Maine Ass'n of Health Plans v. Superintendent of Insurance

2007 ME 69, 923 A.2d 918, 2007 Me. LEXIS 71
CourtSupreme Judicial Court of Maine
DecidedMay 31, 2007
StatusPublished
Cited by16 cases

This text of 2007 ME 69 (Maine Ass'n of Health Plans v. Superintendent of Insurance) is published on Counsel Stack Legal Research, covering Supreme Judicial Court of Maine primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Maine Ass'n of Health Plans v. Superintendent of Insurance, 2007 ME 69, 923 A.2d 918, 2007 Me. LEXIS 71 (Me. 2007).

Opinions

SAUFLEY, C.J.

[¶ 1] We are called upon in this appeal to review one of the funding sources of the Dirigo Health program. Several representatives of health insurers and other payors of health care costs in Maine challenge the decisions of the Dirigo Health Board of Directors and the Superintendent of Insurance that resulted in a calculation of the “aggregate measurable cost savings” to those payors. That calculation will determine the amount that the payors must pay to Dirigo Health to assist in the program’s funding. The legal question presented is whether the Board, and consequently the Superintendent, erred in interpreting and applying the phrase “aggregate measurable cost savings.” We affirm the Superior Court’s (Cumberland County, Cole, J.) judgment, according deference to the reasonable interpretation of an ambiguous statute by the Board and the Superintendent.

I. BACKGROUND

[¶ 2] The Dirigo Health program is the health insurance program that was proposed by Governor Baldacci and authorized by the 121st Maine Legislature in 2003 as part of a broader act aimed at increasing access to affordable health insurance in Maine. See P.L.2003, ch. 469 (effective Sept. 13, 2003). After its start-up year, during which the Dirigo Health [921]*921program was supported through general fund dollars, it was expected to be funded in part by “offset payments” to the State from health insurers and other payors. The amount of the offset payments due from the payors is to be calculated through use of a factor referred to as the “aggregate measurable cost savings,” as described in 24-A M.R.S. § 6913(1)(A) (2006). The method by which aggregate measurable cost savings are calculated affects the amount that may be recouped from the payors to provide funding for Dirigo Health. See 24-A M.R.S. § 6913(2)(C) (2006). The administrative determination of the method for calculating the aggregate measurable cost savings is before us on appeal today.

[¶ 3] As required by law, the Dirigo Health Board of Directors, after a hearing, calculated aggregate measurable cost savings, arriving at a figure of $136.8 million for the first year in which offset payments are required.1 The Superintendent of Insurance, after further hearing, reduced the calculation of cost savings to $43.7 million and otherwise approved the Board’s decision.

[¶4] Several entities representing the interests of payors, specifically, the Maine Association of Health Plans, the Maine State Chamber of Commerce, the Maine Automobile Dealers Association Insurance Trust, and the Bankers Health Trust (collectively, the Association), appealed the Superintendent’s decision to the Superior Court. The Superior Court affirmed the Superintendent’s decision. The Association has appealed from the judgment of the Superior Court, arguing that the Board originally interpreted the term “aggregate measurable cost savings” too broadly and, as a result, the Superintendent erred in including certain measures of savings.

A. Unique Nature of Dirigo Health

[¶ 5] The Dirigo Health program is a unique statutory creation. It is not based on a uniform or model act. Compare with Uniform Health-Care Decisions Act, 18-A M.R.S. §§ 5-801 to 5-818 (2006). It has not been derived from the workings of another state’s program.2 It has no history in the common law. Rather, it represents the efforts of the Governor and the Legislature to respond to a perceived social problem in a manner that had not been tried before.

[¶ 6] Thus, in resolving the disputes that have arisen between and among the parties before us, we find no substantive guidance through precedent. We are limited to the plain language of the statute and, [922]*922where ambiguities exist, the legislative record. Well-settled rules of statutory construction are critical, as is legislative history when interpreting any ambiguous language in the statute.

B. Legislation Aimed at Increasing Access to Health Insurance

[¶ 7] We turn then to the statute at issue. In late 2002, the Governor proposed legislation intended to provide increased access to affordable health insurance in Maine. The Legislature passed an amended version of the Governor’s proposal in 2003 as “An Act To Provide Affordable Health Insurance to Small Businesses and Individuals and To Control Health Care Costs.” P.L.2003, ch. 469. In addition to creating the Dirigo Health program, the Act initiated other changes in health care delivery in Maine.

[¶ 8] The Act set forth a number of methods by which health care costs in Maine could be reduced. Among other things, the Act created the capital investment fund to limit the resources allocated annually pursuant to the certificate of need program, P.L.2003, ch. 469, § B-l (codified at 2 M.R.S. § 102 (2006)); mandated that a certificate of need may be granted only if the project can be funded with the capital investment fund, P.L.2003, ch. 469, § C-8 (codified at 22 M.R.S. § 335(1)(E) (2006)); created the Advisory Council on Health Systems Development to gather and analyze data on health systems development in Maine and required the Governor to adopt a State Health Plan with input from this Council and other agencies and organizations, P.L.2003, ch. 469, § B-l (codified as subsequently amended at 2 M.R.S. §§ 101-105 (2006)); suggested that each health insurance carrier voluntarily limit the pricing of products to no more than 3% underwriting gain, less federal taxes, for the 2003-2004 fiscal year, P.L. 2003, ch. 469, § F-1(1)(C); requested that hospitals voluntarily restrain cost increases, measured in expenses per case mix adjusted discharge,3 to 3.5% or less and hold hospital consolidated operating margins 4 to no more than 3% during the 2003-2004 fiscal year, P.L.2003, ch. 469, § F-1(1)(B); and established the Commission to Study Maine’s Community Hospitals, P.L.2003, ch. 469, § F-3, which ultimately recommended that the Legislature budget and pay past obligations to hospitals promptly and revise future periodic interim payment estimates to include a realistic forecast of the increased use of Maine-Care, and that the State increase Maine-Care payments to physicians and hospitals to cover their costs, see Commission to Study Maine’s Hospitals, Report to the Legislature 5 (Feb.2005).

[¶ 9] In the context of this broader Act, the Legislature also created the Dirigo Health program, the funding of which is at issue in this appeal. See P.L.2003, ch. 469, § A-8 (codified as chapter 87 of title 24-A). Dirigo Health was created “as an independent executive agency” that “arrange[s] for the provision of comprehensive, affordable health care coverage to eligible small employers, including the self-employed, their employees and dependents, and individuals on a voluntary basis.” 24-A M.R.S. § 6902 (2006); P.L. 2003, ch. 469, § A-8.

[¶ 10] The operation of Dirigo Health is supervised by the Board of Directors, which consists of five voting members appointed by the Governor, subject to review by the joint standing committee of the Legislature with jurisdiction over health insurance matters and confirmation by the [923]

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Maine Ass'n of Health Plans v. Superintendent of Insurance
2007 ME 69 (Supreme Judicial Court of Maine, 2007)

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Bluebook (online)
2007 ME 69, 923 A.2d 918, 2007 Me. LEXIS 71, Counsel Stack Legal Research, https://law.counselstack.com/opinion/maine-assn-of-health-plans-v-superintendent-of-insurance-me-2007.