The Maine SBL

The Maine SBL became effective January 1, 2018. The relevant provisions include:

  • A requirement that the provider be paid the greater of 1) the INN rate of the carrier, or 2) the average INN rate of all carriers from the state All Payor Claims Database (APCD).

    An IDR

  • arbitration process for dispute resolution of claims between the provider and the carrier.

  • A 30-day period to negotiate a resolution, starting presumably on the payment date.

  • The ability of the arbitrator to consider the provider’s level of training, previously contracted rates, UCR as determined by data from the APCD, and other factors.

Title 24-A, Maine Insurance Code, Chapter 56-A, §4303-C.

Regarding bifurcation, according to CMS,

Maine does not have an applicable All-Payer Model Agreement that would determine the out-of-network rate. Based on the survey response and CMS communications with Maine Bureau of Insurance and the Maine Department of Health & Human Services staff, CMS understands that Title 24-A, Maine Insurance Code, Chapter 56-A, §4303-C is a specified state law that will apply for purposes of determining the out-of-network rate with respect to items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Maine by nonparticipating providers, nonparticipating emergency facilities or nonparticipating providers of air ambulance services. Therefore, the federal independent dispute resolution process under sections 2799A-1(c) and 2799A-2(b) of the PHS Act and 45 CFR 149.510 and 149.520 will not apply in those cases in Maine.

Letter from CMS to Governor of Maine, December 22, 2021.

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