reglab/housing_qa huggingface dataset:
24-A ME Rev Stat § 4303-F (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4303-F. Reimbursement for ambulance services and participation of ambulance service providers in carrier networks

 §4303-F. Reimbursement for ambulance services and participation of ambulance service providers in carrier networks (CONTAINS TEXT WITH VARYING EFFECTIVE DATES)1.  (TEXT EFFECTIVE UNTIL 12/31/23) (TEXT REPEALED 12/31/23) Reimbursement for ambulance services.  Until December 31, 2023, with respect to a bill for covered emergency services rendered by an ambulance service provider, a carrier shall reimburse the ambulance service provider or enrollee, as applicable, as follows.   A. If the ambulance service provider participates in the carrier's network, the carrier shall reimburse at the ambulance service provider's rate or 200% of the Medicare rate for that service, whichever is less, plus any adjustment required by paragraph C.   [PL 2021, c. 241, §3 (NEW).]B. If the ambulance service provider is an out-of-network provider, the carrier shall reimburse at the ambulance service provider's rate or 180% of the Medicare rate for that service, whichever is less, plus any adjustment required by paragraph C.   [PL 2021, c. 241, §3 (NEW).]C. If the ambulance service provider is located in a rural or super rural area as designated by the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services and eligible for additional Medicare reimbursement for services that were provided to a Medicare enrollee, the carrier shall increase the reimbursement to that ambulance service provider in the same amount as the additional Medicare reimbursement.   [PL 2021, c. 241, §3 (NEW).]D. If, on the effective date of this subsection, an ambulance service provider's charge for ambulance services is below 200% of the Medicare rate for that service, the ambulance service provider may not increase the charge for that service by more than 5% annually.   [PL 2021, c. 241, §3 (NEW).]This subsection is repealed December 31, 2023.   [PL 2021, c. 241, §3 (NEW).] 2.  Network participation; standard contract.  A carrier shall offer a standard contract to all ambulance service providers willing to participate in the carrier's provider network with the following provisions:   A. (TEXT EFFECTIVE UNTIL 12/31/23) (TEXT REPEALED 12/31/23) The reimbursement rate paid for ambulance services conforms to the requirements of subsection 1.   This paragraph is repealed December 31, 2023;   [PL 2021, c. 241, §3 (NEW).]B. The contract term is for a minimum of 24 months;   [PL 2021, c. 241, §3 (NEW).]C. The contract may be terminated as long as the party seeking to terminate the contract provides at least 180 days' prior notice; and   [PL 2021, c. 241, §3 (NEW).]D. The contract provides that an ambulance service provider has a minimum of 120 days to submit a claim.   [PL 2021, c. 241, §3 (NEW).][PL 2021, c. 241, §3 (NEW).] 3.  Exemption.  This section does not apply to air ambulance services.   [PL 2021, c. 241, §3 (NEW).] SECTION HISTORY PL 2021, c. 241, §3 (NEW).
24-A ME Rev Stat § 4305 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4305. Quality of care

 §4305. Quality of care A carrier offering or renewing a health plan that subjects payment of benefits for otherwise covered services to review for clinical necessity, appropriateness, efficacy or efficiency must meet the following requirements relating to quality of care.   [PL 2007, c. 199, Pt. B, §14 (AMD).]1.  Internal quality assurance program.  A health plan must have an ongoing quality assurance program for the health care services provided or reimbursed by the health plan.   [PL 1995, c. 673, §1 (NEW); PL 1995, c. 673, §2 (AFF).] 2.  Written standards.  The standards of quality of care must be described in a written document, which must be available for examination by the superintendent or by the Department of Health and Human Services.   [PL 1995, c. 673, §1 (NEW); PL 1995, c. 673, §2 (AFF); PL 2003, c. 689, Pt. B, §6 (REV).] 3.  Coverage decisions.  Following a determination that a particular service is covered, a carrier may not deny payment for that service based on the enrollee's age, nature of disability or degree of medical dependency.   [PL 1995, c. 673, §1 (NEW); PL 1995, c. 673, §2 (AFF).] SECTION HISTORY PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 742, §14 (AMD). PL 2003, c. 689, §B6 (REV). PL 2007, c. 199, Pt. B, §14 (AMD).
24-A ME Rev Stat § 4306 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4306. Enrollee choice of primary care provider

 §4306. Enrollee choice of primary care provider A carrier offering or renewing a managed care plan shall allow enrollees to choose their own primary care providers, as allowed under the managed care plan's rules, from among the panel of participating providers made available to enrollees under the managed care plan's rules. A carrier shall allow physicians, including, but not limited to, pediatricians and physicians who specialize in obstetrics and gynecology, and physician assistants licensed pursuant to Title 32, section 2594‑E or section 3270‑E and certified nurse practitioners who have been approved by the State Board of Nursing to practice advanced practice registered nursing without the supervision of a physician pursuant to Title 32, section 2102, subsection 2‑A to serve as primary care providers for managed care plans. A carrier is not required to contract with certified nurse practitioners, physician assistants or physicians as primary care providers in any manner that exceeds the access and provider network standards required in this chapter or chapter 56, or any rules adopted pursuant to those chapters. A carrier shall allow enrollees in a managed care plan to change primary care providers without good cause at least once annually and to change with good cause as necessary. When an enrollee fails to choose a primary care provider, the carrier may assign the enrollee a primary care provider located in the same geographic area in which the enrollee resides.   [PL 2019, c. 627, Pt. A, §1 (AMD).]SECTION HISTORY PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 396, §6 (AMD). PL 1999, c. 396, §7 (AFF). PL 1999, c. 742, §15 (AMD). PL 2007, c. 199, Pt. B, §15 (AMD). PL 2011, c. 364, §28 (AMD). PL 2019, c. 627, Pt. A, §1 (AMD).
24-A ME Rev Stat § 4306-A (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4306-A. Patient access to obstetrical and gynecological care

 §4306-A. Patient access to obstetrical and gynecological care Notwithstanding any other requirements of this Title, a carrier offering a health plan in this State subject to the requirements of the federal Affordable Care Act:   [PL 2011, c. 364, §29 (NEW).]1.  Authorization or referral not required.  May not require authorization or referral by the carrier or any other person, including a primary care provider, in the case of a female enrollee who seeks coverage for obstetrical or gynecological care provided by a participating health care professional as described in the federal Affordable Care Act who specializes in obstetrics or gynecology. The health care professional shall agree to otherwise adhere to the health plan's or carrier's policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan, if any, approved by the carrier; and   [PL 2011, c. 364, §29 (NEW).] 2.  Treated as primary care.  Shall treat the provision of obstetrical and gynecological care by a participating health care professional as described in the federal Affordable Care Act who specializes in obstetrics or gynecology, pursuant to subsection 1, as authorized by the primary care provider and the authorization of related obstetrical and gynecological items and services by that professional as the authorization of the primary care provider.   [PL 2011, c. 364, §29 (NEW).] SECTION HISTORY PL 2011, c. 364, §29 (NEW).
24-A ME Rev Stat § 4307 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4307. Construction

 §4307. Construction Nothing in this chapter may be construed to:   [PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).]1.  Purchase services with own funds.  Prohibit an individual from purchasing any health care services with that individual's own funds, whether these services are covered within the individual's benefit package or from another health care provider or plan, except as otherwise provided by federal or state law;   [PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).] 2.  Additional benefits.  Prohibit any plan sponsor from providing additional coverage for benefits, rights or protections not set out in this chapter;   [PL 1999, c. 742, §16 (AMD).] 3.  Provider participation.  Require a carrier to admit to a managed care plan a provider willing to abide by the terms and conditions of the managed care plan; or   [PL 1999, c. 742, §16 (AMD).] 4.  Treatment by religious nonmedical providers.  With respect to coverage of treatment by religious nonmedical providers:   A. Restrict or limit the right of a carrier to include a religious nonmedical provider as a participating provider in a managed care plan;   [PL 1999, c. 742, §17 (NEW).]B. Require a carrier to:   (1) Utilize medically based eligibility standards or criteria in deciding provider status of religious nonmedical providers;   (2) Use medical professionals or criteria to decide enrollee access to religious nonmedical providers;   (3) Utilize medical professionals or criteria in making decisions in internal or external appeals regarding coverage for care by religious nonmedical providers; or   (4) Compel an enrollee to undergo a medical examination or test as a condition of receiving coverage for treatment by a religious nonmedical provider; or   [PL 1999, c. 742, §17 (NEW).]C. Require a carrier to exclude religious nonmedical providers because the providers do not provide medical or other required data, if such data is inconsistent with the religious nonmedical treatment or nursing care provided by the provider.   [PL 1999, c. 742, §17 (NEW).][PL 1999, c. 742, §17 (NEW).] SECTION HISTORY PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 742, §§16,17 (AMD).
24-A ME Rev Stat § 4308 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4308. Indemnification

 §4308. Indemnification A contract between a carrier offering or renewing a health plan and a provider for the provision of services to enrollees may not require the provider to indemnify the carrier for any expenses and liabilities, including, without limitation, judgments, settlements, attorney's fees, court costs and any associated charges incurred in connection with a claim or action brought against the health plan based on the carrier's own fault. Nothing in this section may be construed to remove responsibility of a carrier or provider for expenses or liabilities caused by the carrier's or provider's own negligent acts or omissions or intentional misconduct.   [PL 2007, c. 199, Pt. B, §16 (AMD).]1.  Indemnification.   [PL 1999, c. 742, §18 (RP).] SECTION HISTORY PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 742, §18 (RPR). PL 2007, c. 199, Pt. B, §16 (AMD).
24-A ME Rev Stat § 4309 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4309. Adoption of rules

 §4309. Adoption of rules The superintendent shall adopt rules and establish standards for health plans in order to carry out the purposes of this chapter. Rules adopted pursuant to this chapter are major substantive rules as defined in Title 5, chapter 375, subchapter II-A.   [PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).]SECTION HISTORY PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF).
24-A ME Rev Stat § 4309-A (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4309-A. Compliance with the Affordable Care Act

 §4309-A. Compliance with the Affordable Care Act 1.  Carriers.  A carrier shall comply with all applicable requirements of the federal Affordable Care Act.   [PL 2011, c. 364, §30 (NEW).] 2.  Superintendent.  The superintendent may enforce and administer this section through all powers provided under this Title and Title 24. The superintendent may adopt and amend rules, establish standards and enforce federal statutes and regulations in order to carry out the purposes of the federal Affordable Care Act. Rules or amendments adopted pursuant to this subsection, including amendments to major substantive rules, are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.   [PL 2011, c. 364, §30 (NEW).] SECTION HISTORY PL 2011, c. 364, §30 (NEW).
24-A ME Rev Stat § 4310 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4310. Access to clinical trials

 §4310. Access to clinical trials 1.  Qualified enrollee.  An enrollee is eligible for coverage for participation in an approved clinical trial if the enrollee meets the following conditions:   A. The enrollee has a life-threatening illness for which no standard treatment is effective;   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]B. The enrollee is eligible to participate according to the clinical trial protocol with respect to treatment of such illness;   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]C. The enrollee's participation in the trial offers meaningful potential for significant clinical benefit to the enrollee; and   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]D. The enrollee's referring physician has concluded that the enrollee's participation in such a trial would be appropriate based upon the satisfaction of the conditions in paragraphs A, B and C.   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).][PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).] 2.  Coverage.  A carrier may not deny a qualified enrollee participation in an approved clinical trial or deny, limit or impose additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in the clinical trial. For the purposes of this section, "routine patient costs" does not include the costs of the tests or measurements conducted primarily for the purpose of the clinical trial involved.   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).] 3.  Payment.  A carrier shall provide payment for routine patient costs but is not required to pay for costs of items and services that are reasonably expected to be paid for by the sponsors of an approved clinical trial. In the case of covered items and services, the carrier shall pay participating providers at the agreed upon rate and pay nonparticipating providers at the same rate the carrier would pay for comparable services performed by participating providers.   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).] 4.  Approved clinical trial.  For the purposes of this section, "approved clinical trial" means a clinical research study or clinical investigation approved and funded by the federal Department of Health and Human Services, National Institutes of Health or a cooperative group or center of the National Institutes of Health.   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).] 5.  Application.  The requirements of this section apply to all individual and group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.   [PL 2003, c. 517, Pt. B, §31 (NEW).] SECTION HISTORY PL 1999, c. 742, §19 (NEW). PL 1999, c. 742, §21 (AFF). PL 2003, c. 517, §B31 (AMD).
24-A ME Rev Stat § 4314-A (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4314-A. Coverage for early refills of prescription eye drops

 §4314-A. Coverage for early refills of prescription eye drops 1.  Required coverage.  A carrier offering a health plan in this State shall provide coverage for one early refill of a prescription for eye drops if the following criteria are met:   A. The enrollee requests the refill no earlier than the date on which 70% of the days of use authorized by the prescribing health care provider have elapsed;   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]B. The prescribing health care provider indicated on the original prescription that a specific number of refills are authorized;   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]C. The refill requested by the enrollee does not exceed the number of refills indicated on the original prescription;   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]D. The prescription has not been refilled more than once during the period authorized by the prescribing health care provider prior to the request for an early refill; and   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]E. The prescription eye drops are a covered benefit under the enrollee's health plan.   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).][PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).] 2.  Cost sharing.  A carrier may impose a deductible, copayment or coinsurance requirement for an early refill under this section as permitted under the health plan.   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).] SECTION HISTORY PL 2015, c. 91, §1 (NEW). PL 2015, c. 91, §2 (AFF).
24-A ME Rev Stat § 4315 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4315. Coverage of prosthetic devices

 §4315. Coverage of prosthetic devices 1.  Definition.  As used in this section, "prosthetic device" means an artificial device to replace, in whole or in part, an arm or a leg.   [PL 2003, c. 459, §1 (NEW); PL 2003, c. 459, §2 (AFF).] 2.  Required coverage.  A carrier shall provide coverage for prosthetic devices in all health plans that, at a minimum, equals, except as provided in subsection 8, the coverage and payment for prosthetic devices provided under federal laws and regulations for the aged and disabled pursuant to 42 United States Code, Sections 1395k, 1395l and 1395m and 42 Code of Federal Regulations, Sections 414.202, 414.210, 414.228 and 410.100. Covered benefits must be provided for a prosthetic device determined by the enrollee's provider, in accordance with section 4301‑A, subsection 10‑A, to be the most appropriate model that adequately meets the medical needs of the enrollee.   [PL 2003, c. 688, Pt. I, §1 (AMD).] 3.  Prior authorization.  A carrier may require prior authorization for prosthetic devices in the same manner as prior authorization is required for any other covered benefit.   [PL 2003, c. 459, §1 (NEW); PL 2003, c. 459, §2 (AFF).] 4.  Repair or replacement.  Coverage under this section must also be provided for repair or replacement of a prosthetic device if repair or replacement is determined appropriate by the enrollee's provider.   [PL 2003, c. 459, §1 (NEW); PL 2003, c. 459, §2 (AFF).] 5.  Coverage under managed care plan.  If coverage under this section is provided through a managed care plan, a carrier may require that prosthetic services be rendered by a provider who contracts with the carrier and that a prosthetic device be provided by a vendor designated by the carrier.   [PL 2003, c. 459, §1 (NEW); PL 2003, c. 459, §2 (AFF).] 6.  Exclusions.  Coverage is not required pursuant to this section for a prosthetic device that is designed exclusively for athletic purposes.   [PL 2009, c. 603, §1 (AMD); PL 2009, c. 603, §2 (AFF).] 7.  Application.  The requirements of this section apply to all individual and group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.   [PL 2003, c. 517, Pt. B, §34 (NEW).] 8.  Health savings accounts.  Benefits for prosthetic devices under health plans issued for use in connection with health savings accounts as authorized under Title XII of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 may be subject to the same deductibles and out-of-pocket limits that apply to overall benefits under the contract.   [PL 2003, c. 688, Pt. I, §2 (NEW).] SECTION HISTORY PL 2003, c. 459, §1 (NEW). PL 2003, c. 459, §2 (AFF). PL 2003, c. 517, §B34 (AMD). PL 2003, c. 688, §§I1,2 (AMD). PL 2009, c. 603, §1 (AMD). PL 2009, c. 603, §2 (AFF).
24-A ME Rev Stat § 4317-A (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT|Subchapter 1: HEALTH PLAN REQUIREMENTS|24-A §4317-A. Prescription drug coverage; out-of-pocket expenses for coinsurance

 §4317-A. Prescription drug coverage; out-of-pocket expenses for coinsurance 1.  Out-of-pocket expenses for coinsurance within health plan's total limit.  If a carrier that provides coverage for prescription drugs does not include prescription drugs subject to coinsurance under the total out-of-pocket limit for all benefits provided under a health plan, the carrier shall establish a separate out-of-pocket limit not to exceed $3,500 per year for prescription drugs subject to coinsurance provided under a health plan to the extent not inconsistent with the federal Affordable Care Act.   [PL 2011, c. 611, §1 (NEW); PL 2011, c. 611, §2 (AFF).] 2.  Adjustment of out-of-pocket limits.  A carrier may adjust an out-of-pocket limit, as long as any limit for prescription drugs for coinsurance does not exceed $3,500, to minimize any premium increase that might otherwise result from the requirements of this section. Any adjustment made by a carrier pursuant to this subsection is considered a minor modification under section 2850-B.   [PL 2011, c. 611, §1 (NEW); PL 2011, c. 611, §2 (AFF).] 3.  Construction.  This section may not be construed to prohibit or limit a carrier's ability to establish specialty tiers for prescription drug coverage, to make determinations of medical necessity or to enforce procedures regarding prior authorization or utilization review in accordance with this chapter.   [PL 2011, c. 611, §1 (NEW); PL 2011, c. 611, §2 (AFF).] 4.  Terms consistent with federal law.  For the purposes of this section, the use of the terms "coinsurance" and "out-of-pocket limit" by a carrier must be consistent with the definitions of those terms as prescribed by the Secretary of the United States Department of Health and Human Services pursuant to Section 2715 of the federal Affordable Care Act.   [PL 2011, c. 611, §1 (NEW); PL 2011, c. 611, §2 (AFF).] SECTION HISTORY PL 2011, c. 611, §1 (NEW). PL 2011, c. 611, §2 (AFF).