Sec. C-1. 22 MRSA §3174-V, sub-§2, as amended by PL 2003, c. 469, Pt. A, §7, is further amended to read:
2. Contracted services. When a federally qualified health center otherwise meeting the requirements of subsection 1 contracts with a managed care plan or the Dirigo Health Insurance Program for the provision of MaineCare services, the department shall reimburse that center the difference between the payment received by the center from the managed care plan or the Dirigo Health Insurance Program and 100% of the reasonable cost, reduced by the total copayments for which members are responsible, incurred in providing services within the scope of service approved by the federal Health Resources and Services Administration or the commissioner. Any such managed care contract must provide payments for the services of a center that are not less than the level and amount of payment that the managed care plan or the Dirigo Health Insurance Program would make for services provided by an entity not defined as a federally qualified health center.
Sec. C-2. 22 MRSA §3174-DD, as enacted by PL 2003, c. 469, Pt. A, §6, is amended to read:
§3174-DD. Dirigo Health coverage
The department may contract with one or more health insurance carriers to purchase Dirigo Health Insurance Program coverage for MaineCare members who seek to enroll through their employers pursuant to Title 24-A, section 6910, subsection 4, paragraph B. A MaineCare member who enrolls in a the Dirigo Health Insurance plan Program as a member of an employer group receives full MaineCare benefits through the Dirigo Health Insurance Program. The benefits are delivered through the employer-based health plan, subject to nominal cost sharing as permitted by 42 United States Code, Section 1396o(2003) and additional coverage provided under contract by the department.
Sec. C-3. 24-A MRSA §6903, sub-§§12 and 13, as enacted by PL 2003, c. 469, Pt. A, §8, are amended to read:
12. Participating employer. "Participating employer" means an eligible business that contracts with Dirigo Health pursuant to section 6910, subsection 4, paragraph B and that has employees enrolled in the Dirigo Health Insurance Program.
13. Plan enrollee. "Plan enrollee" means an eligible individual or eligible employee who enrolls in the Dirigo Health Insurance Program through Dirigo Health. "Plan enrollee" includes an eligible employee who is eligible to enroll in MaineCare.
Sec. C-4. 24-A MRSA §6906, as enacted by PL 2003, c. 469, Pt. A, §8, is amended to read:
§6906. Prohibited interests of board members and employees
Board members and employees of Dirigo Health and their spouses and dependent children may not receive any direct personal benefit from the activities of Dirigo Health in assisting any private entity, except that they may participate in the Dirigo Health Insurance Program on the same terms as others may under this chapter. This section does not prohibit corporations or other entities with which board members are associated by reason of ownership or employment from participating in activities of Dirigo Health or receiving services offered by Dirigo Health as long as the ownership or employment is made known to the board and, if applicable, the board members abstain from voting on matters relating to that participation.
Sec. C-5. 24-A MRSA §6908, sub-§1, ¶C, as enacted by PL 2003, c. 469, Pt. A, §8, is amended to read:
C. Have and exercise all powers necessary or convenient to effect the purposes for which Dirigo Health is organized or to further the activities in which Dirigo Health may lawfully be engaged, including the establishment of the Dirigo Health Insurance Program;
Sec. C-6. 24-A MRSA §6908, sub-§2, ¶¶C to F, as enacted by PL 2003, c. 469, Pt. A, §8, are amended to read:
C. Determine the comprehensive services and benefits to be included in the Dirigo Health Insurance Program and develop the specifications for the Dirigo Health Insurance Program in accordance with the provisions in section 6910. Within 30 days of its determination of the benefit package to be offered through the Dirigo Health Insurance Program, the board shall report on the benefit package, including the estimated premium and applicable coinsurance, deductibles, copayments and out-of-pocket maximums, to the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs, the joint standing committee of the Legislature having jurisdiction over insurance and financial services matters and the joint standing committee of the Legislature having jurisdiction over health and human services matters;
D. Develop and implement a program to publicize the existence of Dirigo Health and the Dirigo Health Insurance Program and the eligibility requirements and the enrollment procedures for the Dirigo Health Insurance Program and to maintain public awareness of Dirigo Health and the Dirigo Health Insurance Program;
E. Arrange the provision of Dirigo Health Insurance Program benefit coverage to eligible individuals and eligible employees through contracts with one or more qualified bidders;
F. Develop a high-risk pool for plan enrollees in the Dirigo Health Insurance Program in accordance with the provisions of section 6971; and
Sec. C-7. 24-A MRSA §6908, sub-§6, as enacted by PL 2003, c. 469, Pt. A, §8, is amended to read:
6. Annual report. Beginning September 1, 2004, and annually thereafter, the board shall report on the impact of Dirigo Health on the small group and individual health insurance markets in this State and any reduction in the number of uninsured individuals in the State. The board shall also report on membership in Dirigo Health, the administrative expenses of Dirigo Health, the extent of coverage, the effect on premiums, the number of covered lives, the number of Dirigo Health Insurance Program policies issued or renewed and Dirigo Health Insurance Program premiums earned and claims incurred by health insurance carriers offering coverage under the Dirigo Health Insurance Program. The board shall submit the report to the Governor, the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs, the joint standing committee of the Legislature having jurisdiction over health insurance and financial services matters and the joint standing committee of the Legislature having jurisdiction over health and human services matters.
Sec. C-8. 24-A MRSA §6910, as corrected by RR 2003, c. 1, §22, is amended to read:
1. Dirigo Health Program. Dirigo Health shall arrange for the provision of health benefits coverage through the Dirigo Health Insurance Program not later than October 1, 2004. The Dirigo Health Insurance Program must comply with all relevant requirements of this Title. Dirigo Health Insurance Program coverage may be offered by health insurance carriers that apply to the board and meet qualifications described in this section and any additional qualifications set by the board.
2. Legislative approval of nonprofit health care plan or expansion of public plan. If health insurance carriers do not apply to offer and deliver Dirigo Health Insurance Program coverage, the board may have Dirigo Health provide access to health insurance by proposing the establishment of a nonprofit health care plan organized under Title 13-B and authorized pursuant to Title 24, chapter 19 or by proposing the expansion of an existing public plan. If the board proposes the establishment of a nonprofit health care plan or the expansion of an existing public plan, the board shall submit its proposal, including, but not limited to, a funding mechanism to capitalize a nonprofit health care plan and any recommended legislation to the joint standing committee of the Legislature having jurisdiction over health insurance matters. Dirigo Health may not provide access to health insurance by establishing a nonprofit health care plan or through an existing public plan without specific legislative approval.
3. Carrier participation requirements. To qualify as a carrier of Dirigo Health Insurance Program coverage, a health insurance carrier must:
A. Provide the comprehensive health services and benefits as determined by the board, including a standard benefit package that meets the requirements for mandated coverage for specific health services, specific diseases and for certain providers of health services under Title 24 and this Title and any supplemental benefits the board wishes to make available; and
B. Ensure that:
(1) Providers contracting with a carrier contracted to provide coverage to plan enrollees do not charge plan enrollees or 3rd parties for covered health care services in excess of the amount allowed by the carrier the provider has contracted with, except for applicable copayments, deductibles or coinsurance or as provided in section 4204, subsection 6;
(2) Providers contracting with a carrier contracted to provide coverage to plan enrollees do not refuse to provide services to a plan enrollee on the basis of health status, medical condition, previous insurance status, race, color, creed, age, national origin, citizenship status, gender, sexual orientation, disability or marital status. This subparagraph may not be construed to require a provider to furnish medical services that are not within the scope of that provider's license; and
(3) Providers contracting with a carrier contracted to provide coverage to plan enrollees are reimbursed at the negotiated reimbursement rates between the carrier and its provider network.
Health insurance carriers that seek to qualify to provide Dirigo Health Insurance Program coverage must also qualify as health plans in Medicaid.
4. Contracting authority. Dirigo Health has contracting authority and powers to administer Dirigo Health Insurance as set out in this subsection.
A. Dirigo Health may contract with health insurance carriers licensed to sell health insurance in this State or other private or public third-party administrators to provide Dirigo Health Insurance Program coverage. In addition:
(1) Dirigo Health shall issue requests for proposals from health insurance carriers;
(2) Dirigo Health may include quality improvement, disease prevention, disease management and cost-containment provisions in the contracts with participating health insurance carriers or may arrange for the provision of such services through contracts with other entities;
(3) Dirigo Health shall require participating health insurance carriers to offer a benefit plan identical to the Dirigo Health Insurance Program, for which no Dirigo Health subsidies are available, in the general small group market;
(4) Dirigo Health shall make payments to participating health insurance carriers under a Dirigo Health Insurance Program contract to provide Dirigo Health Insurance Program benefits to plan enrollees not enrolled in MaineCare;
(5) Dirigo Health may set allowable rates for administration and underwriting gains for the Dirigo Health Insurance Program;
(6) Dirigo Health may administer continuation benefits for eligible individuals from employers with 20 or more employees who have purchased health insurance coverage through Dirigo Health for the duration of their eligibility periods for continuation benefits pursuant to the federal Consolidated Omnibus Budget Reconciliation Act, Public Law 99-272, Title X, Private Health Insurance Coverage, Sections 10001 to 10003; and
(7) Dirigo Health may administer or contract to administer the United States Internal Revenue Code of 1986, Section 125 plans for employers and employees participating in Dirigo Health, including medical expense reimbursement accounts and dependent care reimbursement accounts.
B. Dirigo Health shall contract with eligible businesses seeking assistance from Dirigo Health in arranging for health benefits coverage by the Dirigo Health Insurance Program for their employees and dependents as set out in this paragraph.
(1) Dirigo Health may establish contract and other reporting forms and procedures necessary for the efficient administration of contracts.
(2) Dirigo Health shall collect payments from participating employers and plan enrollees to cover the cost of:
(a) The Dirigo Health Insurance Program for enrolled employees and dependents in contribution amounts determined by the board;
(b) Dirigo Health's quality assurance, disease prevention, disease management and cost-containment programs;
(c) Dirigo Health's administrative services; and
(d) Other health promotion costs.
(3) Dirigo Health shall establish the minimum required contribution levels, not to exceed 60%, to be paid by employers toward the aggregate payment in subparagraph (2) and establish an equivalent minimum amount to be paid by employers or plan enrollees and their dependents who are enrolled in MaineCare. The minimum required contribution level to be paid by employers must be prorated for employees that work less than the number of hours of a full-time equivalent employee as determined by the employer. Dirigo Health may establish a separate minimum contribution level to be paid by employers toward coverage for dependents of the employers' enrolled employees.
(4) Dirigo Health shall require participating employers to certify that at least 75% of their employees that work 30 hours or more per week and who do not have other creditable coverage are enrolled in the Dirigo Health Insurance Program and that the employer group otherwise meets the minimum participation requirements specified by section 2808-B, subsection 4, paragraph A.
(5) Dirigo Health shall reduce the payment amounts for plan enrollees eligible for a subsidy under section 6912 accordingly. Dirigo Health shall return any payments made by plan enrollees also enrolled in MaineCare to those enrollees.
(6) Dirigo Health shall require participating employers to pass on any subsidy in section 6912 to the plan enrollee qualifying for the subsidy, up to the amount of payments made by the plan enrollee.
(7) Dirigo Health may establish other criteria for participation.
(8) Dirigo Health may limit the number of participating employers.
C. Dirigo Health may permit eligible individuals to purchase Dirigo Health Insurance Program coverage for themselves and their dependents as set out in this paragraph.
(1) Dirigo Health may establish contract and other reporting forms and procedures necessary for the efficient administration of contracts.
(2) Dirigo Health may collect payments from eligible individuals participating in the Dirigo Health Insurance Program to cover the cost of:
(a) Enrollment in the Dirigo Health Insurance Program for eligible individuals and dependents;
(b) Dirigo Health's quality assurance, disease prevention, disease management and cost-containment programs;
(c) Dirigo Health's administrative services; and
(d) Other health promotion costs.
(3) Dirigo Health shall reduce the payment amounts for individuals eligible for a subsidy under section 6912 accordingly.
(4) Dirigo Health may require that eligible individuals certify that all their dependents are enrolled in the Dirigo Health Insurance Program or are covered by another creditable plan.
(5) Dirigo Health may require an eligible individual who is currently employed by an eligible employer that does not offer health insurance to certify that the current employer did not provide access to an employer-sponsored benefits plan in the 12-month period immediately preceding the eligible individual's application.
(6) Dirigo Health may limit the number of plan enrollees.
(7) Dirigo Health may establish other criteria for participation.
5. Enrollment in Dirigo Health Program. Dirigo Health shall perform, at a minimum, the following functions to facilitate enrollment in the Dirigo Health Insurance Program.
A. Dirigo Health shall publicize the availability of the Dirigo Health Insurance Program to businesses, self-employed individuals and others eligible to enroll in the Dirigo Health Insurance Program.
B. Dirigo Health shall screen all eligible individuals and employees for eligibility for subsidies under section 6912 and eligibility for MaineCare. To facilitate the screening and referral process, Dirigo Health shall provide a single application form for Dirigo Health and MaineCare. The application materials must inform applicants of subsidies available through Dirigo Health and of the additional coverage available through MaineCare. It must allow an applicant to choose on the application form to apply or not to apply for MaineCare or for a subsidy. It must allow an applicant to provide household financial information necessary to determine eligibility for MaineCare or a subsidy. Except when the applicant has declined to apply for MaineCare or a subsidy, an application must be treated as an application for Dirigo Health, for a subsidy and for MaineCare. MaineCare must make the final determination of eligibility for MaineCare.
C. Except as provided in this paragraph, the effective date of coverage for a new enrollee in the Dirigo Health Insurance Program is the first day of the month following receipt of the fully completed application for that enrollee by the carrier contracting with Dirigo Health or the first day of the next month if the fully completed application is received by the carrier within 10 calendar days of the end of the month. If a new enrollee in the Dirigo Health Insurance Program had prior coverage through an individual or small group policy, coverage under the Dirigo Health Insurance Program must take effect the day following termination of that enrollee's prior coverage.
6. Quality improvement, disease management and cost containment. Dirigo Health shall promote quality improvement, disease prevention, disease management and cost-containment programs as part of its administration of the Dirigo Health Insurance Program.
Sec. C-9. 24-A MRSA §6913, sub-§8, ¶A, as enacted by PL 2003, c. 469, Pt. A, §8, is amended to read:
A. On a quarterly basis beginning with the first quarter after the Dirigo Health Insurance Program begins offering coverage, the board shall collect and report on the following:
(1) The total enrollment in the Dirigo Health Insurance Program, including the number of enrollees previously underinsured or uninsured, the number of enrollees previously insured, the number of individual enrollees and the number of enrollees enrolled through small employers;
(2) The total number of enrollees covered in health plans through large employers and self-insured employers;
(3) The number of employers, both small employers and large employers, who have ceased offering health insurance or contributing to the cost of health insurance for employees or who have begun offering coverage on a self-insured basis;
(4) The number of employers, both small employers and large employers, who have begun to offer health insurance or contribute to the cost of health insurance premiums for their employees;
(5) The number of new participating employers in the Dirigo Health Insurance Program;
(6) The number of employers ceasing to offer coverage through the Dirigo Health Insurance Program;
(7) The duration of employers participating in the Dirigo Health Insurance Program; and
(8) A comparison of actual enrollees in the Dirigo Health Insurance Program to the projected enrollees.
Sec. C-10. 24-A MRSA §6971, sub-§§2 and 3, as enacted by PL 2003, c. 469, Pt. A, §8, are amended to read:
2. Disease management. Dirigo Health shall develop appropriate disease management protocols, develop procedures for implementing those protocols and determine the manner in which disease management must be provided to plan enrollees in the high-risk pool. Dirigo Health may include disease management in its contract with participating carriers for the Dirigo Health Insurance Program pursuant to section 6910, contract separately with another entity for disease management services or provide disease management services directly through Dirigo Health.
3. Report. Dirigo Health shall submit a report, no later than January 1, 2006, outlining the disease management protocols, procedures and delivery mechanisms used to provide services to plan enrollees. The report must also include the number of plan enrollees in the high-risk pool, the types of diagnoses managed within the high-risk pool, the claims experience within the high-risk pool and the number and type of claims exceeding $100,000 for enrollees in the high-risk pool and for all enrollees in the Dirigo Health Insurance Program. The report must be submitted to the joint standing committee of the Legislature having jurisdiction over health insurance matters. The committee may make recommendations on the operation of the high-risk pool and may report out legislation to the Second Regular Session of the 122nd Legislature relating to the high-risk pool.
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