Bulletin Describes New Law That Encourages Consumers to Comparison-Shop for Health Care Services

On Sept. 20, 2017, the Maine Insurance Department published Bulletin 424. The bulletin outlines new requirements for health insurance carriers that offer health plans in Maine relating to encouraging consumers to comparison-shop for health care procedures. According to the bulletin, beginning Jan. 1, 2018, carriers must make a website and toll-free telephone number available to enrollees to obtain estimated cost and quality data for comparable health care services obtained from network providers. For this purpose, “comparable health care services” means physical and occupational therapy services, radiology and imaging services, laboratory services and infusion therapy services. Carriers may satisfy that requirement by directing enrollees to the Maine Health Data Organization (MHDO) website. Carriers may not deny payment for a covered health care service solely on the basis that a referral was made for the service by an out-of-network provider.

In addition, beginning Jan. 1, 2019, carriers must provide programs that directly incentivize enrollees (employees) to shop for comparable health care services from low-cost, high-quality participating providers. These incentive programs must be included, at a minimum, in all HSA-compatible small group health plans, other than MEWAs, and must remain available for at least two years (after which the carrier may modify or terminate the program). A detailed description of the incentives must be included in the SBC at the time of enrollment and annually on renewal.

Lastly, beginning Jan. 1, 2019 (and ending on Jan. 1, 2024), carriers must allow enrollees in any health plan (except an HMO) to obtain comparable health care services from out-of-network providers if the price is no higher than the average price paid to network providers for the covered comparable health care service under the enrollee’s health plan.

The bulletin contains no new employer obligations. But Maine employers should be aware of the new consumer protection laws, since they could potentially impact covered employees as they shop for health care services.

Bulletin 424 »