Source: http://legislature.maine.gov/legis/bills/bills_129th/billtexts/SP001002.asp
Timestamp: 2019-04-22 16:08:35+00:00

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B. A carrier may not vary the premium rate due to the gender, health status, occupation or industry, claims experience or policy duration of the individual or any other rating factor not specified in this subsection.
C. A carrier may vary the premium rate due to family membership to the extent permitted by the federal Affordable Care Act . The premium rate for a family must equal the sum of the premiums for each individual in the family, except that it may not be based on more than 3 dependent children who are less than 21 years of age.
D. A carrier may vary the premium rate due to age and tobacco use in accordance with the limitations set out in this paragraph. A carrier that varies the premium rate due to age must vary the premium rate according to a uniform age curve. The superintendent shall adopt rules establishing a uniform age curve that is substantially similar to the age curve in effect on January 1, 2019 under the federal Affordable Care Act. Rules adopted under this paragraph are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
(7) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 2015 , except as provided in subparagraph (9), the maximum rate differential due to age filed by the carrier as determined by ratio is 5 to 1 to the extent permitted by the federal Affordable Care Act. The limitation does not apply for determining rates for an attained age of less than 19 years of age or more than 65 years of age.
(8) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State on or after July 1, 2012, the maximum rate differential due to tobacco use filed by the carrier as determined by ratio is 1.5 to 1 , except that the carrier may not apply a rate differential pursuant to this subparagraph when the covered individual is participating in an evidence-based tobacco cessation strategy approved by the United States Department of Health and Human Services, Food and Drug Administration.
(9) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State on or after the effective date of this subparagraph, the maximum rate differential due to age filed by the carrier as determined by ratio is 3 to 1 for individuals 21 years of age and older on the first day of coverage under the policy, contract or certificate. The variation in rate due to age must be actuarially justified for individuals under 21 years of age consistent with the uniform age rating curve adopted under this paragraph.
Sec. A-4. 24-A MRSA §2736-C, sub-§2, ¶F, as amended by PL 2007, c. 629, Pt. M, §4, is repealed.
Sec. A-5. 24-A MRSA §2736-C, sub-§2, ¶I, as amended by PL 2011, c. 364, §5, is repealed.
5. Loss ratios. Except as provided in subsection 2-B, for all policies and certificates issued on or after the effective date of this section, the superintendent shall disapprove any premium rates filed by any carrier, whether initial or revised, for an individual health policy unless it is anticipated that the aggregate benefits estimated to be paid under all the individual health policies maintained in force by the carrier for the period for which coverage is to be provided will return to policyholders at least 65% of the aggregate premiums collected for those policies, as determined in accordance with accepted actuarial principles and practices and on the basis of incurred claims experience and earned premiums. For the purposes of this calculation, any payments paid pursuant to former section 6913 must be treated as incurred claims medical loss ratio calculated under section 4319 will be at least 80%.
11. Open enrollment; rules. Notwithstanding subsection 3, on or after January 1, 2014, a carrier may restrict enrollment in individual health plans to open enrollment periods and special enrollment periods consistent with requirements of the federal Affordable Care Act to the extent not inconsistent with applicable federal law. The superintendent may adopt rules establishing minimum open enrollment dates and minimum criteria for special enrollment periods for all individual health plans offered in this State. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
1. Dependent child; definition. As used in this section, "dependent child" means the child of a person covered under an individual health insurance policy when that child: .
2. Offer of coverage. Notwithstanding section 2703, subsection 3, an individual health insurance policy that offers coverage for a dependent child must offer such coverage, at the option of the policyholder, until the dependent child is 25 attains 26 years of age. An insurer may require, as a condition of eligibility for coverage in accordance with this section, that a person seeking coverage for a dependent child provide written documentation on an annual basis that the dependent child meets the requirements in subsection 1.
B. A carrier may not vary the premium rate due to the gender, health status, claims experience or policy duration of the eligible group or members of the group or any other rating factor not specified in this section.
C. A carrier may vary the premium rate due to occupation and industry, family membership and participation in wellness programs to the extent permitted by the federal Affordable Care Act. The premium rate for a family must equal the sum of the premiums for each individual in the family, except that it may not be based on more than 3 dependent children who are less than 21 years of age. The superintendent may adopt rules setting forth appropriate methodologies regarding rate discounts for participation in wellness programs and rating for occupation and industry pursuant to this paragraph. Rules adopted pursuant to this paragraph are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
D. A carrier may vary the premium rate due to age , group size and tobacco use only under the following schedule and within the listed percentage bands in accordance with the limitations set out in this paragraph. A carrier that varies the premium rate due to age must vary the premium rate according to a uniform age curve. The superintendent shall adopt rules establishing a uniform age curve that is substantially similar to the age curve in effect on January 1, 2019 under the federal Affordable Care Act. Rules adopted under this paragraph are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
(8) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 2016 , except as provided in subparagraph (10), the maximum rate differential due to age and group size filed by the carrier as determined by ratio is 5 to 1 to the extent permitted by the federal Affordable Care Act. The limitation does not apply for determining rates for an attained age of less than 19 years of age or more than 65 years of age.
(9) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State on or after October 1, 2011, the maximum rate differential due to tobacco use filed by the carrier as determined by ratio is 1.5 to 1 , except that the carrier may not apply a rate differential pursuant to this subparagraph when the covered individual is participating in an evidence-based tobacco cessation strategy approved by the United States Department of Health and Human Services, Food and Drug Administration.
(10) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed in this State on or after the effective date of this Act, the maximum rate differential due to age filed by the carrier as determined by ratio is 3 to 1 for individuals 21 years of age and older on the first day of coverage under the policy, contract or certificate. The variation in rate due to age must be actuarially justified for individuals under 21 years of age consistent with the uniform age rating curve adopted under this paragraph.
Sec. A-12. 24-A MRSA §2808-B, sub-§2, ¶H, as amended by PL 2011, c. 638, §3, is repealed.
1. Dependent child; definition. As used in this section, "dependent child" means the child of a person covered under a group health insurance policy when that child: .
2. Offer of coverage. Notwithstanding section 2822, a group health insurance policy that offers coverage for a dependent child must offer such coverage, at the option of the policyholder parent, until the dependent child is 25 attains 26 years of age. An insurer may require, as a condition of eligibility for coverage in accordance with this section, that a person seeking coverage for a dependent child provide written documentation on an annual basis that the dependent child meets the requirements in subsection 1.
Sec. A-14. 24-A MRSA §2849, sub-§3-A, as enacted by PL 2009, c. 244, Pt. E, §3, is repealed.
Sec. A-15. 24-A MRSA §2849-B, sub-§3-B, as enacted by PL 2009, c. 244, Pt. E, §5, is repealed.
2. Limitation. An individual, group or blanket contract issued by an insurer may not impose a preexisting condition exclusion except as provided in this subsection. A preexisting condition exclusion may not exceed 12 months from the date of enrollment, including the waiting period, if any. For purposes of this subsection, "waiting period" includes any period between the time a substantially complete application for an individual or small group health plan is filed and the time the coverage takes effect. A preexisting condition exclusion may not be more restrictive than as follows. This subsection does not limit a carrier's ability to restrict enrollment in an individual contract to open enrollment and special enrollment periods in accordance with section 2736-C, subsection 11.
A. In a group contract, a preexisting condition exclusion may relate only to conditions for which medical advice, diagnosis, care or treatment was recommended or received during the 6-month period ending on the earlier of the date of enrollment in the contract and the date of enrollment in a prior contract covering the same group if there has not been a gap in coverage of greater than 90 days between contracts. An exclusion may not be imposed relating to pregnancy as a preexisting condition.
B. In an individual contract not subject to paragraph C, or in a blanket policy, a preexisting condition exclusion may relate only to conditions manifesting in symptoms that would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or for which medical advice, diagnosis, care or treatment was recommended or received during the 12 months immediately preceding the date of application or to a pregnancy existing on the effective date of coverage.
C. An individual policy issued on or after January 1, 1998 to a federally eligible individual as defined in section 2848 may not contain a preexisting condition exclusion.
D. A routine preventive screening or test yielding only negative results may not be considered to be diagnosis, care or treatment for the purposes of this subsection.
E. Genetic information may not be used as the basis for imposing a preexisting condition exclusion in the absence of a diagnosis of the condition relating to that information. For the purposes of this paragraph, "genetic information" has the same meaning as set forth in the Code of Federal Regulations.
F. Except for individual health plans in effect on March 23, 2010 that have grandfathered status under the federal Affordable Care Act, a carrier as defined in section 4301-A, subsection 3 offering a health plan as defined in section 4301-A, subsection 7 may not apply a preexisting condition exclusion to any enrollee under 19 years of age. A preexisting condition exclusion may not be imposed on any enrollee after January 1, 2014 to the extent prohibited by the federal Affordable Care Act.
I. In renewing an individual or small group policy in accordance with this section, a carrier may make minor modifications to the coverage, terms and conditions of the policy consistent with other applicable provisions of state and federal laws as long as the modifications meet the conditions specified in this paragraph and are applied uniformly to all policyholders of the same product. Modifications not meeting the requirements in this paragraph are considered a discontinuance of the product pursuant to paragraph G.
(1) A modification pursuant to this paragraph must be approved by the superintendent. The superintendent shall approve the modification if it meets the requirements of this section.
(2) A change in a requirement for eligibility is not a minor modification pursuant to this paragraph if the change results in the exclusion of a class or category of enrollees currently covered.
(3) Benefit modifications required by law are deemed minor modifications for purposes of this paragraph.
(4) Benefit modifications other than modifications required by law are minor modifications only if they meet the requirements of this subparagraph. For purposes of this subparagraph, changes in administrative conditions or requirements specified in the policy, such as preauthorization requirements, are not considered benefit modifications.
(a) The total of any increases in benefits may not increase the actuarial value of the total benefit package by more than 5%.
(b) The total of any decreases in benefits may not decrease the actuarial value of the total benefit package by more than 5%.
(c) For purposes of the calculations in divisions (a) and (b), increases and decreases must be considered separately and may not offset one another.
(5) A carrier must give 60 days' notice of any modification pursuant to this paragraph to all affected policyholders and certificate holders.
1. Dependent child; definition. As used in this section, "dependent child" means the child of a person covered under an individual or group health maintenance organization contract when that child: .
2. Offer of coverage. An individual or group health maintenance organization contract that offers coverage for a dependent child shall must offer such coverage, at the option of the contract holder parent, until the dependent child is 25 attains 26 years of age. An insurer may require, as a condition of eligibility for coverage in accordance with this section, that a person seeking coverage for a dependent child provide written documentation on an annual basis that the dependent child meets the requirements in subsection 1.
M. If the health plan is subject to the requirements of section 4318-A, a description of the incentives available to an enrollee and how to earn such incentives if enrolled in a health plan offering a comparable health care service incentive program designed pursuant to section 4318-A.
E. Health plans subject to the requirements of the federal Affordable Care Act must comply with federal claims and appeal requirements, including, but not limited to, the requirement that benefits for an ongoing course of treatment may not be reduced or terminated without advance notice and an opportunity for advance review, consistent with the requirements of the federal Affordable Care Act 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.
1-A. Access to clinically appropriate prescription drugs. For plan years beginning on or after the effective date of this subsection, a carrier must allow an enrollee, the enrollee's designee or the person who has issued a valid prescription for the enrollee to request and gain access to a clinically appropriate drug not otherwise covered by the health plan. The carrier's process must comply with section 4304 and with this subsection. If the carrier approves a request under this subsection for a drug not otherwise covered by the health plan, the carrier must treat the drug as an essential health benefit, including counting any cost sharing toward the plan's annual limit on cost sharing and including it when calculating the plan's actuarial value.
A. The carrier must determine whether it will cover the drug requested and notify the enrollee, the enrollee's designee, if applicable, and the person who has issued the valid prescription for the enrollee of its coverage decision within 2 business days following receipt of the request. A carrier that grants coverage under this paragraph must provide coverage of the drug for the duration of the prescription, including refills.
B. The carrier must have a process by which an expedited review may be requested in exigent circumstances. Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a nonformulary drug. When an expedited review has been requested, the carrier must determine whether it will cover the drug requested and notify the enrollee, the enrollee's designee, if applicable, and the person who has provided a valid prescription for the enrollee of its coverage decision within 24 hours following receipt of the request. A carrier that grants coverage under this paragraph must provide coverage of the drug for the duration of the exigency.
Sec. A-22. 24-A MRSA §4318, as amended by PL 2011, c. 364, §33, is repealed.
1. Rebates required. Carriers must provide rebates in the large group, small group and individual markets to the extent required by the federal Affordable Care Act and federal regulations adopted pursuant thereto if the medical loss ratio under subsection 2 is less than the minimum medical loss ratio under subsection 3.
B. The denominator is the total amount of premium revenue excluding federal and state taxes and licensing and regulatory fees paid and after accounting for payments or receipts for risk adjustment, risk corridors and reinsurance pursuant to federal law.
C. In the individual market, 80% or such lower minimum medical loss ratio as the Secretary of the United States Department of Health and Human Services determines based on a finding, pursuant to the federal Affordable Care Act and federal regulations adopted pursuant thereto, that an 80% minimum medical loss ratio might destabilize the individual market in this State.
4. Rules. The superintendent may adopt rules to implement this section in a substantially similar manner as required under the federal Affordable Care Act in effect as of January 1, 2019, including, but not limited to, rules establishing the period for which the medical loss ratio is calculated. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
A carrier offering a health plan in this State in the individual, small group or large group market must offer to an individual or group in the State all health plans that are approved for sale in the applicable market and must accept any individual or group that applies for any of those health plans in accordance with the requirements of section 2736-C, subsection 3 and section 2808-B, subsection 4 and section 2850-B.
2. Establish annual limits. Establish annual limits on the dollar value of essential benefits , except that, prior to January 1, 2014, health plans may include restricted annual limits on essential benefits consistent with the requirements of the federal Affordable Care Act and may establish annual limits consistent with waivers granted by the Secretary of the United States Department of Health and Human Services.
3. Application. This section applies to health plans offered or renewed in this State in the individual, small group and large group markets, as those markets are defined under applicable federal law. A health plan may contain annual dollar limits to the extent allowed under the federal Affordable Care Act as of January 1, 2019 if the plan has been continuously renewed since that date, but the plan may not impose any new limits or reduce any existing limit in effect as of January 1, 2019.
Notwithstanding any other requirements of this Title, a carrier offering a health plan subject to the requirements of the federal Affordable Care Act in this State shall, at a minimum, provide coverage that incorporates an essential health benefits and cost-sharing limitations package consistent with the requirements of the federal Affordable Care Act this section.
C. Provides for levels of coverage in accordance with subsection 4.
J. Pediatric services, including oral and vision care, to the extent required by the federal Affordable Care Act as of January 1, 2019.
3. Cost-sharing limitations. With respect to any health plan offered on or after the effective date of this subsection, a carrier shall limit cost sharing on an annual basis in a manner that is consistent with the annual limits established for a health plan subject to the federal Affordable Care Act as of January 1, 2019 and as adjusted by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, or, if the Centers for Medicare and Medicaid Services does not establish annual limits on cost sharing, the superintendent shall adopt rules establishing annual limits on cost sharing under this subsection that are calculated in substantially the same manner as the Centers for Medicare and Medicaid Services calculated the annual limit in the most recent year it calculated the annual limit.
4. Levels of coverage. Carriers shall offer coverage at levels that are substantially similar to the levels of coverage required for health plans subject to the federal Affordable Care Act as of January 1, 2019. The superintendent may adopt rules defining such levels of coverage. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
5. Rule of construction. This section may not be construed to prohibit a health plan from providing benefits in excess of the essential health benefits described in this section.
3. Applicability of section 4320-L. In addition to the requirements of this section, a carrier is subject to section 4320-L.
E. Otherwise deny or limit coverage, deny or limit coverage of a claim or impose additional cost sharing or other limitations or restrictions on coverage for specific health services related to gender transition if such denial, limitation or restriction results in discrimination against a transgender individual.
Nothing in this subsection is intended to determine or restrict a carrier from determining whether a particular health service is medically necessary or otherwise meets applicable coverage requirements in any individual case.
2. Meaningful access for individuals with limited English proficiency. A carrier shall take reasonable steps to provide meaningful access to each enrollee or prospective enrollee under a health plan who has limited proficiency in English.
3. Effective communication for persons with disabilities. A carrier shall take reasonable steps to ensure that communication with an enrollee or prospective enrollee in a health plan who is an individual with a disability is as effective as communication with other enrollees or prospective enrollees.
1. Coverage for treatment for certain mental illnesses. Coverage for medical treatment for mental illnesses listed in paragraph A A-1 by all individual policies is subject to this section.
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.
B. All individual policies and contracts executed, delivered, issued for delivery, continued or renewed in this State must make available provide coverage providing benefits that meet the requirements of this paragraph.
(1) The offer of coverage 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 individual policy.
Sec. D-2. 24-A MRSA §2843, sub-§5-A, as amended by PL 1989, c. 490, §4, is repealed.
6. Coverage for treatment of certain mental illnesses. Coverage for medical treatment for mental illnesses listed in paragraph A-1 is subject to this subsection.
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 health maintenance organization, 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.
(3) If benefits and coverage for the 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.
This subsection does not apply to policies, contracts or certificates covering employees of employers with 20 or fewer employees, whether the group policy is issued to the employer, to an association, to a multiple-employer trust or to another entity.
Sec. D-4. 24-A MRSA §4234-A, sub-§7, as amended by PL 2003, c. 20, Pt. VV, §21 and affected by §25, is repealed.
This amendment replaces the bill and is the majority report of the committee. The purpose of this amendment is to ensure that consumer protections related to health insurance coverage included in the federal Patient Protection and Affordable Care Act are codified in state law.
In Part A, the amendment does the following.
1. It makes clear that carriers in the individual, small group and large group markets must meet guaranteed issue requirements similar to those required by federal law.
2. It makes clear that individual and group health plans may not impose any preexisting condition exclusion on an enrollee. The amendment does permit a carrier to restrict enrollment in individual health plans to open enrollment and special enrollment periods established in rule.
3. It clarifies that carriers offering individual or group health plans may not establish lifetime or annual limits on the dollar value of benefits unless the plan is grandfathered under the federal Affordable Care Act as of January 1, 2019 and does not impose new limits or reduce existing limits. The amendment specifies that the provision prohibiting annual limits on the dollar value of benefits applies to the dollar value of essential health benefits.
4. It allows children, until they attain 26 years of age, to remain on their parents' health insurance policy.
5. It changes the maximum rate differential due to age that may be filed by the carrier to 3 to 1 and requires that rates that vary based on age do so according to a uniform age rating curve.
6. It provides that if a carrier varies premium rates based on family membership, the premium rate must equal the sum of the premiums for each individual in the family.
7. It prohibits a carrier from varying premium rates based on tobacco use for individuals who are enrolled in an evidence-based tobacco cessation program approved by the United States Department of Health and Human Services, Food and Drug Administration.
8. It makes clear that the minimum medical loss ratio in the individual market is 80% without exception.
9. It adds language to prohibit rescissions of coverage consistent with requirements under federal law.
10. It makes changes to the timelines and requirements for determinations by a carrier of coverage for prescription drugs consistent with federal law.
11. It requires carriers to provide information about the health plans offered by the carrier in a standardized manner that is substantially similar to the manner required for health plans subject to the federal Patient Protection and Affordable Care Act as of January 1, 2019.
12. It removes a provision of the bill that would have repealed the authority for certain individuals to purchase coverage under an individual, nonrenewable short-term policy.
13. It prohibits a health plan from reducing or terminating benefits for an ongoing course of treatment, including coverage of a prescription drug, during the course of an appeal of a determination of coverage.
Part B requires that, at a minimum, individual and small group health plans cover essential health benefits that are substantially similar to those benefits required for health plans subject to the federal Patient Protection and Affordable Care Act as of January 1, 2019. The amendment also requires that health plans meet annual limits on cost sharing that are substantially similar to those benefits required for health plans subject to the federal Patient Protection and Affordable Care Act as of January 1, 2019. The amendment removes provisions of the bill that authorized the Superintendent of Insurance to make changes to essential health benefits and cost sharing limits in rule. The amendment clarifies that pediatric dental benefits may not be required of all individual and small group plans if dental coverage is available in accordance with the federal Affordable Care Act as in effect as of January 1, 2019.
Part C adopts nondiscrimination provisions consistent with similar requirements in federal law and rule.
Part D makes changes to current requirements in state law related to mental health parity consistent with similar requirements in federal law and regulations.

References: §2736
 §4
 §2736
 §5
 §2808
 §3
 §2849
 §3
 §2849
 §5
 §4318
 §33
 §2843
 §4
 §4234
 §21
 §25