The Maine surprise billing law (Maine) became effective January 1, 2018, with major updates in 2019–2020 under Public Law 2019, Chapter 668 (“An Act To Protect Consumers from Surprise Emergency Medical Bills”). 

This framework predates the federal No Surprises Act (NSA) and has been recognized by CMS as a Specified State Law (SSL) for insured plans.

For surprise bills and covered out-of-network emergency services, Maine requires carriers to pay the provider using a state-defined benchmark: 

• The carrier must reimburse the OON provider at the greater of:
  
  1. The carrier’s in-network (INN) rate for that service, or
  2. The average / median INN rate for that service from all carriers, as determined from Maine’s All-Payor Claims Database (APCD).

• Enrollee cost-sharing is limited to what they would have paid in-network, and coinsurance must be calculated based on the median in-network rate. 

Providers are prohibited from balance billing beyond the in-network cost-share once they are paid under this section or via the dispute resolution outcome. 

Maine runs its own state IDR system for surprise bills and OON emergency claims:

• If the provider disagrees with the carrier’s payment, the parties have 30 calendar days from payment to negotiate a resolution in good faith. 
• If still unresolved, the provider may submit the dispute to Maine’s independent dispute resolution (arbitration) process under §4303-E. 
• The arbitrator must select a reasonable payment amount, and that determination is binding on carrier, provider, and enrollee for 90 days for that specific service code. During that period, the carrier must pay the same rate on similar claims, and the provider may not re-litigate that service. 

This is effectively baseball-style style arbitration with a state benchmark overlay driven by APCD data.

Maine hard-codes a 30-day negotiation window:

• Begins when the provider is paid under the statute.
• Carrier and OON provider must use this period to attempt to reach an agreement on the final payment. 
• If no agreement is reached, the provider may trigger state IDR under §4303-E.

This 30-day window functions similarly to the federal NSA open negotiation period, but is rooted in state law.

In the state IDR process, the arbitrator can consider a broad set of factors, including: 

• The provider’s level of training, education, and experience
• Previously contracted rates between the parties
• UCR / reasonable value as determined using APCD data
• The complexity of the service and any extenuating clinical factors
• Other relevant information submitted by either party

Unlike the NSA, this is not QPA-centric—Maine’s process leans heavily on APCD data and historical contracted rates.

Maine’s surprise billing protections live in Title 24-A, Maine Insurance Code, Chapter 56-A: 

• §4303-C – Protection from surprise bills and bills for out-of-network emergency services
  
  • Defines “surprise bill” and sets payment + hold-harmless rules. 
• §4303-E – Dispute resolution process
  
  • Establishes Maine’s independent dispute resolution / arbitration system, including filing, timing, and binding effect. 

Separate sections (e.g., the 2019 public law) expand protections to uninsured patients and certain self-insured plan members who can elect to use the state IDR process in defined circumstances. 

CMS has explicitly recognized Maine’s law as a Specified State Law (SSL):

“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… Therefore, the federal independent dispute resolution process… will not apply in those cases in Maine.”

For insured group health plans and individual health insurance coverage issued in Maine:

• Maine’s payment benchmark (INN rate vs APCD average) controls the OON amount.
• Maine state IDR under §4303-E is used for disputes.
• Federal NSA IDR does not apply in those cases.

• Self-funded ERISA plans that do not voluntarily adopt Maine’s SBL.
• Any items/services or coverage types not within the scope of §4303-C as an SSL.

In those buckets, it reverts to: NSA → QPA → 30-day negotiation → Federal IDR.

• State law + state IDR for fully insured / individual plans.
• Federal NSA + Federal IDR for self-funded plans and non-SSL scenarios.