An Act to Expand the Right to Shop for Health Care Services
Maine Legislature, Session 132, LD 1152
Committee: Health Coverage, Insurance and Financial Services
Sponsors: MORRIS
Amends: 24-A MRSA §4318-A, 24-A MRSA §4318-B

Legislative Document
No. 1152
H.P. 757
House of Representatives, March 20, 2025
An Act to Expand the Right to Shop for Health Care Services
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.
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 health care 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 health care costs 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-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 health care costs 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.
SUMMARY
This bill makes the following changes to the law relating to the comparable health care 
service incentive program. 
1.  It removes the requirement that the small group health plan design be compatible 
with a federally authorized health savings account. 
2.  It requires that the incentives be equal to or greater than 25% of the difference 
between the price of the health care 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 nonemergency, outpatient health 
care services included in the definition of "comparable health care service."
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.  The bill removes the exception that the provision does not apply to a 
health maintenance organization plan.  The bill also removes the limitation defining "out-
of-network provider" as a provider located in Massachusetts, New Hampshire or Maine 
that is enrolled in the MaineCare program and participates in Medicare.