An Act to Increase Transparency of and Lower Health Care Costs
Maine Legislature, Session 131, LD 1085
Committee: Health Coverage, Insurance and Financial Services
Sponsors: MORRIS, PERKINS, MOORE, ARATA, BRADSTREET, NESS, SWALLOW, BRAKEY
Amends: 24-A MRSA §4318-A, 24-A MRSA §4318-B

Legislative Document
No. 1085
H.P. 680
House of Representatives, March 9, 2023
An Act to Increase Transparency of and Lower Health Care Costs
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 Representative PERKINS of Dover-Foxcroft,
Senator MOORE of Washington and
Representatives: ARATA of New Gloucester, BRADSTREET of Vassalboro, NESS of 
Fryeburg, SWALLOW of Houlton, Senator: BRAKEY of Androscoggin.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA §4318-A, first ¶, as enacted by PL 2017, c. 232, §8, is 
amended to read:
Beginning January 1, 2019, a A carrier offering a health plan in this State shall 
establish, at a minimum, for all small group health plans as defined in section 2808‑B, 
subsection 1, paragraph G compatible with a health savings account authorized under 
federal law, a health plan design in which enrollees are directly incentivized to shop for 
low-cost, high-quality participating providers for comparable health care services.  
Incentives may include, but are not limited to, cash payments, gift cards or credits or 
reductions of premiums, copayments or deductibles.  A small group health plan design 
created under this section must remain available to enrollees for at least 2 consecutive 
years, except that any changes made to the program after 2 years, including, but not limited 
to, ending the incentive, may not be construed as a change to the small group health plan 
design for the purpose of guaranteed renewability under section 2808‑B, subsection 4 or 
section 2850‑B. Incentives must be equal to or greater than 25% of the difference between 
the price of the service from the provider selected and the statewide average for the same 
covered health care service based on data reported on the publicly accessible health care 
costs website of the Maine Health Data Organization.  A carrier may use the average price 
paid to a network provider for the covered comparable health care service under the 
enrollee’s health plan in lieu of the statewide average price on the Maine Health Data 
Organization’s publicly accessible website as long as the carrier uses a reasonable method 
to calculate the average price paid. A multiple-employer welfare arrangement is not 
considered a carrier for the purposes of this section.
Sec. 2.  24-A MRSA §4318-A, sub-§1, ¶A, as enacted by PL 2017, c. 232, §8, is 
amended to read:
A.  "Comparable health care service" means nonemergency, outpatient health care 
services in the following categories:
(1)  Physical and occupational therapy services;
(2)  Radiology and imaging services;
(3)  Laboratory services; and
(4)  Infusion therapy services.; and
(5)  Surgical procedures.
Sec. 3.  24-A MRSA §4318-A, sub-§8, as enacted by PL 2017, c. 232, §8, is 
repealed.
Sec. 4.  24-A MRSA §4318-B, sub-§1, as enacted by PL 2017, c. 232, §9, is 
amended to read:
1.  Services from out-of-network provider; lower prices.  Beginning January 1, 
2019, if If an enrollee covered under a health plan other than a health maintenance 
organization plan elects to obtain a covered comparable health care service as defined in 
section 4318‑A, subsection 1, paragraph A from an out-of-network provider at a price that 
is the same or less than the statewide average for the same covered health care service based 
on data reported on the publicly accessible health care costs website of the Maine Health 
Data Organization, the carrier shall allow the enrollee to obtain the service from the out-
of-network provider at the provider's charge and, upon request by the enrollee, shall apply 
the payments made by the enrollee for that comparable health care service toward the 
enrollee's deductible and out-of-pocket maximum as specified in the enrollee's health plan 
as if the health care services had been provided by an in-network provider.  A carrier may 
use the average price paid to a network provider for the covered comparable health care 
service under the enrollee's health plan in lieu of the statewide average price on the Maine 
Health Data Organization's publicly accessible website as long as the carrier uses a 
reasonable method to calculate the average price paid and the information is available to 
enrollees through a website accessible to the enrollee and a toll-free telephone number that 
provide, at a minimum, information relating to comparable health care services.  The 
enrollee is responsible for demonstrating to the carrier that payments made by the enrollee 
to the out-of-network provider should be applied toward the enrollee's deductible or out-
of-pocket maximum pursuant to this section.  The carrier shall provide a downloadable or 
interactive online form to the enrollee for the purpose of making such a demonstration and 
may require that copies of bills and proof of payment be submitted by the enrollee.  For the 
purposes of this section, "out-of-network provider" means a provider located in 
Massachusetts, New Hampshire or this State that is enrolled in the MaineCare program and 
participates in Medicare.
Sec. 5.  24-A MRSA §4318-B, sub-§3, as enacted by PL 2017, c. 232, §9, is 
repealed.
SUMMARY
This bill makes the following changes to the law relating to the comparable health care 
incentive program. 
1.  It removes the requirement that the small group health plan design be compatible 
with a health savings account. 
2.  It requires that the incentives be equal to or greater than 25% of the difference 
between the price of the service from the provider selected and the statewide average for 
the same covered health care service based on data reported on the publicly accessible 
health care costs website of the Maine Health Data Organization.  
3.  It adds surgical procedures to the categories of health care services included in the 
definition of "comparable health care service."
4.  It repeals the sunset date of the comparable health care service incentive program, 
which is January 1, 2024. 
Under current law, if an enrollee covered under a health plan other than a health 
maintenance organization plan elects to obtain a covered comparable health care service 
from an out-of-network provider at a price that is the same or less than the statewide 
average for the same covered health care service, the carrier is required to allow the enrollee 
to obtain the service from the out-of-network provider at the provider's charge and, upon 
request by the enrollee, to apply the payments made by the enrollee for that comparable 
health care service toward the enrollee's deductible and out-of-pocket maximum as 
specified in the enrollee's health plan as if the health care services had been provided by an 
in-network provider.  This bill removes the exception that the provision does not apply to 
a health maintenance organization plan and the limitation defining an out-of-network 
provider as a provider located in Massachusetts, New Hampshire or this State that is 
enrolled in the MaineCare program and participates in Medicare. The bill also removes the 
sunset date of the provision of law regarding access to lower-priced services, which is 
January 1, 2024.