrollees with at least 40% of 
the carrier's saved costs for each service or category of comparable health care 
service. Compliance with this requirement may be demonstrated in the aggregate of 
plans offered in this State based on a reasonably anticipated mix of claims. A carrier 
is not required to provide a payment or credit to an enrollee when the carrier's saved 
cost is $50 or less. 
C. A carrier may determine the methodology for calculating the average price paid 
by the carrier for a comparable health care service and the process an enrollee must 
use to document whether the health care provider chosen by an enrollee charges less 
for the comparable health care service than the average price paid by that carrier. 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" (3" to S.P. 470, L.D. 1305 
5. Out-of-network provider. If an enrollee elects to receive a comparable health 
care service from an out-of-network provider that results or would otherwise result in a 
shared savings incentive payment, the carrier shall apply the amount paid for the 
comparable health care service toward the enrollee's cost sharing as specified in the 
enrollee's health plan as if the health care services were provided by a network provider. 
6. No administrative expense. A shared savings incentive payment made by a 
carrier in accordance with this section is not an administrative expense of the carrier for 
rate development or rate filing pw:poses. 
7. Report. Beginning March 1, 2019 and annually on March 1st of each year 
thereafter, a carrier shall file with the superintendent for the most recent calendar year the 
total number of shared savings incentive payments made pursuant to this section, the use 
of comparable health care services by category of service for which shared savings 
incentive payments are made, the total shared savings incentive payments made to 
enrollees, the average amount of shared savings incentive payments made by category of 
service, the total savings achieved below the average prices by category of service and 
the total number and percentage of a carrier's enrollees that participated. Beginning April 
1, 2019 and annually by April 1st of each year thereafter, the superintendent shall submit 
an aggregate report for all carriers containing the information required by this subsection 
to the joint standing committee of the Legislature having jurisdiction over health 
insurance matters. 
8. 
Rules. 
The superintendent may adopt rules as necessary to implement this 
section, including rules establishing criteria for a waiver under subsection 2. Rules 
adopted pursuant to this subsection are routine technical rules as defined in Title 5, 
chapter 375, subchapter 2-A.' 
SUMMARY 
This amendment is the minority report of the committee. The amendment replaces the 
bill and changes the title. 
The amendment requires all carriers offering health plans in the State, beginning 
January 1, 2018, to provide a shared savings incentive program as a component of all 
health plans, except health plans offered through the federally facilitated marketplace 
established pursuant to the federal Affordable Care Act, unless a waiver has been granted 
by the superintendent. The amendment establishes the shared savings incentive program 
for enrollees who elect to receive a comparable health care service that costs less than the 
average price paid for that service by a carrier. The amendment defines "comparable 
health care service" as a service for which a carrier offers a shared savings incentive 
payment and includes, at a minimum, a health care service in the following 4 categories: 
physical and occupational therapy services, obstetrical and gynecological services, 
radiology and imaging services and laboratory services. If an enrollee shops for services, 
the amendment requires a carrier to pay that enrollee a shared savings incentive payment 
of at least 40% of the difference between the average amount for that comparable health 
care service and the amount paid, except that a payment is not required if the saved cost is 
$50 or less. 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT"~" to S.P. 470, L.D. 1305 
The amendment authorizes a carrier to establish its own methodology for calculating 
the average price paid by that carrier under its shared savings incentive program and to 
make health care services received from an out-of-network provider not eligible for a 
shared savings incentive payment. If an enrollee elects to receive health care services 
from an out-of-network provider that would otherwise be eligible for a shared savings 
incentive payment, a carrier shall apply the amount paid for the comparable health care 
service toward the enrollee's cost sharing as specified in the enrollee's health plan as if the 
health care services were provided by a network provider. 
The amendment also requires carriers to provide certain information to the 
Department of Professional and Financial Regulation, Bureau of Insurance on an annual 
basis relating to the payments made to enrollees, the use of health care services for which 
payments are provided and the saved costs if an enrollee elects to receive health care 
services from a provider that cost less than the average cost for a particular admission, 
procedure or service. The Bureau of Insurance is required to report aggregate information 
from all carriers to the Legislature on an annual basis. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
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Approved: 03/15/16 
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LD 1305 
LR 956(03) 
An Act To Encourage Health Insurance Consumers To Comparison Shop for Health Care Procedures 
and Treatment 
Fiscal Detail and Notes 
Fiscal Note for Bill as Amended by Committee Amendment ')''(s - t.{,C) 7) 
Committee: Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Potential future biennium savings - All Funds 
This bill requires, beginning January 1, 2018, that all carriers offering a health plan in the State shall provide a shared 
savings program. Any savings would accrue to carriers, participants and eventually the State through lower premiums. 
The amount of savings will depend on the specific details of each shared savings plan and the participant response to 
the plan. No savings can be detennined at this time. 
Any additional costs to the Department of Professional and Financial Regulation from the provisions of this bill are 
expected to be minor and can be absorbed within existing budgeted resources. 
LR0956(03) - Fiscal Note - Page l of 1