An Act To Further Protect Consumers from Surprise Medical Bills
Maine Legislature, Session 130, LD 0046
Committee: Health Coverage, Insurance and Financial Services
Sponsors: TEPLER
Amends: 24-A MRSA §4303-C, 24-A MRSA §4303-E

Legislative Document
No. 46
H.P. 12
House of Representatives, January 13, 2021
An Act To Further Protect Consumers from Surprise Medical Bills
(EMERGENCY)
Submitted by the Department of Professional and Financial Regulation pursuant to Joint 
Rule 204.
Received by the Clerk of the House on January 11, 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 TEPLER of Topsham.
Emergency preamble.  Whereas, acts and resolves of the Legislature do not 
become effective until 90 days after adjournment unless enacted as emergencies; and
Whereas, it is critically important that this legislation to further protect consumers 
from surprise medical bills take effect before the expiration of the 90-day period; and
Whereas, in the judgment of the Legislature, these facts create an emergency within 
the meaning of the Constitution of Maine and require the following legislation as 
immediately necessary for the preservation of the public peace, health and safety; now, 
therefore,
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA §4303-C, sub-§2, ¶B, as amended by PL 2019, c. 668, §2, is 
further amended to read:
B.  Except as provided for ambulance services in paragraph D, unless the carrier and 
out-of-network provider agree otherwise, a carrier shall reimburse the out-of-network 
provider or enrollee, as applicable, for health care services rendered at the greater of:
(1)  The carrier's median network rate paid for that health care service by a similar 
provider in the enrollee's geographic area where the service was provided; and
(2)  The median network rate paid by all carriers for that health care service by a 
similar provider in the enrollee's geographic area where the service was provided 
as determined by the all-payer claims database maintained by the Maine Health 
Data Organization or, if Maine Health Data Organization claims data is insufficient 
or otherwise inapplicable, another independent medical claims database specified 
by the superintendent;
Sec. 2.  24-A MRSA §4303-E, sub-§1, ¶G, as enacted by PL 2019, c. 668, §3, is 
amended to read:
G.  When the difference between the out-of-network provider's charge and the median 
network rate pursuant to section 4303‑C, subsection 2, paragraph B, subparagraph (1), 
including any applicable enrollee cost sharing, is less than $750, a carrier shall 
reimburse the out-of-network provider directly for the provider's charges for the 
services rendered as long as the provider's charges do not exceed the 80th percentile of 
charges for the particular health care service performed by a health care professional 
in the same or similar specialty and provided in the same geographical area as reported 
in a benchmarking by the Maine Health Data Organization or, if Maine Health Data 
Organization claims data is insufficient or otherwise inapplicable, another independent 
medical claims database specified by the superintendent and maintained by a nonprofit 
organization that is not affiliated with and does not receive funding from a carrier. An 
out-of-network provider may dispute more than one bill with the same carrier for the 
same health care service under this subsection as long as the total of the bills with that 
carrier for that health care service exceeds $750.
Emergency clause.  In view of the emergency cited in the preamble, this legislation 
takes effect when approved.
SUMMARY
This bill provides that information on provider charges as reported by the Maine Health 
Data Organization or, if Maine Health Data Organization claims data is insufficient or 
otherwise inapplicable, another independent medical claims database specified by the 
Superintendent of Insurance must be used to determine the amount a carrier must reimburse 
an out-of-network provider under certain circumstances.  It removes the requirement that a 
benchmarking database be maintained by a nonprofit organization that is not affiliated with 
and does not receive funding from a carrier.  It bases the amount a carrier must reimburse 
an out-of-network provider or enrollee on the rate paid for a health care service in the 
geographic area where the service is provided rather than on the rate paid for a health care 
service in an enrollee's geographic area.