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132nd MAINE LEGISLATURE
FIRST REGULAR SESSION-2025
Legislative Document No. 1152
H.P. 757 House of Representatives, March 20, 2025
An Act to Expand the Right to Shop for Health Care Services
Reference to the Committee on Health Coverage, Insurance and Financial Services
suggested and ordered printed.
ROBERT B. HUNT
Clerk
Presented by Representative MORRIS of Turner.
Page 1 - 132LR0700(01)
1Be it enacted by the People of the State of Maine as follows:
2Sec. 1. 24-A MRSA §4318-A, first ¶, as enacted by PL 2017, c. 232, §8, is
3 amended to read:
4 Beginning January 1, 2019, a A carrier offering a health plan in this State shall
5 establish, at a minimum, for all small group health plans as defined in section 2808‑B,
6 subsection 1, paragraph G compatible with a health savings account authorized under
7 federal law, a health plan design in which enrollees are directly incentivized to shop for
8 low-cost, high-quality participating providers for comparable health care services.
9 Incentives may include, but are not limited to, cash payments, gift cards or credits or
10 reductions of premiums, copayments or deductibles. A small group health plan design
11 created under this section must remain available to enrollees for at least 2 consecutive
12 years, except that any changes made to the program after 2 years, including, but not limited
13 to, ending the incentive, may not be construed as a change to the small group health plan
14 design for the purpose of guaranteed renewability under section 2808‑B, subsection 4 or
15 section 2850‑B. Incentives must be equal to or greater than 25% of the difference between
16 the price of the health care service from the provider selected and the statewide average for
17 the same covered health care service based on data reported on the publicly accessible
18 health care costs website of the Maine Health Data Organization. A carrier may use the
19 average price paid to a network provider for the covered comparable health care service
20 under the enrollee’s health plan in lieu of the statewide average price on the Maine Health
21 Data Organization’s publicly accessible health care costs website as long as the carrier uses
22 a reasonable method to calculate the average price paid. A multiple-employer welfare
23 arrangement is not considered a carrier for the purposes of this section.
24Sec. 2. 24-A MRSA §4318-A, sub-§1, ¶A, as enacted by PL 2017, c. 232, §8, is
25 amended to read:
26 A. "Comparable health care service" means nonemergency, outpatient health care
27 services in the following categories:
28 (1) Physical and occupational therapy services;
29 (2) Radiology and imaging services;
30 (3) Laboratory services; and
31 (4) Infusion therapy services. ; and
32 (5) Surgical procedures.
33Sec. 3. 24-A MRSA §4318-B, sub-§1, as enacted by PL 2017, c. 232, §9, is
34 amended to read:
351. Services from out-of-network provider; lower prices. Beginning January 1,
36 2019, if If an enrollee covered under a health plan other than a health maintenance
37 organization plan elects to obtain a covered comparable health care service as defined in
38 section 4318‑A, subsection 1, paragraph A from an out-of-network provider at a price that
39 is the same or less than the statewide average for the same covered health care service based
40 on data reported on the publicly accessible health care costs website of the Maine Health
41 Data Organization, the carrier shall allow the enrollee to obtain the service from the out-
42 of-network provider at the provider's charge and, upon request by the enrollee, shall apply
43 the payments made by the enrollee for that comparable health care service toward the
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44 enrollee's deductible and out-of-pocket maximum as specified in the enrollee's health plan
45 as if the health care services had been provided by an in-network provider. A carrier may
46 use the average price paid to a network provider for the covered comparable health care
47 service under the enrollee's health plan in lieu of the statewide average price on the Maine
48 Health Data Organization's publicly accessible health care costs website as long as the
49 carrier uses a reasonable method to calculate the average price paid and the information is
50 available to enrollees through a website accessible to the enrollee and a toll-free telephone
51 number that provide, at a minimum, information relating to comparable health care
52 services. The enrollee is responsible for demonstrating to the carrier that payments made
53 by the enrollee to the out-of-network provider should be applied toward the enrollee's
54 deductible or out-of-pocket maximum pursuant to this section. The carrier shall provide a
55 downloadable or interactive online form to the enrollee for the purpose of making such a
56 demonstration and may require that copies of bills and proof of payment be submitted by
57 the enrollee. For the purposes of this section, "out-of-network provider" means a provider
58 located in Massachusetts, New Hampshire or this State that is enrolled in the MaineCare
59 program and participates in Medicare.
17SUMMARY
18 This bill makes the following changes to the law relating to the comparable health care
19 service incentive program.
20 1. It removes the requirement that the small group health plan design be compatible
21 with a federally authorized health savings account.
22 2. It requires that the incentives be equal to or greater than 25% of the difference
23 between the price of the health care service from the provider selected and the statewide
24 average for the same covered health care service based on data reported on the publicly
25 accessible health care costs website of the Maine Health Data Organization.
26 3. It adds surgical procedures to the categories of nonemergency, outpatient health
27 care services included in the definition of "comparable health care service."
28 Under current law, if an enrollee covered under a health plan other than a health
29 maintenance organization plan elects to obtain a covered comparable health care service
30 from an out-of-network provider at a price that is the same or less than the statewide
31 average for the same covered health care service, the carrier is required to allow the enrollee
32 to obtain the service from the out-of-network provider at the provider's charge and, upon
33 request by the enrollee, to apply the payments made by the enrollee for that comparable
34 health care service toward the enrollee's deductible and out-of-pocket maximum as
35 specified in the enrollee's health plan as if the health care services had been provided by an
36 in-network provider. The bill removes the exception that the provision does not apply to a
37 health maintenance organization plan. The bill also removes the limitation defining "out-
38 of-network provider" as a provider located in Massachusetts, New Hampshire or Maine
39 that is enrolled in the MaineCare program and participates in Medicare.
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