An Act To Protect Patients and the Prudent Layperson Standard
Maine Legislature, Session 129, LD 1155
Committee Amendment CA_A_H372 (House)
Amends: 24-A MRSA §4304, 24-A MRSA §4320-C

COMMITTEE AMENDMENT .. ,4" to H.P. 844, L.D. 1155, Bill, "An Act To 
Protect Patients and the Prudent Layperson Standard" 
Amend the bill in section 1 in subsection 4-A in the 2nd line (page 1, line 4 in L.D.) 
by inserting after the following: "health condition" the following: ', including severe 
pain,' 
Amend the bill in section 1 in subsection 4-A in paragraph A in subparagraph (2) in 
the first line (page 1, line 13 in L.D.) by inserting after the following: "function:" the 
following: 'or' 
Amend the bill in section 1 in subsection 4-A in paragraph A by striking out all of 
subparagraph (4) (page 1, line 15 inL.D.). 
Amend the bill in section 1 in subsection 4-B in the last line (page 1, line 23 in L.D.) 
by striking out the following: "by a health care provider" 
Amend the bill by striking out all of sections 2 and 3 and inserting the following: 
'Sec. 2. 24-A MRSA §4304, sub-§5, as enacted by PL 1999, c. 742, §13, is 
amended to read: 
5. Emergency services. When conducting utilization review or maldng a benefit 
determination for emergency services, a carrier shall provide benefits for emergency 
services consistent with the requirements of this subsection and any applicable bureau 
rule. 
A. Before a carrier denies benefits or reduces payment for an emergency service 
based on a determination of the absence of an emergency medical condition or a 
determination that a lower level of care was needed, the carrier shall conduct a 
utilization review done by a board-certified emergency physician who is licensed in 
this State, including a review of the enrollee's medical record related to the 
emergency medical condition subject to dispute. If a carrier requests records related 
to a potential denial of or payment reduction for an enrollee's benefits when 
emergency services were furnished to an enrollee, a provider has an affirmative duty 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT .ft,, to H.P. 844, L.D. 1155 
to respond to the carrier in a timely manner. This paragraph does not apply when a 
reduction in payment is made by a carrier based on a contractually agreed upon 
adjustment for health care service. 
Sec. 3. 24-A MRSA §4320-C, as enacted by PL 2011, c. 364, §34, is amended to 
read: 
§4320-C. Emergency services 
If a carrier offering a health plan subjeot to the requirements of the federal Affordable 
Carn ,'\et provides or covers any benefits with respect to services in an emergency 
department of a hoSf)ital facility or setting, the plan must cover emergency services in 
O 
aooordanoe with the requirements of the federal Affordable Care Aot, inoluding 
requirements that emergenoy servioes be oovered without prior authorization and that 
oost sharing. 
Cost-sharing requirements, expressed as a copayment amount or 
coinsurance rate, for out-of-network services are the same as requirements that would 
apply if such services were provided in network. A carrier offering a health plan in this 
State shall also comply with the requirements of section 4304, subsection 5. 
Sec. 4. Rulemaldng. Notwithstanding the Maine Revised Statutes, Title 24-A, 
section 4309, any rules adopted by the Department of Professional and Financial 
Regulation, Bureau of Insurance to amend rule Chapter 850: Health Plan Accountability 
as necessary to conform to this Act are routine technical rules as defined in Title 5, 
chapter 375, subchapter 2-A.' 
Amend the bill by relettering or renumbering any nonconsecutive Part letter or 
section number to read consecutively. 
SUMMARY 
This amendment makes several changes to the bill. 
1. It removes the reference to inadequately controlled pain and uses the phrase 
"severe pain" to maintain consistency with the definition used in the federal Patient 
Protection and Affordable Care Act. 
2. It clarifies the definition of "emergency service" so that it applies to services 
provided in an emergency setting or facility and makes other changes to maintain 
consistent language within the definition .. 
3. It removes the reference to prior authorization for emergency services in section 2 
of the bill because it is redundant with changes made in section 3. 
4. 
It clarifies that before a carrier denies benefits or reduces payment for an 
emergency service based on a determination of the absence of an emergency medical 
condition or a detennination that a lower level of care was needed, the carrier's utilization 
review must be done by a board-certified emergency physician who is licensed in this 
State and that the review must include a review of the enrollee's medical record related to 
the emergency medical condition subject to dispute. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT,./)" to H.P. 844, L.D. 1155 
5. It provides that any rules adopted by the Department of Professional and Financial 
Regulation, Bureau of Insurance to amend current rules to conform to changes made in 
this legislation are routine technical rules. 
COMMITTEE AMENDMENT