An Act To Encourage Health Insurance Consumers To Comparison Shop for Health Care Procedures and Treatment
Maine Legislature, Session 127, LD 1305
Committee: Insurance and Financial Services
Sponsors: WHITTEMORE, BECK, CUSHING, KATZ, MASON, THIBODEAU, ESPLING, PICCHIOTTI, PRESCOTT, STETKIS
Amends: 22 MRSA §1718-B, 24-A MRSA §4303

Legislative Document 
No. 1305 
S.P. 470 
In Senate, April 9, 2015 
An Act To Encourage Health Insurance Consumers To Comparison 
Shop for Health Care Procedures and Treatment 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
HEATHER J.R. PRIEST 
Secretary of the Senate 
Presented by Senator WHITTEMORE of Somerset. 
Cosponsored by Representative BECK of Waterville and 
Senators: CUSHING of Penobscot, KATZ of Kennebec, MASON of Androscoggin, President 
THIBODEAU of Waldo, Representatives: ESPLING of New Gloucester, PICCHIOTTI of 
Fairfield, PRESCOTT of Waterboro, STETKIS of Canaan. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  22 MRSA §1718-B, sub-§1, ¶C is enacted to read: 
C.  "Allowed amount" means the contractually agreed upon amount paid by a carrier 
to a health care entity for health care services provided to a patient covered by 
insurance. 
Sec. 2.  22 MRSA §1718-B, sub-§§3 and 4 are enacted to read: 
3.  Estimate of charges prior to an admission, procedure or service.  Prior to an 
admission, procedure or service and upon request by a patient or prospective patient, a 
health care entity shall, within 2 working days, disclose the allowed amount if the entity 
participates in the patient's carrier network or the amount that will be charged if the entity 
does not participate in the patient's carrier network for the admission, procedure or 
service, including the amount for any facility fees required.  If a health care entity is 
unable to quote a specific amount in advance due to the health care entity's inability to 
predict the specific treatment or diagnostic code, the health care entity shall disclose what 
is known for the estimated allowed amount if the entity participates in the patient's carrier 
network, or the amount that will be charged if the entity does not participate in the 
patient's carrier network for the proposed admission, procedure or service, including the 
amount for any facility fees required.  The health care entity shall disclose the incomplete 
nature of the estimate and inform the patient or prospective patient of the ability to obtain 
an updated estimate once additional information is obtained.  If a health care entity fails 
to provide an estimate as required by this subsection, the health care entity may not bill 
the patient or the patient's insurance carrier for the admission, procedure or service.  Upon 
request of a patient or prospective patient who is covered by insurance, a health care 
entity that participates in a carrier's network shall, based on the information available to 
the health care entity at the time of the request, provide sufficient information regarding 
the proposed admission, procedure or service for the patient or prospective patient to use 
that carrier's applicable toll-free telephone number and publicly accessible website to 
obtain information about the amount of out-of-pocket costs in accordance with Title 
24-A, section 4303, subsection 20.  A health care entity may assist a patient or 
prospective patient in using a carrier's toll-free telephone number and publicly accessible 
website. 
4.  Access to data.  Notwithstanding any other provision of law, a health care entity 
or another person designated by a health care entity or a patient or prospective patient 
shall have access at no cost to the all-payor and all-settings health care database based on 
claims established by the Maine Health Data Processing Center in accordance with 
section 682 for the purposes of providing information to a patient or prospective patient 
as required by subsection 3.  Disclosure of data to a health care entity or another person 
pursuant to this subsection must be reasonably limited to the minimum extent necessary 
and any information disclosed must be used solely for the purposes of providing 
information to a patient or prospective patient as required by subsection 3. 
Sec. 3.  24-A MRSA §4303, sub-§20 is enacted to read: 
20.  Costs of health care services; estimates and payment.  A carrier offering a 
health plan in this State shall comply with the following requirements with respect to the 
costs of health care services. 
A.  A carrier shall establish a toll-free telephone number and publicly accessible 
website that enables an enrollee to request and obtain from the carrier information on 
the average price paid in the past 12 months to network health care providers for a 
proposed admission, procedure or service in each geographic rating area established 
by the carrier and to request an estimate pursuant to paragraph B. 
B.  Within 2 business days of an enrollee's request, a carrier shall provide a binding 
estimate for the maximum allowed amount or charge for a proposed admission, 
procedure or service and the estimated amount the enrollee will be responsible to pay 
for a proposed admission, procedure or service that is a medically necessary covered 
benefit, based on the information available to the carrier at the time the request is 
made, including any facility fee, copayment, deductible, coinsurance or other 
out-of-pocket amount for any covered health care benefits.  An enrollee may not be 
required to pay more than the disclosed amounts for the covered health care benefits 
that were actually provided, except that this paragraph does not prohibit a carrier 
from imposing cost-sharing requirements disclosed in the enrollee's certificate of 
coverage for unforeseen health care services that arise out of the proposed admission, 
procedure or service.  A carrier shall notify an enrollee that these are estimated costs, 
and that the actual amount the enrollee will be responsible to pay may vary due to 
unforeseen services that arise out of the proposed admission, procedure or service.  
For purposes of this paragraph, "allowed amount" means the contractually agreed 
upon amount paid by a carrier to a health care entity for health care services provided 
to an enrollee in a carrier's health plan. 
C.  If an enrollee elects to receive health care services from a provider that cost less 
than the average amount for a particular admission, procedure or service, a carrier 
shall pay to an enrollee 50% of the saved cost to a maximum of $7,500 except that a 
carrier is not required to make a payment if the saved cost is $50 or less.  A payment 
to an enrollee must be made within 30 days.  If an enrollee elects to receive health 
care services from an out-of-network provider that cost less than the average amount 
for a particular admission, procedure or service, a carrier shall apply the enrollee's 
share of the cost of those health care services as specified in the enrollee's health plan 
toward the enrollee's member cost sharing as if the health care services were provided 
by a network provider. 
D.  Notwithstanding any other provision of law, a carrier or another person 
designated by a carrier or an enrollee shall have access at no cost to the all-payor and 
all-settings health care database based on claims established by the Maine Health 
Data Processing Center in accordance with Title 22, section 682 for the purposes of 
providing information to an enrollee as required by this subsection.  Disclosure of 
data to a carrier or another person pursuant to this paragraph must be reasonably 
limited to the minimum extent necessary and any information disclosed must be used 
solely for the purposes of providing information to an enrollee as required by this 
subsection. 
E.  By February 1st of each year, a carrier shall file with the superintendent for the 
most recent calendar year the total number of requests for a binding estimate pursuant 
to paragraph B, the total number of transactions made pursuant to paragraph C, the 
average cost by service for such transactions, the total savings achieved below the 
average cost by service for such transactions, the total payments made to enrollees 
and the total number and percentage of a carrier's enrollees that participated in such 
transactions. 
SUMMARY 
This bill requires a health care entity to provide an estimate of the allowed amount if 
the entity is within a patient's carrier network or the amount that will be charged if the 
entity does not participate in a patient's carrier network for a proposed admission, 
procedure or service within 2 business days of a patient's request and to assist a patient in 
using a carrier's toll-free telephone number and publicly accessible website to obtain 
information about the out-of-pocket costs for which a patient will be responsible. 
The bill requires health insurance carriers to establish a toll-free telephone number 
and publicly accessible website to provide information to enrollees about health care 
costs. A carrier is required to provide information on the average price paid in the past 12 
months to a network health care provider for a proposed admission, procedure or service 
in each geographic rating area established by the carrier and to provide a binding estimate 
for the maximum allowed amount or charge for a proposed admission, procedure or 
service and the estimated amount the enrollee will be responsible to pay for a proposed 
admission, procedure or service that is a medically necessary covered benefit. 
The bill also requires a carrier to pay an enrollee 50% of the saved cost to a 
maximum of $7,500 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 unless 
the savings is $50 or less.  If an enrollee elects to receive health care services from an 
out-of-network provider that cost less than the average amount for a particular admission, 
procedure or service, a carrier shall apply the enrollee's share of the cost toward the 
enrollee's member cost sharing as if the health care services were provided by a network 
provider. 
The bill authorizes a health care entity, a carrier or another person designated by a 
health care entity, carrier, patient or prospective patient to have access at no cost to the 
all-payor and all-settings health care database for claims for the purposes of providing the 
information required. 
The bill 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 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.