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State insurance regulators in Maine are trying to help patients mix and match out-of-network providers with their health plans' in-network providers.
Robert Carey, the superintendent of the Maine Bureau of Insurance, has issued a bulletin telling health plans that a plan must open up its provider network gates when any care provider wants to refer an enrollee to an in-network specialist or other in-network care provider.
Maine has required plans to let out-of-network direct primary care providers refer patients to in-network resources since 2019.
Now, the state is expanding the requirement to include referrals from any "direct health care provider," not just "direct primary care providers."
The change is the result of a direct care law Maine lawmakers passed earlier this year, and it applies to "all licensed physicians, and other advanced health care practitioners who are authorized to engage in independent medical practice in Maine," according to the bulletin.
A carrier may not deny a referral made by a direct health care provider, or "impose additional cost-sharing or other conditions on the referred service, for the sole reason that the referring provider is out of network or that the referring provider practices on a direct care basis," Carey said.
"The carrier may continue to apply its usual cost-sharing requirements, benefit limitations, and reasonable clinical review criteria to the services referred by the direct health care provider, as long as they would apply if the referring provider had been a participating provider, a clinic, a hospital or another provider," Carey added.
What it means: For an employer's health plan participants, the new Maine network access law may seem like a logical patient protection law.
For an employer or plan administrator struggling to hold costs down, the law may seem to be an attack on wellness strategies, provider credentialing strategies and other strategies designed to reduce the odds that patients will need referrals to specialists, clinics or hospitals.
The backdrop: The American Medical Association recently considered a resolution that could have required all health plans to provide out-of-network benefits, and disputes over claims for reimbursement for out-of-network emergency care may be leading plans to develop new strategies for handling out-of-network care.
New attacks on plans' use of provider networks to try to prevent unnecessary use of care or use of overly expensive care come as health plans also face attacks on other cost-containment strategies, such as "prior authorization" programs, or efforts to determine whether care should be covered before the care has taken place, and moves to deny or "edit" claims for care that has already taken place.
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