Referrals by Out-of-Network Direct Health Care Providers

STATE OF MAINE DEPARTMENT OF PROFESSIONAL & FINANCIAL REGULATION BUREAU OF INSURANCE Office Location: 76 Northern Avenue, Gardiner, Maine 04345 Mailing Address: 34 State House Station, Augusta, Maine 04333 www.maine.gov/pfr/insurance Phone: (207) 624-8475 TTY: Please Call Maine Relay 711 Consumer Assistance: (800) 300-5000 Fax: (207) 624-8599 Janet T. Mills Governor Robert L. Carey Superintendent Joan F. Cohen Commissioner Bulletin 490 Referrals by Out-of-Network Direct Health Care Providers (Supersedes Bulletin 434) In 2019, the Bureau issued Bulletin 434 to describe the requirement for health carriers to honor referrals made by an enrollee’s direct primary care provider, even if that provider is out of network, on the same terms as if the provider had been in the carrier’s network. The purpose of this Bulletin is to update Bulletin 434 to reflect changes to the direct care law enacted by the Legislature in 2025, to include providers who are not primary care providers.1 All licensed physicians, and other advanced health care practitioners who are authorized to engage in independent medical practice in Maine, are now authorized to enter into direct health care service agreements (DHCSAs)2 with patients, and the term “direct primary care provider” has been changed to “direct health care provider” (DHCP) wherever it appears. Conforming changes have been made to the referral provision of the Health Plan Improvement Act, so that it now applies whenever there is a DHCSA between the enrollee and the referring provider.3 As under the prior law, the carrier may not deny a referral made by a DHCP, 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. 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. Insurers are encouraged to make information available on their websites for their plan members who may have a DHCSA, and for direct health care providers, including information for questions regarding referrals. Insurers are also encouraged to develop training and procedures for their employees in how to respond to referrals and other questions from direct health care providers. 1 An Act to Expand Direct Health Care Service Arrangements, P.L. 2025, ch. 358. 2 The relevant definitions and standards are at 22 M.R.S. § 1771. 3 24-A M.R.S. § 4303(22), as amended by P.L. 2025, ch. 358. Page 2 of 2 The law applies only to services referred by the direct health care provider. There is no requirement to cover services rendered by the direct health care provider, including the visit at which the referral is made, except to the extent that coverage is otherwise required under the terms of the plan. November 26, 2025 Robert L. Carey Superintendent of Insurance NOTE: This Bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties, or privileges, nor is it intended to provide legal advice. Readers should consult applicable statutes and rules and contact the Bureau of Insurance if additional information is needed.