LD 130
pg. 6
Page 5 of 22 An Act To Establish a Single-payor Health Care System Page 7 of 22
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LR 241
Item 1

 
charged for medically necessary, emergency health care
services obtained by a plan member from a provider who is not
a participating provider.

 
E.__Copayments or deductibles do not apply to health care
services provided through the plan, except that, to
encourage the use of the most appropriate and cost-effective
mode of service, an organized delivery system may require
reasonable payments by a plan member if payment is approved
by the agency and does not substantially interfere with
access to needed health care services.

 
F.__Accountability to the public of the open plan and
organized delivery systems must be ensured in order to
promote public confidence in the health care delivery system
and awareness of the costs of care.

 
G.__Flexible enrollment and transfer processes that preserve
plan member confidence and ensure that health care needs are
met must be provided.

 
H.__An opportunity for negotiation of fair rates of
compensation with participating providers in the open plan
and organized delivery systems and negotiation with
pharmaceutical companies for similarly classified
pharmaceuticals must be provided.

 
I.__A program to expand services to underserved rural and
low-income communities must be established.

 
J.__Mechanisms must be developed to provide incentives to
participating providers in the open plan and to organized
delivery systems for additional savings that do not
compromise the quality of health care.

 
Rules adopted pursuant to this subsection are routine technical
rules as defined in Title 5, chapter 375, subchapter 2-A.

 
5.__Provider requirements.__Participating providers, the open
plan and organized delivery systems may not charge a plan member
or a 3rd party for covered health services and may not charge
rates in excess of the reimbursement levels set by the agency.__A
participating provider of health care services, the open plan and
organized delivery systems may not refuse to provide services to
a plan member on the basis of health status, medical condition,
previous insurance status, race, color, creed, age, national
origin, citizenship status, gender, sexual orientation,
disability, marital status or arrest record except as appropriate
to the provider's professional specialization or other medically
appropriate circumstances.


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