An Act To Modify Rating Practices for Individual and Small Group Health Plans and To Encourage Value-based Purchasing of Health Care Services
Sec. 1. 24-A MRSA §2736-C, sub-§2, ¶D, as amended by PL 2007, c. 629, Pt. A, §4, is repealed and the following enacted in its place:
(1) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State between January 1, 2012 and December 31, 2012, for each health benefit plan offered by a carrier, the highest premium rate for each rating tier may not exceed 2 times the premium rate that could be charged to an eligible individual with the lowest premium rate for that rating tier in a given rating period.
(2) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State between January 1, 2013 and December 31, 2013, for each health benefit plan offered by a carrier, the highest premium rate for each rating tier may not exceed 2.5 times the premium rate that could be charged to an eligible individual with the lowest premium rate for that rating tier in a given rating period.
(3) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 2014, for each health benefit plan offered by a carrier, the highest premium rate for each rating tier may not exceed 3 times the premium rate that could be charged to an eligible individual with the lowest premium rate for that rating tier in a given rating period.
For purposes of this paragraph, "rating tier" means each category of individual or family composition for which a carrier charges separate rates.
Sec. 2. 24-A MRSA §2808-B, sub-§2, ¶D, as amended by PL 2001, c. 410, Pt. A, §4 and affected by §10, is repealed and the following enacted in its place:
(1) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State between January 1, 2012 and December 31, 2012, for each small group health plan offered by a carrier, the highest premium rate for each rating tier may not exceed 2 times the premium rate that could be charged to an eligible group with the lowest premium rate for that rating tier in a given rating period.
(2) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State between January 1, 2013 and December 31, 2013, for each small group health plan offered by a carrier, the highest premium rate for each rating tier may not exceed 2.5 times the premium rate that could be charged to an eligible group with the lowest premium rate for that rating tier in a given rating period.
(3) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 2014, for each small group health plan offered by a carrier, the highest premium rate for each rating tier may not exceed 3 times the premium rate that could be charged to an eligible group with the lowest premium rate for that rating tier in a given rating period.
For purposes of this paragraph, "rating tier" means each category of small group for which a carrier charges separate rates.
Sec. 3. 24-A MRSA §2808-B, sub-§2, ¶D-1, as amended by PL 2001, c. 410, Pt. A, §5 and affected by §10, is repealed.
Sec. 4. 24-A MRSA §4303, sub-§1, as amended by PL 2009, c. 652, Pt. A, §33, is further amended to read:
(1) The entire network meets overall access standards pursuant to Bureau of Insurance Rule Chapter 850;
(2) The health plan is consistent with product design guidelines for Bureau of Insurance Rule Chapter 750, but only if the health plan is offered by a health maintenance organization;
(3) The health plan does not include financial provisions designed to encourage members to use designated providers of primary, preventive, maternity, obstetrical, ancillary or emergency care services , as defined in Bureau of Insurance Rule Chapter 850;
(4) The financial provisions may apply to all of the enrollees covered under the carrier's health plan; and
(5) The carrier establishes to the satisfaction of the superintendent that the financial provisions permit the provision of better quality services and the quality improvements either significantly outweigh any detrimental impact to covered persons forced to travel longer distances to access services, or the carrier has taken steps to effectively mitigate any detrimental impact associated with requiring covered persons to travel longer distances to access services. The superintendent may consult with other state entities, including the Department of Health and Human Services, Bureau of Health and the Maine Quality Forum established in section 6951, to determine whether the carrier has met the requirements of this subparagraph. The superintendent shall adopt rules regarding the criteria used by the superintendent to determine whether the carrier meets the quality requirements of this subparagraph; and
(6) The financial provisions may not permit travel at a distance that exceeds the standards established in Bureau of Insurance Rule Chapter 850 for mileage and travel time by 100%.
The basis for tiering benefits under a pilot program must be to provide incentives for higher-quality care, improved patient safety or improved efficiency or a combination of those factors. The superintendent shall consult with the Maine Quality Forum under section 6951 in assessing quality. The superintendent shall disapprove or withdraw approval of a pilot program if the superintendent finds that approval or continued operation would cause undue hardship to enrollees in the pilot program or reduce their quality of care.
The superintendent shall consider the experience of approved pilot programs, including consumer complaints and examinations, provider behavior and efficiency, in determining whether or not to reapprove subsequent pilot program applications.
Sec. 5. Application. The requirements of this Act apply to all policies, contracts and certificates subject to this Act that are executed, delivered, issued for delivery, continued or renewed on or after January 1, 2012. For the purposes of this Act, contracts are deemed to be renewed no later than the next anniversary of the contract date.
Sec. 6. Effective date. Those sections of this Act that repeal and replace the Maine Revised Statutes, Title 24-A, section 2736-C, subsection 2, paragraph D and section 2808-B, subsection 2, paragraph D take effect January 1, 2012.
summary
This bill gradually modifies the community rating provisions for individual and small group health plans. It expands in 3 increments the rating bands from the current ratio of 1.5:1 to 3:1 by January 1, 2014.
The bill allows financial incentives except for emergency care services. It maintains the requirement that plans must provide reasonable access to services for all members. It allows plans to provide financial incentives to members to reward providers for quality and efficiency. A carrier must submit annual data to the Superintendent of Insurance showing the impact of such financial incentives on premiums paid by enrollees, payments made to providers, quality of care received and access to health care services by individuals enrolled in health plans.