An Act To Encourage Maine Consumers To Comparison-shop for Certain Health Care Procedures and To Lower Health Care Costs
Maine Legislature, Session 128, LD 0445
Committee Amendment CA_A_S236 (Senate)
Amends: 22 MRSA §1718-B, 22 MRSA §8712, 24-A MRSA §4302, 24-A MRSA §4303, 24-A MRSA §4318-A, 24-A MRSA §4318-B

COMMITTEE AMENDMENT "A" to S.P. 147, L.D. 445, Bill, "An Act To 
Encourage Maine Consumers To Comparison-shop for Certain Health Care Procedures 
and To Lower Health Care Costs" 
Amend the bill by striking out eve1ything after the enacting clause and before the 
summaiy and inserting the following: 
'Sec. 1. 22 MRSA §1718-B, sub-§2, ~ 
is enacted to read: 
D. Beginning Janua1y 1, 2018, at the time a referral or recommendation is made for a 
comparable health care service as defined in Title 24-A, section 4318-A, subsection 
1, paragraph A during an in-person visit, the health care entity making that referral or 
recommendation shall notify a patient who has private health insurance coverage of 
the patient's right to obtain services from a different provider. A health care entity 
shall comply with this paragraph by providing a written notice at the time the health 
care entity recommends or refers a patient for a health care service or procedure that 
may qualify as a comparable health care service. A written notice provided under 
this paragraph must include a notification that, prior to obtaining the recommended 
service, the patient may review the health care price transparency tool provided by 
the patient's carrier or contact the patient's carrier directly via a toll-free telephone 
number so that the patient may consider whether the recommended provider of the 
comparable health care service represents the best value for the patient. A written 
notice provided under this paragraph must also include a description of the service or 
the applicable standard medical codes or cmrent procedural te1minology codes used 
by the American Medical Association sufficient to allow the carrier to assist the 
patient in comparing prices for the comparable health care service. 
Sec. 2. 22 MRSA §8712, sub-§2, as amended by PL 2011, c. 525, §1, is fmiher 
amended to read: 
2. Payments. The organization shall create a publicly accessible interactive website 
that presents rep01is related to payments for services rendered by health care facilities and 
practitioners to residents of the State. The services presented must include, but not be 
limited to, imaging, preventative health, radiology ooa~ surgical services, comparable 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A" to S.P. 147, L.D. 445 
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health care services as defined in Title 24-A, section 4318-A, subsection 1, paragraph A 
and other services that are predominantly elective and may be provided to a large number 
of patients who do not have health insurance or are underinsured. The website must also 
be constructed to display prices paid by individual commercial health insurance 
companies, 3rd-party administrators and, unless prohibited by federal law, governmental 
payors. Beginning October I, 2012, price information posted on the website must be 
posted semiannually, must display the date of posting and, when posted, must be cmTent 
to within 12 months of the date of submission of the information. Payment reports and 
price information posted on the website must include data submitted by payors with 
regard to all health care facilities and practitioners that provide comparable health care 
services as defined in Title 24-A, section 4318-A, subsection 1, paragraph A or services 
for which the organization reports data petiaining to the statewide average price pursuant 
to this subsection or Title 24-A, section 4318-B. Upon notice made by a health care 
facility or practitioner that data posted by the organization pe1iaining to that facility or 
practitioner is inaccurate or incomplete, the organization shall remedy the inaccurate or 
incomplete data within the earlier of 30 days of receipt of the notice and the next 
semiannual posting date. 
Sec. 3. 24-A MRSA §4302, sub-§1, ,il(, as amended by PL 2009, c. 439, Pt. B, 
§ 3, is fmiher amended to read: 
K. A description of the requirements for enrollees to obtain coverage of routine costs 
of clinical trials and information on the manner in which enrollees not eligible to 
patiicipate in clinical trials may qualify for the compassionate use program of the 
federal Food and Drug Administration for use of investigational drugs pursuant to 21 
Code of Federal Regulations, Section 312.34, as amended; ana 
Sec. 4. 24-A MRSA §4302, sub-§1, ~' as enacted by PL 2009, c. 439, Pt. B, 
§4, is amended to read: 
L. A description of a provider profiling program that may be a pati of the health 
plan, including the location of provider petformance ratings in the plan materials or 
on a publicly accessible website, information explaining the provider rating system 
and the basis upon which provider perfonnance is measured, the limitations of the 
data used to measure provider performance, the process for selecting providers and a 
conspicuous written disclaimer explaining the provider performance ratings should 
only be used as a guide for choosing a provider and that enrollees should consult their 
cmTent provider before making a decision about their health care based on a provider 
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rating7; and 
Sec. 5. 24-A MRSA §4302, sub-§1, ~ 
is enacted to read: 
M. If the health plan is subject to the requirements of section 4318-A, a description 
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of the incentives available to an enrollee and how to earn such incentives if enrolled 
in a health plan offering a comparable health care service incentive program designed 
pursuant to section 4318-A. 
Sec. 6. 24-A MRSA §4303, sub-§21 is enacted to read: 
21. Health care price transparency tools. Beginning Januaty 1, 2018, a canier 
offering a health plan in this State shall comply with the following requirements. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT"A "to S.P. 147, L.D. 445 
A. A carrier shall develop and make available a website accessible to enrollees and a 
toll-free telephone number that enable enrollees to obtain information on the 
estimated costs for obtaining a comparable health care service, as defined in Title 
24-A, section 4318-A, subsection 1, paragraph A, from network providers, as well as 
quality data for those providers, to the extent available. A carrier may comply with 
the requirements of this paragraph by directing enrollees to the publicly accessible 
health care costs website of the Maine Health Data Organization. 
B. A carrier shall make available to the enrollee the ability to obtain an estimated 
cost that is based on a description of the service or the applicable standard medical 
codes or current procedural terminology codes used by the American Medical 
Association provided to the enrollee by the provider. Upon an enrollee's request, the 
carrier shall request additional or clarifying code infonnation, if needed, from the 
provider involved with the comparable health care service. If the carrier obtains 
specific code information from the enrollee or the enrollee's provider, the catTier shall 
provide the anticipated charge and the enrollee's anticipated out-of-pocket costs based 
on that code info1mation, to the extent such information is made available to the 
carrier by the provider. 
C. 
A carrier shall notify an enrollee that the amounts are estimates based on 
information available to the carrier at the time the request is made and that the 
amount the enrollee will be responsible to pay may vmy due to unforeseen 
circumstances that arise out of the proposed comparable health care service. This 
subsection 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 comparable health care service or for a procedure or 
service that was not included in the original estimate. This subsection does not 
preclude an enrollee from contacting the caITier to obtain more infmmation about a 
patiicular admission, procedure or service with respect to a particular provider. 
D. Notwithstanding the provisions of this subsection and at the request of a carrier, 
the superintendent may grant an additional year to comply with the provisions of this 
subsection as long as the carrier has demonstrated a good faith effmi to comply with 
the provisions of this subsection and has provided the superintendent with an action 
plan detailing the steps to be taken by the caITier to comply with this subsection no 
later than Janumy 1, 2019. 
Sec. 7. 24-A MRSA §4303, sub-§22 is enacted to read: 
22. Denial of referral by out-of-network provider prohibited. Beginning Januaty 
1, 2018, a carrier may not deny payment for any health care service covered under an 
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enrollee's health plan based solely on the basis that the enrollee's referral was made by a 
provider who is not a member of the carrier's provider network. 
Sec. 8. 24-A MRSA §4318-A is enacted to read: 
§4318-A. Comparable health care service incentive program 
Begim1ing Janumy 1, 2019, a carrier offering a health plan in this State shall 
establish, at a minimum, for all small group health plans as defined in section 2808-B, 
subsection 1, paragraph G compatible with a health savings account authorized under 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A" to S.P. 147, L.D. 445 
federal law, a health plan design in which emollees are directly incentivized to shop for 
low-cost, high-quality participating providers for comparable health care services. 
Incentives may include, but are not limited to, cash payments, gift cards or credits or 
reductions of premiums, copayments or deductibles. A small group health plan design 
created under this section must remain available to enrollees for at least 2 consecutive 
years, except that any changes made to the program after 2 years, including, but not 
limited to, ending the incentive, may not be construed as a change to the small group 
health plan design for the purpose of guaranteed renewability under section 2808-B, 
subsection 4 or section 2850-B. 
A multiple-employer welfare anangement is not 
considered a canier for the purposes of this section. 
1. Definitions. As used in this section, unless the context otherwise indicates, the 
following tenns have the following meanings. 
A. "Comparable health care service" means nonemergency, outpatient health care 
services in the following categories: 
(1) Physical and occupational therapy services; 
(2) Radiology and imaging services; 
(3) Laborat01y services; and 
(4) Infusion therapy services. 
B. 
"Program" means the comparable health care service incentive program 
established by a can-ier pursuant to this section. 
2. Filing with superintendent. Plans filed with the superintendent pursuant to this 
section must disclose, in the summaiy of benefits and explanation of coverage, a detailed 
description of the incentives available to a plan enrollee. The description must clearly 
detail any incentives that may be earned by the emollee, including any limits on such 
incentives, the actions that must be taken in order to eam such incentives and a list of the 
types of services that qualify under the program. This subsection may not be construed to 
prevent a caITier from directing an enrollee to the carrier's website or toll-free telephone 
number for further infonnation on the program in the summaiy of benefits and 
explanation of coverage. The superintendent shall review the filing made by the canier 
to dete1mine if the carrier's program complies with the requirements of this section. 
3. Availability of program; notice to enrollees. Annually at enrollment or renewal, 
a carrier shall provide notice about the availability of the program to an enrollee who is 
enrolled in a health plan eligible for the program as required by section 4302, subsection 
1, paragraph M. 
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4. 
Additional types of nonemergency health care services or procedures. 
Nothing in this section precludes a carrier from including additional types of 
nonemergency health care services or procedures in its program. 
5. 
No administrative expense. 
An 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 purposes. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A 
"to S.P. 147, L.D. 445 
6. Study and evaluation. Beginning March 1, 2020 and annually thereafter, the 
superintendent shall undertake a study and evaluation of the programs created by carriers 
as required by this section. The superintendent may request information on enrollment 
and use of incentives earned by enrollees of a carrier as necessaiy. By April 15, 2020 and 
annually thereafter, the superintendent shall submit an aggregate repott relating to the 
perfonnance of the programs, the use of incentives, the incentives earned by enrollees 
and the cumulative effect of the programs to the joint standing committee of the 
Legislature having jurisdiction over health insurance matters. 
7. 
Rules. 
The superintendent may adopt rules as necessary to implement this 
section. Rules adopted pursuant to this subsection are major substantive rules as defined 
in Title 5, chapter 375, subchapter 2-A. 
8. Repeal. This section is repealed January 1, 2024. 
Sec. 9. 24-A MRSA §4318-B is enacted to read: 
§4318-B. Access to lower-priced services 
1. Services from out-of-network provider; lower prices. Beginning January 1, 
2019, if an enrollee covered under a health plan other than a health maintenance 
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organization plan elects to obtain a covered comparable health care service as defined in 
section 4318-A, subsection 1, paragraph A from an out-of-network provider at a price 
that is the same or less than the statewide average for the same covered health care 
service based on data repotted on the publicly accessible health care costs website of the 
Maine Health Data Organization, the carrier shall allow the enrollee to obtain the service 
from the out-of-network provider at the provider's charge and, upon request by the 
enrollee, shall apply the payments made by the enrollee for that comparable health care 
service toward the enrollee's deductible and out-of-pocket maximum as specified in the 
enrollee's health plan as if the health care services had been provided by an in-network 
provider. A carrier may use the average price paid to a network provider for the covered 
comparable health care service under the enrollee's health plan in lieu of the statewide 
average price on the Maine Health Data Organization's publicly accessible website as 
long as the carrier uses a reasonable method to calculate the average price paid and the 
information is available to enrollees through a website accessible to the enrollee and a 
toll-free telephone number that provide, at a minimum, information relating to 
comparable health care services. The enrollee is responsible for demonstrating to the 
carrier that payments made by the emollee to the out-of-network provider should be 
applied toward the enrollee's deductible or out-of-pocket maximum pursuant to this 
section. 
The carrier shall provide a downloadable or interactive online f01m to the 
enrollee for the purpose of making such a demonstration and may require that copies of 
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bills and proof of payment be submitted by the enrollee. For the purposes of this section, 
"out-of-network provider" means a provider located in Massachusetts, New Hampshire or 
this State that is enrolled in the MaineCare program and paiticipates in Medicare. 
2. 
Rules. 
The superintendent may adopt rules as necessaiy to implement this 
section. Rules adopted pursuant to this subsection are routine technical rules as defined 
in Title 5, chapter 375, subchapter 2-A. 
3. Repeal. This section is repealed Januaiy 1, 2024.' 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A "to S.P. 147, L.D. 445 
SUMMARY 
This amendment replaces the bill. The amendment requires carriers offering health 
plans in the State, beginning Janumy 1, 2019, to establish a small group health plan 
design, for all small group health plans compatible with health savings accounts 
authorized under federal law, in which enrollees are directly incentivized to shop for 
comparable health care services from low-cost, high-quality providers. The amendment 
defines "comparable health care service" as a nonemergency, outpatient health care 
service in the following 4 categories: physical and occupational therapy services; 
radiology and imaging services; laboratory services; and infusion therapy services. The 
amendment requires the Superintendent of Insurance to study and evaluate the incentive 
programs used by carriers and report annually to the Legislature beginning March 1, 
2020. These provisions are repealed on Janumy 1, 2024. 
Beginning Janumy 1, 2018, the amendment requires carriers to develop and make 
available a website and toll-free telephone number to allow enrollees to obtain 
information about estimated costs for obtaining comparable health care services from 
network providers. The amendment permits a carrier to direct enrollees to the publicly 
accessible health care costs website of the Maine Health Data Organization. 
Beginning Janumy 1, 2019, the amendment requires carriers upon request by an 
enrollee to apply the amount paid for a comparable health care se1vice provided by an 
out-of-network provider toward the enrollee's member cost sharing as specified in the 
enrollee's health plan as if the health care se1vices were provided by a network provider, 
as long as the cost of the out-of-network service is the same or less than the statewide 
average payment for the same se1vice based on data reported on the publicly accessible 
health care costs website of the Maine Health Data Organization. A carrier may use the 
average network price paid by the can"ier in lieu of the statewide average payment for the 
same service based on data reported on the publicly accessible health care costs website 
of the Maine Health Data Organization. The amendment defines an out-of-network 
provider as a provider located in Maine, Massachusetts or New Hampshire that is 
enrolled in the MaineCare program as a provider and that pmiicipates in Medicare. This 
provision is repealed Janumy 1, 2024. 
The amendment also requires providers to notify patients of their right to obtain 
comparable health care se1vices from a different provider at the time a provider makes a 
referral or recommendation for a comparable health care service during an in-person visit. 
FISCAL NOTE REQUIRED 
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(See attached) 
COMMITTEE AMENDMENT 
Revised: 06/06/17 feac 
LD 445 
LR 484(02) 
An Act To Encourage Maine Consumers To Comparison-shop for Certain Health Care Procedures 
and To Lower Health Care Costs 
Fiscal Detail and Notes 
Fiscal Note for Bill as Amended by Committee Amendment 'A' LS~;;). :2j_p) 
Committee: Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Potential cunent biennium savings - All Funds 
Minor cost increase - Other Special Revenue Funds 
Beginning Januaiy 1, 2019, carriers in the State must offer, on all small group health plans compatible with a health 
savings account, a health plan designed to incentivize shopping for comparable health care services. The State 
Employee Health Plan (SEHP) is not a small group plan and is not required to provide an incentivied plan. However, 
the SEHP could create a plan to provide incentives (i.e. cash payments, gift cards or premium credits) for members 
who shop for and receive a lower cost, but similar quality, health care service. If enough members receive these lower 
cost services, the SEHP could realize savings. The potential savings are dependant on the SEHP setting up an 
incentivied plan and on member behavior modification, which will only happen through education about the program. 
No estimate of potential savings can be made at this time. 
Any additional costs to the Department of Professional and Financial Regulation to adopt the changes in this bill are 
expected to be minor and can be absorbed within existing budgeted resources. 
LR0484(02) - Fiscal Note - Page I of 1