An Act To Encourage Maine Consumers To Comparison-shop for Certain Health Care Procedures and To Lower Health Care Costs
Sec. 1. 22 MRSA §1718-B, sub-§2, ¶D is enacted to read:
Sec. 2. 24-A MRSA §4318-A is enacted to read:
§ 4318-A. Shared savings incentive program
Beginning January 1, 2018, a carrier offering a health plan in this State shall provide a shared savings incentive program that, at a minimum, meets the requirements of this section.
(1) Physical and occupational therapy services;
(2) Obstetrical and gynecological services;
(3) Radiology and imaging services;
(4) Laboratory services;
(5) Infusion therapy services;
(6) Inpatient and outpatient surgical procedures; and
(7) Outpatient, nonsurgical diagnostic tests and procedures.
SUMMARY
This bill requires all carriers offering health plans in the State, beginning January 1, 2018, to provide a shared savings incentive program as a component of all health plans, except health plans offered through the federally facilitated marketplace established pursuant to the federal Affordable Care Act. The bill establishes the shared savings incentive program for enrollees who elect to receive a comparable health care service that costs less than the average price paid for that service by a carrier. The bill defines "comparable health care service" as a service for which a carrier offers a shared savings incentive payment and includes, at a minimum, a health care service in the following 7 categories: physical and occupational therapy services; obstetrical and gynecological services; radiology and imaging services; laboratory services; infusion therapy services; inpatient and outpatient surgical procedures; and outpatient, nonsurgical diagnostic tests and procedures. If an enrollee shops for services, the bill requires a carrier to pay that enrollee a shared savings incentive payment of at least 50% of the difference between the average amount for that comparable health care service and the amount paid, except that a payment is not required if the saved cost is $50 or less.
The bill authorizes a carrier to establish its own methodology for calculating the average price paid by that carrier under its shared savings incentive program. If an enrollee elects to receive health care services from an out-of-network provider that results in a shared savings incentive payment, a carrier shall apply the amount paid for the comparable health care service toward the enrollee's cost sharing as specified in the enrollee's health plan as if the health care services were provided by a network provider.
The bill also requires carriers to provide certain information to the Department of Professional and Financial Regulation, Bureau of Insurance on an annual basis relating to the payments made to enrollees, the use of health care services for which payments are provided and the saved costs if an enrollee elects to receive health care services from a provider that cost less than the average cost for a particular admission, procedure or service. The Superintendent of Insurance is required to report aggregate information from all carriers to the Legislature on an annual basis.
This bill also requires providers to notify patients of their right to shop for certain health care services pursuant to a carrier's shared savings incentive program.