PLEASE NOTE: Legislative Information cannot perform research, provide legal advice, or interpret Maine law. For legal assistance, please contact a qualified attorney.
An Act To Limit Allowable Health Care Charges in Certain Specified Situations
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4303, sub-§8-A, as enacted by PL 2011, c. 238, Pt. A, §1, is amended to read:
 
8-A. Protection from balance billing by providers.   An enrollee's responsibility for payment under a managed care plan must be limited as provided in this subsection.
 
A. The terms of a managed care plan must provide that the enrollee's responsibility for the cost of covered health care rendered by participating providers is limited to the cost-sharing provisions expressly disclosed in the contract, such as deductibles, copayments and coinsurance, and that if the enrollee has paid the enrollee's share of the charge as specified in the plan, the carrier shall hold the enrollee harmless from any additional amount owed to a participating provider for covered health care.
 
B. Every provider agreement with a participating provider must be in writing and must set forth that if the carrier fails to pay for health care services as set forth in the contract, the enrollee is not liable to the provider for any sums owed by the carrier.
 
C. A participating provider may not collect or attempt to collect any charge from an enrollee for covered health care beyond the amount permitted by the terms of the plan, notwithstanding the carrier's insolvency, the carrier's failure to pay the amount owed by the carrier, any other breach by the carrier of the provider agreement or the failure of the provider agreement to include the written hold harmless provision required by paragraph B.
 
D.  An enrollee's responsibility for the cost of covered health care rendered by an out-of-network provider in the hospital or other health care facility of a participating provider is limited to the cost-sharing provisions expressly disclosed in the contract for services rendered by participating providers. If the enrollee has paid the enrollee's share of the charge as specified in the managed care plan, the carrier shall hold the enrollee harmless from any additional amount owed to an out-of-network provider for covered health care. An enrollee is not liable to any out-of-network provider working within the hospital or health care facility of a participating provider for any charge beyond the amount permitted by the terms of the cost-sharing provisions of the plan.
 
SUMMARY
This bill limits a health plan enrollee's responsibility for the cost of covered health care when an enrollee receives health care services from an out-of-network provider at a participating hospital or other health care facility to the cost-sharing provisions for participating providers.