An Act To Protect Health Care Coverage for Maine Families
Maine Legislature, Session 129, LD 0001
Committee Amendment CA_A_S3 (Senate)
Amends: 24-A MRSA §2736-C, 24-A MRSA §2742-B, 24-A MRSA §2808-B, 24-A MRSA §2833-B, 24-A MRSA §2849, 24-A MRSA §2849-B, 24-A MRSA §2850, 24-A MRSA §2850-B, 24-A MRSA §4233-B, 24-A MRSA §4302, 24-A MRSA §4303, 24-A MRSA §4311, 24-A MRSA §4318, 24-A MRSA §4319, 24-A MRSA §4319-A, 24-A MRSA §4320, 24-A MRSA §4320-D, 24-A MRSA §2850-C, 24-A MRSA §4320-L, 24-A MRSA §2749-C, 24-A MRSA §2843, 24-A MRSA §4234-A

COMMITTEE AMENDMENT" A" to S.P. 10, L.D. 1, Bill, "An Act To Protect 
Health Care Coverage for Maine Families" 
Amend the bill by striking out everything after the enacting clause and before the 
emergency clause and inserting the following: 
'PART A 
Sec. A-1. 24-A MRSA §2736-C, sub-§2, ~, as amended by PL 2007, c. 629, 
Pt. A, §3, is further amended to read: 
B. 
A carrier may not vary the premium rate due to the gender, health status, 
occupation or industry, claims experience or policy duration of the individual or any 
other rating factor not specified in this subsection. 
Sec. A-2. 24-A MRSA §2736-C, sub-§2, 1C, as amended by PL 2011, c. 364, 
§3, is further amended to read: 
C. A carrier may vary the premium rate due to family membership to the extent 
permitted by the federal Affordable Care A.ct. The premium rate for a family must 
equal the sum of the premiums for each individual in the family, except that it may 
not be based on more than 3 dependent children who are less than 21 years of age. 
Sec. A-3. 24-A MRSA §2736-C, sub-§2, 10, as amended by PL 2011, c. 364, 
§4, is further amended to read: 
D. A carrier may vary the premium rate due to age and tobacco use in accordance 
with the limitations set out in this paragraph. A carrier that varies the premium rate 
due to age must vary the premium rate according to a uniform age curve. The 
superintendent shall adopt rules establishing a uniform age curve that is substantially 
similar to the age curve in effect on January 1, 2019 under the federal Affordable 
Care Act. Rules adopted under this paragraph are routine technical rules as defined 
in Title 5, chapter 375, subchapter 2-A. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 10, L.D. 1 
(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 cani.er by more than 33%. 
(3) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State between July 15, 1995 and June 
30, 2012, the premium rate may not deviate above or below the community rate 
filed by the carrier by more than20%. 
(5) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State between July 1, 2012 and 
December 31, 2013, the maximum rate differential due to age filed by the carrier 
as determined by ratio is 3 to 1. The limitation does not apply for determining 
rates for an attained age of less than 19 years of age or more than 65 years of age. 
(6) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State between January 1, 2014 and 
December 31, 2014, the maximum rate differential due to age filed by the carrier 
as determined by ratio is 4 to 1 to the extent permitted by the federal Affordable 
Care Act. The limitation does not apply for determining rates for an attained age 
of less than 19 years of age or more than 65 years of age. 
(7) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State on or after January 1, 2015~ 
except as provided in subparagraph (9), the maximum rate differential due to age 
filed by the carrier as determined by ratio is 5 to 1 to the extent permitted by the 
federal Affordable Care Act. The limitation does not apply for determining rates 
for an attained age ofless than 19 years of age or more than 65 years of age. 
(8) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State on or after July 1, 2012, the 
maximum rate differential due to tobacco use filed by the carrier as determined 
by ratio is 1.5 to 1, except that the carrier may not apply a rate differential 
pursuant to this subparagraph when the covered individual is participating in an 
evidence-based tobacco cessation strategy approved by the United States 
Department of Health and Human Services, Food and Drug Administration. 
.CD For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State on or after the effective date of 
this subparagraph. the maximum rate differential due to age filed by the carrier as 
determined by ratio is 3 to 1 for individuals 21 years of age and older on the first 
day of coverage under the policy, contract or certificate. The variation in rate due 
to age must be actuarially justified for individuals under 21 years of age 
consistent with the uniform age rating curve adopted under this paragraph. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. I 0, L.D. I 
Sec. A-4. 24-A MRSA §2736-C, sub-§2, ,rF, as amended by PL 2007, c. 629, 
Pt. M, §4, is repealed. 
Sec. A-5. 24-A MRSA §2736-C, sub-§2, W, as amended by PL 2011, c. 364, 
§5, is repealed. 
Sec. A-6. 24-A MRSA §2736-C, sub-§5, as amended by PL 2011, c. 90, Pt. D, 
§3, is further amended to read: 
5. Loss ratios. Except as provided in subsection 2-B, for all policies and certificates 
issued on or after the effective date of this section, the superintendent shall disapprove 
any premium rates filed by any carrier, whether initial or revised, for an individual health 
O 
policy unless it is anticipated that the aggregate benefits estimated to be paid under all the 
individual health policies maintained in force by the carrier for the period for v1hich 
coverage is to be provided will return to policyholders at least 65% of the aggregate 
premiums collected for those policies, as determined in aecordanee '.vi.th aeeepted 
actuarial prineiples and practices and on the basis of inCUFred claims experienee and 
earned premiums. For the purposes of this ealeulation, any payments paid pursuant to 
former section 6913 must be treated as ineurred claims medical loss ratio calculated 
under section 4319 will be at least 80%. 
Sec. A-7. 24-A MRSA §2736-C, sub-§11, as enacted by PL 2013, c. 271, §1, is 
amended to read: 
11. Open enrollment; rules. Notwithstanding subsection 3, on or after January 1, 
2014, a carrier may restrict enrollment in individual health plans to open enrollment 
periods and special enrollment periods consistent with requirements of the federal 
Affordable Care Ast to the extent not inconsistent with applicable federal law. The 
superintendent may adopt rules establishing minimum open enrollment dates and 
minimum criteria for special enrollment periods for all individual health plans offered in 
this State. Rules adopted pursuant to this subsection are routine technical rules as defined 
in Title 5, chapter 375, subchapter 2-A. 
Sec. A-8. 24-A MRSA §2742-B, as amended by PL 2007, c. 514, §§1 to 5, is 
further amended to read: 
§2742-B. Mandatory offer to extend coverage for dependent children up to 26 years 
of age 
1. Dependent child; definition. As used in this section, "dependent child" means 
the child of a person covered under an individual health insurance policy ,.vhen that 
£hil4~ 
A.. Is unmarried; 
B. Has no dependent of the ohild's ovm; and 
C. Is a residsnt of this Statei or is enrolkid as a full time student at an aoored-ited 
public or-private--institution of hie.her ec:hication 
2. Offer of coverage. Notwithstanding section 2703, subsection 3, an individual 
health insurance policy that offers coverage for a dependent child must offer such 
coverage, at the option of the policyholder, until the dependent child is--U attains 26 years 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A" to S.P. 10, L.D. 1 
of age. An insurer may require, as a oondition of eligibility for oov~age in ~ooord~noe 
with this seotion, that a person seeking ooverage for a de.pendent oh1ld pro~1de vmtt~n 
dooumentation on an annual basis that the dwendent ohild meets the reamrements m 
1mh1.ection 1. 
Sec. A-9. 24-A MRSA §2808-B, sub-§2, ~' as amended by PL 1993, c. 477, 
Pt. B, §1 and affected by Pt. F, §1, is further amended to read: 
B. A carrier may not vary the premium rate due to the gender, health status, claims 
experience or policy duration of the eligible group or members of the group or any 
other rating factor not specified in this section. 
Sec. A-10. 24-A MRSA §2808-B, sub-§2, ,re, as amended by PL 2011, c. 638, 
§ 1, is further amended to read: 
C. A carrier may vary the premium rate due to oooupation and industry, family 
membership and participation in wellness programs to the extent permitted by the 
federal i\ffordable Care ,'\et. The premium rate for a family must equal the sum of 
the premiums for each individual in the family, except that it may not be based on 
more than 3 dependent children who are less than 21 years of age. 
The 
superintendent may adopt rules setting forth appropriate methodologies regarding rate 
discounts for participation in wellness programs and rating for oooupation and 
industry pursuant to this paragraph. Rules adopted pursuant to this paragraph are 
routine technical rules as defmed in Title 5, chapter 375, subchapter 2-A. 
Sec. A-11. 24-A MRSA §2808-B, sub-§2, ,ii>, as amended by PL 2011, c. 638, 
§2, is further amended to read: 
D. A carrier may vary the premium rate due to age, group size and tobacco use en1y 
under the follov,ring sohedule and within the listed peroentage bands in accordance 
with the limitations set out in this paragraph. A carrier that varies the premium rate 
due to age must vary the premium rate according to a uniform age curve. 
The 
superintendent shall adopt rules establishing a uniform age curve that is substantially 
similar to the age curve in effect on January 1, 2019 under the federal Affordable 
Care Act. Rules adopted under this paragraph are routine technical rules as defmed 
in Title 5, chapter 375, subchapter 2-A. 
(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 between July 15, 1995 and 
September 30, 2011, the premium rate may not deviate above or below the 
community rate filed by the carrier by more than 20%. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" /~" to S.P. 10, L.D. 1 
( 4) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State between October 1, 2011 and 
September 30, 2012, the maximum rate differential due to age filed by the carrier 
as determined by ratio is 2 to 1. The limitation does not apply for determining 
rates for an attained age of less than 19 years of age or more than 65 years of age. 
(5) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State between October 1, 2012 and 
December 31, 2013, the maximum rate differential due to age and group size 
filed by the carrier as determined by ratio is 2.5 to 1. The limitation does not 
apply for determining rates for an attained age of less than 19 years of age or 
more than 65 years of age. 
(6) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State between January 1, 2014 and 
December 31, 2014, the maximum rate differential due to age and group size 
filed by the carrier as determined by ratio is 3 to 1 to the extent permitted by the 
federal Affordable Care Act. The limitation does not apply for determining rates 
for an attained age of less than 19 years of age or more than 65 years of age. 
(7) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State between January 1, 2015 and 
December 31, 2015, the maximum rate differential due to age and group size 
filed by the carrier as determined by ratio is 4 to 1 to the extent permitted by the 
federal Affordable Care Act. The limitation does not apply for determining rates 
for an attained age of less than 19 years of age or more than 65 years of age. 
(8) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State on or after Januaiy 1, 2016~ 
except as provided in subparagraph (10), the maximum rate differential due to 
age and group size filed by the carrier as determined by ratio is 5 to 1 to the 
extent permitted by the federal· Affordable Care Act. The limitation does not 
apply for determining rates for an attained age of less than 19 years of age or 
more than 65 years of age. 
(9) For all policies, contracts or certificates that are executed, delivered, issued 
for delivery, continued or renewed in this State on or after October 1, 2011, the 
maximum rate differential due to tobacco use filed by the carrier as determined 
by ratio is 1.5 to 1, except that the carrier may not apply a rate differential 
pursuant to this subparagraph when the covered individual is participating in an 
evidence-based tobacco cessation strategy approved by the United States 
Department of Health and Human Services, Food and Drug Administration. 
(10) For all policies, contracts or certift9ates that are executed, delivered, issued 
for delivety, continued or r~neweq in this State on or after the effective date of 
this Act, the maximum rate differential due: to a_illLfi1~ the carrier as 
determined by ratio is 3 to 1 for individuals 21 years of age and older on the first 
day of cove~e under the policy, contract or certificate. The variation in rate due 
to age must be actuariaJly justified for individuals under 21 years of age 
consistent with the uniform age rating curve adopted under this paragraph. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A 
"to S.P. 10, L.D. 1 
Sec. A-12. 24-A MRSA §2808-B, sub-§2, ,U, as amended by PL 2011, c. 638, 
§3, is repealed. 
Sec. A-13. 24-A MRSA §2833-B, as amended by PL 2007, c. 514, §§6 to 10, is 
further amended to read: 
§2833-B. Mandatory offer to extend coverage for dependent children up to 26 years 
of age 
1. Dependent child; definition. As used in this section, "dependent child" means 
the child of a person covered under a group health insurance policy when that ohild:~ 
A. Is unmarritid; 
B. Has no dependent of the ohild's ovm; and 
C. Is a resident of this State or is enrolled as a full time student at an aooredited 
publio or private institution of higher education. 
2. 
Offer of coverage. Notwithstanding section 2822, a group health insurance 
policy that offers coverage for a dependent child must offer such coverage, at the option 
of the policyholder parent, until the dependent child~ attains 26 years of age. An 
insurer may require, as a condition of tiligibility for coveragti in aocordancti with this 
section, that a person seeldng ooverage for a dependent ohild provide written 
documentation on an annual basis that the deoendent ohild meets the reauirements in 
,mh1,umti nn 1 
Sec. A-14. 24-A MRSA §2849, sub-§3-A, as enacted by PL 2009, c. 244, Pt. E, 
§3, is repealed. 
Sec. A-15. 24-A MRSA §2849-B, sub-§3-B, as enacted by PL 2009, c. 244, Pt. 
E, §5, is repealed. 
Sec. A-16. 24-A MRSA §2850, sub-§2, as amended by PL 2011, c. 364, §18, is 
further amended to read: 
2. Limitation. An individual, group or blanket contract issued by an insurer may not 
impose a preexisting condition exclusion tiJwept as providtid in this substiction. 
A 
preexisting condition e1wlusion may not exceed 12 months from the date of enrollment, 
inoluding the waiting period, if any. For purposes of this subseotion, "waiting ptiriod" 
inoludes any period between the time a substantially oomplete application for an 
individual or small group health plan is filed and the time the ooverage takes effeot. A 
pretixisting oondition tixolusion may not be more restriotive than as follows. 
This 
subsection does not limit a carrier's ability to restrict enrollment in an individual contract 
to open enrollment and special enrollment periods in accordance with section 2736-C, 
subsection 11. 
A. 
In a group contract, a preexisting oondition exolusion may relate only to 
conditions for 1,vhioh medioal advise, diagnosis, oare or treatment v1as reoommended 
8 
or received during the 6 month period ending on the earlier of the date of enrollment 
in the oontraot and the date of tJnrollmtint in a prior oontraot oovering the same group 
if there has not been a gap in ooverage of greater than 90 days between-oontraots. ,A...n 
ffi{Glm,inn m:w nnt he imnmied relatin2= to nm2=nancv as a nrnexistin2= condition. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 10, L.D. 1 
B. In an individual contract not subject to paragraph C, or in a blanket policy, a 
preexisting condition exclusion may relate only to conditions manifesting in 
symptoms that would cause an ordinarily prudent person to se6k medical advice, 
diagnosis, care or treatment or for 1.vhich medical advice, diagnosis, care or treatment 
was recommended or received during the 12 months immediately preceding the date 
of application or to a pregnancy existing on the effective date of coverage. 
C. An individual policy issued on or after January 1, 1998 to a federally eligible 
individual as defined in section 2848 mav not contain a nreexistine: condition 
exclusion. 
D. A routine preventhre screooing or test yielding only negative results may not be 
considered to be diagnosis, care or treatment for the purposes of this subsection. 
E. Genetic information may not be used as the basis for imposing a preexisting 
condition exclusion in the absence of a diagnosis of the condition relating to that 
information. For the purposes of this paragraph, "genetic information" has the same 
meaning as set forth in the Code of Federal Regulations. 
F. 
Except for individual health plans in effect on March 23, 2010 that have 
7 
grandfathered status under the federal i\Jfordable Care Act, a carrier as defined in 
section 4301 A, subsection 3 offering a health plan as defined in section 4301 A, 
subsection 7 may not apply a preexisting condition exclusion to any enrollee under 19 
years of age. A preexisting condition exclusion may not be imposed on any enrollee 
after January 1, 2014 to the extent prohibited by the federal Affordable Care l'Lct. 
Sec. A-17. 24-A MRSA §2850-B, sub-§3, as amended by PL 2011, c. 90, Pt. F, 
§3 and c. 238, Pt. F, §1, is further amended to read: 
3. Cancellation of coverage; renewal. Coverage may not be rescinded for an 
individual, a group or eligible members and their dependents in those groups once an 
individual, a group or eligible members and their dependents in those groups are covered 
under an individual or group health plan, except that this subsection does not prohibit 
rescission with respect to a covered individual, a group or eligible members and their 
dependents in those groups who have perfornwd an act or practice that constitutes fraud 
or made an intentional misrepresentation of material fact as prohibited by the terms of the 
individual or group health plan to the extent consistent with section 2411. Such coverage 
may not be cancelled, and renewal must be guaranteed to all individuals, to all groups and 
to all eligible members and their dependents in those groups except: 
A. When the policyholder or contract holder fails to pay premiums or contributions 
in accordance with the terms of the contract or the carrier has not received timely 
premium payments; 
B. For fraud or intentional misrepresentation of material fact by the policyholder or 
contract holder; 
C. With respect to coverage of individuals under a gn:mp policy or contract, for fraud 
or intentional misrepresentation of material fact on the part of the individual or th,e 
individual's representative; 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 10, L.D. 1 
D. In the large or small group market, for noncompliance with the carrier's minimum 
participation requirements, which may not exceed the participation requirement when 
the policy was issued; 
E. With respect to a managed care plan, as defined in section 4301-A, ifthere is no 
longer an insured who lives, resides or works in the service area; 
F. When the carrier ceases offering large or small group health plans in compliance 
with subsection 4 and does not renew any existing policies in that market; 
F-1. When the carrier ceases offering individual health plans in compliance with 
section 2736-C, subsection 4 and does not renew any existing policies in that market; 
G. When the carrier ceases offering a product and meets the following requirements: 
(1) In the large group market: 
(a) The carrier provides notice to the policyholder and to the certificate 
holders at least 90 days before termination; 
(b) The carrier offers to each policyholder the option to purchase any other 
product currently being offered in the large group market; and 
( c) In exercising the option to discontinue the product and in offering the 
option of coverage under division (b ), the carrier acts uniformly without 
regard to the claims experience of the policyholders or the health status of the 
certificate holders or their dependents or prospective certificate holders or 
their dependents; 
(2) In the small group market: 
(a) The carrier replaces the product with a product that complies with the 
requirements of this section, including renewability, and with section 
2808-B; 
(b) The superintendent finds that the replacement is in the best interests of 
the policyholders; and 
( c) The carrier provides notice of the replacement to the policyholder and to 
the certificate holders at least 90 days before replacement, including notice of 
the policyholder's right to purchase any other product currently being offered 
by that carrier in the small group market pursuant to section 2808-B, 
subsection 4; or 
(3) In the individual market: 
(a) The carrier replaces the product with a product that complies with the 
requirements of this section, including renewability, and with section 
2736-C; 
(b) The superintendent finds that the replacement is in the best interests of 
the policyholders; and 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 10, L.D. I 
( c) The carrier provides notice of the replacement to the policyholder and, if 
a group policy subject to section 2736-C, to a certificate holder at least 90 
days before replacement, including notice of the policyholder's or certificate 
holder's right to purchase any other product currently being offered by that 
carrier in the individual market pursuant to section 2736-C, subsection 3; 
H. In renewing a large group policy in accordance with this section, a carrier may 
modify the coverage, terms and conditions of the policy consistent with other 
applicable provisions of state and federal laws as long as the modifications are 
applied uniformly to all policyholders of the same product; or 
I. In renewing an individual or small group policy in accordance with this section, a 
carrier may make minor modifications to the coverage, terms and conditions of the 
policy consistent with other applicable provisions of state and federal laws as long as 
the modifications meet the conditions specified in this paragraph and are applied 
uniformly to all policyholders of the same product. Modifications not meeting the 
requirements in this paragraph are considered a discontinuance of the product 
pursuant to paragraph G. 
(1) 
A modification pursuant to this paragraph must be approved by the 
superintendent. The superintendent shall approve the modification if it meets the 
requirements of this section. 
(2) A change in a requirement for eligibility is not a minor modification pursuant 
to this paragraph if the change results in the exclusion of a class or category of 
enrollees currently covered. 
(3) Benefit modifications required by law are deemed minor modifications for 
purposes of this paragraph. 
(4) Benefit modifications other than modifications required by law are minor 
modifications only if they meet the requirements of this subparagraph. 
For 
purposes of this subparagraph, changes in administrative conditions or 
requirements specified in the policy, such as preauthorization requirements, are 
not considered benefit modifications. 
(a) The total of any increases in benefits may not increase the actuarial value 
of the total benefit package by more than 5%. 
(b) The total of any decreases in benefits may not decrease the actuarial 
value of the total benefit package by more than 5%. 
(c) For purposes of the calculations in divisions (a) and (b), increases and 
decreases must be considered separately and may not offset one another. 
(5) A carrier must give 60 days' notice of any modification pursuant to this 
paragraph to all affected policybolde.rs and certificate holders. 
Sec. A-18. 24-A MRSA §4233-B, as amended by PL 2007, c. 514, §§11 to 15, is 
further amended to read: 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT .. ;\ "to S.P. 10, L.D. 1 
§4233-B. Mandatory offer to extend coverage for dependent children up to 26 years 
of age 
1. Dependent child; definition. As used in this section, "dependent child" means 
the child of a person covered under an individual or group health maintenance 
organization contract when that ehild:~ 
A. Is unmarried; 
B. Has no dependent of the ehild's ovm: and 
C. Is a resident of this State or is· enrolled as a full time student at an aeoredited 
publio or private institution of higher edueation. 
o 
2. 
Off er of coverage. An individual or group health maintenance organization 
contract that offers coverage for a dependent child shall must offer such coverage, at the 
option of the eontraet holder parent, until the dependent child ~ 
attains 26 years of 
age. An insurer may require, as a eondition of eligibility for ooverage in aooordanoe with 
this seetion, that a person seeking ooverage for a dependent ohild provide vmtten 
dooumentation on an annual basis that the deoendent ehild meets the reauirements in 
subseetion 1. 
Sec. A-19. 24-A MRSA §4302, sub-§1, as amended by PL 2017, c. 232, §§3-5, 
is further amended to read: 
1. 
Description of plan. A carrier shall provide to prospective emollees and 
participating providers, and to members of the public and nonparticipating providers upon 
request, information on the terms and c.onditions of the plan to enable those persons to 
make informed decisions regarding their choice of plan. A carrier shall provide this 
information annually to current emollees, participating providers and the superintendent. 
This information must be presented in a standardized format acceptable to the 
superintendent. 
In adopting rules or developing standardized reporting formats, the 
superintendent shall consider the nature of the health plan and the extent to which rules or 
standardized formats are appropriate to the plan. All written and oral descriptions of the 
health plan must be truthful and must use appropriate and objective terms that are easy to 
understand. 
These descriptions must be consistent with standards developed for 
supplemental insurance coverage under the United States Social Security Act, Title 
XVIII, 42 United States Code, Sections 301 to 1397 (1988). Descriptions of plans under 
this subsection must be standardized so that enrollees may compare the attributes of the 
plans and be in a format that is substantially similar to the format required for a carrier 
pursuant to the federal Affordable Care Act as of January 1. 2019. After a carrier has 
provided the required information, the annual information requirement under this 
subsection may be satisfied by the provision of any amendments to the materials on an 
annual basis. A carrier shall post descriptions of its plans on its publicly accessible 
website and, in addition to the plan description, include a link to the health plan's 
certificate of coverage. Specific items that must be included in a description are as 
follows: 
A. Coverage provisions, benefits and any exclusions by category of service, type of 
provider and, if applicable, by spt>"Hic service, including but not limited to the 
following types of exclusions and limitations: 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 10, L.D. 1 
(1) Health care services excluded from coverage; 
(2) Health care services requiring copayments or deductibles paid by enrollees; 
(3) Restrictions on access to a particular provider type; 
( 4) Health care services that are or may be provided only by referral; and 
( 5) Childhood immunizations as recommended by the United States Department 
of Health and Human Services, Centers for Disease Control and Prevention and 
the American Academy of Pediatrics; 
B. Any prior authorization or other review requirements, including preauthorization 
review, concurrent review, postservice review, postpayment review and any 
procedures that may result in the enrollee being denied coverage or not being 
provided a particular service; 
C. A general description of the methods used to compensate providers, including 
capitation and methods in which providers receive compensation based upon 
referrals, utilization or cost criteria; 
D. 
An explanation of how health plan limitations affect enrollees, including 
information on enrollee financial responsibilities for payment of coinsurance or other 
noncovered or out-of-plan services and limits on preexisting conditions and waiting 
periods; 
E. The terms under which the health plan may be renewed by the plan members or 
enrollees, including any reservation by the health plan of any right to increase 
premiums; 
F. A statement as to when benefits cease in the event of nonpayment of the prepaid 
or periodic premium and the effect of nonpayment upon the enrollees who are 
hospitalized or undergoing treatment for an ongoing condition; 
G. A description of the manner in which the plan addresses the following: the 
provision of appropriate and accessible care in a timely fashion; an effective and 
timely grievance process and the circumstances in which an enrollee may obtain a 
2nd opinion; timely determinations of coverage issues; confidentiality of medical 
records; and written copies of coverage decisions that are not explicit in the health 
plan agreement. 
The description must also include a statement explaining the 
circumstances under which health status may be considered in making coverage 
decisions in accordance with state and federal laws and that enrollees may refuse 
particular treatments without jeopardizing future treatment; 
H. Procedures an enrollee must follow to obtain drugs and medicines that are subject 
to a plan list or plan formulary, if any; a description of the forrnulary; and a 
description of the extent to which an enrollee will be reimbursed for the cost of a 
drug that is not on a plan list or plan formulary. Enrollees may .request additional 
information related to specific drugs t.hat are not on the drug formulary; 
I. Information on where and in what manner health care services may be obtained; 
COMMITTEE AMENDMENT 
,! 
COMMITTEE AMENDMENT 4\ "to S.P. 10, L.D. 1 
J. A description of the independent external review procedures and the circumstances 
under which an enrollee is entitled to independent external review as required by this 
chapter; 
K. A description of the requirements for enrollees to obtain coverage of routine costs 
of clinical trials and information on the manner in which enrollees not eligible to 
participate in clinical trials may qualify for the compassionate use program of the 
federal Food and Drng Administration for use of investigational drugs pursuant to 21 
Code of Federal Regulations, Section 312.34, as amended; 
L. A description of a provider profiling program that may be a part of the health 
plan, including the location of provider performance ratings in the plan materials or 
on a publicly accessible website, information explaining the provider rating system 
and the basis upon which provider performance is measured, the limitations of the 
data used to measure provider performance, the process for selecting providers and a 
conspicuous written disclaimer explaining the provider performance ratings should 
only be used as a guide for choosing a provider and that enrollees should consult their 
current provider before making a decision about their health care based on a provider 
rating; and 
M. If the health plan is subject to the requirements of section 4318-A, a description 
of the incentives available to an enrollee and how to earn such incentives if enrolled 
in a health plan offering a comparable health care service incentive program designed 
pursuant to section 4318-A. 
Sec. A-20. 24-A MRSA §4303, sub-§4, ,i_E, as enacted by PL 2011, c. 364, §25, 
is amended to read: 
E. Health plans subjeot to the requirements of the federal Affordable Care Aot must 
oomply v:ith federal olaims and appeal requirements, inoluding, but not limited to, the 
requirement that benefits for an ongoing oourse of treatment may not be reduoed or 
terminated v:ithout advanoe notioe and an opportunity for advanoe review, oonsistent 
with th@ requirements of the federal Affordable Care f,.ot reduce or terminate benefits 
for an ongoing course of treatment, including coverage of a prescription drug, during 
the course of an appeal pursuant to the grievance procedure used by the carrier or any 
independent external review in accordance with section 4312. 
Sec. A-21. 24-A MRSA §4311, sub-§1-A is enacted to read: 
1-A. 
Access to clinically appropriate prescription drugs. 
For plan years 
beginning on or after the effective date of this subsection, a carrier must allow an 
enrollee, the enrollee's designee or the person who has issued a valid prescription for the 
enrollee to request and gain access to a clinically appropriate drug not otherwise covered 
by the health plan. The carrier's process must comply with section 4304 and with this 
subsection. If the carrier approves a request under this subsection for a drug not 
otherwise covered by the health plan, the carrier must treat the drug as an essential health 
benefit, including counting any cost sharing toward the plan's annual limit on cost sharing 
and including it when calculating the plan's actuarial value. 
A. The carrier must determine whether it will cover the drug requested and notify the 
enrollee, the enrollee's designee, if applicable, and the person who has issued the 
valid prescription for the enrollee of its coverage decision within 2 business days 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A "to S.P. 10, L.D. 1 
following receipt of the request. A carrier that grants coverage under this paragraph 
must provide coverage of the drug for the duration of the prescription, including 
refills. 
B. The carrier must have a process by which an expedited review may be requested 
in exigent circumstances. Exigent circumstances exist when an enrollee is suffering 
from a health condition that may seriously jeopardize the enrollee's life, health or 
ability to regain maximum function or when an enrollee is undergoing a current 
course of treatment using a nonformulary drug. When an expedited review has been 
requested, the carrier must determine whether it will cover the drug requested and 
notify the enrollee, the enrollee's designee, if applicable, and the person who has 
provided a valid prescription for the enrollee of its coverage decision within 24 hours 
following receipt of the request. A carrier that grants coverage under this paragraph 
must provide coverage of the drug for the duration of the exigency. 
Sec. A-22. 24-A MRSA §4318, as amended by PL 2011, c. 364, §33, is repealed. 
Sec. A-23. 24-A MRSA §4319, as enacted by PL 2011, c. 90, Pt. D, §5, is 
amended to read: 
§4319. Rebates 
1. Rebates required. Carriers must provide rebates in the large group, small group 
and individual markets to the extent required by the federal Affordable Care Aet and 
federal regulations adopted pursuant thereto if the medical loss ratio under subsection 2 is 
less than the minimum medical loss ratio under subsection 3. 
2. Medical loss ratio. For purposes of this section, the medical loss ratio is the ratio 
of the numerator to the denominator as described in paragraphs A and B, respectively, 
plus any credibility adjustment. The period for whieh the medical loss ratio is determined 
and the meaning of all terms used in this subseetion must be in aeeordanee with the 
federal Affordable Care Aot and federal regulations adopted pursuant thereto. For the 
purposes of this subsection: 
A. The numerator is the amount expended on reimbursement for clinical services 
provided to enrollees and activities that improve health care quality; and 
B. The denominator is the total amount of premium revenue excluding federal and 
state taxes and licensing and regulatory fees paid and after accounting for payments 
or receipts for risk adjustment, risk corridors and reinsurance pursuant to federal law. 
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 sueh lov,rer minir~cratie---a~ 
Seeretary of the United States Department of Health and Human S~B:ines 
. , 
Affm:aable--Car~-Aetc--ffiHi--fe-oora-l 
regulations adopted pursuant thereto, that ~rn-:medioal loss ratio-might 
AA!'ltahili7.A the iniliviiln~. 
COMMITTEE AMENDMENT 
COMMITTEEAMENDMENT"A "toS.P.10,L.D.1 
4. 
Rules. 
The superintendent may adopt rules to implement this section in a 
substantially similar manner as required under the federal Affordable Care Act in effect 
as of January 1, 2019, including, but not limited to, rules establishing the period for 
which the medical loss ratio is calculated. Rules adopted pursuant to this subsection are 
routine technical rules as defined in Title 5, chapter 375, subchapter 2-A. 
Sec. A-24. 24-A MRSA §4319-A is enacted to read: 
§4319-A. Guaranteed issue 
A carrier offering a health plan in this State in the individual, small group or large 
group market must off er to an individual or group in the State all health plans that are 
approved for sale in the applicable market and must accept any individual or group that 
applies for any of those health plans in accordance with the requirements of section 
2736-C, subsection 3 and section 2808-B, subsection 4 and section 2850-B. 
Sec. A-25. 24-A MRSA §4320, as enacted by PL 2011, c. 364, §34, is amended 
to read: 
§4320. No lifetime or annual limits on health plans 
Notwithstanding the requirements of seotion 4318, a A carrier offering a health plan 
subjeot to the federal Affordable Care Aot in the individual, small group or large group 
market, as those markets are defined under applicable federal law, 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, exoept that, prior to January 1, 2014, health plans may inolude restrioted annual 
limits on essential benefits oonsistent with the requirements of the federal Affordable 
Care Aot and may establish annual limits oonsistent v,rith waivers granted by the 
Seoretary of the United States Department of Health and Human Servioes. 
3. Application. This section applies to health plans offered or renewed in this State 
in the individual, small group and large group markets, as those markets are defined 
under applicable federal law. A health plan may contain annual dollar limits to the extent 
allowed under the federal Affordable Care Act as of January 1, 2019 if the plan has been 
continuously renewed since that date, but the plan may not impose any new limits or 
reduce any existing limit in effect as of January 1, 2019. 
PARTB 
Sec. B-1. 24-A MRSA §4320-D, as enacted by PL 2011, c. 364, §34, is amended 
to read: 
§4320-D. Comprehensive health coverage 
Notwithstanding any other requirements of this Title, a carrier offering a health plan 
subjeot to the requirements of the federal ,\ffordable Care Aot in this State shall, at a 
minimum, provide coverage that incorporates an essential health benefits and oost 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A "to S.P. 10, L.D. 1 
sharing limitations package consistent with the requirements of the federal Affordable 
Care A.et this section. 
1. Essential health benefits package; definition. As used in this section, "essential 
health benefits package" means, with respect to any health plan, coverage that: 
A. Provides for the essential health benefits in accordance with subsection 2: 
B. Limits cost sharing for coverage in accordance with subsection 3; and 
C. Provides for levels of coverage in accordance with subsection 4. 
2. Substantially similar to federal Affordable Care Act; required categories. 
With respect to any individual or small group health plan offered on or after January 1, 
2020, a carrier shall provide essential health benefits that are substantially similar to that 
of the essential health benefits required in this State for a health plan subject to the federal 
Affordable Care Act as of January 1, 2019. Essential health benefits required for a health 
plan must include at least the following general categories and the items and services 
covered within the categories: 
A. Ambulatory patient services; 
B. Emergency services; 
C. Hospitalization: 
D. Maternity and newborn care; 
E. Mental health and substance use disorder services, including behavioral health 
treatment: 
F. Prescription drugs; 
G. Rehabilitative and habilitative services and devices; 
H. Laboratory services: 
I. Preventive and wellness services and chronic disease management: and 
J. Pediatric services, including oral and vision care, to the extent required by the 
· 
federal Affordable Care Act as of January l, 2019. 
3. Cost-sharing limitations. With;respect to any health plan offered on or after the 
effective date of this subsection, a carrier shall limit cost sharing on an annual basis in a 
manner that is consistent with the annual limits established for a health plan subject to the 
federal Affordable Care Act as of January 1, 2019 and as adjusted by the United States 
Department of Health and Human Services, Centers for Medicare and Medicaid Services, 
or, if the Centers for Medicare and Medicaid Services does not establish annual limits on 
cost sharing, the superintendent shall adopt rules establishing annual limits on cost 
sharing under this subsection that are calculated in substantially the same manner as the 
Centers for Medicare and Medicaid Service~ calculated the annual limit in the most 
recent year it calculated the annual limit. 
4. Levels of covera~. Carriers shall offer coverage at levels that are substantially 
similar to the levels of coverage required for health plans subject to the federal 
Affordable Care Act as of January 1, 2019. The superintendent may adopt rules defining 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 10, L.D. 1 
such levels of coverage. Rules adopted pursuant to this subsection are routine technical 
rules as defined in Title 5, chapter 375, subchapter 2-A. 
5. Rule of construction. This section may not be construed to prohibit a health plan 
from providing benefits in excess of the essential health benefits described in this section. 
PARTC 
Sec. C-1. 24-A MRSA §2850-C, sub-§3 is enacted to read: 
3. Applicability of section 4320-L. In addition to the requirements of this section, a 
carrier is subject to section 4320-L. 
Sec. C-2. 24-A MRSA §4320-L is enacted to read: 
§4320-L. Nondiscrimination 
1. Nondiscrimination. An individual may not, on the basis of race, color, national 
origin, sex, sexual orientation, gender identity, age or disability, be exduded from 
participation in, be denied benefits of or otherwise be subjected to discrimination under 
any health plan offered in accordance with this Title. A carrier may not in offering, 
providing or administering a health plan: 
A. Deny, cancel, limit or refuse to issue or renew a health plan or other health-related 
coverage, deny or limit coverage of a claim or impose additional cost sharing or other 
limitations or restrictions on coverage on the basis of race, color, national origin, sex, 
sexual orientation, gender identity, age or disability; 
B. Have or implement marketing practices or benefit designs that discriminate on the 
basis of race, color, national origin, sex, sexual orientation, gender identity, age or 
disability in a health plan or other health-related coverage; 
C. Deny or limit coverage, deny or limit coverage of a claim or impose additional 
cost sharing or other limitations or restrictions on coverage for any health services 
that are ordinarily or exclusively available to individuals of one sex to a transgender 
individual based on the fact that the individual's sex assigned at birth, gender identity 
or gender otherwise recorded is different from the one to which such health services 
are ordinarily or exclusively available; 
D. Have or implement a categorical coverage exclusion or limitation for all health 
services related to gender transition; or 
E. Otherwise deny or limit coverage, deny or limit coverage of a claim or impose 
additional cost sharing or other limitations or restrictions on coverage for specific 
health services related to gender transition if such denial, limitation or restriction 
results in discrimination against a transgender individual. 
Nothing in this subsection is intended to determine or restrict a carrier from determining 
whether a particular health service is medically necessary or otherwise meets applicable 
coverage requirements in any individual case. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 10, L.D. 1 
2. Meaningful access for individuals with limited English proficiency. A carrier 
shall take reasonable steps to provide meaningful access to each enrollee or prospective 
enrollee under a health plan who has limited proficiency in English. 
3. Effective communication for persons with disabilities. A carrier shall take 
reasonable steps to ensure that communication with an enrollee or prospective enrollee in 
a health plan who is an individual with a disability is as effective as communication with 
other enrollees or prospective enrollees .• 
PARTD 
Sec. D-1. 24-A MRSA §2749-C, sub-§1, as amended by PL 2003, c. 20, Pt. VV, 
§8 and affected by §25, is further amended to read: 
1. Coverage for treatment for certain mental illnesses. Coverage for medical 
treatment for mental illnesses listed in paragraph -A- A-1 by all individual policies is 
subject to this section. 
A. All individual polioies must make available ooverage providing, at a minimum, 
benefits aooording to paragraph B, subparagraph (1) for a person reoeiving medioal 
treatment for any of the following mental illnesses diagnosed by a lioensed allopathio 
or osteopathio physioian or a licensed psychologist v1ho is trained and has reoeived a 
doctorat6 in psyohology sp6oializing in th6 6Valuation and tr6atment of mental illn6ss: 
(1) Sohizophrenia: 
(2) Bipolar disorder; 
(3) Pervasive developmental disorder. or autism: 
(4) Paranoia; 
(5) Panic disorder; 
(6) Obsessive oompulsive disorder: or 
(7) Major depressive disorder. 
A-1. All individual contracts must provide, at a minimum, benefits according to 
paragraph B, subparagraph (1) for a person receiving medical treatment for any of the 
following categories of mental illness as defined in the Diagnostic and Statistical 
Manual as defined in section 2843, subsection 3, paragraph A-1, except for those that 
are designated as "V" codes by the Diagnostic and Statistical Manual: 
(1) Psychotic disorders, including schizophrenia; 
(2) Dissociative disorders; 
(3) Mood disorders; 
(4) Anxiety disorders; 
(5) Personality disorders; 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 10, L.D. 1 
(6) Paraphilias; 
(7) Attention deficit and disruptive behavior disorders; 
(8) Pervasive developmental disorders; 
(9) Tic disorders; 
(10) Eating disorders, including bulimia and anorexia; and 
(11) Substance use disorders. 
For the purposes of this paragraph, the mental illness must be diagnosed by a licensed 
allopathic or osteopathic physician or a licensed psychologist who is trained and has 
received a doctorate in psychology specializing in the evaluation and treatment of 
mental illness. 
· 
B. All individual policies and contracts executed, delivered, issued for delivery, 
continued or renewed in this State must make available provide coverage providing 
benefits that meet the requirements of this paragraph. 
(1) The offer of coverage must provide benefits for the treatment and diagnosis 
of mental illnesses under terms and conditions that are no less extensive than the 
benefits provided for medical treatment for physical illnesses. 
(2) At the request of a reimbursing insurer, a provider of medical treatment for 
mental illness shall furnish data substantiating that initial or continued treatment 
is medically necessary health care. When making the determination of whether 
treatment is medically necessary health care, the provider shall use the same 
criteria for medical treatment for mental illness as for medical treatment for 
physical illness under the individual policy. 
Sec. D-2. 24-A MRSA §2843, sub-§5-A, as amended by PL 1989, c. 490, §4, is 
repealed. 
Sec. D-3. 24-A MRSA §4234-A, sub-§6, as amended by PL 2017, c. 407, Pt. A, 
§98, is further amended to read: 
6. Coverage for treatment of certain mental illnesses. Coverage for medical 
treatment for mental illnesses listed in paragraph A-1 is subject to this subsection. 
A-1. 
All individual and group contracts must provide, at a minimum, benefits 
according to paragraph B, subparagraph (1) for a person receiving medical treatment 
for any of the following categories of mental illness as defined in the Diagnostic and 
Statistical Manual, except for those designated as "V" codes in the Diagnostic and 
Statistical Manual: 
(1) Psychotic disorders, including schizophrenia; 
(2) Dissociative disorders; 
(3) Mood disorders; 
(4) Anxiety disorders; 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT "A "to S.P. 10, L.D. 1 
(5) Personality disorders; 
(6) Paraphilias; 
(7) Attention deficit and disruptive behavior disorders; 
(8) Pervasive developmental disorders; 
(9) Tic disorders; 
(10) Eating disorders, including bulimia and anorexia; and 
(11) Substance use disorders. 
For the purposes of this paragraph, the mental illness must be diagnosed by a licensed 
allopathic or osteopathic physician or a licensed psychologist who is trained and has 
received a doctorate in psychology specializing in the evaluation and treatment of 
mental illness. 
B. All policies, contracts and certificates executed, delivered, issued for delivery, 
continued or renewed in this State must provide benefits that meet the requirements 
of this paragraph. 
(1) The contracts must provide benefits for the treatment and diagnosis of mental 
illnesses under terms and conditions that are no less extensive than the benefits 
provided for medical treatment for physical illnesses. 
(2) At the request of a reimbursing health maintenance organization, a provider 
of medical treatment for mental illness shall furnish data substantiating that initial 
or continued treatment is medically necessary health care. When making the 
determination of whether treatment is medically necessary health care, the 
provider shall use the same criteria for medical treatment for mental illness as for 
medical treatment for physical illness under the group contract. 
(3) If benefits and coverage for the treatment of physical illness are provided on 
an expense-incurred basis, the benefits and coverage required under this 
subsection may be delivered separately under a managed care system. 
( 4) A policy or contract may not have separate maximums for physical illness 
and mental illness, separate deductibles and coinsurance amounts for physical 
illness and mental illness, separate out-of-pocket limits in a benefit period of not 
more than 12 months for physical illness and mental illness or separate office 
visit limits for physical illness and mental illness. 
(5) A health benefit plan may not impose a limitation on coverage or benefits for 
mental illness unless that same limitation is also imposed on the cov,erage and 
benefits for physical illness covered under the policy or contract. 
( 6) Copayments required under a policy or contract for benefits and coverage for 
mental illness must be actuarially equivalent to any coinsurance requirements or, 
if there are no coinsurance requirements, may not be greater than any copayment 
or coinsurance required under the policy or contract for a benefit or coverage for 
a physical illness. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" A "to S.P. 10, L.D. 1 
(7) For the purposes of this section, a medication management visit associated 
with a mental illness must be· covered in the same manner as a medication 
management visit for the treatment of a physical illness and may not be counted 
in the calculation of any maximum outpatient treatment visit limits. 
This subseotion does not apply to polioies, oontraots or oertifioates severing employees of 
employers with 20 or fewer employees, whether the group polioy is issued to the 
employer, to an assooiation, to a multiple employer trust or to another entity. 
Sec. D-4. 24-A MRSA §4234-A, sub-§7, as amended by PL 2003, c. 20, Pt. VV, 
§21 and affected by §25, is repealed.' 
SUMMARY 
This amendment replaces the bill and is the majority report of the committee. The 
purpose of this amendment is to ensure that consumer protections related to health 
insurance coverage included in the federal Patient Protection and Affordable Care Act are 
codified in state law. 
In Part A, the amendment does the following. 
1. It makes clear that carriers in the individual, small group and large group markets 
must meet guaranteed issue requirements similar to those required by federal law. 
2. 
It makes clear that individual and group health plans may not impose any 
preexisting condition exclusion on an enrollee. The amendment does permit a carrier to 
restrict enrollment in individual health plans to open enrollment and special enrollment 
periods established in rule. 
3. It clarifies that carriers offering individual or group health plans may not establish 
lifetime or annual limits on the dollar value of benefits unless the plan is grandfathered 
under the federal Affordable Care Act as of January 1, 2019 and does not impose new 
limits or reduce existing limits. The amendment specifies that the provision prohibiting 
annual limits on the dollar value of benefits applies to the dollar value of essential health 
benefits. 
4. It allows children, until they attain 26 years of age, to remain on their parents' 
health insurance policy. 
5. It changes the maximum rate differential due to age that may be filed by the 
carrier to 3 to 1 and requires that rates that vary based on age do so according to a 
uniform age rating curve. 
6. It provides that if a carrier varies premium rates based on family membership, the 
premium rate must equal the sum of the premiums for each individual in the family. 
7. 
It prohibits a carrier from varying premium rates based on tobacco use for 
individuals who are enrolled in an evidence-based tobacco cessation program approved 
by the United States Department of Health and Human Services, Food and Drug 
Administration. 
8. It makes clear that the minimum medical loss ratio in the individual market is 80% 
without exception. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT";\ "to S.P. 10, LD. 1 
9. It adds language to prohibit rescissions of coverage consistent with requirements 
under federal law. 
10. It makes changes to the timelines and requirements for determinations by a 
carrier of coverage for prescription drugs consistent with federal law. 
11. It requires carriers to provide information about the health plans offered by the 
carrier in a standardized manner that is substantially similar to the manner required for 
health plans subject to the federal Patient Protection and Affordable Care Act as of 
January 1, 2019. 
12. It removes a provision of the bill that would have repealed the authority for 
O 
certain individuals to purchase coverage under an individual, nonrenewable short-term 
policy. 
13. It prohibits a health plan from reducing or terminating benefits for an ongoing 
course of treatment, including coverage of a prescription drug, during the course of an 
appeal of a determination of coverage. 
Part B requires that, at a minimum, individual and small group health plans cover 
essential health benefits that are substantially similar to those benefits required for health 
plans subject to the federal Patient Protection and Affordable Care Act as of January 1, 
2019. The amendment also requires that health plans meet annual limits on cost sharing 
that are substantially similar to those benefits required for health plans subject to the 
federal Patient Protection and Affordable Care Act as of January 1, 2019. 
The 
amendment removes provisions of the bill that authorized the Superintendent of 
Insurance to make changes to essential health benefits and cost sharing limits in rule. The 
amendment clarifies that pediatric dental benefits may not be required of all individual 
and small group plans if dental coverage is available in accordance with the federal 
Affordable Care Act as in effect as of January 1, 2019. 
Part C adopts nondiscrimination provisions consistent with similar requirements in 
federal law and rule. 
Part D makes changes to current requirements in state law related to mental health 
parity consistent with similar requirements in federal law and regulations. 
COMMITTEE AMENDMENT