An Act To Protect Maine Consumers from Unexpected Medical Bills
Maine Legislature, Session 128, LD 1557
Committee: Insurance and Financial Services
Sponsors: GROHMAN, WHITTEMORE, ESPLING, FOLEY, GINZLER, PRESCOTT, SANBORN, VACHON, CARSON, DOW
Amends: 24-A MRSA §2770, 24-A MRSA §2770-A

Legislative Document
No. 1557
H.P. 1073
House of Representatives, May 2, 2017
An Act To Protect Maine Consumers from Unexpected Medical 
Bills
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed.
ROBERT B. HUNT
Clerk
Presented by Representative GROHMAN of Biddeford.
Cosponsored by Senator WHITTEMORE of Somerset and
Representatives: ESPLING of New Gloucester, FOLEY of Wells, GINZLER of Bridgton, 
PRESCOTT of Waterboro, SANBORN of Portland, VACHON of Scarborough, Senators: 
CARSON of Cumberland, DOW of Lincoln.
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  24-A MRSA §2770 is enacted to read: 
§2770.  Protections for covered persons 
1.  Definitions.  As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings. 
A.  "Covered person" means an individual who is covered as a policyholder, 
participant or dependent under a plan, policy or contract for health benefits. 
B.  "Facility-based provider" means a provider who provides to a patient in an 
inpatient or ambulatory care facility health care services that are typically arranged 
by the facility by contract or agreement with the facility-based provider as part of the 
facility's general business operations, the specific provider of which within the 
facility is generally not selected or chosen by the covered person or the covered 
person's health benefit plan. 
C.  "Nonparticipating facility-based provider" means a provider who provides to a 
patient in an inpatient or ambulatory care facility health care services and who has 
not agreed to the terms of a health carrier contract or is not otherwise obligated under 
the terms of a contract to provide health care services to covered persons with an 
expectation of receiving payment, other than coinsurance, copayments or deductibles, 
directly or indirectly from the health carrier. 
D.  "Participating facility" means an institution providing health care services or a 
health care setting, including but not limited to hospitals and other licensed inpatient 
centers, ambulatory surgical or treatment centers, skilled nursing facilities, residential 
treatment centers, urgent care centers, diagnostic, laboratory and imaging centers and 
rehabilitation and other therapeutic health settings, that has agreed under a contract 
with a health carrier or with its contractor or subcontractor to provide health care 
services to covered persons with an expectation of receiving payment, other than 
coinsurance, copayments or deductibles, directly or indirectly from the health carrier. 
E.  "Participating provider" means a provider who, under a contract with a health 
carrier or with its contractor or subcontractor, has agreed to provide health care 
services to covered persons with an expectation of receiving payment, other than 
coinsurance, copayments or deductibles, directly or indirectly from the health carrier. 
2.  Hold harmless provision.  A contract between a health carrier and a participating 
facility must include a hold harmless provision that specifies that, if health care services 
are provided to a covered person by a nonparticipating facility-based provider at the 
participating facility, neither the nonparticipating facility-based provider nor the 
participating facility may bill, charge, collect a deposit from, seek compensation, 
remuneration or reimbursement from or have any recourse against the covered person for 
those services as long as the covered person was unaware, or could not reasonably be 
expected to have been aware, that the services were being provided by a nonparticipating 
facility-based provider. 
3.  Agreement to accept and pay charges for services provided by 
nonparticipating facility-based provider.  Nothing in this section precludes a covered 
person from agreeing to accept and pay the charges for health care services provided by a 
nonparticipating facility-based provider. 
4.  Health carrier payments for nonparticipating facility-based provider 
services.  If health care services are provided to a covered person by a nonparticipating 
facility-based provider at a participating facility and the covered person was unaware or 
could not reasonably be expected to have been aware that the services were being 
provided by a nonparticipating facility-based provider, payment to the nonparticipating 
facility-based provider is governed by this subsection. 
A.  The health carrier may elect to pay to the nonparticipating facility-based provider 
either: 
(1)  The bills for the health care services that are submitted to it by the 
nonparticipating facility-based provider; or 
(2)  The higher of the health carrier's contracted rate and 120% of the Medicare 
payment rate for the same or similar services in the same geographic region. 
B.  If a nonparticipating facility-based provider objects to the payment elected by the 
health carrier in accordance with paragraph A, the nonparticipating facility-based 
provider may choose to participate in the provider mediation process set forth in 
subsection 5. 
C.  Nothing in this subsection precludes a health carrier and a nonparticipating 
facility-based provider from agreeing to a payment arrangement other than that set 
forth in this section. 
5.  Mediation process.  A health carrier shall establish a mediation process for 
resolving objections raised by nonparticipating facility-based providers in accordance 
with subsection 4, paragraph B regarding the payment by the health carrier for health care 
services. 
A.  The mediation process must be established in accordance with recognized 
mediation standards set by a national association for arbitration, mediation or dispute 
resolution. 
B.  Following completion of the mediation process, the cost of mediation must be 
split evenly and paid by the health carrier and the nonparticipating facility-based 
provider. 
C.  The mediation process may not be used when the health carrier and the 
nonparticipating facility-based provider agree to a separate payment arrangement or 
when the covered person agrees to accept and pay the nonparticipating facility-based 
provider's charges for the services provided by the nonparticipating facility-based 
provider. 
D.  A health carrier shall maintain records regarding the mediations requested and 
completed in accordance with this subsection during each calendar year and, upon 
request, shall submit a report on those mediations to the superintendent in the format 
specified by the superintendent. 
6.  Notification requirements.  A health carrier that provides coverage to a covered 
person shall provide notice to that covered person or that covered person's authorized 
representative at the time of any precertification for a covered benefit that is to be 
provided at a facility that is not in the covered person's health benefit plan network that 
the services requested or provided may not be covered under either the covered person's 
health plan benefits or under any other provision of this section. The notice must clearly 
specify that the covered person may be wholly responsible for the entirety of any charges 
incurred as a result of that treatment or service. The notice must also inform the covered 
person or the covered person's authorized representative of options available to access 
covered services from a participating provider. 
Sec. 2.  24-A MRSA §2770-A is enacted to read: 
§2770-A.  Provider directories 
1.  Requirement.  A health carrier shall make available provider directories in 
accordance with this section. 
A.  A health carrier shall post electronically a current and accurate provider directory 
for each of its network plans with the information and search functions, as described 
in subsection 3.  In making the directory available electronically, the carrier shall 
ensure that the general public is able to view all of the current providers for a plan 
through a clearly identifiable link or tab and without creating or accessing an account 
or entering a policy or contract number. 
B.  A health carrier shall update each network plan provider directory at least 
monthly.  The health carrier shall periodically audit at least a reasonable sample size 
of its provider directories for accuracy and retain documentation of such an audit to 
be made available to the superintendent upon request. 
C.  A health carrier shall provide a print copy, or a print copy of the requested 
directory information, of a current provider directory with the information described 
in subsection 2 upon request of a covered person or a prospective covered person. 
D.  For each network plan, a health carrier shall include in plain language in both the 
electronic and print directories the following general information: 
(1)  A description of the criteria the carrier has used to build its provider network; 
(2)  If applicable, a description of the criteria the carrier has used to tier 
providers; 
(3)  If applicable, how the carrier designates the different provider tiers or levels 
in the network and identifies for each specific provider, hospital or other type of 
facility in the network which tier in which each is placed, for example by name, 
symbols or grouping, in order for a covered person or a prospective covered 
person to be able to identify the provider tier; and 
(4)  If applicable, that authorization or referral may be required to access some 
providers. 
E.  A health carrier shall make it clear in both its electronic and print directories 
which provider directory applies to which network plan, such as including the 
specific name of the network plan as marketed and issued in this State.  The health 
carrier shall include in both its electronic and print directories a customer service 
e-mail address and telephone number or electronic link that covered persons or the 
general public may use to notify the health carrier of inaccurate provider directory 
information. 
F.  For the information required pursuant to subsections 2, 3 and 4 in a provider 
directory pertaining to a health care professional, a hospital or a facility other than a 
hospital, a health carrier shall make available through the directory the source of the 
information and any limitations, if applicable. 
G.  A provider directory, whether in electronic or print format, must accommodate 
the communication needs of individuals with disabilities and include a link to or 
information regarding available assistance for persons with limited English 
proficiency. 
2.  Information in searchable format.  A health carrier shall make available through 
an electronic provider directory, for each network plan, the information under this 
subsection in a searchable format: 
A.  For health care professionals: 
(1)  The health care professional's name; 
(2)  The health care professional's gender; 
(3)  The participating office location or locations; 
(4)  The health care professional's specialty, if applicable; 
(5)  Medical group affiliations, if applicable; 
(6)  Facility affiliations, if applicable; 
(7)  Participating facility affiliations, if applicable; 
(8)  Languages spoken other than English by the health care professional, if 
applicable; and 
(9)  Whether the health care professional is accepting new patients; 
B.  For hospitals: 
(1)  The hospital's name; 
(2)  The hospital's type; 
(3)  Participating hospital location; and 
(4)  The hospital's accreditation status. 
This paragraph does not apply to a health carrier that offers network plans that consist 
solely of limited scope dental plans or limited scope vision plans; and 
C.  For facilities, other than hospitals, by type: 
(1)  The facility's name; 
(2)  The facility's type; 
(3)  Types of services performed; and 
(4)  Participating facility location or locations. 
This paragraph does not apply to a health carrier that offers network plans that consist 
solely of limited scope dental plans or limited scope vision plans. 
3.  Additional information.  In the electronic provider directories, for each network 
plan, a health carrier shall make available the following information in addition to all of 
the information available under subsection 2: 
A.  For health care professionals: 
(1)  Contact information.  This subparagraph does not apply to a health carrier 
that offers network plans that consist solely of limited scope dental plans or 
limited scope vision plans; 
(2)  Board certifications.  This subparagraph does not apply to a health carrier 
that offers network plans that consist solely of limited scope dental plans or 
limited scope vision plans; and 
(3)  Languages spoken other than English by clinical staff, if applicable; 
B.  For hospitals, the telephone number. This paragraph does not apply to a health 
carrier that offers network plans that consist solely of limited scope dental plans or 
limited scope vision plans; and 
C.  For facilities other than hospitals, the telephone number.  This paragraph does not 
apply to a health carrier that offers network plans that consist solely of limited scope 
dental plans or limited scope vision plans. 
4.  Information available in printed form.  A health carrier shall make available in 
print, upon request, the following provider directory information for the applicable 
network plan: 
A.  For health care professionals: 
(1)  The health care professional's name; 
(2)  The health care professional's contact information; 
(3)  Participating office location or locations; 
(4)  The health care professional's specialty, if applicable; 
(5)  Languages spoken other than English by the health care professional, if 
applicable; and 
(6)  Whether the health care professional is accepting new patients; 
B.  For hospitals: 
(1)  The hospital's name; 
(2)  The hospital's type; and 
(3)  Participating hospital location and telephone number; and 
C.  For facilities, other than hospitals, by type: 
(1)  The facility's name; 
(2)  The facility's type; 
(3)  Types of services performed; and 
(4)  Participating facility location and telephone number. 
The health carrier shall include a disclosure in the directory that the information included 
in the directory is accurate as of the date of printing and that covered persons or 
prospective covered persons should consult the carrier's electronic provider directory on 
its website to obtain current provider directory information. 
5.  Rulemaking.  The superintendent shall adopt rules to implement this section.  
Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, 
chapter 375, subchapter 2-A. 
SUMMARY 
This bill requires that when health care services are provided to a covered person by a 
nonparticipating facility-based provider at a participating facility and the covered person 
was unaware or could not reasonably be expected to have been aware that the services 
were being provided by a nonparticipating facility-based provider, the covered person 
may not be billed for those health care services.  The bill requires the implementation of 
associated notification and mediation processes. The bill also requires health carriers to 
make available provider directories.