MAINE

Overview

Maine is a state that actively promotes healthcare price transparency. The Maine Health Data Organization (MHDO), an independent executive agency that the legislature established in 1996, operates the state’s all-payer claims database (APCD). The MHDO has collected health insurance claims information since 2003 and currently shares claims from commercial insurance carriers, third party administrators (TPAs), pharmacy benefit managers (PBMs), dental benefit administrators, MaineCare (Maine Medicaid), and CMS (Medicare). Maine also protects patients from surprise bills. Insurance carriers may legally only require enrollees to pay up to the in-network out-of-pocket cost for surprise bills from an out-of-network provider. In 2020, the legislature passed a law that requires providers to disclose to non-emergency referred enrollees whether the provider is in the enrollee’s health plan’s network before the enrollee schedules an appointment for the service (LD 2111). Maine also requires insurance carriers to offer and post notice of a shared savings plan that incentivizes patients to shop for low-cost, high-quality participating providers for comparable health services. Incentives include cash payments, gift cards, credits or reductions in premiums, copayments or deductibles.

Maine has made strides in pharmaceutical legislation as the first state in the country to enact a law to require drugs distributed in the state to be made available at a fair market price and without restrictions to generic companies for use as samples to accelerate the development of lower-cost generics. In recent sessions, the state passed several pharmaceutical laws, including measures that regulate PBMs (LD 1504), increase drug price transparency (LD 1162), allow drug importation from Canada (LD 1272), and establish a Drug Affordability Review Board (LD 1499). Another new prescription drug price transparency law, LD 1406, directs the MHDO to collect data from manufacturers and report annually to Maine legislators the 25 most commonly prescribed drugs that experience large cost hikes.

In health system and delivery reform, Maine requires coverage parity and cost-sharing parity for telehealth services. Although there has been proposed legislation, current law does not require reimbursement parity in telemedicine. The state has also proposed reform initiatives for a public option plan and a single-payer system, but neither passed the legislature. In 2018, the CMS approved Maine’s 1332 innovation waiver for its reinsurance program under the Maine Guaranteed Access Reinsurance Program Association to lower individual market premiums and premium tax credits. Additionally, Governor Mills signed into law LD 1 (2019), which requires insurers to offer the ten essential benefits and protections of the Affordable Care Act (ACA), regardless of the ACA’s fate.

To ensure market competition, Maine law requires written notice to the Attorney General (AG) of any merger or consolidation of a nonprofit hospital. The state also requires a Certificate of Need (CON) for any construction, expansion, acquisition, acquisition of control, or transfer of ownership of a health care facility. Nonprofit hospital mergers require approval from the AG, or alternatively, a court if the AG does not approve. Mergers that would exchange assets valued at less than $50,000 require notice instead of approval. Otherwise, the fair market value of the assets to be converted is a factor in the merger review criteria. Maine also prohibits most-favored nation clauses in provider contracts to deter anticompetitive behavior.

See below for an overview of existing Maine state mandates. Click on citation tab for detailed information of specific statutes (click link to download statute text).

State Action


Current Legislative Session: 12/2/2020 - 6/16/2021 (2021-2022 term). *Current session bill updates are ongoing. Check back weekly for updates.

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© 2018-2020 The SLIHCQ DatabaseInitial funding for this project was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.

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© 2018-2020 The SLIHCQ DatabaseInitial funding for this project was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.
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Additional Resources

STATE 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, 2020 and is valid through June 30, 2021. To view Maine’s 2020-2021 Budget, click here.

REGULATION & ENFORCEMENT

  • 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.
  • 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, No. 14-35173 (March 7, 2014), 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 for the states.

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