H.P. 1621 - L.D. 2251
An Act to Permit Direct Contracting with State Governmental Entities for the Provision of Services to Eligible Participants in Government Health Programs
Emergency preamble. Whereas, Acts of the Legislature do not become effective until 90 days after adjournment unless enacted as emergencies; and
Whereas, the State administers state and federally sponsored health programs; and
Whereas, it is in the best interests of the people of the State for the State to encourage maximum participation by managed care entities in these programs; and
Whereas, it is in the best interests of the people of the State for the State to manage the health care of program recipients and clients while offering reasonable choice within a competitive and cost-effective environment; 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,
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 22 MRSA §3173, as amended by PL 1997, c. 530, Pt. A, §34, is further amended by adding at the end a new paragraph to read:
The department may enter into contracts with health care servicing entities for the provision, financing, management and oversight of the delivery of health care services in order to carry out these programs. For the purposes of this section, "health care servicing entity" means a partnership, association, corporation, limited liability company or other legal entity that enters into a contract to provide or arrange for the provision of a defined set of health care services; to assume responsibility for some aspects of quality assurance, utilization review, provider credentialing and provider relations or other related network management functions; and to assume financial risk for provision of such services to recipients through capitation reimbursement or other risk-sharing arrangements. "Health care servicing entity" does not include insurers or health maintenance organizations. In all contracts with health care servicing entities, the department shall include standards, developed in consultation with the Superintendent of Insurance, to be met by the contracting entity in the areas of financial solvency, quality assurance, utilization review, network sufficiency, access to services, network performance, complaint and grievance procedures and records maintenance. Prior to contracting with any health care servicing entity, the department must have in place a memorandum of understanding with the Superintendent of Insurance for the provision of technical assistance, which must provide for the sharing of information between the department and the superintendent and the analysis of that information by the superintendent as it relates to the fiscal integrity of the contracting entity. The department may require periodic reporting by the health care servicing entity as to activities and operations of the entity, including the entity's activities undertaken pursuant to commercial contracts with licensed insurers and health maintenance organizations. The department may share with the Superintendent of Insurance all documents filed by the health care servicing entity, including documents subject to confidential treatment if that information is treated with the same degree of confidentiality as is required of the department.
Sec. 2. 24-A MRSA §10, sub-§2, as amended by PL 1997, c. 457, §8, is further amended to read:
2. Fraternal benefit societies, except as stated in chapter 55; or
Sec. 3. 24-A MRSA §10, sub-§4, as amended by PL 1985, c. 399, §1, is further amended to read:
4. Unless otherwise expressly provided by this Title, a domestic insurer heretofore formed under a special Act of the Legislature, where when inconsistent with such special Act as heretofore amended.;
Sec. 4. 24-A MRSA §10, sub-§§5 and 6 are enacted to read:
5. The government contracting activities of a health care servicing entity, as defined in Title 22, section 3173, contracting, whether directly or as a subcontractor, with the Department of Human Services, unless otherwise expressly provided by this Title. This Title may apply to other insurance or managed care activities of a health care servicing entity; or
6. The government contracting activities of a health care servicing entity, as defined in Title 34-B, section 1204, contracting, whether directly or as a subcontractor, with the Department of Mental Health, Mental Retardation and Substance Abuse Services, unless otherwise expressly provided by this Title. This Title may apply to any other insurance or managed care activities of a health care servicing entity.
Sec. 5. 34-B MRSA §1204, sub-§9 is enacted to read:
9. Contracts with health care servicing entities. The commissioner may enter into contracts with health care servicing entities for the financing, management and oversight of the delivery of mental health, mental retardation and substance abuse services to clients pursuant to a state or federally sponsored health program in which the department participates or administers. For the purposes of this subsection, "health care servicing entity" means a partnership, association, corporation, limited liability company or other legal entity that enters into a contract with the State to provide or arrange for the provision of a defined set of health care services; to assume responsibility for some aspects of quality assurance, utilization review, provider credentialing and provider relations or other related network management functions; and to assume financial risk for provision of such services to clients through capitation reimbursement or other risk-sharing arrangements. "Health care servicing entity" does not include insurers or health maintenance organizations. In contracting with health care servicing entities, the commissioner:
A. Shall include in all contracts with the health care servicing entities standards, developed in
consultation with the Superintendent of Insurance, to be met by the contracting entity in the areas of financial solvency, quality assurance, utilization review, network sufficiency, access to services, network performance, complaint and grievance procedures and records maintenance;
B. Prior to contracting with any health care servicing entity, must have in place a memorandum of understanding with the Superintendent of Insurance for the provision of technical assistance, which must provide for the sharing of information between the department and the superintendent and the analysis of that information by the superintendent as it relates to the fiscal integrity of the contracting entity;
C. May require periodic reporting by the health care servicing entity as to activities and operations of the entity, including the entity's activities undertaken pursuant to commercial contracts with licensed insurers and health maintenance organizations;
D. May share with the Superintendent of Insurance all documents filed by the health care servicing entity, including documents subject to confidential treatment if the information is treated with the same degree of confidentiality as is required of the department; and
E. May make all necessary rules for the administration of contracts with health care servicing entities. All rules adopted pursuant to this paragraph are routine technical rules as defined in Title 5, chapter 375, subchapter II-A.
Emergency clause. In view of the emergency cited in the preamble, this Act takes effect when approved.
Effective April 2, 1998.
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