An Act Concerning Prior Authorizations for Health Care /ro~ider Services
Maine Legislature, Session 131, LD 0796
Committee Amendment CA_A_H954 (House)
Amends: 24-A MRSA §4301-A, 24-A MRSA §4303, 24-A MRSA §4304, 24-A MRSA §4312, 24-A MRSA §4302

COMMITTEE AMENDMENT" J" to H.P. 485, L.D. 796, "An Act Concerning 
Prior Authorizations for Health Care /ro~ider Services" 
Amend the bill by striking out everything after the enacting clause and inserting the 
following: 
'PART A 
Sec. A-1. 24-A MRSA §4301-A, sub-§1, as amended by PL 2011, c. 364, §20, is 
further amended to read: 
1. Adverse health care treatment decision. "Adverse health care treatment decision" 
means a health care treatment decision made by or on behalf of a carrier offering or 
renewing a health plan denying in whole or in part payment for or provision of otherwise 
covered services requested by or on behalf of an enrollee. "Adverse health care treatment 
decision" includes a rescission determination and an initial coverage eligibility 
determination, consistent with the requirements of the federal Affordable Care Act, and a 
prior authorization determination in accordance with section 4304. 
Sec. A-2. 24-A MRSA §4301-A, sub-§2, as enacted by PL 1999, c. 742, §3, is 
amended to read: 
2. Authorized representative. "Authorized representative" means: 
A. A person to whom an enrollee has given express written consent to represent the 
enrollee in an external review; 
B. A person authorized by law to provide consent to request an external review for an 
enrollee; eF 
C. A family member of an enrollee or an enrollee's treating health care provider when 
the enrollee is unable to provide consent to request an external review-:-_;_m: 
D. A provider that is actively treating an enrollee. 
Sec. A-3. 24-A MRSA §4303, sub-§4, as amended by PL 2019, c. 5, Pt. A, §20, 
is further amended to read: 
COMMITTEE AMENDMENT 
~os 1 
COMMITTEE AMENDMENT "A" to H.P. 485, L.D. 796 
4. Grievance procedure for enrollees, A carrier offering or renewing a health plan 
in this State shall establish and maintain a grievance procedure that meets standards 
developed by the superintendent to provide for the resolution of claims denials. prior 
authorization denials or other matters by which enrollees are aggrieved. 
A. The grievance procedure must include, at a minimum, the following: 
(1) Notice to the enrollee and the enrollee's provider promptly of any claim denial.,, 
prior authorization denial or other matter by which enrollees are likely to be 
aggrieved, stating the basis for the decision, the right to file a grievance, the 
procedure for doing so and the time period in which the grievance must be filed; 
(2) Timelines within which grievances must be processed, including expedited 
processing for exigent circumstances. Timelines must be sufficiently expeditious 
to resolve grievances promptly. Decisions for second level grievance reviews as 
defined by bureau rules must be issued within 30 calendar days if the insured has 
not requested the opportunity to appear in person before authorized representatives 
of the health carrier; 
(3) Procedures for the submission of relevant information and enrollee or provider 
participation; 
(4) Provision to the aggrieved party of a written statement upon the conclusion of 
any grievance process, setting forth the reasons for any decision. The statement 
must include notice to the aggrieved party of any subsequent appeal or external 
review rights, the procedure and time limitations for exercising those rights and 
notice of the right to file a complaint with the Bureau oflnsurance and the toll-free 
telephone number of the bureau; afte 
(5) Decision-making by one or more individuals not previously involved in 
making the decision subject to the grievance,; and 
(6) Procedures for a provider actively treating an enrollee to act as an authorized 
representative of the enrollee within the meaning of section 4301-A subsection 2, 
paragraph D and file a grievance on the enrollee's behalf as long as the provider 
notifies the enrollee in writing at least 14 days prior to filing a grievance and within 
days after filing a grievance or withdrawing a grievance. The enrollee has the 
right to affirmatively object to a provider that has filed a grievance at any time, and 
the enrollee has the right to notify the health carrier at any time that the enrollee 
intends to take the place of the provider as a party to the grievance. 
B. In any appeal under the grievance procedure in which a professional medical 
opinion regarding a health condition is a material issue in the dispute, the aggrieved 
party is entitled to an independent 2nd opinion, paid for by the plan, of a provider of 
the same specialty participating in the plan. If a provider of the same specialty does 
not participate in the plan, then the 2nd opinion must be given by a nonparticipating 
provider. 
C. In any appeal under the grievance procedure, the carrier shall provide auxiliary 
telecommunications devices or qualified interpreter services by a person proficient in 
American Sign Language when requested by an enrollee who is deaf or hard-of-hearing 
or printed materials in an accessible format, including Braille, large-print materials, 
computer diskette, audio cassette or a reader when requested by an enrollee who is 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A "_to H.P. 485, L.D. 796 
visually impaired to allow the enrollee to exercise the enrollee's right to an appeal under 
this subsection. 
D. Notwithstanding this subsection, a group health plan sponsored by an agricultural 
cooperative association located outside of this State that provides health insurance 
coverage to members of one or more agricultural cooperative associations located 
within this State may employ a grievance procedure for enrollees in the group health 
plan that meets the requirements of the state in which the group health plan is located 
if enrollees in the group health plan that reside in this State have the right to 
independent external review in accordance with section 4312 following any adverse 
health care treatment decision. Any difference in the grievance procedure requirements 
between those of the state in which the group health plan is located and those of this 
State must be limited to the number of days required for notification of prior 
authorization for nonemergency services and the number of days required for the 
issuance of a decision following the filing of an appeal of an adverse health care 
treatment decision. Enrollees in the group health plan that reside in this State must be 
notified as to the grievance procedure used by the group health plan and their right to 
independent external review in accordance with section 4312. 
E. Health plans may not reduce or terminate benefits for an ongoing course of 
treatment, including coverage of a prescription drug, during the course of an appeal 
pursuant to the grievance procedure used by the carrier or any independent external 
review in accordance with section 4312. 
Sec, A-4. 24-A MRSA §4304, sub-§2, ~ 
is enacted to read: 
E. If a covered medically necessary service cannot be delivered on the approved date 
of an approved prior authorization request, a carrier may not deny the claim if the 
covered medically necessary service is provided within 14 days before or after the 
approved date. 
Sec. A-5. 24-A MRSA §4304, sub-§2, Wis enacted to read: 
F. 
For nonemergency services provided without a required prior authorization 
approval, a carrier may not deny a claim for nonemergency services that were within 
the scope of the enrollee's coverage pending medical necessity review and may not 
impose a penalty on the provider for failing to obtain a prior authorization of greater 
than 15% of the contractually allowed amount for the services that required prior 
authorization approval. 
Sec. A-6. 24-A MRSA §4304, sub-§5, ,f-B is enacted to read: 
B. The medical necessity of emergency services may not be based on whether those 
services were provided by participating or nonparticipating providers. Restrictions on 
coverage of emergency services provided by nonparticipating providers may not be 
greater than restrictions that apply when those services are provided by participating 
providers. 
Sec, A-7. 24-A MRSA §4304, sub-§5, 1C is enacted to read: 
C. 
If an enrollee receives an emergency service that requires immediate 
post-evaluation or post-stabilization services, a carrier may not require prior 
authorization for the post-evaluation or post-stabilization services provided during the 
COMMITTEE AMENDMENT 
?§?s 1 
'i,•· 
COMMITTEE AMENDMENT" A" to H.P. 4~5, L.D. 796 
same encounter. 
If the post-evaluation or post-stabilization services reguire an 
inpatient level of care, the carrier shall make a utilization review determination within 
hours of receiving a request for those services and the carrier is responsible for 
payment for those services for the duration until the carrier affirmatively notifies the 
provider otherwise. If the utilization review determination is not made within 24 hours, 
the services for which the utilization review was requested are deemed approved until 
the carrier affirmatively notifies the provider otherwise. 
Sec. A-8. 24-A MRSA §4312, first ,r, as amended by PL 2007, c. 199, Pt. B, § 17, 
is further amended to read: 
An enrollee or the enrollee's authorized representative has the right to an independent 
external review of a carrier's adverse health care treatment decision made by or on behalf 
of a carrier offering or renewing a health plan in accordance with the requirements of this 
section. An enrollee's failure to obtain authorization prior to receiving an otherwise covered 
service may not preclude an enrollee from exercising the enrollee's rights under this section. 
Sec. A-9. 24-A MRSA §4312, sub-§1-A is enacted to read: 
1-A. 
Request for independent external review by enrollee's authorized 
representative. A request for an independent external review may be made by an 
enrollee's authorized representative as defined in section 4301-A. subsection 2, paragraph 
D in accordance with this subsection. 
A. The enrollee's authorized representative shall notify the enrollee in writing at least 
days prior to filing a request for independent external review and within 7 days after 
filing the request or withdrawing the request. 
B. The enrollee may affirmatively object to the request for independent external review 
at any time prior to the filing of a reguest by an enrollee's authorized representative 
and, after a request has been filed. may notify the bureau at any time that the enrollee 
intends to take the place of the enrollee's authorized representative as a party in the 
independent external review. 
Sec. A-10. Application. This Part applies to all policies, contracts and certificates 
executed, delivered, issued for delivery, continued or renewed on or after January 1, 2025. 
For purposes of this Part, all contracts are deemed to be renewed no later than the next 
yearly anniversary of the contract date. 
PARTB 
Sec. B-1. 24-A MRSA §4302, sub-§2, as amended by PL 2007, c. 199, Pt. B, §3, 
is further amended to read: 
2. 
Plan eomplaiB-t; complaints and adverse decisions; prior authorf!lla-tion 
statistics. A carrier shall provide annually to the superintendent information for each 
health plan that it offers or renews on plan complaints; and adverse decisions aad prior 
authofi:;z;a-tios statistics. This statistical information must contain, at a minimum: 
A. The ratio of the number of complaints received by the plan to the total number of 
enrollees, reported by type of complaint and category of enrollee; 
B. The ratio of the number of adverse decisions issued by the plan to the number of 
complaints received, reported by category; 
COMMITTEE AMENDMENT 
·f{oS 
•~.h•· 
COMMITTEE AMENDMENT 'A "to H.P. 485, L.D. 796 
C. The Fatio of the 1l-l:liRbeF ofpFioF authol'izatioas deaied by the plaa to the aumbeF of 
pFioF authoFizatioas Feqaested, Feported by eategoey; 
D. The ratio of the number of successful enrollee appeals overturning the original 
denial to the total number of appeals filed; 
E. The percentage of disenrollments by enrollees and providers from the health plan 
within the previous 12 months and the reasons for the disenrollments. With respect to 
enrollees, the information provided in this paragraph must differentiate between 
voluntary and involuntary disenrollments; and 
F. Enrollee satisfaction statistics, including provider-to-enrollee ratio by geographic 
region and medical specialty and a report on what actions, if any, the carrier has taken 
to improve complaint handling and eliminate the causes of valid complaints. 
Sec. B-2. 24-A MRSA §4302, sub-§2-A is enacted to read: 
2-A. Reporting of information related to prior authorization. In addition to the 
information required to be provided under subsection 2, a carrier shall annually report to 
the superintendent the following information related to prior authorization determinations 
for the prior calendar year: 
A. A list of all items and services that require prior authorization: 
B. The number and percentage of standard prior authorization requests that were 
approved. aggregated for all items and services: 
C. The number and percentage of standard prior authorization requests that were 
denied, aggregated for all items and services: 
D. The number and percentage of standard prior authorization requests that were 
approved after appeal. aggregated for all items and services: 
E. The number and percentage of prior authorization requests for which the time frame 
for review was extended and the request approved, aggregated for all items and 
services: 
F. The number and percentage of expedited prior authorization requests that were 
approved. aggregated for all items and services: 
G. The number and percentage of expedited prior authorization requests that were 
denied. aggregated for all items and services: 
H. The average and median time that elapsed between the submission of a request and 
a determination by the carrier, for standard prior authorizations, aggregated for all 
items and services: 
I. The average and median time that elapsed between the submission of a request and 
a decision by the carrier for expedited prior authorizations. aggregated for all items and 
services: and 
J. The average and median time that elapsed between the submission of a concurrent 
care prior authorization request to extend a course of treatment and a determination by 
the carrier, aggregated for all items and services. 
Sec. B-3. 24-A MRSA §4302, sub-§2-B is enacted to read: 
COMMITTEE AMENDMENT 
C. 
~Q~-
,.,, 
COMMITTEE AMENDMENT ,A "to H.P. 485, L.D. 796 
2-B. Data reporting; utilization review data. Beginning April 1. 2025 and April 1st 
of each year thereafter, the superintendent shall collect the information required under 
subsections 2 and 2-A. together with the utilization review information collected pursuant 
to section 2749, and post this information on the bureau's publicly accessible website. 
Sec. B-4. Reporting on data submitted by health insurance carriers on 
prior authorization determinations. The Superintendent of Insurance shall survey 
health insurance carriers in this State to request data from carriers for calendar years 2021, 
2022 and 2023 that, at a minimum, provides information related to prior authorization 
dete1minations as described in the Maine Revised Statutes, Title 24-A, section 4302, 
subsection 2-A. No later than January 15, 2025, the Superintendent shall submit to the 
joint standing committee of the Legislature having jurisdiction over health coverage, 
insurance and financial services matters a report that collects the data submitted by each 
carrier related to prior authorization determinations. The joint standing committee of the 
Legislature having jurisdiction over health coverage, insurance and financial services 
matters may report out a bill to the 132nd Legislature in 2025 based on the report provided 
in accordance with this section.' 
Amend the bill by relettering or renumbering any nonconsecutive Part letter or section 
number to read consecutively. 
SUMMARY 
This amendment replaces the bill, which is a concept draft. The amendment, which is 
the majority report of the committee, does the following. 
In Part A, the amendment permits a provider that is actively treating an enrollee to act 
as an authorized representative of an enrollee for purposes of grievances and appeals of 
health insurance carrier decisions without requiring prior written authorization from the 
enrollee. The amendment does require that a provider actively treating an enrollee must 
notify an enrollee at least 14 days prior to filing a grievance or appeal and within 7 days 
after filing a grievance or appeal or withdrawing a grievance or appeal and also permits an 
enrollee to affirmatively object to the provider's action. 
The amendment requires carriers to allow prior authorization approvals to be effective 
for a 2-week period before and after a specific date. It also prohibits carriers from denying 
claims for nonemergency services that were within the scope of the enrollee's coverage 
pending medical necessity review and prohibits carriers from imposing a penalty of more 
than 15% of the contractually allowed amount for the services that required prior 
authorization approval on the provider for failing to obtain a prior authorization. 
The amendment prohibits carriers from making determinations of medical necessity 
based on whether those services are provided by participating or nonparticipating 
providers. The amendment also provides that, if a patient needs immediate post-evaluation 
or post-stabilization services, a carrier is prohibited from requiring prior authorization for 
those services provided during the same encounter. If post-evaluation or post-stabilization 
services necessitate inpatient care, a carrier is permitted to impose prior authorization for 
those services but carriers are required to respond to the prior authorization request within 
hours. If the provider does not receive a determination from the carrier within 24 hours, 
the care is deemed approved until the carrier affirmatively notifies the provider otherwise. 
COMMITTEE AMENDMENT 
i'?'b 1 
COMMITTEE AMENDMENT "Ir" to H.P. 485, L.D, 796 
The requirements of Part A apply to all policies, contracts or certificates executed, 
delivered, issued for delivery, continued or renewed on or after January 1, 2025. 
Part B requires carriers to report certain information related to prior authorization 
determinations and also requires the Department of Professional and Financial Regulation, 
Bureau of Insurance to annually report aggregate data for carriers, including posting 
inf01mation on the bureau's publicly accessible website. 
Part B also requires the Superintendent of Insurance to collect data related to prior 
authorization determinations for calendar years 2021, 2022 and 2023 from health insurance 
carriers. It requires the superintendent to report this information to the joint standing 
committee of the Legislature having jurisdiction over health coverage, insurance and 
financial services matters no later than January 15, 2025 and authorizes the committee to 
report out legislation based on the report to the 132nd Legislature in 2025. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
Approved: 04/09/24 .;rk:rae 
LD796 
LR 1786(02) 
An Act Concerning Prior Authorizations for Health Care Provider Services 
Fiscal Note for Bill as Amended by Committee Amendment ;4• (H--f .5' V 
Committee: Health Coverage, Insurance and Financial Services 
Net Cost (Savings) 
General Fund 
Highway Fund. 
Appropriations/ Allocations 
General Fund 
Highway Fund 
Fiscal Detail and Notes 
/' 
Fiscal Note Required: Yes 
Fiscal Note 
FY2023-24 
$0 
$0 
$0 
$0 
FY2024-25 
$0 
$0 
$0 
$0 
Projections 
FY 2025-26 
$50,058 
$18,475 
$50,058 
$18,475 
Projections 
FY2026-27 
$50,058 
$18,4' 
$50,058 
$18,475 
The bill prohibits carriers from denying claims for nonemergency services that were within the scope of the enrollee's 
coverage pending medical necessity review and prohibits carriers from imposing a penalty of more than 15% of the 
contracJually allowed amount for the services that required prior authorization approval on the provider for failing to 
obtain a prior authorization. 
The requirements of the bill apply to health plans issued or renewed on or after January 1, 2025. The State Employee 
Health Plan's first impacted plan year will be SFY 2026 and is estimated to cost $110,874 annually thereafter. The 
costs are split across the General Fund ($50,058), Highway Funds ($18,475) and all other funds ($42,341). 
Any additional costs to the Department of Professional and Financial Regulation from the provisions of this bill are 
expected to be minor and can be absorbed within existing budgeted resources.