Out-Of-Network Provider Referrals Must Be Accepted

On July 13, 2018, Superintendent of Insurance Cioppa issued Bulletin 430 to clarify the legislative intent behind a recently enacted law that prohibits a carrier from denying payment for any covered health care service solely on the basis that the referral was made by a provider that was not a member of the carrier's provider network. The bulletin is in response to questions the bureau received about the interpretation and scope of the law change, including whether it prohibits so-called "gatekeeper" plans, which are typical for HMOs, from requiring all referrals to be made by the enrollee's designated primary care provider (PCP).

As background, effective Jan. 1, 2018, Gov. LePage signed 24-A M.R.S. §4303(22) into law. This law prohibits a carrier from denying an enrollee's referral for a covered service solely because it is from an out-of-network provider. The law applies to all carriers including HMOs and also limits carriers using tiered networks or other incentive programs that require the use of particular designated providers and exclude "non-designated" network providers from making referrals.

The bulletin clarifies that the law doesn't mean carriers must honor all referrals made by out-of-network providers, or that carriers can't impose reasonable restrictions that don't distinguish between referring providers on the basis of network membership. For example, a carrier may still deny the referral if the proposed service doesn't meet the carrier's documented clinical review criteria, to the extent otherwise permitted by law. The law does, however, prohibit any "gatekeeper" procedure traditionally used by HMOs.

This bulletin is intended for informational purposes and is primarily focused on carriers. So, fully insured employers don't need to take any action.

Bulletin 430 »
24-A M.R.S. §4303(22) »