02-031 DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION

BUREAU OF INSURANCE

Chapter 855: HEALTH INSURANCE PAYMENT REFORM PILOT PROJECTS

Section 1. Authority and Purpose

1. This rule is adopted pursuant to 24-A M.R.S.A. §§ 212 and 4320-H and 2011 Public Law Chapter 270 §4, to establish procedures and policies for authorization of pilot projects relating to health insurance provider payment reform strategies.

Section 2. Definitions

1. For purposes of this rule, the following terms have the following meanings:

1. “Accountable care organization” means a group of health care providers operating under a payment agreement to provide health care services to a defined set of individuals with established benchmarks for the quality and cost of those health care services consistent with federal law and regulations.
2. “Carrier” and “health plan” have the meanings set forth in 24-A M.R.S.A. §§ 4301‑A(3) & (7).

1. C. “Pilot project” means a project that allows a health insurance carrier that offers health plans in this State to implement payment reform strategies with providers through an accountable care organization to reduce costs and improve the quality of patient care, but does not include projects otherwise permitted by law.

Section 3. Authorization of Health Insurance Payment Reform Pilot Projects

1. A. A carrier that offers health plans in this State may seek authorization from the Superintendent to conduct a pilot project that implements payment reform strategies with providers through an accountable care organization to reduce costs and improve the quality of patient care.
   1. B. In order to be approved, a pilot project application must:

1. include a detailed project narrative including, where appropriate a work plan and project timeline, including project commencement and conclusion dates;
2. demonstrate consistency with the payment reform principles set forth in Section 4 of this Rule;

1. 3. include copies of all contracts, written agreements, memoranda of understanding, or other similar documents pertinent to the program. Forms to be used in multiple agreements should be submitted in blank;
   1. 4. demonstrate compliance with all applicable Maine laws;
      1. 5. include a methodology for periodic measurement and evaluation of the results of the pilot project. The methodology shall include identification of the baseline data or information to be analyzed and the analysis of project costs, project benefits, the effect of the project in reducing health care costs, any effect on insurance premiums, and any effect on the quality of care;
      2. 6. provide for reporting to the Superintendent by May 31 of each year the pilot project results as of December 31 of the preceding year, or on such other schedule as may be agreed to by the carrier and the Superintendent; and
      3. 7. have received accreditation status from the National Council on Quality Accreditation (NCQA) or provided such other assurances of quality as the Superintendent may determine acceptable.

Section 4. Payment Reform Principles

1. Pilot projects must demonstrate consistency with the following payment reform principles:
   1. A. Support for integrated, efficient, and effective systems of care delivery and payment;
   2. B. Promotion of a patient-centered approach to service payment and delivery;
   3. C. Encouragement and reward for the prevention and management of disease;
   4. D. Incentives that do not reward the denial or restriction of medically necessary care;
   5. E. Promotion of the value of care over volume to measurably lower costs; and
   6. F. Support for payments and processes that are transparent, easy to understand, and simple to administer for patients, providers, purchasers, and other stakeholders. If a health insurance carrier implements a pilot project that restricts provider participation on the basis of cost and/or quality benchmarks, those benchmarks should be transparent to the provider community.

Section 5. Compliance with Other Laws

1. Pilot projects authorized under this Rule and complying with the payment reform principles set forth in Section 4 shall not be considered prohibited financial incentives under 24-A M.R.S.A. §4303(3-B). Pilot projects are subject to all other applicable Maine statutes and rules.

Section 6. Confidentiality

1. Any information contained in an application for authorization of a pilot project or in other documents filed with the Superintendent pursuant to this Rule shall be treated by the Superintendent as a “public record” within the meaning of the Maine Freedom of Access Act, 1 M.R.S.A. §§ 401 et seq., unless a legal basis for confidentiality exists. Any applicant who seeks to assert the confidentiality of any document or documents filed pursuant to this Rule shall clearly state the basis for the assertion at the time of filing and shall provide both redacted and unredacted originals of the documents to which the assertion relates. Unredacted documents subject to an assertion of confidentiality shall be clearly identified as confidential. The cover letter to the filing shall identify information subject to a confidentiality assertion and where it is located within the filing.

   There shall be a rebuttable presumption that any documents that are subject to an assertion of confidentiality are confidential. If a request for the documents is received, or if the Superintendent determines that the filing party has not adequately supported the assertion of confidentiality, the filing party shall be provided an opportunity to provide the Superintendent, and the requesting party if applicable, detailed legal support for the basis for the assertion according to Maine law then in effect. The requesting party shall be provided an opportunity to provide responsive legal support for the document request. The Superintendent shall then notify both the filing party and the requesting party of his or her determination as to confidentiality of the documents in question. Should the Superintendent determine that the documents or any portion of the documents are not entitled to confidential treatment, the filing party shall be provided an opportunity to seek judicial review before their release.

Section 7. Effective Date

1. This Rule is effective April 13, 2013.

STATUTORY AUTHORITY: 24-A MRSA §§ 212, 4320-H; 2011 P.L. c. 270 §4

EFFECTIVE DATE:

April 13, 2013 – filing 2013-081