An Act To Implement the Requirements of the Federal Patient Protection and Affordable Care Act
Maine Legislature, Session 125, LD 1554
Committee: Insurance and Financial Services
Sponsors: RICHARDSON
Amends: 24-A MRSA §14, 24-A MRSA §2736-C, 24-A MRSA §2808-B, 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 §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 §4320-G, 24-A MRSA §6451-A

Legislative Document 
No. 1554 
H.P. 1140 
House of Representatives, May 5, 2011 
An Act To Implement the Requirements of the Federal Patient 
Protection and Affordable Care Act 
Submitted by the Department of Professional and Financial Regulation pursuant to Joint 
Rule 204. 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
HEATHER J.R. PRIEST 
Clerk 
Presented by Representative RICHARDSON of Warren. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  24-A MRSA §14 is enacted to read: 
§14.  "Affordable Care Act" defined 
"Affordable Care Act" means the federal Patient Protection and Affordable Care Act, 
Public Law 111-148, adopted March 23, 2010, as amended by the federal Health Care 
and Education Reconciliation Act of 2010, Public Law 111-152, and federal regulations 
adopted pursuant to that Act. 
Sec. 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. 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.  Variations due to 
tobacco use may not exceed a ratio of 1.5 to 1. 
Sec. 4.  24-A MRSA §2736-C, sub-§2, ¶I is enacted to read: 
I.  Except for grandfathered health plans under the Affordable Care Act, a carrier 
shall consider all enrollees in all individual health plans offered by the carrier to be 
members of a single risk pool to the extent required by the Affordable Care Act. 
Sec. 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. 
Except for individuals with grandfathered health plans under the Affordable Care Act, 
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. 
Sec. 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.  "Eligible Prior to January 1, 2014, "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 from October 1, 2001 to 
December 31, 2013. 
Sec. 7.  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.  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. 
Except for employers with plans that have grandfathered status under the Affordable 
Care Act, 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. 
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.  Except for plans that have grandfathered status under the Affordable Care Act, a 
carrier shall consider all enrollees in all small group health plans offered by the 
carrier to be members of a single risk pool to the extent required by the Affordable 
Care Act. 
Sec. 8.  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 date until which paid claims must be included as incurred 
claims.  Beginning January 1, 2011, both the reporting period and the date until 
which paid claims must be included as incurred claims must be consistent with those 
for the rebates required pursuant to the Affordable Care Act. 
Sec. 9.  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 Affordable Care 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 as is required for rebates required by the 
Affordable Care Act. The total of all refunds must equal the excess premiums, unless 
larger amounts are required under section 4320-D. 
(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. 10.  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. 11.  24-A MRSA §2850, sub-§2, ¶F is enacted to read: 
F.  Except for individual health plans in effect on March 23, 2010 that have 
grandfathered status under the Affordable Care Act, a carrier as defined in section 
4301-A, subsection 3 offering a health plan as defined in section 4301-A, subsection 
may not apply a preexisting condition exclusion to any enrollee under 19 years of 
age.  A preexisting condition exclusion may not be imposed on any enrollee after 
January 1, 2014 to the extent prohibited by the Affordable Care Act. 
Sec. 12.  24-A MRSA §4218-A is enacted to read: 
§4218-A.  Compliance with the 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 Affordable Care 
Act.  Rules or amendments to rules 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. 13.  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 decisions" includes rescission determinations and initial coverage eligibility 
determinations, consistent with the requirements of the Affordable Care Act. 
Sec. 14.  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.; or 
H.  Notwithstanding any other provision of this Title, an entity offering coverage in 
this State that is subject to the requirements of the Affordable Care Act. 
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. 
Sec. 15.  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 Affordable Care Act.  A plan that 
is subject to the requirements of the Affordable Care Act and offered in this State by a 
carrier, including, but not limited to, a qualified health plan offered on an American 
Health Benefit Exchange or a SHOP Exchange, is a health plan for purposes of this 
chapter. 
Sec. 16.  24-A MRSA §4302, sub-§6 is enacted to read: 
6.  Reporting required pursuant to the Affordable Care Act.  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 Affordable Care Act.  Carriers 
shall provide the information to the superintendent upon request. 
Sec. 17.  24-A MRSA §4303, sub-§4, ¶E is enacted to read: 
E.  Health plans subject to the requirements of the Affordable Care Act must comply 
with federal claims and appeal requirements, including, but not limited to, the 
requirement that benefits for an ongoing course of treatment may not be reduced or 
terminated without providing advance notice and an opportunity for advance review, 
consistent with the requirements of the Affordable Care Act. 
Sec. 18.  24-A MRSA §4303, sub-§15 is enacted to read: 
15.  Uniform explanation of coverage documents and standardized definitions.  
A carrier offering a health plan in this State shall: 
A.  Provide to applicants, enrollees and policyholders or certificate holders a 
summary of benefits and an explanation of coverage that accurately describe the 
benefits and coverage under the applicable plan or coverage.  A summary of benefits 
and an explanation of coverage must conform with the requirements of the 
Affordable Care Act; and 
B.  Use standard definitions of insurance-related and medical-related terms in 
connection with health insurance coverage as required by the Affordable Care Act. 
Sec. 19.  24-A MRSA §4303, sub-§16 is enacted to read: 
16.  Language and culture.  All notices to applicants, enrollees and policyholders or 
certificate holders subject to the requirements of the Affordable Care Act must be 
provided in a culturally and linguistically appropriate manner consistent with the 
requirements of the Affordable Care Act. 
Sec. 20.  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. 21.  24-A MRSA §4306-A is enacted to read: 
§4306-A.  Patient access to obstetrical and gynecological care 
Notwithstanding any other requirements of this Title, a carrier offering a health plan 
in this State subject to the requirements of the Affordable Care Act: 
1.  Authorization or referral not required.  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 health care professional as described in the Affordable Care Act who 
specializes in obstetrics or gynecology.  The health care professional shall 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.  Treated as primary care.  Shall treat the provision of obstetrical and 
gynecological care by a participating health care professional as described in the 
Affordable Care Act who specializes in obstetrics or gynecology, pursuant to subsection 
1, as authorized by the primary care provider and the authorization of related obstetrical 
and gynecological items and services by that professional as the authorization of the 
primary care provider. 
Sec. 22.  24-A MRSA §4309-A is enacted to read: 
§4309-A.  Compliance with the Affordable Care Act 
1.  Carriers.  A carrier shall comply with all applicable requirements of the 
Affordable Care Act. 
2.  Superintendent.  The superintendent may enforce and administer this section 
through all powers provided under this Title and Title 24.  The superintendent may adopt 
and amend rules, establish standards and enforce federal statutes and regulations in order 
to carry out the purposes of the Affordable Care Act.  Rules or amendments adopted 
pursuant to this subsection, including amendments to major substantive rules, are routine 
technical rules as defined in Title 5, chapter 375, subchapter 2-A. 
Sec. 23.  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 and may not make a request for external 
review under an individual plan until the enrollee has exhausted one level 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.  An enrollee may not be required to pay 
any filing fee as a condition of processing a request for external review. 
Sec. 24.  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 internal appeal; 
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 
D.   The enrollee has died.; or 
E.  The adverse health care treatment decision to be reviewed concerns an admission, 
availability of care, a continued stay or health care services when the claimant has 
received emergency services but has not been discharged from the facility that 
provided the emergency services. 
Sec. 25.  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 
subsection 3 and under section 4319 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. 26.  24-A MRSA §4319 is enacted to read: 
§4319.  No lifetime or annual limits on health plans subject to the Affordable Care 
Act 
Notwithstanding the requirements of section 4318, a carrier offering a health plan 
subject to the Affordable Care Act may not: 
1.  Establish lifetime limits.  Establish lifetime limits on the dollar value of benefits 
for any participant or beneficiary; or 
2.  Establish annual limits.  Establish annual limits on the dollar value of essential 
benefits, except that, prior to January 1, 2014, health plans may include restricted annual 
limits on essential benefits consistent with the requirements of the Affordable Care Act 
and may establish annual limits consistent with waivers granted by the Secretary of the 
United States Department of Health and Human Services. 
Sec. 27.  24-A MRSA §4320 is enacted to read: 
§4320.  Coverage of preventive health services 
Notwithstanding any other requirements of this Title, a carrier offering a health plan 
subject to the Affordable Care Act shall, at a minimum, provide coverage for and may not 
impose cost-sharing requirements for preventive services as required by the Affordable 
Care Act. 
Sec. 28.  24-A MRSA §4320-A is enacted to read: 
§4320-A.  Extension of dependent coverage 
A carrier offering a health plan subject to the requirements of the Affordable Care 
Act that provides dependent coverage of children shall continue to make such coverage 
available for an adult child until the child turns 26 years of age, consistent with the 
Affordable Care Act. 
Sec. 29.  24-A MRSA §4320-B is enacted to read: 
§4320-B.  Emergency services 
If a carrier offering a health plan subject to the requirements of the Affordable Care 
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 Affordable Care 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 
requirements that would apply if such services were provided in network. 
Sec. 30.  24-A MRSA §4320-C is enacted to read: 
§4320-C.  Comprehensive health coverage 
Notwithstanding any other requirements of this Title, a carrier offering a health plan 
subject to the requirements of the Affordable Care Act shall, at a minimum, provide 
coverage that incorporates the essential benefits and cost-sharing limitations consistent 
with the requirements of the Affordable Care Act. 
Sec. 31.  24-A MRSA §4320-D is enacted to read: 
§4320-D.  Rebates 
1.  Definition.  For purposes of this section, "medical loss ratio" means a fraction, the 
numerator of which is the amount expended on reimbursement for clinical services 
provided to enrollees and activities that improve health care quality and the denominator 
of which is the total amount of premium revenue excluding federal and state taxes and 
licensing or regulatory fees after accounting for payments or receipts for risk adjustment, 
risk corridors and reinsurance under section 4320-E, determined in accordance with the 
Affordable Care Act, including with regard to the period over which the medical loss 
ratio is determined. 
2.  Rebates required.  A carrier shall provide rebates in the large group, small group 
and individual markets, to the extent required by the Affordable Care Act, if the medical 
loss ratio is less than the minimum medical loss ratio required by subsection 3. In the 
small group market, a carrier must pay the larger of any rebate required by this section 
and any refund required by section 2808-B, subsection 2-C. 
3.  Minimum medical loss ratio.  The minimum medical loss ratio is: 
A.  Eighty-five percent in the large group market; 
B.  Eighty percent in the small group market; and 
C.  In the individual market, 80% or such lower medical loss ratio as the Secretary of 
the United States Department of Health and Human Services determines based on a 
finding, pursuant to the Affordable Care Act, that the 80% minimum medical loss 
ratio may destabilize the individual market in this State. 
Sec. 32.  24-A MRSA §4320-E is enacted to read: 
§4320-E.  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 Affordable Care Act. 
2.  Risk corridors.  A carrier 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 Affordable Care Act. 
3.  Risk adjustment.  The superintendent shall establish a risk adjustment program as 
required by Section 1343 of the Affordable Care Act. 
Sec. 33.  24-A MRSA §4320-F is enacted to read: 
§4320-F.  Oversight of plans offered on the American Health Benefit Exchange and 
the SHOP Exchange 
1.  Superintendent's authority preserved.  Except as otherwise expressly provided 
by applicable law, the requirements established by this Title, Title 24 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 the American Health Benefit Exchange or the SHOP Exchange pursuant to 
the Affordable Care Act; or 
B.  Recognition by the applicable federal agency of a carrier as a qualified nonprofit 
health insurance issuer or as an issuer of multistate qualified health plans, or of a 
health plan as a multistate qualified health plan, pursuant to the Affordable Care Act. 
2.  Coordination with exchanges.  The superintendent has all additional powers and 
duties conferred upon a state insurance regulator with respect to the American Health 
Benefit Exchange and the SHOP Exchange by the Affordable Care Act.  The 
superintendent may enter into agreements with the American Health Benefit Exchange 
and the SHOP Exchange 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 the 
American Health Benefit Exchange or the SHOP Exchange. 
Sec. 34.  24-A MRSA §4320-G is enacted to read: 
§4320-G.  Applicability to health plans grandfathered under the Affordable Care 
Act 
A health plan that is exempt from certain requirements of the Affordable Care Act 
because it has grandfathered status is also exempt, to the same extent, from substantially 
similar provisions in this Title and Title 24 enacted after January 1, 2011, except to the 
extent that those provisions state that they apply to grandfathered health plans. 
Sec. 35.  24-A MRSA §6451-A, sub-§3-A is enacted to read: 
3-A.  Qualified nonprofit health insurance issuers.  Qualified nonprofit health 
insurance issuers as defined in Section 1322 of the Affordable Care Act are considered 
health organizations for purposes of this chapter. 
SUMMARY 
This bill amends the state health insurance laws to incorporate changes to implement 
the requirements of the federal Patient Protection and Affordable Care Act adopted in 
2010.