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USA Statutes : maine
Title : Title 24-A. MAINE INSURANCE CODE
Chapter : Chapter 87. DIRIGO HEALTH (HEADING. PL 2003, c. 469, Pt. A, @8 (new))
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Title 24-A - §6901. Short title
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6901. Short title
This chapter may be known and cited as "the Dirigo Health Act."
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6902. Dirigo Health established; declaration of necessity
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6902. Dirigo Health established; declaration of necessity
Dirigo Health is established as an independent executive agency to arrange for the provision of comprehensive, affordable
health care coverage to eligible small employers, including the self-employed, their employees and dependents, and individuals
on a voluntary basis. Dirigo Health is also responsible for monitoring and improving the quality of health care in this State.
The exercise by Dirigo Health of the powers conferred by this chapter must be deemed and held to be the performance of essential
governmental functions.
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6903. Definitions
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6903. Definitions
As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings.
[2003, c. 469, Pt. A, §8 (new).]
1. Board. "Board" means the Board of Directors of Dirigo Health, as established in section 6904.
[2003, c. 469, Pt. A, §8 (new).]
2. Child. "Child" means a natural child, stepchild, adopted child or child placed for adoption with a plan enrollee.
[2003, c. 469, Pt. A, §8 (new).]
3. Dependent. "Dependent" means a spouse, an unmarried child under 19 years of age, a child who is a student under 23 years of age and
is financially dependent upon a plan enrollee or a person of any age who is the child of a plan enrollee and is disabled and
dependent upon that plan enrollee. "Dependent" may include a domestic partner consistent with sections 2741-A, 2832-A and
4249 and Title 24, section 2319-A.
[2003, c. 469, Pt. A, §8 (new).]
4. Dirigo Health Insurance.
[2005, c. 400, Pt. A, §3 (rp).]
4-A. Dirigo Health Program. "Dirigo Health Program" means the program of services provided by Dirigo Health that includes comprehensive health benefits
coverage, subsidies, wellness programs and quality improvement initiatives.
[2005, c. 400, Pt. A, §4 (new).]
5. Eligible business. "Eligible business" means a business that employs at least 2 but not more than 50 eligible employees, the majority of whom
are employed in the State, including a municipality that has 50 or fewer employees.
After one year of operation of Dirigo Health, the board may, by rule, define "eligible business" to include larger public
or private employers.
[2003, c. 469, Pt. A, §8 (new).]
6. Eligible employee. "Eligible employee" means an employee of an eligible business who works at least 20 hours per week for that eligible business.
"Eligible employee" does not include an employee who works on a temporary or substitute basis or who does not work more than
26 weeks annually.
[2003, c. 469, Pt. A, §8 (new).]
7. Eligible individual. "Eligible individual" means:
A. A self-employed individual who:
(1) Works and resides in the State; and
(2) Is organized as a sole proprietorship or in any other legally recognized manner in which a self-employed individual
may organize, a substantial part of whose income derives from a trade or business through which the individual has attempted
to earn taxable income;
[2003, c. 469, Pt. A, §8 (new).]
B. An unemployed individual who resides in this State; or
[2003, c. 469, Pt. A, §8 (new).]
C. An individual employed in an eligible business that does not offer health insurance.
[2003, c. 469, Pt. A, §8 (new).]
[2003, c. 469, Pt. A, §8 (new).]
8. Employer. "Employer" means the owner or responsible agent of a business authorized to sign contracts on behalf of the business.
[2003, c. 469, Pt. A, §8 (new).]
9. Executive director. "Executive director" means the Executive Director of Dirigo Health.
[2003, c. 469, Pt. A, §8 (new).]
10. Health insurance carrier. "Health insurance carrier" means:
A. An insurance company licensed in accordance with this Title to provide health insurance;
[2003, c. 469, Pt. A, §8 (new).]
B. A health maintenance organization licensed pursuant to chapter 56;
[2003, c. 469, Pt. A, §8 (new).]
C. A preferred provider arrangement administrator registered pursuant to chapter 32;
[2003, c. 469, Pt. A, §8 (new).]
D. A nonprofit hospital or medical service organization or health plan licensed pursuant to Title 24; or
[2003, c. 469, Pt. A, §8 (new).]
E. An employee benefit excess insurance company licensed in accordance with this Title to provide property and casualty insurance
that provides employee benefit excess insurance pursuant to section 707, subsection 1, paragraph C-1.
[2003, c. 469, Pt. A, §8 (new).]
[2003, c. 469, Pt. A, §8 (new).]
11. Health plan in Medicaid. "Health plan in Medicaid" means a health insurance carrier that meets the requirements of 42 Code of Federal Regulations,
Part 438 (2002) and has a contract with the Department of Health and Human Services to provide MaineCare-covered services
to individuals enrolled in MaineCare.
[2003, c. 469, Pt. A, §8 (new); c. 689, Pt. B, §6 (rev).]
12. Participating employer. "Participating employer" means an eligible business that contracts with Dirigo Health pursuant to section 6910, subsection
4, paragraph B and that has employees enrolled in the Dirigo Health Program.
[2005, c. 400, Pt. C, §3 (amd).]
13. Plan enrollee. "Plan enrollee" means an eligible individual or eligible employee who enrolls in the Dirigo Health Program through Dirigo
Health. "Plan enrollee" includes an eligible employee who is eligible to enroll in MaineCare.
[2005, c. 400, Pt. C, §3 (amd).]
14. Provider. "Provider" means any person, organization, corporation or association that provides health care services and products and
is authorized to provide those services and products under the laws of this State.
[2003, c. 469, Pt. A, §8 (new).]
15. Reinsurance or reinsurer. "Reinsurance" and "reinsurer" have the same meanings as in section 741.
[2003, c. 469, Pt. A, §8 (new).]
16. Resident. "Resident" has the same meaning as in section 2736-C, subsection 1, paragraph C-2.
[2003, c. 469, Pt. A, §8 (new).]
17. Subsidy. "Subsidy" means a subsidy as described in section 6912.
[2003, c. 469, Pt. A, §8 (new).]
18. Third-party administrator. "Third-party administrator" means any person who, on behalf of any person who establishes a health insurance plan covering
residents, receives or collects charges, contributions or premiums for or settles claims on residents in connection with any
type of health benefit provided in or as an alternative to insurance as defined by section 704, other than:
A. Any person listed in section 1901, subsection 1, paragraphs A to C and paragraphs E to O; or
[2003, c. 469, Pt. A, §8 (new).]
B. Any person who provides those services in connection with a group health plan sponsored by an agricultural cooperative association
located outside of this State that provides heath insurance coverage to members and employees of agricultural cooperative
associations located within this State.
[2003, c. 469, Pt. A, §8 (new).]
[2003, c. 469, Pt. A, §8 (new).]
19. Unemployed individual. "Unemployed individual" means an individual who does not work more than 20 hours a week for any single employer.
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6904. Board of Directors of Dirigo Health
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6904. Board of Directors of Dirigo Health
Dirigo Health operates under the supervision of a Board of Directors established in accordance with this section.
[2003, c. 469, Pt. A, §8 (new).]
1. Appointments. The board consists of 5 voting members and 3 ex officio, nonvoting members as follows.
A. The 5 voting members of the board must be appointed by the Governor, subject to review by the joint standing committee of
the Legislature having jurisdiction over health insurance matters and confirmation by the Senate.
[2003, c. 469, Pt. A, §8 (new).]
B. The 3 ex officio, nonvoting members of the board are:
(1) The Commissioner of Professional and Financial Regulation or the commissioner's designee;
(2) The director of the Governor's Office of Health Policy and Finance or the director of a successor agency; and
(3) The Commissioner of Administrative and Financial Services or the commissioner's designee.
[2003, c. 469, Pt. A, §8 (new).]
[2003, c. 469, Pt. A, §8 (new).]
2. Qualifications of voting members. Voting members of the board:
A. Must have knowledge of and experience in one or more of the following areas:
(1) Health care purchasing;
(2) Health insurance;
(3) MaineCare;
(4) Health policy and law;
(5) State management and budget; or
(6) Health care financing; and
[2003, c. 469, Pt. A, §8 (new).]
B. Except as provided in this paragraph, may not be:
(1) A representative or employee of an insurance carrier authorized to do business in this State;
(2) A representative or employee of a health care provider operating in this State; or
(3) Affiliated with a health or health-related organization regulated by State Government.
A nonpracticing health care practitioner, retired or former health care administrator or retired or former employee of a health
insurance carrier is not prohibited from being considered for board membership as long as that person is not currently affiliated
with a health or health-related organization.
[2003, c. 469, Pt. A, §8 (new).]
[2003, c. 469, Pt. A, §8 (new).]
3. Terms of office. Voting members serve 3-year terms. Voting members may serve up to 2 consecutive terms. Of the initial appointees, one member
serves an initial term of one year, 2 members serve initial terms of 2 years and 2 members serve initial terms of 3 years.
The Governor shall fill any vacancy for an unexpired term in accordance with subsections 1 and 2. Members reaching the end
of their terms may serve until replacements are named.
[2003, c. 469, Pt. A, §8 (new).]
4. Chair. The Governor shall appoint one of the voting members as the chair of the board.
[2003, c. 469, Pt. A, §8 (new).]
5. Quorum. Three voting members of the board constitute a quorum.
[2003, c. 469, Pt. A, §8 (new).]
6. Affirmative vote. An affirmative vote of 3 members is required for any action taken by the board.
[2003, c. 469, Pt. A, §8 (new).]
7. Compensation. A member of the board must be compensated according to the provisions of Title 5, section 12004-G, subsection 14-D; a member
must receive compensation whenever that member fulfills any board duties in accordance with board bylaws.
[2003, c. 469, Pt. A, §8 (new).]
8. Meetings. The board shall meet at least 4 times a year at regular intervals and may also meet at other times at the call of the chair
or the executive director. All meetings of the board are public proceedings within the meaning of Title 1, chapter 13, subchapter
1.
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6905. Limitation on liability
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6905. Limitation on liability
A member of the board or an employee of Dirigo Health is not subject to any personal liability for having acted within the
course and scope of membership or employment to carry out any power or duty under this chapter. Dirigo Health shall indemnify
any member of the board and any employee of Dirigo Health against expenses actually and necessarily incurred by that member
or employee in connection with the defense of any action or proceeding in which that member or employee is made a party by
reason of past or present authority with Dirigo Health.
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6906. Prohibited interests of board members and employees
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6906. Prohibited interests of board members and employees
Board members and employees of Dirigo Health and their spouses and dependent children may not receive any direct personal
benefit from the activities of Dirigo Health in assisting any private entity, except that they may participate in the Dirigo
Health Program on the same terms as others may under this chapter. This section does not prohibit corporations or other entities
with which board members are associated by reason of ownership or employment from participating in activities of Dirigo Health
or receiving services offered by Dirigo Health as long as the ownership or employment is made known to the board and, if applicable,
the board members abstain from voting on matters relating to that participation.
[2005, c. 400, Pt. C, §4 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6907. Confidential records
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6907. Confidential records
Except as provided in subsections 1 and 2, information obtained by Dirigo Health under this chapter is a public record within
the meaning of Title 1, chapter 13, subchapter 1.
[2003, c. 469, Pt. A, §8 (new).]
1. Financial information. Any personally identifiable financial information, supporting data or tax return of any person obtained by Dirigo Health
under this chapter is confidential and not open to public inspection.
[2003, c. 469, Pt. A, §8 (new).]
2. Health information. Health information obtained by Dirigo Health under this chapter that is covered by the federal Health Insurance Portability
and Accountability Act of 1996, Public Law 104-191, 110 Stat. 1936 or information covered by chapter 24 or Title 22, section
1711-C is confidential and not open to public inspection.
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6908. Powers and duties of Dirigo Health (CONFLICT)
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6908. Powers and duties of Dirigo Health (CONFLICT)
1. Powers. Subject to any limitations contained in this chapter or in any other law, Dirigo Health may:
A. Take any legal actions necessary or proper to recover or collect savings offset payments due Dirigo Health or that are necessary
for the proper administration of Dirigo Health;
[2003, c. 469, Pt. A, §8 (new).]
B. Make and alter bylaws, not inconsistent with this chapter or with the laws of this State, for the administration and regulation
of the activities of Dirigo Health;
[2003, c. 469, Pt. A, §8 (new).]
C. Have and exercise all powers necessary or convenient to effect the purposes for which Dirigo Health is organized or to further
the activities in which Dirigo Health may lawfully be engaged, including the establishment of the Dirigo Health Program;
[2005, c. 400, Pt. C, §5 (amd).]
D. Engage in legislative liaison activities, including gathering information regarding legislation, analyzing the effect of
legislation, communicating with Legislators and attending and giving testimony at legislative sessions, public hearings or
committee hearings;
[2003, c. 469, Pt. A, §8 (new).]
E. Take any legal actions necessary to avoid the payment of improper claims against Dirigo Health or the coverage provided
by or through Dirigo Health, to recover any amounts erroneously or improperly paid by Dirigo Health, to recover any amounts
paid by Dirigo Health as a result of mistake of fact or law and to recover other amounts due Dirigo Health;
[2003, c. 469, Pt. A, §8 (new).]
F. Enter into contracts with qualified 3rd parties both private and public for any service necessary to carry out the purposes
of this chapter;
[2003, c. 469, Pt. A, §8 (new).]
G. Conduct studies and analyses related to the provision of health care, health care costs and quality;
[2003, c. 469, Pt. A, §8 (new).]
H. Establish and administer a revolving loan fund to assist health care practitioners and health care providers in the purchase
of hardware and software necessary to implement the requirements for electronic submission of claims. Dirigo Health may solicit
matching contributions to the fund from each health insurance carrier licensed to do business in this State;
[2003, c. 469, Pt. A, §8 (new).]
I. Apply for and receive funds, grants or contracts from public and private sources;
[2003, c. 469, Pt. A, §8 (new).]
J. Contract with the Maine Health Data Organization and other organizations with expertise in health care data, including a
nonprofit health data processing entity in this State, to assist the Maine Quality Forum established in section 6951 in the
performance of its responsibilities;
[2003, c. 469, Pt. A, §8 (new).]
K. Provide staff support and other assistance to the Maine Quality Forum established in section 6951, including assigning a
director and other staff as needed to conduct the work of the Maine Quality Forum; and
[2003, c. 469, Pt. A, §8 (new).]
L. In accordance with the limitations and restrictions of this chapter, cause any of its powers or duties to be carried out
by one or more organizations organized, created or operated under the laws of this State.
[2003, c. 469, Pt. A, §8 (new).]
[2005, c. 400, Pt. C, §5 (amd).]
2. Duties. Dirigo Health shall:
A. Establish administrative and accounting procedures as recommended by the State Controller for the operation of Dirigo Health
in accordance with Title 5;
[2003, c. 469, Pt. A, §8 (new).]
B. Collect the savings offset payments provided in section 6913;
[2003, c. 469, Pt. A, §8 (new).]
C. Determine the comprehensive services and benefits to be included in the Dirigo Health Program and develop the specifications
for the Dirigo Health Program in accordance with the provisions in section 6910. Within 30 days of its determination of the
benefit package to be offered through the Dirigo Health Program, the board shall report on the benefit package, including
the estimated premium and applicable coinsurance, deductibles, copayments and out-of-pocket maximums, to the joint standing
committee of the Legislature having jurisdiction over appropriations and financial affairs, the joint standing committee of
the Legislature having jurisdiction over insurance and financial services matters and the joint standing committee of the
Legislature having jurisdiction over health and human services matters;
[2005, c. 400, Pt. C, §6 (amd).]
D. Develop and implement a program to publicize the existence of Dirigo Health and the Dirigo Health Program and the eligibility
requirements and the enrollment procedures for the Dirigo Health Program and to maintain public awareness of Dirigo Health
and the Dirigo Health Program;
[2005, c. 400, Pt. C, §6 (amd).]
E. Arrange the provision of Dirigo Health Program benefit coverage to eligible individuals and eligible employees through contracts
with one or more qualified bidders;
[2005, c. 400, Pt. C, §6 (amd).]
F. Develop a high-risk pool for plan enrollees in the Dirigo Health Program in accordance with the provisions of section 6971;
and
[2005, c. 400, Pt. C, §6 (amd).]
G. Establish and operate the Maine Quality Forum in accordance with the provisions of section 6951.
[2003, c. 469, Pt. A, §8 (new).]
[2005, c. 400, Pt. C, §6 (amd).]
3. Budget. The revenues and expenditures of Dirigo Health are subject to legislative approval in the biennial budget process. At the
direction of the board, the executive director shall prepare the budget for the administration and operation of Dirigo Health
in accordance with the provisions of law that apply to departments of State Government.
[2003, c. 469, Pt. A, §8 (new).]
4. Audit. Dirigo Health must be audited annually by the State Auditor. The board may, in its discretion, arrange for an independent
audit to be conducted. A copy of the audit must be provided to the State Controller, to the superintendent, to the joint standing
committee of the Legislature having jurisdiction over appropriations and financial affairs, to the joint standing committee
of the Legislature having jurisdiction over insurance and financial services matters and to the joint standing committee of
the Legislature having jurisdiction over health and human services matters.
[2003, c. 469, Pt. A, §8 (new).]
5. Rulemaking. Dirigo Health may adopt rules as necessary for the proper administration and enforcement of this chapter, pursuant to the
Maine Administrative Procedure Act. Unless otherwise specified, rules adopted pursuant to this chapter are routine technical
rules as defined in Title 5, chapter 375, subchapter 2-A.
[2003, c. 469, Pt. A, §8 (new).]
6. Annual report. Beginning September 1, 2004, and annually thereafter, the board shall report on the impact of Dirigo Health on the small
group and individual health insurance markets in this State and any reduction in the number of uninsured individuals in the
State. The board shall also report on membership in Dirigo Health, the administrative expenses of Dirigo Health, the extent
of coverage, the effect on premiums, the number of covered lives, the number of Dirigo Health Program policies issued or renewed
and Dirigo Health Program premiums earned and claims incurred by health insurance carriers offering coverage under the Dirigo
Health Program. The board shall submit the report to the Governor, the joint standing committee of the Legislature having
jurisdiction over appropriations and financial affairs, the joint standing committee of the Legislature having jurisdiction
over health insurance and financial services matters and the joint standing committee of the Legislature having jurisdiction
over health and human services matters.
[2005, c. 400, Pt. C, §7 (amd).]
7. Technical assistance from other state agencies. Other state agencies, including, but not limited to, the bureau, the Department of Health and Human Services, Maine Revenue
Services and the Maine Health Data Organization, shall provide technical assistance and expertise to Dirigo Health upon request.
[2003, c. 469, Pt. A, §8 (new); c. 689, Pt. B, §6 (rev).]
8. Legal counsel. The Attorney General, when requested, shall furnish any legal assistance, counsel or advice Dirigo Health requires in the
discharge of its duties.
[2003, c. 469, Pt. A, §8 (new).]
9. Coordination with federal, state and local health care systems. Dirigo Health shall institute a system to coordinate the activities of Dirigo Health with the health care programs of the
Federal Government and state and municipal governments.
[2003, c. 469, Pt. A, §8 (new).]
10. Initial staffing. Upon request from the board, the Governor shall provide staffing assistance to Dirigo Health in the initial phases of its
operation.
[2003, c. 469, Pt. A, §8 (new).]
11. Advisory committees. Dirigo Health may appoint advisory committees to advise and assist Dirigo Health. Members of an advisory committee serve
without compensation but may be reimbursed by Dirigo Health for necessary expenses while on official business of the advisory
committee.
[2003, c. 469, Pt. A, §8 (new).]
12. (CONFLICT: Text as enacted by PL 2005, c. 394, §3) Legislative jurisdiction. Notwithstanding any provision of law to the contrary, legislative jurisdiction for oversight of Dirigo Health is governed
by the Joint Rules of the Legislature. In adopting the joint rules, the Legislature shall give consideration to ensuring
that legislative oversight of Dirigo Health is thorough and ongoing, that normal budgetary procedures and controls are exercised
and that committee jurisdiction is consistent with the subject matter jurisdiction of the joint standing committees.
[2005, c. 394, §3 (new).]
12. (CONFLICT: Text as enacted by PL 2005, c. 400, Pt. A, §5) Report; jurisdiction. Dirigo Health shall report twice annually, once in January and once during the last month of the regular legislative session,
to the joint standing committee of the Legislature having jurisdiction over insurance and financial services matters on the
Dirigo Health Program and budget. Minutes of meetings of the Board of Directors of Dirigo Health must be provided to each
member of the joint standing committees of the Legislature having jurisdiction over insurance and financial services matters,
health and human services matters and appropriations and financial affairs.
[2005, c. 400, Pt. A, §5 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6909. Executive director
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6909. Executive director
1. Appointed position. The executive director is appointed by the board and serves at the pleasure of the board. The position of executive director
is a major policy-influencing position as designated in Title 5, section 934-B.
[2003, c. 469, Pt. A, §8 (new).]
2. Duties of executive director. The executive director shall:
A. Serve as the liaison between the board of directors and Dirigo Health and serve as secretary and treasurer to the board;
[2003, c. 469, Pt. A, §8 (new).]
B. Manage Dirigo Health's programs and services, including the Maine Quality Forum established under section 6951;
[2003, c. 469, Pt. A, §8 (new).]
C. Employ or contract on behalf of Dirigo Health for professional and nonprofessional personnel or service. Employees of Dirigo
Health are subject to the Civil Service Law, except that the position of Director of the Maine Quality Forum is not subject
to the Civil Service Law;
[2003, c. 469, Pt. A, §8 (new).]
D. Approve all accounts for salaries, per diems, allowable expenses of Dirigo Health or of any employee or consultant and expenses
incidental to the operation of Dirigo Health; and
[2003, c. 469, Pt. A, §8 (new).]
E. Perform other duties prescribed by the board to carry out the functions of this chapter.
[2003, c. 469, Pt. A, §8 (new).]
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6910. Dirigo Health Program
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6910. Dirigo Health Program
1. Dirigo Health Program. Dirigo Health shall arrange for the provision of health benefits coverage through the Dirigo Health Program not later than
October 1, 2004. The Dirigo Health Program must comply with all relevant requirements of this Title. Dirigo Health Program
coverage may be offered by health insurance carriers that apply to the board and meet qualifications described in this section
and any additional qualifications set by the board.
[2005, c. 400, Pt. C, §8 (amd).]
2. Legislative approval of nonprofit health care plan or expansion of public plan. If health insurance carriers do not apply to offer and deliver Dirigo Health Program coverage, the board may have Dirigo
Health provide access to health insurance by proposing the establishment of a nonprofit health care plan organized under Title
13-B and authorized pursuant to Title 24, chapter 19 or by proposing the expansion of an existing public plan. If the board
proposes the establishment of a nonprofit health care plan or the expansion of an existing public plan, the board shall submit
its proposal, including, but not limited to, a funding mechanism to capitalize a nonprofit health care plan and any recommended
legislation to the joint standing committee of the Legislature having jurisdiction over health insurance matters. Dirigo Health
may not provide access to health insurance by establishing a nonprofit health care plan or through an existing public plan
without specific legislative approval.
[2005, c. 400, Pt. C, §8 (amd).]
3. Carrier participation requirements. To qualify as a carrier of Dirigo Health Program coverage, a health insurance carrier must:
A. Provide the comprehensive health services and benefits as determined by the board, including a standard benefit package
that meets the requirements for mandated coverage for specific health services, specific diseases and for certain providers
of health services under Title 24 and this Title and any supplemental benefits the board wishes to make available; and
[2003, c. 469, Pt. A, §8 (new).]
B. Ensure that:
(1) Providers contracting with a carrier contracted to provide coverage to plan enrollees do not charge plan enrollees or
3rd parties for covered health care services in excess of the amount allowed by the carrier the provider has contracted with,
except for applicable copayments, deductibles or coinsurance or as provided in section 4204, subsection 6;
(2) Providers contracting with a carrier contracted to provide coverage to plan enrollees do not refuse to provide services
to a plan enrollee on the basis of health status, medical condition, previous insurance status, race, color, creed, age, national
origin, citizenship status, gender, sexual orientation, disability or marital status. This subparagraph may not be construed
to require a provider to furnish medical services that are not within the scope of that provider's license; and
(3) Providers contracting with a carrier contracted to provide coverage to plan enrollees are reimbursed at the negotiated
reimbursement rates between the carrier and its provider network.
[RR 2003, c. 1, §22 (cor).]
Health insurance carriers that seek to qualify to provide Dirigo Health Program coverage must also qualify as health plans
in Medicaid.
[2005, c. 400, Pt. C, §8 (amd).]
4. Contracting authority. Dirigo Health has contracting authority and powers to administer Dirigo Health Insurance as set out in this subsection.
A. Dirigo Health may contract with health insurance carriers licensed to sell health insurance in this State or other private
or public third-party administrators to provide Dirigo Health Program coverage. In addition:
(1) Dirigo Health shall issue requests for proposals from health insurance carriers;
(2) Dirigo Health may include quality improvement, disease prevention, disease management and cost-containment provisions
in the contracts with participating health insurance carriers or may arrange for the provision of such services through contracts
with other entities;
(3) Dirigo Health shall require participating health insurance carriers to offer a benefit plan identical to the Dirigo
Health Program, for which no Dirigo Health subsidies are available, in the general small group market;
(4) Dirigo Health shall make payments to participating health insurance carriers under a Dirigo Health Program contract
to provide Dirigo Health Program benefits to plan enrollees not enrolled in MaineCare;
(5) Dirigo Health may set allowable rates for administration and underwriting gains for the Dirigo Health Program;
(6) Dirigo Health may administer continuation benefits for eligible individuals from employers with 20 or more employees
who have purchased health insurance coverage through Dirigo Health for the duration of their eligibility periods for continuation
benefits pursuant to the federal Consolidated Omnibus Budget Reconciliation Act, Public Law 99-272, Title X, Private Health
Insurance Coverage, Sections 10001 to 10003; and
(7) Dirigo Health may administer or contract to administer the United States Internal Revenue Code of 1986, Section 125
plans for employers and employees participating in Dirigo Health, including medical expense reimbursement accounts and dependent
care reimbursement accounts.
[2005, c. 400, Pt. C, §8 (amd).]
B. Dirigo Health shall contract with eligible businesses seeking assistance from Dirigo Health in arranging for health benefits
coverage by the Dirigo Health Program for their employees and dependents as set out in this paragraph.
(1) Dirigo Health may establish contract and other reporting forms and procedures necessary for the efficient administration
of contracts.
(2) Dirigo Health shall collect payments from participating employers and plan enrollees to cover the cost of:
(a) The Dirigo Health Program for enrolled employees and dependents in contribution amounts determined by the board;
(b) Dirigo Health's quality assurance, disease prevention, disease management and cost-containment programs;
(c) Dirigo Health's administrative services; and
(d) Other health promotion costs.
(3) Dirigo Health shall establish the minimum required contribution levels, not to exceed 60%, to be paid by employers toward
the aggregate payment in subparagraph (2) and establish an equivalent minimum amount to be paid by employers or plan enrollees
and their dependents who are enrolled in MaineCare. The minimum required contribution level to be paid by employers must
be prorated for employees that work less than the number of hours of a full-time equivalent employee as determined by the
employer. Dirigo Health may establish a separate minimum contribution level to be paid by employers toward coverage for dependents
of the employers' enrolled employees.
(4) Dirigo Health shall require participating employers to certify that at least 75% of their employees that work 30 hours
or more per week and who do not have other creditable coverage are enrolled in the Dirigo Health Program and that the employer
group otherwise meets the minimum participation requirements specified by section 2808-B, subsection 4, paragraph A.
(5) Dirigo Health shall reduce the payment amounts for plan enrollees eligible for a subsidy under section 6912 accordingly.
Dirigo Health shall return any payments made by plan enrollees also enrolled in MaineCare to those enrollees.
(6) Dirigo Health shall require participating employers to pass on any subsidy in section 6912 to the plan enrollee qualifying
for the subsidy, up to the amount of payments made by the plan enrollee.
(7) Dirigo Health may establish other criteria for participation.
(8) Dirigo Health may limit the number of participating employers.
[2005, c. 400, Pt. C, §8 (amd).]
C. Dirigo Health may permit eligible individuals to purchase Dirigo Health Program coverage for themselves and their dependents
as set out in this paragraph.
(1) Dirigo Health may establish contract and other reporting forms and procedures necessary for the efficient administration
of contracts.
(2) Dirigo Health may collect payments from eligible individuals participating in the Dirigo Health Program to cover the
cost of:
(a) Enrollment in the Dirigo Health Program for eligible individuals and dependents;
(b) Dirigo Health's quality assurance, disease prevention, disease management and cost-containment programs;
(c) Dirigo Health's administrative services; and
(d) Other health promotion costs.
(3) Dirigo Health shall reduce the payment amounts for individuals eligible for a subsidy under section 6912 accordingly.
(4) Dirigo Health may require that eligible individuals certify that all their dependents are enrolled in the Dirigo Health
Program or are covered by another creditable plan.
(5) Dirigo Health may require an eligible individual who is currently employed by an eligible employer that does not offer
health insurance to certify that the current employer did not provide access to an employer-sponsored benefits plan in the
12-month period immediately preceding the eligible individual's application.
(6) Dirigo Health may limit the number of plan enrollees.
(7) Dirigo Health may establish other criteria for participation.
[2005, c. 400, Pt. C, §8 (amd).]
[2005, c. 400, Pt. C, §8 (amd).]
5. Enrollment in Dirigo Health Program. Dirigo Health shall perform, at a minimum, the following functions to facilitate enrollment in the Dirigo Health Program.
A. Dirigo Health shall publicize the availability of the Dirigo Health Program to businesses, self-employed individuals and
others eligible to enroll in the Dirigo Health Program.
[2005, c. 400, Pt. C, §8 (amd).]
B. Dirigo Health shall screen all eligible individuals and employees for eligibility for subsidies under section 6912 and eligibility
for MaineCare. To facilitate the screening and referral process, Dirigo Health shall provide a single application form for
Dirigo Health and MaineCare. The application materials must inform applicants of subsidies available through Dirigo Health
and of the additional coverage available through MaineCare. It must allow an applicant to choose on the application form
to apply or not to apply for MaineCare or for a subsidy. It must allow an applicant to provide household financial information
necessary to determine eligibility for MaineCare or a subsidy. Except when the applicant has declined to apply for MaineCare
or a subsidy, an application must be treated as an application for Dirigo Health, for a subsidy and for MaineCare. MaineCare
must make the final determination of eligibility for MaineCare.
[2003, c. 469, Pt. A, §8 (new).]
C. Except as provided in this paragraph, the effective date of coverage for a new enrollee in the Dirigo Health Program is
the first day of the month following receipt of the fully completed application for that enrollee by the carrier contracting
with Dirigo Health or the first day of the next month if the fully completed application is received by the carrier within
10 calendar days of the end of the month. If a new enrollee in the Dirigo Health Program had prior coverage through an individual
or small group policy, coverage under the Dirigo Health Program must take effect the day following termination of that enrollee's
prior coverage.
[2005, c. 400, Pt. C, §8 (amd).]
[2005, c. 400, Pt. C, §8 (amd).]
6. Quality improvement, disease management and cost containment. Dirigo Health shall promote quality improvement, disease prevention, disease management and cost-containment programs as
part of its administration of the Dirigo Health Program.
[2005, c. 400, Pt. C, §8 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6911. Coordination with MaineCare
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6911. Coordination with MaineCare
The Department of Health and Human Services is the state agency responsible for the financing and administration of MaineCare.
It shall pay for MaineCare benefits for MaineCare-eligible individuals, including those enrolled in health plans in MaineCare
that are providing coverage under the Dirigo Health Program. An individual participating in the Dirigo Health Program who
applies for and is determined eligible for MaineCare is enrolled directly in MaineCare.
[2005, c. 400, Pt. A, §6 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6912. Subsidies
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6912. Subsidies
Dirigo Health may establish sliding-scale subsidies for the purchase of Dirigo Health Program coverage paid by eligible individuals
or employees whose income is under 300% of the federal poverty level. Dirigo Health may also establish sliding-scale subsidies
for the purchase of employer-sponsored health coverage paid by employees of businesses with more than 50 employees, whose
income is under 300% of the federal poverty level.
[2005, c. 400, Pt. A, §7 (amd).]
1. Administration. Dirigo Health shall, by rule, establish procedures to administer this section.
[2003, c. 469, Pt. A, §8 (new).]
2. Eligibility for subsidy. To be eligible for a subsidy an individual or employee must:
A. Be enrolled in the Dirigo Health Program, have an income under 300% of the federal poverty level and be a resident of the
State; or
[2005, c. 400, Pt. A, §8 (amd).]
B. Be enrolled in a health plan of an employer with more than 50 employees and have an income under 300% of the federal poverty
level. The health plan must meet any criteria established by Dirigo Health. The individual must meet other eligibility criteria
established by Dirigo Health.
[2005, c. 400, Pt. A, §8 (amd).]
[2005, c. 400, Pt. A, §8 (amd).]
3. Limitation of subsidies. Dirigo Health shall limit the availability of subsidies to reflect limitations of available funds.
[2003, c. 469, Pt. A, §8 (new).]
4. Limitation on amount subsidized. Dirigo Health may limit the amount subsidized of the payment made by individual plan enrollees under section 6910, subsection
4, paragraph C to 40% of the payment to more closely parallel the subsidy received by employees. In no case may the subsidy
granted to eligible individuals in accordance with subsection 2, paragraph A exceed the maximum subsidy level available to
other eligible individuals.
[2003, c. 469, Pt. A, §8 (new).]
5. Notification of subsidy. Dirigo Health shall notify applicants and their employers in writing of their eligibility and approved level of subsidy.
[2003, c. 469, Pt. A, §8 (new).]
6. Report. Within 30 days after any subsidies are established pursuant to this section, the board shall report on the amount of the
subsidies, the funding required for the subsidies and the estimated number of Dirigo Health Program enrollees eligible for
the subsidies and submit the report to the joint standing committee of the Legislature having jurisdiction over appropriations
and financial affairs, the joint standing committee of the Legislature having jurisdiction over insurance and financial services
matters and the joint standing committee of the Legislature having jurisdiction over health and human services matters.
[2005, c. 400, Pt. A, §9 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6913. Savings offset payments against health insurance carriers, employee benefit excess insurance carriers and third-party administrators
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6913. Savings offset payments against health insurance carriers, employee benefit excess insurance carriers and third-party administrators
1. Determination of cost savings. The following are the procedures for determining cost savings.
A. After an opportunity for a hearing conducted pursuant to Title 5, chapter 375, subchapter 4, the board shall determine annually
not later than April 1st the aggregate measurable cost savings, including any reduction or avoidance of bad debt and charity
care costs to health care providers in this State as a result of the operation of Dirigo Health and any increased MaineCare
enrollment due to an expansion in MaineCare eligibility occurring after June 30, 2004.
[2005, c. 400, Pt. A, §10 (new).]
B. Within 30 days of the board's determination pursuant to paragraph A, the board shall file with the superintendent its determination
as well as the supporting information for that determination. The filing constitutes a public record.
[2005, c. 400, Pt. A, §10 (new).]
C. Following a public hearing held in accordance with the Maine Administrative Procedure Act and no later than 6 weeks following
the receipt of the board's determination, the superintendent shall issue an order approving, in whole or in part, or disapproving
the filing made under paragraph B. The board is designated a party to the hearing. The superintendent shall approve the
filing upon a determination that the aggregate measurable cost savings filed by the board are reasonably supported by the
evidence in the record.
[2005, c. 400, Pt. A, §10 (new).]
[2005, c. 400, Pt. A, §10 (rpr).]
2. Determination of savings offset amount. The board shall determine annually a savings offset amount to be paid by health insurance carriers, employee benefit excess
insurance carriers and 3rd-party administrators, not including carriers and 3rd-party administrators with respect to accidental
injury, specified disease, hospital indemnity, dental, vision, disability income, long-term care, Medicare supplement or other
limited benefit health insurance. The board shall determine the savings offset amount in accordance with the following:
A. Not later than April of each year, the board shall prospectively determine the savings offset amount to be applied during
each 12-month calendar year period;
[2005, c. 400, Pt. A, §11 (new).]
B. To determine the savings offset amount, the board shall use the criteria and reports described in subsections 7 and 8;
[2005, c. 400, Pt. A, §11 (new).]
C. The savings offset amount must reflect and may not exceed aggregate measurable cost savings, as determined by the board pursuant
to subsection 1; and
[2005, c. 400, Pt. A, §11 (new).]
D. The savings offset amount calculation is limited to the amount of funds necessary to provide subsidies pursuant to section
6912 and to support the Maine Quality Forum established in section 6951 and may not include general administrative expenses
of Dirigo Health, except for general administrative expenses of the Maine Quality Forum.
[2005, c. 400, Pt. A, §11 (new).]
The savings offset amount determined by the board in accordance with this subsection is the determining factor for inclusion
of savings offset payments in premiums through rate setting review by the bureau.
[2005, c. 400, Pt. A, §11 (rpr).]
3. Savings offset payments required from health insurance carriers, 3rd-party administrators and employee benefit excess insurance
carriers. Except for the carriers and 3rd-party administrators that are specifically excluded in subsection 2, each health insurance
carrier, 3rd-party administrator and employee benefit excess insurance carrier shall pay a savings offset payment. The following
provisions govern savings offset payments.
A. The board shall calculate savings offset payments as a percentage of paid claims, as defined by the board pursuant to subsection
10. The board shall make reasonable efforts to ensure that paid claims are counted only once with respect to any savings offset
payment. The board may verify each health insurance carrier's, 3rd-party administrator's and employee benefit excess insurance
carrier's savings offset payment based on annual statements and other reports the board determines to be necessary.
[2005, c. 400, Pt. A, §11 (new).]
B. Maximum savings offset payments are as follows:
(1) For health insurance carriers, the savings offset payment may not exceed 4.0% of annual paid claims for health care on
policies issued pursuant to the laws of this State that insure residents of this State;
(2) For 3rd-party administrators, the savings offset payment may not exceed 4.0% of annual paid claims for health care for
residents of this State; and
(3) For employee benefit excess insurance carriers, the savings offset payment may not exceed 4.0% of annual paid claims
on employee benefit excess insurance policies, as defined in section 707, subsection 1, paragraph C-1, issued pursuant to
the laws of this State that insure residents of this State.
[2005, c. 400, Pt. A, §11 (new).]
C. A health insurance and employee benefit excess insurance carrier may not be required to pay a savings offset payment on
policies or contracts insuring federal employees.
[2005, c. 400, Pt. A, §11 (new).]
D. Savings offset payments apply to claims paid for plan years beginning on or after January 1, 2006.
[2005, c. 400, Pt. A, §11 (new).]
E. Savings offset payments may not begin until 12 months after Dirigo Health begins providing health insurance coverage;
[2005, c. 400, Pt. A, §11 (new).]
F. Savings offset payments must be made quarterly and are due not less than 60 days after the close of the quarter and with
a minimum of 30 days' written notice by Dirigo Health to health insurance carriers, employee benefit excess insurance carriers
and 3rd-party administrators and must accrue interest at 12% per annum on or after the due date, except that:
(1) For plan years beginning between January 1, 2006 and March 31, 2006, both days inclusive, savings offset payments must
be made monthly for January 2006, February 2006 and March 2006 and are due not less than 60 days after the close of each of
those calendar months; and
(2) Savings offset payments for 3rd-party administrators for groups of 500 or fewer members may be made annually not less
than 60 days after the close of the plan year.
[2005, c. 400, Pt. A, §11 (new).]
G. Savings offset payments received by Dirigo Health must be pooled with other revenues of the agency in the Dirigo Health Fund
established in section 6915; and
[2005, c. 400, Pt. A, §11 (new).]
H. Annual savings offset payments received must be reconciled by Dirigo Health. Any unused payments must reduce the next savings
offset payment charged to health insurance carriers, 3rd-party administrators and employee benefit excess insurance carriers
according to a formula developed by the board.
[2005, c. 400, Pt. A, §11 (new).]
[2005, c. 400, Pt. A, §11 (rpr).]
4. Determination of savings offset payments.
[2005, c. 400, Pt. A, §12 (rp).]
5. Failure to pay savings offset payments. The superintendent may suspend or revoke, after notice and hearing, the certificate of authority to transact insurance in
this State of any health insurance carrier or employee benefit excess insurance carrier or the license of any third-party
administrator to operate in this State that fails to pay a savings offset payment. In addition, the superintendent may assess
civil penalties against any health insurance carrier, employee benefit excess insurance carrier or third-party administrator
that fails to pay a savings offset payment or may take any other enforcement action authorized under section 12-A to collect
any unpaid savings offset payments.
[2003, c. 469, Pt. A, §8 (new).]
6. Savings offset payments through reductions in growth in State's health care spending and bad debt and charity care.
[2005, c. 400, Pt. A, §12 (rp).]
7. Demonstration of recovery of savings offset payments through reduction in rate of growth in State's health spending and
bad debt and charity care. In accordance with the requirements of this subsection, every health insurance carrier and health care provider shall demonstrate
that best efforts have been made to ensure that a carrier has recovered savings offset payments made pursuant to this section
through negotiated reimbursement rates that reflect health care providers' reductions or stabilization in the cost of bad
debt and charity care as a result of the operation of Dirigo Health and any increased enrollment due to an expansion in MaineCare
eligibility occurring after June 30, 2004.
A. A health insurance carrier shall use best efforts to ensure health insurance premiums reflect any such recovery of savings
offset payments as those savings offset payments are reflected through incurred claims experience in accordance with subsection
9.
[2003, c. 469, Pt. A, §8 (new).]
B. During any negotiation with a health insurance carrier relating to a health care provider's reimbursement agreement with
that carrier, a health care provider shall provide data relating to any reduction or avoidance of bad debt and charity care
costs to health care providers in this State, as a result of the operation of Dirigo Health and as a result of any increased
enrollment due to an expansion in MaineCare eligibility occurring after June 30, 2004.
[2003, c. 469, Pt. A, §8 (new).]
[2003, c. 469, Pt. A, §8 (new).]
8. Reports. The following reports are required in accordance with this subsection.
A. On a quarterly basis beginning with the first quarter after the Dirigo Health Program begins offering coverage, the board
shall collect and report on the following:
(1) The total enrollment in the Dirigo Health Program, including the number of enrollees previously underinsured or uninsured,
the number of enrollees previously insured, the number of individual enrollees and the number of enrollees enrolled through
small employers;
(2) The total number of enrollees covered in health plans through large employers and self-insured employers;
(3) The number of employers, both small employers and large employers, who have ceased offering health insurance or contributing
to the cost of health insurance for employees or who have begun offering coverage on a self-insured basis;
(4) The number of employers, both small employers and large employers, who have begun to offer health insurance or contribute
to the cost of health insurance premiums for their employees;
(5) The number of new participating employers in the Dirigo Health Program;
(6) The number of employers ceasing to offer coverage through the Dirigo Health Program;
(7) The duration of employers participating in the Dirigo Health Program; and
(8) A comparison of actual enrollees in the Dirigo Health Program to the projected enrollees.
[2005, c. 400, Pt. C, §9 (amd).]
B. The board shall establish the total health care spending in the State for the base year of 2002 and shall annually determine,
in collaboration with the superintendent, appropriate actuarially supported trend factors that reflect savings consistent
with subsection 1 and compare rates of spending growth to the base year of 2002. The board shall collect on an annual basis,
in consultation with the superintendent, the total cost to the State's health care providers of bad debt and charity care
beginning with the base year of 2002. This information may be compiled through mechanisms, including, but not limited to,
standard reporting or statistically accurate surveys of providers and practitioners. The board shall utilize existing data
on file with state agencies or other organizations to minimize duplication. The comparisons to the base year must be reported
beginning March 1, 2004 and annually thereafter.
[2003, c. 469, Pt. A, §8 (new).]
C. Health insurance carriers and health care providers shall report annually, beginning March 1, 2005 and thereafter, information
regarding the experience of a prior 12-month period on the efforts undertaken by the carrier and provider to recover savings
offset payments, as reflected in reimbursement rates, through a reduction or stabilization in bad debt and charity care costs
as a result of the operation of Dirigo Health and any increased enrollment due to an expansion in MaineCare eligibility occurring
after June 30, 2004. The board shall determine the appropriate format for the report and utilize existing data on file with
state agencies or other organizations to minimize duplication. The report must be submitted to the board. Using the information
submitted by carriers and providers, the board shall submit a summary of that information by October 1, 2005 and annually
thereafter.
[2003, c. 469, Pt. A, §8 (new).]
D. The quarterly reports required to be submitted by the board pursuant to paragraph A and the annual reports required to be
submitted by the board pursuant to paragraphs B and C must be submitted to the superintendent, to the joint standing committee
of the Legislature having jurisdiction over appropriations and financial affairs, to the joint standing committee of the Legislature
having jurisdiction over insurance and financial services matters, and to the joint standing committee of the Legislature
having jurisdiction over health and human services matters.
[2003, c. 469, Pt. A, §8 (new).]
[2005, c. 400, Pt. C, §9 (amd).]
9. Demonstration of offset. As provided in sections 2736-C, 2808-B and 2839-B, the claims experience used to determine any filed premiums or rating
formula must reasonably reflect, in accordance with accepted actuarial standards, known changes and offsets in payments by
the carrier to health care providers in this State, including any reduction or avoidance of bad debt and charity care costs
to health care providers in this State as a result of the operation of Dirigo Health and any increased enrollment due to an
expansion in MaineCare eligibility occurring after June 30, 2004 as determined by the board consistent with subsection 1.
[2003, c. 469, Pt. A, §8 (new).]
10. Definition of paid claims; rulemaking. The board shall adopt rules regarding the definition of paid claims for the purposes of calculating savings offset payments
for health insurance carriers, 3rd-party administrators and employee benefit excess insurance carriers due on or after January
1, 2007. Rules adopted pursuant to this subsection are major substantive rules as defined in Title 5, chapter 375, subchapter
2-A.
[2005, c. 400, Pt. A, §13 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6914. Intragovernmental transfer
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6914. Intragovernmental transfer
Starting July 1, 2004, Dirigo Health shall transfer funds, as necessary, to a special dedicated, nonlapsing revenue account
administered by the agency of State Government that administers MaineCare for the purpose of providing a state match for federal
Medicaid dollars. Dirigo Health shall annually set the amount of contribution.
[2005, c. 400, Pt. A, §14 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6915. Dirigo Health Enterprise Fund
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 1: GENERAL PROVISIONS (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6915. Dirigo Health Enterprise Fund
The Dirigo Health Enterprise Fund is created as an enterprise fund for the deposit of any funds advanced for initial operating
expenses, payments made by employers and individuals, any savings offset payments made pursuant to section 6913 and any funds
received from any public or private source. The fund may not lapse, but must be carried forward to carry out the purposes
of this chapter.
[2005, c. 386, Pt. D, §3 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6951. Maine Quality Forum
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 2: HEALTH CARE QUALITY (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6951. Maine Quality Forum
The Maine Quality Forum, referred to in this subchapter as "the forum," is established within Dirigo Health. The forum is
governed by the board with advice from the Maine Quality Forum Advisory Council pursuant to section 6952. The forum must
be funded, at least in part, through the savings offset payments made pursuant to section 6913. Except as provided in section
6907, subsection 2, information obtained by the forum is a public record as provided by Title 1, chapter 13, subchapter 1.
The forum shall perform the following duties.
[2003, c. 469, Pt. A, §8 (new).]
1. Research dissemination. The forum shall collect and disseminate research regarding health care quality, evidence-based medicine and patient safety
to promote best practices.
[2003, c. 469, Pt. A, §8 (new).]
2. Quality and performance measures. The forum shall adopt a set of measures to evaluate and compare health care quality and provider performance. The measures
must be adopted with guidance from the advisory council pursuant to section 6952. The quality measures adopted by the forum
must be the basis for the rules for the collection of quality data adopted by the Maine Health Data Organization pursuant
to Title 22, section 8708-A.
[2003, c. 469, Pt. A, §8 (new).]
3. Data coordination. The forum shall coordinate the collection of health care quality data in the State. The forum shall work with the Maine
Health Data Organization and other entities that collect health care data to minimize duplication and to minimize the burden
on providers of data.
[2003, c. 469, Pt. A, §8 (new).]
4. Reporting. The forum shall work collaboratively with the Maine Health Data Organization, health care providers, health insurance carriers
and others to report in useable formats comparative health care quality information to consumers, purchasers, providers, insurers
and policy makers. The forum shall produce annual quality reports in conjunction with the Maine Health Data Organization pursuant
to Title 22, section 8712.
[2003, c. 469, Pt. A, §8 (new).]
5. Consumer education. The forum shall conduct education campaigns to help health care consumers make informed decisions and engage in healthy
lifestyles.
[2003, c. 469, Pt. A, §8 (new).]
6. Technology assessment. The forum shall conduct technology assessment reviews to guide the use and distribution of new technologies in this State.
The forum shall make recommendations to the certificate of need program under Title 22, chapter 103-A.
[2003, c. 469, Pt. A, §8 (new).]
7. Electronic data. The forum shall encourage the adoption of electronic technology and assist health care practitioners to implement electronic
systems for medical records and submission of claims. The assistance may include, but is not limited to, practitioner education,
identification or establishment of low-interest financing options for hardware and software and system implementation support.
[2003, c. 469, Pt. A, §8 (new).]
8. State health plan. The forum shall make recommendations for inclusion in the State Health Plan described under Title 2, chapter 5, including
recommendations based on the technology assessment reviews under subsection 6.
[2003, c. 469, Pt. A, §8 (new).]
9. Annual report. The forum shall make an annual report to the public. The forum shall provide the report to the joint standing committees
of the Legislature having jurisdiction over appropriations and financial affairs, health and human services matters and insurance
and financial services matters.
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6952. Maine Quality Forum Advisory Council
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 2: HEALTH CARE QUALITY (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6952. Maine Quality Forum Advisory Council
The Maine Quality Forum Advisory Council, referred to in this subchapter as "the advisory council," is a 17-member body established
by Title 5, section 12004-I, subsection 30-A, to advise the forum. Except as provided in section 6907, subsection 2, information
obtained by the advisory council is a public record as provided by Title 1, chapter 13, subchapter 1.
[2003, c. 469, Pt. A, §8 (new).]
1. Appointment; composition. The Governor shall appoint the following members with the approval of the joint standing committee of the Legislature having
jurisdiction over health and human services matters:
A. Seven members representing providers, including 3 physicians, one registered nurse, one representative of hospitals, one
mental health provider and one health care practitioner who is not a physician. The 3 physician members must represent allopathic
physicians, osteopathic physicians, primary care physicians and specialist physicians;
[2003, c. 469, Pt. A, §8 (new).]
B. Four members representing consumers, including one employee who receives health care through a commercially insured product,
one representative of organized labor, one representative of a consumer health advocacy group and one representative of the
uninsured or MaineCare recipients;
[2003, c. 469, Pt. A, §8 (new).]
C. Four members representing employers, including one member of the State Employee Health Commission, one representative of
a private employer with more than 1,000 full-time equivalent employees, one representative of a private employer with 50 to
1,000 full-time employees and one representative of a private employer with fewer than 50 employees;
[2003, c. 469, Pt. A, §8 (new).]
D. One representative of a private health plan; and
[2003, c. 469, Pt. A, §8 (new).]
E. One representative of the MaineCare program.
[2003, c. 469, Pt. A, §8 (new).]
Prior to making appointments to the advisory council, the Governor shall seek nominations from the public and from a statewide
allopathic association, a statewide osteopathic association, a statewide hospital association, a statewide nurses association,
a statewide health purchasing collaborative, a statewide health management coalition, organized labor, a statewide organization
representing consumers advocating for affordable health care, a statewide association representing consumers of mental health
services, a national association of retired persons, a statewide citizen action organization, a statewide organization advocating
equal justice, a statewide organization representing local chambers of commerce, a statewide organization representing businesses
for social responsibility, a statewide small business alliance, a national federation of independent businesses, a statewide
association of health plans and other entities as appropriate.
[2003, c. 469, Pt. A, §8 (new).]
2. Terms. Members of the advisory council serve 5-year terms except for initial appointments. Initial appointments must include 5
members appointed to 3-year terms, 6 members appointed to 4-year terms and 6 members appointed to 5-year terms. A member
may not serve more than 2 consecutive terms.
[2003, c. 469, Pt. A, §8 (new).]
3. Compensation. Members of the advisory council are eligible for compensation according to the provisions of Title 5, chapter 379.
[2003, c. 469, Pt. A, §8 (new).]
4. Quorum. A quorum is a majority of the members of the advisory council.
[2003, c. 469, Pt. A, §8 (new).]
5. Chair and officers. The advisory council shall annually choose one of its members to serve as chair for a one-year term. The advisory council
may select other officers and designate their duties.
[2003, c. 469, Pt. A, §8 (new).]
6. Meetings. The advisory council shall meet at least 4 times a year at regular intervals and may meet at other times at the call of
the chair or the executive director of Dirigo Health. Meetings of the council are public proceedings as provided by Title
1, chapter 13, subchapter 1.
[2003, c. 469, Pt. A, §8 (new).]
7. Duties. The advisory council shall:
A. Convene a group of health care providers to provide input and advice to the council. The council shall invite members broadly
representing health care practitioners as defined in Title 24, section 2502, subsection 1-A, health care providers as defined
in Title 24, section 2502, subsection 2, federally qualified health centers and pharmacists. Members serve as volunteers and
without compensation or reimbursement for expenses;
[2003, c. 469, Pt. A, §8 (new).]
B. Provide expertise in health care quality to assist the board;
[2003, c. 469, Pt. A, §8 (new).]
C. Advise and support the forum by:
(1) Establishing and monitoring, with Dirigo Health, an annual work plan for the forum;
(2) Providing guidance in the adoption of quality and performance measures;
(3) Serving as a liaison between the provider group established in paragraph A and the forum;
(4) Conducting public hearings and meetings; and
(5) Reviewing consumer education materials developed by the forum;
[2003, c. 469, Pt. A, §8 (new).]
D. Make recommendations regarding quality assurance and quality improvement priorities for inclusion in the State Health Plan
described in Title 2, chapter 5; and
[2003, c. 469, Pt. A, §8 (new).]
E. Serve as a liaison between the forum and other organizations working in the field of health care quality.
[2003, c. 469, Pt. A, §8 (new).]
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §6971. Dirigo Health High-risk Pool
Title 24-A: MAINE INSURANCE CODE
Chapter 87: DIRIGO HEALTH (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
Subchapter 3: DIRIGO HEALTH HIGH-RISK POOL (HEADING: PL 2003, c. 469, Pt. A, @8 (new))
§6971. Dirigo Health High-risk Pool
Dirigo Health shall establish the Dirigo Health High-risk Pool, referred to in this section as "the high-risk pool" for plan
enrollees in accordance with this section.
[2003, c. 469, Pt. A, §8 (new).]
1. Eligible enrollees for high-risk pool. A plan enrollee must be included in the high-risk pool if:
A. The total cost of health care services for the enrollee exceeds $100,000 in any 12-month period; or
[2003, c. 469, Pt. A, §8 (new).]
B. The enrollee has been diagnosed with one or more of the following conditions: acquired immune deficiency syndrome (HIVAIDS),
angina pectoris, cirrhosis of the liver, coronary occlusion, cystic fibrosis, Friedreich's ataxia, hemophilia, Hodgkin's disease,
Huntington's chorea, juvenile diabetes, leukemia, metastatic cancer, motor or sensory aphasia, multiple sclerosis, muscular
dystrophy, myasthenia gravis, myotonia, heart disease requiring open-heart surgery, Parkinson's disease, polycystic kidney
disease, psychotic disorders, quadriplegia, stroke, syringomyelia, and Wilson's disease.
[2003, c. 469, Pt. A, §8 (new).]
[2003, c. 469, Pt. A, §8 (new).]
2. Disease management. Dirigo Health shall develop appropriate disease management protocols, develop procedures for implementing those protocols
and determine the manner in which disease management must be provided to plan enrollees in the high-risk pool. Dirigo Health
may include disease management in its contract with participating carriers for the Dirigo Health Program pursuant to section
6910, contract separately with another entity for disease management services or provide disease management services directly
through Dirigo Health.
[2005, c. 400, Pt. C, §10 (amd).]
3. Report. Dirigo Health shall submit a report, no later than January 1, 2006, outlining the disease management protocols, procedures
and delivery mechanisms used to provide services to plan enrollees. The report must also include the number of plan enrollees
in the high-risk pool, the types of diagnoses managed within the high-risk pool, the claims experience within the high-risk
pool and the number and type of claims exceeding $100,000 for enrollees in the high-risk pool and for all enrollees in the
Dirigo Health Program. The report must be submitted to the joint standing committee of the Legislature having jurisdiction
over health insurance matters. The committee may make recommendations on the operation of the high-risk pool and may report
out legislation to the Second Regular Session of the 122nd Legislature relating to the high-risk pool.
[2005, c. 400, Pt. C, §10 (amd).]
4. Establishment of statewide high-risk pool. After 3 years of operation, but no later than October 1, 2007, Dirigo Health shall evaluate the impact of Dirigo Health
on average premium rates in this State and on the rate of uninsured individuals in this State and compare the trends in those
rates to the trends in the average premium rates and average rates of uninsured individuals for the 31 states that have established
a statewide high-risk pool as of July 1, 2003. The board shall submit the evaluation of the impact of Dirigo Health in this
State in comparison to states with high-risk pools to the joint standing committee of the Legislature having jurisdiction
over health insurance matters by January 1, 2008. If the trend in average premium rates in this State and rate of uninsured
individuals exceed the trend for the average among the 31 states with high-risk pools, the board shall submit legislation
on January 1, 2008 to the Second Regular Session of the 123rd Legislature that proposes to establish a statewide high-risk
pool in this State consistent with the characteristics of high-risk pools operating in other states.
[2003, c. 469, Pt. A, §8 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
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