Provider List 24-A MRS 3958

In accordance with the provisions of Section 3952(5-A) of the Enabling Act, the Board of Directors of MGARA, in consultation with and based on analysis by the Maine Department of Health and Human Services and Maine Health Data Organization, developed, and may amend from time to time, a list of certain High Priced Items or Services (HPIS) that contribute to MGARA’s costs and offer an opportunity of saving. The reinsurance provided under the Reinsurance Program for a High-Priced Item or Service shall not exceed two hundred percent (200%) of the allowed charge determined for such item or service under the original Medicare fee-for-service program for the applicable year in which the claim arose. Section 3958(1)(B) of the Enabling Act requires (i) each member insurer to report for each plan year the name of each High Priced Item or Service for which such Member Insurer’s payment exceeded the HPIS Limit and the name of the Provider that received payment; and (ii) MGARA to annually compile and publish a list of all names so reported.

Maine Guaranteed Access Reinsurance Association
In accordance with the provisions of Section 3952(5-A) of the Enabling Act, the Board of Directors of MGARA, in consultation with
and based on analysis by the Maine Department of Health and Human Services and Maine Health Data Organization, developed,
and may amend from time to time, a list of certain high-priced items or services that contribute to MGARA’s costs and offer an
opportunity of saving.

The HPISs for the year 2024 are:
APC          GROUP TITLE
5115          Level 5 Musculoskeletal Procedures
5375          Level 5 Urology and Related Services
5571          Level 1 Imaging with Contrast
5623          Level 3 Radiation Therapy
5671          Level 1 Pathology
5771          Cardiac Rehabilitation
8005          CT and CTA without Contrast Composite

The reinsurance provided under the Reinsurance Program for a High-Priced Item or Service shall not exceed two hundred
percent (200%) of the allowed charge determined for such item or service under the original Medicare fee-for-service program
for the applicable year in which the claim arose.
Section 3958(1)(B) of the Enabling Act requires (i) each member insurer to report for each plan year the name of each High-
Priced Item or Service for which such Member Insurer’s payment exceeded the HPIS Limit and the name of the Provider that
received payment; and (ii) MGARA to annually compile and publish a list of all names so reported. Below is that list of names.

PROVIDER
Cary Medical Center
Central Maine Medical Center
Franklin Memorial Hospital
Maine Medical Center
Maine General Medical Center
Mid Coast Hospital
Northern Light AR Gould Hospital
Northern Light Eastern Maine Medical Center
Northern Light Inland Hospital
Northern Light Maine Coast Hospital
York Hospital
Northern Light Mercy Hospital
Northern Maine Medical Center
Pen Bay Medical Center
Southern Maine Health Care – Biddeford Medical Center
St. Joseph Hospital
St. Mary’s Regional Medical Center