An Act To Protect Consumers from Surprise Emergency Medical Bills
Sec. 1. 22 MRSA §1718-D, as enacted by PL 2017, c. 218, §1 and affected by §3, is amended to read:
§ 1718-D. Prohibition on balance billing for surprise bills ; disputes of surprise bills for uninsured patients and persons covered under self-insured health benefit plans
Sec. 2. 24-A MRSA §4303-C, as enacted by PL 2017, c. 218, §2 and affected by §3, is amended to read:
§ 4303-C. Protection from surprise bills
(1) Whether there is a gross disparity between the fee charged by the out-of-network provider for services rendered as compared to:
(a) Fees paid to the provider for the same services rendered by the provider to other enrollees in a carrier's health plans in which the provider is not participating; and
(b) Fees paid by the carrier to reimburse similarly qualified providers for the same services in the same region who are not participating with the carrier;
(2) The out-of-network provider's level of training, education, specialization, quality and experience and, in the case of a hospital, the teaching staff, scope of services and case mix;
(3) The out-of-network provider's contracted rates for comparable services in the same geographic area with regard to patients in health care plans in which the provider is not participating;
(4) The circumstances and complexity of the particular case, including time and place of the service;
(5) Individual patient characteristics; and
(6) The usual and customary cost of the health care service as determined by the 80th percentile of the particular health care service performed by a provider in the same or similar specialty, as determined by the all-payer claims database maintained by the Maine Health Data Organization or, if Maine Health Data Organization claims data is insufficient or otherwise inapplicable, another independent medical claims database. If authorized by rule, the superintendent may enter into an agreement to obtain data from an independent medical claims database to carry out the functions of this subparagraph.
(1) Whether the determination was in favor of the carrier, out-of-network provider or uninsured patient;
(2) The payment amount offered by each side of the independent dispute resolution process and the award amount from the independent dispute resolution determination;
(3) The category and practice specialty of each out-of-network provider involved, as applicable; and
(4) A description of the health care service that was subject to dispute;
The superintendent shall submit the report to the joint standing committee of the Legislature having jurisdiction over health insurance matters and shall post the report on the bureau's publicly accessible website.
Sec. 3. 24-A MRSA §4303-E is enacted to read:
§ 4303-E. Payment after resolution of surprise bill disputes
Following an independent dispute resolution determination pursuant to section 4303-C, subsection 3, the determination by the independent dispute resolution entity of a reasonable payment for a specific health care service or treatment rendered by an out-of-network provider is binding on a carrier, out-of-network provider and enrollee for 90 days. During that 90-day period, a carrier shall reimburse an out-of-network provider at that same rate for that specific health care service or treatment and an out-of-network provider may not dispute any bill for that service under section 4303-C.
Sec. 4. 24-A MRSA §4320-C, as amended by PL 2019, c. 238, §3, is further amended to read:
§ 4320-C. Emergency services
If a carrier offering a health plan provides or covers any benefits with respect to services in an emergency facility or setting, the plan must cover emergency services without prior authorization. Cost-sharing requirements, expressed such as a deductible, copayment amount or coinsurance rate, for out-of-network services are the same as requirements that would apply if such services were provided in network , and any payment made by an enrollee pursuant to this section must be applied to the enrollee's in-network cost-sharing limit. Except with respect to a surprise bill for emergency services as provided for in section 4303-C, the enrollee's responsibility for payment for covered out-of-network emergency services must be limited so that if the enrollee has paid the enrollee's share of the charge as specified in the plan for in-network services, the carrier shall hold the enrollee harmless from any additional amount owed to an out-of-network provider for covered emergency services and make payment to the out-of-network provider in accordance with subsection 1. A carrier offering a health plan in this State shall also comply with the requirements of section 4304, subsection 5.
This bill amends the law providing consumer protection for surprise medical bills to include surprise bills for emergency services. In the event of a dispute with respect to a surprise medical bill, the bill directs the Superintendent of Insurance to develop an independent dispute resolution process to determine a reasonable payment for health care services.