An Act to Allow Employers to Shop for Competitive Health Plan Options by Expanding the Disclosure of Health Claims Information
Maine Legislature, Session 131, LD 1373
Committee: Health Coverage, Insurance and Financial Services
Sponsors: MORRIS, BRAKEY
Amends: 24-A MRSA §2215, 24-A MRSA §2803-A

Legislative Document
No. 1373
H.P. 887
House of Representatives, March 28, 2023
An Act to Allow Employers to Shop for Competitive Health Plan 
Options by Expanding the Disclosure of Health Claims Information
Reference to the Committee on Health Coverage, Insurance and Financial Services 
suggested and ordered printed.
ROBERT B. HUNT
Clerk
Presented by Representative MORRIS of Turner.
Cosponsored by Senator: BRAKEY of Androscoggin.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA §2215, sub-§1, ¶L, as enacted by PL 1997, c. 677, §3 and 
affected by §5, is amended to read:
L.  To a group policyholder for the purpose of reporting claims experience or 
conducting an audit of the regulated insurance entity's operations or services, only if 
the information disclosed is aggregate information and reasonably necessary for the 
group policyholder to conduct the review or audit, and to a group policyholder or 
employer to the extent necessary for reporting loss information in compliance with 
section 2803-A;
Sec. 2.  24-A MRSA §2803-A, as amended by PL 2015, c. 420, §2, is further 
amended to read:
§2803-A.  Loss information
1.  Definitions.  As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings.
A.  "Insurance policy" means the insurance policy relating to the loss information 
requested pursuant to this section.
A-1.  "High-cost claimant" means an individual insured whose aggregate claims exceed 
$50,000 during the 12-month period preceding the request for loss information.
B.  "Loss information" means the aggregate claims experience of the group insurance 
policy or contract.  "Loss information" includes the amount of premium received, the 
amount of claims paid and the loss ratio.  "Loss information" does not include any 
information or data pertaining to the medical diagnosis, treatment or health status that 
identifies an individual covered under the group contract or policy.
C.  "Loss ratio" means the ratio between the amount of premium received and the 
amount of claims paid by the insurer under the group insurance contract or policy.
2.  Disclosure of basic loss information.  Upon written request, every insurer shall 
provide loss information, in accordance with the minimum requirements of paragraph A, 
concerning a group policy or contract to its policyholder, to a former policyholder or to a 
school administrative unit pursuant to Title 20‑A, section 1001, subsection 14, paragraph 
E within 21 business days of the date of the request.  This subsection does not apply to a 
former policyholder whose coverage terminated more than 18 months prior to the date of 
a request.  For the purposes of this subsection, "school administrative unit" has the same 
meaning as in Title 20‑A, section 1, subsection 26.
A.  The loss information provided by an insurer must include:
(1)  A minimum of 24 months of claims data or, if that period is less than 24 
months, claims data for the period the policyholder, former policyholder or school 
administrative unit has been insured by the insurer;
(2)  The loss ratio by month with medical and pharmacy claims identified 
individually;
(3)  High-cost claimant reports that coincide with the time frames of any loss ratio 
reports provided.  High-cost claimant reports must include, at a minimum, 
enrollment status of active or terminated insureds, primary diagnosis and sufficient 
data regarding prognosis, to the extent the prognosis is known, to estimate 
anticipated claim cost for the 12-month coverage period immediately following the 
report request; and
(4)  A statement describing precertification requests for hospital stays of 5 days or 
longer that were made during the 30-day period preceding the date of the report 
request.
3.  Transmittal of request.  An insurance contractor or producer or other authorized 
representative who receives a request for loss information in accordance with this section 
shall transmit the request for loss information to the insurer within 4 business days.
A.  An insurer receiving a disclosure request under subsection 2 may transmit high-
cost claimant data directly to another insurer or underwriter, or to a contractor or 
producer that has signed with that insurer a business associate agreement that is in 
accordance with 45 Code of Federal Regulations, Sections 164.502(e) and 164.504(e), 
for the purpose of securing quotes, developing actuarial reports, facilitating claim 
management or other activities related to quoting or managing the group health plan 
sponsored by the requesting group policyholder.
B.  A group policyholder receiving any high-cost claimant reports shall take all 
precautions and actions required under 45 Code of Federal Regulations, Section 
164.504(f) with respect to the privacy and security of protected health information of 
a high-cost claimant, notwithstanding any exemption that may apply to the 
policyholder under federal law.  An insurer that has received a disclosure request under 
subsection 2 may not transmit high-cost claimant data to any group policyholder that 
is not in compliance with this paragraph.
4.  Exception.  An insurer is not required to provide the loss information described in 
this section for a group that is eligible for small group coverage pursuant to section 2808‑B.:
A.  For a group that is eligible for small group coverage pursuant to section 2808‑B; or
B.  If the insurer is otherwise prohibited from disclosing that information under state 
or federal law.
SUMMARY
This bill expands the scope of loss information that must be provided to an employer 
to facilitate the employer's shopping for group health insurance coverage, including 
disclosure of a minimum of 24 months of claims data, to the extent possible, and 
information related to high-cost claimants.