HP0887, LD 1274, item 1, An Act To Promote Universal Health Care, Including Dental, Vision and Hearing Care

An Act To Promote Universal Health Care, Including Dental, Vision and Hearing Care

Be it enacted by the People of the State of Maine as follows:

PART A

Sec. A-1. 24-A MRSA c. 95 is enacted to read:

CHAPTER 95

HEALTHY MAINE ACT

§ 7501. Short title

This chapter may be known and cited as "the Healthy Maine Act."

§ 7502. Definitions

As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings.

1. Beneficiary. "Beneficiary" means an individual whose primary residence is in the State.

2. Board. "Board" means the board of trustees of Healthy Maine established in section 7504.

3. Children's Health Insurance Program. "Children's Health Insurance Program" means the children's health benefit plan established in Title 22, section 3174-T.

4. Healthy Maine. "Healthy Maine" means the body created in section 7503.

5. MaineCare. "MaineCare" means the medical assistance program authorized in Title XIX of the federal Social Security Act, as amended, and administered under Title 22, chapter 855.

6. Provider. "Provider" means a health care professional licensed by the State and includes individuals, hospitals and other health care facilities licensed or certified by the State. "Provider" includes an individual or entity that provides services, medical interventions, pharmaceuticals or equipment used to treat beneficiaries.

§ 7503. Healthy Maine; establishment; governance

Healthy Maine is created as a body corporate and politic and a public instrumentality of the State to finance health care services for all residents of the State, to administer state and federal health care funds and to institute fiscally sound payment policies that improve and maintain high standards for value, quality and healthy outcomes for all beneficiaries.

§ 7504. Board of trustees of Healthy Maine

1. Establishment. The board of trustees of Healthy Maine is established to oversee the operations of Healthy Maine.

2. Terms. Members of the board serve 4-year terms, and members may serve a maximum of 3 consecutive 4-year terms. Members reaching the end of their terms may serve until replacements are named.

3. Removal of member. A member of the board may be removed for cause by a majority vote of the other members.

4. Duties of the board. The board shall:

A. Adopt bylaws, procedures, rules and policies, and ratify, amend or reject those bylaws, procedures, rules and policies adopted by the board;

B. Hire staff to administer the operations of Healthy Maine, including a chief executive officer, a chief financial officer and a chief medical officer;

C. Establish a central purchasing authority responsible for negotiating favorable prices for prescription drugs, medical equipment and other products and services required by Healthy Maine;

D. Provide funds to the superintendent for the operation of separate ombudsman offices for beneficiaries and providers, each of which must have the capacity to investigate and respond to inquiries and complaints and make recommendations to the board. Funding provided pursuant to this paragraph must be sufficient to allow the timely completion of all investigations;

E. Establish and fund an office for the investigation and prevention of fraud. The office may bring civil actions in the name of Healthy Maine to recover any monies or the value of any benefits obtained by fraud or mistake and may refer fraudulent conduct to a district attorney for criminal prosecution;

F. Establish procedures for managing surplus funding by maintaining necessary operating reserves, increasing benefits or issuing refunds to members;

G. Establish procedures for ensuring financial sustainability by adjusting payments and benefits;

H. Adopt rules for independent annual performance and financial audits;

I. Adopt rules that protect beneficiary confidentiality while allowing for publicly available research of Healthy Maine's databases;

J. Adopt rules to ensure transparency in its operations and decision making. The rules must be at least as strict as the requirements in the laws governing freedom of access set forth in Title 1, chapter 13;

K. Approve and make publicly available an annual budget;

L. Facilitate creation of efficient medical records and billing records systems that:

(1) Can be easily accessed by providers and beneficiaries;

(2) Allow Healthy Maine to maintain a central database of medical records suitable for management and cross-sectional and longitudinal research purposes;

(3) Ensure the confidentiality of beneficiaries' medical records in compliance with all federal and state health care laws, regulations and rules concerning the confidentiality of patient medical records; and

(4) Is easily portable to and interoperable with all other medical records systems in use throughout the State;

M. Administer all state funds for health care services provided to beneficiaries;

N. Establish policies and procedures to pay benefits for health care services rendered to a beneficiary who is temporarily living or traveling in another state; and

O. Establish an appeals procedure that allows beneficiaries and providers to challenge coverage and payment decisions. Final action on an appeal is subject to judicial review according to state law for the review of final agency actions.

5. Authority of the board. The board may:

A. Authorize reasonable compensation and expense reimbursement for the members;

B. Seek waivers from state and federal laws, rules and regulations;

C. Seek and accept gifts, grants and donations on behalf of Healthy Maine;

D. Adopt rules as necessary for the proper administration and enforcement of this chapter; and

E. Exercise other powers necessary and proper to fulfill Healthy Maine's responsibilities.

§ 7505. Health care services

1. Required services. Healthy Maine shall contract with providers to pay for health care services to beneficiaries, which must include:

A. Ambulatory patient services, including primary and specialty care;

B. Hospitalization;

C. Prescription drugs and durable medical equipment;

D. Mental health and substance use disorder services, including behavioral health treatment;

E. Emergency and urgent care;

F. Preventive and wellness services and chronic disease management;

G. Rehabilitative and habilitative services and devices;

H. Pediatric services, including oral, vision and hearing care;

I. Laboratory services;

J. Maternity and newborn care;

K. Palliative and end-of-life care; and

L. Dental, vision and hearing care.

2. Additional services. The board may authorize payment for services not specified in subsection 1.

3. Healthy Maine responsible for payment. Healthy Maine shall pay for health care services to beneficiaries in accordance with this subsection.

A. Healthy Maine shall pay for health care services to beneficiaries regardless of the cause of their injuries or illnesses.

B. Beginning July 1, 2020, Healthy Maine shall assume responsibility for payment of all reasonable and necessary medical expenses incurred by workers who suffer injuries or illnesses arising out of and in the course of their employment. Healthy Maine's responsibility extends only to employees whose employers are required under the Maine Workers' Compensation Act of 1992 to provide workers' compensation insurance for their employees. Workers suffering from injuries or illnesses arising out of and in the course of their employment are entitled to the same benefits and have the same rights and responsibilities as other beneficiaries.

C. For individuals eligible for MaineCare, the Children's Health Insurance Program and any other federal health care programs to be administered by Healthy Maine, the benefit package under Healthy Maine must include:

(1) The benefits required by federal law;

(2) Any optional MaineCare benefits authorized under state law or services covered under the Children's Health Insurance Program for which these individuals are eligible; and

(3) Any additional benefits provided in Healthy Maine's benefit package.

D. An individual who loses eligibility for state or federal benefits under MaineCare or the Children's Health Insurance Program must receive the same benefits as any other beneficiary of Healthy Maine.

4. Deductibles prohibited. Healthy Maine may not charge deductibles to beneficiaries.

5. Waiver of copayments; primary and preventive care services. The board shall adopt rules for waiving copayments when copayments will cause financial hardship for a beneficiary. The board may not require copayments for designated primary and preventive care services.

6. Approval required. A provider may not require a beneficiary to make a copayment or submit to any other cost-sharing arrangement without Healthy Maine's approval.

7. Choice of provider. Healthy Maine shall allow beneficiaries to choose their own primary care providers.

8. Access to services. Healthy Maine may provide funding and other support to improve access to health care services for all beneficiaries regardless of where they live in the State and may provide funding and other support for statewide access to emergency and trauma care services.

§ 7506. Healthy Maine secondary payor; state health plan; subrogation rights

1. Secondary payor. Healthy Maine serves as a secondary payor to any health insurance plan in which a beneficiary may be responsible for a beneficiary's health care expenses. The total of Healthy Maine's payment and all other payments may not exceed the amount that Healthy Maine would pay if it were the only payor.

2. State health plan. Healthy Maine serves as a state health plan that pays for designated supplemental health care services for Medicare beneficiaries, except that Healthy Maine may not pay for services:

A. That are covered by Medicare Parts A, B and D;

B. That are covered by a Medicare Advantage plan that a beneficiary has with an entity other than Healthy Maine; or

C. That would have been paid by Medicare Parts B or D had the beneficiary purchased those optional Medicare coverages, unless:

(1) Healthy Maine has an agreement with the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services that requires it to pay for services that would have been paid under Medicare Parts B or D; or

(2) Healthy Maine offers a Medicare Advantage plan and the beneficiary voluntarily enrolls in that plan.

3. Rights of subrogation. Healthy Maine has full rights of subrogation, ahead of the rights of a workers' compensation or other insurer or health care plan, including the right to bring an independent lawsuit or to intervene in a lawsuit filed by a beneficiary, in order to recover health care costs from collateral sources for which the beneficiary has a right of action for compensation against the person or entity that caused the beneficiary's illness or injury. Healthy Maine may assert a lien against any proceeds recovered by the beneficiary.

Healthy Maine may recover health care payments from any other collateral source, such as a health insurance plan, health benefit plan or other payor that is primary to Healthy Maine.

§ 7507. Effective date

This chapter takes effect July 1, 2020.

PART B

Sec. B-1. Transition. The Department of Health and Human Services and any other affected department or agency of the State shall assist Healthy Maine in seeking all waivers, exemptions and agreements from State Government and the Federal Government that are necessary to transfer health care funding from the Federal Government and from any state departments and agencies to Healthy Maine.

Sec. B-2. Interim meetings; implementing legislation. The Joint Standing Committee on Health and Human Services and the Joint Standing Committee on Insurance and Financial Services are authorized to jointly meet as needed, but shall meet at least 3 times, during the 2017 legislative interim to oversee planning and implementation related to the establishment of Healthy Maine. At these meetings, the Commissioner of Health and Human Services and the Superintendent of Insurance shall brief the committees on planning issues, progress, challenges and the timeline for implementation. The committees shall provide opportunities for health care consumers, providers and advocates to speak to the committee. The committees shall jointly submit legislation to the Second Regular Session of the 128th Legislature by January 15, 2018 to implement Part A of this Act. The committees shall include in the legislation provisions to:

1. Fund the operation of Healthy Maine;

2. Transfer responsibility for administering the MaineCare program and the children's health insurance program established in the Maine Revised Statutes, Title 22, section 3174-T from the Department of Health and Human Services to Healthy Maine;

3. Transfer responsibility for administering any other state or federal health care program to Healthy Maine;

4. Obtain all waivers, exemptions and agreements from State Government and the Federal Government that are necessary to transfer health care funding from the Federal Government and from any state departments and agencies to Healthy Maine;

5. Transfer to Healthy Maine all state and federal funds associated with programs for which Healthy Maine will assume responsibility;

6. Enable Healthy Maine to receive the appropriate federal fund contribution in lieu of the federal premium tax credits, cost-sharing subsidies and small business tax credits provided in the federal Patient Protection and Affordable Care Act or its successor acts;

7. Repeal or amend, as appropriate, those provisions of the Maine Workers' Compensation Act of 1992 and any other provisions of law that concern the provision of medical care for workers who suffer injuries or illnesses arising out of and in the course of their employment and for the payment of premiums for medical benefits, whether by employers or insurers covered under the laws governing workers' compensation or that otherwise conflict with Title 24-A, chapter 95;

8. Ensure that the State's expenditures for health care services, including the State's responsibility for providing matching funds for MaineCare and other federally supported health care programs, do not fall below the expenditure levels for health care services in the year preceding the effective date of Part A of this Act;

9. Determine the process for selecting or electing the members of the board of trustees of Healthy Maine established in Title 24-A, section 7504; and

10. Effectuate a smooth and efficient transfer of the programs and responsibilities and to enable affected departments and agencies to assist Healthy Maine in the assumption of its duties.

Sec. B-3. Transfer of state and federal funds; responsibility for distribution. No later than July 1, 2020, the State shall transfer to Healthy Maine all state and federal funds for MaineCare, the children's health insurance program established in the Maine Revised Statutes, Title 22, section 3174-T and any other program to be administered by Healthy Maine. The State may retain any funds necessary to meet payment obligations that exist as of the date of transfer. Upon receipt of this funding, Healthy Maine is responsible for paying for all benefits and services previously paid by State Government and the Federal Government with those funds, and Healthy Maine shall assume responsibility for the proper administration and distribution of state and federal funds pursuant to state and federal law.

Sec. B-4. Phase-in; delivery of service models. Healthy Maine shall assume payment for health care services in a manner designed to minimize disruptions to existing delivery and payment systems. Healthy Maine shall phase in payment reforms and a unified billing system and shall employ payment models that optimize quality, value, patient experience and healthy outcomes for beneficiaries.

summary

This bill establishes a single-payer health care system in the State, effective July 1, 2020, that finances health care services for most Maine residents. The bill directs the Joint Standing Committee on Health and Human Services and the Joint Standing Committee on Insurance and Financial Services to jointly submit during the 2017 legislative interim legislation to fully implement the single-payer system.

HP0887 LD 1274	Session - 128th Maine Legislature		LR 1545 Item 1
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