An Act Regarding O the Process for Obtaining Prior Authorization for Health Insurance Purposes
Maine Legislature, Session 129, LD 0705
Committee Amendment CA_A_S175 (Senate)
Amends: 24-A MRSA §4304, 24-A MRSA §4311

COMMITTEE AMENDMENT "ft "to S.P. 218, L.D. 705, Bill, "An Act Regarding 
O 
the Process for Obtaining Prior Authorization for Health Insurance Purposes" 
Amend the bill by striking out everything after the enacting clause and inserting the 
following: 
'Sec. 1. 24-A MRSA §4304, sub-§2, as amended by PL 1999, c. 742, §12, is 
further amended to read: 
2. Prior authorization of nonemergency services. Requests Except for a request in 
exigent circumstances as described in section 4311, subsection 1-A, paragraph B, a 
request by a provider for prior authorization of a nonemergency service must be answered 
by a carrier within 72 hours or 2 business days, whichever is less. in accordance with this 
subsection. Both the provider and the emollee on whose behalf the authorization was 
rsqusstsd must b@ notified by th@ oarri@r of its dstsnmaation. If th@ infonnation 
submitted is insuffioi@Rt to mak@ a dscisioR, th@ carrisr shall notify th@ pro:vidsr within 2 
business days of the additioaal mfonnatioa aecessary to reader a deoisioa. If the carrier 
dstsrmiass that outside consul-tatioa is ascsssary, th@ carrier shall aotify th@ pro:vidsr and 
the emollee for v,rhom the servioe 1.vas requested within 2 busiaess days. The carrier shall 
make a good faith estimate of whoo th@ fiaal dstSnnffiatioa v,rill b@ mads and ooB:taot th@ 
emollee and the provider as sooa as practioable. Notifioatioa requiremeB:ts ooder this 
subsectioa are satisfied by 1.vrittea aotifioatioa postfl:larked v.1ithin the time limit speoified. 
A. 
Both the provider and the enrollee on whose behalf the authorization was 
requested must be notified by the carrier of its determination. 
B. If the carrier responds to a request by a provider for prior authorization with a 
request for additional information, the carrier shall make a decision within 72 hours 
or 2 business days. whichever is less, after receiving the requested information. 
C. If the carrier responds that outside consultation is necessary before making a 
decision. the carrier shall make a decision within 72 hours or 2 business days, 
whichever is less. from the time of the carrier's initial response. 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" ji "to S.P. 218, L.D. 705 , 
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D. The prior authorization standards used by a carrier must be clear and readily 
available. A provider must make best efforts to provide all information necessary to 
evaluate a request, and the carrier must make best efforts to limit requests for 
additional information. 
If a carrier does not grant or deny a request for prior authorization within the time frames 
required under this subsection, the request for prior authorization by the provider is 
granted. 
Sec. 2. 24-A MRSA §4304, sub-§§2-A and 2-B are enacted to read: 
2-A. 
Prior authorization of medication-assisted treatment for opioid use 
disorder. A carrier may not require prior authorization for medication-assisted treatment 
for opioid use disorder for the prescription of at least one drug for each therapeutic class 
of medication used in medication-assisted treatment, except that a carrier may not impose 
any prior authorization requirements on a pregnant woman for medication-assisted 
treatment for opioid use disorder. For the purposes of this subsection, "medication-
assisted treatment" means an evidence-based practice that combines pharmacological 
interventions with substance use disorder counseling. 
2-B. Electronic transmission of prior authorization requests. Beginning no later 
than January 1. 2020, if a health plan provides coverage for prescription drugs, the carrier 
must accept and respond to prior authorization requests in accordance with subsection 2 
through a secure electronic transmission using standards adopted by a national council for 
prescription drug programs for electronic prescribing transactions. For the purposes of 
this subsection, transmission of a facsimile through a proprietary payer portal or by use of 
an electronic form is not considered electronic transmission. 
Sec. 3. 24-A MRSA §4311, sub-§1-A, ,rA, as enacted by PL 2019, c. 5, Pt. A, 
§21, is amended to read: 
A. The carrier must determine whether it will cover the drug requested and notify the 
enrollee, the enrollee's designee, if applicable, and the person who has issued the 
valid prescription for the enrollee of its coverage decision within 72 hours or 2 
business days, whichever is less, following receipt of the request. A carrier that 
grants coverage under this paragraph must provide coverage of the drug for the 
duration of the prescription, including refills. 
Sec. 4. Rulemaking. The Department of Professional and Financial Regulation, 
Bureau of Insurance shall amend its rule Chapter 850, Health Plan Accountability: 
1. To conform to the changes made in this Act; and 
2. To replace the term "urgent care" with the term "exigent circumstances" as used in 
this Act and to change the timeline for review decisions when exigent circumstances exist 
to no more than 24 hours after receiving the request. 
Notwithstanding the Maine Revised Statutes, Title 24-A, section 4309, any rules 
adopted pursuant to this section are routine technical rules as defined in Title 5, chapter 
7 5, subchapter 2-A. 
Sec. 5. Report on electronic transmission of prior authorization request 
for medical services; authorization to report out legislation. No later than 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" A-" to S.P. 218, L.D. 705 ( c~ \ l S-j 
January 1, 2020, health insurance carriers, in cooperation with the Maine Association of 
Health Plans, shall report to the Joint Standing Committee on Health Coverage, Insurance 
and Financial Services on efforts to develop standards for secure electronic transmission 
of prior authorization requests that meet requirements of the federal Health Insurance 
Portability and Accountability Act of 1996, Public Law 104-191. The committee may 
report out legislation to the Second Regular Session of the 129th Legislature related to the 
electronic transmission of prior authorization requests for medical services.' 
Amend the bill by relettering or renumbering any nonconsecutive Part letter or 
section number to read consecutively. 
SUMMARY 
This amendment replaces the bill. The amendment does the following to amend the 
prior authorization process for health insurance carriers. 
1. It reduces the time frame for a carrier's response to a prior authorization request 
from 2 business days to 72 hours or 2 business days, whichever is less, and clarifies that 
the same time frame for a response applies in instances when a carrier requests additional 
information or requires outside consultation. It also provides that a request for prior 
authorization is granted if a carrier fails to respond within the required time frames. 
2. It clarifies a provision in existing law to reflect the change in time frame. 
3. It prohibits a carrier from requiring prior authorization for medication-assisted 
treatment for opioid use disorder for the prescription of at least one drug for each type of 
medication used in medication-assisted treatment, except that a carrier may not require 
prior authorization for medication-assisted treatment for opioid use disorder for a 
pregnant woman. 
4. It requires a health insurance carrier to develop an electronic transmission system 
for prior authorization of prescription drug orders by January 1, 2020. 
5. It requires health insurance carriers to report, no later than January 1, 2020, to the 
Joint Standing Committee on Health Coverage, Insurance and Financial Services on 
efforts to develop standards for secure electronic transmission of prior authorization 
requests. It also authorizes the committee to report out legislation to the Second Regular 
Session of the 129th Legislature related to the electronic transmission of prior 
authorization requests for medical services. 
6. It directs the Department of Professional and Financial Regulation, Bureau of 
Insurance to amend its rules regarding health plan accountability to conform to the 
statutory changes and designates those rules as routine technical. 
COMMITTEE AMENDMENT