An Act To Require Advance Review and Approval of Certain Small Group Health Insurance Rate Increases and To Implement the Requirements of the Federal Patient Protection and Affordable Care Act
Maine Legislature, Session 125, LD 1179
Committee: Insurance and Financial Services
Sponsors: GOODE, BRANNIGAN, CAIN, EVES, GRAHAM, MORRISON, PRIEST, SANBORN, STUCKEY, TREAT
Amends: 24-A MRSA §2808-B, 24-A MRSA §2736-C, 24-A MRSA §2850, 24-A MRSA §4218-A, 24-A MRSA §4301-A, 24-A MRSA §4302, 24-A MRSA §4303, 24-A MRSA §4306, 24-A MRSA §4306-A, 24-A MRSA §4309-A, 24-A MRSA §4312, 24-A MRSA §4317-A, 24-A MRSA §4318, 24-A MRSA §4319, 24-A MRSA §4320, 24-A MRSA §4320-A, 24-A MRSA §4320-B, 24-A MRSA §4320-C, 24-A MRSA §4320-D, 24-A MRSA §4320-E, 24-A MRSA §4320-F, 24-A MRSA §6451

Legislative Document 
No. 1179 
H.P. 877 
House of Representatives, March 17, 2011 
An Act To Require Advance Review and Approval of Certain Small 
Group Health Insurance Rate Increases and To Implement the 
Requirements of the Federal Patient Protection and Affordable 
Care Act 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
HEATHER J.R. PRIEST 
Clerk 
Presented by Representative GOODE of Bangor. 
Cosponsored by Senator BRANNIGAN of Cumberland and 
Representatives: CAIN of Orono, EVES of North Berwick, GRAHAM of North Yarmouth, 
MORRISON of South Portland, PRIEST of Brunswick, SANBORN of Gorham, STUCKEY of 
Portland, TREAT of Hallowell. 
Be it enacted by the People of the State of Maine as follows: 
PART A 
Sec. A-1.  24-A MRSA §2808-B, sub-§2-A, ¶C, as amended by PL 2007, c. 
629, Pt. M, §6, is further amended to read: 
C.  Rates for small group health plans must be filed in accordance with this section 
and subsections subsection 2-B and 2-C for premium rates effective on or after July 
1, 2004, except that the filing of rates for small group health plans are not required to 
account for any payment or any recovery of that payment pursuant to subsection 2-B, 
paragraph D and former section 6913 for rates effective before July 1, 2005. 
Sec. A-2.  24-A MRSA §2808-B, sub-§2-B, as amended by PL 2009, c. 244, Pt. 
C, §§8 and 9 and Pt. G, §2, is further amended to read: 
2-B.  Rate review and hearings.  Except as provided in subsection 2-C, rate Rate 
filings are subject to this subsection. 
A.  Rates subject to this subsection must be filed for approval by the superintendent. 
The superintendent shall disapprove any premium rates filed by any carrier, whether 
initial or revised, for a small group health plan unless it is anticipated that the 
aggregate benefits estimated to be paid under all the small group health plans 
maintained in force by the carrier for the period for which coverage is to be provided 
will return to policyholders at least 75% 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. 
B.    If at any time the superintendent has reason to believe that a filing does not meet 
the requirements that rates not be excessive, inadequate or unfairly discriminatory or 
that the filing violates any of the provisions of chapter 23, the superintendent shall 
cause a hearing to be held.  Hearings held under this subsection must conform to the 
procedural requirements set forth in Title 5, chapter 375, subchapter 4.  If a filing 
proposes an increase in rates in a small group health plan, the superintendent shall 
cause a hearing to be held at the request of the Attorney General. In any hearing 
conducted under this paragraph, the insurer has the burden of proving rates are not 
excessive, inadequate or unfairly discriminatory.  The superintendent shall issue an 
order or decision within 30 days after the close of the hearing or of any rehearing or 
reargument or within such other period as the superintendent for good cause may 
require, but not to exceed an additional 30 days.  In the order or decision, the 
superintendent shall either approve or disapprove the rate filing.  If the superintendent 
disapproves the rate filing, the superintendent shall establish the date on which the 
filing is no longer effective, specify the filing the superintendent would approve and 
authorize the insurer to submit a new filing in accordance with the terms of the order 
or decision. 
C.   When a filing is not accompanied by the information upon which the carrier 
supports the filing or the superintendent does not have sufficient information to 
determine whether the filing meets the requirements that rates not be excessive, 
inadequate, or unfairly discriminatory or not in compliance with section 6913, the 
superintendent shall require the carrier to furnish the information upon which it 
supports the filing. 
D.  A carrier that adjusts its rate shall account for the savings offset payment or any 
recovery of that savings offset payment in its experience consistent with this section 
and former section 6913. 
Sec. A-3.  24-A MRSA §2808-B, sub-§2-C, as amended by PL 2007, c. 629, Pt. 
M, §10, is repealed. 
PART B 
Sec. B-1.  24-A MRSA §2736-C, sub-§1, ¶B-1 is enacted to read: 
B-1.  "Federal act" means the federal Patient Protection and Affordable Care Act, 
Public Law 111-148, as amended by the federal Health Care and Education 
Reconciliation Act of 2010, Public Law 111-152, and any amendments to or 
regulations or guidance issued under those acts. 
Sec. B-2.  24-A MRSA §2736-C, sub-§2, ¶C, as amended by PL 2001, c. 410, 
Pt. A, §1 and affected by §10, is further amended to read: 
C.  A For all policies, contracts or certificates that are executed, delivered, issued for 
delivery, continued or renewed in this State before January 1, 2014, a carrier may 
vary the premium rate due to smoking status and family membership.  The 
superintendent may adopt rules setting forth appropriate methodologies regarding rate 
discounts based on smoking status.  Rules adopted pursuant to this paragraph are 
routine technical rules as defined in Title 5, chapter 375, subchapter II-A 2-A. 
Sec. B-3.  24-A MRSA §2736-C, sub-§2, ¶C-1 is enacted to read: 
C-1.  For all policies, contracts or certificates that are executed, delivered, issued for 
delivery, continued or renewed in this State on or after January 1, 2014, a carrier may 
vary the premium rate due to tobacco use and family membership.  Premium rate 
variations due to tobacco use may not exceed a ratio of 1.5 to 1. 
Sec. B-4.  24-A MRSA §2736-C, sub-§2, ¶I is enacted to read: 
I.  A carrier must consider all enrollees in all individual health plans offered by the 
carrier, except plans that have grandfathered status under the federal act, to be 
members of a single risk pool to the extent required by the federal act. 
Sec. B-5.  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 subsection 3, paragraph A; subsection 6, paragraph A; 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 premium rate requirements of 
subsection 2 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 with a similar purpose or effect; 
E.    The association's group health 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; 
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. 
This subsection does not apply to policies, contracts or certificates that are executed, 
delivered, issued for delivery, continued or renewed in this State on or after January 1, 
2014, except with respect to association members whose coverage has grandfathered 
status under the federal act. 
Sec. B-6.  24-A MRSA §2808-B, sub-§1, ¶D, as repealed and replaced by PL 
2003, c. 428, Pt. H, §5, is amended to read: 
D.    Prior to January 1, 2014, "Eligible eligible group" means any person, firm, 
corporation, partnership, association or subgroup engaged actively in a business that 
employed an average of 50 or fewer eligible employees during the preceding calendar 
year.  On or after January 1, 2014, "eligible group" means any person, firm, 
corporation, partnership, association or subgroup engaged actively in a business that 
employed an average of 100 or fewer employees during the preceding calendar year. 
(1)  If an employer was not in existence throughout the preceding calendar year, 
the determination must be based on the average number of employees that the 
employer is reasonably expected to employ on business days in the current 
calendar year. 
(2)  In determining the number of eligible employees, companies that are 
affiliated companies or that are eligible to file a combined tax return for purposes 
of state taxation are considered one employer. 
(3)  A group is not an eligible group if there is any one other state where there are 
more eligible employees than are employed within this State and the group had 
coverage in that state or is eligible for guaranteed issuance of coverage in that 
state. 
(4)  An employer qualifies as an eligible group for 2-person coverage if the 
employer provides a carrier with the following information demonstrating that 
the employer's business and employees meet the minimum qualifications for 
group coverage in paragraph C: 
(a)  A copy of the most recent quarterly combined filing for income tax 
withholding and unemployment contributions, Form 941/C1-ME; 
(b)  For an employee claimed to be an employee eligible for group coverage 
whose name is not listed on Form 941/C1-ME, a copy of the employer's 
payroll records for the most recent 3 months showing tax withholding or a 
wage report from a payroll company showing wages paid to that employee 
for the most recent quarter with tax withholding; 
(c)  If an employer is exempt from filing Form 941/C1-ME for group 
coverage, documentation of that exemption and a copy of the employer's 
payroll records for the most recent 3 months showing tax withholding or a 
wage report from a payroll company showing wages paid to that employee 
for the most recent quarter with tax withholding; or 
(d)  If the name of the business owner or employee does not appear on Form 
941/C1-ME, a copy of one of the following: 
(i)  Federal income tax Form Schedule C or Schedule F; 
(ii)  Federal income tax Form 1120S, Schedule K-1; 
(iii)  Federal income tax Form 1065, Schedule K-1; 
(iv)  A workers' compensation insurance audit or evidence of a waiver of 
benefits under Title 39-A; 
(v)  A description of operations in a commercial general liability 
insurance policy or equivalent insurance policy providing coverage for 
the business; or 
(vi)  A signature card from a financial institution or credit union 
authorizing the employee to sign checks on a business checking or share 
draft account that is at least 6 months old; a notarized affidavit from the 
employer describing the duties of the employee and the average number 
of hours worked by the employee and attesting that the employer is not 
defrauding the carrier and is aware of the consequences of committing 
fraud or making a material misrepresentation to the carrier, including a 
loss of coverage and benefits; and, if the group coverage is purchased 
through a producer, a notarized affidavit from the producer affirming the 
producer's belief that the employer qualifies as an eligible group for 
coverage. 
In determining if a new business or a business that adds an owner or a new 
employee to payroll during the course of a year qualifies as an eligible group for 
2-person coverage under this subparagraph, the employer must submit an 
affidavit stating that all employees meet the criteria in this subparagraph and that 
the documentation and forms required under this subparagraph will be provided 
to the carrier when payroll records become available, when ownership 
distribution forms become available or the first renewal date of the coverage, 
whichever date is earlier. A false affidavit or misrepresentation on an affidavit 
submitted by an employer may result in the loss of group coverage and 
repayment of claims paid. This subparagraph may not be construed to prohibit a 
carrier from recognizing an employer as an eligible group if the employer has not 
produced the documentation required in this subparagraph. 
This subparagraph applies only to an employer applying for group health 
insurance coverage as a 2-person group on or after between October 1, 2001 and 
December 31, 2013. 
Sec. B-7.  24-A MRSA §2808-B, sub-§1, ¶D-1 is enacted to read: 
D-1.  "Federal act" means the federal Patient Protection and Affordable Care Act, 
Public Law 111-148, as amended by the federal Health Care and Education 
Reconciliation Act of 2010, Public Law 111-152, and any amendments to or 
regulations or guidance issued under those acts. 
Sec. B-8.  24-A MRSA §2808-B, sub-§2, as amended by PL 2003, c. 469, Pt. E, 
§§14 and 15, is further amended to read: 
2.  Rating practices.  The following requirements apply to the rating practices of 
carriers providing small group health plans.  This subsection does not apply to policies 
issued before January 1, 1998 to eligible groups that employed, on average, 25 to 50 
eligible employees until their first renewal date on or after January 1, 1998. 
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.  For all 
policies, contracts or certificates that are executed, delivered, issued for delivery, 
continued or renewed in this State on or after January 1, 2014, a carrier may not vary 
the premium rate due to occupation, industry or group size. 
C.  A For all policies, contracts or certificates that are executed, delivered, issued for 
delivery, continued or renewed in this State before January 1, 2014, a carrier may 
vary the premium rate due to family membership, smoking status, participation in 
wellness programs and group size.  The superintendent may adopt rules setting forth 
appropriate methodologies regarding rate discounts pursuant to this paragraph.  The 
superintendent may adopt rules to phase out group size variations gradually over a 
period not to exceed 2 years, prior to January 1, 2014.  Rules adopted pursuant to this 
paragraph are routine technical rules as defined in Title 5, chapter 375, subchapter II-
A 2-A. 
C-1.  For all policies, contracts or certificates that are executed, delivered, issued for 
delivery, continued or renewed in this State on or after January 1, 2014, a carrier may 
vary the premium rate due to family membership and tobacco use.  Premium rate 
variations due to tobacco use may not exceed a ratio of 1.5 to 1. 
D.  A carrier may vary the premium rate due to age, occupation or industry and 
geographic area only under the following schedule and within the listed percentage 
bands. 
(1)  For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State between July 15, 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 before January 
1, 2014, the premium rate may not deviate above or below the community rate 
filed by the carrier by more than 20%, except as provided in paragraph D-1. 
(4)  For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State on or after January 1, 2014, the 
premium rate may not deviate above or below the community rate filed by the 
carrier based on age and geographic area by more than 20%. 
D-1.  With respect to eligible groups that employed, on average, 25 to 50 eligible 
employees in the preceding calendar year, a carrier may vary the premium rate due to 
age, occupation or industry and geographic area only under the following schedule 
and within the listed percentage bands. 
(1)  For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State in 1998, the premium rate may 
not deviate above or below the community rate filed by the carrier by more than 
40%. 
(2)  For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State in 1999, the premium rate may 
not deviate above or below the community rate filed by the carrier by more than 
30%. 
(3)  For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State after January 1, 2000, the 
premium rate may not deviate above or below the community rate filed by the 
carrier by more than 20%. 
D-2.  Notwithstanding the requirements of paragraph D, rates with respect to 
employees whose work site is not in this State may be based on area adjustment 
factors appropriate to that location. 
E.  The superintendent may authorize a carrier to establish a separate community rate 
for an association group organized pursuant to section 2805-A or a trustee group 
organized pursuant to section 2806, as long as association group membership or 
eligibility for participation in the trustee group is not conditional on health status, 
claims experience or other risk selection criteria and all small group health plans 
offered by the carrier through that association or trustee group: 
(1)  Are otherwise in compliance with the premium rate requirements of this 
subsection; and 
(2)  Are offered on a guaranteed issue basis to all eligible employers that are 
members of the association or are eligible to participate in the trustee group 
except that a professional association may require that a minimum percentage of 
the eligible professionals employed by a subgroup be members of the association 
in order for the subgroup to be eligible for issuance or renewal of coverage 
through the association.  The minimum percentage must not exceed 90%.  For 
purposes of this subparagraph, "professional association" means an association 
that: 
(a)  Serves a single profession that requires a significant amount of education, 
training or experience or a license or certificate from a state authority to 
practice that profession; 
(b)  Has been actively in existence for 5 years; 
(c)  Has a constitution and bylaws or other analogous governing documents; 
(d)  Has been formed and maintained in good faith for purposes other than 
obtaining insurance; 
(e)  Is not owned or controlled by a carrier or affiliated with a carrier; 
(g)  Has a least 1,000 members if it is a national association; 200 members if 
it is a state or local association; 
(h)  All members and dependents of members are eligible for coverage 
regardless of health status or claims experience; and 
(i)  Is governed by a board of directors and sponsors annual meetings of its 
members. 
Producers may only market association memberships, accept applications for 
membership or sign up members in the professional association where the individuals 
are actively engaged in or directly related to the profession represented by the 
professional association. 
This paragraph does not apply to policies, contracts or certificates that are executed, 
delivered, issued for delivery, continued or renewed in this State on or after January 
1, 2014, except plans that have grandfathered status under the federal act. 
F.    Premium rates charged to a private purchasing alliance, as defined by chapter 
18-A, may be reduced in accordance with rules adopted pursuant to that chapter. 
H.  A carrier must consider all enrollees in all small group health plans offered by the 
carrier, except plans that have grandfathered status under the federal act, to be 
members of a single risk pool to the extent required by the federal act. 
Sec. B-9.  24-A MRSA §2808-B, sub-§2-C, ¶B, as enacted by PL 2003, c. 469, 
Pt. E, §16, is amended to read: 
B.    On an annual schedule as determined by the superintendent, the carrier shall file 
a report with the superintendent showing aggregate earned premiums and incurred 
claims for the period the rates were in effect. Incurred claims must include claims 
paid to a date 6 months after the end of the annual reporting period determined by the 
superintendent and an estimate of unpaid claims.  The report must state how the 
unpaid claims estimate was determined.  The superintendent shall determine the 
reporting period and the paid-to date, except that beginning January 1, 2011, both the 
reporting period and the paid-to date must be consistent with those for the rebates 
required pursuant to the federal act and federal regulations adopted pursuant to the 
federal act. 
Sec. B-10.  24-A MRSA §2808-B, sub-§2-C, ¶C, as amended by PL 2007, c. 
629, Pt. M, §10, is further amended to read: 
C.  If incurred claims were less than 78% of aggregate earned premiums over a 
continuous 36-month period, the carrier shall refund a percentage of the premium to 
the current in-force policyholder.  The refund must be paid on a basis consistent with 
requirements for rebates required pursuant to the federal act and federal regulations 
adopted pursuant to the federal act.  For the purposes of calculating this loss-ratio 
percentage, any payments paid pursuant to former section 6913 must be treated as 
incurred claims.  The excess premium is the amount of premium above that amount 
necessary to achieve a 78% loss ratio for all of the carrier's small group policies 
during the same 36-month period.  The refund must be distributed to policyholders in 
an amount reasonably calculated to correspond to the aggregate experience of all 
policyholders holding policies having similar benefits in the same manner required 
for rebates required by the federal act and federal regulations adopted pursuant to the 
federal act. The total of all refunds must equal the excess premiums.  Larger amounts 
may be required as set forth in section 4320-C. 
(1)  For determination of loss-ratio percentages in 2005, actual aggregate incurred 
claims expenses include expenses incurred in 2005 and projected expenses for 
2006 and 2007.  For determination of loss-ratio percentages in 2006, actual 
incurred claims expenses include expenses in 2005 and 2006 and projected 
expenses for 2007. 
(2)  The superintendent may waive the requirement for refunds during the first 3 
years after the effective date of this subsection or for the period between the last 
reporting period ending before January 1, 2011 and the first reporting period 
beginning on or after January 1, 2011. 
Sec. B-11.  24-A MRSA §2808-B, sub-§6, ¶I, as enacted by PL 1993, c. 477, Pt. 
B, §3 and affected by Pt. F, §1, is amended to read: 
I.  Notwithstanding any other provision of this section, prior to January 1, 2014, a 
carrier may choose whether it will offer to groups having only one member coverage 
under the carrier's individual health policies offered to other individuals in this State 
in accordance with section 2736-C or coverage under a small group health plan in 
accordance with this section, or both, but the carrier need not offer to groups of one 
both small group and individual health coverage. 
Sec. B-12.  24-A MRSA §2850, sub-§2, ¶F is enacted to read: 
F.  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, except that this prohibition may not 
apply to individual health plans in effect on March 23, 2010 that have grandfathered 
status under the federal act.  A preexisting condition exclusion may not be imposed 
on any enrollee after January 1, 2014 to the extent prohibited by the federal act and 
federal regulations adopted pursuant to the federal act.  For the purposes of this 
paragraph, "federal act" has the same meaning as in section 2808-B, subsection 1, 
paragraph D-1. 
Sec. B-13.  24-A MRSA §4218-A is enacted to read: 
§4218-A.  Compliance with the federal Patient Protection and Affordable Care Act 
The superintendent may adopt and amend rules, establish standards and enforce 
federal statutes and regulations in order to carry out the purposes of the federal Patient 
Protection and Affordable Care Act, Public Law 111-148, as amended by the federal 
Health Care and Education Reconciliation Act of 2010, Public Law 111-152, and any 
amendments to or regulations or guidance issued under those acts.  Rules or amendments 
adopted pursuant to this section, including amendments to major substantive rules, are 
routine technical rules as defined in Title 5, chapter 375, subchapter 2-A. 
Sec. B-14.  24-A MRSA §4301-A, sub-§1, as amended by PL 2007, c. 199, Pt. 
B, §1, is further amended to read: 
1.  Adverse health care treatment decision. "Adverse health care treatment 
decision" means a health care treatment decision made by or on behalf of a carrier 
offering or renewing a health plan denying in whole or in part payment for or provision of 
otherwise covered services requested by or on behalf of an enrollee.  "Adverse health care 
treatment decision" also includes rescission determinations and initial coverage eligibility 
determinations, consistent with the requirements of the federal act. 
Sec. B-15.  24-A MRSA §4301-A, sub-§3, as enacted by PL 1999, c. 742, §3, is 
amended to read: 
3.  Carrier.  "Carrier" means: 
A.  An insurance company licensed in accordance with this Title to provide health 
insurance; 
B.  A health maintenance organization licensed pursuant to chapter 56; 
C.  A preferred provider arrangement administrator registered pursuant to chapter 32; 
D.  A fraternal benefit society, as defined by section 4101; 
E.  A nonprofit hospital or medical service organization or health plan licensed 
pursuant to Title 24; 
F.  A multiple-employer welfare arrangement licensed pursuant to chapter 81; or 
G.  A self-insured employer subject to state regulation as described in section 
2848-A. 
An employer exempted from the applicability of this chapter under the federal Employee 
Retirement Income Security Act of 1974, 29 United States Code, Sections 1001 to 1461 
(1988) is not considered a carrier.  Notwithstanding any other provision of this Title, any 
other entity offering coverage in this State that is subject to the requirements of the 
federal act is considered a carrier. 
Sec. B-16.  24-A MRSA §4301-A, sub-§5-A is enacted to read: 
5-A.  Federal act.  "Federal act" means the federal Patient Protection and Affordable 
Care Act, Public Law 111-148, as amended by the federal Health Care and Education 
Reconciliation Act of 2010, Public Law 111-152, and any amendments to or regulations 
or guidance issued under those acts. 
Sec. B-17.  24-A MRSA §4301-A, sub-§7, as enacted by PL 1999, c. 742, §3, is 
amended to read: 
7.  Health plan.  "Health plan" means a plan offered or administered by a carrier that 
provides for the financing or delivery of health care services to persons enrolled in the 
plan, other than a plan that provides only accidental injury, specified disease, hospital 
indemnity, Medicare supplement, disability income, long-term care or other limited 
benefit coverage not subject to the requirements of the federal act.  Any plan that is 
subject to the requirements of the federal act and offered in this State by a carrier, 
including, but not limited to, any qualified health plan offered through an American 
Health Benefits Exchange or Small Business Health Options Program Exchange pursuant 
to the federal act, is considered a health plan for purposes of this chapter. 
Sec. B-18.  24-A MRSA §4302, sub-§6 is enacted to read: 
6.  Reporting required pursuant to the federal Patient Protection and Affordable 
Care Act.  In addition to and notwithstanding any other requirements of this Title, a 
carrier shall provide to the Secretary of the United States Department of Health and 
Human Services, and make available to the public when required by federal law, any 
information required by the federal act and federal regulations adopted pursuant to the 
federal act.  A carrier shall also provide the information to the superintendent upon 
request. 
Sec. B-19.  24-A MRSA §4303, sub-§4, ¶E is enacted to read: 
E.  A health plan subject to the requirements of the federal act must comply with 
federal claims and appeal requirements, including but not limited to the requirement 
that benefits for an ongoing course of treatment cannot be reduced or terminated 
without providing advance notice and an opportunity for advance review, consistent 
with the requirements of the federal act and federal regulations adopted pursuant to 
the federal act. 
Sec. B-20.  24-A MRSA §4303, sub-§15 is enacted to read: 
15.  Uniform explanation of coverage documents and standardized definitions.  
The following applies with respect to uniform explanation of coverage documents and 
standardized definitions used by a carrier. 
A.  A carrier offering a health plan in this State shall provide to applicants, enrollees 
and policyholders or certificate holders a summary of benefits and coverage 
explanation that accurately describes the benefits and coverage under the applicable 
plan or coverage. Any summary of benefits and coverage explanation must conform 
with the requirements of the federal act and federal regulations adopted pursuant to 
the federal act. 
B.  A carrier offering a health plan in this State shall use standard definitions of 
insurance-related and medical-related terms in connection with health insurance 
coverage as required by the federal act and federal regulations adopted pursuant to 
the federal act. 
Sec. B-21.  24-A MRSA §4303, sub-§16 is enacted to read: 
16.  Language and culture.  All notices to enrollees subject to the requirements of 
the federal act must be provided in a culturally and linguistically appropriate manner 
consistent with the requirements of the federal act and federal regulations adopted 
pursuant to the federal act. 
Sec. B-22.  24-A MRSA §4306, as amended by PL 2007, c. 199, Pt. B, §15, is 
further amended to read: 
§4306.  Enrollee choice of primary care provider 
A carrier offering or renewing a managed care plan shall allow enrollees to choose 
their own primary care providers, as allowed under the managed care plan's rules, from 
among the panel of participating providers made available to enrollees under the managed 
care plan's rules.  A carrier shall allow physicians, including but not limited to 
pediatricians and physicians who specialize in obstetrics and gynecology, and certified 
nurse practitioners who have been approved by the State Board of Nursing to practice 
advanced practice registered nursing without the supervision of a physician pursuant to 
Title 32, section 2102, subsection 2-A, to serve as primary care providers for managed 
care plans.  A carrier is not required to contract with certified nurse practitioners or 
physicians as primary care providers in any manner that exceeds the access and provider 
network standards required in this chapter or chapter 56, or any rules adopted pursuant to 
those chapters.  A carrier shall allow enrollees in a managed care plan to change primary 
care providers without good cause at least once annually and to change with good cause 
as necessary.  When an enrollee fails to choose a primary care provider, the carrier may 
assign the enrollee a primary care provider located in the same geographic area in which 
the enrollee resides. 
Sec. B-23.  24-A MRSA §4306-A is enacted to read: 
§4306-A.  Patient access to obstetrical and gynecological care 
In addition to and notwithstanding any other requirements of this Title, a carrier 
offering a health plan in this State subject to the requirements of the federal act: 
1.  Prior authorization or referral.  May not require authorization or referral by the 
carrier or any other person, including a primary care provider, in the case of a female 
enrollee who seeks coverage for obstetrical or gynecological care provided by a 
participating provider who specializes in obstetrics or gynecology.  The participating 
provider must agree to otherwise adhere to the health plan's or carrier's policies and 
procedures, including procedures regarding referrals and obtaining prior authorization 
and providing services pursuant to a treatment plan, if any, approved by the carrier; and 
2.  Authorization of treatment.  Shall consider the provision of obstetrical and 
gynecological care and the ordering of related obstetrical and gynecological items and 
services by a participating provider who specializes in obstetrics or gynecology, pursuant 
to the direct access described in subsection 1, as authorized by the primary care provider. 
Sec. B-24.  24-A MRSA §4309-A is enacted to read: 
§4309-A.  Compliance with the federal act 
1.  Enforcement.  Carriers must comply with all applicable requirements of the 
federal act and federal regulations adopted pursuant to the federal act.  The 
superintendent may enforce and administer this section through all powers provided 
under Title 24 and this Title. 
2.  Rules.  The superintendent may adopt and amend rules, establish standards and 
enforce federal statutes and regulations in order to carry out the purposes of the federal 
act and federal regulations adopted pursuant to the federal act.  Rules or amendments 
adopted pursuant to this section, including amendments to major substantive rules, are 
routine technical rules as defined in Title 5, chapter 375, subchapter 2-A. 
Sec. B-25.  24-A MRSA §4312, sub-§1, as enacted by PL 1999, c. 742, §19, is 
amended to read: 
1.  Request for external review.  An enrollee or the enrollee's authorized 
representative shall make a written request for external review of an adverse health care 
treatment decision to the bureau.  Except as provided in subsection 2, an enrollee may not 
make a request for external review under a group plan until the enrollee has exhausted all 
levels of a carrier's internal grievance procedure.  A request for external review must be 
made within 12 months of the date an enrollee has received a final adverse health care 
treatment decision under a carrier's internal grievance procedure, and an enrollee may not 
make a request for external review under an individual plan until the enrollee has 
completed one review of an adverse health care treatment decision under a carrier's 
internal grievance procedure.  An enrollee may not be required to pay any filing fee as a 
condition of processing a request for external review. 
Sec. B-26.  24-A MRSA §4312, sub-§2, as enacted by PL 1999, c. 742, §19, is 
amended to read: 
2.  Expedited request for external review.  An enrollee or an enrollee's authorized 
representative is not required to exhaust all levels of a carrier's internal grievance 
procedure in accordance with subsection 1 before filing a request for external review if: 
A.    The carrier has failed to make a decision on an internal grievance within the time 
period required, or has otherwise failed to adhere to all the requirements applicable to 
the appeal pursuant to state and federal law, or the enrollee has applied for expedited 
external review at the same time as applying for an expedited review under a carrier's 
internal grievance procedure; 
B.    The carrier and the enrollee mutually agree to bypass the internal grievance 
procedure; 
C.    The life or health of the enrollee is in serious jeopardy, or the decision concerns 
an admission, availability of care, continued stay or health care services for which the 
enrollee received emergency services, but has not been discharged from a facility; or 
D.   The enrollee has died. 
Sec. B-27.  24-A MRSA §4317-A is enacted to read: 
§4317-A.  No lifetime or annual limits on health plans subject to the federal act 
In addition to and notwithstanding the requirements of section 4318, a carrier offering 
a health plan subject to the federal act may not: 
1.  Lifetime limits on dollar value of benefits.  Establish lifetime limits on the dollar 
value of benefits for any participant or beneficiary; or 
2.  Annual limits on dollar value of benefits.  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 act and federal regulations adopted pursuant to the federal act, and may establish 
annual limits consistent with waivers granted by the Secretary of the United States 
Department of Health and Human Services. 
Sec. B-28.  24-A MRSA §4318, sub-§4, as reallocated by RR 2009, c. 2, §70, is 
amended to read: 
4.  Disclosure.  A health plan issued after the effective date of this section that 
includes an annual or lifetime maximum aggregate benefit limit as permitted under 
section 4317-A and subsection 3 must include a disclosure of the applicable limit on the 
face page of the individual policy or group certificate. The disclosure must be printed in a 
font that is larger or bolder than the font used in the body of the face page. 
Sec. B-29.  24-A MRSA §4319 is enacted to read: 
§4319.  Coverage of preventive health services 
In addition to and notwithstanding any other requirements of this Title, a carrier 
offering a health plan subject to the federal act shall, at a minimum, provide coverage for 
and may not impose cost-sharing requirements for preventive services as required by the 
federal act and federal regulations adopted pursuant to the federal act. 
Sec. B-30.  24-A MRSA §4320 is enacted to read: 
§4320.  Extension of dependent coverage 
A carrier offering a health plan subject to the requirements of the federal act that 
provides dependent coverage of children shall continue to make such coverage available 
for an adult child until the child attains 26 years of age, consistent with the federal act and 
federal regulations adopted pursuant to the federal act. 
Sec. B-31.  24-A MRSA §4320-A is enacted to read: 
§4320-A.  Emergency services 
If a carrier offering a health plan subject to the requirements of the federal act 
provides or covers any benefits with respect to services in an emergency department of a 
hospital, the plan must cover emergency services in accordance with the requirements of 
the federal act and federal regulations adopted pursuant to the federal act, including 
requirements that emergency services be covered without prior authorization and that 
cost-sharing requirements expressed as a copayment amount or coinsurance rate for out-
of-network services are the same as would apply if such services were provided 
in-network. 
Sec. B-32.  24-A MRSA §4320-B is enacted to read: 
§4320-B.  Comprehensive health coverage 
In addition to and notwithstanding any other requirements of this Title, a carrier 
offering a health plan subject to the requirements of the federal act shall, at a minimum, 
provide coverage that incorporates the essential benefits and cost-sharing limitations 
consistent with the requirements of the federal act and federal regulations adopted 
pursuant to the federal act. 
Sec. B-33.  24-A MRSA §4320-C is enacted to read: 
§4320-C.  Rebates 
1.  Rebates required.  Carriers must provide rebates in the large group, small group 
and individual markets, to the extent required by the federal act and federal regulations 
adopted pursuant to the federal act, if the medical loss ratio defined in subsection 2 is less 
than the minimum medical loss ratio required by subsection 3. In the small group market, 
carriers must pay the larger of any rebate required by this section and any refund required 
by section 2808-B, subsection 2-C. 
2.  Medical loss ratio.  For purposes of this section, the medical loss ratio is 
expressed as a percentage, the numerator of which is described in paragraph A and the 
denominator of which is described in paragraph B, plus any credibility adjustment.  The 
time period over which the medical loss ratio is determined and the meaning of all terms 
used in this subsection are in accordance with the federal act and federal regulations 
adopted pursuant to the federal act. 
A.  The numerator is the amount expended on reimbursement for clinical services 
provided to enrollees and activities that improve health care quality. 
B.  The denominator is the total amount of premium revenue, excluding federal and 
state taxes and licensing or regulatory fees, and after accounting for payments or 
receipts for risk adjustment, risk corridors and reinsurance under section 4320-D. 
3.  Minimum medical loss ratio.  The minimum medical loss ratio is: 
A.  In the large group market, 85%; 
B.  In the small group market, 80%; and 
C.  In the individual market, 80%, or lower if the Secretary of the United States 
Department of Health and Human Services determines based on a finding, pursuant 
to the federal act and federal regulations adopted pursuant to the federal act, that the 
80% minimum medical loss ratio may destabilize the individual market in this State. 
Sec. B-34.  24-A MRSA §4320-D is enacted to read: 
§4320-D.  Reinsurance, risk corridors and risk adjustment 
1.  Transitional reinsurance program.  The superintendent shall establish a 
transitional reinsurance program for calendar years 2014, 2015 and 2016 as required by 
Section 1341 of the federal act and federal regulations adopted pursuant to the federal act. 
2.  Risk corridors.  Carriers shall make any payments required under the risk 
corridors program established by the Secretary of the United States Department of Health 
and Human Services for calendar years 2014, 2015 and 2016 as required by Section 1342 
of the federal act and federal regulations adopted pursuant to the federal act. 
3.  Risk adjustment.  The superintendent shall establish a risk adjustment program as 
required by Section 1343 of the federal act and federal regulations adopted pursuant to 
the federal act. 
Sec. B-35.  24-A MRSA §4320-E is enacted to read: 
§4320-E.  Oversight of plans offered through an exchange established in state law 
pursuant to the federal act 
1.  Superintendent's authority preserved.  Except as otherwise expressly provided 
by applicable law, all requirements established by Title 24, this Title and rules adopted by 
the superintendent continue to apply to carriers and health plans, and are not extinguished 
or modified in any way by: 
A.  Certification of a health plan as a qualified health plan, or any other determination 
made by an exchange pursuant to the federal act; or 
B.  Recognition by the applicable federal agency of a carrier as a qualified nonprofit 
health insurance issuer or as an issuer of qualified multistate health plans, or of a 
health plan as a qualified multistate health plan, pursuant to the federal act. 
2.  Coordination with exchanges.  The superintendent has all additional powers and 
duties conferred upon a state insurance regulator with respect to American Health Benefit 
Exchanges and Small Business Health Option Program Exchanges by the federal act and 
regulations adopted pursuant to the federal act.  The superintendent may enter into 
agreements with an exchange established under state law relating to coordination of 
responsibilities and such agreements may provide for the superintendent to assume 
additional authority relating to the certification of qualified health plans or the 
authorization of a carrier to participate in any exchange. 
Sec. B-36.  24-A MRSA §4320-F is enacted to read: 
§4320-F.  Applicability to health plans grandfathered under the federal act 
A health plan that is exempt from certain requirements of the federal act because the 
health plan has grandfathered status is also exempt, to the same extent, from the 
substantially similar provisions in Title 24 and this Title. 
Sec. B-37.  24-A MRSA §6451, sub-§6-B is enacted to read: 
6-B.  Qualified nonprofit health insurance issuer.  "Qualified nonprofit health 
insurance issuer" has the same meaning as in Section 1322 of the federal Patient 
Protection and Affordable Care Act, Public Law 111-148.  A qualified nonprofit health 
insurance issuer is considered a health organization for purposes of this chapter. 
SUMMARY 
Part A of the bill makes the rate review process for small group health insurance rates 
the same as the process for individual health insurance. Part A requires that, if a filing 
proposes an increase in rates in a small group health plan, the Superintendent of 
Insurance shall hold a hearing on the proposed rate increase at the request of the Attorney 
General. Part A makes it clear that in any hearings the burden of proving proposed rates 
are not excessive, inadequate or unfairly discriminatory is on the insurer.  Part A also 
repeals the optional rate review process that permits small group health insurers that meet 
a minimum 78% medical loss ratio to file rates with the Department of Professional and 
Financial Regulations, Bureau of Insurance for informational purposes. 
Part B of the bill amends the Maine Insurance Code to conform to the requirements 
of the federal Patient Protection and Affordable Care Act, Public Law 111-148.  Part B 
also authorizes the Superintendent of Insurance to amend rules for consistency with the 
requirements of the federal law and any regulations adopted pursuant to that law.