An Act to Maintain the Integrity of the Individual and Small Group Health Insurance Markets
Maine Legislature, Session 131, LD 1253
Committee: Health Coverage, Insurance and Financial Services
Sponsors: MORRIS
Amends: 24-A MRSA §2792, 24-A MRSA §2793, 24-A MRSA §2808-B, 24-A MRSA §3958

Legislative Document
No. 1253
H.P. 801
House of Representatives, March 21, 2023
An Act to Maintain the Integrity of the Individual and Small Group 
Health Insurance Markets
Reference to the Committee on Health Coverage, Insurance and Financial Services 
suggested and ordered printed.
ROBERT B. HUNT
Clerk
Presented by Representative MORRIS of Turner.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA §2792, as amended by PL 2021, c. 361, §§1 and 2, is repealed.
Sec. 2.  24-A MRSA §2793, sub-§1, as amended by PL 2021, c. 361, §3, is further 
amended to read:
1.  Clear choice design.  For the purposes of this section, "clear choice design" means 
a set of annual copayments, coinsurance and deductibles for all or a designated subset of 
the essential health benefits. An individual health plan subject to section 2736‑C or a pooled 
market health plan subject to section 2792 must conform to one of the clear choice designs 
developed pursuant to this section unless it is approved as an alternative plan under 
subsection 4.
Sec. 3.  24-A MRSA §2808-B, sub-§2-A, ¶B, as amended by PL 2019, c. 653, Pt. 
B, §4, is further amended to read:
B.  A filing and all supporting information, except for protected health information 
required to be kept confidential by state or federal statute and except for descriptions 
of the amount and terms or conditions or reimbursement in a contract between an 
insurer and a 3rd party, are public records notwithstanding Title 1, section 402, 
subsection 3, paragraph B and become part of the official record of any hearing held 
pursuant to subsection 2‑B, paragraph B or section 2792, subsection 2.
Sec. 4.  24-A MRSA §2808-B, sub-§2-A, ¶C, as amended by PL 2019, c. 653, Pt. 
B, §5, is further amended to read:
C.  Rates for small group health plans must be filed in accordance with this section and 
subsections 2-B and 2-C or section 2792, as applicable, for premium rates effective on 
or after July 1, 2004, except that the rates for small group health plans are not required 
to account for any payment or any recovery of that payment pursuant to subsection 
2‑B, paragraph D and former section 6913 for rates effective before July 1, 2005.
Sec. 5.  24-A MRSA §2808-B, sub-§2-B, as amended by PL 2019, c. 653, Pt. B, 
§6, is further amended to read:
2-B.  Rate review and hearings.  Except as provided in subsection 2‑C and section 
2792, rate filings are subject to this subsection.
A.  Rates subject to this subsection must be filed for approval by the superintendent. 
The superintendent shall disapprove any premium rates filed by any carrier, whether 
initial or revised, for a small group health plan unless it is anticipated that the aggregate 
benefits estimated to be paid under all the small group health plans maintained in force 
by the carrier for the period for which coverage is to be provided will return to 
policyholders at least 75% of the aggregate premiums collected for those policies, as 
determined in accordance with accepted actuarial principles and practices and on the 
basis of incurred claims experience and earned premiums. For the purposes of this 
calculation, any payments paid pursuant to former section 6913 must be treated as 
incurred claims.
B.  If at any time the superintendent has reason to believe that a filing does not meet 
the requirements that rates not be excessive, inadequate or unfairly discriminatory or 
that the filing violates any of the provisions of chapter 23, the superintendent shall 
cause a hearing to be held.  Hearings held under this subsection must conform to the 
procedural requirements set forth in Title 5, chapter 375, subchapter 4.  The 
superintendent shall issue an order or decision within 30 days after the close of the 
hearing or of any rehearing or reargument or within such other period as the 
superintendent for good cause may require, but not to exceed an additional 30 days.  In 
the order or decision, the superintendent shall either approve or disapprove the rate 
filing.  If the superintendent disapproves the rate filing, the superintendent shall 
establish the date on which the filing is no longer effective, specify the filing the 
superintendent would approve and authorize the insurer to submit a new filing in 
accordance with the terms of the order or decision.
C.  When a filing is not accompanied by the information upon which the carrier 
supports the filing or the superintendent does not have sufficient information to 
determine whether the filing meets the requirements that rates not be excessive, 
inadequate or unfairly discriminatory, the superintendent shall require the carrier to 
furnish the information upon which it supports the filing.
D.  A carrier that adjusts its rate shall account for the savings offset payment or any 
recovery of that savings offset payment in its experience consistent with this section 
and former section 6913.
Sec. 6.  24-A MRSA §2808-B, sub-§2-C, as amended by PL 2019, c. 653, Pt. B, 
§7, is further amended to read:
2-C.  Guaranteed loss ratio.  Notwithstanding subsection 2‑B, rate filings for a 
credible block of small group health plans may be filed in accordance with this subsection 
instead of subsection 2‑B, except as otherwise provided in section 2792.  Rates filed in 
accordance with this subsection are filed for informational purposes.
A.  A block of small group health plans is considered credible if the anticipated average 
number of members during the period for which the rates will be in effect meets 
standards for full or partial credibility pursuant to the federal Affordable Care Act. The 
rate filing must state the anticipated average number of members during the period for 
which the rates will be in effect and the basis for the estimate.  If the superintendent 
determines that the number of members is likely to be less than needed to meet the 
credibility standard, the filing is subject to subsection 2‑B.
Sec. 7.  24-A MRSA §3958, sub-§1, as amended by PL 2021, c. 361, §5, is further 
amended to read:
1.  Reinsurance amount.  A member insurer offering an individual health plan under 
section 2736‑C must be reinsured by the association to the level of coverage provided in 
this subsection and is liable to the association for any applicable reinsurance premium at 
the rate established in accordance with subsection 2.  For calendar year 2023 and 
subsequent calendar years, the association shall also reinsure member insurers for small 
group health plans issued under section 2808‑B, unless otherwise provided in rules adopted 
by the superintendent pursuant to section 2792, subsection 5.
A.  Beginning July 1, 2012, except as otherwise provided in paragraph A‑1, the 
association shall reimburse a member insurer for claims incurred with respect to a 
person designated for reinsurance by the member insurer pursuant to section 3959 after 
the insurer has incurred an initial level of claims for that person of $7,500 for covered 
benefits in a calendar year.  In addition, the insurer is responsible for 10% of the next 
$25,000 of claims paid during a calendar year.  The amount of reimbursement is 90% 
of the amount incurred between $7,500 and $32,500 and 100% of the amount incurred 
in excess of $32,500 for claims incurred in that calendar year with respect to that 
person.  For calendar year 2012, only claims incurred on or after July 1st are considered 
in determining the member insurer's reimbursement.  With the approval of the 
superintendent, the association may annually adjust the initial level of claims and the 
maximum limit to be retained by the insurer to reflect changes in costs, utilization, 
available funding and any other factors affecting the sustainable operation of the 
association.
A-1.  In any plan year in which a pooled market is operating in accordance with section 
2792, the association shall operate a retrospective reinsurance program providing 
coverage to member insurers for all individual and small group health plans issued in 
this State in that plan year.  For plan years beginning in 2022, if the pooled market has 
not been implemented pursuant to section 2792, subsection 5, the association may 
operate a retrospective reinsurance program for individual health plans, subject to the 
approval of the superintendent.
(1)  The association shall reimburse member insurers based on the total eligible 
claims paid during a calendar year for a single individual in excess of the 
attachment point specified by the board. The board may establish multiple layers 
of coverage with different attachment points and different percentages of claims 
payments to be reimbursed by the association.
(2)  Eligible claims by all individuals enrolled in individual or small group health 
plans in this State may not be disqualified for reimbursement on the basis of health 
conditions, predesignation by the member insurer or any other differentiating 
factor.
(3)  The board shall annually review the attachment points and coinsurance 
percentages and make any adjustments that are necessary to ensure that the 
retrospective reinsurance program operates on an actuarially sound basis.
(4)  The board shall ensure that any surplus in the retrospective reinsurance 
program at the conclusion of a plan year is used to lower attachment points, 
increase coinsurance rates or both for that plan year, consistent with its 
responsibility to ensure that the program operates on an actuarially sound basis.
B.  A member insurer shall apply all managed care, utilization review, case 
management, preferred provider arrangements, claims processing and other methods 
of operation without regard to whether claims paid for coverage are reinsured under 
this subsection.  A member insurer shall report for each plan year the name of each 
high-priced item or service for which its payment exceeded the amount allowed for 
eligible claims and the name of the provider that received this payment.  The 
association shall annually compile and publish a list of all reported names.
SUMMARY
This bill removes the requirement that individual and small group health plans must be 
offered through a pooled market.