The State of Maine is making important news in the benefits claim auditing field with the Act to Improve Accountability and Understanding of Data in Insurance Transactions. It’s a new law that became effective on January 1, 2026, and requires third party administrators (TPAs) and pharmacy benefit managers (PBMs) licensed in Maine to allow a full audit of claims.

The new Audit Act in Maine takes direct aim at TPAs and PBMs that would limit or restrict employer-funded medical and Rx plans and their auditors from accessing data necessary to complete a full review of claims. The new law also has two other crucial provisions. The first involves pre-payment auditing of high-cost medical claims and the second covers information about how much PBMs pay pharmacies on behalf of a self-funded plan.

The Maine law joins similar legislation enacted recently in Indiana and newer laws in other states that are beginning to require greater transparency from PBMs and TPAs.

 

Why New Laws Like This are Increasingly Needed

Employer-funded medical and pharmacy plans eternally deal with rising costs and the anti-competitive actions of some TPAs and PBMs have caused State Legislatures to take action. Maine and Indiana have now put in place laws to remove or prohibit restrictions on auditing claims, while other states (Illinois, Iowa, California) have recent laws on the books covering PBM business practices.

All of these laws benefit self-funded plan sponsors and address various concerns such as stopping financial incentives for use of PBM-owned pharmacies; prohibiting restricted networks that exclude certain pharmacies; and, outlaw spread pricing where PBMs charge plans more for medications than they pay manufacturers. Arkansas has gone as far as prohibiting PBMs from owning pharmacies.

 

Full Access for Claim Auditing is a Must

As claim auditors, we continuously remind our client organizations about the vital need for complete data access. When we audit TPAs and PBMs, we must have open access to review all claims so that we can report on various important issues.

• Contract term compliance
• Financial performance guarantees
• Mistakes and overpayments

Audits also provide valuable data and support for fiduciary responsibilities, made even more important recently by a trend of class-action fiduciary breach lawsuits against plans and their sponsors.

“Plan sponsors have a fiduciary duty to their members, and you simply cannot meet that obligation without complete, unrestricted access to claims data. Maine has made that a legal right. We’ve been making that case to clients for years — it’s gratifying to see state law catch up.” – Auke van Scheltinga, TFG Partners

Wise and well-run plans have always tried to reject audit restrictions that TPAs and PBMs attempt to write into their service agreements and now laws in some states make the restrictions illegal. Free and open claim audits are the most effective oversight a group health plan sponsor can run to doublecheck charges from providers and claim administrators. However, restrictions on claim audits built into TPA and PBM contracts remain common, even with U.S, Government guidance to reject gag clauses as part of guidance to plan sponsors for implementing Part 69 of the Consolidated Appropriations Act of 2021.

Among the most troubling restrictions have been those limiting the number of claims auditors can review, limits on auditor selection and audit fees, and limits on the data points available for review.

 

Important Points About Maine’s Audit Act

The Maine Audit Act has two parts, the first is 24-A MRSA § 1914 covering TPAs and the second is 24-A MRSA § 4349-A applying to PBMs. It applies only to contracts TPAs and PBMs have with sponsors of self-insured group health plans and prohibits audit restrictions in service agreements for those plans. The spirit of the law is to ensure employers free access to claims data for audits so that they are not limited in running thorough oversight of their plans.

For TPAs: Maine now requires that contracts allow employers to audit post-payment claims at least once each calendar year puts a stop to confidentiality provisions that interfere with audit rights. It goes a step farther in mandating the level of data provided, covering all important areas.

• Billed and paid amounts for medical and hospital services
• Administrative and processing fees
• Details about network fees and negotiated discounts
• Other items such as cost-containment fees, subrogation, repricing

Other valuable provisions stop TPAs from profiting on audits, allowing them to charge only the direct cost of providing the data, and stop them from interfering with the choice of auditor, and the quantity of type of claims available for review. Lastly, the law addresses high-cost claims of $100,000 or more, giving sponsors the ability to run a pre-payment audit to confirm TPAs closely follow contract terms.

For PBMs: The Audit Act requires data access and transparency like the provisions for TPAs, mandating that PBMs also allow post-payment claim audits at least once each calendar year; give auditors access to needed data points; omit excessive confidentiality clauses; allow plan sponsors to select an audit firm; and, permit all claims to be reviewed.

In addition, PBMs must promptly provide data when employers request it about prescription prices, and any dispensing fees paid to a pharmacy of pharmacist – all due within 30 days of the original request.

Enforcement: Violations are punishable under Maine’s Trade Laws and enforced by the State Attorney General or by consumers filing legal action accusing a TPA or PBM of violating the Audit Act’s requirements. The law is also written to avoid conflicts with the Employee Retirement Income Security Act of 1974, as amended (ERISA), and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which contains privacy and security provisions. Therefore, the law applies only to TPAs and PBMs licensed to do business in Main and does not cover Group Health Plans or employers.

 

Why We Applaud Maine’s Audit Act

At TFG Partners, we’ve been auditing claims for self-ensured group health plans since their inception, and our process reviews every claim paid for unmatched accuracy. One of the reasons we added PBM RFP Consulting to our menu of services several years ago was to help address practices like the ones now illegal in Maine.

There is no substitute for full data access for employers that sponsor medical and Rx plans. Claim audits provide essential oversight and when done strategically tremendous insight for management about a host of financial and member service considerations. They are also essential for meeting fiduciary responsibilities. We applaud Maine’s foresight and hope many more states soon follow suit.

Regardless of where your company or organization is based or operates, we can assist with claim audits that lead the industry in their accuracy and value. If you’re in-house at a plan sponsor and want to take your audits and oversight to the next level, please call or contact us online today.