Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT HEADING: PL 1997, C. 792, §2 (RPR)
Subchapter 1: HEALTH PLAN REQUIREMENTS HEADING: PL 1997, C. 792, §2 (NEW)
§4303. Plan requirements
A carrier offering or renewing a health plan in this State must meet the following requirements. [2007, c. 199, Pt. B, §4 (AMD).]
1.Demonstration of adequate access to providers.
A carrier offering or renewing a managed care plan shall provide to its members
reasonable access to health care services. A carrier may provide incentives to members
to use designated providers based on cost or quality, but may not require members
to use designated providers of health care services.
A. [2007, c. 199, Pt. B, §5 (AMD); MRSA T.24-A, §4303, sub-1, ¶A (RP).]
B. [2011, c. 90, Pt. F, §7 (RP).]
C. [2011, c. 90, Pt. F, §7 (RP).]
2011, c. 90, Pt. F, §7 (RPR)
The credentialling of providers by a carrier is governed by this subsection.
A. The granting of credentials must be based on objective standards that are available
to providers upon application for credentialling. A carrier shall consult with appropriately
qualified health care professionals in developing its credentialling standards. [1997, c. 163, §1 (AMD).]
B. All credentialling decisions, including those granting, denying or withdrawing credentials,
must be in writing. The provider must be provided with all reasons for the denial
of an application for credentialling or the withdrawal of credentials. A withdrawal
of credentials must be treated as a provider termination and is subject to the requirements
of subsection 3-A. [1997, c. 163, §1 (AMD).]
C. A carrier shall establish and maintain an appeal procedure, including the provider's
right to a hearing, for dealing with provider concerns relating to the denial of credentialling
for not meeting the objective credentialling standards of the plan and the contractual
relationship between the carrier and the provider. The superintendent shall determine
whether the process provided by a carrier is fair and reasonable. This procedure
must be specified in every contract between a carrier and a provider or between a
carrier and a provider network if a carrier does not contract with providers individually. [1995, c. 673, Pt. C, §1 (NEW); 1995, c. 673, Pt. C, §2 (AFF).]
D. A carrier shall make credentialling decisions, including those granting or denying
credentials, within 60 days of receipt of a completed credentialling application from
a provider. The time period for granting or denying credentials may be extended upon
written notification from the carrier within 60 days following submission of a completed
application stating that information contained in the application requires additional
time for verification. All credentialling decisions must be made within 180 days of
receipt of a completed application. For the purposes of this paragraph, an application
is completed if the application includes all of the information required by the uniform
credentialling application used by carriers and providers in this State, such attachments
to that application as required by the carrier at the time of application and all
corrections required by the carrier. A carrier shall review the entire application
before returning it to the provider for corrections with a comprehensive list of all
corrections needed at the time the application is first returned to the provider.
A carrier may not require that a provider have a home address within the State before
accepting an application. [2003, c. 108, §1 (NEW).]
E. [2013, c. 383, §4 (RP).]
2013, c. 383, §4 (AMD)
3.Provider's right to advocate for medically appropriate care.
A carrier offering or renewing a managed care plan may not terminate or otherwise discipline a participating provider
because the provider advocates for medically appropriate health care. A carrier may
not restrict a provider from disclosing to any enrollee any information the provider
determines appropriate regarding the nature of treatment and any risks or alternatives
to treatment, the availability of other therapy, consultations or tests or the decision
of any plan to authorize or deny health care services or benefits.
A. For the purposes of this section, "to advocate for medically appropriate health care"
means to discuss or recommend a course of treatment to an enrollee; to appeal a managed
care plan's decision to deny payment for a service pursuant to an established grievance
or appeal procedure; or to protest a decision, policy or practice that the provider,
consistent with the degree of learning and skill ordinarily possessed by reputable
providers, reasonably believes impairs the provider's ability to provide medically
appropriate health care to the provider's patients. [1995, c. 673, Pt. C, §1 (NEW); 1995, c. 673, Pt. C, §2 (AFF).]
B. Nothing in this subsection may be construed to prohibit a plan from making a determination
not to pay for a particular medical treatment or service or to enforce reasonable
peer review or utilization review protocols. [1995, c. 673, Pt. C, §1 (NEW); 1995, c. 673, Pt. C, §2 (AFF).]
2007, c. 199, Pt. B, §6 (AMD)
3-A.Termination of participating providers.
A carrier offering or renewing a managed care plan may not terminate or nonrenew a contract with a participating
provider unless the carrier provides the provider with a written explanation prior
to the termination or nonrenewal of the reasons for the proposed contract termination
or nonrenewal and provides an opportunity for a review or hearing in accordance with
this subsection. The existence of a termination without cause provision in a carrier's
contract with a provider does not supersede the requirements of this subsection.
This subsection does not apply to termination cases involving imminent harm to patient
care, a final determination of fraud by a governmental agency, a final disciplinary
action by a state licensing board or other governmental agency that impairs the ability
of a provider to practice. A review or hearing of proposed contract termination must
meet the following requirements.
A. The notice of the proposed contract termination or nonrenewal provided by the carrier
to the participating provider must include:
(1) The reason or reasons for the proposed action in sufficient detail to permit
the provider to respond;
(2) Reference to the evidence or documentation underlying the carrier's decision
to pursue the proposed action. A carrier shall permit a provider to review this evidence
and documentation upon request;
(3) Notice that the provider has the right to request a review or hearing before
a panel appointed by the carrier;
(4) A time limit of not less than 30 days from the date the provider receives the
notice within which a provider may request a review or hearing; and
(5) A time limit for a hearing date that must be not less than 30 days after the
date of receipt of a request for a hearing.
Termination or nonrenewal may not be effective earlier than 60 days from the receipt
of the notice of termination or nonrenewal. [1997, c. 163, §2 (NEW).]
B. A hearing panel must be composed of at least 3 persons appointed by the carrier and
one person on the hearing panel must be a clinical peer in the same discipline and
the same or similar specialty of the provider under review. A hearing panel may be
composed of more than 3 persons if the number of clinical peers on the hearing panel
constitutes 1/3 or more of the total membership of the panel. [1997, c. 163, §2 (NEW).]
C. A hearing panel shall render a written decision on the proposed action in a timely
manner. This decision must be either the reinstatement of the provider by the carrier,
the provisional reinstatement of the provider subject to conditions established by
the carrier or the termination or nonrenewal of the provider. [1997, c. 163, §2 (NEW).]
D. A decision by a hearing panel to terminate or nonrenew a contract with a provider
may not become effective less than 60 days after the receipt by the provider of the
hearing panel's decision or until the termination date in the provider's contract,
whichever is earlier. [1997, c. 163, §2 (NEW).]
2007, c. 199, Pt. B, §7 (AMD)
3-B.Prohibition on financial incentives.
A carrier offering or renewing 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 health care
services covered under the plan to an enrollee. This subsection may not be construed
to prohibit pilot projects authorized pursuant to section 4320-H or 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.
RR 2011, c. 1, §41 (COR)
4.Grievance procedure for enrollees.
A carrier offering or renewing a health plan in this State shall establish and maintain a grievance procedure that
meets standards developed by the superintendent to provide for the resolution of claims
denials or other matters by which enrollees are aggrieved.
A. The grievance procedure must include, at a minimum, the following:
(1) Notice to the enrollee promptly of any claim denial or other matter by which
enrollees are likely to be aggrieved, stating the basis for the decision, the right
to file a grievance, the procedure for doing so and the time period in which the grievance
must be filed;
(2) Timelines within which grievances must be processed, including expedited processing
for exigent circumstances. Timelines must be sufficiently expeditious to resolve
grievances promptly. Decisions for second level grievance reviews as defined by bureau rules must be
issued within 30 calendar days if the insured has not requested the opportunity to
appear in person before authorized representatives of the health carrier;
(3) Procedures for the submission of relevant information and enrollee participation;
(4) Provision to the aggrieved party of a written statement upon the conclusion of
any grievance process, setting forth the reasons for any decision. The statement
must include notice to the aggrieved party of any subsequent appeal or external review
rights, the procedure and time limitations for exercising those rights and notice
of the right to file a complaint with the Bureau of Insurance and the toll-free telephone
number of the bureau; and
(5) Decision-making by one or more individuals not previously involved in making
the decision subject to the grievance. [2007, c. 199, Pt. B, §9 (AMD).]
B. In any appeal under the grievance procedure in which a professional medical opinion
regarding a health condition is a material issue in the dispute, the aggrieved party
is entitled to an independent 2nd opinion, paid for by the plan, of a provider of
the same specialty participating in the plan. If a provider of the same specialty
does not participate in the plan, then the 2nd opinion must be given by a nonparticipating
provider. [1995, c. 673, Pt. C, §1 (NEW); 1995, c. 673, Pt. C, §2 (AFF).]
C. In any appeal under the grievance procedure, the carrier shall provide auxiliary telecommunications
devices or qualified interpreter services by a person proficient in American Sign
Language when requested by an enrollee who is deaf or hard-of-hearing or printed materials
in an accessible format, including Braille, large-print materials, computer diskette,
audio cassette or a reader when requested by an enrollee who is visually impaired
to allow the enrollee to exercise the enrollee's right to an appeal under this subsection. [1999, c. 742, §9 (NEW).]
D. Notwithstanding this subsection, a group health plan sponsored by an agricultural
cooperative association located outside of this State that provides health insurance
coverage to members of one or more agricultural cooperative associations located within
this State may employ a grievance procedure for enrollees in the group health plan
that meets the requirements of the state in which the group health plan is located
if enrollees in the group health plan that reside in this State have the right to
independent external review in accordance with section 4312 following any adverse
health care treatment decision. Any difference in the grievance procedure requirements
between those of the state in which the group health plan is located and those of
this State must be limited to the number of days required for notification of prior
authorization for nonemergency services and the number of days required for the issuance
of a decision following the filing of an appeal of an adverse health care treatment
decision. Enrollees in the group health plan that reside in this State must be notified
as to the grievance procedure used by the group health plan and their right to independent
external review in accordance with section 4312. [2003, c. 309, §1 (NEW).]
E. Health plans subject to the requirements of the federal Affordable Care Act must comply
with federal claims and appeal requirements, including, but not limited to, the requirement
that benefits for an ongoing course of treatment may not be reduced or terminated
without advance notice and an opportunity for advance review, consistent with the
requirements of the federal Affordable Care Act. [2011, c. 364, §25 (NEW).]
2011, c. 364, §25 (AMD)
5.Identification of services provided by certified nurse practitioners and certified
All claims for coverage of services provided by certified nurse practitioners and
certified nurse midwives must identify the certified nurse practitioners and certified
nurse midwives who provided those services. A carrier offering or renewing a health plan in this State shall assign identification numbers or codes to certified
nurse practitioners and certified nurse midwives who provide covered services for
enrollees covered under that plan. A claim submitted for payment to a carrier by
a health care provider or facility must include the identification number or code
of the certified nurse practitioner or certified nurse midwife who provided the service
and may not be submitted using the identification number or code of a physician or
other health care provider who did not provide the covered service.
2007, c. 199, Pt. B, §10 (AMD)
6.Standing referrals to specialists.
A carrier shall establish and maintain a procedure to allow an enrollee with a special
condition requiring ongoing care from a specialist to receive a standing referral
to a specialist participating in the carrier's network for treatment of that special
condition. If the carrier or the enrollee's primary care provider, in consultation
with the carrier's medical director, determines that a standing referral is appropriate,
the carrier shall ensure that the enrollee receives such a referral to a specialist.
If a specialist able to treat the enrollee's special condition does not participate
in the carrier's network, then the carrier shall ensure that the enrollee receives
a standing referral to a nonparticipating specialist. A standing referral must be
made pursuant to a treatment plan approved by the carrier's medical director in consultation
with the enrollee's primary care provider. After the standing referral is made, the
specialist is authorized to provide health care services to the enrollee in the same
manner as the enrollee's primary care provider, subject to the terms of the treatment
1999, c. 742, §10 (NEW)
7.Continuity of care.
If a contract between a carrier and a provider is terminated or benefits or coverage
provided by a provider is terminated because of a change in the terms of provider
participation in a health plan and an enrollee is undergoing a course of treatment
from the provider at the time of termination, the carrier shall provide continuity
of care in accordance with the requirements in paragraphs A to C. This section does
not apply to provider terminations exempt from the requirements of subsection 3-A.
If a managed care contract for the provision of health insurance coverage between
a plan sponsor and a carrier is replaced within the meaning of section 2849 with a
different managed care contract and a health care provider that has been providing
health care services to an enrollee is not in the replacement carrier's network, the
replacement carrier shall provide continuity of care in accordance with the requirements
in paragraphs A to C in the same manner as if the provider had been terminated from
the replacement carrier's network as of the date of the policy replacement, but only
with respect to benefits that are covered under the replacement contract.
A. The carrier shall notify an enrollee of the termination of the provider's contract
at least 60 days in advance of the date of termination. When circumstances related
to the termination render such notice impossible, the carrier shall provide affected
enrollees as much notice as is reasonably possible. The notice given to the enrollee
must include instructions on obtaining an alternate provider and must offer the carrier's
assistance with obtaining an alternate provider and ensuring that there is no inappropriate
disruption in the enrollee's ongoing treatment. [1999, c. 742, §10 (NEW).]
B. The carrier shall permit the enrollee to continue or be covered, with respect to the
course of treatment with the provider, for a transitional period of at least 60 days
from the date of notice to the enrollee of the provider's termination except that
if an enrollee is in the 2nd trimester of pregnancy at the time of the provider's
termination and the provider is treating the enrollee during the pregnancy, the transitional
period must extend through the provision of postpartum care directly related to the
pregnancy. [1999, c. 742, §10 (NEW).]
C. A carrier may make coverage of continued treatment by a provider under paragraph B
conditional upon the provider's agreeing to the following terms and conditions.
(1) The provider agrees to accept reimbursement from the carrier at rates applicable
prior to the start of the transitional period as payment in full and not to impose
cost-sharing with respect to the enrollee in an amount that would exceed the cost-sharing
that could have been imposed if the contract between the carrier and the provider
had not been terminated.
(2) The provider agrees to adhere to the quality assurance standards of the carrier
responsible for payment and to provide the carrier necessary medical information related
to the care provided.
(3) The provider agrees otherwise to adhere to the carrier's policies and procedures,
including procedures regarding referrals and prior authorizations and providing services
pursuant to any treatment plan approved by the carrier. [1999, c. 742, §10 (NEW).]
1999, c. 742, §10 (NEW)
7-A.Continuity of prescriptions.
If an enrollee has been undergoing a course of treatment with a prescription drug
by prior authorization of a carrier and the enrollee’s coverage with one carrier is
replaced with coverage from another carrier pursuant to section 2849-B, the replacement
carrier shall honor the prior authorization for that prescription drug and provide
coverage in the same manner as the previous carrier until the replacement carrier
conducts a review of the prior authorization for that prescription drug with the enrollee’s
prescribing provider. Policies must include a notice of the right to request a review
with the enrollee’s provider, and the replacing carrier must honor the prior carrier’s
authorization for a period not to exceed 6 months if the enrollee’s provider participates
in the review and requests the prior authorization be continued. The replacing carrier
is not required to provide benefits for conditions or services not otherwise covered
under the replacement policy, and cost sharing may be based on the copayments and
coinsurance requirements of the replacement policy.
2009, c. 439, Pt. F, §1 (NEW)
8.Maximum allowable charges.
All policies, contracts and certificates executed, delivered and issued by a carrier
under which the insured or enrollee may be subject to balance billing when charges
exceed a maximum considered usual, customary and reasonable by the carrier or that
contain contractual language of similar import must be subject to the following.
A. If benefits for covered services are limited to a maximum amount based on any combination
of usual, customary and reasonable charges or other similar method, the carrier must:
(1) Clearly disclose that the insured or enrollee may be subject to balance billing
as a result of claims adjustment; and
(2) Provide a toll-free number that an insured or enrollee may call prior to receiving
services to determine the maximum allowable charge permitted by the carrier for a
specified service. [2001, c. 410, Pt. B, §5 (NEW).]
B. The carrier must provide to the superintendent on request complete information on
the methodology and specific data used by the carrier or any 3rd party on behalf of
the carrier in adjusting any claim submitted by or on behalf of the insured or enrollee.
In considering the reasonableness of the methodology for calculating maximum allowable
charges, the superintendent shall consider whether the methodology takes into account
relevant data specific to this State if there is sufficient data to constitute a representative
sample of charge data for the same or comparable service. [2001, c. 410, Pt. B, §5 (NEW).]
2001, c. 410, Pt. B, §5 (NEW)
8-A.Protection from balance billing by participating providers.
An enrollee's responsibility for payment under a managed care plan must be limited
as provided in this subsection.
A. The terms of a managed care plan must provide that the enrollee's responsibility for
the cost of covered health care rendered by participating providers is limited to
the cost-sharing provisions expressly disclosed in the contract, such as deductibles,
copayments and coinsurance, and that if the enrollee has paid the enrollee's share
of the charge as specified in the plan, the carrier shall hold the enrollee harmless
from any additional amount owed to a participating provider for covered health care. [2011, c. 238, Pt. A, §1 (NEW).]
B. Every provider agreement with a participating provider must be in writing and must
set forth that if the carrier fails to pay for health care services as set forth in
the contract, the enrollee is not liable to the provider for any sums owed by the
carrier. [2011, c. 238, Pt. A, §1 (NEW).]
C. A participating provider may not collect or attempt to collect any charge from an
enrollee for covered health care beyond the amount permitted by the terms of the plan,
notwithstanding the carrier's insolvency, the carrier's failure to pay the amount
owed by the carrier, any other breach by the carrier of the provider agreement or
the failure of the provider agreement to include the written hold harmless provision
required by paragraph B. [2011, c. 238, Pt. A, §1 (NEW).]
2011, c. 238, Pt. A, §1 (NEW)
9. (REALLOCATED TO T. 24-A, §4303, sub-§11) Absolute discretion clauses.
RR 2003, c. 1, §21 (RAL);
2003, c. 110, §1 (NEW)
9.Notice of amendments to provider agreements.
A carrier offering or renewing a health plan in this State shall notify a participating provider of a proposed amendment
to a provider agreement at least 60 days prior to the amendment's proposed effective
date. If an amendment that has substantial impact on the rights and obligations of
providers is made to a manual, policy or procedure document referenced in the provider
agreement, such as material changes to fee schedules or material changes to procedural
coding rules specified in the manual, policy or procedure document, the carrier shall
provide 60 days' notice to the provider. After the 60-day notice period has expired,
the amendment to a manual, policy or procedure document becomes effective and binding
on both the carrier and the provider subject to any applicable termination provisions
in the provider agreement, except that the carrier and provider may mutually agree
to waive the 60-day notice requirement. This subsection may not be construed to limit
the ability of a carrier and provider to mutually agree to the proposed change at
any time after the provider has received notice of the proposed amendment.
2007, c. 199, Pt. B, §11 (AMD)
10.Limits on retrospective denials.
A carrier offering a health plan in this State may not impose on any provider any
retrospective denial of a previously paid claim or any part of that previously paid
A. The carrier has provided the reason for the retrospective denial in writing to the
provider; and [2003, c. 218, §9 (NEW).]
B. The time that has elapsed since the date of payment of the previously paid claim does
not exceed 12 months. The retrospective denial of a previously paid claim may be
permitted beyond 12 months from the date of payment only for the following reasons:
(1) The claim was submitted fraudulently;
(2) The claim payment was incorrect because the provider or the insured was already
paid for the health care services identified in the claim;
(3) The health care services identified in the claim were not delivered by the provider;
(4) The claim payment was for services covered by Title XVIII, Title XIX or Title
XXI of the Social Security Act;
(5) The claim payment is the subject of adjustment with another insurer, administrator
or payor; or
(6) The claim payment is the subject of legal action. [2007, c. 106, §1 (AMD).]
For purposes of this subsection, "retrospective denial of a previously paid claim"
means any attempt by a carrier to retroactively collect payments already made to a
provider with respect to a claim by requiring repayment of such payments, reducing
other payments currently owed to the provider, withholding or setting off against
future payments or reducing or affecting the future claim payments to the provider
in any other manner. The provider has 6 months from the date of notification under
this subsection to determine whether the insured has other appropriate insurance that
was in effect on the date of service. Notwithstanding the terms of the provider agreement,
the carrier shall allow for the submission of a claim that was previously denied by
another insurer because of the insured's transfer or termination of coverage.
2007, c. 106, §1 (AMD)
11. (REALLOCATED FROM T. 24-A, §4303, sub-§9) Absolute discretion clauses.
The use and enforcement of an absolute discretion clause is governed by this subsection.
A. A policy, contract, certificate or agreement offered, delivered, issued or renewed
for delivery in this State by a carrier to provide, deliver, arrange for, pay for
or reimburse any of the costs of health care services may not contain a provision
purporting to reserve sole or absolute discretion to the carrier to interpret the
terms of the contract or to provide standards of interpretation or review that are
inconsistent with the laws of this State. [RR 2003, c. 1, §21 (RAL).]
B. A carrier may not enforce a provision in a policy, contract, certificate or agreement
that was offered, delivered or issued for delivery in this State and has been continued
or renewed by a group policy holder or individual enrollee in this State that purports
to reserve sole or absolute discretion to the carrier to interpret the terms of the
contract or to provide standards of interpretation or review that are inconsistent
with the laws of this State. [RR 2003, c. 1, §21 (RAL).]
RR 2003, c. 1, §21 (RAL)
12.Publication of policies by carriers.
A carrier must publish at least 5 individual health plans with the highest level of
enrollment and at least 5 small group health plans with the highest level of enrollment
on the carrier’s publicly accessible website in a manner that will allow consumers
to review the coverage offered under each policy. The policies posted on the website
must be updated when changes are made to the policies by the carrier. The appearance
of the policy on the website must duplicate the appearance of a paper copy of the
policy. The bureau shall provide a link from its website to each carrier’s website.
A carrier must review annually which policies to post and make any necessary changes
on its website. A carrier must post the required policies on its website within 90
days after the effective date of this subsection.
2009, c. 439, Pt. A, §3 (NEW)
13.Explanation of benefits.
A carrier offering an individual expense-incurred health plan to residents of this
State or an expense-incurred group health plan to an employer in this State shall
provide individual policyholders and group certificate holders with clear written
explanations of benefit documents in response to the filing of any claim providing
for coverage of hospital or medical expenses. The explanation of benefits must include
all of the following information:
A. The date of service; [2009, c. 439, Pt. A, §4 (NEW).]
B. The provider of the service; [2009, c. 439, Pt. A, §4 (NEW).]
C. An identification of the service for which the claim is made; [2009, c. 439, Pt. A, §4 (NEW).]
D. Any amount the insured is obligated to pay under the policy for copayment or coinsurance; [2009, c. 439, Pt. A, §4 (NEW).]
E. A telephone number and address where the insured may obtain clarification of the explanation
of benefits; [2009, c. 439, Pt. A, §4 (NEW).]
F. A notice of appeal rights; and [2009, c. 439, Pt. A, §4 (NEW).]
G. A notice of the right to file a complaint with the bureau after exhausting any appeals
under a carrier's internal appeals process. [2009, c. 439, Pt. A, §4 (NEW).]
The superintendent shall establish by rule the minimum information and standards for
explanation of benefits forms used by carriers, taking into consideration any input
from stakeholders and any national standards for explanation of benefits forms. Rules
adopted pursuant to this subsection are routine technical rules as defined in Title
5, chapter 375, subchapter 2-A. This subsection applies to any explanation of benefits
form issued on or after January 1, 2010.
2009, c. 439, Pt. A, §4 (NEW)
The superintendent may by rule define standard policy terms that must be used in
all policies issued by carriers offering health plans in the State. Rules adopted
pursuant to this subsection are routine technical rules as defined in Title 5, chapter
375, subchapter 2-A.
2009, c. 439, Pt. A, §5 (NEW)
15.Uniform explanation of coverage documents and standardized definitions.
A carrier offering a health plan in this State shall:
A. Provide to applicants, enrollees and policyholders or certificate holders a summary
of benefits and an explanation of coverage that accurately describe the benefits and
coverage under the applicable plan or coverage. A summary of benefits and an explanation
of coverage must conform with the requirements of the federal Affordable Care Act;
and [2011, c. 364, §26 (NEW).]
B. Use standard definitions of insurance-related and medical-related terms in connection
with health insurance coverage as required by the federal Affordable Care Act. [2011, c. 364, §26 (NEW).]
(Subsection 15 as enacted by PL 2011, c. 451, §1 is REALLOCATED TO TITLE 24-A, SECTION
4303, SUBSECTION 17)
2011, c. 364, §26 (NEW)
16.Language and culture.
All notices to applicants, enrollees and policyholders or certificate holders subject
to the requirements of the federal Affordable Care Act must be provided in a culturally
and linguistically appropriate manner consistent with the requirements of the federal
Affordable Care Act.
2011, c. 364, §27 (NEW)
17. (REALLOCATED FROM T. 24-A, §4303, sub-§15) Prohibition on "most favored nation" clauses.
Participation agreements between carriers and providers are governed by this subsection.
A. A participation agreement between a carrier and a provider may not include a provision,
commonly referred to as a "most favored nation" clause, that:
(1) Prohibits, or grants the carrier an option to prohibit, the provider from entering
into a participation agreement with another carrier to provide services at a lower
price than the payment specified in the participation agreement;
(2) Requires, or grants the carrier an option to require, the provider to accept
a lower payment in the event the provider agrees to provide services to any other
carrier at a lower price;
(3) Requires, or grants the carrier an option of, termination or renegotiation of
the existing participation agreement in the event the provider agrees to provide services
to any other carrier at a lower price; or
(4) Requires the provider to disclose its reimbursement rates from other carriers. [RR 2011, c. 1, §42 (RAL).]
B. The superintendent may grant a waiver to paragraph A on application by either a carrier
or a provider. A carrier or provider requesting a waiver for more than one participation
agreement must file a separate application for each requested waiver. The superintendent
may grant a waiver only after issuing a finding that the inclusion in the participation
agreement of a most favored nation clause as described in paragraph A is not anticompetitive.
A carrier or provider requesting a waiver may request a hearing on the application
for a waiver in accordance with section 229. The findings and decision of the superintendent
are final agency actions for the purposes of Title 5, chapter 375, subchapter 7 and,
notwithstanding section 236, subsection 2, may be appealed regardless of whether a
hearing was held. The superintendent's review under this paragraph is limited to
the most favored nation clause, and any decision under this paragraph is for purposes
of this subsection only and may not be construed as a finding or decision regarding
the legality of the provision under other applicable law. [RR 2011, c. 1, §42 (RAL).]
C. Prior to the issuance of the superintendent's findings and decision on an application
for a waiver pursuant to this subsection, any contract, proposal or draft legal instrument
submitted to the superintendent in an application for a waiver is not a public record
for the purposes of Title 1, chapter 13, except that the name and business address
of the parties to an application for a waiver are public information. After the issuance
of the superintendent's findings and decision, the superintendent may disclose any
information that the superintendent determines is not proprietary information. For
the purposes of this paragraph, "proprietary information" means information that is
a trade secret or production, commercial or financial information the disclosure of
which would impair the competitive position of the carrier or provider submitting
the information and would make available information not otherwise publicly available. [RR 2011, c. 1, §42 (RAL).]
D. A carrier may not discriminate or retaliate against a provider for filing or opposing
an application for a waiver under this subsection. [RR 2011, c. 1, §42 (RAL).]
E. A provider may not discriminate or retaliate against a carrier for filing or opposing
an application for a waiver under this subsection. [RR 2011, c. 1, §42 (RAL).]
F. For the purposes of this subsection, the factors the superintendent may consider in
determining whether to grant a waiver based on a finding that the inclusion of a most
favored nation clause as described in paragraph A is not anticompetitive include,
but are not limited to:
(1) Any reduction or limit on competition among carriers or providers;
(2) The impact on quality and availability of health care services, including the
geographic distribution of providers;
(3) The size of the provider and the type of any specialty;
(4) The market share of the carrier and the provider;
(5) The impact on the price and stability of health insurance and health care services
to consumers; and
(6) The impact on reimbursement rates in the provider marketplace. [RR 2011, c. 1, §42 (RAL).]
RR 2011, c. 1, §42 (RAL)
18.Provider contract requirements.
A carrier offering a health plan must meet the requirements of this subsection with
respect to a contract offered by the carrier to a provider, including a contract offered
through a preferred provider arrangement, as defined in section 2671, subsection 7.
This subsection does not apply to dental or vision plans.
A. If the contract for a preferred provider arrangement includes a reference to policies
or procedures to which a contracting provider would be bound, all such policies and
procedures must be provided to the provider for review in an easily accessible manner
upon the provider's request at the time the contract is offered. [2013, c. 399, §1 (NEW).]
B. Upon the provider's request at the time a contract for a preferred provider arrangement
is offered, the following must be provided to a provider for review:
(1) The fee schedule or, if there is not a fee schedule for one or more of the services
covered under the contract, the terms under which payment is determined. A carrier
may require a provider to execute a nondisclosure agreement covering the information
provided under this subparagraph; and
(2) The identity of all carriers for which the provider is agreeing to provide services
to health plan enrollees. [2013, c. 399, §1 (NEW).]
C. As a condition of participation in one of the carrier's preferred provider arrangements,
a contract offered by a carrier may not require a provider to participate in any other
carrier's network subsequently offered by the carrier or by a carrier's preferred
provider arrangement. [2013, c. 399, §1 (NEW).]
D. Without the provider's prior written consent, a provider's contractual participation
in a carrier's preferred provider arrangement may not:
(1) Subject the provider to health plan payor requirements or fee schedules that
materially differ from the terms of the provider's contract with the carrier, unless
those materially different terms are set out in writing in a separate section of the
contract, such as an exhibit or amendment; or
(2) Permit the terms of the provider's existing preferred provider arrangement contract
to be superseded by a carrier's subsequent contract with a health plan payor. [2013, c. 399, §1 (NEW).]
E. A preferred provider arrangement contract may not require a provider providing a service
to an enrollee under a health plan included in the provider's contract to obtain preauthorization
if the enrollee's health plan does not require prior authorization as a condition
of coverage. [2013, c. 399, §1 (NEW).]
F. Explanation of remittance advices or comparable documents, whether in paper or electronic
form, that accompany and identify payment of a provider's claims under a carrier's
contract, including contracts offered through a preferred provider arrangement, must
identify the administrator and payor of the provider's claims and include contact
information. [2013, c. 399, §1 (NEW).]
The requirements of this subsection do not apply to a carrier offering a health plan
with respect to preferred provider arrangement contracts with a hospital or pharmacy.
2013, c. 399, §1 (NEW)
19.Information about provider networks.
A carrier offering a managed care plan shall prominently disclose to applicants, prospective
enrollees and enrollees information about the carrier's provider network for the applicable
managed care plan, including whether there are hospitals, health care facilities,
physicians or other providers not included in the plan's network and any differences
in an enrollee's financial responsibilities for payment of covered services to a participating
provider and to a provider not included in a provider network. The superintendent
may adopt rules that set forth the manner, content and required disclosure of the
information in accordance with this subsection. Rules adopted pursuant to this subsection
are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
2013, c. 535, §1 (NEW)
1995, c. 673, Pt. C, §1 (NEW).
1995, c. 673, Pt. C, §2 (AFF).
1997, c. 163, §§1, 2 (AMD).
1999, c. 396, §5 (AMD).
1999, c. 396, §7 (AFF).
1999, c. 742, §§6-10 (AMD).
2001, c. 288, §5 (AMD).
2001, c. 410, Pt. B, §5 (AMD).
RR 2003, c. 1, §21 (COR).
2003, c. 108, §1 (AMD).
2003, c. 110, §1 (AMD).
2003, c. 218, §9 (AMD).
2003, c. 309, §1 (AMD).
2003, c. 469, Pt. E, §20 (AMD).
2003, c. 689, Pt. B, §6 (REV).
2007, c. 106, §1 (AMD).
2007, c. 199, Pt. B, §§4-11 (AMD).
2009, c. 357, §1 (AMD).
2009, c. 439, Pt. A, §§3-5 (AMD).
2009, c. 439, Pt. B, §5 (AMD).
2009, c. 439, Pt. F, §1 (AMD).
2009, c. 652, Pt. A, §33 (AMD).
RR 2011, c. 1, §§41, 42 (COR).
2011, c. 90, Pt. F, §7 (AMD).
2011, c. 238, Pt. A, §1 (AMD).
2011, c. 270, §1 (AMD).
2011, c. 364, §§25-27 (AMD).
2011, c. 451, §1 (AMD).
2011, c. 451, §2 (AFF).
2013, c. 383, §4 (AMD).
2013, c. 399, §1 (AMD).
2013, c. 535, §1 (AMD).
Data for this page extracted on 10/06/2014 09:04:03.
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