Maine has been active in regulating healthcare price transparency. Maine makes available the state’s All-Payer Claims Database (APCD), for which the state has collected health insurance claims information since 2003. The APCD currently holds claims from commercial insurance carriers, third party administrators (TPAs), pharmacy benefit managers (PBMs), dental benefit administrators, MaineCare (Maine Medicaid), and CMS (Medicare).
Early in 2015, Maine passed a bill that requires health benefit plans selling plans in Maine to provide beneficiaries with an online drug formulary. The state legislature also tried—but failed—to pass a bill that would have established financial penalties for entities that are required to disclose price information under Maine’s APCD and fail to do so.
In early 2018, Maine passed a bill to promote prescription drug price transparency (LD1406), which directs the Maine Health Data Organization to report on the 25 most commonly prescribed drugs that have experienced large cost hikes. The organization must establish a plan for data collection from manufacturers, and provide Maine lawmakers with an annual report on prescription drug prices beginning in April 2019. Also in 2018, Maine passed legislation to maintain parts of the Affordable Care Act’s essential health benefits over the governor’s veto, and proposed a single-payor universal health care system.
Maine’s most recent legislative session ran from 1/2/2018 – 4/18/2018.
Recent Legislative Developments
|2017-2018||LD1406||AN ACT TO PROMOTE PRESCRIPTION DRUG PRICE TRANSPARENCY: requires the Attorney General to compile a list of certain drugs and list the drugs’ percentage of wholesale acquisition cost increase, if any, and make the list available to the public on a publicly accessible website. Drug manufactures would be required to provide justification of the increase of cost as well.||Passed – 4/18/2018 (Chapter 406)|
|LD6||AN ACT TO PROHIBIT INSURANCE CARRIERS FROM CHARGING ENROLLES FOR PRESCRIPTION DRUGS IN AMOUNTS THAT EXCEED THE DRUGS’ COSTS: prohibits a carrier or pharmacy benefits manager to impose on an enrollee a copayment or other charge that exceeds the claim cost of a prescription drug. If information related to an enrollee’s out-of-pocket cost of the clinical efficacy of a prescription drug or alternative medication is available to a pharmacy provider, a carrier or pharmacy benefits manager may not penalize provider for providing that information to enrollee.||Passed – Signed by the Governor– 5/5/2017.|
|2015-2016||LD636||AN ACT TO PROVIDE CONSUMERS OF HEALTH CARE WITH INFORMATION REGARDING HEALTH CARE COSTS: requires carriers that offer health plans in Maine to provide enrollees and prospective enrollees with information, on a publicly accessible website, regarding: (i) each prescription drug formulary for each health plan it offers (and updates to the formulary would need to be posted within 72 hours); (ii) the requirements for utilization review, prior authorization, or step therapy for each prescription drug covered by the health plan; (iii) cost-sharing requirements for prescription drug use, including how it will affect deductibles; (iv) plan exclusions; and (v) the amount of coverage provided under a health plan for out-of-network providers or non-covered health care services, as well as any right of appeal.||Passed — Signed by the governor.|
|LD1150||AN ACT REGARDING MAXIMUM ALLOWABLE COST PRICING LISTS USED BY PHARMACY BENEFIT MANAGERS: establishes requirements for maximum allowable cost pricing lists used by pharmacy benefit managers and requires pharmacy benefit managers to make disclosures regarding that pricing and methods used to establish that pricing to plan sponsors. It established an appeal process for pharmacies for disputes relating to the maximum allowable cost pricing and provides financial penalties for violations.||Passed – Signed by Governor–4/11/2016.|
|LD813||PENALTIES FOR FAILURE TO COMPLY WITH DISCLOSURE OF HEALTH CARE CHARGES: In Maine, health care entities are required, via 22 MRSA Section 1718, to make available to patients the prices of the health care entity’s most frequently provided health care services and procedures and must prominently display the price transparency tools available from the Maine Health Data Organization’s website. LD813 would have provided penalties for failure to comply with these disclosures. LD813 would have allowed individuals aggrieved by an intentional violation to bring a civil action in Superior Court. It would also have subjected hospitals, ambulatory surgical centers, and health care entities that commit intentional violations to civil penalties up to $5,000, payable to the state. LD813 would also have allowed fine of up to $10,000 for health care practitioners—and up to $50,000 for health care facilities—that violate the provision after receiving due notice of the violating conduct.||Inactive — Died.|
|LD1305||AN ACT TO ENCOURAGE HEALTH INSURANCE CONSUMERS TO COMPARISON SHOP FOR HEALTH CARE PROCEDURES AND TREATMENT: would require health care entities to disclose the allowed amount/amount to be charged at least two working days prior to a patient’s receipt of admission, a procedure, or a service if a patient requests it. If the health care entity cannot predict, with certainty, the charges, it must do so to the best of its ability. Should a health care entity fail to disclose the required information, it would be prohibited from billing the patient or the patient’s insurance carrier for the admission, procedure, or service. If the health care entity participates in the patient’s carrier network, the entity would be required to provide sufficient information about the cost of the admission, procedure, or service via a publicly accessible website and a toll-free phone number.
LD1305 would also require that health care entities and insurance carriers have access—at no cost—to the Main Health Data Processing Center’s all-payor and all-settings health care database for the purpose of providing cost information to its patients and prospective patients. Disclosed information would be reasonably limited to the minimum extent necessary and could only be used for the purposes of providing patients with information about prospective admissions, procedures, and services.
LD1305 would also require health carriers to a establish toll-free phone numbers and publicly accessible websites that would enable their enrollees to request and obtain information regarding the average price paid in the last 12 months to network providers for proposed admissions, procedures, and services—by geographic rating area. Health carriers would be required to provide an enrollee with a binding estimate for the maximum allowed charge within 2 business days of a request.
Additionally, if an enrollee were to elect to receive health care services from a provider that cost less than the average amount for a particular admission, procedure or service, a carrier would be required to pay to an enrollee 50% of the saved cost to a maximum of $7,500 except that a carrier is not required to make a payment if the saved cost is $50 or less. A payment to an enrollee would need to be made within 30 days. If an enrollee were to elect to receive health care services from an out-of-network provider that cost less than the average amount for a particular admission, procedure or service, a carrier would be required to apply the enrollee’s share of the cost of those health care services as specified in the enrollee’s health plan toward the enrollee’s member cost sharing as if the health care services were provided by a network provider.
LD1305 would also require all carriers to file with superintendent of insurance, on an annual basis: the total number of patient requests for binding estimates, the total number of cost-savings transactions made, the average cost of these transactions, the total savings achieved below the average cost by services for such transactions, the total number of payments made to enrollees, and the total number and percentage of a carrier’s enrollees that participated in such transactions.
|Inactive — Died.|
- None identified.
|2017-2018||LD 386 139
|AN ACT TO ESTABLISH UNIVERSAL HEALTH CARE FOR MAINE: establishes a single-payor, universal health care system in the state.||Inactive/Dead – 2/22/18.|
|LD 1476||AN ACT TO ENSURE CONTINUED COVERAGE FOR ESSENTIAL HEALTH CARE: incorporates current requirements under the federal Patient Protection and Affordable Care Act for coverage of preventive health services, including services for women, into state law.||Passed – Governor’s Veto Overridden 3/28/18. (24-A Maine Ins. Code § 4320-A)|
We compile state statutes relate to healthcare price and competition, including healthcare transparency, markets, and costs. For a complete listing of all health related statutes visit the State Health Practice Database for Research.
Transparency in Healthcare
- The Maine Health Data Organization (MHDO) was established by the Maine Legislature in 1996 as an independent executive agency to collect clinical and financial health care information and to exercise responsible stewardship in making this information accessible to the public. 22 Maine Rev. Stat. § 8701 – 8713. Some examples of MHDO’s work include: 1. MHDO makes available the state’s All-Payer Claims Database, for which the state has has collected health insurance claims information since 2003. The APCD currently holds claims from commercial insurance carriers, third party administrators (TPAs), pharmacy benefit managers (PBMs), dental benefit administrators, MaineCare(Maine Medicaid), and CMS (Medicare). 2. MHDO provides a range of cost and quality information, including on Maine HealthCost, which provides cost information on common procedures at a number of facilities. 3. MHDO recently received a $2.6 million grant from the Centers for Medicare & Medicaid Services (CMS) to enhance its website’s offerings.
- 24-A MRSA §4317, sub-§13: Prohibition on excessive copayments or charges; disclosure not penalized. A carrier or pharmacy benefits manager may not impose on an enrollee a copayment or other charge that exceeds the claim cost of a prescription drug. If information related to an enrollee’s out-of-pocket cost or the clinical efficacy of a prescription drug or alternative medication is available to a pharmacy provider, a carrier or pharmacy benefits manager may not penalize a pharmacy provider for providing that information to an enrollee.
- 24-A MRSA §4317, sub-§12: establishes requirements for maximum allowable cost pricing lists used by pharmacy benefit managers and requires pharmacy benefit managers to make disclosures regarding that pricing and methods used to establish that pricing to plan sponsors. It established an appeal process for pharmacies for disputes relating to the maximum allowable cost pricing and provides financial penalties for violations.
- 24-A MRSA §4303, sub-§20 requires carriers that offer health plans in Maine to provide enrollees and prospective enrollees with information, on a publicly accessible website, regarding: (i) each prescription drug formulary for each health plan it offers (and updates to the formulary would need to be posted within 72 hours); (ii) the requirements for utilization review, prior authorization, or step therapy for each prescription drug covered by the health plan; (iii) cost-sharing requirements for prescription drug use, including how it will affect deductibles; (iv) plan exclusions; and (v) the amount of coverage provided under a health plan for out-of-network providers or non-covered health care services, as well as any right of appeal.
- 22 MRSA § 1718-B, the April 2014 revision of 22 MRSA §1718-A, effective January 1, 2014, requires providers to publish prices for their most common services. Specifically: 1. Healthcare entities must provide pricing information (price charged in the absence of insurance, for their most frequently performed procedures (those performed at least 50 times in the previous calendar year); and 2. Healthcare entities must prominently display information about MHDO’s price transparency tools.
- 24-A Maine Ins. Code §4303prescribes requirements for health plan contracts. Among other things, the statute prohibits certain contract provisions including (1) those which induce financial incentives to deny medically necessary services and (2) most-favored-nations clauses.
- 24-A Maine Ins. Code § 4320-H: 2012 legislation that authorized a pilot program to allow for insurance carriers to implement payment reform strategies with providers through the structure of ACOs.
- 22 M.R.S. § 327, Maine’s Certificate of Need Provision, has the following articulated purpose: “The Legislature finds that unnecessary construction or modification of health care facilities and duplication of health services are substantial factors in the cost of health care and the ability of the public to obtain necessary medical services.” Guidelines for obtaining CONs are available here.
- 10 M.R.S. § 201 contains Maine’s antitrust law, which is similar to federal antitrust laws, and is enforced, in part, by the Consumer Protection Division of the Maine Attorney General’s Office.
- 24-A Maine Ins. Code § 4320-A: incorporates current requirements under the federal Patient Protection and Affordable Care Act for coverage of preventive health services, including services for women, into state law.
- 22 M.R.S. §§ 1841-52, the Hospital and Health Care Provider Cooperation Act, supports cooperation among providers, provides for the issuance of certificates of public advantage, and provides an exemption from federal antitrust scrutiny (under the state action doctrine). The articulated purpose of the law is:
- “The Legislature finds that it is necessary and appropriate to encourage hospitals and other health care providers to cooperate and enter into agreements that will facilitate cost containment, improve quality of care and increase access to health care services. This Act provides processes for state review of overall public benefit, for approval through certificates of public advantage and for continuing supervision. It is the intent of the Legislature that a certificate of public advantage approved under this chapter provide state action immunity under applicable federal antitrust laws.”
FY 2018-2019 BUDGET
Maine enacts budgets on a two-year cycle, beginning July 1 of each odd-numbered year. Maine’s new Biennial Budget will take effect on July 1, 2017 and is valid through June 30, 2019. To view Maine’s 2018-2019 Budget, click here.
- Maine was one of 16 states to file an amicus brief supporting the FTC’s winning position in the Ninth Circuit appeal of St. Luke’s Health Care Sys. v. FTC, decided February 10, 2015. The States’ brief stated that the acceleration of health care costs due to the growth of large health care provider systems had become a matter of grave concern.
- Maine v. MaineHealth, Maine Sup. Ct. No. 13CD-11-285 (2011): In 2011, Maine’s Attorney General challenged Maine Medical Center’s (MCC) proposed acquisition of the two largest cardiology groups in southern Maine: Maine Cardiological Associates (MCA) and Cardiovascular Consultants of Maine (CCM). MMC is controlled by MaineHealth (MH), the largest health system in southern Maine. The parties had applied to the Maine Department of Health and Human Services (Maine DHHS) for a certificate of public advantage under 22 M.R.S. §§ 1841-52, the Hospital and Health Care Provider Cooperation Act. But, the cooperative agreement was ineligible for a certificate of public advantage (or immunity from federal antitrust laws) because the law is limited to horizontal mergers, whereas this deal was vertical in that it would combine a hospital and physician practice. Instead, the state challenged the merger. Eventually, the state and the parties entered into a five-year consent decree imposing conduct remedies including with regard to payments received, rates charged, services offered, employment contracts and compensation, and network affiliations. Key documents from the case, including consent decree available on state AG’s website.