An Act to Improve Accountability and Understanding of Data in
Maine Legislature, Session 132, LD 1906
Committee: Health Coverage, Insurance and Financial Services
Sponsors: BAILEY, MORRIS, DAUGHTRY, FECTEAU
Amends: 24-A MRSA §1914, 24-A MRSA §4347, 24-A MRSA §4349-A

Legislative Document
No. 1906
S.P. 747
In Senate, May 6, 2025
An Act to Improve Accountability and Understanding of Data in 
Insurance Transactions
Reference to the Committee on Health Coverage, Insurance and Financial Services 
suggested and ordered printed.
DAREK M. GRANT
Secretary of the Senate
Presented by Senator BAILEY of York.
Cosponsored by Representative MORRIS of Turner and
Senator: President DAUGHTRY of Cumberland, Representatives: BOYER of Cape Elizabeth, 
Speaker FECTEAU of Biddeford, FOLEY of Wells, GATTINE of Westbrook, GRAMLICH of 
Old Orchard Beach, MATHIESON of Kittery, OLSEN of Raymond.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA §1914 is enacted to read:
§1914.  Plan sponsor access to claims data; right to audit
1.  Ownership of claims data.  Any contract between an administrator and a plan 
sponsor to provide health coverage must provide that the plan sponsor owns the claims data 
relating to the contract.
2.  High-cost claims data.  Upon request of a plan sponsor, an administrator shall 
provide data on a high-cost claim within 20 business days of a request so that a plan sponsor 
may perform an audit to ensure compliance with the plan sponsor's contract prior to 
payment of the high-cost claim.  The data must include itemized billing statements and 
medical records associated with the claim.  For the purposes of this subsection, "high-cost 
claim" means any claim related to an individual provided health coverage by a plan sponsor 
in which the aggregate for an episode of care exceeds $50,000.
3.  Claims data; right to audit.  An administrator that contracts with a plan sponsor 
to provide health coverage shall permit a plan sponsor to perform a post-payment audit of 
all claims paid to ensure compliance with the contract at least once in a calendar year as 
long as the request is not earlier than 6 months following a previously requested audit.  
Upon request of a plan sponsor as part of an audit, an administrator shall disclose the 
following information specific to the plan sponsor or, if requested by the plan sponsor, to 
the plan sponsor's delegated business associate, within 20 business days:
A. Claims data, including electronic claims transactions, received by the administrator 
on any current standardized claim form approved by the Federal Government for 
professional services or institutional services.  The form or transaction may be 
modified as necessary to comply with the federal Health Insurance Portability and 
Accountability Act of 1996, Public Law 104-191; 
B. Claims payments, electronic funds transfers or remittance advice notices provided 
by the administrator as electronic files compliant with the federal Health Insurance 
Portability and Accountability Act of 1996, Public Law 104-191, including, but not 
limited to, electronic claims transactions for both the billed amount and the paid 
amount for professional services and both the billed amount and the paid amount for 
institutional services.  The files may be modified only as necessary to comply with the 
federal Health Insurance Portability and Accountability Act of 1996, Public Law 
104-191.  In the event that paper claims are provided, the administrator shall convert 
the paper claims to an electronic format; 
C. Any fees charged to the plan sponsor related to plan administration and claims 
processing, including renegotiation fees, access fees, repricing fees or enhanced review 
fees; 
D. Any out-of-network fees or out-of-network negotiated discounts, aligned incentive 
program fees, pay-for-performance payments and recoveries, cost-containment 
program fees, overpayment recovery program fees, subrogation fees and any other 
special program fees and discounts; and
E.  Itemized billing statements and medical records associated with a specific claim if 
requested by the plan sponsor or plan sponsor's auditor.
4.  No conditions or fees on audit.  An administrator may not impose on a plan 
sponsor: 
A. Any fees for requesting an audit under this section that exceed the direct expenses 
properly and actually incurred by the administrator to provide the data; 
B. Any fees associated with selecting an auditor other than an auditor designated by 
the administrator; or
C. Any conditions that would restrict a plan sponsor's right to conduct an audit under 
this section, including, but not limited to, restrictions on: 
(1) The time period covered by the audit; 
(2) The number of claims analyzed; 
(3) The type of analysis conducted; 
(4) The data elements used in the analysis; 
(5) The plan sponsor's choice of auditor; or 
(6) The means by which an auditor is compensated by a plan sponsor. 
5.  Compliance with federal Health Insurance Portability and Accountability Act 
of 1996.  Information provided by an administrator to a plan sponsor in accordance with 
this section must comply with any applicable requirements of the federal Health Insurance 
Portability and Accountability Act of 1996, Public Law 104-191. 
6.  Application.  This section applies to any contract between an administrator and a 
plan sponsor that is entered into, issued, amended or renewed on or after January 1, 2026, 
and an administrator may not enter into, issue, amend or renew any contract on or after 
January 1, 2026 that contains any provision that violates this section. 
Sec. 2.  24-A MRSA §4347, sub-§18-A is enacted to read:
18-A.  Plan sponsor.  "Plan sponsor" has the same meaning as in section 1901, 
subsection 8.
Sec. 3.  24-A MRSA §4349-A is enacted to read:
§4349-A.  Plan sponsor access to claims data; right to audit
1.  Ownership of claims data.  Any contract between a pharmacy benefits manager 
and a plan sponsor to provide health coverage must provide that the plan sponsor owns the 
claims data relating to the contract.
2.  Prescription drug data.  Within 20 business days of a request from a plan sponsor, 
a pharmacy benefits manager shall provide data to the plan sponsor regarding the actual 
amounts directly or indirectly paid by the pharmacy benefits manager to a pharmacy or 
pharmacist on behalf of the plan sponsor for a prescription drug and for the pharmacy 
services associated with dispensing that drug. 
3.  Claims data; right to audit.  Notwithstanding section 4350-C, a pharmacy benefits 
manager that contracts with a plan sponsor to provide prescription drug coverage shall 
permit a plan sponsor to perform a post-payment audit of claims paid to ensure compliance 
with the contract at least once in a calendar year as long as the request is not earlier than 6 
months following a previously requested audit.  Upon request of a plan sponsor as part of 
an audit, a pharmacy benefits manager shall disclose to the plan sponsor or, if requested by 
the plan sponsor, to the plan sponsor's designated business associate the following 
information specific to the plan sponsor within 20 business days:
A. Rebate amounts, identified by the drug and therapeutic category, secured on 
prescription drugs provided by a pharmaceutical manufacturer that are generated by 
claims processed through the plan maintained by the plan sponsor;
B. Prescription drug and medical device claims, including electronic claims 
transactions, received by the pharmacy benefits manager on any current standardized 
claim form approved by the Federal Government for these services.  The form or 
transaction may be modified as necessary to comply with the federal Health Insurance 
Portability and Accountability Act of 1996, Public Law 104-191 as long as claims 
information is not withheld from a plan sponsor who has demonstrated compliance 
with the use and disclosure requirements of 45 Code of Federal Regulations, Section 
164.504(f); 
C. Prescription drug and medical device claims payments, electronic funds transfers or 
remittance advice notices provided by the pharmacy benefits manager as electronic 
files.  The files may be modified only as necessary to comply with the federal Health 
Insurance Portability and Accountability Act of 1996, Public Law 104-191.  In the 
event that paper claims are provided, the pharmacy benefits manager shall convert the 
paper claims to an electronic format; and
D. Any other revenue and fees derived by the pharmacy benefits manager from the 
contract, including all direct or indirect remuneration from pharmaceutical 
manufacturers regardless of whether the remuneration is classified as a rebate, fee or 
other classification.  
4.  No conditions or fees on audit.  A pharmacy benefits manager may not impose on 
a plan sponsor: 
A. Any fees for requesting an audit under this section that exceed the direct expenses 
properly and actually incurred by the pharmacy benefits manager to provide the data; 
B. Any fees associated with selecting an auditor other than an auditor designated by 
the pharmacy benefits manager; or
C. Any conditions that would restrict a plan sponsor's right to conduct an audit under 
this section, including, but not limited to, restrictions on:
(1) The time period covered by the audit;
(2) The number of claims analyzed;
(3) The type of analysis conducted;
(4) The data elements used in the analysis; 
(5) The plan sponsor's choice of auditor; or
(6) The means by which an auditor is compensated by a plan sponsor. 
5.  Compliance with federal Health Insurance Portability and Accountability Act 
of 1996.  Information provided by a pharmacy benefits manager to a plan sponsor in 
accordance with this section must comply with any applicable requirements of the federal 
Health Insurance Portability and Accountability Act of 1996, Public Law 104-191.
6.  Application.  This section applies to any contract between a pharmacy benefits 
manager and a plan sponsor that is entered into, issued, amended or renewed on or after 
January 1, 2026, and an administrator may not enter into, issue, amend or renew any 
contract on or after January 1, 2026 that contains any provision that violates this section. 
SUMMARY
This bill requires administrators and pharmacy benefits managers that provide health 
coverage or prescription drug coverage under a contract with a plan sponsor, including any 
person that offers health coverage or prescription drug coverage to its employees or 
members through a self-funded health benefit plan, to provide certain claims information 
to a plan sponsor upon request.  The bill also gives a plan sponsor the right to request an 
audit to ensure compliance with a contract at least once every calendar year as long as the 
request is at least 6 months after a previously requested audit.