CHAPTER 288
H.P. 216 - L.D. 251
An Act to Define "Medically Necessary Health Care" and Clarify its Application by Health Plans and Managed Care Plans
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4301-A, sub-§6, as enacted by PL 1999, c. 742, §3, is amended to read:
6. Health care treatment decision. "Health care treatment decision" means a decision regarding diagnosis, care or treatment when medical services are provided by a health plan, or a benefits decision involving issues of medical necessity determinations regarding medically necessary health care, preexisting condition determinations and determinations regarding experimental or investigational services.
Sec. 2. 24-A MRSA §4301-A, sub-§10, as enacted by PL 1999, c. 742, §3, is repealed.
Sec. 3. 24-A MRSA §4301-A, sub-§10-A is enacted to read:
10-A. Medically necessary health care. "Medically necessary health care" means health care services or products provided to an enrollee for the purpose of preventing, diagnosing or treating an illness, injury or disease or the symptoms of an illness, injury or disease in a manner that is:
A. Consistent with generally accepted standards of medical practice;
B. Clinically appropriate in terms of type, frequency, extent, site and duration;
C. Demonstrated through scientific evidence to be effective in improving health outcomes;
D. Representative of "best practices" in the medical profession; and
E. Not primarily for the convenience of the enrollee or physician or other health care practitioner.
Sec. 4. 24-A MRSA §4301-A, sub-§11, as enacted by PL 1999, c. 742, §3, is repealed.
Sec. 5. 24-A MRSA §4303, sub-§3-B, as enacted by PL 1999, c. 742, §7, is amended to read:
3-B. Prohibition on financial incentives. A carrier offering a managed care plan may not offer or pay any type of material inducement, bonus or other financial incentive to a participating provider to deny, reduce, withhold, limit or delay specific medically necessary and appropriate health care services covered under the plan to an enrollee. This subsection may not be construed to prohibit contracts that contain incentive plans that involve general payments such as capitation payments or risk-sharing agreements that are made with respect to providers or groups of providers or that are made with respect to groups of enrollees.
Sec. 6. 24-A MRSA §4304, sub-§1, as enacted by PL 1995, c. 673, Pt. C, §1 and affected by §2, is amended to read:
1. Requirements for medical review or utilization review practices. A carrier must appoint a medical director who is responsible for reviewing and approving the carrier's policies governing the clinical aspects of coverage determinations by any health plan that it offers. A carrier's medical review or utilization review practices must be governed by the standard of medically necessary health care as defined in this chapter.
Effective September 21, 2001, unless otherwise indicated.
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