24-A M.R.S. § 5054 — ME Code / Title 24-A / Chapter 68 / Section 5054
24-A §5054. Certification by superintendent
Status: in_force

1. Filing of form. Any insurer, nonprofit hospital or medical service organization, or nonprofit health care plan may, at the time it files a policy or contract for approval for issuance or delivery in the State, or at any time thereafter, request that the superintendent certify the policy or contract as a long-term care policy within the meaning of section 5051 . Within 60 days of receipt of a request for certification, the superintendent shall: A. Certify in writing that the policy or contract complies with this section; [PL 1989, c. 556, Pt. B, §4 (NEW).] B. Deny the request in writing, stating the reasons for denial; or [PL 1989, c. 556, Pt. B, §4 (NEW).] C. Notify the insurer or nonprofit hospital or medical service organization or nonprofit health care plan, in writing, that an insufficient basis exists for determining whether a certification should be made, indicating in what respects the request was insufficient. [PL 1997, c. 604, Pt. D, §6 (AMD).] [PL 1997, c. 604, Pt. D, §6 (AMD).]

2. Standards for compliance. The superintendent shall certify a policy or contract submitted for review under this section as a long-term care policy if the superintendent finds that the policy or contract: A. Is a long-term care policy within the meaning of section 5051 ; and [PL 1989, c. 556, Pt. B, §4 (NEW).] B. Complies with all standards applicable to long-term care policies as set forth in this chapter and in chapters 27 , 33 and 35 and in rules adopted pursuant to any of those chapters by the superintendent. Waivers granted under the rules shall be taken into consideration. [PL 1989, c. 556, Pt. B, §4 (NEW).] [PL 1989, c. 556, Pt. B, §4 (NEW).]
24-A M.R.S. § 2481 — ME Code / Title 24-A / Chapter 28 / Section 2481
24-A §2481. Product filing and approval -- Article 10
Status: in_force

1. Filing of product with commission. Insurers and 3rd-party filers seeking to have a product approved by the commission shall file the product with, and pay applicable filing fees to, the commission. Nothing in this chapter may be construed to restrict or otherwise prevent an insurer from filing its product with the insurance department in any state where the insurer is licensed to conduct the business of insurance, and such filing is subject to the laws of the states where filed. [PL 2003, c. 680, §1 (NEW).]

2. Commission to establish filing and review processes. The commission shall establish appropriate filing and review processes and procedures pursuant to commission rules and operating procedures. Notwithstanding any other provision of this chapter, the commission shall promulgate rules to establish conditions and procedures for providing public access to product filing information. In establishing such rules, the commission shall consider the interests of the public in having access to such information, as well as protection of personal medical and financial information and trade secrets that may be contained in a product filing or supporting information. [PL 2003, c. 680, §1 (NEW).]

3. Product approved by commission may be sold in certain compacting states. Any product approved by the commission may be sold or otherwise issued in those compacting states in which the insurer is legally authorized to do business. [PL 2003, c. 680, §1 (NEW).]
24-A M.R.S. § 4219 — ME Code / Title 24-A / Chapter 56 / Section 4219
24-A §4219. Administrative procedures
Status: in_force

1. When the superintendent has cause to believe that grounds exist for the suspension or revocation of a certificate of authority, the superintendent shall notify the health maintenance organization and the Commissioner of Health and Human Services in writing specifically stating the grounds for suspension or revocation. The Commissioner of Health and Human Services, or the commissioner's designated representative, shall participate in any disciplinary proceedings. In the process of determining whether grounds for suspension or revocation exist the findings of the commissioner with respect to matters relating to the quality of health care services provided are conclusive and binding upon the Superintendent of Insurance. The duration of and conditions attached to any suspension are determined by the superintendent after a hearing held in accordance with Title 5, chapter 375, subchapter IV . [PL 1997, c. 592, §72 (AMD); PL 2003, c. 689, Pt. B, §7 (REV).]

2. The Superintendent of Insurance, acting in concert with the Commissioner of Health and Human Services, has the authority to amend, modify or refuse to renew any certificate of authority for cause, pursuant to the Maine Administrative Procedure Act, Title 5, chapter 375, subchapter IV . [PL 1977, c. 694, §436 (RPR); PL 2003, c. 689, Pt. B, §7 (REV).]
24-A M.R.S. § 412 — ME Code / Title 24-A / Chapter 5 / Section 412
24-A §412. Deposits
Status: in_force

1. No insurance company other than a domestic real estate title insurance company or a domestic mutual fire insurance company that is transacting only the business of fire, marine or glass on the assessment plan may do so in this State unless it makes and maintains a deposit with the Superintendent of Insurance, as security for all its policyholders, of securities that are determined eligible for deposit under section 1253 . The deposit must be maintained in a minimum actual market value that, exclusive of interest, may never be less than $100,000. The deposit must be retained by the superintendent and disposed of as directed by section 1263 . [PL 1999, c. 113, §16 (AMD).]

2. Any admitted foreign insurance company may file with the superintendent a certificate of the insurance supervisory official of such other jurisdiction that the supervisory official holds in trust and on deposit for benefit of all the policyholders of the company a deposit of not less than $100,000 in such securities as are required or permitted to be deposited with that supervisory official by the laws of that jurisdiction. These securities are to be of a character consistent with investment authority in such jurisdiction. Such certificate must contain a statement by the supervisory official that the supervisory official is satisfied that the actual market value of these securities is of minimum value of $100,000. A deposit may not be required to be maintained in this State while such a deposit, if so certified, is retained by the supervisory official. [RR 2021, c. 1, Pt. B, §178 (COR).]

3. The superintendent shall receive and hold in trust deposits made under this section by any domestic insurance company in compliance with the laws of this or any other state, to enable it to do business in this or any other state, and in like manner shall hold deposits made by a foreign company under the laws of this State. The company making such deposit shall be entitled to any investment income thereon and with the superintendent's consent, if not inconsistent with the laws under which such deposit was made, may exchange in whole or in part such securities comprising the deposit for other approved securities of equal value. [PL 1975, c. 77 (RPR).]

4. The superintendent shall not authorize an alien insurer to transact insurance in this State unless it makes in this State through the superintendent and thereafter continuously maintains a deposit, representing funds in excess of all the insurer's liabilities under insurance contracts in force in the United States of America, of a fair market value in amount not less than the minimum paid-in capital stock required under this Title of a foreign stock insurer authorized to transact like kinds of insurance in this State. The superintendent may require additional trusteed surplus funds in reasonable amount to secure the interest of beneficiaries under policies insured by the alien insurer. In addition to the foregoing trusteed surplus account, an alien insurer authorized pursuant to this Title shall establish and maintain in one or more states of the United States a deposit or deposits of trust assets of a kind and quality as generally required by this section. The value of the deposit or deposits shall be at least equal to those obligations resulting from insurance in force in the United States. The deposit or deposits shall, if located outside the State, be subject to administration standards comparable to those contained in this Title. The deposit shall be held in trust for the exclusive benefit of the insurer's policyholders and creditors in the United States of America. A. In lieu of such a deposit made or maintained in this State, the superintendent shall accept the certificate in proper form of the insurance supervisory official having general supervision of insurers in any other state to the effect that a deposit of like quality and amount, or part thereof, by such insurer is being maintained for like purposes in public custody or control pursuant to the laws of such state. [PL 1975, c. 77 (NEW).] [PL 1985, c. 330, §2 (AMD).]

5. All such deposits in this State are subject to the provisions of chapter 15 (Administration of Deposits). [PL 1975, c. 77 (NEW).]
24-A M.R.S. § 4214 — ME Code / Title 24-A / Chapter 56 / Section 4214
24-A §4214. Powers of insurers and nonprofit hospital or medical service corporations
Status: in_force

1. Subject to the provisions of sections 222 , 3479 to 3482 and chapters 13 and 13‑A , an insurance company licensed in this State or a nonprofit hospital, medical or health care service organization may establish, maintain, own, merge with, organize and operate a health maintenance organization under this chapter, either directly as a division or line of business, or indirectly through a subsidiary or affiliate. Subject to the provisions of section 222 and chapters 13 and 13‑A , 2 or more such insurance companies, or nonprofit hospital, medical or health care service organizations, or subsidiaries or affiliates, may jointly organize and operate a health maintenance organization. The business of an insurer or hospital or medical service corporation that establishes, maintains, owns, merges with, organizes or operates a health maintenance organization is considered to include the providing of health care by a health maintenance organization. [PL 1993, c. 702, Pt. A, §14 (AMD).]

1-A. A domestic insurer that establishes, maintains, merges with or organizes and operates a health maintenance organization as a division or line of business is governed in its investment of funds allocated to that line of business by the provisions of section 4204, subsection 3‑A . [PL 1993, c. 702, Pt. A, §15 (NEW).]

2. Notwithstanding any provision of this Title, an insurer or a nonprofit hospital and medical service corporation may contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through health maintenance organizations and to provide coverage in the event of the failure of the health maintenance organization to meet its obligations. [PL 1975, c. 503 (NEW).]

3. The enrollees of a health maintenance organization constitute a permissible group, under such laws, and shall not be counted as part of any group for the purposes of chapter 35 . Among other things, under such contracts, the insurer or nonprofit hospital or medical service corporation may make benefit payments to health maintenance organizations for health care services rendered by providers pursuant to the health maintenance organization. [PL 1975, c. 503 (NEW).]

4. [PL 1989, c. 842, §16 (RP).]
24-A M.R.S. § 5011 — ME Code / Title 24-A / Chapter 67 / Section 5011
24-A §5011. Rating restrictions
Status: in_force

1. Community rating. This subsection applies to any policy delivered or issued for delivery on or after January 1, 1993. It also applies, as of the first policy or certificate anniversary on or after January 1, 1993, to policies or certificates delivered or issued for delivery in 1992. A. Rates for policies subject to this subsection may not vary based on age, gender, health status, claims experience, policy duration, industry or occupation. [PL 1991, c. 740, §13 (NEW).] B. In revising rates for standardized plans, an issuer shall pool all experience for standardized plans under individual policies. Experience may be pooled separately for each standardized plan or experience for similar benefits in different standardized plans may be pooled, including, but not limited to, basing the component of the rate for skilled nursing coinsurance on the pooled experience of all standardized plans that include that benefit. Group plans may be rated separately. A group with credible experience may be rated differently than other groups. [PL 2001, c. 258, Pt. F, §4 (AMD).] C. An issuer that offers both group and individual plans may not use stricter medical underwriting standards for any group plan than it uses for individual plans. [PL 2001, c. 258, Pt. F, §5 (NEW).] D. An issuer may not use stricter medical underwriting standards than any affiliated issuer uses for its individual plans. [PL 2001, c. 258, Pt. F, §5 (NEW).] [PL 2001, c. 258, Pt. F, §§4, 5 (AMD).]

2. Discounts. Issuers that do not vary rates for a standardized plan based on age, gender, health status, claims experience, policy duration, industry or occupation, and that do not refuse issue of that plan to any individual or group based on health status, may provide discounts on that plan to individuals who purchase coverage during their initial period of enrollment in Medicare Part B at or after 65 years of age, subject to approval by the superintendent. The superintendent may adopt rules governing the appropriate use of discounts. [PL 2003, c. 428, Pt. H, §7 (AMD).]
24-A M.R.S. § 4452 — ME Code / Title 24-A / Chapter 57 / Section 4452
24-A §4452. Report to Legislature
Status: in_force

At the end of each calendar year, the association shall submit a report of its activities to the joint standing committee of the Legislature having jurisdiction over banking and insurance matters. The report must include the amount of assessments made against each account, the name of the insolvent insurer to which the assessments are attributable and the amount of funds borrowed, if any, by the association and the repayment date of any loan. [PL 1989, c. 751, §7 (NEW).]
24-A M.R.S. § 2476 — ME Code / Title 24-A / Chapter 28 / Section 2476
24-A §2476. Organization of the commission -- Article 5
Status: in_force

1. Membership. Each compacting state has one member. Each member must be qualified to serve in that capacity pursuant to applicable law of the compacting state. A member may be removed or suspended from office as provided by the law of the state from which the member is appointed. A vacancy occurring in the commission must be filled in accordance with the laws of the compacting state where the vacancy exists. This subsection may not be construed to affect the manner in which a compacting state determines the election or appointment and qualification of its own commissioner. [PL 2003, c. 680, §1 (NEW).]

2. One vote. Each member is entitled to one vote and has an opportunity to participate in the governance of the commission in accordance with the bylaws. Notwithstanding any provision of the compact to the contrary, action of the commission with respect to the promulgation of a uniform standard does not take effect unless 2/3 of the members vote in favor of the uniform standard. [PL 2003, c. 680, §1 (NEW).]

3. Bylaws. The commission shall, by a majority of the members, adopt bylaws to govern its conduct as may be necessary or appropriate to carry out the purposes and exercise the powers of the compact, including, but not limited to: A. Establishing the fiscal year of the commission; [PL 2003, c. 680, §1 (NEW).] B. Providing reasonable procedures for appointing and electing members, as well as holding meetings, of the management committee established under subsection 5 ; [PL 2003, c. 680, §1 (NEW).] C. Providing reasonable standards and procedures: (1) For the establishment and meetings of other committees; and (2) Governing any general or specific delegation of any authority or function of the commission; [RR 2003, c. 2, §86 (COR).] D. Providing reasonable procedures for calling and conducting meetings of the commission that consist of a majority of commission members, ensuring reasonable advance notice of each meeting and providing for the right of citizens to attend each meeting with enumerated exceptions designed to protect the public's interest, the privacy of individuals and insurers' proprietary information, including trade secrets. The commission may meet in camera only after a majority of the entire membership votes to close a meeting in whole or in part. As soon as practicable, the commission shall make public a copy of the vote to close the meeting revealing the vote of each member with no proxy votes allowed and votes taken during the meeting; [PL 2003, c. 680, §1 (NEW).] E. Establishing the titles, duties, authority and reasonable procedures for the election of the officers of the commission; [PL 2003, c. 680, §1 (NEW).] F. Providing reasonable standards and procedures for the establishment of the personnel policies and programs of the commission. Notwithstanding any civil service or similar laws of any compacting state, the bylaws exclusively govern the personnel policies and programs of the commission; [PL 2003, c. 680, §1 (NEW).] G. Promulgating a code of ethics to address permissible and prohibited activities of commission members and employees; and [PL 2003, c. 680, §1 (NEW).] H. Providing a mechanism for winding up the operations of the commission and the equitable disposition of any surplus funds that might exist after the termination of the compact after the payment or reserving of all of its debts and obligations. [PL 2003, c. 680, §1 (NEW).] [RR 2003, c. 2, §86 (COR).]

4. File bylaws with compacting states. The commission shall publish its bylaws in a convenient form and file a copy of the bylaws and a copy of any amendment to the bylaws with the appropriate agency or officer in each of the compacting states. [PL 2003, c. 680, §1 (NEW).]

5. Management committee. The commission shall establish a management committee. A. The management committee consists of no more than 14 members as follows: (1) One member from each of the 6 compacting states with the largest premium volume for individual and group annuities and life, disability income and long-term care insurance products, determined from the records of the National Association of Insurance Commissioners for the prior year; (2) Four members from those compacting states with at least 2% of the market based on the premium volume described in subparagraph (1) other than the 6 compacting states with the largest premium volume, selected on a rotating basis as provided in the bylaws; and (3) Four members from those compacting states with less than 2% of the market based on the premium volume described in subparagraph (1) with one selected from each of the 4 zone regions of the National Association of Insurance Commissioners as provided in the bylaws. [PL 2003, c. 680, §1 (NEW).] B. The management committee has such authority and duties as may be set forth in the bylaws, including, but not limited to: (1) Managing the affairs of the commission in a manner consistent with the bylaws and purposes of the commission; (2) Establishing and overseeing an organizational structure within and appropriate procedures for the commission to provide for the creation of uniform standards and other rules, receipt and review of product filings, administrative and technical support functions, review of decisions regarding the disapproval of a product filing and review of elections made by a compacting state to opt out of a uniform standard. A uniform standard may not be submitted to the compacting states for adoption unless approved by 2/3 of the members of the management committee; (3) Overseeing the offices of the commission; and (4) Planning, implementing and coordinating communications and activities with other state, federal and local government organizations in order to advance the goals of the commission. [PL 2003, c. 680, §1 (NEW).] C. The commission shall elect annually its officers from the management committee, with each having such authority and duties, as specified in the bylaws. [PL 2003, c. 680, §1 (NEW).] D. The management committee may, subject to the approval of the commission, appoint or retain an executive director for such period, upon such terms and conditions and for such compensation as the commission determines appropriate. The executive director shall serve as secretary to the commission, but may not be a member of the commission. The executive director shall hire and supervise such other staff as may be authorized by the commission. [PL 2003, c. 680, §1 (NEW).] [PL 2003, c. 680, §1 (NEW).]

6. Legislative committee. A legislative committee of state legislators or their designees is established to monitor the operations of, and make recommendations to, the commission, including the management committee. The manner of selection and term of any legislative committee member is set by the bylaws. Prior to the adoption by the commission of any uniform standard, revision to the bylaws, annual budget or other significant matter as may be provided in the bylaws, the management committee shall consult with and report to the legislative committee. [PL 2003, c. 680, §1 (NEW).]

7. Advisory committees. The commission shall establish 2 advisory committees, one composed of consumer representatives independent of the insurance industry and the other composed of insurance industry representatives. [PL 2003, c. 680, §1 (NEW).]

8. Additional advisory committees. The commission may establish advisory committees in addition to those described in subsection 7 as its bylaws may provide for the carrying out of its functions. [PL 2003, c. 680, §1 (NEW).]

9. Corporate records of the commission. The commission shall maintain its corporate books and records in accordance with the bylaws. [PL 2003, c. 680, §1 (NEW).]

10. Qualified immunity, defense and indemnification. The members, officers, executive director, employees and representatives of the commission are immune from suit and liability, either personally or in their official capacity, for any claim for damage to or loss of property or personal injury or other civil liability caused by or arising out of any actual or alleged act, error or omission that occurred, or that the person against whom the claim is made had a reasonable basis for believing occurred, within the scope of commission employment, duties or responsibilities. Nothing in this subsection may be construed to protect any person from suit or liability for any damage, loss, injury or liability caused by the intentional or willful and wanton misconduct of that person. [PL 2003, c. 680, §1 (NEW).]

11. Defend. The commission shall defend any member, officer, executive director, employee or representative of the commission in any civil action seeking to impose liability arising out of any actual or alleged act, error or omission that occurred within the scope of commission employment, duties or responsibilities, or that the person against whom the claim is made had a reasonable basis for believing occurred within the scope of commission employment, duties or responsibilities, as long as the actual or alleged act, error or omission did not result from that person's intentional or willful and wanton misconduct. Nothing in this subsection may be construed to prohibit that person from retaining counsel. [PL 2003, c. 680, §1 (NEW).]

12. Indemnification. The commission shall indemnify and hold harmless any member, officer, executive director, employee or representative of the commission for the amount of any settlement or judgment obtained against that person arising out of any actual or alleged act, error or omission that occurred within the scope of commission employment, duties or responsibilities, or that such person had a reasonable basis for believing occurred within the scope of commission employment, duties or responsibilities, as long as the actual or alleged act, error or omission did not result from the intentional or willful and wanton misconduct of that person. [PL 2003, c. 680, §1 (NEW).]
24 M.R.S. § 2332-M — ME Code / Title 24 / Chapter 19 / Section 2332-M
24 §2332-M. Coverage for general anesthesia for dentistry
Status: in_force

1. Enrollee defined. For the purposes of this section, unless the context otherwise indicates, "enrollee" means a person who is covered under an individual or group health insurance contract provided by a nonprofit hospital and medical service organization. [PL 2001, c. 423, §1 (NEW); PL 2001, c. 423, §5 (AFF).]

2. General anesthesia and associated facility charges. All individual and group nonprofit hospital and medical service organization contracts must provide coverage for general anesthesia and associated facility charges for dental procedures rendered in a hospital when the clinical status or underlying medical condition of an enrollee requires dental procedures that ordinarily would not require general anesthesia to be rendered in a hospital. The nonprofit hospital and medical service organization may require prior authorization of general anesthesia and associated charges required for dental care procedures in the same manner that prior authorization is required for other covered diseases or conditions. [PL 2001, c. 423, §1 (NEW); PL 2001, c. 423, §5 (AFF).]

3. Limitations on coverage. This section applies only to general anesthesia and associated facility charges for only the following enrollees if the enrollees meet the criteria in subsection 2 : A. Enrollees, including infants, exhibiting physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, can not be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce a superior result; [PL 2001, c. 423, §1 (NEW); PL 2001, c. 423, §5 (AFF).] B. Enrollees demonstrating dental treatment needs for which local anesthesia is ineffective because of acute infection, anatomic variation or allergy; [PL 2001, c. 423, §1 (NEW); PL 2001, c. 423, §5 (AFF).] C. Extremely uncooperative, fearful, anxious or uncommunicative children or adolescents with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity; and [PL 2001, c. 423, §1 (NEW); PL 2001, c. 423, §5 (AFF).] D. Enrollees who have sustained extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised. [PL 2001, c. 423, §1 (NEW); PL 2001, c. 423, §5 (AFF).] [PL 2001, c. 423, §1 (NEW); PL 2001, c. 423, §5 (AFF).]

4. Dental procedures and dentist's fee not covered. This section does not require a nonprofit hospital and medical service organization to cover any charges for the dental procedure itself, including, but not limited to, the professional fee of the dentist. Coverage for anesthesia and associated facility charges pursuant to this section is subject to all other terms and conditions of the individual or group contract that apply generally to other benefits. [PL 2001, c. 423, §1 (NEW); PL 2001, c. 423, §5 (AFF).]

5. Coordination of benefits with dental insurance. If an enrollee eligible for coverage under this section is also eligible for coverage for general anesthesia and associated facility charges under a dental insurance policy or contract, the nonprofit health care service organization or insurer providing dental insurance is the primary payer responsible for those charges and the nonprofit hospital and medical service organization is the secondary payer. [PL 2001, c. 423, §1 (NEW); PL 2001, c. 423, §5 (AFF).]

6. Application. The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date. [PL 2003, c. 517, Pt. B, §10 (NEW).]
24-A M.R.S. § 790 — ME Code / Title 24-A / Chapter 9 / Section 790
24-A §790. Officers and directors
Status: in_force

The directors of a special purpose reinsurance vehicle shall elect officers that they consider necessary to carry out the purposes of the reinsurance vehicle pursuant to this subchapter. The provisions of Title 13‑C, section 857 apply to the indemnification of officers and directors of reinsurance vehicles organized under this subchapter. [PL 2003, c. 249, §2 (NEW).]

1. Appointment; election of officers; directors. Each special purpose reinsurance vehicle authorized to do business in this State shall notify the superintendent within 30 days after the appointment or election of any new officers or directors. [PL 2003, c. 249, §2 (NEW).]

2. Removal of officer; director. When the superintendent determines that an officer or director does not meet the standards set forth in this section, the superintendent shall, after notice and opportunity for hearing afforded to the officer or director, and after a finding that the officer or director is incompetent or untrustworthy or of known bad character, order the removal of the person. If the reinsurance vehicle does not comply with a removal order within 30 days, the superintendent may suspend that reinsurance vehicle's limited certificate of authority until such time as the order is complied with. [PL 2003, c. 249, §2 (NEW).]

3. Loans with affiliate. The reinsurance vehicle may make no loans to any special purpose reinsurance vehicle organizer, owner, director, officer, manager or affiliate of the reinsurance vehicle. [PL 2003, c. 249, §2 (NEW).]
24-A M.R.S. § 2385-B — ME Code / Title 24-A / Chapter 25 / Section 2385-B
24-A §2385-B. Disclosure of premium information
Status: in_force

All policies issued to employers for workers' compensation insurance must disclose clearly to the employer as separate figures the base rate and the employer's experience modification factor. [PL 2001, c. 176, §1 (AMD).]

Upon request from an employer, when a policy is issued to an employer for workers' compensation insurance, it must be accompanied by a statement disclosing the percentages of premium expended during the previous year by the insurer for claims paid, loss control and other administrative costs, medical provider expenses, insurer and employee attorney's fees and private investigation costs. [PL 2001, c. 176, §1 (AMD).]
24-A M.R.S. § 3554 — ME Code / Title 24-A / Chapter 49 / Section 3554
24-A §3554. Change of location; emergency boards of directors
Status: in_force

Notwithstanding any provision of its charter, any domestic insurance organization, without complying with any provision of law requiring approval, or application for approval, of a change of location of its principal office may, from time to time, change the location thereof during an acute emergency to a suitable location within the United States, and may carry on its business at such new location during such acute emergency, and for a reasonable time thereafter. Any insurance organization which changes the location of its principal office during an acute emergency shall notify the superintendent thereof in writing as soon as practical, stating the address of the new location, the address of the former location, and the dates when business is ceasing at the former location and commencing at the latter location. [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).]

Notwithstanding any contrary provision of law or with its charter, if at any time during an acute emergency affecting any domestic insurance organization, no person otherwise empowered to call meetings of the board is capable of acting, a meeting thereof may be called by any director or acting director or if no director or acting director is capable of acting, by any officer or acting officer. If it shall be impracticable or impossible to give notice of a meeting of the board in the manner prescribed by charter and law, other than this chapter, the person calling such a meeting may give notice thereof by making such reasonable efforts as circumstances may permit to notify each director and acting director of the time and place of the meeting, but need not specify the purposes thereof. Failure of any director or acting director to receive actual notice of a meeting of directors and acting directors shall not affect the power of the directors and acting directors present at such meeting to exercise the powers of an emergency board of directors as prescribed in this section. Nothing in this chapter shall be construed as requiring a meeting of the board of such an organization to be convened in any manner different from that prescribed by its charter and by the provisions of law other than this chapter. [PL 1969, c. 132, §1 (NEW).]

If 3 or more directors and acting directors of any domestic insurance organization are present at any meeting of its board duly convened during an acute emergency affecting such domestic insurance organization, they shall constitute its emergency board of directors which, notwithstanding any contrary provision of law or of its charter, shall have the power, subject to the limitations prescribed by this chapter, by a majority of those present, to take any and every action which may be necessary to enable such domestic insurance organization to meet the exigencies of the acute emergency and conduct its business during such period, but no other powers. The powers of an emergency board of directors shall include, but shall not be limited to, the following powers: [PL 1969, c. 132, §1 (NEW).]

1. Fill vacancies and absentees. At any meeting, to elect such acting directors as it may deem necessary, without regard to the number of directors which would otherwise be required, to serve in any positions on such board which are vacant or in place of any directors or acting directors who are absent from such meeting, but not to elect any director on a permanent basis; [PL 1969, c. 132, §1 (NEW).]

2. Acting officers and duties. To elect such acting officers as it may deem necessary, without regard to the number of officers which would otherwise be required, to serve in any offices which are vacant or in place of any officers or acting officers who fail to appear and assume their duties, to fix the compensation and determine the powers and duties of acting officers and to remove acting officers but not to remove any officer or to fill any vacancy on a permanent basis or to cause the insurance organization to enter into any contract of employment for a term in excess of one year; [PL 1969, c. 132, §1 (NEW).]

3. Change of location. To cause the insurance organization to change the location of its principal office, pursuant to this section, or any of its places of business, and to authorize such action as it may deem appropriate to acquire space and facilities at new locations, but not to acquire for use as its principal office property in fee or for a term in excess of one year; [PL 1969, c. 132, §1 (NEW).]

4. Postpone meetings. To postpone any meeting of the stockholders, policyholders or members or directors of such organization if, in the judgment of majority of the members of such emergency board of directors, it would be impracticable to hold such meeting at the time it would otherwise have been held or conducted; [PL 1969, c. 132, §1 (NEW).]

5. Call meetings. If it shall appear to an emergency board of directors that a quorum of the board cannot be assembled within a reasonable time, to call a meeting of the stockholders, policyholders or members of the insurance organization to be held as soon as the circumstances may reasonably permit, at a place to be designated by the emergency board of directors within this State or a contiguous state, for the purpose of electing directors to fill vacancies on the board, but for no other purpose, and to propose nominees for such election. Any such meetings of stockholders, policyholders or members shall be held upon notice given in accordance with the charter of the organization and applicable law other than this section. [PL 1969, c. 132, §1 (NEW).]

As soon as practicable after each meeting of an emergency board of directors, the person who presided thereat shall notify the superintendent in writing of the time and place of such meeting, of the manner in which notice thereof was given, of the persons present and of all actions taken at such meeting. [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).]

A person prohibited by law or by the charter of a domestic insurance organization from serving as a member of its board is not eligible to serve as an acting director, except that a person is not disqualified to serve as an acting director by reason of the person's not being a stockholder, policyholder or member of such insurance organization, by reason of the person's not being a resident of this State or of a contiguous state, or by reason of the number of directors or acting directors who are officers, acting officers or employees of the insurance organization. Any person may serve as an acting director of a fund who is a director, acting director, officer or acting officer of an organization that is a party to the agreement creating the fund. An oath of acting directors is not required. [RR 2021, c. 1, Pt. B, §302 (COR).]

Acting directors elected under this section or appointed under section 3555 are entitled to vote at all meetings of emergency board of directors equally with directors. Acting directors are not entitled to take part in the deliberations or to vote at any meeting of the board that is duly convened in accordance with the applicable provisions of its charter and of law other than this chapter and at which a quorum is present. Each acting director shall serve until the director or acting director in whose place the acting director was elected or appointed attends the meeting of the board or until the director is duly elected to fill the vacancy in which such acting director has been serving, whichever event occurs earlier. An acting director is entitled to the compensation, if any, payable to a director. [RR 2021, c. 1, Pt. B, §303 (COR).]

Acting officers elected pursuant to this section have powers and duties and receive such compensation as may from time to time be determined by the emergency board of directors. Each acting officer shall serve until the officer in whose place the acting officer was elected appears and assumes the officer's duties or until the officer's successor officer or acting officer is elected, whichever event occurs earlier. [RR 2021, c. 1, Pt. B, §304 (COR).]

This section shall not be deemed applicable during a period of acute emergency to any domestic organization operating in accordance with and under emergency bylaws theretofore approved by the superintendent. [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).]
24-A M.R.S. § 2708 — ME Code / Title 24-A / Chapter 33 / Section 2708
24-A §2708. Reinstatement
Status: in_force

1. There shall be a provision as follows: Reinstatement: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept such premium, without requiring in connection therewith an application for reinstatement, shall reinstate the policy; provided, however, that if the insurer or such agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon approval of such application by the insurer or, lacking such approval, upon the 45th day following the date of such conditional receipt unless the insurer has previously notified the insured in writing of its disapproval of such application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than ten days after such date. In all other respects the insured and insurer shall have the same rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed herein or attached hereto in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement. [PL 1969, c. 132, §1 (NEW).]

2. The last sentence of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums A. Until at least age 50, or [PL 1969, c. 132, §1 (NEW).] B. In the case of a policy issued after age 44, for at least 5 years from its date of issue. [PL 1969, c. 132, §1 (NEW).] [PL 1969, c. 132, §1 (NEW).]
24-A M.R.S. § 2743-A — ME Code / Title 24-A / Chapter 33 / Section 2743-A
24-A §2743-A. Maternity and routine newborn care
Status: in_force

An insurer that issues individual contracts providing maternity benefits, including benefits for childbirth, shall provide coverage for services related to maternity and routine newborn care, including coverage for hospital stay, in accordance with the attending physician's or attending certified nurse midwife's determination in conjunction with the mother that the mother and newborn meet the criteria outlined in the "Guidelines for Perinatal Care," published by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology. For the purposes of this section, "routine newborn care" does not include any services provided after the mother has been discharged from the hospital. For the purposes of this section, "attending physician" includes the obstetrician, pediatrician or other physician attending the mother and newborn. Benefits for routine newborn care required by this section are part of the mother's benefit. The mother and the newborn are treated as one person in calculating the deductible, coinsurance and copayments for coverage required by this section. [PL 2001, c. 258, Pt. A, §2 (AMD).]
24-A M.R.S. § 2155-A — ME Code / Title 24-A / Chapter 23 / Section 2155-A
24-A §2155-A. Dumping prohibited
Status: in_force

The guaranteed issue requirements of section 2736‑C may not be used by insurers, health maintenance organizations, agents, brokers, consultants or any other persons to provide separate coverage to an employee or dependent with a health condition to improve the claims experience of an employer-sponsored group health benefit plan. [PL 1997, c. 370, Pt. B, §1 (NEW).]
24-A M.R.S. § 1420-N — ME Code / Title 24-A / Chapter 16 / Section 1420-N
24-A §1420-N. Notification to superintendent of termination
Status: in_force

1. Termination for cause. An insurer or authorized representative of the insurer that terminates the appointment, employment, contract or other insurance business relationship with a producer shall notify the superintendent within 30 days following the effective date of the termination, using a format prescribed by the superintendent, if the reason for termination is one of the reasons set forth in section 1420‑K or the insurer has knowledge the producer was found by a court, government body or self-regulatory organization authorized by law to have engaged in any of the activities in section 1420‑K . Upon the written request of the superintendent, the insurer shall provide additional information, documents, records or other data pertaining to the termination or activity of the producer. [PL 2001, c. 259, §24 (NEW).]

2. Termination without cause. An insurer or authorized representative of the insurer that terminates the appointment, employment or contract with a producer for any reason not set forth in section 1420‑K shall notify the superintendent within 30 days following the effective date of the termination, using a format prescribed by the superintendent. Upon written request of the superintendent, the insurer shall provide additional information, documents, records or other data pertaining to the termination. [PL 2001, c. 259, §24 (NEW).]

3. Ongoing notification requirement. The insurer or the authorized representative of the insurer shall promptly notify the superintendent in a format acceptable to the superintendent if, upon further review or investigation, the insurer discovers additional information that would have been reportable to the superintendent in accordance with subsection 1 had the insurer then known of its existence. [PL 2001, c. 259, §24 (NEW).]

4. Copy of notification to be provided to producer. Notification to the producer and comments by the producer must be as follows. A. Within 15 days after making the notification required by subsections 1 , 2 and 3 , the insurer shall mail a copy of the notification to the producer at the producer's last known address. If the producer is terminated for cause for any of the reasons listed in section 1420‑K , the insurer shall provide a copy of the notification to the producer at the producer's last known address by certified mail, return receipt requested, postage prepaid or by overnight delivery using a nationally recognized carrier. [PL 2001, c. 259, §24 (NEW).] B. Within 30 days after the producer has received the original or additional notification, the producer may file written comments concerning the substance of the notification with the superintendent. The producer shall, by the same means, simultaneously send a copy of the comments to the reporting insurer and the comments become a part of the superintendent's file and accompany every copy of a report distributed or disclosed for any reason about the producer as permitted under subsection 6 . [PL 2001, c. 259, §24 (NEW).] [PL 2001, c. 259, §24 (NEW).]

5. Immunities. This subsection governs immunities. A. In the absence of actual malice, an insurer, the authorized representative of the insurer, a producer, the superintendent or an organization of which the superintendent is a member that compiles the information concerning the termination and makes it available to other insurance commissioners or regulatory or law enforcement agencies is not subject to civil liability for making this information available, and a civil cause of action may not arise against these entities or their respective agents or employees as a result of reporting or providing information under this section. [PL 2001, c. 259, §24 (NEW).] B. In any action brought against a person that may have immunity under paragraph A for making any statement required by this section or providing any information relating to any statement that may be requested by the superintendent, the party bringing the action shall plead specifically in any allegation that paragraph A does not apply because the person making the statement or providing the information did so with actual malice. [PL 2001, c. 259, §24 (NEW).] C. Paragraph A or B does not abrogate or modify any existing statutory or common law privileges or immunities. [PL 2001, c. 259, §24 (NEW).] [PL 2001, c. 259, §24 (NEW).]

6. Confidentiality. Subject to limitations set out in this subsection, any documents, materials or other information in the control or possession of the bureau that is furnished by an insurer or producer or an employee or agent acting on behalf of the insurer or producer or that is obtained by the superintendent in an investigation pursuant to this section is confidential, is not subject to subpoena and is not subject to discovery or admissible in evidence in any private civil action except by a court order for good cause. A. The superintendent is, however, authorized to use the documents, materials or other information in the furtherance of any regulatory or legal action brought as a part of the superintendent's duties. [PL 2001, c. 259, §24 (NEW).] B. Neither the superintendent nor any person who received documents, materials or other information while acting under the authority of the superintendent may be permitted or required to testify in any private civil action concerning any confidential documents, materials or information except as ordered by a court for good cause. [PL 2001, c. 259, §24 (NEW).] C. In order to assist in the performance of the superintendent's duties under this subchapter, the superintendent: (1) May share documents, materials or other information, including the confidential and privileged documents, materials or information subject to paragraph A , with other state, federal and international regulatory agencies, with the National Association of Insurance Commissioners, its affiliates or subsidiaries or any successor organization, and with state, federal and international law enforcement authorities, provided that the recipient agrees to maintain the confidentiality of the documents, materials or other information; (2) May receive documents, materials or information, including otherwise confidential and privileged documents, materials or information, from the National Association of Insurance Commissioners, its affiliates or subsidiaries or any successor organization, and from regulatory and law enforcement officials of other foreign or domestic jurisdictions and shall maintain as confidential or privileged any documents, materials or information received with notice or the understanding that it is confidential or privileged under the laws of the jurisdiction that is the source of the documents, materials or information; and (3) May enter into agreements governing sharing and use of information consistent with this subsection. [PL 2001, c. 259, §24 (NEW).] D. No waiver of any applicable privilege or claim of confidentiality in the documents, materials or information occurs as a result of disclosure to the superintendent under this section or as a result of sharing as authorized in paragraph C . [PL 2001, c. 259, §24 (NEW).] E. Nothing in this subchapter prohibits the superintendent from releasing final, adjudicated actions including for cause terminations that are open to public inspection pursuant to Title 1, chapter 13, subchapter I to a database or other clearinghouse service maintained by the National Association of Insurance Commissioners, its affiliates or subsidiaries or any successor organization. [PL 2001, c. 259, §24 (NEW).] [PL 2001, c. 259, §24 (NEW).]

7. Penalties for failing to report. An insurer, producer or an employee or agent acting on behalf of the insurer or producer that fails to report as required under the provisions of this section or that is found to have reported with actual malice by a court of competent jurisdiction may, after notice and hearing, have its license suspended or revoked and may be fined in accordance with section 12‑A . [PL 2001, c. 259, §24 (NEW).]
24-A M.R.S. § 748 — ME Code / Title 24-A / Chapter 9 / Section 748
24-A §748. Books, records and powers; reinsurance intermediary-managers
Status: in_force

1. Records required. For at least 10 years after expiration of each contract of reinsurance transacted by the reinsurance intermediary-manager, the reinsurance intermediary-manager shall keep a complete record for each transaction showing: A. The type of contract, limits, underwriting restrictions, classes of risks and territory; [PL 1991, c. 828, §20 (NEW).] B. Period of coverage, including effective and expiration dates, cancellation provisions and notice required for cancellation, and status of disposition of outstanding reserves on covered risks; [PL 1991, c. 828, §20 (NEW).] C. Reporting and settlement requirements of balances; [PL 1991, c. 828, §20 (NEW).] D. Rate used to compute the reinsurance premium; [PL 1991, c. 828, §20 (NEW).] E. Names and addresses of reinsurers; [PL 1991, c. 828, §20 (NEW).] F. Rates of all reinsurance commissions, including the commissions on any retrocessions handled by the reinsurance intermediary-manager; [PL 1991, c. 828, §20 (NEW).] G. Related correspondence and memoranda; [PL 1991, c. 828, §20 (NEW).] H. Proof of placement; [PL 1991, c. 828, §20 (NEW).] I. Details regarding retrocessions handled by the reinsurance intermediary-manager including the identity of retrocessionaires and the percentage of each contract assumed or ceded; [PL 1991, c. 828, §20 (NEW).] J. Financial records, including but not limited to, premium and loss accounts; and [PL 1991, c. 828, §20 (NEW).] K. When the reinsurance intermediary-manager places a reinsurance contract on behalf of a ceding insurer: (1) Directly from any assuming reinsurer, written evidence that the assuming reinsurer has agreed to assume the risk; or (2) If placed through a representative of the assuming reinsurer, other than an employee, written evidence that the reinsurer has delegated binding authority to the representative. [PL 1991, c. 828, §20 (NEW).] [PL 1991, c. 828, §20 (NEW).]
24-A M.R.S. § 4449 — ME Code / Title 24-A / Chapter 57 / Section 4449
24-A §4449. Stay of proceedings; reopening of default judgments
Status: in_force

All proceedings in which the insolvent insurer is a party or is obligated to defend a party in any court in this State shall be stayed for 60 days from the date the insolvency is determined, and may be stayed by the Superior Court for additional time solely as is deemed necessary to permit proper defense by the association of all pending causes of action. The association shall provide to the superintendent a copy of any such request for stay and supporting documents filed with the court. As to any covered claims arising from a judgment under any decision, verdict or finding based on the default of the insolvent insurer or its failure to defend an insured, the association either on its own behalf or on behalf of such insured may apply to have such judgment, order, decision, verdict or finding set aside by the same court or administrator that made such judgment, order, decision, verdict or finding and shall be permitted to defend against such claim on the merits. [PL 1985, c. 279, §8 (AMD).]

The liquidator, receiver or statutory successor of an insolvent insurer covered by this subchapter shall permit access by the board of directors, or its authorized representative, to those records of the insolvent insurer which are necessary for the board to carry out its functions under this subchapter with regard to covered claims. The liquidator, receiver or statutory successor shall provide the board or its representative with copies of these records upon request by the board and at the expense of the board. [PL 1987, c. 707, §12 (NEW).]

This section does not authorize a stay of proceedings before the Workers' Compensation Board, or of proceedings in Superior Court to enforce orders of the Workers' Compensation Board. A stay of workers' compensation proceedings before the Workers' Compensation Board or the Superior Court may be granted if otherwise authorized by law, provided that good cause for a stay exists and that reasonable diligence was exhibited by the insurer, the employer, the association and their counsel to proceed with the proceeding prior to the insolvency. [PL 1989, c. 67, §9 (NEW); PL 1991, c. 885, Pt. D, §2 (AMD).]
24-A M.R.S. § 2847-T — ME Code / Title 24-A / Chapter 35 / Section 2847-T
24-A §2847-T. Coverage for the diagnosis and treatment of autism spectrum disorders (REALLOCATED FROM TITLE 24-A, SECTION 2847-R)
Status: in_force

(REALLOCATED FROM TITLE 24-A, SECTION 2847-R)

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Applied behavior analysis" means the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement and functional analysis of the relations between environment and behavior. [PL 2011, c. 420, Pt. A, §26 (RAL).] B. "Autism spectrum disorders" means any of the pervasive developmental disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, published by the American Psychiatric Association, including autistic disorder, Asperger's disorder and pervasive developmental disorder not otherwise specified. [PL 2011, c. 420, Pt. A, §26 (RAL).] C. "Treatment of autism spectrum disorders" includes the following types of care prescribed, provided or ordered for an individual diagnosed with an autism spectrum disorder: (1) Habilitative or rehabilitative services, including applied behavior analysis or other professional or counseling services necessary to develop, maintain and restore the functioning of an individual to the extent possible. To be eligible for coverage, applied behavior analysis must be provided by a person professionally certified by a national board of behavior analysts or performed under the supervision of a person professionally certified by a national board of behavior analysts; (2) Counseling services provided by a licensed psychiatrist, psychologist, clinical professional counselor or clinical social worker; and (3) Therapy services provided by a licensed or certified speech therapist, occupational therapist or physical therapist. [PL 2011, c. 420, Pt. A, §26 (RAL).] [PL 2011, c. 420, Pt. A, §26 (RAL).]

2. Required coverage. All group health insurance policies, contracts and certificates must provide coverage for autism spectrum disorders for an individual covered under a policy, contract or certificate who is 10 years of age or under in accordance with the following. A. The policy, contract or certificate must provide coverage for any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder. [PL 2011, c. 420, Pt. A, §26 (RAL).] B. The policy, contract or certificate must provide coverage for the treatment of autism spectrum disorders when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary health care as defined in section 4301‑A, subsection 10‑A . A licensed physician or licensed psychologist may be required to demonstrate ongoing medical necessity for coverage provided under this section at least annually. [PL 2011, c. 420, Pt. A, §26 (RAL).] C. The policy, contract or certificate may not include any limits on the number of visits. [PL 2011, c. 420, Pt. A, §26 (RAL).] D. Notwithstanding section 2843 and to the extent allowed by federal law, the policy, contract or certificate may limit coverage for applied behavior analysis to $36,000 per year. An insurer may not apply payments for coverage unrelated to autism spectrum disorders to any maximum benefit established under this paragraph. [PL 2011, c. 420, Pt. A, §26 (RAL).] E. This subsection may not be construed to require coverage for prescription drugs if prescription drug coverage is not provided by the policy, contract or certificate. Coverage for prescription drugs for the treatment of autism spectrum disorders must be determined in the same manner as coverage for prescription drugs for the treatment of any other illness or condition is determined under the policy, contract or certificate. [PL 2011, c. 420, Pt. A, §26 (RAL).] [PL 2013, c. 597, §2 (AMD); PL 2013, c. 597, §4 (AFF).]

3. Limits; coinsurance; deductibles. Except as otherwise provided in this section, any policy, contract or certificate that provides coverage for services under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section. [PL 2011, c. 420, Pt. A, §26 (RAL).]

4. Individualized education plan. This section may not be construed to affect any obligation to provide services to an individual with an autism spectrum disorder under an individualized education plan or an individualized family service plan. [PL 2011, c. 420, Pt. A, §26 (RAL).]
24-A M.R.S. § 4438 — ME Code / Title 24-A / Chapter 57 / Section 4438
24-A §4438. Powers and duties of the association
Status: in_force

1. Powers and duties. The association shall: A. Be obligated to pay covered claims existing prior to the determination of the insolvency or arising within 30 days after the determination of insolvency, or before the policy expiration date if less than 30 days after the determination of insolvency, or before the insured replaces the policy or causes its cancellation, if within 30 days of the determination. The obligation must be satisfied by paying to the claimant: (1) Except as provided in this paragraph, the full amount of a covered claim for benefits, including interest and all penalties payable to a claimant under the Maine Workers' Compensation Act of 1992, or unearned premium under workers' compensation insurance coverage; (2) An amount not exceeding $25,000 per policy for a covered claim for the return of an unearned premium; (2-A) An amount not exceeding $500,000 for covered claims arising out of a single insured event under a policy or endorsement of cybersecurity insurance, regardless of the number of claims made or the number of claimants; or (3) An amount not exceeding $300,000 per claim for all other covered claims. In no event is the association obligated to pay a claimant an amount in excess of the obligation of the insolvent insurer under the policy or coverage from which the claim arises. The association shall pay only that amount of unearned premium in excess of $50. Notwithstanding any other provisions of this subchapter, a covered claim does not include any claim filed with the association after the earlier of 24 months after the date of the order of liquidation or the final date set by the court for the filing of claims against the liquidator or receiver of an insolvent insurer. The association, in its discretion, may accept a late filed claim as a covered claim when the claimant demonstrates good cause. The demonstration of good cause by a claimant includes showing that the existence of the claim was not known to the claimant prior to the bar date and that the claimant filed the claim within 60 days of learning of the claim; [PL 2025, c. 348, §§40, 41 (AMD).] A-1. Pay to the workers' compensation residual market pool the sum of $1,538,039 on or before February 15th, May 15th, August 15th and November 15th of each year beginning August 15, 1996 and continuing for 40 consecutive calendar quarters. Each payment made under this paragraph must be treated as the payment of a covered claim except that the association may not seek reimbursement or recoupment from any source other than by assessments to member insurers. Member insurers are allowed to recognize assessments made pursuant to this paragraph in rates and premiums as provided in section 4447 ; [PL 1995, c. 289, §14 (NEW).] B. Be deemed the insurer to the extent of its obligation on covered claims, and to such extent the association shall have all rights, duties and obligations of the insolvent insurer as if the insurer had not become insolvent; [PL 1969, c. 561 (NEW).] C. Allocate claims paid and expenses incurred among the 3 accounts separately; and assess member insurers separately for each account in amounts necessary to pay: (1) The obligations of the association under paragraph A , subsequent to an insolvency, the obligations of the accounts for shortfalls under section 4440‑A , and for preinsolvency assessments, if required by section 4440, subsection 3, paragraph B , and the obligations of the association under paragraph A‑1 ; (2) The expenses of handling covered claims subsequent to an insolvency; (3) The cost of examinations under section 4445 ; and (4) Other expenses authorized by this subchapter; [PL 1995, c. 289, §15 (AMD).] D. Investigate claims brought against the association and adjust, compromise, settle and pay covered claims to the extent of the association's obligation and deny all other claims. The association shall pay covered claims in any reasonable order, including the payment of claims as such are received from the claimants or in groups or categories of claims. The association may review settlements, releases and judgments to which the insolvent insurer or its insureds were parties to determine the extent to which such settlements, releases and judgments may be properly contested; [PL 1985, c. 279, §5 (AMD).] E. Notify such persons as the superintendent directs under section 4441, subsection 2, paragraph A ; [PL 1969, c. 561 (NEW); PL 1973, c. 585, §12 (AMD).] F. Handle claims through its employees or through one or more insurers licensed in the State or other persons using employees licensed as adjusters in the State designated as servicing facilities. Designation of a servicing facility is subject to the approval of the superintendent, but designation of a member insurer as a servicing facility may be declined by such insurer; [PL 2009, c. 129, §2 (AMD); PL 2009, c. 129, §13 (AFF).] G. Reimburse each servicing facility for obligations of the association paid by the facility and for expenses incurred by the facility while handling claims on behalf of the association; [PL 1969, c. 561 (NEW).] H. Pay the other expenses of the association authorized by this subchapter; and [PL 2009, c. 129, §3 (AMD); PL 2009, c. 129, §13 (AFF).] I. Pay all penalties, sanctions, forfeitures and fines provided for under the Maine Workers' Compensation Act of 1992 including penalties payable to the Workers' Compensation Board and the General Fund, except the penalty provided for in Title 39‑A, section 359, subsection 2 . No penalty, fine, forfeiture, attorney's fees or other sanction may be imposed on the association if: (1) The Workers' Compensation Board finds that the association was prevented from complying with the Maine Workers' Compensation Act of 1992 because the association was unable in the exercise of reasonable diligence to obtain the records of the insolvent insurer; or (2) The Workers' Compensation Board finds that the association was prevented from complying with the Maine Workers' Compensation Act of 1992 because of circumstances beyond its reasonable control. [PL 2009, c. 129, §4 (NEW); PL 2009, c. 129, §13 (AFF).] [PL 2025, c. 348, §§40, 41 (AMD).]

2. Permission. The association may: A. Employ or retain such persons as are necessary to handle claims, provide covered policy benefits and services and perform other duties of the association; [PL 2025, c. 348, §42 (AMD).] B. Borrow funds necessary to effect the purposes of this subchapter in accord with the plan of operation; [PL 1969, c. 561 (NEW).] C. Sue or be sued and may intervene as a party before any court in this State that has jurisdiction over an insolvent insurer as defined by this subchapter; [PL 2001, c. 478, §9 (AMD); PL 2001, c. 478, §11 (AFF).] D. Negotiate and become a party to such contracts as are necessary to carry out the purpose of this subchapter; [PL 1969, c. 561 (NEW).] E. Perform such other acts as are necessary or proper to effectuate the purpose of this subchapter; [PL 1969, c. 561 (NEW).] F. Refund to the member insurers in proportion to the contribution of each member insurer to that account that amount by which the assets of the account exceed the liabilities, if, at the end of any calendar year, the board of directors finds that the assets of the association in any account exceed the liabilities of that account as estimated by the board of directors for the coming year. [PL 1969, c. 561 (NEW).] [PL 2025, c. 348, §42 (AMD).]
24-A M.R.S. § 2552 — ME Code / Title 24-A / Chapter 29 / Section 2552
24-A §2552. Definitions
Status: in_force

For the purposes of sections 2553 and 2554 the "published monthly average" means: [PL 1981, c. 188, §4 (NEW).]

1. Moody's Corporate Bond Yield Average-Monthly Average Corporates as published by Moody's Investors Services, Inc. or any successor thereto; or [PL 1981, c. 188, §4 (NEW).]

2. In the event that Moody's Corporate Bond Yield Average-Monthly Average Corporates is no longer published, a substantially similar average, established by regulation issued by the superintendent. [PL 1981, c. 188, §4 (NEW).]
24-A M.R.S. § 1909 — ME Code / Title 24-A / Chapter 18 / Section 1909
24-A §1909. Fiduciary accounts and duties
Status: in_force

1. Administrators shall hold in a fiduciary capacity all contributions and premiums received or collected on behalf of a plan sponsor or insurer, except service fees owed to the administrator pursuant to the written agreement between the plan sponsor, insurer, health care service plan or health maintenance organization and the administrator. These funds may not be used as general operating funds of the administrator. All contributions and premiums received or collected by the administrator from residents of this State that the administrator holds more than 30 days or deposits into an account that is not under the control of the plan sponsor, health care service plan, health maintenance organization or insurer, must be placed in a special fiduciary account, designated as an ATF. All resident and quasi-resident licensees required to maintain an ATF under this section shall maintain the ATF with one or more financial institutions located within the State and subject to jurisdiction of the courts of this State. Funds belonging to 2 or more plans may be held in the same ATF, provided the administrator's records clearly indicate the funds belonging to each plan. Checks drawn on the ATF must indicate on the face of the checks that the checks are drawn on the administrator's ATF. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]

2. The administrator may make the following disbursements from the ATF: A. Contributions and premiums due insurers or other persons providing life, accident and health, or workers' compensation coverage for a plan; [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] B. Return contributions and premiums to a plan or covered individual; [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] C. Commissions or administrative fees due to the administrator when earned under a written agreement; and [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] D. Transfers into the CASA of the administrator. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]

3. For each plan for which an ATF is required, the balance in the ATF must at all times be the amount deposited plus accrued interest, if any, less authorized disbursements. If the balance at the financial institution, with respect to the ATF, is less than the amount deposited plus accrued interest, if any, less authorized disbursements, the administrator is presumed, for purposes of license revocation or suspension, to have misappropriated funds and to have acted in a financially irresponsible manner. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]

4. Before establishing an ATF that is interest bearing or income producing, the administrator shall disclose the nature of the account to the plan sponsor, health care service plan, health maintenance organization or insurer on whose behalf the funds are to be held. The administrator shall secure written consent and authorization from the plan sponsor, health care service plan, health maintenance organization or insurer for the investment of the money and disposition of the interest or earnings. An administrator may not make any investment that assumes a risk other than the risk that the obligor might not pay the principal when due. The administrator may not use specialized techniques or strategies that incur additional risks to generate higher returns or to extend maturities. Such techniques include, but are not limited to, the use of financial futures or options, buying on margins and pledging of ATF balances. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]

5. Administrators may place ATF funds in interest bearing or income producing investments and retain the interest or income on the funds, provided the administrator obtains the prior written authorization of the plan sponsors, health care service plans, health maintenance organizations or insurers on whose behalf the funds are to be held. In addition to savings and checking accounts, an administrator may invest in the following: A. Direct obligations of the United States or government agency securities with maturities of not more than one year; [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] B. Certificates of deposit, with a maturity of not more than one year, issued by financial institutions insured by the Federal Deposit Insurance Corporation (FDIC) or Federal Savings and Loan Insurance Corporation (FSLIC), provided any such deposit does not exceed the maximum level of insurance protection provided to certificates of deposit held by those institutions; [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] C. Repurchase agreements with financial institutions or government securities dealers recognized as primary dealers by the Federal Reserve System provided: (1) The value of the repurchase agreement is collateralized with assets that are allowable investments for ATF funds; (2) The collateral has a market value, at the time the repurchase agreement is entered into, at least equal to the value of the repurchase agreement; and (3) The repurchase agreement does not exceed 30 days; [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] D. Commercial paper, provided the commercial paper is rated at least P-1 by Moody's Investors Service, Inc. or at least A-1 by Standard & Poor's Corporation; or [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] E. Money market funds, provided the money market fund invests exclusively in assets that are allowable investments pursuant to paragraphs A to D for ATF funds. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] Each investment transaction must be made in the name of the administrator's ATF. The administrator shall maintain evidence of any such investments. Each investment transaction must flow through the administrator's ATF. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]

6. The administrator shall hold in a fiduciary capacity all money that the administrator receives to pay claims and claim adjustment expenses. All resident and quasi-resident licensees shall place all such money for claims and claim adjustment expenses for residents of this State, whether received from a plan sponsor, health care service plan, health maintenance organization or insurer or from the administrator's ATF, in a special fiduciary account in a financial institution located in this State. The account must be designated a CASA. Funds belonging to 2 or more plans may be held in the same CASA, provided the administrator's records clearly indicate the funds belonging to each plan. Checks drawn on the CASA must indicate on the face of the checks that the checks are drawn on the administrator's CASA. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]

7. No deposit may be made into a CASA and no disbursement may be made from a CASA except for claims and claim adjustment expenses. For each plan for which a CASA is required, the balance in the CASA must at all times be the amount deposited less claims and claims adjustment expenses paid. If the CASA balance is less than that amount, the administrator shall be presumed, for purposes of license revocation or suspension, to have misappropriated funds and to have acted in a financially irresponsible manner. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]

8. Administrators shall maintain detailed books and records that reflect all transactions involving the receipt and disbursement of: A. Contributions and premiums received on behalf of a plan sponsor, health care service plan, health maintenance organization or insurer; and [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] B. Claims and claim adjustment expenses received and paid on behalf of a plan sponsor, health care service plan, health maintenance organization or insurer. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]

9. The detailed preparation, journalizing and posting of books and records required by subsection 8 must be maintained on a timely basis and all journal entries for receipts and disbursements must be supported by evidential matter that must be referenced in the journal entry so that receipts and disbursements may be traced for verification. Administrators shall prepare and maintain monthly financial institution account reconciliations of any ATF and CASA established by the administrator. Reconciliation of accounts is timely if accomplished not more than 45 days after the end of the month in which the transaction occurred. The reconciliation must include, at a minimum, the following: A. The source and amount of any money received and deposited by the administrator, and the date of receipt and deposit; [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] B. The date each disbursement was made, the person to whom the disbursement was made and a written explanation of any difference between the amount disbursed and the amount billed or authorized; and [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] C. A description of the disbursement in sufficient detail to identify the source document substantiating the purpose of the disbursement. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).] [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]

10. Failure to accurately maintain the required books and records in a timely manner is deemed to be untrustworthy, hazardous or injurious to participants in the plan or the public and financially irresponsible. [PL 1989, c. 846, Pt. D, §2 (NEW); PL 1989, c. 846, Pt. E, §4 (AFF).]
24-A M.R.S. § 3473 — ME Code / Title 24-A / Chapter 47 / Section 3473
24-A §3473. Conversion of stock insurer to ordinary business corporation
Status: in_force

1. A domestic stock insurer may convert to a Maine ordinary business corporation through the following procedures: A. The insurer must give the superintendent written notice of its intent to convert to an ordinary business corporation; [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).] B. The insurer must bulk reinsure all of its insurance, if any, in force, with another authorized insurer under a bulk reinsurance agreement approved by the superintendent as provided in section 3483 . The agreement of bulk reinsurance may be made contingent upon approval of stockholders as provided in paragraph D ; [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).] C. The insurer must set aside funds in a special reserve in such amount and subject to such administration as may be found by the superintendent to be reasonable and adequate for the purpose, for payment of all obligations, if any, of the insurer incurred by it and remaining unpaid under its insurance contracts prior to the effective date of such bulk reinsurance, or make other reasonable disposition satisfactory to the superintendent for such payment; [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).] D. The proposed conversion must be approved by affirmative vote of not less than 2/3 of each class of outstanding securities of the insurer having voting rights, at a special meeting of holders of such securities called for the purpose; and at such meeting and by a like vote the certificate of organization or articles of incorporation of the corporation must be amended to remove from the certificate of organization or articles of incorporation the power to transact an insurance business as an insurer, to provide for such new powers and purposes authorized by the general corporation laws of this State as may be consistent with the purposes for which the corporation is thereafter to exist, and to make such further alterations in the certificate of organization or articles of incorporation as may be required under such general corporation laws of an ordinary business corporation; [RR 2023, c. 2, Pt. A, §36 (COR).] E. Security holders of the corporation who dissent from such proposed conversion shall have the same applicable rights as exist under such general corporation laws with respect to dissent from a proposed merger of the corporation; and [PL 1969, c. 132, §1 (NEW).] F. Upon compliance with paragraphs A to D , and upon filing of the amendment of the certificate of organization or articles of incorporation with the superintendent and otherwise as required by laws applicable to ordinary business corporations, the conversion becomes effective. [PL 2013, c. 299, §16 (AMD).] [RR 2023, c. 2, Pt. A, §36 (COR).]

2. An insurer which has once converted to an ordinary business corporation shall not have power thereafter to convert to an insurer; and no ordinary business corporation shall have power to convert to an insurer. [PL 1969, c. 132, §1 (NEW).]
24-A M.R.S. § 5083 — ME Code / Title 24-A / Chapter 68-A / Section 5083
24-A §5083. Payment of claims
Status: in_force

1. Notice of claim for benefits; response by insured. Notwithstanding any other provision of this Title, upon receipt of a notice of claim for benefits under a policy or certificate of long-term care insurance delivered or issued for delivery in this State, an insurer, whether actively marketing or renewing long-term care insurance in this State, shall provide the insured a written statement with sufficient detail to permit the insured to understand and respond with the documentation specified in subsection 2 . The written statement must be provided by the insurer within 10 business days following receipt of the notice of claim. For purposes of this section, "insured" includes a person designated by the insured as the insured's representative. [PL 2013, c. 278, §2 (NEW).]

2. Documentation. The documentation an insurer may require of an insured for the payment of a claim for benefits under a policy or certificate of long-term care insurance includes, but is not limited to: A. A statement from the insured making the claim for benefits; [PL 2013, c. 278, §2 (NEW).] B. A signed release permitting the insurer to obtain personal health care information about the insured pursuant to the federal Health Insurance Portability and Accountability Act of 1996; [PL 2013, c. 278, §2 (NEW).] C. A statement from the insured's physician, including the appropriate diagnosis and a treatment and care plan for the insured; [PL 2013, c. 278, §2 (NEW).] D. A statement from the long-term care provider rendering services to the insured, including an itemized bill for services, the provider's license number and any daily nursing notes; and [PL 2013, c. 278, §2 (NEW).] E. A copy of any power of attorney executed by the insured. [PL 2013, c. 278, §2 (NEW).] Except for information solely in the possession of the insured, the burden is on the insurer to obtain any information other than that described in paragraphs A to E that is reasonably necessary to pay or continue paying the claim. The insured has a continuing obligation to cooperate with the insurer in order for the insurer to obtain needed information. [PL 2013, c. 278, §2 (NEW).]

3. Payment of claim. A claim for payment of benefits under a policy or certificate of long-term care insurance delivered or issued for delivery in this State is payable within 30 days after the documentation and information identified in subsection 2 as reasonably necessary to pay the claim for benefits have been received by the insurer. Within 30 days after receipt of that documentation and information, the insurer shall either pay the claim or issue a written notice to the insured declining to pay all or part of the claim and the specific reason for denial in accordance with this subsection. A. An insurer may not extend the time for payment of a claim beyond 30 days after receipt of documentation and information related to a technical issue as designated in rules adopted by the bureau. [PL 2013, c. 278, §2 (NEW).] B. Except as provided in paragraph A , an insurer may delay payment of a claim and request additional documentation and information related to a substantive issue as designated in rules adopted by the bureau. [PL 2013, c. 278, §2 (NEW).] [PL 2013, c. 278, §2 (NEW).]

4. Ongoing claim. Except for information solely in the possession of the insured, if, during the course of an ongoing claim for benefits paid on a monthly or recurring basis, the insurer identifies the need for additional reasonable documentation to ensure the insured remains entitled to benefits under the policy or certificate of long-term care insurance, the burden is on the insurer to obtain that information. The insured has a continuing obligation to cooperate with the insurer in order for the insurer to obtain needed information. [PL 2013, c. 278, §2 (NEW).]

5. Appeals of claims denials. An insured who receives a claims denial in accordance with this section has the right to internal appeal and, after exhausting an insurer's internal appeals process, the right to request an external review. The superintendent shall adopt rules to determine the standards for internal appeal and external review in a manner consistent with model legislation adopted by the National Association of Insurance Commissioners, or its successor organization. The written notice to the insured declining to pay all or part of the claim as required by subsection 3 must include a statement informing the insured of the insured's rights to internal appeal and external review and a statement of the insured's right to seek assistance or file a complaint with the bureau and the toll-free telephone number of the bureau. [PL 2013, c. 278, §2 (NEW).]

6. Interest on overdue claim. An undisputed claim that is not paid within 30 days is overdue. If an insurer fails to pay an undisputed claim or any undisputed part of the claim when due, the amount of the overdue claim or part of the claim bears interest at the rate of 1 1/2% per month after the due date. [PL 2013, c. 278, §2 (NEW).]

7. Attorney's fees. Reasonable attorney's fees for advising and representing a claimant on an overdue claim or action for an overdue claim must be paid by the insurer if overdue benefits are recovered in an action against the insurer or if overdue benefits are paid after receipt of notice of the attorney's representation. [PL 2013, c. 278, §2 (NEW).]

8. No limitation on action by insured. This section does not prohibit or limit any claim or action for a claim that the insured has against the insurer. [PL 2013, c. 278, §2 (NEW).]

9. Rules. The superintendent may adopt or amend rules in order to carry out the purposes of this section. Rules adopted pursuant to this section, including amendments to existing rules designated as major substantive, are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A . [PL 2013, c. 278, §2 (NEW).]
24-A M.R.S. § 4751 — ME Code / Title 24-A / Chapter 65 / Section 4751
24-A §4751. Life, noncancellable health, hospital expense and hospital and surgical expense insurance contracts; default in payment of premium during strike of insurance agents
Status: in_force

1. Default. No contract of life, noncancellable health, hospital expense or hospital and surgical expense, insurance which goes into effect in this State on or after the 30th day after January 2, 1970 shall lapse during any 30-day period immediately following the inception of a strike by reason of any default in the payment of any premium during a strike of insurance agents employed by an insurer authorized to transact business in this State, if A. The collection of the contract premium was, at commencement of the strike, a duty, charge or obligation of any of such agents, according to the records, books, instructions, practice or organization of the insurer, and [PL 1969, c. 374 (NEW).] B. Such agents are represented for purposes of collective bargaining by a labor organization which has been so recognized or certified or has been a party to any collective bargaining agreement with the insurer. [PL 1969, c. 374 (NEW).] [PL 1969, c. 374 (NEW).]

2. Definitions. For the purpose of this section: A. Lapse. "Lapse" shall mean lapse, be terminated or in any way modified or qualified as to the obligations of the insurer and the right of the insured. [PL 1969, c. 374 (NEW).] B. Premium. "Premium" shall mean premium, interest, assessment or any other payment or charge for or in connection with the insurance which would be due to the insurer under the insurance contract during the strike of agents, except for the operation of this section. [PL 1969, c. 374 (NEW).] C. Strike. "Strike" shall mean strike or other concerted stoppage of work by employees, including a stoppage by reason of the expiration of a collective bargaining agreement, so long as any of the foregoing is authorized by the labor organization according to the labor organization's own interpretation and application of its applicable internal rules and procedures. [PL 1969, c. 374 (NEW).] [PL 1969, c. 374 (NEW).]

3. Claims. If a claim under any insurance contract covered by this section arises during a 30-day period immediately following the inception of a strike, the insurer may deduct from any amounts payable on account of the claim any premiums which are thus in default. [PL 1969, c. 374 (NEW).]

4. Notice. Within 10 days from the inception of a strike, notice of same containing instructions to make payment of premiums by mail shall be mailed to each affected insured by the insurer. [PL 1969, c. 374 (NEW).]
24-A M.R.S. § 704-A — ME Code / Title 24-A / Chapter 9 / Section 704-A
24-A §704-A. Health maintenance organization
Status: in_force

For purposes of this Title, "health maintenance organization" is defined in section 4202‑A, subsection 10 . [PL 1993, c. 702, Pt. A, §9 (NEW).]
24-A M.R.S. § 3479 — ME Code / Title 24-A / Chapter 47 / Section 3479
24-A §3479. -- plan, agreement of merger, consolidation; approval by corporations
Status: in_force

1. The plan and agreement for a merger or consolidation referred to in section 3478 shall be in writing signed by the duly authorized officers and under the corporate seals of the respective insurers; and shall be acknowledged to be the act, deed and agreement of the insurer by one of the executing officers of the respective insurers before an officer authorized by law to take acknowledgments of deeds. The plan and agreement shall be approved and authorized by vote of the majority of the directors of the respective insurers, and approved by vote of at least 2/3 of such policyholders of the respective insurers who are entitled to vote and do vote thereon in person or by proxy at a special meeting of such members call for the purpose. [PL 1969, c. 132, §1 (NEW).]

2. Notice of such special meeting of members shall be given by publishing the same once weekly for 3 consecutive weeks in a newspaper circulated in each county of this State, the last such publication to be at least 7 days prior to such meeting. Notice to its members by a foreign insurer shall be in accordance with the laws of its domiciliary jurisdiction. [PL 1969, c. 132, §1 (NEW).]

3. All of the members of the insurer shall be bound by the vote of policyholders as above provided for, and shall not have thereafter any right as to dissent or appraisal. [PL 1969, c. 132, §1 (NEW).]
24-A M.R.S. § 6903 — ME Code / Title 24-A / Chapter 87 / Section 6903
24-A §6903. Definitions
Status: in_force

As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings. [PL 2003, c. 469, Pt. A, §8 (NEW).]

1. Board. "Board" means the Board of Trustees of Dirigo Health, as established in section 6904 . [PL 2007, c. 447, §3 (AMD).]

1-A. Behavioral health care. "Behavioral health care" means services to address mental health and substance use conditions. [PL 2021, c. 603, Pt. A, §1 (NEW).]

2. Child. "Child" means a natural child, stepchild, adopted child or child placed for adoption with a plan enrollee. [PL 2003, c. 469, Pt. A, §8 (NEW).]

3. Dependent. "Dependent" means a spouse, a domestic partner, an unmarried child under 19 years of age, a child who is a student under 23 years of age and is financially dependent upon a plan enrollee or a person of any age who is the child of a plan enrollee and is disabled and dependent upon that plan enrollee. [PL 2021, c. 567, §40 (AMD).]

4. Dirigo Health Insurance. [PL 2005, c. 400, Pt. A, §3 (RP).]

4-A. Dirigo Health Program. "Dirigo Health Program" means the program of services provided by Dirigo Health that includes comprehensive health benefits coverage, subsidies, wellness programs and quality improvement initiatives. [PL 2005, c. 400, Pt. A, §4 (NEW).]

5. Eligible business. "Eligible business" means a business that employs at least 2 but not more than 50 eligible employees, the majority of whom are employed in the State, including a municipality that has 50 or fewer employees. After one year of operation of Dirigo Health, the board may, by rule, define "eligible business" to include larger public or private employers. [PL 2003, c. 469, Pt. A, §8 (NEW).]

6. Eligible employee. "Eligible employee" means an employee of an eligible business who works at least 20 hours per week for that eligible business. "Eligible employee" does not include an employee who works on a temporary or substitute basis or who does not work more than 26 weeks annually. [PL 2003, c. 469, Pt. A, §8 (NEW).]

7. Eligible individual. "Eligible individual" means: A. A self-employed individual who: (1) Works and resides in the State; and (2) Is organized as a sole proprietorship or in any other legally recognized manner in which a self-employed individual may organize, a substantial part of whose income derives from a trade or business through which the individual has attempted to earn taxable income; [PL 2003, c. 469, Pt. A, §8 (NEW).] B. An unemployed individual who resides in this State; or [PL 2003, c. 469, Pt. A, §8 (NEW).] C. An individual employed in an eligible business that does not offer health insurance. [PL 2003, c. 469, Pt. A, §8 (NEW).] [PL 2003, c. 469, Pt. A, §8 (NEW).]

8. Employer. "Employer" means the owner or responsible agent of a business authorized to sign contracts on behalf of the business. [PL 2003, c. 469, Pt. A, §8 (NEW).]

9. Executive director. "Executive director" means the Executive Director of Dirigo Health. [PL 2003, c. 469, Pt. A, §8 (NEW).]

10. Health insurance carrier. "Health insurance carrier" means: A. An insurance company licensed in accordance with this Title to provide health insurance; [PL 2003, c. 469, Pt. A, §8 (NEW).] B. A health maintenance organization licensed pursuant to chapter 56 ; [PL 2003, c. 469, Pt. A, §8 (NEW).] C. A preferred provider arrangement administrator registered pursuant to chapter 32 ; [PL 2003, c. 469, Pt. A, §8 (NEW).] D. A nonprofit hospital or medical service organization or health plan licensed pursuant to Title 24 ; or [PL 2003, c. 469, Pt. A, §8 (NEW).] E. An employee benefit excess insurance company licensed in accordance with this Title to provide property and casualty insurance that provides employee benefit excess insurance pursuant to section 707, subsection 1, paragraph C‑1 . [PL 2003, c. 469, Pt. A, §8 (NEW).] [PL 2003, c. 469, Pt. A, §8 (NEW).]

11. Health plan in Medicaid. "Health plan in Medicaid" means a health insurance carrier that meets the requirements of 42 Code of Federal Regulations, Part 438 (2002) and has a contract with the Department of Health and Human Services to provide MaineCare-covered services to individuals enrolled in MaineCare. [PL 2003, c. 469, Pt. A, §8 (NEW); PL 2003, c. 689, Pt. B, §6 (REV).]

12. Participating employer. "Participating employer" means an eligible business that contracts with Dirigo Health pursuant to section 6910, subsection 4, paragraph B and that has employees enrolled in the Dirigo Health Program. [PL 2005, c. 400, Pt. C, §3 (AMD).]

13. Plan enrollee. "Plan enrollee" means an eligible individual or eligible employee who enrolls in the Dirigo Health Program through Dirigo Health. "Plan enrollee" includes an eligible employee who is eligible to enroll in MaineCare. [PL 2005, c. 400, Pt. C, §3 (AMD).]

13-A. Practitioner-specific quality data. "Practitioner-specific quality data" means material in electronic or paper format that provides information about the professional performance of a health care practitioner licensed to provide health care in the State. "Practitioner-specific quality data" includes, but is not limited to, records, reports, working papers, drafts, analyses, e-mail, interoffice and intraoffice memoranda and other data collected, used, produced or maintained by the Maine Quality Forum, established in section 6951 , for the purposes of measuring a health care practitioner's professional performance against consensus best practices and local and national patterns of health care. [PL 2005, c. 615, §1 (NEW).]

13-B. Primary care. "Primary care" means regular check‑ups, wellness and general health care provided by a provider with whom a patient has initial contact for a health issue, not including an urgent care or emergency health issue, and by whom the patient may be referred to a specialist. [PL 2019, c. 244, §1 (NEW).]

14. Provider. "Provider" means any person, organization, corporation or association that provides health care services and products and is authorized to provide those services and products under the laws of this State. [PL 2003, c. 469, Pt. A, §8 (NEW).]

15. Reinsurance or reinsurer. "Reinsurance" and "reinsurer" have the same meanings as in section 741 . [PL 2003, c. 469, Pt. A, §8 (NEW).]

16. Resident. "Resident" has the same meaning as in section 2736‑C, subsection 1, paragraph C‑2 . [PL 2003, c. 469, Pt. A, §8 (NEW).]

17. Subsidy. "Subsidy" means a subsidy as described in section 6912 . [PL 2003, c. 469, Pt. A, §8 (NEW).]

18. Third-party administrator. "Third-party administrator" means any person who, on behalf of any person who establishes a health insurance plan covering residents, receives or collects charges, contributions or premiums for or settles claims on residents in connection with any type of health benefit provided in or as an alternative to insurance as defined by section 704 , other than: A. Any person listed in section 1901, subsection 1, paragraphs A to C and paragraphs E to O ; or [PL 2003, c. 469, Pt. A, §8 (NEW).] B. A person who provides those services in connection with a group health plan sponsored by an agricultural cooperative association located outside of this State that provides health insurance coverage to members and employees of agricultural cooperative associations located within this State. [RR 2021, c. 2, Pt. A, §87 (COR).] [RR 2021, c. 2, Pt. A, §87 (COR).]

19. Unemployed individual. "Unemployed individual" means an individual who does not work more than 20 hours a week for any single employer. [PL 2003, c. 469, Pt. A, §8 (NEW).]
24-A M.R.S. § 3705 — ME Code / Title 24-A / Chapter 52 / Section 3705
24-A §3705. Nonstate agency
Status: in_force

The company is not considered a state agency or instrumentality of the State for any purpose. The company is not and may never be supported in any way by the State's General Fund or any guaranty by the State, any state agency or a division of the State. The State may not borrow or otherwise appropriate funds from the company. [PL 1991, c. 885, Pt. C, §6 (AMD).]
24-A M.R.S. § 4210 — ME Code / Title 24-A / Chapter 56 / Section 4210
24-A §4210. Open enrollment
Status: in_force

1. After a health maintenance organization has been in operation 24 months, it shall have an annual open enrollment period of at least one month during which it accepts enrollees up to the limits of its capacity, as determined by the health maintenance organization, in the order in which they apply for enrollment. To the extent not inconsistent with the requirements of chapter 36 and sections 2736‑C and 2808‑B as qualified by section 4222‑B, subsection 3 , a health maintenance organization may apply to the superintendent for authorization to impose such underwriting restrictions upon enrollment as are necessary to preserve its financial stability, to prevent excessive adverse selection by prospective enrollees or to avoid unreasonably high or unmarketable charges for enrollee coverage for health care services. The superintendent shall approve or deny the application within 10 days of the receipt of that application from the health maintenance organization. [PL 1995, c. 332, Pt. O, §4 (AMD).]

2. Health maintenance organizations providing or arranging for services exclusively on a group contract basis may limit the open enrollment provided for in this section to all members of the group or groups covered by such contracts. [PL 1975, c. 503 (NEW).]
24-A M.R.S. § 7111 — ME Code / Title 24-A / Chapter 91 / Section 7111
24-A §7111. Rule-making authority
Status: in_force

The superintendent may adopt rules necessary to implement this chapter. Rules adopted pursuant to this section are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A . [PL 2011, c. 345, §4 (NEW); PL 2011, c. 345, §7 (AFF).]
24-A M.R.S. § 1468 — ME Code / Title 24-A / Chapter 16 / Section 1468
24-A §1468. Records
Status: in_force

The consultant shall keep at the consultant's place of business all contracts with clients for a period of 3 years from the termination of the contracts. For the purpose of investigation or examination by the superintendent, contracts may be maintained in electronic form. [PL 1997, c. 457, §23 (NEW); PL 1997, c. 457, §55 (AFF).]
24-A M.R.S. § 2768 — ME Code / Title 24-A / Chapter 33 / Section 2768
24-A §2768. Coverage for the diagnosis and treatment of autism spectrum disorders (REALLOCATED FROM TITLE 24-A, SECTION 2766)
Status: in_force

(REALLOCATED FROM TITLE 24-A, SECTION 2766)

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Applied behavior analysis" means the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the use of direct observation, measurement and functional analysis of the relations between environment and behavior. [PL 2011, c. 420, Pt. A, §24 (RAL).] B. "Autism spectrum disorders" means any of the pervasive developmental disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, published by the American Psychiatric Association, including autistic disorder, Asperger's disorder and pervasive developmental disorder not otherwise specified. [PL 2011, c. 420, Pt. A, §24 (RAL).] C. "Treatment of autism spectrum disorders" includes the following types of care prescribed, provided or ordered for an individual diagnosed with an autism spectrum disorder: (1) Habilitative or rehabilitative services, including applied behavior analysis or other professional or counseling services necessary to develop, maintain and restore the functioning of an individual to the extent possible. To be eligible for coverage, applied behavior analysis must be provided by a person professionally certified by a national board of behavior analysts or performed under the supervision of a person professionally certified by a national board of behavior analysts; (2) Counseling services provided by a licensed psychiatrist, psychologist, clinical professional counselor or clinical social worker; and (3) Therapy services provided by a licensed or certified speech therapist, occupational therapist or physical therapist. [PL 2011, c. 420, Pt. A, §24 (RAL).] [PL 2011, c. 420, Pt. A, §24 (RAL).]

2. Required coverage. All individual health insurance policies and contracts must provide coverage for autism spectrum disorders for an individual covered under a policy or contract who is 10 years of age or under in accordance with the following. A. The policy or contract must provide coverage for any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder. [PL 2011, c. 420, Pt. A, §24 (RAL).] B. The policy or contract must provide coverage for the treatment of autism spectrum disorders when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary health care as defined in section 4301‑A, subsection 10‑A . A licensed physician or licensed psychologist may be required to demonstrate ongoing medical necessity for coverage provided under this section at least annually. [PL 2011, c. 420, Pt. A, §24 (RAL).] C. The policy or contract may not include any limits on the number of visits. [PL 2011, c. 420, Pt. A, §24 (RAL).] D. The policy or contract may limit coverage for applied behavior analysis to $36,000 per year. An insurer may not apply payments for coverage unrelated to autism spectrum disorders to any maximum benefit established under this paragraph. [PL 2011, c. 420, Pt. A, §24 (RAL).] E. This subsection may not be construed to require coverage for prescription drugs if prescription drug coverage is not provided by the policy or contract. Coverage for prescription drugs for the treatment of autism spectrum disorders must be determined in the same manner as coverage for prescription drugs for the treatment of any other illness or condition is determined under the policy or contract. [PL 2011, c. 420, Pt. A, §24 (RAL).] [PL 2013, c. 597, §1 (AMD); PL 2013, c. 597, §4 (AFF).]

3. Limits; coinsurance; deductibles. Except as otherwise provided in this section, any policy or contract that provides coverage for services under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section. [PL 2011, c. 420, Pt. A, §24 (RAL).]

4. Individualized education plan. This section may not be construed to affect any obligation to provide services to an individual with an autism spectrum disorder under an individualized education plan or an individualized family service plan. [PL 2011, c. 420, Pt. A, §24 (RAL).]
24-A M.R.S. § 952-B — ME Code / Title 24-A / Chapter 11 / Section 952-B
24-A §952-B. Applicability of reserving methodologies
Status: in_force

Sections 953 to 958‑A do not apply to a policy or contract that is issued on or after the operative date of the valuation manual and is subject to section 959 , unless those sections are made applicable by reference in whole or part in the valuation manual. [PL 2013, c. 238, Pt. C, §6 (NEW).]
24-A M.R.S. § 5055 — ME Code / Title 24-A / Chapter 68 / Section 5055
24-A §5055. Tax incentives available
Status: in_force

1. Reduced premium tax. Any insurance company choosing to offer an insurance policy which is certified by the superintendent as a long-term care policy shall qualify for the reduced tax on premiums collected under Title 36, section 2513 . [PL 1989, c. 556, Pt. B, §4 (NEW).]

2. Income tax reduction. Any person paying premiums for a policy or contract which is certified by the superintendent as a long-term care policy shall qualify for the income tax deduction provided for in Title 36, section 5122 . [PL 1989, c. 556, Pt. B, §4 (NEW).]

3. Credit for employers. An employer providing long-term care benefits to its employees may qualify for the tax credit provided by Title 36, section 2525‑A or 5217‑C . [PL 2017, c. 170, Pt. G, §1 (AMD).]

4. Life insurance riders. With respect to life insurance riders that qualify as long-term care policies, the tax incentives provided by this section shall apply only to that portion of the premium attributable to the rider. [PL 1989, c. 556, Pt. B, §4 (NEW).]

5. Provision of records. Any person who holds a group long-term care policy pursuant to or under which premiums are paid in whole or in part by certificate holders or other 3rd parties shall provide to those certificate holders or 3rd parties adequate and timely records to enable those persons to have knowledge of the tax reduction to which they may be entitled under subsection 2 and under Title 36, section 5122 . [PL 1989, c. 556, Pt. B, §4 (NEW).]
24-A M.R.S. § 4406 — ME Code / Title 24-A / Chapter 57 / Section 4406
24-A §4406. -- conduct of hearings, both administrative and by the court, in summary proceedings
Status: in_force

1. The superintendent shall hold all hearings in summary proceedings privately unless the insurer requests a public hearing, in which case the hearing shall be public. [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).]

2. The court may hold all hearings in summary proceedings and judicial reviews thereof privately in chambers, and shall do so on request of the insurer proceeded against. [PL 1969, c. 132, §1 (NEW).]

3. In all summary proceedings and judicial reviews thereof, all records of the insurer, other documents, and all insurance bureau files and court records and papers, so far as they pertain to or are part of the record of the summary proceedings, are and remain confidential except as necessary to obtain compliance therewith, unless the court after hearing arguments by the parties in chambers orders otherwise, or unless the insurer requests that the matter be made public. Until the court otherwise orders, all papers filed with the clerk of court must be held by the clerk of court in a confidential file. [RR 2021, c. 1, Pt. B, §385 (COR).]

4. If at any time it appears to the court that any person whose interest is or will be substantially affected by an order did not appear at the hearing and has not been served, the court may order that notice be given and the proceedings be adjourned to give such person opportunity to appear, on such terms as may be reasonable and just. [PL 1969, c. 132, §1 (NEW).]
24-A M.R.S. § 4303 — ME Code / Title 24-A / Chapter 56-A / Section 4303
24-A §4303. Plan requirements
Status: in_force

A carrier offering or renewing a health plan in this State must meet the following requirements. [PL 2007, c. 199, Pt. B, §4 (AMD).]

1. Demonstration of adequate access to providers. A carrier offering or renewing a managed care plan shall provide to its members reasonable access to health care services. A carrier may provide incentives to members to use designated providers based on cost or quality, but may not require members to use designated providers of health care services. A. [PL 2007, c. 199, Pt. B, §5 (AMD); MRSA T. 24-A §4303, sub-1, ¶A (RP).] B. [PL 2011, c. 90, Pt. F, §7 (RP).] C. [PL 2011, c. 90, Pt. F, §7 (RP).] [PL 2011, c. 90, Pt. F, §7 (RPR).]

2. Credentialing. The credentialing of providers by a carrier is governed by this subsection. A. The granting of credentials must be based on objective standards that are available to providers upon application for credentialing. A carrier shall consult with appropriately qualified health care professionals in developing its credentialing standards. [PL 2015, c. 84, §1 (AMD).] B. All credentialing decisions, including those granting, denying or withdrawing credentials, must be in writing. The provider must be provided with all reasons for the denial of an application for credentialing or the withdrawal of credentials. A withdrawal of credentials must be treated as a provider termination and is subject to the requirements of subsections 3‑A and 3‑C . [PL 2023, c. 648, Pt. E, §8 (AMD).] C. A carrier shall establish and maintain an appeal procedure, including the provider's right to a hearing, for dealing with provider concerns relating to the denial of credentialing for not meeting the objective credentialing standards of the plan and the contractual relationship between the carrier and the provider. The superintendent shall determine whether the process provided by a carrier is fair and reasonable. This procedure must be specified in every contract between a carrier and a provider or between a carrier and a provider network if a carrier does not contract with providers individually. [PL 2015, c. 84, §1 (AMD).] D. A carrier shall make credentialing decisions, including those granting or denying credentials, within 60 days of receipt of a completed credentialing application from a provider. For the purposes of this paragraph, an application is completed if the application includes all of the information required by the uniform credentialing application used by carriers and providers in this State, such attachments to that application as required by the carrier at the time of application and all corrections required by the carrier. Within 30 days of initial receipt of a credentialing application, a carrier shall review the entire application and, if it is incomplete, shall return it to the provider for corrections with a comprehensive list of all corrections needed at the time the application is first returned to the provider. A carrier may not require that a provider have a home address within the State before accepting an application. A carrier that is unable to make a credentialing decision on a completed credentialing application within the 60-day period as required in this paragraph shall notify the bureau in writing prior to the expiration of the 60-day period on that application and request authorization for an extension on that application. A carrier that requests an extension shall also submit to the bureau an explanation of the reasons why the credentialing decision on an application is taking longer than is permitted or, if the problem is not specific to a particular application, a written remediation plan to bring the carrier’s credentialing practices in line with the 60-day limit in this paragraph. [PL 2021, c. 603, Pt. B, §1 (AMD).] E. [PL 2013, c. 383, §4 (RP).] [PL 2023, c. 648, Pt. E, §8 (AMD).]

2-A. Payment to provider for services rendered during pendency of credentialing. A carrier offering or renewing a health plan in the State shall pay claims for services rendered to an enrollee by a provider prior to credentials being granted from the date a complete application for credentialing is submitted to the carrier as long as credentials are granted to that provider by the carrier in accordance with the requirements of subsection 2 . A provider intending to submit a claim pursuant to this subsection may not submit the claim until the provider has been notified by the carrier whether the provider has been credentialed and of the effective date of any credentials. If a claim is submitted prior to the date credentials are granted, the carrier may process that claim in the same manner as a claim submitted by a provider that has not been credentialed. [PL 2015, c. 84, §2 (NEW).]

3. Provider's right to advocate for medically appropriate care. A carrier offering or renewing a managed care plan may not terminate or otherwise discipline a participating provider because the provider advocates for medically appropriate health care. A carrier may not restrict a provider from disclosing to any enrollee any information the provider determines appropriate regarding the nature of treatment and any risks or alternatives to treatment, the availability of other therapy, consultations or tests or the decision of any plan to authorize or deny health care services or benefits. A. For the purposes of this section, "to advocate for medically appropriate health care" means to discuss or recommend a course of treatment, including gender-affirming health care services and reproductive health care services, to an enrollee; to appeal a managed care plan's decision to deny payment for a service, including gender-affirming health care services and reproductive health care services, pursuant to an established grievance or appeal procedure; or to protest a decision, policy or practice that the provider, consistent with the degree of learning and skill ordinarily possessed by reputable providers, reasonably believes impairs the provider's ability to provide medically appropriate health care, including gender-affirming health care services and reproductive health care services, to the provider's patients. [PL 2023, c. 648, Pt. E, §9 (AMD).] B. Nothing in this subsection may be construed to prohibit a plan from making a determination not to pay for a particular medical treatment or service or to enforce reasonable peer review or utilization review protocols. [PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).] [PL 2023, c. 648, Pt. E, §9 (AMD).]

3-A. Termination of participating providers. A carrier offering or renewing a managed care plan may not terminate or nonrenew a contract with a participating provider unless the carrier provides the provider with a written explanation prior to the termination or nonrenewal of the reasons for the proposed contract termination or nonrenewal and provides an opportunity for a review or hearing in accordance with this subsection. The existence of a termination without cause provision in a carrier's contract with a provider does not supersede the requirements of this subsection. This subsection does not apply to termination cases involving imminent harm to patient care, a final determination of fraud by a governmental agency, a final disciplinary action by a state licensing board or other governmental agency that impairs the ability of a provider to practice. A review or hearing of proposed contract termination must meet the following requirements. A. The notice of the proposed contract termination or nonrenewal provided by the carrier to the participating provider must include: (1) The reason or reasons for the proposed action in sufficient detail to permit the provider to respond; (2) Reference to the evidence or documentation underlying the carrier's decision to pursue the proposed action. A carrier shall permit a provider to review this evidence and documentation upon request; (3) Notice that the provider has the right to request a review or hearing before a panel appointed by the carrier; (4) A time limit of not less than 30 days from the date the provider receives the notice within which a provider may request a review or hearing; and (5) A time limit for a hearing date that must be not less than 30 days after the date of receipt of a request for a hearing. Termination or nonrenewal may not be effective earlier than 60 days from the receipt of the notice of termination or nonrenewal. [PL 1997, c. 163, §2 (NEW).] B. A hearing panel must be composed of at least 3 persons appointed by the carrier and one person on the hearing panel must be a clinical peer in the same discipline and the same or similar specialty of the provider under review. A hearing panel may be composed of more than 3 persons if the number of clinical peers on the hearing panel constitutes 1/3 or more of the total membership of the panel. [PL 1997, c. 163, §2 (NEW).] C. A hearing panel shall render a written decision on the proposed action in a timely manner. This decision must be either the reinstatement of the provider by the carrier, the provisional reinstatement of the provider subject to conditions established by the carrier or the termination or nonrenewal of the provider. [PL 1997, c. 163, §2 (NEW).] D. A decision by a hearing panel to terminate or nonrenew a contract with a provider may not become effective less than 60 days after the receipt by the provider of the hearing panel's decision or until the termination date in the provider's contract, whichever is earlier. [PL 1997, c. 163, §2 (NEW).] [PL 2007, c. 199, Pt. B, §7 (AMD).]

3-B. Prohibition on financial incentives. A carrier offering or renewing a managed care plan may not offer or pay any type of material inducement, bonus or other financial incentive to a participating provider to deny, reduce, withhold, limit or delay specific medically necessary health care services covered under the plan to an enrollee. This subsection may not be construed to prohibit pilot projects authorized pursuant to section 4320‑H or to prohibit contracts that contain incentive plans that involve general payments such as capitation payments or risk-sharing agreements that are made with respect to providers or groups of providers or that are made with respect to groups of enrollees. [RR 2011, c. 1, §41 (COR).]

3-C. Provider's right to engage in legally protected health care activity. A carrier offering or renewing a health plan in this State may not terminate or nonrenew a contract with a participating provider or impose any monetary penalties or financial disincentives on a participating provider on the sole basis that the participating provider engages in legally protected health care activity or aids and assists legally protected health care activity. [PL 2023, c. 648, Pt. E, §10 (NEW).]

4. Grievance procedure for enrollees. A carrier offering or renewing a health plan in this State shall establish and maintain a grievance procedure that meets standards developed by the superintendent to provide for the resolution of claims denials, prior authorization denials or other matters by which enrollees are aggrieved. A. The grievance procedure must include, at a minimum, the following: (1) Notice to the enrollee and the enrollee's provider promptly of any claim denial, prior authorization denial or other matter by which enrollees are likely to be aggrieved, stating the basis for the decision, the right to file a grievance, the procedure for doing so and the time period in which the grievance must be filed; (2) Timelines within which grievances must be processed, including expedited processing for exigent circumstances. Timelines must be sufficiently expeditious to resolve grievances promptly. Decisions for second level grievance reviews as defined by bureau rules must be issued within 30 calendar days if the insured has not requested the opportunity to appear in person before authorized representatives of the health carrier; (3) Procedures for the submission of relevant information and enrollee or provider participation; (4) Provision to the aggrieved party of a written statement upon the conclusion of any grievance process, setting forth the reasons for any decision. The statement must include notice to the aggrieved party of any subsequent appeal or external review rights, the procedure and time limitations for exercising those rights and notice of the right to file a complaint with the Bureau of Insurance and the toll-free telephone number of the bureau; (5) Decision-making by one or more individuals not previously involved in making the decision subject to the grievance; and (6) Procedures for a provider actively treating an enrollee to act as an authorized representative of the enrollee within the meaning of section 4301‑A, subsection 2, paragraph D and file a grievance on the enrollee's behalf as long as the provider notifies the enrollee in writing at least 14 days prior to filing a grievance and within 7 days after filing a grievance or withdrawing a grievance. The enrollee has the right to affirmatively object to a provider that has filed a grievance at any time, and the enrollee has the right to notify the health carrier at any time that the enrollee intends to take the place of the provider as a party to the grievance. [RR 2023, c. 2, Pt. A, §37 (COR).] B. In any appeal under the grievance procedure in which a professional medical opinion regarding a health condition is a material issue in the dispute, the aggrieved party is entitled to an independent 2nd opinion, paid for by the plan, of a provider of the same specialty participating in the plan. If a provider of the same specialty does not participate in the plan, then the 2nd opinion must be given by a nonparticipating provider. [PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).] C. In any appeal under the grievance procedure, the carrier shall provide auxiliary telecommunications devices or qualified interpreter services by a person proficient in American Sign Language when requested by an enrollee who is deaf or hard-of-hearing or printed materials in an accessible format, including Braille, large-print materials, computer diskette, audio cassette or a reader when requested by an enrollee who is visually impaired to allow the enrollee to exercise the enrollee's right to an appeal under this subsection. [PL 1999, c. 742, §9 (NEW).] D. Notwithstanding this subsection, a group health plan sponsored by an agricultural cooperative association located outside of this State that provides health insurance coverage to members of one or more agricultural cooperative associations located within this State may employ a grievance procedure for enrollees in the group health plan that meets the requirements of the state in which the group health plan is located if enrollees in the group health plan that reside in this State have the right to independent external review in accordance with section 4312 following any adverse health care treatment decision. Any difference in the grievance procedure requirements between those of the state in which the group health plan is located and those of this State must be limited to the number of days required for notification of prior authorization for nonemergency services and the number of days required for the issuance of a decision following the filing of an appeal of an adverse health care treatment decision. Enrollees in the group health plan that reside in this State must be notified as to the grievance procedure used by the group health plan and their right to independent external review in accordance with section 4312 . [PL 2003, c. 309, §1 (NEW).] E. Health plans may not reduce or terminate benefits for an ongoing course of treatment, including coverage of a prescription drug, during the course of an appeal pursuant to the grievance procedure used by the carrier or any independent external review in accordance with section 4312 . [PL 2019, c. 5, Pt. A, §20 (AMD).] [RR 2023, c. 2, Pt. A, §37 (COR).]

5. Identification of services provided by certified nurse practitioners, certified midwives and certified nurse midwives. All claims for coverage of services provided by certified nurse practitioners, certified midwives and certified nurse midwives must identify the certified nurse practitioners, certified midwives and certified nurse midwives who provided those services. A carrier offering or renewing a health plan in this State shall assign identification numbers or codes to certified nurse practitioners, certified midwives and certified nurse midwives who provide covered services for enrollees covered under that plan. A claim submitted for payment to a carrier by a health care provider or facility must include the identification number or code of the certified nurse practitioner, certified midwife or certified nurse midwife who provided the service and may not be submitted using the identification number or code of a physician or other health care provider who did not provide the covered service. [PL 2021, c. 79, §5 (AMD); PL 2021, c. 79, §6 (AFF).]

6. Standing referrals to specialists. A carrier shall establish and maintain a procedure to allow an enrollee with a special condition requiring ongoing care from a specialist to receive a standing referral to a specialist participating in the carrier's network for treatment of that special condition. If the carrier or the enrollee's primary care provider, in consultation with the carrier's medical director, determines that a standing referral is appropriate, the carrier shall ensure that the enrollee receives such a referral to a specialist. If a specialist able to treat the enrollee's special condition does not participate in the carrier's network, then the carrier shall ensure that the enrollee receives a standing referral to a nonparticipating specialist. A standing referral must be made pursuant to a treatment plan approved by the carrier's medical director in consultation with the enrollee's primary care provider. After the standing referral is made, the specialist is authorized to provide health care services to the enrollee in the same manner as the enrollee's primary care provider, subject to the terms of the treatment plan. [PL 1999, c. 742, §10 (NEW).]

7. Continuity of care. If a contract between a carrier and a provider is terminated or benefits or coverage provided by a provider is terminated because of a change in the terms of provider participation in a health plan and an enrollee is undergoing a course of treatment from the provider at the time of termination, the carrier shall provide continuity of care in accordance with the requirements in paragraphs A to C . This section does not apply to provider terminations exempt from the requirements of subsection 3‑A . If a managed care contract for the provision of health insurance coverage between a plan sponsor and a carrier is replaced within the meaning of section 2849 with a different managed care contract and a health care provider that has been providing health care services to an enrollee is not in the replacement carrier's network, the replacement carrier shall provide continuity of care in accordance with the requirements in paragraphs A to C in the same manner as if the provider had been terminated from the replacement carrier's network as of the date of the policy replacement, but only with respect to benefits that are covered under the replacement contract. A. The carrier shall notify an enrollee of the termination of the provider's contract at least 60 days in advance of the date of termination. When circumstances related to the termination render such notice impossible, the carrier shall provide affected enrollees as much notice as is reasonably possible. The notice given to the enrollee must include instructions on obtaining an alternate provider and must offer the carrier's assistance with obtaining an alternate provider and ensuring that there is no inappropriate disruption in the enrollee's ongoing treatment. [PL 1999, c. 742, §10 (NEW).] B. The carrier shall permit the enrollee to continue or be covered, with respect to the course of treatment with the provider, for a transitional period of at least 60 days from the date of notice to the enrollee of the provider's termination except that if an enrollee is in the 2nd trimester of pregnancy at the time of the provider's termination and the provider is treating the enrollee during the pregnancy, the transitional period must extend through the provision of postpartum care directly related to the pregnancy. [PL 1999, c. 742, §10 (NEW).] C. A carrier may make coverage of continued treatment by a provider under paragraph B conditional upon the provider's agreeing to the following terms and conditions. (1) The provider agrees to accept reimbursement from the carrier at rates applicable prior to the start of the transitional period as payment in full and not to impose cost-sharing with respect to the enrollee in an amount that would exceed the cost-sharing that could have been imposed if the contract between the carrier and the provider had not been terminated. (2) The provider agrees to adhere to the quality assurance standards of the carrier responsible for payment and to provide the carrier necessary medical information related to the care provided. (3) The provider agrees otherwise to adhere to the carrier's policies and procedures, including procedures regarding referrals and prior authorizations and providing services pursuant to any treatment plan approved by the carrier. [PL 1999, c. 742, §10 (NEW).] [PL 1999, c. 742, §10 (NEW).]

7-A. Continuity of prescriptions. If an enrollee has been undergoing a course of treatment with a prescription drug by prior authorization of a carrier and the enrollee’s coverage with one carrier is replaced with coverage from another carrier pursuant to section 2849‑B , the replacement carrier shall honor the prior authorization for that prescription drug and provide coverage in the same manner as the previous carrier until the replacement carrier conducts a review of the prior authorization for that prescription drug with the enrollee’s prescribing provider. Policies must include a notice of the right to request a review with the enrollee’s provider, and the replacing carrier must honor the prior carrier’s authorization for a period not to exceed 6 months if the enrollee’s provider participates in the review and requests the prior authorization be continued. The replacing carrier is not required to provide benefits for conditions or services not otherwise covered under the replacement policy, and cost sharing may be based on the copayments and coinsurance requirements of the replacement policy. [PL 2009, c. 439, Pt. F, §1 (NEW).]

8. Maximum allowable charges. All policies, contracts and certificates executed, delivered and issued by a carrier under which the insured or enrollee may be subject to balance billing when charges exceed a maximum considered usual, customary and reasonable by the carrier or that contain contractual language of similar import must be subject to the following. A. If benefits for covered services are limited to a maximum amount based on any combination of usual, customary and reasonable charges or other similar method, the carrier must: (1) Clearly disclose that the insured or enrollee may be subject to balance billing as a result of claims adjustment; and (2) Provide a toll-free number that an insured or enrollee may call prior to receiving services to determine the maximum allowable charge permitted by the carrier for a specified service. [PL 2001, c. 410, Pt. B, §5 (NEW).] B. The carrier must provide to the superintendent on request complete information on the methodology and specific data used by the carrier or any 3rd party on behalf of the carrier in adjusting any claim submitted by or on behalf of the insured or enrollee. In considering the reasonableness of the methodology for calculating maximum allowable charges, the superintendent shall consider whether the methodology takes into account relevant data specific to this State if there is sufficient data to constitute a representative sample of charge data for the same or comparable service. [PL 2001, c. 410, Pt. B, §5 (NEW).] [PL 2001, c. 410, Pt. B, §5 (NEW).]

8-A. Protection from balance billing by participating providers. An enrollee's responsibility for payment under a managed care plan must be limited as provided in this subsection. A. The terms of a managed care plan must provide that the enrollee's responsibility for the cost of covered health care rendered by participating providers is limited to the cost-sharing provisions expressly disclosed in the contract, such as deductibles, copayments and coinsurance, and that if the enrollee has paid the enrollee's share of the charge as specified in the plan, the carrier shall hold the enrollee harmless from any additional amount owed to a participating provider for covered health care. [PL 2011, c. 238, Pt. A, §1 (NEW).] B. Every provider agreement with a participating provider must be in writing and must set forth that if the carrier fails to pay for health care services as set forth in the contract, the enrollee is not liable to the provider for any sums owed by the carrier. [PL 2011, c. 238, Pt. A, §1 (NEW).] C. A participating provider may not collect or attempt to collect any charge from an enrollee for covered health care beyond the amount permitted by the terms of the plan, notwithstanding the carrier's insolvency, the carrier's failure to pay the amount owed by the carrier, any other breach by the carrier of the provider agreement or the failure of the provider agreement to include the written hold harmless provision required by paragraph B . [PL 2011, c. 238, Pt. A, §1 (NEW).] [PL 2011, c. 238, Pt. A, §1 (NEW).]

9. Notice of amendments to provider agreements. A carrier offering or renewing a health plan in this State shall notify a participating provider of a proposed amendment to a provider agreement at least 60 days prior to the amendment's proposed effective date and may file such notice of a proposed amendment to a provider agreement only 4 times per calendar year on January 1st, April 1st, July 1st and October 1st, except that, at any time, a carrier may file a notice of a proposed amendment in response to a requirement of the State or Federal Government or due to a change in current procedural terminology codes used by the American Medical Association. If an amendment that has substantial impact on the rights and obligations of providers is made to a manual, policy or procedure document referenced in the provider agreement, such as material changes to fee schedules or material changes to procedural coding rules specified in the manual, policy or procedure document, the carrier shall provide 60 days' notice to the provider. If the change is to a reimbursement policy and the estimated aggregate change to participating provider reimbursement as a result of the change is more than $500,000 per year, the notice must include the carrier's good faith estimate of the total annual financial impact of the amendment on the aggregate amount of reimbursement payments made by the carrier to all providers within the State with whom the carrier has a provider agreement. After the 60-day notice period has expired, the amendment to a manual, policy or procedure document becomes effective and binding on both the carrier and the provider subject to any applicable termination provisions in the provider agreement, except that the carrier and provider may mutually agree to waive the 60-day notice requirement. This subsection may not be construed to limit the ability of a carrier and provider to mutually agree to the proposed change at any time after the provider has received notice of the proposed amendment. If the notice required by this subsection is provided by electronic communication, the subject line of the electronic communication must indicate that notice of an amendment to a provider agreement or manual, policy or procedure document is included in the communication and the notice of the amendment must be provided as an attachment to the communication, as a separate document. As part of the notice required under this subsection, a carrier shall provide a copy of the revised provider agreement, manual, policy or procedure document without changes being noted and a copy of the revised provider agreement, manual, policy or procedure document with changes being noted by underlining added language and by striking through deleted language. [PL 2023, c. 574, §1 (AMD).] Revisor's Note: (Subsection 9 as enacted by PL 2003, c. 110, §1 is REALLOCATED TO TITLE 24-A, SECTION 4303, SUBSECTION 11)

10. Limits on retrospective denials. Except as provided in paragraphs C and D , a carrier offering a health plan in this State may not impose on any provider any retrospective denial of a previously paid claim or any part of that previously paid claim unless the carrier has provided the reason for the retrospective denial in writing to the provider and the time that has elapsed since the date of payment of the previously paid claim does not exceed 12 months. A. [PL 2023, c. 574, §2 (RP).] B. [PL 2023, c. 574, §2 (RP).] C. The retrospective denial of a previously paid claim may be permitted from 12 months from the date of payment until no later than 36 months from the date of payment for the following reasons only: (1) The claim payment was incorrectly made because the provider or the insured was already paid in full for the health care services identified in the claim; (2) The health care services identified in the claim were not delivered by the provider; (3) The claim payment is the subject of adjustment with another insurer, administrator or payor; or (4) The claim payment is the subject of legal action. [PL 2023, c. 574, §2 (NEW).] D. The retrospective denial of a previously paid claim may be permitted beyond 12 months from the date of payment for the following reasons only: (1) The claim was submitted fraudulently; or (2) The claim payment was for services covered by Title XVIII, Title XIX or Title XXI of the Social Security Act. [PL 2023, c. 574, §2 (NEW).] For purposes of this subsection, "retrospective denial of a previously paid claim" means any attempt by a carrier to retroactively collect payments already made to a provider with respect to a claim by requiring repayment of such payments, reducing other payments currently owed to the provider, withholding or setting off against future payments or reducing or affecting the reimbursement rates for future claim payments to the provider in any other manner. The provider has 6 months from the date of notification under this subsection to determine whether the insured has other appropriate insurance that was in effect on the date of service. Notwithstanding the terms of the provider agreement, the carrier shall allow for the submission of a claim that was previously denied by another insurer because of the insured's transfer or termination of coverage. [PL 2023, c. 574, §2 (AMD).]

11. (REALLOCATED FROM T. 24-A, §4303, sub-§9) Absolute discretion clauses. The use and enforcement of an absolute discretion clause is governed by this subsection. A. A policy, contract, certificate or agreement offered, delivered, issued or renewed for delivery in this State by a carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services may not contain a provision purporting to reserve sole or absolute discretion to the carrier to interpret the terms of the contract or to provide standards of interpretation or review that are inconsistent with the laws of this State. [RR 2003, c. 1, §21 (RAL).] B. A carrier may not enforce a provision in a policy, contract, certificate or agreement that was offered, delivered or issued for delivery in this State and has been continued or renewed by a group policy holder or individual enrollee in this State that purports to reserve sole or absolute discretion to the carrier to interpret the terms of the contract or to provide standards of interpretation or review that are inconsistent with the laws of this State. [RR 2003, c. 1, §21 (RAL).] [RR 2003, c. 1, §21 (RAL).]

12. Publication of policies by carriers. A carrier must publish at least 5 individual health plans with the highest level of enrollment and at least 5 small group health plans with the highest level of enrollment on the carrier’s publicly accessible website in a manner that will allow consumers to review the coverage offered under each policy. The policies posted on the website must be updated when changes are made to the policies by the carrier. The appearance of the policy on the website must duplicate the appearance of a paper copy of the policy. The bureau shall provide a link from its website to each carrier’s website. A carrier must review annually which policies to post and make any necessary changes on its website. A carrier must post the required policies on its website within 90 days after the effective date of this subsection. [PL 2009, c. 439, Pt. A, §3 (NEW).]

13. Explanation of benefits. A carrier offering an individual expense-incurred health plan to residents of this State or an expense-incurred group health plan to an employer in this State shall provide individual policyholders and group certificate holders with clear written explanations of benefit documents in response to the filing of any claim providing for coverage of hospital or medical expenses. The explanation of benefits must include all of the following information: A. The date of service; [PL 2009, c. 439, Pt. A, §4 (NEW).] B. The provider of the service; [PL 2009, c. 439, Pt. A, §4 (NEW).] C. An identification of the service for which the claim is made; [PL 2009, c. 439, Pt. A, §4 (NEW).] D. Any amount the insured is obligated to pay under the policy for copayment or coinsurance; [PL 2009, c. 439, Pt. A, §4 (NEW).] E. A telephone number and address where the insured may obtain clarification of the explanation of benefits; [PL 2009, c. 439, Pt. A, §4 (NEW).] F. A notice of appeal rights; and [PL 2009, c. 439, Pt. A, §4 (NEW).] G. A notice of the right to file a complaint with the bureau after exhausting any appeals under a carrier's internal appeals process. [PL 2009, c. 439, Pt. A, §4 (NEW).] The superintendent shall establish by rule the minimum information and standards for explanation of benefits forms used by carriers, taking into consideration any input from stakeholders and any national standards for explanation of benefits forms. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A . This subsection applies to any explanation of benefits form issued on or after January 1, 2010. [PL 2009, c. 439, Pt. A, §4 (NEW).]

14. Policy terms. The superintendent may by rule define standard policy terms that must be used in all policies issued by carriers offering health plans in the State. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A . [PL 2009, c. 439, Pt. A, §5 (NEW).]

15. Uniform explanation of coverage documents and standardized definitions. A carrier offering a health plan in this State shall: A. Provide to applicants, enrollees and policyholders or certificate holders a summary of benefits and an explanation of coverage that accurately describe the benefits and coverage under the applicable plan or coverage. A summary of benefits and an explanation of coverage must conform with the requirements of the federal Affordable Care Act; [PL 2023, c. 80, §2 (AMD); PL 2023, c. 80, §3 (AFF).] B. Use standard definitions of insurance-related and medical-related terms in connection with health insurance coverage as required by the federal Affordable Care Act; and [PL 2023, c. 80, §2 (AMD); PL 2023, c. 80, §3 (AFF).] C. Provide notice to enrollees and policyholders or certificate holders that preventive services are covered without cost sharing as provided in section 4320‑A, subsection 1 , but services related to a specific health concern, condition or injury may be separately billed as an office visit and may be subject to cost-sharing requirements as provided in the health plan. [PL 2023, c. 80, §2 (NEW); PL 2023, c. 80, §3 (AFF).] [PL 2023, c. 80, §2 (AMD); PL 2023, c. 80, §3 (AFF).] Revisor's Note: (Subsection 15 as enacted by PL 2011, c. 451, §1 is REALLOCATED TO TITLE 24-A, SECTION 4303, SUBSECTION 17)

16. Language and culture. All notices to applicants, enrollees and policyholders or certificate holders subject to the requirements of the federal Affordable Care Act must be provided in a culturally and linguistically appropriate manner consistent with the requirements of the federal Affordable Care Act. [PL 2011, c. 364, §27 (NEW).]

17. (REALLOCATED FROM T. 24-A, §4303, sub-§15) Prohibition on "most favored nation" clauses. Participation agreements between carriers and providers are governed by this subsection. A. A participation agreement between a carrier and a provider may not include a provision, commonly referred to as a "most favored nation" clause, that: (1) Prohibits, or grants the carrier an option to prohibit, the provider from entering into a participation agreement with another carrier to provide services at a lower price than the payment specified in the participation agreement; (2) Requires, or grants the carrier an option to require, the provider to accept a lower payment in the event the provider agrees to provide services to any other carrier at a lower price; (3) Requires, or grants the carrier an option of, termination or renegotiation of the existing participation agreement in the event the provider agrees to provide services to any other carrier at a lower price; or (4) Requires the provider to disclose its reimbursement rates from other carriers. [RR 2011, c. 1, §42 (RAL).] B. The superintendent may grant a waiver to paragraph A on application by either a carrier or a provider. A carrier or provider requesting a waiver for more than one participation agreement must file a separate application for each requested waiver. The superintendent may grant a waiver only after issuing a finding that the inclusion in the participation agreement of a most favored nation clause as described in paragraph A is not anticompetitive. A carrier or provider requesting a waiver may request a hearing on the application for a waiver in accordance with section 229 . The findings and decision of the superintendent are final agency actions for the purposes of Title 5, chapter 375, subchapter 7 and, notwithstanding section 236, subsection 2 , may be appealed regardless of whether a hearing was held. The superintendent's review under this paragraph is limited to the most favored nation clause, and any decision under this paragraph is for purposes of this subsection only and may not be construed as a finding or decision regarding the legality of the provision under other applicable law. [RR 2011, c. 1, §42 (RAL).] C. Prior to the issuance of the superintendent's findings and decision on an application for a waiver pursuant to this subsection, any contract, proposal or draft legal instrument submitted to the superintendent in an application for a waiver is not a public record for the purposes of Title 1, chapter 13 , except that the name and business address of the parties to an application for a waiver are public information. After the issuance of the superintendent's findings and decision, the superintendent may disclose any information that the superintendent determines is not proprietary information. For the purposes of this paragraph, "proprietary information" means information that is a trade secret or production, commercial or financial information the disclosure of which would impair the competitive position of the carrier or provider submitting the information and would make available information not otherwise publicly available. [RR 2011, c. 1, §42 (RAL).] D. A carrier may not discriminate or retaliate against a provider for filing or opposing an application for a waiver under this subsection. [RR 2011, c. 1, §42 (RAL).] E. A provider may not discriminate or retaliate against a carrier for filing or opposing an application for a waiver under this subsection. [RR 2011, c. 1, §42 (RAL).] F. For the purposes of this subsection, the factors the superintendent may consider in determining whether to grant a waiver based on a finding that the inclusion of a most favored nation clause as described in paragraph A is not anticompetitive include, but are not limited to: (1) Any reduction or limit on competition among carriers or providers; (2) The impact on quality and availability of health care services, including the geographic distribution of providers; (3) The size of the provider and the type of any specialty; (4) The market share of the carrier and the provider; (5) The impact on the price and stability of health insurance and health care services to consumers; and (6) The impact on reimbursement rates in the provider marketplace. [RR 2011, c. 1, §42 (RAL).] [RR 2011, c. 1, §42 (RAL).]

18. Provider contract requirements. A carrier offering a health plan must meet the requirements of this subsection with respect to a contract offered by the carrier to a provider, including a contract offered through a preferred provider arrangement, as defined in section 2671, subsection 7 . This subsection does not apply to dental or vision plans. A. If the contract for a preferred provider arrangement includes a reference to policies or procedures to which a contracting provider would be bound, all such policies and procedures must be provided to the provider for review in an easily accessible manner upon the provider's request at the time the contract is offered. [PL 2013, c. 399, §1 (NEW).] B. Upon the provider's request at the time a contract for a preferred provider arrangement is offered, the following must be provided to a provider for review: (1) The fee schedule or, if there is not a fee schedule for one or more of the services covered under the contract, the terms under which payment is determined. A carrier may require a provider to execute a nondisclosure agreement covering the information provided under this subparagraph; (2) The identity of all carriers for which the provider is agreeing to provide services to health plan enrollees; and (3) Contact information for the carrier's employee responsible for negotiating all contract terms with the provider, including, but not limited to, the fee schedule. Contact information provided under this subparagraph must include, at a minimum, the position title of the carrier's employee, the employee's telephone number and the employee's e-mail address. A carrier shall update this contact information on the carrier's electronic portal for providers or, if the carrier does not have an electronic portal, by other means of electronic notification to providers. [PL 2025, c. 295, §1 (AMD).] C. As a condition of participation in one of the carrier's preferred provider arrangements, a contract offered by a carrier may not require a provider to participate in any other carrier's network subsequently offered by the carrier or by a carrier's preferred provider arrangement. [PL 2013, c. 399, §1 (NEW).] D. Without the provider's prior written consent, a provider's contractual participation in a carrier's preferred provider arrangement may not: (1) Subject the provider to health plan payor requirements or fee schedules that materially differ from the terms of the provider's contract with the carrier, unless those materially different terms are set out in writing in a separate section of the contract, such as an exhibit or amendment; or (2) Permit the terms of the provider's existing preferred provider arrangement contract to be superseded by a carrier's subsequent contract with a health plan payor. [PL 2013, c. 399, §1 (NEW).] E. A preferred provider arrangement contract may not require a provider providing a service to an enrollee under a health plan included in the provider's contract to obtain preauthorization if the enrollee's health plan does not require prior authorization as a condition of coverage. [PL 2013, c. 399, §1 (NEW).] F. Explanation of remittance advices or comparable documents, whether in paper or electronic form, that accompany and identify payment of a provider's claims under a carrier's contract, including contracts offered through a preferred provider arrangement, must identify the administrator and payor of the provider's claims and include contact information. [PL 2013, c. 399, §1 (NEW).] The requirements of this subsection do not apply to a carrier offering a health plan with respect to preferred provider arrangement contracts with a hospital or pharmacy. [PL 2025, c. 295, §1 (AMD).]

19. Information about provider networks. A carrier offering a managed care plan shall prominently disclose to applicants, prospective enrollees and enrollees information about the carrier's provider network for the applicable managed care plan, including whether there are hospitals, health care facilities, physicians or other providers not included in the plan's network and any differences in an enrollee's financial responsibilities for payment of covered services to a participating provider and to a provider not included in a provider network. The superintendent may adopt rules that set forth the manner, content and required disclosure of the information in accordance with this subsection. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A . [PL 2013, c. 535, §1 (NEW).]

20. Information about prescription drugs. Consistent with the requirements of the federal Affordable Care Act, a carrier offering a health plan in this State shall provide the following information to prospective enrollees and enrollees with respect to prescription drug coverage on its publicly accessible website. A. A carrier shall post each prescription drug formulary for each health plan offered by the carrier. The prescription drug formularies must be posted in a manner that allows prospective enrollees and enrollees to search the formularies and compare formularies to determine whether a particular prescription drug is covered under a formulary. When a change is made to a formulary, the updated formulary must be posted on the website within 72 hours. [PL 2015, c. 260, §1 (NEW).] B. A carrier shall provide an explanation of: (1) The requirements for utilization review, prior authorization or step therapy for each category of prescription drug covered under a health plan; (2) The cost-sharing requirements for prescription drug coverage, including a description of how the costs of prescription drugs will specifically be applied or not applied to any deductible or out-of-pocket maximum required under a health plan; (3) The exclusions from coverage under a health plan and any restrictions on use or quantity of covered health care services in each category of benefits; and (4) The amount of coverage provided under a health plan for out-of-network providers or noncovered health care services and any right of appeal available to an enrollee when out-of-network providers or noncovered health care services are medically necessary. [PL 2015, c. 260, §1 (NEW).] [PL 2015, c. 260, §1 (NEW).]

21. Health care price transparency tools. Beginning January 1, 2018, a carrier offering a health plan in this State shall comply with the following requirements. A. A carrier shall develop and make available a website accessible to enrollees and a toll-free telephone number that enable enrollees to obtain information on the estimated costs for obtaining a comparable health care service, as defined in Title 24‑A, section 4318‑A, subsection 1, paragraph A , from network providers, as well as quality data for those providers, to the extent available. A carrier may comply with the requirements of this paragraph by directing enrollees to the publicly accessible health care costs website of the Maine Health Data Organization. [PL 2017, c. 232, §6 (NEW).] B. A carrier shall make available to the enrollee through a toll-free telephone number the ability to obtain an estimated cost of a scheduled health care service or a comparable health care service that is based on a description of the service or the applicable standard medical codes or current procedural terminology codes used by the American Medical Association provided to the enrollee by the provider. Upon an enrollee's request, the carrier shall request additional or clarifying code information, if needed, from the provider involved with the scheduled health care service or comparable health care service. If the carrier obtains specific code information from the enrollee or the enrollee's provider, the carrier shall provide the anticipated allowed amount and the enrollee's anticipated out-of-pocket costs based on that code information, to the extent such information is made available to the carrier by the provider. Notwithstanding other provisions of this paragraph, a carrier does not commit a violation of this paragraph if the carrier complies with federal regulations for price transparency relating to an estimate of an enrollee's cost-sharing responsibility. [PL 2023, c. 584, Pt. A, §5 (AMD).] C. A carrier shall notify an enrollee that the amounts are estimates based on information available to the carrier at the time the request is made and that the amount the enrollee will be responsible to pay may vary due to unforeseen circumstances that arise out of the proposed scheduled health care service or comparable health care service. This subsection does not prohibit a carrier from imposing cost-sharing requirements disclosed in the enrollee's certificate of coverage for unforeseen health care services that arise out of the proposed scheduled health care service or comparable health care service or for a procedure or service that was not included in the original estimate. This subsection does not preclude an enrollee from contacting the carrier to obtain more information about a particular admission, procedure or service with respect to a particular provider. [PL 2023, c. 584, Pt. A, §5 (AMD).] D. [PL 2023, c. 584, Pt. A, §5 (RP).] [PL 2023, c. 584, Pt. A, §5 (AMD).]

22. Denial of referral by out-of-network provider prohibited. Beginning January 1, 2018, a carrier may not deny payment for any health care service covered under an enrollee's health plan based solely on the basis that the enrollee's referral was made by a direct health care provider who is not a member of the carrier's provider network. A carrier may not apply a deductible, coinsurance or copayment greater than the applicable deductible, coinsurance or copayment that would apply to the same health care service if the service was referred by a participating primary care provider. A carrier may require a direct health care provider making a referral who is not a member of the carrier's provider network to provide information demonstrating that the provider is a direct health care provider through a written attestation or copy of a direct health care service agreement with an enrollee and may request additional information necessary to implement this subsection. As used in this subsection, "direct health care provider" has the same meaning as in Title 22, section 1771, subsection 1, paragraph B . [PL 2025, c. 358, §3 (AMD).]

22-A. Denial of referral during urgent care visit prohibited. A carrier may not deny payment for any behavioral health care service or physical therapy service covered under an enrollee's health plan based solely on the basis that the enrollee's referral was not made by the enrollee's primary care provider as long as the enrollee's referral is made by a provider during an urgent care visit and the provider notifies the enrollee’s primary care provider of the referral. A carrier may not apply a deductible, coinsurance or copayment greater than the applicable deductible, coinsurance or copayment that would apply to the same health care service if the service was referred by the enrollee's primary care provider. A carrier may require a provider of urgent care that is making a referral to provide additional information necessary to implement this subsection. [PL 2023, c. 119, §3 (NEW); PL 2023, c. 119, §4 (AFF).]

23. Duplicative or incorrect claims payments. If a carrier has made a duplicative or incorrect payment on a claim with respect to a health plan: A. If the claim payment was made to a provider, the carrier shall retroactively seek collection related to that payment directly from the provider; and [PL 2019, c. 30, §1 (NEW).] B. The carrier may not attempt to retroactively seek collection related to the claim payment from an enrollee unless the enrollee was already paid directly for the services identified in the claim and a provider submits evidence to the carrier that the enrollee did not forward payment to the provider. After a provider has submitted evidence that the enrollee did not forward payment to the provider, a carrier may require an enrollee to provide evidence of payment to the provider. [PL 2019, c. 30, §1 (NEW).] [PL 2019, c. 30, §1 (NEW).]

24. Practice or facility-wide prepayment review of providers. A practice or facility-wide prepayment review of the documentation or records of a provider conducted by a carrier for the purposes of identifying fraud, waste or abuse, determining whether the documentation is appropriate or adequate to support a claim for covered health care services or determining whether health care services are or were medically necessary health care as a condition of payment must be conducted in accordance with the following requirements. A. When a carrier subjects a provider or facility to a practice or facility-wide prepayment review, the carrier shall provide a process to allow claims and documentation to be submitted to the carrier electronically for purposes of proving timely filing and tracking the carrier's compliance with time limits in other applicable laws. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] B. Claims subject to a practice or facility-wide prepayment review must be paid or disputed within 30 days as required by section 2436 . Any claim that is not disputed pursuant to section 2436 or paid within 30 days by the carrier is overdue and subject to interest in accordance with section 2436 . [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] C. Any records of an enrollee reviewed as part of a practice or facility-wide prepayment review must be reviewed by the same reviewer to the extent possible. The reviewer who performs the practice or facility-wide prepayment review is the primary contact person for the provider related to an audit, review, denial or nonpayment of a claim. Any practice or facility-wide prepayment review that involves clinical or professional judgement must be conducted by or in consultation with a clinical peer. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] D. A carrier may not apply additional or different documentation standards beyond the standards set by the professional association of the provider subject to practice or facility-wide prepayment review if those standards are publicly available or made available to the carrier. This paragraph does not prohibit carriers from establishing or applying medical policies or clinical guidelines to determine whether a service is a covered benefit and medically necessary health care. This paragraph does not apply to claims submitted by a hospital or other health care facility. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] E. A carrier may not deny payment of a claim for covered health care services by a provider solely on the basis of a minor documentation error or omission, including, but not limited to, misspelling, use of an abbreviation or a correctable error, unless the carrier affords the provider or enrollee the opportunity to resubmit the claim to correct the identified error. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] F. If a carrier requires additional information as part of a practice or facility-wide prepayment review of a claim for covered health care services by a provider, the carrier shall inform the provider with reasonable specificity of the information needed by the carrier to adjudicate the claim. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] G. Additional information required by a carrier is considered timely filed by the provider if submitted within 30 days from the date the provider received notice from the carrier of the errors, omissions or additional information needed. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] H. A carrier shall provide information on how a provider may appeal the denial of a claim, including the mailing or e-mail address or fax number where an appeal should be sent, on its publicly accessible website or in a provider manual. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] I. A carrier shall provide an opportunity to appeal the results of an audit leading to the provider being put on a practice or facility-wide prepayment review. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] J. A carrier may not audit a provider or require that a provider's claims be subject to practice or facility-wide prepayment review as retribution for raising contract disputes. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).] For the purposes of this subsection, "practice or facility-wide prepayment review" means a manual review or audit process of all, or substantially all, of a provider's claims by a carrier or the carrier's agent. [PL 2021, c. 272, §1 (NEW); PL 2021, c. 272, §2 (AFF).]

25. Second opinion. An enrollee in a health plan may not be required to obtain a 2nd opinion from a provider that practices in the same office location as the enrollee's provider. Notwithstanding any provision of this Title to the contrary, if the 2nd opinion is obtained from an out-of-network provider because a network provider is not available in accordance with section 4303, subsection 1 and Bureau of Insurance Rule Chapter 850: Health Plan Accountability, a carrier may not apply a deductible, coinsurance or copayment for the 2nd opinion in an amount greater than the deductible, coinsurance or copayment that would apply to the same health care service if the service were obtained from a network provider, and the amount of any coinsurance or copayment must be applied to the enrollee's in-network deductible. [PL 2023, c. 348, §1 (NEW); PL 2023, c. 348, §2 (AFF).] Revisor's Note: (Subsection 25 as enacted by PL 2023, c. 382, §1 is REALLOCATED TO TITLE 24-A, SECTION 4303, SUBSECTION 26)

26. (REALLOCATED FROM T. 24-A, §4303, sub-§25) Disclosure to enrollees of cash price. A carrier may not prohibit a provider from providing an enrollee with the option of paying the provider's discounted cash price for health care services. For the purposes of this subsection, "discounted cash price" means: A. With respect to a hospital, the discounted cash price as that term is defined in 45 Code of Federal Regulations, Section 180.20 if the hospital has a discounted cash price and does not mean the amount charged to individuals who are eligible for free care or are eligible for the amounts charged pursuant to a hospital’s financial assistance policy; or [PL 2023, c. 382, §1 (NEW); RR 2023, c. 1, Pt. A, §22 (RAL).] B. With respect to a provider that is not a hospital, the charge that applies to an enrollee who is paying for a health care service without filing any claim with a carrier. [PL 2023, c. 382, §1 (NEW); RR 2023, c. 1, Pt. A, §22 (RAL).] [PL 2023, c. 382, §1 (NEW); RR 2023, c. 1, Pt. A, §22 (RAL).]
24-A M.R.S. § 4609 — ME Code / Title 24-A / Chapter 62 / Section 4609
24-A §4609. Assessments
Status: in_force

1. Assessments; collection. For the purpose of providing the funds necessary to carry out the powers and duties of the association, the board of directors shall assess the member insurers, separately for each account, at such times and for such amounts as the board finds necessary. Assessments are due not less than 30 days after prior written notice to the member insurers and accrue interest at 10% annually on and after the due date. [PL 2005, c. 346, §7 (AMD); PL 2005, c. 346, §16 (AFF).]

2. Classes of assessments. [PL 2005, c. 346, §7 (RP); PL 2005, c. 346, §16 (AFF).]

2-A. Classes of assessments. There are 2 classes of assessments, as set out in this subsection. A. Class A assessments are authorized and called for the purpose of meeting administrative costs and other general expenses. Class A assessments may be authorized and called whether or not related to a particular impaired or insolvent insurer. [PL 2005, c. 346, §7 (NEW); PL 2005, c. 346, §16 (AFF).] B. Class B assessments are authorized and called to the extent necessary to carry out the powers and duties of the association under section 4608 with regard to an impaired or an insolvent insurer. [PL 2005, c. 346, §7 (NEW); PL 2005, c. 346, §16 (AFF).] [PL 2005, c. 346, §7 (NEW); PL 2005, c. 346, §16 (AFF).]

3. Determination of assessments. [PL 2005, c. 346, §7 (RP); PL 2005, c. 346, §16 (AFF).]

3-A. Determination of assessments. Assessments must be determined as follows: A. The amount of any Class A assessment, as described in subsection 2‑A , for each account must be determined by the board of directors and may be authorized and called on a pro rata or non-pro rata basis. If pro rata, it must be allocated in the same proportions as a Class B assessment under paragraph C , and the board has the power to credit it against future Class B assessments. [PL 2017, c. 382, §25 (AMD).] B. [PL 2017, c. 382, §25 (RP).] C. Class B assessments, as described in subsection 2‑A , must be allocated as follows. (1) Except for assessments related to long-term care insurance that are subject to allocation under subparagraph (2), the amount of the assessment must be allocated among the accounts pursuant to an allocation formula that may be based on the premiums or reserves of the impaired or insolvent insurer or any other standard determined by the board of directors in its sole discretion as being fair and reasonable under the circumstances. (2) The amount of any Class B assessment for liabilities arising out of long-term care insurance written by the impaired or insolvent insurer, if the impairment or insolvency is declared on or after July 1, 2018, must be allocated among the accounts according to a methodology included in the plan of operation and approved by the superintendent. The methodology must provide for 50% of the assessment to be allocated to member insurers that are health insurers and 50% to be allocated to member insurers that are life and annuity insurers. (3) All Class B assessments must be allocated among member insurers within each account in the proportion that the premiums received by each assessed member insurer, on business in this State covered by the account, bears to premiums received on such business by all assessed member insurers, for the most recent calendar year for which information is available preceding the year in which the insurer became insolvent or, in the case of an assessment with respect to an impaired insurer, preceding the year in which the insurer became impaired. (4) Health maintenance organizations are not subject to Class B assessments arising out of impairments or insolvencies declared before July 1, 2018. [PL 2017, c. 382, §25 (AMD).] D. Assessments for funds to meet the requirements of the association with respect to an impaired or insolvent insurer may not be authorized or called until necessary to implement the purposes of this chapter. Classification of assessments under subsection 2‑A and computation of assessments under this paragraph must be made with a reasonable degree of accuracy, recognizing that exact determinations may not always be possible. [PL 2005, c. 346, §7 (NEW); PL 2005, c. 346, §16 (AFF).] E. This subsection may not be a factor in determining whether the protection provided by laws for residents of this State by the domiciliary jurisdiction of a foreign or alien insurer is substantially similar to the protection provided by this chapter for residents of other states. [PL 2017, c. 382, §25 (NEW).] [PL 2017, c. 382, §25 (AMD).]

4. Abatement or deferral of assessments. The association may abate or defer, in whole or in part, the assessment of a member insurer if, in the opinion of the board of directors, payment of the assessment would endanger the ability of the member insurer to fulfill its contractual obligations. Once the conditions that caused a deferral have been removed or rectified, the member insurer shall pay all assessments that were deferred pursuant to a repayment plan approved by the association. The total of all assessments upon a member insurer for each account may not in any one calendar year exceed 2% of the insurer's premiums in this State on the policies covered by the account. [PL 2005, c. 346, §7 (AMD); PL 2005, c. 346, §16 (AFF).]

5. Additional assessment for abatements or deferrals. In the event an assessment against a member insurer is abated or deferred, in whole or in part, because of the limitations set forth in subsection 4 , the amount by which the assessment is abated or deferred must be assessed against the other member insurers in a manner consistent with the basis for assessments set forth in this section. [PL 2005, c. 346, §7 (AMD); PL 2005, c. 346, §16 (AFF).]

6. Refunds. The board of directors may, by an equitable method as established in the plan of operation, refund to member insurers, in proportion to the contribution of each insurer to that account, the amount by which the assets of the account exceed the amount the board finds is necessary to carry out during the coming year the obligations of the association with regard to that account, including assets accruing from net realized gains and income from investments. A reasonable amount may be retained in any account to provide funds for the continuing expenses of the association and for future losses if refunds are impractical. [PL 2005, c. 346, §7 (AMD); PL 2005, c. 346, §16 (AFF).]

7. Consideration of assessments in determining premium rates and dividends. It is proper for any member insurer in determining its premium rates and policyowner dividends as to any kind of insurance within the scope of this chapter, to consider the amount reasonably necessary to meet its assessment obligations under this chapter. [PL 2005, c. 346, §7 (AMD); PL 2005, c. 346, §16 (AFF).]

8. Assessment shortfalls. If the maximum assessment, together with the other assets of the association in any account, does not provide in any one year in any one account an amount sufficient to make all necessary payments from that account, the shortfall must be assessed as an obligation of the other accounts of the association. Each member insurer's assessment must be in the proportion that its premium for the calendar year preceding the assessment on the kinds of insurance in the accounts to be assessed bears to the total premium of all member insurers for the same calendar year on the kinds of insurance in those accounts. The total of assessments against a member insurer for shortfalls under this section and section 4440 in any one calendar year may not exceed 2% of that member insurer's premiums in this State or for policies covered by the account. [PL 2005, c. 346, §7 (AMD); PL 2005, c. 346, §16 (AFF).]

9. Certificate of contribution. The association shall issue to each insurer paying an assessment under this chapter, other than a Class A assessment, a certificate of contribution, in a form prescribed by the superintendent, for the amount of the assessment so paid. All outstanding certificates are of equal dignity and priority without reference to amounts or dates of issue. [PL 2005, c. 346, §7 (NEW); PL 2005, c. 346, §16 (AFF).]
24-A M.R.S. § 3355 — ME Code / Title 24-A / Chapter 47 / Section 3355
24-A §3355. Deposit of qualifying premiums; effective date of insurance
Status: in_force

1. All sums collected by a domestic mutual corporation as premiums or fees on qualifying applications for insurance therein shall be deposited in trust in a bank or trust company in this State under a written trust agreement consistent with this section and with section 3354, subsection 3, paragraph C . The corporation shall file an executed copy of such trust agreement with the superintendent. [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).]

2. Upon issuance to the corporation of a certificate of authority as an insurer for the kind or kinds of insurance for which such applications were solicited, all funds so held in trust shall become the funds of the insurer, and the insurer shall thereafter in due course issue and deliver its policies for which premiums had been paid and accepted. The insurance provided by such policies shall be effective as of the date of the certificate of authority or thereafter as provided by the respective policies. [PL 1969, c. 132, §1 (NEW).]
24-A M.R.S. § 2843 — ME Code / Title 24-A / Chapter 35 / Section 2843
24-A §2843. Mental health services coverage
Status: in_force

1. Findings. The Legislature finds that: A. Mental illness affects nearly 170,000 Maine people each year, resulting in anguish, grief, desperation, fear, isolation and a sense of hopelessness of significant levels among victims and families; [PL 1983, c. 515, §6 (NEW).] B. Consequences of mental illness include the expenditure of millions of dollars of public funds for treatment and losses of millions of dollars by Maine businesses in accidents, absenteeism, nonproductivity and turnover. Excessive stress and anxiety and other forms of mental illness clearly contribute to general health problems and costs; [PL 1983, c. 515, §6 (NEW).] C. Typical health coverage in this State discriminates against mental illness, the victims and affected families with nonexistent or limited benefits compared to provisions for other illnesses; and [PL 1983, c. 515, §6 (NEW).] D. Experience in this State and several other states demonstrates that the risk of mental illness can be insured at reasonable cost and with adequate controls on quality and utilization of treatment. [PL 1983, c. 515, §6 (NEW).] [PL 1983, c. 515, §6 (NEW).]

2. Policy and purpose. The Legislature declares that it is the policy of this State to: A. Promote equitable and nondiscriminatory health coverage benefits for all forms of illness, including mental and emotional disorders, which are of significant consequence to the health of Maine people and which can be treated in a cost effective manner; [PL 1983, c. 515, §6 (NEW).] B. Assure that victims of mental and other illnesses have access to and choice of appropriate treatment at the earliest point of illness in least restrictive settings; [PL 1983, c. 515, §6 (NEW).] C. Assure that costs of treatment of mental illness are supported through an equitable combination of public and private responsibilities; and [PL 1983, c. 515, §6 (NEW).] D. Assure that the Legislature reasonably exercises its legal responsibility for insurance policy in this State by prescribing types of illnesses and treatment for which benefits shall be provided. [PL 1983, c. 515, §6 (NEW).] [PL 1983, c. 515, §6 (NEW).]

3. Definitions. For purposes of this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Day treatment services" includes psychoeducational, physiological, psychological and psychosocial concepts, techniques and processes to maintain or develop functional skills of clients, provided to individuals and groups for periods of more than 2 hours but less than 24 hours per day. [PL 1983, c. 515, §6 (NEW).] A-1. "Diagnostic and statistical manual" means the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, published by the American Psychiatric Association. [PL 2003, c. 20, Pt. VV, §10 (NEW); PL 2003, c. 20, Pt. VV, §25 (AFF).] A-2. "Home health care services" means those services rendered by a licensed provider of mental health services to provide medically necessary health care to a person suffering from a mental illness in the person's place of residence if: (1) Hospitalization or confinement in a residential treatment facility would otherwise have been required if home health care services were not provided; (2) Hospitalization or confinement in a residential treatment facility is not required as an antecedent to the provision of home health care services; and (3) The services are prescribed in writing by a licensed allopathic or osteopathic physician or a licensed psychologist who is trained and has received a doctorate in psychology specializing in the evaluation and treatment of mental illness. [PL 2003, c. 20, Pt. VV, §10 (NEW); PL 2003, c. 20, Pt. VV, §25 (AFF).] A-3. "Evidence-based practices" means clinically sound and scientifically based policies, practices and programs that reflect expert consensus on the prevention, treatment and recovery science, including, but not limited to, policies, practices and programs published and disseminated by the Substance Abuse and Mental Health Services Administration and the Title IV-E Prevention Services Clearinghouse within the United States Department of Health and Human Services, the What Works Clearinghouse within the United States Department of Education, Institute of Education Sciences and the California Evidence-Based Clearinghouse for Child Welfare within the California Department of Social Services, Office of Child Abuse Prevention. [PL 2021, c. 595, §3 (NEW).] B. "Inpatient services" includes a range of physiological, psychological and other intervention concepts, techniques and processes in a community mental health psychiatric inpatient unit, general hospital psychiatric unit or psychiatric hospital licensed by the Department of Health and Human Services or accredited public hospital to restore psychosocial functioning sufficient to allow maintenance and support of the client in a less restrictive setting. [PL 1983, c. 515, §6 (NEW); PL 2003, c. 689, Pt. B, §6 (REV).] B-1. "Medically necessary health care" has the same meaning as in section 4301‑A, subsection 10‑A . [PL 2003, c. 20, Pt. VV, §11 (NEW); PL 2003, c. 20, Pt. VV, §25 (AFF).] C. "Outpatient services" includes screening, evaluation, consultations, diagnosis and treatment involving use of psychoeducational, physiological, psychological and psychosocial evaluative and interventive concepts, techniques and processes provided to individuals and groups. [PL 1983, c. 515, §6 (NEW).] D. "Person suffering from a mental illness" means a person whose psychobiological processes are impaired severely enough to manifest problems in the areas of social, psychological or biological functioning. Such a person has a disorder of thought, mood, perception, orientation or memory that impairs judgment, behavior, capacity to recognize or ability to cope with the ordinary demands of life. The person manifests an impaired capacity to maintain acceptable levels of functioning in the areas of intellect, emotion or physical well-being. [PL 2003, c. 20, Pt. VV, §12 (AMD); PL 2003, c. 20, Pt. VV, §25 (AFF).] E. "Provider" means individuals included in section 2835 , and a licensed physician with 3 years approved residency in psychiatry, an accredited public hospital or psychiatric hospital or a community agency licensed at the comprehensive service level by the Department of Health and Human Services. All agency or institutional providers named in this paragraph shall assure that services are supervised by a psychiatrist or licensed psychologist. [PL 1983, c. 816, §B7 (AMD); PL 1995, c. 560, Pt. K, §82 (AMD); PL 1995, c. 560, Pt. K, §83 (AFF); PL 2001, c. 354, §3 (AMD); PL 2003, c. 689, Pt. B, §6 (REV).] [PL 2021, c. 595, §3 (AMD).]

4. Requirement. Every insurer that issues group health care contracts providing coverage to residents of this State shall provide benefits as required in this section to any subscriber or other person covered under those contracts for conditions arising from mental illness. [PL 2003, c. 20, Pt. VV, §13 (AMD); PL 2003, c. 20, Pt. VV, §25 (AFF).]

5. Services. Each group contract must provide for medically necessary health care for a person suffering from mental illness. Medically necessary health care includes, but is not limited to, the following services for a person suffering from a mental illness: A. Inpatient care; [PL 1983, c. 515, §6 (NEW).] B. Day treatment services; [PL 2003, c. 20, Pt. VV, §13 (AMD); PL 2003, c. 20, Pt. VV, §25 (AFF).] C. Outpatient services; and [PL 2003, c. 20, Pt. VV, §13 (AMD); PL 2003, c. 20, Pt. VV, §25 (AFF).] D. Home health care services. [PL 2003, c. 20, Pt. VV, §13 (NEW); PL 2003, c. 20, Pt. VV, §25 (AFF).] [PL 2003, c. 20, Pt. VV, §13 (AMD); PL 2003, c. 20, Pt. VV, §25 (AFF).]

5-A. Exceptions. [PL 2019, c. 5, Pt. D, §2 (RP).]

5-B. Coverage for certain mental illness treatment. [PL 1991, c. 881, §3 (NEW); PL 1991, c. 881, §7 (AFF); PL 1991, c. 881, §8 (RP).]

5-C. Coverage for treatment for certain mental illness. Coverage for medical treatment for mental illnesses listed in paragraph A‑1 is subject to this subsection. A. [PL 2003, c. 20, Pt. VV, §14 (RP); PL 2003, c. 20, Pt. VV, §25 (AFF).] A-1. All group contracts must provide, at a minimum, benefits according to paragraph B , subparagraph (1) for a person receiving medical treatment for any of the following categories of mental illness as defined in the Diagnostic and Statistical Manual, except for those that are designated as "V" codes by the Diagnostic and Statistical Manual: (1) Psychotic disorders, including schizophrenia; (2) Dissociative disorders; (3) Mood disorders; (4) Anxiety disorders; (5) Personality disorders; (6) Paraphilias; (7) Attention deficit and disruptive behavior disorders; (8) Pervasive developmental disorders; (9) Tic disorders; (10) Eating disorders, including bulimia and anorexia; and (11) Substance use disorders. For the purposes of this paragraph, the mental illness must be diagnosed by a licensed allopathic or osteopathic physician or a licensed psychologist who is trained and has received a doctorate in psychology specializing in the evaluation and treatment of mental illness. [PL 2017, c. 407, Pt. A, §96 (AMD).] B. All policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State must provide benefits that meet the requirements of this paragraph. (1) The contracts must provide benefits for the treatment and diagnosis of mental illnesses under terms and conditions that are no less extensive than the benefits provided for medical treatment for physical illnesses. (2) At the request of a reimbursing insurer, a provider of medical treatment for mental illness shall furnish data substantiating that initial or continued treatment is medically necessary health care. When making the determination of whether treatment is medically necessary health care, the provider shall use the same criteria for medical treatment for mental illness as for medical treatment for physical illness under the group contract. An insurer may not deny treatment for mental health services that use evidence-based practices and are determined to be medically necessary health care for an individual 21 years of age or younger. (3) If benefits and coverage provided for treatment of physical illness are provided on an expense-incurred basis, the benefits and coverage required under this subsection may be delivered separately under a managed care system. (4) A policy or contract may not have separate maximums for physical illness and mental illness, separate deductibles and coinsurance amounts for physical illness and mental illness, separate out-of-pocket limits in a benefit period of not more than 12 months for physical illness and mental illness or separate office visit limits for physical illness and mental illness. (5) A health benefit plan may not impose a limitation on coverage or benefits for mental illness unless that same limitation is also imposed on the coverage and benefits for physical illness covered under the policy or contract. (6) Copayments required under a policy or contract for benefits and coverage for mental illness must be actuarially equivalent to any coinsurance requirements or, if there are no coinsurance requirements, may not be greater than any copayment or coinsurance required under the policy or contract for a benefit or coverage for a physical illness. (7) For the purposes of this section, a medication management visit associated with a mental illness must be covered in the same manner as a medication management visit for the treatment of a physical illness and may not be counted in the calculation of any maximum outpatient treatment visit limits. [PL 2021, c. 595, §4 (AMD).] [PL 2021, c. 595, §§4, 5 (AMD).]

5-D. Mandated offer of coverage for certain mental illnesses. [PL 2021, c. 595, §6 (RP).]

6. Limits; coinsurance; deductibles. Any policy or contract which provides coverage for the services required by this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section. [PL 1983, c. 515, §6 (NEW).]

7. Reports to the Superintendent of Insurance. Every insurer subject to this section shall report its experience for each calendar year to the superintendent not later than April 30th of the following year. The report must be in a form prescribed by the superintendent and include the amount of claims paid in this State for the services required by this section and the total amount of claims paid in this State for group health care contracts, both separated between those paid for inpatient, day treatment and outpatient services. The superintendent shall compile this data for all insurers in an annual report. [PL 1995, c. 407, §8 (AMD).]

8. Application. This section does not apply to accidental injury, specified disease, hospital indemnity, Medicare supplement, long-term care or other limited benefit health insurance policies. Except as otherwise provided in this section, the requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date. [PL 2003, c. 517, Pt. B, §16 (AMD).]
24-A M.R.S. § 4244 — ME Code / Title 24-A / Chapter 56 / Section 4244
24-A §4244. Coverage for prostate cancer screening (REALLOCATED FROM TITLE 24-A, SECTION 4243)
Status: in_force

(REALLOCATED FROM TITLE 24-A, SECTION 4243)

1. Definition. As used in this section, "services for the early detection of prostate cancer" means the following procedures provided to a man for the purpose of early detection of prostate cancer: A. A digital rectal examination; and [RR 1997, c. 2, §53 (RAL).] B. A prostate-specific antigen test. [RR 1997, c. 2, §53 (RAL).] [RR 1997, c. 2, §53 (RAL).]

2. Required coverage for prostate cancer screening. All health maintenance organization individual and group contracts must provide coverage for services for the early detection of prostate cancer. The contracts must reimburse for services for the early detection of prostate cancer, if recommended by a physician, at least once a year for men 50 years of age or older until a man reaches the age of 72. [RR 1997, c. 2, §53 (RAL).]

3. Application. The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after September 1, 1998. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date. [RR 1997, c. 2, §53 (RAL).]
24-A M.R.S. § 2162-A — ME Code / Title 24-A / Chapter 23 / Section 2162-A
24-A §2162-A. Payment of dividend conditioned upon renewal; unfair trade practice
Status: in_force

It is an unfair trade practice to make the payment of a policy dividend or any portion of a dividend conditioned upon renewal of the policy or contracts. This section does not apply to the first year dividend on life insurance policies. [PL 1985, c. 548 (NEW).]
24-A M.R.S. § 2270 — ME Code / Title 24-A / Chapter 24-B / Section 2270
24-A §2270. Penalties
Status: in_force

The superintendent may take any enforcement action permitted under section 12‑A against any person that violates any provision of this chapter. [PL 2021, c. 24, §1 (NEW).]
24-A M.R.S. § 604 — ME Code / Title 24-A / Chapter 7 / Section 604
24-A §604. Insurance Regulatory Fund
Status: in_force

1. There is created in the State Treasury a dedicated account to be designated the "Insurance Regulatory Fund," the funds of which are hereby appropriated for the partial support and maintenance of the Insurance Bureau. [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).]

2. The Treasurer of State shall credit the following funds to the Insurance Regulatory Fund: A. The balance, if any, remaining on January 1, 1970 of funds allocated to the bureau pursuant to Title 24, section 372 ; [PL 1973, c. 625, §136 (AMD).] B. Fees, licenses and other charges collected and remitted by the superintendent under section 601 (fee schedule), or as increased pursuant to section 428 (retaliatory provision); [PL 1985, c. 446, §3 (AMD).] C. [PL 1997, c. 457, §22 (RP).] D. Amounts assessed by the superintendent under Title 24, section 2332 ; [PL 1985, c. 446, §3 (AMD).] E. Amounts assessed by the superintendent under section 237 ; [PL 1985, c. 446, §3 (NEW).] F. Amounts assessed by the superintendent under Title 39‑A, section 409 ; and [PL 1991, c. 885, Pt. E, §24 (AMD); PL 1991, c. 885, Pt. E, §47 (AFF).] G. Such other amounts as may be expressly required by law to be so credited. [PL 1985, c. 446, §3 (NEW).] [PL 2001, c. 559, §1 (AMD); PL 2001, c. 559, §2 (AFF).]

3. Expenditures by the bureau from the Insurance Regulatory Fund shall be subject to budget control in the same manner as applies to departments of State in general. [PL 1969, c. 132, §1 (NEW); PL 1973, c. 585, §12 (AMD).]