An Act To Provide Affordable Health Insurance to Small Businesses and Individuals and To Control Heal.~h Care Costs LR 2137(11)
Maine Legislature, Session 121, LD 1611
Committee Amendment CA_A-HA_B_H573 (House)
Amends: 24-A MRSA §2848, 24-A MRSA §2849-B, 24-A MRSA §2736-C, 24-A MRSA §420

HOUSE 
AMENDMENT "B" to COMMITTEE 
AMENDMENT 
"A" 
1187, 
L.D. 
1611, 
Bill, 
"An 
Act To 
Provide Affordable 
Insurance to Small Businesses and Individuals and To 
Health Care Costs" 
to H.P. 
Health 
Control 
Amend 
the 
amendment 
by 
striking out all 
of 
the first 
paragraph after the title. 
Further 
amend the amendment by striking out all of the 
emergency preamble (page 1, lines 27 to 49 and page 2, lines 1 
and 5 in amendment) 
Further amend the amendment on page 2, line 7 by striking 
out the following: 
"Further amend" and inserting in its place 
the following: 
'Amend' 
Further amend the amendment by striking out all of Parts A 
to H and inserting in their place the following: 
'PART A 
Sec. A·I. 24·A MRSA §2736·~, sub·§3, as corrected by RR 2001, 
c. 1, §30, is amended to read: 
3. 
Guaranteed issuance and guaranteed renewal. 
providing 
indi~idual 
health 
plans 
must 
meet 
the 
requirements on issuance and renewal. 
Carriers 
following 
A~--~~-~~6t-~-~~a~afi~eea--~-~~--~&ideB&&-~--tRi6 
S tate - etRe~ - ~4iafi- -t.~ ~ 
-.k-h<ru-t:- -p-aj<-inq--a--PFeffii-'ciHI-fe I' 
Meaieal'e-Pa£t-A'--~~-~~~-~~-~r-~~~Sr-eeyeF~e-~~st 
ge-~~~-~e--a-~~-~~~~--eemi-ei-~ee-~~~~~-e~i~i9~e 
iRaiyia~a~6T-~~~~~-4B-~~-6S4Sr-~~a~a~e6~-~~-tRe 
Page l-LR2l37(11) 
HOUSE AMENDMENT 
HOUSE 
AMENDMENT 
L. D. 1611 
.f; " to COMMITTEE 
AMENDMENT 
"A" to H.P. 1187, 
leB~~R-~~-~~~-~Rey-~-~-le~ally-~~~~-~~-~Ris 
S~a~eT--~~~-~-{eQeFallY-~~~~~-~~~~r-eeyeFa~e 
Beea--~&-~-~~-~e--aa--~~~~-~-~~~~~~-was 
~eFmiBa~es-fe£-£~paymeR~-~-~~~~-&~-~reyie~&-9± 
Qays--e£--~~--~~~-~---~a~a&~~~--mi&re~re&ea&a&iea--e{ 
ma~eFial-fae~-Q~£J£~-~~~~~~~~r-~a-a-maBa~eQ 
eaFe-p~aB7-~~-~~~~~~~~~r-¥~y~&-eever~e-a 
eaFFieF-may" 
~l+-~~Y&~-~e--~~-w&e-£eJ~£~--~~-BeF 
FesiQe-wi~RiB-~he-~~~~~~~~~~-&a&-~laa-{eF 
a~-leas~-9-meB~Rs-e{-eaeR-yeaFt-aBa 
~6+--~-eeyeFa~e-~~-iBQiyiQyals-~~--~Re-~~~~--Ras 
QemeBS~Fa~eQ-~e-~Re-Sy~eFin~eBQent~s-satis{aetien-tRat .. 
~a+---~-~~££J~--Qee&-~-haye--&a&-~~~-te 
Qe.iyeF---~~~---aQe~ya~ely---~~---aQQi~ienal 
eBFe.lees-~~~~~~-e£-~-Qe&~aa&eQ-pa£~-~-its 
6eFyiee--~~--geeaYSe--~---i~s--~~~~~--te 
eHi6tiB~-enFelleest-aBa 
~9+---~~-~rr~r--is--~~~-~~~--~FeyisieB 
yni{eFmly-~e-~~~~~~-~~-wi&~~&-Fe~aFQ 
te-anY-RealtR-FelateQ-'aeteFT 
A-€~£J~-~~~&~-eeyeFa~e-J£-~~~~&a-tRi6 
paFa!FapR-~-~--enFe •• --~~~~-~~~~-witRin 
~ae-~~-6¥~ee~-~-Q~i~~-~~-~~-er-~~-eF 
6Y9!F9ypS-~~~-~Ra~-~-fe£-~-pe£J~-e~-~~-Qays 
afteF-~ae-Qate-e{-tRe-{iF6t-Qenial-e{-eeyeFa~eT 
B. 
Renewal is guaranteed, pursuant to section 2850-B. 
bT---A--€~£J~--J~-~-~--&a&-~yaraa&eeQ--issyanee 
Fe~yiFemen~6--e~-~~~~~-~~~-~£~--~he--{ellewiB~ 
Fe~yiFements-aFe-metT 
~1+---~-~~~~--Qges-~-~~-eF-~~~r-~-Bew 
iBQiyiQyal-£~~~~~&-eF-~~~-~~-e~~&~Y&-Qa~e 
ef-tais-seetieBt 
~6+---~f-~&~--~~~~-~~~-~~-~£~~--we£e--Be~ 
issyeQ-~~-!ya£aR~eeQ-~~~-9a&i&-~£e-~~-eB 
eF-~~~--~eeemger-~~--~~~Jr-~J-~-pe~4e4e6-~-ge 
FeneweQ-~-&a&-ea££ie£-~-reaewal-~~~-~-~yaFan~eeQ 
a'teF-tae-,iFst-swea-FeRewal-Qatet-aBs 
~6+---~-~~~~--eemp~4e6--wi&A-~~-~~~~-pFaetiees 
Fe~yiFemeB~S-ef-6YBSeetieR-6T 
HOUSE AMENDMENT 
HOUSE 
AMENDMENT 
L.D. 1611 
to COMMITTEE 
AMENDMENT 
"A" to H. P. 1187, 
D. 
NetwitRstaBeiB~-~~~~r-eaFFieFS Carriers offering 
supplemental coverage for the Civilian 
Program 
for 
the 
Uniformed 
Services, 
required 
to 
issue 
this 
coverage 
if 
insurance does not have CHAMPUS coverage. 
Heal th and Medical 
CHAMPUS, 
are 
not 
the 
applicant 
for 
E. 
An individual may not be denied health insurance due to 
age or gender. 
Nothing in this subsection may be construed to require a carrier 
to market health insurance to individuals more than 65 years of 
~ 
Sec. A·2. 24·A MRSA §2736·C, sub·§9, as enacted by PL 1995, c. 
570, §7, is amended to read: 
9. 
Exemption for certain associations. 
The superintendent 
may exempt a group health insurance policy or group nonprofit 
hospital or medical service corporation contract issued to an 
association group, organized pursuant to section 2805-A, from the 
requirements 
of 
s\i.9Seeti9B--~ ... ---pa-~-aph---At 
subsection 
6, 
paragraph At and subsection 8 if: 
A. 
Issuance and renewal of coverage under the pOlicy or 
contract is guaranteed to all members of the association who 
are residents of this State and to their dependents; 
B. 
Rates for the association comply with the premi urn rate 
requirements 
of 
subsection 
or 
are 
established 
on 
a 
nationwide basis and substantially comply with the purposes 
of this section, except that exempted associations may be 
rated separately from the carrier's other individual health 
plans, if any; 
C. 
The 
group's 
anticipated 
loss 
ratio, 
as 
defined 
in 
subsection 5, is at least 75': 
D. 
The association's membership criteria do not include 
age, health status, medical utilization history or any other 
factor wi~h a similar purpose or effect; 
E. 
The association's group heal th plan is not marketed to 
the general pUblic: 
F. 
The 
association does 
not 
allow insurance 
agents 
or 
brokers 
to 
market 
association 
memberships, 
accept 
applications for memberships or enroll members, except when 
the association is an association of insurance agents or 
brokers organized under section 2805-A; 
HOUSE AMENDMENT 
~ 
1it 
~ 
HOUSE 
AMENDMENT ,8" to COMMITTEE 
AMENDMENT 
"A" to H.P. 
L.D. 1611 
1187, 
G. 
Insurance is provided 
as 
an 
incidental benefit of 
association membership 
and 
the 
primary purposes 
of 
the 
association do not include group buying or mass marketing of 
insurance or other goods and services: and 
H. 
Granting 
an 
exemption 
to 
the 
association does 
not 
conflict with the purposes of this section. 
Sec. A-3. 24-A MRSA §2848, sub-§l-B, fA, as amended by PL 
1999, c. 256, Pt. L, §2, is further amended to read: 
A. 
"Federally creditable coverage" means health benefits or 
coverage provided under any of the following: 
(1) 
An employee welfare benefit plan as defined in 
Section 3(1) of the federal Employee Retirement Income 
Security Act of 1974, 29 United States Code, 'Section 
1001, 
or a 
plan that would be 
an employee welfare 
benefit 
plan 
but 
for 
the 
"goverrunenta1 
plan" 
or 
"nonelecting 
church 
plan" 
exceptions, 
if 
the 
plan 
provides medical care as defined in subsection 2-A, and 
includes items and services paid for as medical care 
directly 
or 
through 
insurance, 
reimbursement 
or 
otherwise: 
(2) 
Benefits 
consisting 
of 
medical 
care 
provided 
directly, 
through 
insurance 
or 
reimbursement 
and 
including items and services paid for as medical care 
under a policy, contract or certificate offered by a 
carrier; 
(3) 
Part A or Part B of Title XVIII of the Social 
Security Act, Medicare: 
(4) 
Title XIX of the Social Security Act, Medicaid, 
other than coverage consisting solely of benefits under 
Section 1928 of the Social Security Act or a state 
children's health insurance program under Title XXI of 
the Social Security Act: 
(5) 
The Civilian Health and Medical Program for the 
Uniformed Services, 
CHAMPUS, 
United States Code, 
Chapter 55; 
(6) 
A medical 
care program of 
the federal 
Indian 
Health Care 
Improvement Act, 
United States Code, 
Section 1601 or of a tribal organization; 
(7) 
A state health benefits risk pool; 
HOUSE AMENDMENT 
ffJ) 
r~ ... _ 
HOUSE 
AMENDMENT "8,, to COMMITTEE 
AMENDMENT "A" to H.P. 
L.D. 1611 
1187, 
(8) 
A health plan offered under the federal Employees 
Health Benefits Amendments Act, 
United States Code, 
Chapter 89; 
(9) 
A 
public 
health 
regulations authorized 
Service 
Act, 
Section 
Public Law 104-191; 
e~ 
plan 
as 
defined 
in 
federal 
by the federal 
Public Health 
2701(c)(1)(I), 
as 
amended 
by 
(10) 
A health benefit plan under Section 5(e) of the 
Peace 
Corps 
Act, 
United 
States 
Code, 
Section 
2504(e)~.L...Q.1: 
( 11) 
Insurance coverage offered by the Comprehensive 
Health 
Insurance 
Risk 
Pool 
Association pursuant 
to 
chapter 54. 
Sec. A-4. 24-A MRSA §2849-B, sub-§2, ,A, as amended by PL 
2001, c. 258, Pt. E, §7, is further amended to read: 
A. 
That person was covered under aH-~~~~~-eF g group 
contract or policy issued by 
any nonprofit hospital or 
medical service organization, insurerr QI health maintenance 
organization, or was 
covered under 
an uninsured employee 
benefit plan that provides 
payment 
for 
health 
services 
received by employees and their dependents or a governmental 
program, 
including, 
but not limited to, 
those listed in 
section 2848, subsection I-B, paragraph A, subparagraphs (3) 
to (10). 
For purposes of this section, the individual or 
group policy under which the person is seeking coverage is 
the "succeeding policy." 
The group 
e~--i-n4i¥-iEiQal contract 
or policy, uninsured employee benefit plan or governmental 
program that previously covered the person is the "prior 
contract or policy"; and 
Sec. A·5. 24·A MRSA c. 54 is enacted to read: 
CHAPTER 54 
Coo>Rpq;NSlVE HEALTH INSURANCE RISIC pooL ASSOCIATION 
§390l. 
Short title 
This 
chapter 
may 
be 
cited as 
"the Comprehensive Health 
Insurance Risk Pool Association Act." 
§3902. 
Purpose 
It is the purpose of this chapter to establish a mechanism 
to spread among all insurers doing business in this State the 
HOUSE AMENDMENT 
0tS 
.~ 
~ 
HOUSE 
AMENDMENT ·8" to COMMITTEE 
AMENDMENT 
"A" to H.P. 1187, 
L.D. 1611 
cost of providing health and accident insurance coverage to those 
residents of this State who because of health conditions consume 
unusually 
large 
amounts 
of 
health 
care 
and 
to 
ensure 
a 
competitive insurance market. 
§3903. 
Definitions 
As 
used 
in this 
chapter, 
unless 
the 
context 
otherwise 
indicates, the following terms have the following meanings. 
1. Association. "Association" means the Comprehensive Health 
Insurance Risk Pool Association established in section 3904. 
2. 
Board. 
"Board" 
means 
the board of directors of the 
association. 
3. 
Covered person. 
"Covered person" means any individual 
resident of this State, not including dependents, who; 
A. Is eligible to receive benefits from any insurer: 
B. 
Is eligible 
for 
benefits 
under 
the 
federal 
Health 
Insurance Portability and Accountability Act of 1996; or 
C. 
Has 
been 
certified 
as 
eligible 
for 
federal 
trade 
adjustment 
assistance 
or 
for 
pension 
benefit 
guarantee 
corporation assistance, 
as provided by the federal Trade 
Adjustment Assistance Reform Act of 2002. 
4. 
Dependent. 
"Dependent" 
means 
a 
resident 
spouse 
or 
resident unmarried child under 19 years of age or a child who is 
a student under 23 years of age and who is financially dependent 
upon the parent or 
a 
child of any age 
who is disabled and 
dependent upon the parent. 
5. 
Health maintenance organization. 
"Health maintenance 
Qrganization" means any organization authorized under chapter 56 
to operate a health maintenance organization in this State. 
6. 
Insurer. 
"Insurer" means any entity that is authorized 
to write medical insurance or that provides medical insurance in 
this State. For the purposes of this chapter, "insurer" includes 
an 
insurance 
company, 
nonprofit hospital 
and medical 
service 
organization. 
fraternal 
benefit 
society, 
health 
maintenance 
organization, 
self-insurance 
arrangement 
that provides 
health 
care benefits in this State to the extent allowed under the 
federal 
Employee 
Retirement 
Income 
Security 
Act 
of 
1974, 
3rd-party administrator, multiple-employer welfare arrangement, 
any other entity providing medical insurance or health benefits 
HOUSE AMENDMENT 
t~ 
"."4f 
".,.;, 
ttf.!;. -
HOUSE 
AMENDMENT "8,, to COMMITTEE 
AMENDMENT 
"A" to H.P. 
1187, 
L.D. 1611 
subject 
to 
state 
insurance 
regulation 
and 
any 
reinsurer 
reinsuring health insurance in this State. 
7. 
Medical 
insurance. 
"Medical 
insurance" 
means 
any 
hospital and medical expense-incurred policy, nonprofit hospital 
and 
medical 
service 
plan, 
health 
maintenance 
organization 
subscriber contract or other health care plan or arrangement that 
pays for or furnishes medical or health care services whether by 
insurance or otherwise, whether sold as an individual or group 
policy. "Medical insurance" does not include accidental injury, 
specified disease, hospital indemnity, dental, vision, disability 
income, long term care or other limited benefit health insurance 
or credit insurance or Medicare supplement insurance: coverage 
issued as a supplement to liability insurance: insurance ar1s1ng 
out of 
workers' compensation or similar law: automobile medical 
payment insurance or insurance under which benefits are payable 
with or without regard to fault and that is statutorily required 
to be contained in any liability insurance policy or equivalent 
self -insurance. 
8. 
Medicare. 
"Medicare" means coverage under both Parts A 
and B of Title XVIII of the federal Social Security Act, 
United States Code, Section 1395 et seq., as amended. 
9. 
Plan. "Plan" means the health insurance plan adopted by 
the board pursuant to this chapter. 
10. 
Producer. 
"Producer" means a person who is licensed to 
sell health insurance in this State. 
11. 
Resident. 
"Resident" means an individual who; 
A. 
Is legally located in the United States and has been 
legally domiciled in this State for a period not to exceed 
one year to be established by the board and subject to the 
approval of the superintendent: 
B. 
Is legally domiciled in this State on the date of 
application to the plan and is eligible for enrollment in 
the risk pool under this chapter as a result of the federal 
Health Insurance Portability and Accountability Act of 1996: 
Q.l: 
C. 
Is legally domiciled in this State on the date of 
application to the plan and has been certified as eligible 
for 
federal 
trade 
adjustment 
assistance 
or 
for 
pension 
benefit guarantee corporation assistance, as provided by the 
federal Trade Adjustment Assistance Reform Act of 2002. 
HOUSE AMENDMENT 
~ 
-..:...-
G<;. 
~ 
HOUSE 
AMENDMENT "8,, to COMMITTEE 
AMENDMENT 
"A" to H.P. 
L.D. 1611 
1187, 
12. 
Reinsurer. 
"Reinsurer" means any insurer from whom any 
person providing health insurance for any Maine resident procures 
insurance for itself with the insurer with respect to all or part 
of 
the 
medical 
insurance 
risk 
of 
the 
person. 
"Reinsurer" 
includes 
an 
insurer 
that 
provides 
employee 
benefits 
excess 
insurance. 
l3. 
Third-party administrator. 
"Third-party administrator" 
means any entity that is paying or processing medical insurance 
claims for any resident. 
§3904. 
Comprehensive Health Insurance Risk Pool AssociatioD 
1. 
Risk 
pool 
established. 
The 
Comprehensive 
Health 
Insurance Risk Pool Association is established as 
a 
nonprofit 
legal entity. 
As 
a condition of doing business, eyery insurer 
that has sold medical insurance within the previous 12 months or 
is actiyely marketing a medical insurance policy in this State 
must participate in the association. 
2. 
Board of directors. 
The association is governed by a 
hQard of directors in accordance with the following. 
A. 
The board consists of 9 members appointed as follows: 
(l) 
Four members appointed by the superintendent. of 
whom 2 members must be chosen from the general public 
and may not be associated with the medical profession, 
a hospital or an insurer: one member must represent 
medical providers: and one member must represent health 
insurance producers. 
Any board member appointed by the 
superintendent may be remoyed at any time without cause: 
(2) 
Three members appointed by the member insurers. at 
least 2 of whom are domestic insurers: and 
(3) 
Two Legislators who serye as the Senate and House 
chairs 
of 
the 
joint 
standing 
committee 
of 
the 
Legislature having jurisdiction oyer health insurance 
matters, or the Legislators' designees. 
who serye as 
nonyoting, ex officio members of the board. 
B. 
Of 
those 
members 
of 
the 
board 
appointed 
by 
the 
superintendent. one member shall serye for 
a 
term of one 
year, 2 members for a term of 2 years and one member for a 
term of 3 years. 
Of those members appointed by the member 
insurers. one member shall serve for a term of one year. one 
member shall serve for a 
term of 2 years and one member 
shall serye for a term of 3 years. 
The appointing authority 
shall 
designate 
the 
period 
of 
seryice 
of 
each 
initial 
HOUSE AMENDMENT 
~i;:; 
'':.1 
~~ 
HOUSE 
AMENDMENT 
.. 8.. to COMMITTEE AMENDMENT "A" to H. P. 
L.D. 1611 
1187, 
appointee at the time of appointment. All terms after the 
initial terms must be for 3 years. 
C. 
The board shall elect one of its members as chair. 
D. 
Board members 
may 
be 
reimbursed 
from 
funds 
of the 
association for actual and necessary expenses incurred by 
them as members but may not otherwise be compensated for 
their services. 
3. 
Plan of operation. 
The association shall adopt a plan 
of operation in accordance with the reguirements of this chapter 
and submit its articles. 
bylaws 
and operating rules to the 
superintendent for approval. 
If the association fails to adopt 
the plan of operation and suitable articles and bylaws within 90 
days after the appointment of the board, the superintendent shall 
adopt rules to effectuate the requirements of this chapter and 
those rules remain in effect until superseded by a 
plan of 
operation and articles and bylaws submitted by the association 
and approved by the superintendent. 
Rules adopted pursuant to 
this subsection by the superintendent are routine technical rules 
as defined in Title 5, chapter 375, subchapter 2-11.. 
4. 
Immunity. 
A board member is not liable and is immune 
from suit at law or eguity for any conduct performed in good 
faith that is within the subject matter over which the board has 
been given jurisdiction. 
§3905. 
Liability and indemnification 
1. 
Liability. 
The board and its employees may not be held 
liable for any obligations of the association. 
A cause of action 
may not arise against the association; the board, its agents or 
its employees i 
any member insurer or its agents. employees or 
producers i or the superintendent for any action or omission in 
the performance of powers and duties pursuant to this chapter. 
Z. 
Indemnjfication. 
The board may provide in its bylaws or 
rules for indemnification of, and legal representation for, its 
members and employees. 
§3906. 
Duties and powers of association 
1. 
Duties. 
The association shall; 
A. 
Establish administrative and accounting procedures for 
the operation of the association; 
HOUSE AMENDMENT 
v:;. 
0.'-
Q 
~ 
HOUSE 
AMENDMENT "t:>" to COMMITTEE 
AMENDMENT 
"A" to H.P. 1187, 
L.D. 1611 
B. 
Establish 
procedures 
under 
which 
applicants 
and 
participants in the plan may have grievances reviewed by an 
impartial body and reported to the board; 
C. 
Select a plan administrator in accordance with section 
.l.2.QlL 
D. 
Collect the assessments provided in section 3908. 
The 
level 
of 
payments 
must 
be 
established 
by 
the 
board. 
Assessments 
must 
be 
collected pursuant 
to 
the 
plan of 
operation 
approved 
by 
the 
board. 
In 
addition 
to 
the 
collection 
of 
such 
assessments« 
the 
association 
shall 
collect an organizational assessment or assessments from all 
insurers as necessary to provide for expenses that have been 
incurred or are estimated to be incurred prior to receipt of 
the 
first 
calendar 
year 
assessments. 
Organizational 
assessments must be equal in amount for all insurers but may 
not 
exceed 
$500 
per 
insurer 
for 
all 
such 
assessments. 
Assessments are due and payable within 30 days of receipt of 
the assessment notice by the insurer; 
E. 
Require that all policy forms issued by the association 
conform to standard forms developed by the association. 
The 
forms must be approved by the superintendent.and must comply 
with this Title; and 
F. 
Develop 
and 
implement 
a 
program 
to 
publicize 
the 
existence of the plan, the eligibility requirements for the 
plan and the procedures for enrollment in the plan and to 
maintain public awareness of the plan. 
2. 
Povers. The association may; 
A. 
Exercise powers granted to insurers under the laws of 
this State; 
B. 
Enter into contracts as necessary or proper to carry out 
the provisions and purposes of this chapter, including the 
authority, with the approval of the superintendent, to enter 
into contracts with similar organizations of other states 
for the joint performance of common administrative functions 
or with persons or other organizations for the performance 
of administrative functions; 
C. 
Sue or 
be 
sued, 
including taking any 
legal actions 
necessary or proper to recover or collect assessments due 
the association; 
D. 
Take any legal actions necessary to avoid the payment of 
improper 
claims 
against the association or 
the 
coverage 
HOUSE AMENDMENT 
HOUSE 
AMENDMENT 
• .,e;.. to COMMITTEE 
AMENDMENT "A" to H. P. 
L.D. 1611 
1187 « 
provided by or 
through the association, 
to 
recover 
any 
amounts erroneously or improperly paid by the association, 
to recover any amounts paid by the association as a result 
of mistake of fact or law or to recover other amounts due 
the association; 
E. 
Establish, and modify from time to time as appropriate, 
rates, rate schedules, rate adjustments, eXBense allowances, 
producers' 
referral fees, 
claim reserve formulas and any 
other actuarial function appropriate to the operation of the 
association in accordance with section 3910; 
F. 
Issue policies of insurance in accordance with the 
requirements of this chapter; 
G. 
Appoint 
appropriate 
legal, 
actuarial 
and 
other 
couunittees as necessary to provide technical assistance in 
the operation of the plan, policy and other contract design 
and 
any 
other 
function 
within 
the 
authority 
of 
the 
association; 
H. 
Borrow money to effect the purposes of the association. 
Any 
notes 
or 
other 
evidence 
of 
indebtedness 
of 
the 
association not in default must be legal investments for 
insurers and may be carried as admitted assets; 
I, 
Establish 
rules, 
conditions 
and 
procedures 
for 
reinsuring risks of member insurers desiring to issue plan 
coverage to individuals otherwise eligible for plan coverage 
in their own names; 
J. 
Prepare and distribute application forms and enrollment 
instruction forms to insurance producers and to the general 
public; 
K. 
Provide 
for 
reinsuranCe 
of 
risks 
incurred 
by 
the 
association. The provision of reinsurance may 
not subject 
the 
association 
to 
any 
of 
the 
capital 
or 
surplus 
requirements, if any, otherwise·applicable to reinsurers; 
L. 
Issue additional types of health insurance policies to 
provide 
optional 
coverage, 
including Medicare 
supplement 
health insurance; 
M. 
Provide for 
and employ cost-containment measures and 
requirements, 
including. but not limited to, preadmission 
screening, 
2nd 
surgical 
opinion, 
concurrent 
utilization 
review and individual case management for the purpose of 
making the benefit plan more cost-effective; 
HOUSE AMENDMENT 
(~i; 
f.-' 
41:"" 
~ 
HOUSE 
AMENDMENT ·8" to COMMITTEE 
AMENDMENT 
"A" to H.P. 1187, 
L.D. 1611 
N. 
Design, utilize, contract or otherwise arrange for the 
delivery of cost-effective health care services, including 
establishing 
or 
contracting 
with 
preferred 
provider 
organizations, 
health maintenance organizations 
and other 
limited network provider arrangements; and 
O. 
Apply 
for 
funds 
or 
grants 
from 
public 
or priyate 
sources, 
including federal 
grants 
provideC!, 
to 
qualified 
high-risk pools. 
3. 
Additional duties and powers. 
The supe r intendent may, 
by rule, establish additional powers and duties of the board and 
may adopt such rules as are necessary and proper to implement 
this chapter. 
Rules 
adopted pursuant to this subsection are 
routine technical rules as defined in .Title 5, 
chapter 375, 
subchapter 2-11.. 
4. 
Reyiew for solvency. 
The superintendent shall reyiew 
the 
association 
at 
least 
every 
years 
to 
determine 
its 
solyency. 
If the superintendent determines that the funds of the 
association are insufficient to support enrollment of additional 
persons, the superintendent may order the association to increase 
its 
assessment 
or 
increase 
its 
premium 
rates. 
If 
the 
superintendent determines that the funds of the association are 
insufficient to support the enrollment of additional persons and 
that the cap of assessments in section 3908 is too low to support 
the enrollment of 
additional persons, 
the 
superintendent may 
order the association to charge an assessment in excess of the 
cap for a period not to exceed 12 months. 
5. 
Annual report. 
The association shall report annually to 
the 
joint 
standing 
committee 
of 
the 
Legislature 
haying 
jurisdiction over health insurance matters by March 15th. 
The 
report 
must 
include 
information 
on 
the 
benefits 
and 
rate 
structure of coverage offered by the association, the financial 
solvency of the association and the administratiye expenses of 
the plan. 
6. 
Audit. 
The association must be audited at least every 3 
years. A copy of the audit must be provided to the superintendent 
and to the joint standing committee of the Legislature having 
jurisdiction over health insurance matters. 
§3907. 
Selection of plan administrator 
1. 
Selection of p~an administrator. 
The board shall select 
an insurer or 
3rd-party administrator, 
through 
a 
competitive 
bidding 
process, 
to 
administer 
the 
plan. 
The 
board 
shall 
eyaluate bids submitted under this subsection based on criteria 
established by the board, including; 
HOUSE AMENDMENT 
<t:) 
....... 
,0 
1:; 
HOUSE 
AMENDMENT ,[3" to COMMITTEE 
AMENDMENT 
"A" to H.P. 
L.D. 1611 
1187, 
A. 
The 
insurer's proven ability to handle 
large group 
accident and health insurance; 
B. 
The 
efficiency 
of 
the 
insurer's 
claims-paying 
procedures; and 
C. 
An estimate of total charges for administering the plan. 
2. 
Contract 
~ith 
plan 
administrator. 
The 
plan 
administrator selected pursuant to subsection 1 
serves for 
a 
period of 3 years. 
At least one year prior to the expiration of 
each 3-year period of service by a plan administrator, the board 
shall invite all insurers, including the current administering 
insurer. to submit bids to serve as the plan administrator for 
the 
succeeding 
3-year 
period. 
The 
selection 
of 
the 
plan 
administrator for the succeeding period must be made at least 6 
months prior to the ending of the 3-year period. 
3. 
Duties of plan administrator. 
The plan administrator 
selected pursuant to subsection 1 shall: 
A. 
Perform 
all 
eligibility 
and 
administrative 
claims-payment functions relating to the plan: 
5. 
Pay a producer's referral fee as established by the 
board to each insurance producer who refers an applicant to 
the plan, if the applicant's application is accepted. 
The 
selling or marketing of the plan is not limited to the plan 
administrator 
or 
its producers. 
The 
plan 
administrator 
shall pay the referral fees from funds received as premiums 
for the plan; 
C. 
Establish a premium billing procedure for collection of 
~iums from 
insured 
persons. 
Billings 
must 
be 
made 
periodically as determined by the board; 
Dr 
Perform all necessary functions to ensure timely payment 
of benefits to covered persons under the plan, including: 
(1) 
Making 
available 
information 
relating 
to 
the 
proper manner of submitting a claim for benefits under 
the plan and distributing forms upon which submissions 
must be made; 
(2) 
Evaluating 
the eligibility of 
each 
claim 
for 
payment under the plan: and 
(3) 
Notifying 
each 
claimant within 
days 
after 
receiving a properly completed and executed proof of 
HOUSE AMENDMENT 
HOUSE 
AMENDMENT ,,8.. to COMMITTEE 
AMENDMENT 
"A" to H. P. 
L.D. 1611 
1187, 
loss 
whether 
the 
claim 
is 
accepted, 
rejected 
or 
compromised. 
The 
board 
shall 
establish 
reasonable 
reimbursement amounts for any services covered under 
the benefit plans; 
E. 
Submit 
regular 
reports 
to 
the 
board 
regarding 
the 
operation of the plan. 
The freguency, content and form of 
the reports must be as determined by the board; 
F. 
Following the close of each calendar year, determine net 
premiums. 
reinsurance premiums less administrative expense 
allowance, the expense of administration pertaining to the 
reinsurance operations of the association and the incurred 
losses of 
the year 
and 
report this 
information to 
the 
superintendent; and 
G. 
Pay claims expenses from the premium payments received 
from or on behalf of covered persons under the plan. 
If the 
payments 
by 
the 
plan administrator 
for 
claims 
expenses 
exceed the portion of premiums allocated by the board for 
payment of claims expenses, the board shall provide the plan 
administrator with additional funds for payment of claims 
expenses. 
4. 
Pa.yment to pIg administrator. 
The plan administrator 
selected pursuant to subsection 1 must be paid, as provided in 
the contract of the association, for its direct and indirect 
expenses incurred in the performance of its services. As used in 
this subsection. "direct and indirect expenses" includes that 
portion of the audited administrative costs, printing expenses, 
claims 
administration 
expenses. 
management 
expenses, 
building 
overhead expenses and other actual operating and administrative 
expenses of the plan administrator that are approved by the board 
as allocable to the administration of the plan and included in 
the bid specifications. 
S3908. 
AsseSsments against insurers 
1. 
Assessments. 
For the purpose of providing the funds 
necessary to carry out the powers and duties of the association, 
the board shell assess member insurers at such a time and for 
such Mounts as the board finds necessary. 
Assessments must be 
due not less than 30 days after written notice to the member 
insurers and must accrue interest at 12'\ per annum on and after 
the due date. 
2. 
Maximum assessment. 
Each insurer must be assessed an 
Mount not to exceed $2 per covered person insured or reinsured 
by 
each 
insurer per month 
for 
medical 
insurance. 
A member 
HOUSE AMENDMENT 
~,,,-~ 
f.,t;. ~J, 
~ 
..;;-.. 
rt: 
HOUSE 
AMENDMENT ,8" to COMMITTEE 
AMENDMENT 
"A" to H.P. 1187, 
L.D. 1611 
insurer may not be assessed on policies or contracts insuring 
federal or state employees. 
3. 
Determination of assessment. 
The 
board 
shall 
make 
reasonable efforts to ensure that each covered person is counted 
only once with respect to any assessment. 
For that purpose, the 
board shall reguire each insurer that obtains excess or stop loss 
insurance 
to 
include 
~n its 
count 
of 
covered 
persons 
all 
individuals whose 
coverage is insured, 
in whole or in part, 
through excess or stop loss coverage. 
The board shall allow a 
reinsurer to exclude from its number of covered persons those who 
have 
been counted by the primary insurer or by the primary 
reinsurer or primary excess or stop loss insurer for the purpose 
of determining its assessment under this subsection. The board 
may verify each insurer' s assessment based on annual statements 
and other reports determined to be necesSary by the board. 
The 
board may use any reasonable method of estimating the number of 
covered persons of an insurer if the specific number is unknown. 
4. 
Excess funds. 
If assessments and other receipts by the 
association, board or plan administrator exceed the actual losses 
and administrative expenses of the plan, the board shall hold the 
excess as interest and may 
use those excess funds 
to offset 
future 
losses or to 
reduce 
plan premiums. 
As 
used in this 
subsection, "future losses" includes reserves for claims incurred 
but not reported. 
5. 
Failure to pay assessment. 
The 
superintendent 
may 
suspend or revoke, after notice and hearing, the certificate of 
authority to transact insurance in this State of 
any member 
insurer that fails to pay an assessment. 
As an alternative, the 
superintendent may levy a penalty on any member insurer that 
fai 1 s 
to 
pay 
an 
as ses sment 
when 
due. 
In 
addition, 
the 
superintendent may use any power granted to the superintendent by 
this Title to collect any unpaid assessment. 
§3909. 
Ayailability of coverage 
The association shall offer a choice of 2 or more coverage 
options through the plan. The reguirements of this plan become 
effective 
October 
1, 
2003. 
Policies 
offered 
through 
the 
association must be available for sale February 1, 
2004. 
The 
association shall directly insure the coverage provided by the 
plan, 
and 
the 
policies 
must 
be 
issued 
through 
the 
plan 
administrator. 
S3910. 
Requirements for coverage 
1. 
CoVerage offered. 
The plan must offer in an annually 
renewable policy the coverage specified in this section for each 
HOUSE AMENDMENT 
~ 
"-
~;.) 
.,.. ': 
.. !-"W 
HOUSE 
AMENDMENT 
.. B 
.. 
to COMMI TTEE 
AMENDMENT 
"A" 
L.D. 1611 
to H.P. 1187, 
eligible person. 
If en eligible person is also eligible for 
Medicare coverage, the plan may not payor reimburse any person 
for expenses paid by Medicare. 
Any person whose health insurance 
coverage is involuntarily terminated for any reason other than 
nonpayment of premium ma::r- apply for coverage under the plan. 
If 
such coverage is applied for within 90 days after the involuntary 
termination and if premiums are paid for the entire period of 
coverage, 
the effective date of the coverage is the date of 
termination of the previQus coverage. 
2. 
Major medical 'expense coverage. 
The plan must offer 
major medical expense coverage to every eligible person who is 
not eligible for Medicare. 
The coverage to be issued by the 
plan, 
its 
schedule 
of 
benefits 
and 
exclusions 
and 
other 
limitations must be established by the board and may be amended 
from time to time subject to the approval of the superintendent. 
In establishing the plan coverage, 
the board shall take into 
consideration the levels of health insurance provided in the 
State and medical economic factors as determined appropriate. 
3. 
Rates. 
Rates 
~or coverage issued by the association 
must meet the reguirements of this subsection. 
A. 
Rates 
may 
no: 
be 
unreasonable 
in 
relation 
to 
the 
benefits provided, 
the risk experience and the reasonable 
expenses of providing the coverage. 
B. 
Rate schedules must comply with section 2736-C and are 
subject to approval by the superintendent. 
C. 
Standard 
risk 
rates 
for 
coverage 
issued 
by 
the 
association must be established by the association, subject 
to 
approval 
by 
the 
superintendent, 
using 
reasonable 
actuarial 
technigues 
and 
must 
reflect 
anticipated 
experiences 
and 
expenses 
of 
such 
coverage 
for 
standard 
risks. The premium for the' standard risk rates must range 
from a minimum of l25~ to a maximum of 
150~ of the weighted 
average 
of 
rates 
charged 
by 
those 
insurers 
and 
health 
maintenance' 
organizations 
with 
individuals 
enrolled 
in 
similar medical insurance plans. 
4. 
Compliance 
wi~~ state law. 
Products offered by the 
association must comply -..-:th the provisions of this Title that 
apply to similar insurance products. 
5. 
Other sources p:-i~ary. 
The association must be payer of 
last resort of benefits whenever any other benefit or source of 
3rd-party payment is a'nilable. 
The coverage provided by the 
association must 
be 
con3idered excess 
coverage, 
and benefits 
otherwise payable under association coverage must be reduced by 
HOUSE AMENDMENT 
~ 
~ 
ft·.>! 
HOUSE 
AMENDMENT "8,, to COMMITTEE 
AMENDMENT 
"A" to H.P. 
L.D. 1611 
1187, 
all amounts paid or payable through any other health insurance 
and by all hospital and medical expense benefits paid or payable 
under any short term, accident. dental only, vision-only, fixed 
indemnity, limited benefit or credit insurance; coverage issued 
as 
a 
supplement to liability insurance; workers' 
compensation 
coverage; 
automobile 
medical 
payment; 
or 
liability insurance 
whether or not proVided 
on the basis of fault, 
and by 
any 
hospital or medical benefits paid or payable by. any insurer or 
insurance arrangement or any hospital or medical benefits paid or 
payable under or provided pursuant to any state or federal law or 
program. 
6. 
Recover:y of claims paid. 
An amount paid or payable by 
Medicare 
or 
any 
other 
governmental 
program 
or 
any 
other 
insurance, 
or self-insurance maintained in lieu of otherwise 
statutorily required insurance, may not be made or recognized as 
claims 
under 
such 
a 
policy or 
be 
recognized as 
or 
towards 
satisfaction of applicable deductibles or out-of-pocket maximums 
or to reduce the limits of benefits available. 
The association 
has a cause of action against a participant for the recovery of 
the amount of any benefits paid to the participant that should 
not have been claimed or recognized as claims because of the 
prov~s~ons of 
this 
subsection 
or 
because 
the 
benefits 
are 
otherwise not covered. 
Benefits due from the association may be 
reduced or refused as a setoff against any amount recoverable 
under this Subsection. 
§3911. 
Eligibility for cgyerage 
1. 
Eligibility; aDplication for coverage. 
An individual 
who is and continues to be a resident is eligible for coverage 
under 
the 
plan if evidence 
is 
provided 
of 
rejection, 
a 
requirement 
of 
restrictive 
riders, 
a 
rate 
increase 
or 
a 
preexisting conditions limitation on a qualified plan, the effect 
of which is to substantially reduce coverage from that received 
by 
a 
person 
considered 
a 
standard 
risk 
by 
at ·least 
one 
association 
member 
within 
months 
of 
the 
date 
of 
the 
certificate. 
or 
if 
the 
individual 
meets 
other 
eligibility 
requirements adopted by :-ule by the superintendent that are not 
inconsistent with this chapter and that evidence that a person is 
unable to obtain coverage substantially similar to that which may 
be obtained by a person ,.,no is considered a standard risk. 
Rules 
adopted pursuant to this subsection are routine technical rules 
as defined in Title 5, chapter 375, subchapter 2 A. 
2. 
Change of domic:.le. 
The board shall develop standards 
for eligibility for coverage by the association for any natural 
person who changes that person' s domicile to this State and who 
at the time domicile is established in this State is insured by 
an organization similar 70 the association. 
The eligible maximum 
HOUSE AMENDMENT 
HOUSE 
AMENDMENT 
.. e.. to COMMITTEE 
AMENDMENT 
.. A" to H. P . 
L.D. 1611 
1187, 
lifetime benefits for that covered person may not exceed the 
lifetime benefits available through the association, 
less any 
benefits 
received 
from 
a 
similar organization in the 
former 
domiciliary state. 
3. 
Eligibility.,..; thout 
application. 
The 
board 
shall 
develop a list of medical or health conditions for which a person 
is 
eligible 
for 
plan 
coverage 
without 
apply~ng for 
health 
insurance under subsection 1. 
A person who can demonstrate the 
existence or history of any medical or health conditions on the 
list developed by the board may not be reguired to provide the 
evidence specified in subsection 1. The board may amend the list 
from time to time as appropriate. 
•• 
Exclusions from eligibility. 
A person is not eligible 
for coverage under the plan if: 
A. 
The person has or obtains health insurance coverage 
substantially similar to or more comprehensive than ·a plan 
policy or would be eligible to have coverage if the person 
elected to obtain it, except that: 
(1) 
A person 
may maintain other 
coverage 
for 
the 
period of time the person is satisfying a preexisting 
condition waiting period under a plan policy: and 
(2) 
A person may maintain plan coverage for the period 
of 
time 
the 
person 
is 
satisfying 
a 
preexisting 
condition waiting period under another health insurance 
policy intended to replace the plan policy; 
B. 
The 
person 
is 
determined eligible 
for 
health 
care 
benefits under the MaineCare program pursuant to Title 22; 
C. 
The person previQusly terminated plan coverage. unless 
months have elapsed since the person's last termination; 
D. 
The person has met the lifetime maximum benefit amount 
under the plan of $3,000,000; 
E. 
The 
person 
is 
an 
inmate 
or 
resident 
of 
a 
public 
instituti'oni or 
F. 
The person's premiums are paid for or reimbursed under 
any government-sponso=ed program or by any government agency 
or health care provider. except as an otherwise qualifying 
full-time employee, or dependent thereof, of a government 
agency or health care provider. 
HOUSE AMENDMENT 
HOUSE 
AMENDMENT 
.. f!;.. to COMMITTEE 
AMENDMENT 
"A" to H. P. 
1187 I 
L.D. 1611 
5. 
Termination of coverage. 
The coverage of any person 
ceases; 
A. 
On the date a person is no longer a resident; 
B. 
Upon the death of the covered person; 
C. 
On 
the date state law reguires cancellation of the 
policy; or 
D. 
At the option of the association, 
days after the 
association 
makes 
any 
inguiry 
concerning 
the 
person's 
eligibility or place of residence to which the person does 
not reply. 
§39l2. 
Actions against association or members based upon joint 
or collective actions 
Participation 
in 
the 
association, 
the 
establishment 
of 
rates, 
forms or procedures or anY 
other joint or collective 
action, reguired by this chapter may not be the basis of any 
legal action criminal or civil liability or penalty against the 
association or any member insurer. 
§3913. 
Reimbursement of carriers 
1. 
Reimbursement. 
A carrier may seek reimbursement from 
the association, and the association shall reimburse the carrier, 
to the extent claims made by a member after February L 
2004 
exceed premiums paid on a calendar year basis by the member to 
the carrier for a member who meets the following criteria; 
A. 
The carrier sold an individual health plan to the member 
between December 1, 1993 and February 1, 2004 and the policy 
that was sold has been continuously renewed by the member j 
.an.Q 
HOUSE AMENDMENT 
.::;) 
~ 
(J,;;,:' 
HOUSE 
AMENDMENT "0,, to COMMITTEE 
AMENDMENT 
"A" to H. P. 
L.D. 1611 
1187, 
B. 
The carrier is able to determine through the use of 
individual 
health 
statements. 
claims 
history 
or 
any 
reasonable means that. at any time while the policy was in 
effect. the member was diagnosed with one of the following 
medical conditions: 
acquired immune deficiency syndrome or 
HIV/AIDS. angina pectoris. cirrhosis of the liver. coronary 
occlusion. cystic fibrosis. Friedreich's ataxia. hemophilia. 
Hodgkin's disease. Huntington's chorea. 
juvenile diabetes, 
leukemia. 
metastatic 
cancer. 
motor 
or 
sensory 
aphasia. 
multiple sclerosis. muscular dystrophy, myasthenia gravis, 
myotonia. 
heart 
disease 
requ~r~ng 
open 
heart 
surgery. 
Parkinson's disease, 
polycystic kidney disease. 
psychotic 
disorders. guadriplegia. stroke. syringomyelia and Wilson's 
disease. 
2. 
Rules. 
The Superintendent of Insurance may adopt rules 
to facilitate payment to a carrier pursuant to this section. 
Rules ado}?ted pursuant to this subsection are routine technical 
rules as defined in Title 5. chapter 375. subchapter 2-A. 
Sec. A-6. Application for federal grant. 
Within 30 days of the 
effective date of this Act, the Superintendent of Insurance shall 
submit an application to the federal Department of Health and 
Human Services, Health Resources and Services Administration for 
a 
federal 
seed 
grant 
to 
support 
the 
creation 
and 
initial 
operation 
of 
the 
Comprehensive 
Health 
Insurance 
Risk 
Pool 
Association established in the Maine 
Revised Statutes, Title 
24-A, chapter 54. 
Sec. A-7. 
Study of reinsurance. 
The 
Comprehensive 
Health 
Insurance Risk Pool Association established pursuant to the Maine 
Revised Statutes, Title 24-A, section 3904 shall conduct a study 
of the possibility of offering a reinsurance pool for the small 
group medical insurance market in order to spread the cost of 
high-riSk 
individuals 
for 
the 
small 
group 
medical 
insurance 
market. 
The study must address the cost of the reinsurance pool, 
potential 
funding 
mechanisms 
and 
the 
effectiveness 
of 
a 
reinsurance pool. 
The association may address any other issues 
regarding a reinsurance pool that it determines are relevant in 
the study. 
The association shall submit its report to the joint 
standing committee of the Legislature having jurisdiction over 
health insurance matters by March 1, 2005. 
Sec. A-8. Effective date. 
That section of this Part that amends 
the 
Maine 
Revised 
Statutes, 
Title 
24-A, 
section 
2736-C, 
subsection 3 takes effect February 1, 2005. 
PARTB 
HOUSE AMENDMENT 
c-s '-
Q 
~ 
HOUSE 
AMENDMENT .f!;" to COMMITTEE 
AMENDMENT "A" to H.P. 
L.D. 1611 
1187, 
Sec. B-1. 24-A MRSA §2736-C, sub-§2, ,B, as enacted by PL 
1993, c. 477, Pt. C, §l and affected by Pt. F, §l, is amended to 
read: 
B. 
A carrier may not vary the premium rate due to the 
gender, 
Rea~&R-6~a~w6T claims experience or policy duration 
of the individual. 
A carrier may vary the premium rate 
based on health status. age or tobacco use only as permitted 
in paragraph D. 
Sec. B-2. 24-A MRSA §2736-C, sub-§2, ,C, as 
2001, c. 410, Pte A, §l and affected by §10, is 
to read: 
amended by PL 
further amended 
C. 
A carrier may vary the premium rate due to 
6A19kiR~ 
6tat~s-aRd family membership. 
TRe-~~~~~-ad9pt 
F ~;}, e 6 - 6 e-\:~4 R4J- .f-&-r-t-b- -app.r~...,i..a.t-e- -rAe-t-hGdG-l-G<J-i-es- -~a 
FG i,.R<J - Fat e 
di6e9YRt6-~-&&-~~~~~~r--Rw~e6-~~-pYF6yaRt 
t9--\:~~-~~~~~-F&~&i,.Re-~eeRRiea~-~~~~~~i,.&&G-iR 
Title-~T-eRapteF-~+eT-6yaeRapteF-~~-AT 
Sec. 8-3. 24-A MRSA §2736-C, sub-§2, 1rD, as 
2001, c. 410, Pt. A, §2 and affected by §10, is 
to read: 
amended by PL 
further amended 
D. 
A carrier may vary the premium rate due to age, health 
status. occupation or industry 
aRd~ geographic area 9Rly 
wRdeF--~~--f9~~9W4R~--~~--~--wi,.&ai,.&--~~--~i6ted 
peFeeR~a4Je--9aRd6 and tobacco use in accordance with the 
following limitations. 
(1) 
For all policies, contracts or certificates that 
are executed, delivered, issued for delivery, continued 
or renewed in this State between December 1, 1993 and 
July 14, 1994, the premium rate may not deviate above 
or below the community rate filed by the carrier by 
more than 50'\. 
(2) 
For all policies, contracts or certificates that 
are executed, delivered, issued for delivery, continued 
or renewed in this State between July 15, 1994 and July 
14, 1995, the premium rate may not deviate above or 
below the community rate filed by the carrier by more 
than 33'\. 
(3) 
For all policies, contracts or certificates that 
are executed, delivered, issued for delivery, continued 
or 
renewed in this State after July 15, 
1995, 
the 
HOUSE AMENDMENT 
e~ 
6-.." 
,,;;a 
r.-: 
HOUSE 
AMENDMENT "B" to COMMITTEE 
AMENDMENT 
"A" to H.P. 
L.D. 1611 
1187, 
premium 
rate 
may 
not 
deviate 
above 
or 
below 
the 
community rate filed by the carrier by more than 20~. 
(4) 
The 
maximum 
premium 
differential 
for 
age 
as 
determined by ratio is 4 to 1. 
The limitation may not 
apply for determining rates for an attained age of less 
than 19 years or more than 65 years. 
( 5) 
The maximum differential due to health status is 
1. 5 to 1. 
and the maximum differential rate due to 
tobacco use is 1. 5 to 1. 
Rate limitations based on 
health status do not apply to rate variations based on 
an insured's status as a tobacco user. 
(6) 
Permissible rating characteristics may not include 
changes in health status after issue. 
Sec. B-4. 24-A MRSA §2736-C, sub-§2, V is enacted to read: 
F. 
A carrier that offered individual health plans, other 
than the standard and basic plan required to be offered 
pursuant to this section, during calendar year 
2002 
may 
establish a separate community rate for individuals applying 
for 
coverage under 
an 
individual health plan after the 
effective date of this paragraph. 
PARTC 
Sec. C-l. Premium subsidies. 
The Department of Human Services 
shall establish a program, by routine technical rules adopted in 
accordance with the Maine Revised Statutes, Title 5, chapter 375, 
subchapter 
2-A, 
to 
provide 
premium 
assistance 
to 
Medicaid-eligible 
individuals. 
The 
program 
must 
provide 
assistance 
to 
qualified 
individuals 
equal 
to 
the 
value 
of 
MaineCare benefits for which they are eligible and must ensure 
that the assistance is used to procure private health insurance 
coverage through employers or health insurance coverage by a plan 
offered in the individual market. 
Sec. C-2. Waiver. 
The Department of Human Services shall 
seek 
any necessary 
and appropriate waivers 
from 
the Federal 
Government 
needed 
to establish 
and 
maintain 
the 
program 
of 
premium assistance under this Part. 
PARTD 
Sec. D-l. 24-A MRSA §420S, sub-§l, ,C, as enacted by PL 1975, 
c. 503, is amended to read: 
HOUSE AMENDMENT 
f'!-$ 
,~ 
~ 
~: 
HOUSE 
AMENDMENT "0,, to COMMITTEE 
AMENDMENT 
"A" to H.P. 
L.D. 1611 
1187, 
C. 
The furnishing of health care services through providers 
whieh ~ 
are under contract with or employed by the health 
maintenance organization. 
A health maintenance organization 
may 
furnish health care services 
through providers that 
exceed the standard geographic accessibility limits imposed 
by 
the bureau by 
rule 
for 
specialty care 
and hospital 
services 
with 
the 
exception 
of 
hospital 
services 
for 
emergencies and maternity care; 
PARTE 
Sec. E-l. 24 MRSA c. 21, sub-c. 11 is enacted to read: 
SUBCHAPTER 11 
LIMITS ON RClfECONOMIC DAMAGES 
§2991. 
Limits on noneconomic damages 
1. 
Definitions. 
As 
used in this subchapter, unless the 
context 
otherwise 
indicates, 
the 
following 
terms 
have 
the 
following meanings. 
A. 
"Noneconomic 
damages" 
means 
subj ective, 
nonpecuniary 
damages 
arising 
from 
pain, 
suffering, 
inconvenience, 
physical 
impairment, 
disfigurement, 
mental 
anguish, 
emotional stress, loss of society and companionShip, loss of 
consortium, 
injury 
to 
reputation, 
humiliation, 
other 
nonpecuniary damages and any other theory of damages such as 
fear of loss, illness or injury. 
2. 
Limitation. 
In an action for professional negligence as 
defined in section 2502, the award for noneconomic damages to a 
prevailing party may not exceed $250,000. 
If the trial of the 
action is by a jury, the jury may not be informed of the damage 
award limitation established in this section. 
If the jury awards 
total damages in excess of $250, OOQ, the court shall direct the 
jury to establish the portion of the total damages awarded that 
is 
for 
noneconomic 
damages. 
If 
the 
portion 
that 
is 
for 
noneconomic damages exceeds $250,00Q, the court shall reduce the 
award for noneconomic damages to that amount. unless a further 
reduction is warranted by exercise of the powers described in 
subsection 3, 
3. 
Court's powers. 
Nothing in this section is intended to 
eliminate the court's powers 
of additur 
and remittitur with 
regard to all damages, except to the extent that the power of 
HOUSE AMENDMENT 
\,,~. 
,+ 
.,,-.: 
HOUSE 
AMENDMENT 
L.D. 1611 
"~,, to COMMITTEE 
AMENDMENT 
"A" to H.P. 1187, 
additur is limited with regard to noneconomic damages beyond the 
limitation established in subsection 2. 
4. 
Ap,plication. 
This section applies to all cases in which 
notices of claim are filed after the effective date of this 
section •. 
Further amend the amendment on page 74 by striking out all 
of the emergency clause. 
SUMMARY 
Part A creates the Comprehensive Health Insurance Risk Pool 
Association to spread the cost of high-risk individuals among all 
health 
insurers. 
The 
high-risk 
pool 
is 
funded 
through 
an 
assessment on insurers. 
This Part requires the State to submit 
an application to the Federal Government for federal assistance 
to create a high-risk pool. 
Part A also removes the guaranteed issuance requirement for 
individual health plans effective February 1, 2005. 
Part B broadens the community 
heal th insurance to allow increased 
based on age and health status. 
rating bands 
variation of 
in individual 
premium rates 
Part C directs the Department of Human Services to provide 
Medicaid-eligible individuals with premium subsidies so that the 
value of MaineCare benefits may be applied to the purchase of 
private health insurance through employers or a plan offered in 
the individual market. 
The department is further directed to 
seek any waivers needed from the Federal Government. 
Part D provides that a health maintenance organization may 
furnish health care services through providers that exceed the 
standard 
geographic 
accessibility 
limits 
imposed-
by 
the 
Department of Professional and Financial Regulation, Bureau of 
Insurance by rule for specialty care and hospital services with 
the exception of hospital services for emergencies and maternity 
care. 
Part E sets a limit of $250,000 on noneconomic damages in 
medical liability actions. 
Under this Part, a plaintiff is still 
entitled 
to 
the 
full 
economic 
loss, 
including all 
medical 
expenses, 
rehabilitation 
services, 
custodial 
care, 
loss 
of 
HOUSE AMENDMENT 
HOUSE 
AMENDMENT 
.. 8.. to COMMITTEE 
AMENDMENT 
"A" to H. P • 
L.D. 1611 
1187, 
earnings 
and earning capacity, 
loss of 
income 
and 
any other 
verifiable monetary losses. 
FISCAL "UTE REQClRED 
" 
(See attacb.~d): 
;; 
///~ 
// > / / 
';..0 ,'/ , .. ' /' 
c-
SPONSORED BY: // Et-l .:/1'/1- .~ 
(Representative CROSTHWAITE) 
TOWN: 
Ellsworth 
HOUSE AMENDMENT 
~et Cost (Savings) 
General Fund 
Lppropriations/ Allocations 
General Fund 
Federal Expenditures Fund 
Other Special Revenue Funds 
Revenue 
Federal Expenditures Fund 
Other Special Revenue Funds 
Transfers 
General Fund 
Other Special Revenue Funds 
Fiscal Detail and ~otes 
Approved: 06/12/03 ;1dae 
Office of Fiscal and Program Review 
LD 1611 
An Act To Provide Affordable Health Insurance to Small Businesses and 
Individuals and To Control Heal.~h Care Costs 
LR 2137(11) 
Fiscal Note for House Amendment" " to Committee Amendment" " 
Sponsor: Rep. Crosthwaitl 
Fiscal Note Required: Yes 
Fiscal Note 
2003-04 
($53,500,000) 
($500,000) 
($973,188) 
($2,066,756) 
($973,188) 
··$0 
$53,000,000 
($53,000,000) 
2004-05 
($500,000) 
($500,000) 
($47,487,284) 
($101,191,729) 
Projecti(>ns 
2005-06 
($500,000 
($500,000) 
($111,313,873) 
($260,850,284) 
Projections 
2006-07 
($500,000) 
($500,000) 
($161,845,977) 
($'3:"7.250,067) 
($47,487.284) ($111,313,873) 
($161,845,977) 
($62,457,480) ($251,537,581) 
($326.551,591) 
$0 
$0 
$0 
$0 
$0 
SO 
This amendment would eliminate all spending and revenue associated with Committee Amendment A. It is assumed 
that any additional costs to the Department of Professional and Financial Regulation in implementing the replacement 
provisions of this amendment can be absorbed by the Department utilizing existing resources. It is further assumed tha t 
any additional costs to the Department of Human Services in securing the necessary approvals and implementing the 
program under Part C can be absorbed by the Department utilizing existing resources. The fiscal impact of the program 
that would be implemented under Part C cannot be determined at this time. 
LR2137(ll) • Fiscal Note· Page 1 of 1