An Act To Protect Maine Consumers from Unexpected Medical Bills
Maine Legislature, Session 128, LD 1557
Committee Amendment CA_A_H459 (House)
Amends: 22 MRSA §1718-D

COMMITTEE AMENDMENT "Pt" to H.P. 1073, L.D. 1557, Bill, "An Act To 
Protect Maine Consumers from Unexpected Medical Bills" 
Amend the bill by striking out everything after the enacting clause and before the 
summary and inserting the following: 
'Sec. 1. 22 MRSA §1718-D is enacted to read: 
§1718-D. Prohibition on balance billing for surprise bills 
1. Definitions. As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings. 
A. "Enrollee" has the same meaning as in Title 24-A, section 4301-A, subsection 5. 
B. "Health plan" has the same meaning as in Title 24-A, section 4301-A, subsection 
L. 
C. "Provider" has the same meaning as in Title 24-A, section 4301-A, subsection 16. 
D. "Surprise bill" has the same meaning as in Title 24-A, section 4303-C, subsection 
1. 
2. Prohibition on balance billing. An out-of-network provider reimbursed for a 
surprise bill under Title 24-A, section 4303-C, subsection 2, paragraph B may not bill an 
enrollee for health care services beyond the applicable coinsurance, copayment. 
deductible or other out-of-pocket cost expense that would be imposed for the health care 
services if the services were rendered by a network provider under the enrollee's health 
plan. 
Sec. 2. 24-A MRSA §§4303-C and 4303-D are enacted to read: 
§4303-C. Protection from smprise biUs 
1. Surprise bill defined. As used in this section, unless the context othe1wise 
indicates, "surprise bill" means a bill for health care services, other than emergency 
services, received by an enrollee for covered services rendered by an out-of-network 
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COMMITTEE AMENDMENT "p "to H.P. 1073, L.D. 1557 
provider, when such services were rendered by that out-of-network provider at a network 
provider, during a service or procedure perfo1med by a network provider or during a 
service or procedure previously approved or authorized by the carrier and the enrollee did 
not knowingly elect to obtain such services from that out-of-network provider. "Surprise 
bill" does not include a bill for health care services received by an enrollee when a 
network provider was available to render the services and the enrollee knowingly elected 
to obtain the services from another provider who was an out-of-network provider. 
2. Requirements. With respect to a surprise bill: 
A. 
A caffier shall require an enrollee to pay only the applicable coinsurance, 
copayment, deductible or other out-of-pocket expense that would be imposed for 
health care services if the services were rendered by a network provider; 
B. A carrier shall reimburse the out-of-network provider or enrollee, as applicable, 
for health care services rendered at the average network rate under the emollee's 
health care plan as payment in full, unless the carrier and out-of-network provider 
agree otherwise; and 
C. 
Notwithstanding paragraph B, if a carrier has an inadequate network, as 
determined by the superintendent, the carrier shall ensure that the enrollee obtains the 
covered service at no greater cost to the enrollee than if the service were obtained 
from a network provider or shall make other arrangements acceptable to the 
superintendent. 
§4303-D. Provider directories 
1. Requirement. A carrier shall make available provider directories in accordance 
with this section. 
A. A carrier shall post electronically a current and accurate provider directory for 
each of its network plans with the infonnation and search functions described in 
subsection 2. In making the directo1y 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 canier shall update each provider directoty at least monthly. The 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 carrier shall provide a print copy, or a print copy of the requested directoty 
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infonnation, of a current provider directory with the info1mation described in 
subsection 2 upon request of a covered person or a prospective covered person. 
D. 
For each network plan, a carrier shall include in plain language in both the 
electronic and print directories the following general infotmation: 
(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; 
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COMMITTEE AMENDMENT "A" to H.P. 1073, L.D. 1557 
(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 the tier in which each is placed, whether by name, 
symbols, grouping or another designation, so that a covered person or a 
prospective covered person is able to identify the provider tier; and 
( 4) If applicable, that authorization or referral may be required to access some 
providers. 
E. 
A carrier shall make clear in both its electronic and print directories which 
provider directory applies to which network plan by including the specific name of 
the network plan as marketed and issued in this State. The 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 carrier of inaccurate provider directory information. 
F. For the information required pursuant to subsections 2, 3 and 4 in a provider 
directory pe1taining to a health care professional, a hospital or a facility other than a 
hospital, a carrier shall make available through the direct01y the source of the 
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information and any limitations on the information, if applicable. 
G. A provider directory, whether in electronic or print format, must accommodate 
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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 carrier shall make available through an 
electronic provider direct01y, 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 pa1ticipating 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 other than English spoken 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; 
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(2) The hospital's type; 
(3) Patticipating hospital location; and 
( 4) The hospital's accreditation status. 
This paragraph does not apply to a ca1Tier 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 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 carrier shall make available the following infonnation 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 carrier that 
offers network plans that consist solely of limited scope dental plans or limited 
scope vision plans; 
(2) Board ce1tifications. This subparagraph does not apply to a carrier that offers 
network plans that consist solely of limited scope dental plans or limited scope 
vision plans; and 
(3) Languages other than English spoken by clinical staff, if applicable; 
B. For hospitals, the telephone number. This paragraph does not apply to a 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 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 carrier shall make available in print, 
upon request, the following provider direct01y infonnation for the applicable network 
plan: 
A. For health care professionals: 
(1) The health care professional's name; 
(2) The health care professional's contact infotmation; 
(3) Patticipating office location or locations; 
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COMMITTEE AMENDMENT "H" to H.P. 1073, L.D. 1557 
( 4) The health care professional's specialty, if applicable; 
(5) Languages other than English spoken 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) Paiticipating 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 carrier shall include a disclosure in the directo1y that the information included in the 
directo1y 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 direct01y information. 
5. Rulemaldng. The superintendent may 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. 
Sec. 3. Effective date. This Act takes effect January 1, 2018.' 
SUMMARY 
This amendment replaces the bill. The amendment provides that a carrier shall 
require an enrollee that receives a surprise bill from an out-of-network provider to pay 
only the applicable cost-sharing coinsurance, copayment, deductible or other out-of-
pocket expense that would be imposed for the health care services if the services were 
rendered by a network provider. The amendment also sets the reimbursement rate for that 
out-of-network provider at the network rate under the enrollee's health plan unless the 
carrier and out-of-network provider agree otherwise. If an out-of-network provider is 
reimbursed by the carrier, the provider may not bill the enrollee for any amount beyond 
the enrollee's applicable cost sharing. Under the amendment, "surprise bill" means a bill 
for health care services, other than emergency services, received by an emollee for 
services rendered by an out-of-network provider, when the services were rendered by the 
out-of-network provider at a network provider, during a service or procedure perfonned 
by a network provider or during a service or procedure previously approved or authorized 
by the carrier and the enrollee did not knowingly elect to obtain such services from the 
out-of-network provider. 
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Like the bill, the amendment requires health carriers to make available provider 
directories. The amendment provides discretion to the Superintendent of Insurance to 
determine if rulemaking is necessary. 
The amendment adds an effective date of January 1, 2018. 
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