Public Laws

124th Legislature

First Regular Session

Parts: A B C D E F

Chapter 439

H.P. 830 - L.D. 1205


Sec. B-1. 24-A MRSA 4301-A, sub-16-A is enacted to read:

16-A. Provider profiling program. "Provider profiling program" means a program that uses provider data in order to rate or rank provider quality or efficiency of care by the use of a grade, star, tier, rating or any other form of designation.

Sec. B-2. 24-A MRSA 4302, sub-1, J, as enacted by PL 1999, c. 742, 5, is amended to read:

J.A description of the independent external review procedures and the circumstances under which an enrollee is entitled to independent external review as required by this chapter; and

Sec. B-3. 24-A MRSA 4302, sub-1, K, as enacted by PL 1999, c. 742, 5, is amended to read:

K.A description of the requirements for enrollees to obtain coverage of routine costs of clinical trials and information on the manner in which enrollees not eligible to participate in clinical trials may qualify for the compassionate use program of the federal Food and Drug Administration for use of investigational drugs pursuant to 21 Code of Federal Regulations, Section 312.34, as amended . ; and

Sec. B-4. 24-A MRSA 4302, sub-1, L is enacted to read:

L. A description of a provider profiling program that may be a part of the health plan, including the location of provider performance ratings in the plan materials or on a publicly accessible website, information explaining the provider rating system and the basis upon which provider performance is measured, the limitations of the data used to measure provider performance, the process for selecting providers and a conspicuous written disclaimer explaining the provider performance ratings should only be used as a guide for choosing a provider and that enrollees should consult their current provider before making a decision about their health care based on a provider rating.

Sec. B-5. 24-A MRSA 4303, sub-2, E is enacted to read:

E. A carrier with a provider profiling program shall:

(1) Disclose to providers the methodologies, criteria, data and analysis used to evaluate provider quality, performance and cost-efficiency ratings;

(2) Create and share with providers their provider profile at least 60 days prior to using or publicly disclosing the results of the provider profiling program;

(3) Afford providers the opportunity to correct errors, submit additional information for consideration and seek review of data and performance ratings; and

(4) Afford providers due process appeal rights to challenge the profiling determination described in this subsection and by Bureau of Insurance Rule Chapter 850, Health Plan Accountability.

If a carrier has a provider profiling program that includes out-of-network providers, a carrier must meet the requirements of this paragraph with regard to an out-of-network provider as well as for a provider in a carrier's network.

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