An Act to Improve
Maine Legislature, Session 132, LD 1906
Committee Amendment CA_A_S367 (Senate)
Amends: 24-A MRSA §1914, 24-A MRSA §4347, 24-A MRSA §4349-A

COMMITTEE AMENDMENT" /J,- " to S.P. 747, L.D. 1906, "An Act to Improve 
Accountability and Understanding of Data in Insul'ance Transactions" 
Amend the bill by stl'iking out everything aftet· the enacting clause and insetting the 
following: 
1Sec. 1. 24-A MRSA §1914 is enacted to read: 
§1914. Plan sponsor access to claims data; right to audit 
1, High-cost claims data, Upon request of a plan sponsor that has certified its 
compliance with the use and disclosure requirements of 45 Code of Federal Regulations. 
Section 164,504<0, an administrator shall provide data on a high-cost claim so that a plan 
sponsor may perform an audit to ensure compliance with the plan sponsor's contt·act prior 
to payment of the high-cost claim. The data must include any itemized billing statements 
and medical records associated with the claim in the possession of the administrator or the 
administrator's agents. The plan sponsor 01· the plan sponsor's designee shall make a request 
for data on a high-cost claim within 2 business days of receipt of the claim and the 
administrator must provide the requested information within 30 business days of the 
request. For the purposes of this subsection, "high~cost claim" means any claim related to 
an individual provided health coverage by a plan sponsor that exceeds $100,000. 
2. 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 1·equested audit. 
Upon request of a plan sponsor as pa1t of an audit. an administrator shall disclose within 
business days to a plan sponsot· that has ce1tified its compliance with the use and 
disclosure reguit'ements of 45 Code of Federal Regulations. Section 164.504(0 ot', to the 
extent permitted by law and if l'equested by the plan sponsor, to the plan sponsor's 
designated business associate the following information specific to the plan sponsor: 
A. Claims data received by the administrator via electronic claims transactions on any 
cutTent standardized claim fo1•111 approved by the Federal Government for professional 
Page I - 132LR0896(02) 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" A" to S.P. 747, L.D. 1906 (t5,-'5(f I 
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services or institutional services. The form or transaction may be modified only 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 prnvided 
by the administrator as electronic files compliant with the federal Health Insurance 
Portability and Accountability Act of 1996. Public Law I 04-191. including. but not 
limited to. electronic claims trnnsactions for both the billed amount and the paid 
amount fo1· professional services and both the billed amount and the paid amount for 
institutional services. The files may be modified only as necessaty to comply with the 
federal Health Insurance Portability and Accountability Act of 1996, Public Law 
104-191. and the federal Health Information Technology for Economic and Clinical 
Health Act of 2009. Title XIII. Subtitle D. Public Law 111-5. and any regulations 
promulgated under those laws: 
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: and 
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. 
3, No conditions or fees on audit, An administrator may not impose on a plan 
sponsor: 
A. Any fees relating to an audit request under this section that exceed the direct 
expenses properly and actually incurred by the administrator to provide the data: or 
B. Any conditions that would restrict a plan sponsor1s right to conduct an audit under 
this section. including, but not limited to. restrictions on: 
(1) The time period covered by the audit, except that a request pursuant to this 
section must be made within 24 months of the end of each plan year to be audited: 
(2) The number of claims analyzed: 
0 
(3) The type of analysis conducted: 
( 4) The data elements used in the analysis: 
(5) The means by which an auditor is compensated by a plan sponsor; or 
(6) The plan sponsor's choice of auditor as long as the plan sponsor ce1tifies that 
the audito1· has adequate conflict of interest protection provisions to prevent 
conflicts of interest from adversely affecting the outcome of the audit. 
4. Nondisclosure and data use agreement. An administrator may require that the plan 
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sponsor and the plan sponsor's designated business associate execute a nondisclosure and 
data use ag1·eement that reasonably restricts the auditor's use of data prnvided by the 
administrator to the sole purpose of conducting an audit on behalf of a plan sponsor. The 
coverage limits of any cybel'security insurance or liability insurance policy required under 
the nondisclosure and data use agreement may not exceed the administrator's limit of 
liability under the services agreement between the plan sponsor and the administrntor, if 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" /t "to S.P. 747, L.D. 1906 (::i,.. -3 t7/ 
such limit applies. In addition. an administrator is not required to provide data to an auditor 
selected by a plan sponsor if the auditor has p1·eviously breached a nondisclosure and data 
use agreement with that administrator or refuses to execute a nondisclosure and data use 
agreement, 
5, Compliance with federal law. 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, and the federal Health Information Technology for Economic and Clinical Health 
Act of 2009. Title XIII. Subtitle D, Public Law 111-5. and any regulations promulgated 
under those laws. 
6, Application, An administrator may not ente1· into, issue, amend or renew any 
contract or network services agreement with a plan sponsor on or after January 1. 2026 that 
contains any provision that violates this section. 
7, Exclusive enforcement; violation, Notwithstanding section 12-A. a violation of this 
section is subject to exclusive enforcement under the Maine Unfair Trade Practices Act, 
including any of the remedies provided for in the Act. A violation is committed each time 
a prohibited act under this section occurs. Investigations of violations by administrators 
may include a 3rd party that may possess evidence supporting such investigation. 
Sec, 2. 24-A MRSA §4347t sub-§18-A is enacted to read: 
18-A. Plan sponsor, "Plan sponsor" has the same meaning as in section 190 l. 
subsection 8, except that "plan sponsor" does not include an employer that offers or 
provides a health plan that is insured by an insurer authorized to do business in this State. 
Sec. 3. 24-A MRSA §4349-A is enacted to read: 
§4349-A. Plan sponsor access to claims data; right to audit 
1. Prescription drug data, Within 30 business days of a request from a plan sponsor 
that has ce11ifled its compliance with the use and disclosure requirements of 45 Code of 
Federal Regulations. Section 164.504(0. a pharmacy benefits manager shall provide data 
to the plan sponsor regarding the actual amounts directly or indit·ectly paid by the pharmacy 
benefits manager to a pharmacy or pharmacist on behalf of the plan sponsor for a 
prescription drug and any dispensing fee for a prescription dt'llg, 
2, 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 within 30 business days to a plan 
sponsor who has certified its compliance with the use and disclosure requirements of 45 
Code of Federal Regulations. Section 164.504{f). or. to the extent permitted by law and if 
requested by the plan sponsot', to the plan sponsor's designated business associate the 
following information specific to the plan sponsor: 
A. Rebate amounts, identified by the drng and therapeutic categol'y, secured on 
prescription drugs provided by a pharmaceutical manufactul'er that a1·e generated by 
COMMITTEE AMENDMENT 
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COMMI'ITEE AMENDMENT" ft" to S.P. 747, L.D. 1906 (>"' '3 .. '1) 
claims processed through the plan maintained by the plan sponsor and administered by 
the pharmacy benefits manager; 
B. Prescription drng and device claims received by the pharmacy benefits manager via 
electrnnic claims transactions on any cmrent standardized claim form approved by the 
Federal Government for these services. The form or transaction may be modified only 
as necessary to comply with the federal Health Insurance Portability and 
Accountability Act of 1996, Public Law 104-191, and the federal Health Information 
Technology for Economic and Clinical Health Act of 2009, Title XIII, Subtitle D, 
Public Law 111-5, and any regulations promulgated under those laws: 
C. Prescription drug and device claims payments, electronic funds transfers or 
remittance advice notices prnvided by the pharmacy benefits manager as electronic 
files. The flies may be modified only as necessary to comply with the federal Health 
Insurnnce Portability and Accountability Act of 1996, Public Law 104-191, and the 
federal Health Information Technology for Economic and Clinical Health Act of 2009, 
Title XIII, Subtitle D. Public Law 11 I "S, and any regulations prnmulgated under those 
laws: and 
D. Any other revenue and fees derived by the pharmacy benefits manager from the 
contract, including all direct or indirect remuneration from phat·maceutical 
manufacturers 1·egardless of whether the remuneration is classified as a rebate, fee or 
other classification. 
3, No conditions or fees on audit. A pharmacy benefits manager may not impose on 
a plan sponsor: 
A. Any fees relating to an audit request under this section that exceed the direct 
expenses properly and actually incuned by the pharmacy benefits manager to provide 
the data: or 
B. Any conditions that would restl'ict a plan sponsor's right to conduct an audit under 
this section, including, but not limited to, restrictions on: 
(1) The time period cove1·ed by the audit. except that any request pursuant to this 
section must be made within 24 months of the end of each plan year to be audited: 
(2) The number of claims analyzed; 
(3) The type of analysis conducted: 
( 4) The data elements used in the analysis; 
(5) The means by which an auditor is compensated by a plan sponsor: or 
(6) The plan sponsor's choice of auditor as long as the plan sponsor certifies that 
the auditor has adequate conflict of interest protection provisions to prevent 
conflicts of interest from adversely affecting the outcome of the audit. 
4, Nondisclosure and data use aa;reement. A pharmacy benefits manager may 
requit'e that the plan sponsor and the plan sponsor's designated business associate execute 
a nondisclosure and data use agreement that reasonably restricts the auditor's use of data 
provided by the pharmacy benefits manage1· to the sole purpose of conducting an audit on 
behalf of a plan sponsor. The coverage limits of any cybersecmity insurance or liability 
insurance policy required under the nondisclosure and data use agreement may not exceed 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" PJ' "to S.P. 747, L.D. 1906 (5,..>C,.1/ 
the pharmacy benefits manager's limit of liability under the services agreement between 
the plan sponsor and the pharmacy benefits manager, if such limit applies. In addition, a 
pharmacy benefits manage1· is not required to provide data to an auditor selected by a plan 
sponsor if the auditor has previously breached a nondisclosure and data use agreement with 
that pharmacy benefits manager or refuses to execute a nondisclosure and data use 
agreement. 
5, Compliance with federal law. 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, and the federal Health Information Technology for Economic and 
Clinical Health Act of 2009, Title XIII, Subtitle D. Public Law 111-5. and any regulations 
promulgated under those laws. 
6, Application. An administrator or pharmacy benefits manager may not enter into, 
issue. amend or renew any contract or network services agreement with a plan sponsor on 
or after January 1. 2026 that contains any provision that violates this section. 
7. Exclusive enforcement; violation, Notwithstanding section 12-A, a violation of 
this section is subject to exclusive enforcement under the Maine Unfair Trade Practices 
Act, including any of the remedies provided fo1· in the Act. A violation is committed each 
time a prnhibited act under this section occurs. Investigations of violations by pharmacy 
benefits managers may include a 3rd party that may possess evidence supporting such 
investigation.' 
Amend the bill by relettering or renumbering any nonconsecutive Part lettel' or section 
number to read consecutively. 
SUMMARY 
This amendment replaces the bill. 
The amendment 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 
amendment 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. 
The amendment does the following. 
l. It clarifies that claim forms or electronic claims transactions may be modified only 
as necessary to comply with the federal Health Insurance Po1tability and Accountability 
Act of 1996 and the federal Health Information Technology for Economic and Clinical 
Health Act of 2009. 
2. It clarifies that data to be prnvided to a plan sponsor must be in the possession of 
the administrntol' or its agents. 
3, It authorizes a plan sponsor to request information related to a high-cost claim that 
exceeds $100,000 and provides that a high-cost claim is any claim that exceeds the 
threshold. 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" /J "to S.P. 747, L.D. 1906 (5,.'S'l) 
4. It l'equires a plan sponsor or its designee to request high-cost claims data within 2 
business days of receiving the high-cost claim and requires an administrator to respond to 
a request within 30 business days. 
5. It requires an administrator to provide claims data received by the administrator via 
electrnnic claims transactions. 
6. It requires an administrator to provide itemized billing statements and medical 
records associated with specific high-cost claims if requested by a plan sponsor. 
7. It specifies that a request for an audit must be made within 24 months of the end of 
each plan year to be audited and rquires the plan sponsor to certify that its choice of auditor 
has adequate conflict of interest prntection provisions to prevent conflicts of interest from 
adversely affecting the outcome of the audit. 
8. It authorizes an administrntor or pharmacy benefits manager to require that the plan 
sponsor and its auditor execute a nondisclosure and data use agreement that reasonably 
restricts the auditor's use of data to the sole purpose of conducting an audit on behalf of the 
plan sponsor. It also limits the amount of cybersecurity or liability insurance that can be 
required in the nondisclosure and data use agreement to no more than the administrator1s 
or pharmacy benefits manager's limit of liability under the service agreement between the 
plan sponsor and the administrator or pharmacy benefits manager. It also states that an 
administrator or pharmacy benefits manager is not required to share data with an auditor 
that has previously breached a nondisclosure and data use agreement with that 
administrator or pharmacy benefits manager. 
9. It provides that rebate amounts to be reported are those generated by claims 
processed through the plan administered by the pharmacy benefits manager. 
l 0. It provides that an administrator or pharmacy benefits manager may not enter into 
any contract or network service agreement that would violate the provisions. 
11. It places enforcement of the provisions exclusively under the Maine Unfafr Trade 
Practices Act. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
Approved: 06/06/25 LRL 
LD 1906 
LR 896(02) 
An Act to Improve Accountability and Understanding of Data in Insurance Transactions 
Fiscal Note for BiH as Amended by Committee Amendment ''A" { > .. 3 61\ 
Committee: Health Coverage, Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Potential current biennium cost increase - General Fund 
Fiscal Detail and Notes 
This bill allows 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. Any costs to the State Employee Health Plan are dependent on whether the 
State seeks an audit, the nature and scope of any audit, and the costs associated with the audit, A more precise fiscal 
estimate cannot be determined at this time. 
LR0896(02) - Fiscal Note - Page t of 1