SP0470, LD 1305, item 2, ‘An Act To Improve Transparency and Help Consumers Compare Costs for Health Care Procedures and Treatment’

Amend the bill by striking out the title and substituting the following:

‘An Act To Improve Transparency and Help Consumers Compare Costs for Health Care Procedures and Treatment’

Amend the bill by striking out everything after the enacting clause and before the summary and inserting the following:

‘Sec. 1. 24-A MRSA §4303-C is enacted to read:

§ 4303-C. Payments for health care services; estimates

A carrier offering a health plan in this State shall comply with the following requirements with respect to payments for health care services.

1. Payment information; availability on website. By January 1, 2018, a carrier shall establish an interactive mechanism on its publicly accessible website that enables an enrollee to request and obtain from the carrier information on the payments made by the carrier to network providers for health care services. The interactive mechanism must allow an enrollee seeking information about the cost of a particular health care service to compare costs among network providers. If a carrier is unable to comply under this subsection, a carrier may satisfy the requirements of this subsection by providing a link on its publicly accessible website to enable an enrollee to obtain payment information for that carrier through the publicly accessible website established by the Maine Health Data Organization pursuant to Title 22, section 8712, subsection 2.

2. Estimate of out-of-pocket costs. Beginning January 1, 2018, within a reasonable time of an enrollee's request, a carrier shall provide a good faith estimate of the amount the enrollee will be responsible to pay out of pocket for a proposed nonemergency procedure or service that is a medically necessary covered benefit from a carrier's network provider, including any copayment, deductible, coinsurance or other out-of-pocket amount for any covered benefit, based on the information available to the carrier at the time the request is made. This subsection does not prohibit a carrier from imposing cost-sharing requirements disclosed in the enrollee's certificate of coverage for unforeseen health care services that arise out of the nonemergency procedure or service or for a procedure or service provided to an enrollee that was not included in the original estimate. A carrier shall notify an enrollee that these are estimated costs, and that the actual amount the enrollee will be responsible to pay may vary due to unforeseen circumstances that arise out of the proposed nonemergency procedure or service. For purposes of this subsection, "nonemergency procedure or service" means a nonemergency health care procedure or health care service in the following categories only:

A. Office visits;

B. Physical and occupational therapy services;

C. Integrative medicine services;

D. Mental health services;

E. Obstetrical and gynecological services;

F. Radiology and imaging services; and

G. Laboratory services.’

summary

This amendment is the majority report of the committee. The amendment replaces the bill, changes the title and does the following.

The amendment requires a health insurance carrier by January 1, 2018 to establish an interactive mechanism on its publicly accessible website that enables an enrollee to request and obtain from the carrier information on the payments made by the carrier to network providers for health care services. The interactive mechanism must allow an enrollee seeking information about the cost of a particular health care service to compare costs among network providers. The amendment allows a carrier that is unable to comply to provide a link on its publicly accessible website to enable an enrollee to use the Maine Health Data Organization's CompareMaine website.

The amendment requires health insurance carriers beginning January 1, 2018 to provide a good faith estimate, within a reasonable time of a request, of the estimated amount of the out-of-pocket costs to be paid by the enrollee for a proposed nonemergency procedure or service from a network provider. The amendment defines a nonemergency procedure or service as a procedure or service in one of the following 7 categories: office visits; physical and occupational therapy services; integrative medicine services; mental health services; obstetrical and gynecological services; radiology and imaging services; and laboratory services.

SP0470 LD 1305	Session - 127th Maine Legislature C "A", Filing Number S-406, Sponsored by		LR 956 Item 2
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