An Act To Protect Consumers from Surprise Emergency Medical Bills
Emergency preamble. Whereas, acts and resolves of the Legislature do not become effective until 90 days after adjournment unless enacted as emergencies; and
Whereas, it is critically important that this legislation take effect before the expiration of the 90-day period; and
Whereas, in the judgment of the Legislature, these facts create an emergency within the meaning of the Constitution of Maine and require the following legislation as immediately necessary for the preservation of the public peace, health and safety; now, therefore,'
Sec. 1. 22 MRSA §1718-D, as enacted by PL 2017, c. 218, §1 and affected by §3, is amended to read:
§ 1718-D. Prohibition on balance billing for surprise bills and bills for out-of-network emergency services; disputes of bills for uninsured patients and persons covered under self-insured health benefit plans
Sec. 2. 24-A MRSA §4303-C, as enacted by PL 2017, c. 218, §2 and affected by §3, is amended to read:
§ 4303-C. Protection from surprise bills and bills for out-of-network emergency services
(1) The carrier's median network rate paid for that health care service by a similar provider in the enrollee's geographic area; and
(2) The median network rate paid by all carriers for that health care service by a similar provider in the enrollee's geographic area as determined by the all-payer claims database maintained by the Maine Health Data Organization or, if Maine Health Data Organization claims data is insufficient or otherwise inapplicable, another independent medical claims database;
This paragraph is repealed October 1, 2021;
Sec. 3. 24-A MRSA §4303-E is enacted to read:
§ 4303-E. Dispute resolution process for surprise bills and bills for out-of-network emergency services
(1) The out-of-network provider's level of training, education, specialization, quality and experience and, in the case of a hospital, the teaching staff, scope of services and case mix;
(2) The out-of-network provider's previously contracted rate with the carrier, if the provider had a contract with the carrier that was terminated or expired within one year prior to the dispute; and
(3) The median network rate for the particular health care service performed by a provider in the same or similar specialty, as determined by the all-payer claims database maintained by the Maine Health Data Organization or, if Maine Health Data Organization claims data is insufficient or otherwise inapplicable, another independent medical claims database. If authorized by rule, the superintendent may enter into an agreement to obtain data from an independent medical claims database to carry out the functions of this subparagraph.
(1) Whether the determination was in favor of the carrier, out-of-network provider or uninsured patient;
(2) The payment amount offered by each side of the independent dispute resolution process and the award amount from the independent dispute resolution determination;
(3) The category and practice specialty of each out-of-network provider involved, as applicable; and
(4) A description of the health care service that was subject to dispute;
The superintendent shall submit the report to the joint standing committee of the Legislature having jurisdiction over health insurance matters and shall post the report on the bureau's publicly accessible website.
Sec. 4. 24-A MRSA §4320-C, as amended by PL 2019, c. 238, §3, is further amended to read:
§ 4320-C. Emergency services
If a carrier offering a health plan provides or covers any benefits with respect to services in an emergency facility or setting, the plan must cover emergency services without prior authorization. Cost-sharing requirements, expressed such as a deductible, copayment amount or coinsurance rate, for out-of-network services are the same as requirements that would apply if such services were provided in network , and any payment made by an enrollee pursuant to this section must be applied to the enrollee's in-network cost-sharing limit. The enrollee's responsibility for payment for covered out-of-network emergency services must be limited so that if the enrollee has paid the enrollee's share of the charge as specified in the plan for in-network services, the carrier shall hold the enrollee harmless from any additional amount owed to an out-of-network provider for covered emergency services and make payment to the out-of-network provider in accordance with section 4303-C or, if there is a dispute, in accordance with section 4303-E. A carrier offering a health plan in this State shall also comply with the requirements of section 4304, subsection 5.
Sec. 5. Review of reimbursement rates for ambulance services. The Emergency Medical Services' Board shall convene a stakeholder group, including the Maine Ambulance Association, representatives of municipal and private ambulance services, health insurance carriers and the Department of Professional and Financial Regulation, Bureau of Insurance, to review issues related to reimbursement rates for ambulance services. The stakeholder group shall:
1. Consider current reimbursement rates paid by carriers and other payors for ambulance services for ambulance providers participating in carrier networks and for ambulance providers that are out of network;
2. Consider the reimbursement rates required under the Maine Revised Statutes, Title 24-A, section 4303-C for emergency services rendered by out of network providers and the availability of the dispute resolution process under Title 24-A, section 4303-E to those providers;
3. Determine the ambulance providers that participate in carrier networks and identify any barriers to participation in those networks; and
4. Develop recommendations for improving the participation of ambulance services in carrier networks, including proposals to provide assistance with contract negotiation or to amend the reimbursement rates required under law.
The Emergency Medical Services' Board shall submit a report, including any recommendations, to the joint standing committee of the Legislature having jurisdiction over health coverage, insurance and financial services matters no later than February 1, 2021. The joint standing committee may report out a bill based on the report to the First Regular Session of the 130th Legislature.
Sec. 6. Appropriations and allocations. The following appropriations and allocations are made.
PROFESSIONAL AND FINANCIAL REGULATION, DEPARTMENT OF
Administrative Services - Professional and Financial Regulation 0094
Initiative: Provides allocation in fiscal year 2020-21 for software development.
OTHER SPECIAL REVENUE FUNDS | 2019-20 | 2020-21 |
All Other
|
$0 | $25,000 |
OTHER SPECIAL REVENUE FUNDS TOTAL | $0 | $25,000 |
Administrative Services - Professional and Financial Regulation 0094
Initiative: Provides allocation to establish one part-time Insurance Actuarial Assistant position and All Other costs beginning October 1, 2020.
OTHER SPECIAL REVENUE FUNDS | 2019-20 | 2020-21 |
All Other
|
$0 | $2,616 |
OTHER SPECIAL REVENUE FUNDS TOTAL | $0 | $2,616 |
Insurance - Bureau of 0092
Initiative: Provides allocation to establish one part-time Insurance Actuarial Assistant position and All Other costs beginning October 1, 2020.
OTHER SPECIAL REVENUE FUNDS | 2019-20 | 2020-21 |
POSITIONS - LEGISLATIVE COUNT
|
0.000 | 0.500 |
Personal Services
|
$0 | $39,605 |
All Other
|
$0 | $6,684 |
OTHER SPECIAL REVENUE FUNDS TOTAL | $0 | $46,289 |
PROFESSIONAL AND FINANCIAL REGULATION, DEPARTMENT OF | ||
DEPARTMENT TOTALS | 2019-20 | 2020-21 |
OTHER SPECIAL REVENUE FUNDS
|
$0 | $73,905 |
DEPARTMENT TOTAL - ALL FUNDS | $0 | $73,905 |
Emergency clause. In view of the emergency cited in the preamble, this legislation takes effect when approved.