An Act Regarding Targets for Health Plan Investments in Primary Care and Behavioral Health
Maine Legislature, Session 130, LD 1196
Committee: Health Coverage, Insurance and Financial Services
Sponsors: ZAGER, CLAXTON, CONNOR, FECTEAU, MEYER, TEPLER, JACKSON, MOORE, SANBORN
Amends: 5 MRSA §285, 22 MRSA §3173-J, 24-A MRSA §2303, 24-A MRSA §4319-B

Legislative Document
No. 1196
H.P. 874
House of Representatives, March 22, 2021
An Act Regarding Targets for Health Plan Investments in Primary 
Care and Behavioral Health
Received by the Clerk of the House on March 18, 2021.  Referred to the Committee on 
Health Coverage, Insurance and Financial Services pursuant to Joint Rule 308.2 and ordered 
printed pursuant to Joint Rule 401.
ROBERT B. HUNT
Clerk
Presented by Representative ZAGER of Portland.
Cosponsored by Senator CLAXTON of Androscoggin and
Representatives: CONNOR of Lewiston, Speaker FECTEAU of Biddeford, MEYER of Eliot, 
TEPLER of Topsham, Senators: President JACKSON of Aroostook, MOORE of Washington, 
SANBORN of Cumberland.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  5 MRSA §285, sub-§17 is enacted to read:
17.  Targets for investment in primary care and behavioral health care.  Beginning 
in plan year 2023, the State shall meet the following requirements related to targets for 
investment and spending in primary care and behavioral health care in the group health 
plan.
A.  As used in this subsection, unless the context otherwise indicates, the following 
terms have the following meanings.
(1)  "Behavioral health care" means mental health services, including community-
based or peer support treatments for substance use disorder provided by licensed 
health care practitioners providing services within their scope of practice, 
regardless of practice setting.
"Behavioral health care" also includes provider loan repayments and services such 
as health information technology services, recruitment services and practice 
transformation services that support the practitioners described in this 
subparagraph in the delivery of behavioral health care services.
(2)  "Primary care" means care provided by:
(a)  Primary care practitioners, including family physicians, internists, 
pediatricians and geriatricians, except when practicing inpatient care or when 
practicing in an emergency department or stand-alone urgent care clinic;
(b)  Obstetrician-gynecologists who assume responsibility for a patient's 
general primary care according to the gynecologic and nongynecologic 
standards of the United States Preventive Services Task Force or its successor 
organization except when practicing inpatient care or in an emergency 
department or stand-alone urgent care clinic;
(c)  Physicians or surgeons of any specialty when providing general or 
reproductive care to special populations or in special circumstances, including, 
but not limited to, in clinics for persons who are homeless or indigent, federally 
qualified health centers, home-based palliative care, school-based health 
centers and general clinics focusing on traditionally marginalized populations 
such as indigenous or other people of color, immigrants, asylum-seekers, 
migrant workers, persons who are marginalized on the basis of gender identity 
or sexual orientation, victims of human trafficking, incarcerated individuals 
and victims of declared natural or human-caused disasters; and
(d)  Advanced practice clinicians providing the services described in divisions 
(a) to (c).
"Primary care" also includes provider loan repayments and services such as health 
information technology services, recruitment services and practice transformation 
services that support the practitioners described in this subparagraph in the delivery 
of primary care services.
B.  Targets for investment and spending by the State in the group health plan for 
primary care and behavioral health care are established as follows.
(1)  For plan year 2023, the group health plan shall determine its baseline 
percentage of combined spending on primary care and behavioral health care based 
on claims data reported for plan year 2019 and report that percentage to the 
Superintendent of Insurance by January 1, 2022.  The superintendent shall establish 
the median percentage for all health insurance carriers for plan year 2023.  In 
subsequent plan years, the superintendent shall recalculate the median so that plan 
year 2024 is based on claims data reported for calendar year 2023, plan year 2025 
is based on claims data reported for calendar year 2024 and plan year 2026 is based 
on claims data reported for calendar year 2025.
(2)  Beginning in plan year 2023 and through plan year 2026, if the group health 
plan spends less than or equal to the median described in subparagraph (1) on 
primary care and behavioral health care, the group health plan shall increase its 
percentage spent on primary care and behavioral health care combined by at least 
2% the following plan year over the plan year referenced in subparagraph (1) plus 
an increase equal to the rate of increase each year in the Consumer Price Index for 
medical care services as reported by the United States Department of Labor, 
Bureau of Labor Statistics.
(3)  Beginning in plan year 2023 and through plan year 2026, if the group health 
plan spends above the median described in subparagraph (1) on primary care and 
behavioral health care, the group health plan shall increase its percentage spent on 
primary care and behavioral health care combined by at least 1% the following 
plan year over the plan year referenced in subparagraph (1) plus an increase equal 
to the rate of increase each year in the Consumer Price Index for medical care 
services as reported by the United States Department of Labor, Bureau of Labor 
Statistics.
(4)  The Superintendent of Insurance shall recalculate the median for each plan 
year based on the reference plan year described in subparagraph (1).  The 
requirements of subparagraphs (2) and (3) must be adjusted each plan year based 
on the group health plan's updated percentage spent on primary care and behavioral 
health care combined.
(5)  The group health plan may demonstrate that the targets required by this 
subsection are met by averaging its increases in spending on primary care and 
behavioral health care combined over more than one plan year as long as the total 
increases required pursuant to this subsection through plan year 2026 are met each 
year.
(6)  For plan year 2027 and each plan year thereafter, the group health plan shall 
maintain, at a minimum, the total combined spending on primary care and 
behavioral health care required pursuant to this section for plan year 2026.
The group health plan shall meet the targets required in this paragraph without 
increasing spending on total health expenditures.  The group health plan may also meet 
the targets required in this paragraph by making supplemental payments focused on 
primary care and behavioral health care.
Sec. 2.  22 MRSA §3173-J is enacted to read:
§3173-J.  Targets for investment in primary care and behavioral health care
Beginning in fiscal year 2023, the department shall meet the following requirements 
related to targets for investment and spending in primary care and behavioral health care 
in the MaineCare program.
1.  Definitions.  As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings.
A.  "Behavioral health care" means mental health services, including community-based 
or peer support treatments for substance use disorder provided by licensed health care 
practitioners providing services within their scope of practice, regardless of practice 
setting.
"Behavioral health care" also includes provider loan repayments and services such as 
health information technology services, recruitment services and practice 
transformation services that support the practitioners described in this paragraph in the 
delivery of behavioral health care services.
B.  "Primary care" means care provided by:
(1)  Primary care practitioners, including family physicians, internists, 
pediatricians and geriatricians, except when practicing inpatient care or when 
practicing in an emergency department or stand-alone urgent care clinic;
(2)  Obstetrician-gynecologists who assume responsibility for a patient's general 
primary care according to the gynecologic and nongynecologic standards of the 
United States Preventive Services Task Force or its successor organization except 
when practicing inpatient care or in an emergency department or stand-alone 
urgent care clinic;
(3)  Physicians or surgeons of any specialty when providing general or 
reproductive care to special populations or in special circumstances, including, but 
not limited to, in clinics for persons who are homeless or indigent, federally 
qualified health centers, home-based palliative care, school-based health centers 
and general clinics focusing on traditionally marginalized populations such as 
indigenous or other people of color, immigrants, asylum-seekers, migrant workers, 
persons who are marginalized on the basis of gender identity or sexual orientation, 
victims of human trafficking, incarcerated individuals and victims of declared 
natural or human-caused disasters; and
(4)  Advanced practice clinicians providing the services described in 
subparagraphs (1) to (3).
"Primary care" also includes provider loan repayments and services such as health 
information technology services, recruitment services and practice transformation 
services that support the practitioners described in this paragraph in the delivery of 
primary care services.
2.  Targets.  Targets for investment and spending by the department in primary care 
and behavioral health care are established as follows.
A.  For fiscal year 2023, the department shall determine its baseline percentage of 
combined spending on primary care and behavioral health care based on claims data 
reported for fiscal year 2019 and report that percentage to the Superintendent of 
Insurance by January 1, 2022.  The superintendent shall establish the median 
percentage for all health insurance carriers for plan year 2023.  In subsequent plan 
years, the superintendent shall recalculate the median so that plan year 2024 is based 
on claims data reported for calendar year 2023, plan year 2025 is based on claims data 
reported for calendar year 2024 and plan year 2026 is based on claims data reported 
for calendar year 2025.
B.  Beginning in fiscal year 2023 and through fiscal year 2026, if the MaineCare 
program spends less than or equal to the median for all health insurance carriers 
described in paragraph A on primary care and behavioral health care, the department 
shall increase its percentage spent on primary health care and behavioral health care 
combined by at least 2% the following fiscal year over the fiscal year referenced in 
paragraph B plus an increase equal to the rate of increase each year in the Consumer 
Price Index for medical care services as reported by the United States Department of 
Labor, Bureau of Labor Statistics.
C.  Beginning in fiscal year 2023 and through fiscal year 2026, if the MaineCare 
program spends above the median described in paragraph A on primary care and 
behavioral health care, the department shall increase its percentage spent on primary 
health care and behavioral health care combined by at least 1% the following fiscal 
year over the fiscal year referenced in paragraph B plus an increase equal to the rate of 
increase each year in the Consumer Price Index for medical care services as reported 
by the United States Department of Labor, Bureau of Labor Statistics.
D.  The Superintendent of Insurance shall recalculate the median for each fiscal year 
based on the reference fiscal year described in paragraph A.  The requirements of 
paragraphs B and C must be adjusted each fiscal year based on the MaineCare 
program's updated percentage spent on primary care and behavioral health care 
combined.
E.  The department may demonstrate that the targets required by this subsection are 
met by averaging its increases in spending on primary care and behavioral health care 
combined over more than one fiscal year as long as the total increases required pursuant 
to this subsection through fiscal year 2027 are met.
F.  For fiscal year 2027 and each fiscal year thereafter, the department shall maintain, 
at a minimum, the total combined spending on primary care and behavioral health care 
required pursuant to this section for fiscal year 2026.
The department shall meet the targets required in this subsection without increasing 
spending on total health expenditures.  The department may also meet the targets required 
in this subsection by making supplemental payments focused on primary care and 
behavioral health care.
Sec. 3.  24-A MRSA §2303, sub-§1, ¶B, as enacted by PL 1969, c. 132, §1, is 
amended to read:
B.  Rates shall may not be excessive, inadequate or unfairly discriminatory and, in the 
case of health insurance rates beginning for plan year 2023, must comply with the 
requirements of section 4319-B.
Sec. 4.  24-A MRSA §4319-B is enacted to read:
§4319-B.  Targets for investment in primary care and behavioral health
Beginning in plan year 2023, carriers in the large group, small group and individual 
markets shall meet the following requirements related to targets for investment and 
spending in primary care and behavioral health care.
1.  Definitions.  As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings.
A.  "Behavioral health care" means mental health services, including community-based 
or peer support treatments for substance use disorder provided by licensed healthcare 
practitioners providing services within their scope of practice, regardless of practice 
setting.
"Behavioral health care" also includes provider loan repayments and services such as 
health information technology services, recruitment services and practice 
transformation services that support the practitioners described in this paragraph in the 
delivery of behavioral health care services.
B.  "Primary care" means care provided by:
(1)  Primary care practitioners, including family physicians, internists, 
pediatricians and geriatricians, except when practicing inpatient care, or when 
practicing in an emergency department or stand-alone urgent care clinic;
(2)  Obstetrician-gynecologists who assume responsibility for a patient's general 
primary care according to the gynecologic and nongynecologic standards of the 
United States Preventive Services Task Force or its successor organization except 
when practicing inpatient care or in an emergency department or stand-alone 
urgent care clinic;
(3)  Physicians or surgeons of any specialty when providing general or 
reproductive care to special populations or in special circumstances, including, but 
not limited to, in clinics for persons who are homeless or indigent, federally 
qualified health centers, home-based palliative care, school-based health centers 
and general clinics focusing on traditionally marginalized populations such as 
indigenous or other people of color, immigrants, asylum-seekers, migrant workers, 
persons who are marginalized on the basis of gender identity or sexual orientation, 
victims of human trafficking, incarcerated individuals and victims of declared 
natural or human-caused disasters; and
(4)  Advanced practice clinicians providing the services described in 
subparagraphs (1) to (3).
"Primary care" also includes provider loan repayments and services such as health 
information technology services, recruitment services and practice transformation 
services that support the practitioners described in this paragraph in the delivery of 
primary care services.
2.  Targets.  Targets for investment and spending by a carrier in primary care and 
behavioral health care are established as follows.
A.  For plan year 2023, each carrier shall determine its baseline percentage of combined 
spending on primary care and behavioral health care based on claims data reported for 
plan year 2019 and report that percentage to the superintendent.  The superintendent 
shall establish the median percentage for all carriers for plan year 2023.  In subsequent 
plan years, the superintendent shall recalculate the median so that plan year 2024 is 
based on claims data reported for calendar year 2023, plan year 2025 is based on claims 
data reported for calendar year 2024 and plan year 2026 is based on claims data 
reported for calendar year 2025.
B.  Beginning in plan year 2023 and through plan year 2026, if a carrier spends less 
than or equal to the median described in paragraph A on primary care and behavioral 
health care, the carrier shall increase its percentage spent on primary care and 
behavioral health care combined by at least 2% the following plan year over the plan 
year referenced in paragraph A plus an increase equal to the rate of increase each year 
in the Consumer Price Index for medical care services as reported by the United States 
Department of Labor, Bureau of Labor Statistics.
C.  Beginning in plan year 2023 and through plan year 2026, if the carrier spends at or 
above the median described in paragraph A on primary care and behavioral health care, 
the carrier shall increase its percentage spent on primary care and behavioral health 
care combined by at least 1% the following plan year over the plan year referenced in 
paragraph A plus an increase equal to the rate of increase each year in the Consumer 
Price Index for medical care services as reported by the United States Department of 
Labor, Bureau of Labor Statistics.
D.  The superintendent shall recalculate the median for each plan year based on the 
reference plan year described in paragraph A.  The requirements of paragraphs B and 
C must be adjusted each year based on the carrier's updated percentage spent on 
primary care and behavioral health care combined.
E.  A carrier may demonstrate that the targets required by the subsection are met by 
averaging its increases in spending on primary care and behavioral health care 
combined over more than one plan year as long as the total increases required pursuant 
to this subsection through plan year 2026 are met.
F.  For plan year 2027 and each fiscal year thereafter, the carrier shall maintain, at a 
minimum, the total combined spending on primary care and behavioral health care 
required pursuant to this section for plan year 2026.
A carrier shall meet the targets required in this subsection by reducing avoidable health 
care spending without increasing spending on total health expenditures.  A carrier may also 
meet the targets required in this subsection by making supplemental payments to providers 
focused on primary care and behavioral health care.
3.  Rate approval.  Beginning in plan year 2023, the superintendent may not approve 
any rate filed by a carrier unless the carrier demonstrates that the targets required by this 
section have been met.  The superintendent may approve rates provisionally for one year, 
if the superintendent is satisfied with an action plan submitted by a carrier to meet the 
targets described in this section.  As part of any rate filing, the superintendent may require 
a carrier to provide such additional information as necessary to determine compliance with 
this section.
SUMMARY
This bill requires health carriers to meet certain targets for investment and spending in 
primary care and behavioral health care beginning in plan year 2023 and through plan year 
2026.  Overall spending may not increase to meet the targets. The bill establishes a 
benchmark for combined spending in primary care and behavioral health care as a 
percentage of overall health spending.  The benchmark is indexed to the median amount 
spent by carriers on primary care and behavioral health care for plan year 2019.  The bill 
requires carriers to increase relative spending in these areas by at least 2% per year if 
spending is less than or equal to the median and at least 1% per year if spending is above 
the median.  Beginning in plan year 2027, carriers are required to maintain, at a minimum, 
the total combined spending on primary care and behavioral health care achieved in plan 
year 2026.  The bill prohibits the Superintendent of Insurance from approving health 
insurance rates filed by a carrier unless the carrier demonstrates that the targets have been 
met.  The bill also authorizes a carrier to meet the spending targets by supplemental 
payments focused on primary care and behavioral health care.
The bill also requires the MaineCare program and the state employee health plan to 
meet the same targets beginning in 2023.