An Act To Amend the Mental Health Insurance Coverage Laws
Maine Legislature, Session 129, LD 1694
Committee: Health Coverage, Insurance and Financial Services
Sponsors: GRATWICK, SCHNECK, CARPENTER, CLAXTON, DILL, MILLETT, ROSEN
Amends: 24 MRSA §2325-A, 24 MRSA §2325-D, 24-A MRSA §238, 24-A MRSA §2749-C, 24-A MRSA §2749-D, 24-A MRSA §2843, 24-A MRSA §2847-V, 24-A MRSA §4234-A, 24-A MRSA §4234-F

Legislative Document
No. 1694
S.P. 559
In Senate, May 7, 2019
An Act To Amend the Mental Health Insurance Coverage Laws
Reference to the Committee on Health Coverage, Insurance and Financial Services 
suggested and ordered printed.
DAREK M. GRANT
Secretary of the Senate
Presented by Senator GRATWICK of Penobscot.
Cosponsored by Representative SCHNECK of Bangor and
Senators: CARPENTER of Aroostook, CLAXTON of Androscoggin, DILL of Penobscot, 
MILLETT of Cumberland, ROSEN of Hancock.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24 MRSA §2325-A, sub-§8, as amended by PL 1995, c. 407, §3, is 
repealed and the following enacted in its place:
8.  Reports to the superintendent.  A nonprofit hospital and medical service 
organization shall submit annual reports in accordance with this subsection.
A.  A nonprofit hospital or medical service organization subject to this section shall 
report its experience for each calendar year to the superintendent no later than April 
30th of the following year.  The report must be in a form prescribed by the 
superintendent and include the amount of claims paid in this State for the services 
required by this section and the total amount of claims paid in this State for group 
health care contracts, both separated according to those paid for inpatient, day 
treatment and outpatient services.  The superintendent shall compile this data for all 
nonprofit hospitals and medical service organizations in an annual report.
B.  A nonprofit hospital or medical service organization subject to this section shall 
submit an annual report to the superintendent no later than April 30th that contains 
the following information:
(1)  A description of the process used to develop or select the medically 
necessary health care criteria for mental illness and substance use disorder 
benefits and the process used to develop or select the medically necessary health 
care criteria for medical and surgical benefits;
(2)  Identification of all nonquantitative treatment limitations that are applied to 
mental illness and substance use disorder benefits and medical and surgical 
benefits within each classification of benefits.  The report must include 
information demonstrating that each nonquantitative treatment limitation that 
applies to mental illness and substance use disorder benefits also applies to 
medical and surgical benefits within any classification of benefits; and
(3)  The results of an analysis that demonstrate that for the medically necessary 
health care criteria described in subparagraph (1) and for each nonquantitative 
treatment limitation identified in subparagraph (2), as written and in operation, 
the processes, strategies, evidentiary standards or other factors used in applying 
the medically necessary health care criteria and each nonquantitative treatment 
limitation to mental illness and substance use disorder benefits within each 
classification of benefits are comparable to, and are applied no more stringently 
than, the processes, strategies, evidentiary standards or other factors used in 
applying the medically necessary health care criteria and each nonquantitative 
treatment limitation to medical and surgical benefits within the corresponding 
classification of benefits.  At a minimum, the results of the analysis must:
(a)  Identify the factors used to determine that a nonquantitative treatment 
limitation applies to a benefit, including factors that were considered but 
rejected;
(b)  Identify and define the specific evidentiary standards used to define the 
factors and any other evidence relied upon in designing each nonquantitative 
treatment limitation;
(c)  Identify and describe the comparative analyses, including the results of 
the analyses, used to determine that the processes and strategies used to 
design each nonquantitative treatment limitation, as written, for mental 
illness and substance use disorder benefits are comparable to, and are applied 
no more stringently than, the processes and strategies used to design each 
nonquantitative treatment limitation, as written, for medical and surgical 
benefits;
(d)  Identify and describe the comparative analyses, including the results of 
the analyses, used to determine that the processes and strategies used to apply 
each nonquantitative treatment limitation, in operation, for mental illness and 
substance use disorder benefits are comparable to, and applied no more 
stringently than, the processes and strategies used to apply each 
nonquantitative treatment limitation, in operation, for medical and surgical 
benefits; and
(e)  Disclose the specific findings and conclusions reached by the nonprofit 
hospital or medical service organization that the results of the analyses in this 
subparagraph indicate that the nonprofit hospital or medical service 
organization is in compliance with this section and the federal Paul Wellstone 
and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 
and its implementing and related regulations, which include 45 Code of 
Federal Regulations, Sections 146.136, 147.160 and 156.115(a)(3).
For the purposes of this paragraph, "nonquantitative treatment limitation" means a 
limitation that is not expressed numerically but otherwise limits the scope or duration 
of benefits for treatment.
Sec. 2.  24 MRSA §2325-D is enacted to read:
§2325-D.  Prescription drug benefits for substance use disorder treatment
A nonprofit hospital or medical service organization that issues group health care 
contracts that provide prescription drug benefits for the treatment of substance use 
disorder:
1.  Prior authorization requirements.  May not impose any prior authorization 
requirements on any prescription medication approved by the federal Food and Drug 
Administration for the treatment of substance use disorder;
2.  Step therapy requirements.  May not impose any step therapy requirements 
before the nonprofit hospital or medical service organization authorizes coverage for a 
prescription medication approved by the federal Food and Drug Administration for the 
treatment of substance use disorder;
3.  Drug formulary.  Shall place all prescription medications approved by the federal 
Food and Drug Administration for the treatment of substance use disorder on the lowest 
tier of the drug formulary developed and maintained by the nonprofit hospital or medical 
service organization; and
4.  Court-ordered medication.  May not exclude coverage for any prescription 
medication approved by the federal Food and Drug Administration for the treatment of 
substance use disorder or any associated counseling or wraparound services on the 
grounds that such medications and services were court ordered.
Sec. 3.  24-A MRSA §238 is enacted to read:
§238.  Implementation of federal mental health parity laws
1.  Implementation of federal mental health parity laws.  The superintendent shall 
implement and enforce applicable provisions of the federal Paul Wellstone and Pete 
Domenici Mental Health Parity and Addiction Equity Act of 2008, and any amendments 
to and federal guidance or regulations relevant to that Act, including 45 Code of Federal 
Regulations, Sections 146.136, 147.136, 147.160 and 156.115(a)(3), by:
A.  Proactively ensuring compliance by insurers, health maintenance organizations 
and nonprofit hospital or medical service organizations that execute, deliver, issue for 
delivery, continue or renew individual policies or individual and group health care 
contracts;
B.  Evaluating all consumer or provider complaints regarding mental illness and 
substance use disorder coverage for possible parity violations;
C.  Performing parity compliance market conduct examinations of insurers, health 
maintenance organizations and nonprofit hospital or medical service organizations 
that execute, deliver, issue for delivery, continue or renew individual policies or 
individual and group health care contracts, particularly market conduct examinations 
that focus on nonquantitative treatment limitations, including, but not limited to, prior 
authorization, concurrent review, retrospective review, step therapy, network 
admission standards, reimbursement rates and geographic restrictions; and
D.  Requesting that insurers, health maintenance organizations and nonprofit hospital 
or medical service organizations submit comparative analyses during the form review 
process demonstrating how they design and apply nonquantitative treatment 
limitation, both as written and in operation, for mental illness and substance use 
disorder benefits as compared to how they design and apply nonquantitative 
treatment limitation, as written and in operation, for medical and surgical benefits.
The superintendent may adopt rules, as authorized under section 212, as may be 
necessary to effectuate any provisions of the federal Paul Wellstone and Pete Domenici 
Mental Health Parity and Addiction Equity Act of 2008 that relate to the business of 
insurance.  Rules adopted pursuant to this subsection are routine technical rules as 
defined in Title 5, chapter 375, subchapter 2-A.
2.  Report.  No later than March 1, 2020 and periodically thereafter, the 
superintendent shall provide a report and educational presentation to the Legislature.  The 
report must:
A.  Cover the methodology the superintendent is using to check for compliance with 
the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 
Equity Act of 2008 and any federal regulations or guidance relating to the compliance 
and oversight of that Act;
B.  Cover the methodology the superintendent is using to check for compliance with 
sections 2749-C, 2842, 2843 and 4234-A and Title 24, sections 2325-A and 2329;
C.  Identify market conduct examinations conducted or completed during the 
preceding 12-month period regarding compliance with parity in mental illness and 
substance use disorder benefits under state and federal laws, and summarize the 
results of such market conduct examinations;
D.  Detail any educational or corrective actions the superintendent has taken to ensure 
insurer compliance with the federal Paul Wellstone and Pete Domenici Mental Health 
Parity and Addiction Equity Act of 2008 and sections 2749-C, 2842, 2843 and 
4234-A and Title 24, sections 2325-A and 2329; and
E.  Be written in nontechnical, understandable language and made available to the 
public by posting the report on the bureau's publicly accessible website and other 
means the superintendent finds appropriate.
Sec. 4.  24-A MRSA §2749-C, sub-§4, as enacted by PL 1995, c. 407, §5, is 
repealed and the following enacted in its place:
4.  Reports to the superintendent.  An insurer shall submit annual reports in 
accordance with this subsection.
A.  An insurer subject to this section shall report its experience for each calendar year 
to the superintendent no later than April 30th of the following year.  The report must 
be in a form prescribed by the superintendent and include the amount of claims paid 
in this State for the services required by this section and the total amount of claims 
paid in this State for individual health care policies, both separated according to those 
paid for inpatient, day treatment and outpatient services, as those terms are defined in 
section 2843.  The superintendent shall compile this data for all insurers in an annual 
report.
B.  An insurer subject to this section shall submit an annual report to the 
superintendent no later than April 30th that contains the following information:
(1)  A description of the process used to develop or select the medically 
necessary health care criteria for mental illness and substance use disorder 
benefits and the process used to develop or select the medically necessary health 
care criteria for medical and surgical benefits;
(2)  Identification of all nonquantitative treatment limitations that are applied to 
mental illness and substance use disorder benefits and medical and surgical 
benefits within each classification of benefits.  The report must include 
information demonstrating that each nonquantitative treatment limitation that 
applies to mental illness and substance use disorder benefits also applies to 
medical and surgical benefits within any classification of benefits; and
(3)  The results of an analysis that demonstrate that for the medically necessary 
health care criteria described in subparagraph (1) and for each nonquantitative 
treatment limitation identified in subparagraph (2), as written and in operation, 
the processes, strategies, evidentiary standards or other factors used in applying 
the medically necessary health care criteria and each nonquantitative treatment 
limitation to mental illness and substance use disorder benefits within each 
classification of benefits are comparable to, and are applied no more stringently 
than, the processes, strategies, evidentiary standards or other factors used in 
applying the medically necessary health care criteria and each nonquantitative 
treatment limitation to medical and surgical benefits within the corresponding 
classification of benefits.  At a minimum, the results of the analysis must:
(a)  Identify the factors used to determine that a nonquantitative treatment 
limitation applies to a benefit, including factors that were considered but 
rejected;
(b)  Identify and define the specific evidentiary standards used to define the 
factors and any other evidence relied upon in designing each nonquantitative 
treatment limitation;
(c)  Identify and describe the comparative analyses, including the results of 
the analyses, used to determine that the processes and strategies used to 
design each nonquantitative treatment limitation, as written, for mental 
illness and substance use disorder benefits are comparable to, and are applied 
no more stringently than, the processes and strategies used to design each 
nonquantitative treatment limitation, as written, for medical and surgical 
benefits;
(d)  Identify and describe the comparative analyses, including the results of 
the analyses, used to determine that the processes and strategies used to apply 
each nonquantitative treatment limitation, in operation, for mental illness and 
substance use disorder benefits are comparable to, and applied no more 
stringently than, the processes and strategies used to apply each 
nonquantitative treatment limitation, in operation, for medical and surgical 
benefits; and
(e)  Disclose the specific findings and conclusions reached by the insurer that 
the results of the analyses in this subparagraph indicate that the insurer is in 
compliance with this section and the federal Paul Wellstone and Pete 
Domenici Mental Health Parity and Addiction Equity Act of 2008 and its 
implementing and related regulations, which include 45 Code of Federal 
Regulations, Sections 146.136, 147.160 and 156.115(a)(3).
For the purposes of this paragraph, "nonquantitative treatment limitation" means a 
limitation that is not expressed numerically but otherwise limits the scope or duration 
of benefits for treatment.
Sec. 5.  24-A MRSA §2749-D is enacted to read:
§2749-D.  Prescription drug benefits for substance use disorder treatment
An insurer that executes, delivers, issues for delivery, continues or renews individual 
health care policies that provide prescription drug benefits for the treatment of substance 
use disorder:
1.  Prior authorization requirements.  May not impose any prior authorization 
requirements on any prescription medication approved by the federal Food and Drug 
Administration for the treatment of substance use disorder;
2.  Step therapy requirements.  May not impose any step therapy requirements 
before the insurer authorizes coverage for a prescription medication approved by the 
federal Food and Drug Administration for the treatment of substance use disorder;
3.  Drug formulary.  Shall place all prescription medications approved by the federal 
Food and Drug Administration for the treatment of substance use disorder on the lowest 
tier of the drug formulary developed and maintained by the insurer; and
4.  Court-ordered medication.  May not exclude coverage for any prescription 
medication approved by the federal Food and Drug Administration for the treatment of 
substance use disorder or any associated counseling or wraparound services on the 
grounds that such medications and services were court ordered.
Sec. 6.  24-A MRSA §2843, sub-§7, as amended by PL 1995, c. 407, §8, is 
repealed and the following enacted in its place:
7.  Reports to the superintendent.  An insurer shall submit annual reports in 
accordance with this subsection.
A.  An insurer subject to this section shall report its experience for each calendar year 
to the superintendent no later than April 30th of the following year.  The report must 
be in a form prescribed by the superintendent and include the amount of claims paid 
in this State for the services required by this section and the total amount of claims 
paid in this State for group health care contracts, both separated according to those 
paid for inpatient, day treatment and outpatient services.  The superintendent shall 
compile this data for all insurers in an annual report.
B.  An insurer subject to this section shall submit an annual report to the 
superintendent no later than April 30th that contains the following information:
(1)  A description of the process used to develop or select the medically 
necessary health care criteria for mental illness and substance use disorder 
benefits and the process used to develop or select the medically necessary health 
care criteria for medical and surgical benefits;
(2)  Identification of all nonquantitative treatment limitations that are applied to 
mental illness and substance use disorder benefits and medical and surgical 
benefits within each classification of benefits.  The report must include 
information demonstrating that each nonquantitative treatment limitation that 
applies to mental illness and substance use disorder benefits also applies to 
medical and surgical benefits within any classification of benefits; and
(3)  The results of an analysis that demonstrate that for the medically necessary 
health care criteria described in subparagraph (1) and for each nonquantitative 
treatment limitation identified in subparagraph (2), as written and in operation, 
the processes, strategies, evidentiary standards or other factors used in applying 
the medically necessary health care criteria and each nonquantitative treatment 
limitation to mental illness and substance use disorder benefits within each 
classification of benefits are comparable to, and are applied no more stringently 
than, the processes, strategies, evidentiary standards or other factors used in 
applying the medically necessary health care criteria and each nonquantitative 
treatment limitation to medical and surgical benefits within the corresponding 
classification of benefits.  At a minimum, the results of the analysis must:
(a)  Identify the factors used to determine that a nonquantitative treatment 
limitation applies to a benefit, including factors that were considered but 
rejected;
(b)  Identify and define the specific evidentiary standards used to define the 
factors and any other evidence relied upon in designing each nonquantitative 
treatment limitation;
(c)  Identify and describe the comparative analyses, including the results of 
the analyses, used to determine that the processes and strategies used to 
design each nonquantitative treatment limitation, as written, for mental 
illness and substance use disorder benefits are comparable to, and are applied 
no more stringently than, the processes and strategies used to design each 
nonquantitative treatment limitation, as written, for medical and surgical 
benefits;
(d)  Identify and describe the comparative analyses, including the results of 
the analyses, used to determine that the processes and strategies used to apply 
each nonquantitative treatment limitation, in operation, for mental illness and 
substance use disorder benefits are comparable to, and applied no more 
stringently than, the processes and strategies used to apply each 
nonquantitative treatment limitation, in operation, for medical and surgical 
benefits; and
(e)  Disclose the specific findings and conclusions reached by the insurer that 
the results of the analyses in this subparagraph indicate that the insurer is in 
compliance with this section and the federal Paul Wellstone and Pete 
Domenici Mental Health Parity and Addiction Equity Act of 2008 and its 
implementing and related regulations, which include 45 Code of Federal 
Regulations, Sections 146.136, 147.160 and 156.115(a)(3).
For the purposes of this paragraph, "nonquantitative treatment limitation" means a 
limitation that is not expressed numerically but otherwise limits the scope or duration 
of benefits for treatment.
Sec. 7.  24-A MRSA §2847-V is enacted to read:
§2847-V.  Prescription drug benefits for substance use disorder treatment
An insurer that issues group health care contracts that provide prescription drug 
benefits for the treatment of substance use disorder:
1.  Prior authorization requirements.  May not impose any prior authorization 
requirements on any prescription medication approved by the federal Food and Drug 
Administration for the treatment of substance use disorder;
2.  Step therapy requirements.  May not impose any step therapy requirements 
before the insurer authorizes coverage for a prescription medication approved by the 
federal Food and Drug Administration for the treatment of substance use disorder;
3.  Drug formulary.  Shall place all prescription medications approved by the federal 
Food and Drug Administration for the treatment of substance use disorder on the lowest 
tier of the drug formulary developed and maintained by the insurer; and
4.  Court-ordered medication.  May not exclude coverage for any prescription 
medication approved by the federal Food and Drug Administration for the treatment of 
substance use disorder or any associated counseling or wraparound services on the 
grounds that such medications and services were court ordered.
Sec. 8.  24-A MRSA §4234-A, sub-§10, as enacted by PL 1995, c. 407, §10, is 
repealed and the following enacted in its place:
10.  Reports to the superintendent.  A health maintenance organization shall submit 
annual reports in accordance with this subsection.
A.  A health maintenance organization subject to this section shall report its 
experience for each calendar year to the superintendent no later than April 30th of the 
following year.  The report must be in a form prescribed by the superintendent and 
include the amount of claims paid in this State for the services required by this 
section and the total amount of claims paid in this State for individual and group 
health care contracts, both separated according to those paid for inpatient, day 
treatment and outpatient services.  The superintendent shall compile this data for all 
health maintenance organizations in an annual report.
B.  A health maintenance organization subject to this section shall submit an annual 
report to the superintendent no later than April 30th that contains the following 
information:
(1)  A description of the process used to develop or select the medically 
necessary health care criteria for mental illness and substance use disorder 
benefits and the process used to develop or select the medically necessary health 
care criteria for medical and surgical benefits;
(2)  Identification of all nonquantitative treatment limitations that are applied to 
mental illness and substance use disorder benefits and medical and surgical 
benefits within each classification of benefits.  The report must include 
information demonstrating that each nonquantitative treatment limitation that 
applies to mental illness and substance use disorder benefits also applies to 
medical and surgical benefits within any classification of benefits; and
(3)  The results of an analysis that demonstrate that for the medically necessary 
health care criteria described in subparagraph (1) and for each nonquantitative 
treatment limitation identified in subparagraph (2), as written and in operation, 
the processes, strategies, evidentiary standards or other factors used in applying 
the medically necessary health care criteria and each nonquantitative treatment 
limitation to mental illness and substance use disorder benefits within each 
classification of benefits are comparable to, and are applied no more stringently 
than, the processes, strategies, evidentiary standards or other factors used in 
applying the medically necessary health care criteria and each nonquantitative 
treatment limitation to medical and surgical benefits within the corresponding 
classification of benefits.  At a minimum, the results of the analysis must:
(a)  Identify the factors used to determine that a nonquantitative treatment 
limitation applies to a benefit, including factors that were considered but 
rejected;
(b)  Identify and define the specific evidentiary standards used to define the 
factors and any other evidence relied upon in designing each nonquantitative 
treatment limitation;
(c)  Identify and describe the comparative analyses, including the results of 
the analyses, used to determine that the processes and strategies used to 
design each nonquantitative treatment limitation, as written, for mental 
illness and substance use disorder benefits are comparable to, and are applied 
no more stringently than, the processes and strategies used to design each 
nonquantitative treatment limitation, as written, for medical and surgical 
benefits;
(d)  Identify and describe the comparative analyses, including the results of 
the analyses, used to determine that the processes and strategies used to apply 
each nonquantitative treatment limitation, in operation, for mental illness and 
substance use disorder benefits are comparable to, and applied no more 
stringently than, the processes and strategies used to apply each 
nonquantitative treatment limitation, in operation, for medical and surgical 
benefits; and
(e)  Disclose the specific findings and conclusions reached by the health 
maintenance organization that the results of the analyses in this subparagraph 
indicate that the health maintenance organization is in compliance with this 
section and the federal Paul Wellstone and Pete Domenici Mental Health 
Parity and Addiction Equity Act of 2008 and its implementing and related 
regulations, which include 45 Code of Federal Regulations, Sections 
146.136, 147.160 and 156.115(a)(3).
For the purposes of this paragraph, "nonquantitative treatment limitation" means a 
limitation that is not expressed numerically but otherwise limits the scope or duration 
of benefits for treatment.
Sec. 9.  24-A MRSA §4234-F is enacted to read:
§4234-F.  Prescription drug benefits for substance use disorder treatment
A health maintenance organization that executes, delivers, issues for delivery, 
continues or renews individual and group health care contracts that provide prescription 
drug benefits for the treatment of substance use disorder:
1.  Prior authorization requirements.  May not impose any prior authorization 
requirements on any prescription medication approved by the federal Food and Drug 
Administration for the treatment of substance use disorder;
2.  Step therapy requirements.  May not impose any step therapy requirements 
before the health maintenance organization authorizes coverage for a prescription 
medication approved by the federal Food and Drug Administration for the treatment of 
substance use disorder;
3.  Drug formulary.  Shall place all prescription medications approved by the federal 
Food and Drug Administration for the treatment of substance use disorder on the lowest 
tier of the drug formulary developed and maintained by the health maintenance 
organization; and
4.  Court-ordered medication.  May not exclude coverage for any prescription 
medication approved by the federal Food and Drug Administration for the treatment of 
substance use disorder or any associated counseling or wraparound services on the 
grounds that such medications and services were court ordered.
Sec. 10.  Application.  The requirements of this Act apply to all insurers, health 
maintenance organizations and nonprofit hospital or medical service organizations that 
execute, deliver, issue for delivery, continue or renew individual and group health care 
policies, contracts and certificates in this State on or after January 1, 2020.
SUMMARY
This bill requires insurers, health maintenance organizations and nonprofit hospital or 
medical service organizations to submit mental health and substance use disorder parity 
compliance reports to the Superintendent of Insurance.  It specifies how the 
superintendent of Insurance may enforce parity requirements and provides parity 
reporting requirements for the superintendent.  The bill also prohibits certain types of 
medical management protocols from being used in conjunction with prescription 
medications used to treat substance use disorder.