reglab/housing_qa huggingface dataset:
24-A ME Rev Stat § 4235 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4235. Standardized claim forms

 §4235. Standardized claim forms All health maintenance organizations providing payment or reimbursement for diagnosis or treatment of a condition or a complaint by a licensed health care practitioner must accept the current standardized claim form for professional services approved by the Federal Government and submitted electronically. All health maintenance organizations providing payment or reimbursement for diagnosis or treatment of a condition or a complaint by a licensed hospital must accept the current standardized claim form for professional or facility services, as applicable, approved by the Federal Government and submitted electronically. A health maintenance organization may not be required to accept a claim submitted on a form other than the applicable form specified in this section and may not be required to accept a claim that is not submitted electronically, except from a health care practitioner who is exempt pursuant to Title 24, section 2985. All services provided by a health care practitioner in an office setting must be submitted on the standardized federal form used by noninstitutional providers and suppliers. Services in a nonoffice setting may be billed as negotiated between the health maintenance organization and health care practitioner. For purposes of this section, "office setting" means a location where the health care practitioner routinely provides health examinations, diagnosis and treatment of illness or injury on an ambulatory basis whether or not the office is physically located within a facility.   [PL 2005, c. 97, §4 (AMD).]SECTION HISTORY PL 1993, c. 477, §D12 (NEW). PL 1993, c. 477, §F1 (AFF). PL 2003, c. 218, §8 (AMD). PL 2003, c. 469, §D8 (AMD). PL 2003, c. 469, §D9 (AFF). PL 2005, c. 97, §4 (AMD).
24-A ME Rev Stat § 4237 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4237. Coverage for breast cancer treatment

 §4237. Coverage for breast cancer treatment 1.  Inpatient care.  All individual and group coverage subject to this chapter that provides coverage for medical and surgical benefits must ensure that inpatient coverage with respect to the treatment of breast cancer is provided for a period of time determined by the attending physician, after providing notice to the patient regarding the coverage required by this subsection and in consultation with the patient, to be medically appropriate following a mastectomy, a lumpectomy or a lymph node dissection for the treatment of breast cancer.   Nothing in this subsection may be construed to require the provision of inpatient coverage if the attending physician and patient determine that a shorter period of hospital stay is appropriate.   In implementing the requirements of this subsection, an individual or group coverage contract may not modify the terms and conditions of coverage based on the determination by any enrollee to request less than the minimum coverage required under this subsection.   All individual and group coverage subject to this subsection must provide written notice to each enrollee under the contract regarding the coverage required by this subsection. The notice must be prominently positioned in any literature or correspondence made available or distributed by the plan and must be transmitted in the next mailing made by the plan to the enrollee or as part of any yearly information packet sent to the enrollee, whichever is earlier. The notice must also be made available to any physician participating in the insurer's provider network.   [PL 2015, c. 227, §4 (AMD); PL 2015, c. 227, §5 (AFF).] 2.  Reconstruction.  All individual and group coverage subject to this chapter that provides coverage for mastectomy surgery must provide coverage for reconstruction of the breast on which surgery has been performed and surgery and reconstruction of the other breast to produce a symmetrical appearance if the patient elects reconstruction and in the manner chosen by the patient and the physician.   [PL 1997, c. 408, §7 (NEW); PL 1997, c. 408, §8 (AFF).] 3.  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, §24 (NEW).] SECTION HISTORY RR 1995, c. 1, §19 (COR). RR 1995, c. 1, §21 (COR). PL 1995, c. 295, §5 (NEW). PL 1995, c. 369, §4 (NEW). PL 1995, c. 418, §C4 (NEW). PL 1997, c. 408, §7 (RPR). PL 1997, c. 408, §8 (AFF). PL 2003, c. 517, §B24 (AMD). PL 2015, c. 227, §4 (AMD). PL 2015, c. 227, §5 (AFF).
24-A ME Rev Stat § 4237-A (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4237-A. Screening mammograms

 §4237-A. Screening mammograms 1.  Definition.  For purposes of this section, "screening mammogram" means a radiologic procedure that is provided to an asymptomatic woman for the purpose of early detection of breast cancer and that consists of 2 radiographic views per breast. A screening mammogram also includes an additional radiologic procedure recommended by a provider when the results of an initial radiologic procedure are not definitive.   [PL 2007, c. 153, §3 (AMD); PL 2007, c. 153, §5 (AFF).] 2.  Required coverage.  All individual and group coverage subject to this chapter must provide coverage for screening mammograms performed by providers that meet the standards established by the Department of Health and Human Services rules relating to radiation protection. The policies must reimburse for screening mammograms performed at least once a year for women 40 years of age and over.   [PL 1997, c. 408, §7 (NEW); PL 1997, c. 408, §8 (AFF); PL 2003, c. 689, Pt. B, §6 (REV).] 3.  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, §25 (NEW).] SECTION HISTORY PL 1997, c. 408, §7 (NEW). PL 1997, c. 408, §8 (AFF). PL 2003, c. 517, §B25 (AMD). PL 2003, c. 689, §B6 (REV). PL 2007, c. 153, §3 (AMD). PL 2007, c. 153, §5 (AFF).
24-A ME Rev Stat § 4238 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4238. Medical food coverage for inborn error of metabolism

 §4238. Medical food coverage for inborn error of metabolism 1.  Inborn error of metabolism; special modified low-protein food product.  As used in this section, "inborn error of metabolism" means a genetically determined biochemical disorder in which a specific enzyme defect produces a metabolic block that may have pathogenic consequences at birth or later in life. As used in this section, "special modified low-protein food product" means food formulated to reduce the protein content to less than one gram of protein per serving and does not include foods naturally low in protein.   [PL 1995, c. 369, §4 (NEW).] 2.  Required coverage.  All health maintenance organization individual and group contracts must provide coverage for metabolic formula and special modified low-protein food products that have been prescribed by a licensed physician for a person with an inborn error of metabolism. The contracts must reimburse:   A. For metabolic formula; and   [PL 1995, c. 369, §4 (NEW).]B. Up to $3,000 per year for special modified low-protein food products.   [PL 1995, c. 369, §4 (NEW).][PL 1995, c. 369, §4 (NEW).] 3.  Application.  The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 1996. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.   [PL 1995, c. 369, §4 (NEW).] SECTION HISTORY RR 1995, c. 1, §19 (RNU). PL 1995, c. 369, §4 (NEW).
24-A ME Rev Stat § 4239 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4239. Medical child support

 §4239. Medical child support A health maintenance organization must comply with 42 United States Code, Section 1396g‑1.   [PL 1995, c. 418, Pt. C, §4 (NEW).]SECTION HISTORY RR 1995, c. 1, §21 (RNU). PL 1995, c. 418, §C4 (NEW).
24-A ME Rev Stat § 4240 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4240. Coverage for diabetes supplies

 §4240. Coverage for diabetes supplies All health maintenance organization individual and group health contracts and certificates must provide coverage for the medically appropriate and necessary equipment, limited to insulin, oral hypoglycemic agents, monitors, test strips, syringes and lancets, and the out-patient self-management training and educational services used to treat diabetes, if:   [PL 2003, c. 517, Pt. A, §10 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).]1.  Certification of medical necessity.  The enrollee's treating physician or a physician who specializes in the treatment of diabetes certifies that the equipment and services are necessary; and   [PL 1995, c. 592, §4 (NEW).] 2.  Provision of medical services.  The diabetes out-patient self-management training and educational services are provided through ambulatory diabetes education facilities authorized by the State's Diabetes Control Project within the Bureau of Health.   [PL 1995, c. 592, §4 (NEW).] The requirements of this section apply to all 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. A, §10 (NEW); PL 2003, c. 517, Pt. A, §13 (AFF).]Revisor's Note: §4240. Coverage for Pap tests (As enacted by PL 1995, c. 617, §5 is REALLOCATED TO TITLE 24-A, SECTION 4242)SECTION HISTORY RR 1995, c. 2, §53 (RAL). PL 1995, c. 592, §4 (NEW). PL 1995, c. 617, §5 (NEW). PL 1995, c. 617, §6 (AFF). PL 2003, c. 517, §A10 (AMD). PL 2003, c. 517, §A13 (AFF).
24-A ME Rev Stat § 4241 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4241. Gynecological and obstetrical services

 §4241. Gynecological and obstetrical services 1.  Coverage in managed care plans.  With respect to managed care plans that require enrollees to select primary care physicians, a health maintenance organization that issues group policies, contracts and certificates must meet the following requirements.   A. The health maintenance organization must permit a physician who specializes in obstetrics and gynecology to serve as a primary care physician if the physician qualifies under the organization's credentialling policy.   [PL 1995, c. 617, §5 (NEW); PL 1995, c. 617, §6 (AFF).]B. All group plan contracts must provide coverage for an annual gynecological examination, including routine pelvic and clinical breast examinations, performed by a physician, certified nurse practitioner or certified nurse midwife participating in the plan, without requiring the prior approval of the primary care physician.   [PL 1995, c. 617, §5 (NEW); PL 1995, c. 617, §6 (AFF).]C. If the examination specified in paragraph B reveals a gynecological condition for which another visit to the physician participating in the plan is medically required and appropriate, or for any gynecological care beyond the annual examination, the carrier may require the patient or the examining physician, certified nurse practitioner or certified nurse midwife to secure from the patient's primary care physician a referral to the participating physician, certified nurse practitioner or certified nurse midwife from whom such care may be obtained.   [PL 1995, c. 617, §5 (NEW); PL 1995, c. 617, §6 (AFF).][PL 2003, c. 517, Pt. A, §11 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).] 2.  Application.  This section applies to all 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. A, §11 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).] This section does not prohibit a carrier from requiring a physician, certified nurse practitioner or certified nurse midwife participating in the plan to inform a woman's primary care physician prior to each treatment pursuant to this section.   [PL 1995, c. 617, §5 (NEW); PL 1995, c. 617, §6 (AFF).]SECTION HISTORY PL 1995, c. 617, §5 (NEW). PL 1995, c. 617, §6 (AFF). PL 2003, c. 517, §A11 (AMD). PL 2003, c. 517, §A13 (AFF).
24-A ME Rev Stat § 4242 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4242. Coverage for Pap tests (REALLOCATED FROM TITLE 24-A, SECTION 4240)

 §4242. Coverage for Pap tests (REALLOCATED FROM TITLE 24-A, SECTION 4240)All health maintenance organization plan contracts and certificates must provide coverage for screening Pap tests recommended by a physician.   [PL 2003, c. 517, Pt. A, §12 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).]SECTION HISTORY RR 1995, c. 2, §53 (RAL). PL 2003, c. 517, §A12 (AMD). PL 2003, c. 517, §A13 (AFF).
24-A ME Rev Stat § 4243 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4243. Limits on priority liens; subrogation

 §4243. Limits on priority liens; subrogation An individual or group contract subject to this chapter may not provide for subrogation or priority over the enrollee of payment for any hospital, nursing, medical or surgical services or of any expenses paid or reimbursed under the coverage, in the event the enrollee is entitled to receive payment or reimbursement from any other person as a result of legal action or claim, except as provided in this section.   [PL 1997, c. 369, §3 (NEW).]The coverage may contain a provision that allows the payments, if that provision is approved by the superintendent and if that provision required the prior written approval of the insured and allows such payments only on a just and equitable basis and not on the basis of a priority lien. A "just and equitable basis" means that any factors that diminish the potential value of the enrollee's claim may likewise reduce the share in the claim for those claiming payment for services or reimbursement. Such factors include, but are not limited to:   [PL 1997, c. 369, §3 (NEW).]1.  Legal defenses.  Questions of liability and comparative negligence or other legal defenses;   [PL 1997, c. 369, §3 (NEW).] 2.  Exigencies of trial.  Exigencies of trial that reduce a settlement or award in order to resolve the claim; and   [PL 1997, c. 369, §3 (NEW).] 3.  Limits of coverage.  Limits on the amount of applicable insurance coverage that reduce the claim to an amount recoverable by the insured.   [PL 1997, c. 369, §3 (NEW).] In the event of a dispute as to the application of any such provision or the amount available for payment to those claiming payment for services or reimbursement, that dispute must be determined, if the action is pending, before the court in which it is pending; or if no action is pending, by filing an action in any court for determination of the dispute.   [PL 1997, c. 369, §3 (NEW).]Revisor's Note: §4243. Coverage for prostate cancer screening (As enacted by PL 1997, c. 754, §4 is REALLOCATED TO TITLE 24-A, SECTION 4244)SECTION HISTORY RR 1997, c. 2, §53 (RAL). PL 1997, c. 369, §3 (NEW). PL 1997, c. 754, §4 (NEW).
24-A ME Rev Stat § 4244 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4244. Coverage for prostate cancer screening (REALLOCATED FROM TITLE 24-A, SECTION 4243)

 §4244. Coverage for prostate cancer screening (REALLOCATED FROM TITLE 24-A, SECTION 4243)1.  Definition.  As used in this section, "services for the early detection of prostate cancer" means the following procedures provided to a man for the purpose of early detection of prostate cancer:   A. A digital rectal examination; and   [RR 1997, c. 2, §53 (RAL).]B. A prostate-specific antigen test.   [RR 1997, c. 2, §53 (RAL).][RR 1997, c. 2, §53 (RAL).] 2.  Required coverage for prostate cancer screening.  All health maintenance organization individual and group contracts must provide coverage for services for the early detection of prostate cancer. The contracts must reimburse for services for the early detection of prostate cancer, if recommended by a physician, at least once a year for men 50 years of age or older until a man reaches the age of 72.   [RR 1997, c. 2, §53 (RAL).] 3.  Application.  The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after September 1, 1998. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.   [RR 1997, c. 2, §53 (RAL).] SECTION HISTORY RR 1997, c. 2, §53 (RAL).
24-A ME Rev Stat § 4245 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4245. NCQA accreditation survey report

 §4245. NCQA accreditation survey report 1.  Access and confidentiality.  The superintendent or the Commissioner of Health and Human Services may require a health maintenance organization to submit its NCQA accreditation survey report. An NCQA accreditation survey report obtained by or submitted to the superintendent or the Commissioner of Health and Human Services is confidential, is not subject to subpoena and may not be made public by the superintendent or the Commissioner of Health and Human Services except as otherwise provided in this section.   [PL 1999, c. 256, Pt. Q, §2 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).] 2.  Use in examination.  In conducting an examination of a health maintenance organization pursuant to section 4215, the superintendent or the Commissioner of Health and Human Services has the discretion to adopt relevant findings in the NCQA accreditation survey report in whole or in part as the examiner's conclusions, if the examiner determines that the NCQA survey, by itself or in combination with the examiner's own findings, sufficiently demonstrates that the health maintenance organization has satisfied the pertinent requirements of this chapter. If the NCQA accreditation survey report indicates that the health maintenance organization may not be in compliance with one or more requirements of this chapter, the examiner may investigate and make independent findings.   [PL 1999, c. 256, Pt. Q, §2 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).] 3.  Examination report.  The information from the NCQA accreditation survey report that sufficiently demonstrates that the health maintenance organization has satisfied the pertinent requirements of this section as adopted by the superintendent or the Commissioner of Health and Human Services pursuant to subsection 2 may be incorporated into an examination report, which is a public record except for any information relating to an individual applicant or enrollee.   [PL 1999, c. 256, Pt. Q, §2 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).] 4.  Use of information for regulatory purposes.  The confidentiality of the NCQA accreditation survey report does not prohibit its use by the superintendent or the Commissioner of Health and Human Services for regulatory or law enforcement purposes subject to the restrictions of section 216, subsection 5 and section 226, subsection 7.   [PL 1999, c. 256, Pt. Q, §2 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).] Revisor's Note: §4245. Coverage for contraceptives (As enacted by PL 1999, c. 341, §4 and affected by §5 is REALLOCATED TO TITLE 24-A, SECTION 4247)Revisor's Note: §4245. Coverage for services of certified nurse practitioners; certified nurse midwives (As enacted by PL 1999, c. 396, §4 and affected by §7 is REALLOCATED TO TITLE 24-A, SECTION 4248) SECTION HISTORY RR 1999, c. 1, §§37,38 (RAL). PL 1999, c. 256, §Q2 (NEW). PL 1999, c. 341, §4 (NEW). PL 1999, c. 341, §5 (AFF). PL 1999, c. 396, §4 (NEW). PL 1999, c. 396, §7 (AFF). PL 2003, c. 689, §B7 (REV).
24-A ME Rev Stat § 4246 (2021)
2021 Maine Revised Statutes|TITLE 24-A: MAINE INSURANCE CODE|Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS|24-A §4246. Coverage for services provided by registered nurse first assistants

 §4246. Coverage for services provided by registered nurse first assistants 1.  Definitions.  As used in this section, unless the context otherwise indicates, the following terms have the following meanings.   A. "Perioperative nursing" means a practice of nursing in which the nurse provides preoperative, intraoperative and postoperative nursing care to surgical patients.   [PL 1999, c. 412, §4 (NEW).]B. "Recognized program" means a program that addresses all content of the core curriculum for registered nurse first assistants as established by the Association of Operating Room Nurses or its successor organization.   [PL 1999, c. 412, §4 (NEW).]C. "Registered nurse first assistant," or "RNFA," means a person who:   (1) Is licensed as a registered nurse under Title 32, chapter 31;   (2) Is experienced in perioperative nursing; and   (3) Has successfully completed a recognized program.   [PL 1999, c. 412, §4 (NEW).][PL 1999, c. 412, §4 (NEW).] 2.  Institutional powers.  Each health care institution, as defined in Title 22, chapter 405, may establish specific procedures for the appointment and reappointment of registered nurse first assistants and for granting, renewing and revising their clinical privileges.   [PL 1999, c. 412, §4 (NEW).] 3.  Required coverage for services.  Notwithstanding any other provisions of this chapter, a health maintenance organization that issues individual and group health care contracts that provide coverage for surgical first assisting benefits or services shall provide coverage and payment under those contracts to a registered nurse first assistant who performs services that are within the scope of a registered nurse first assistant's qualifications. The provisions of this subsection apply only if reimbursement for an assisting physician would be covered and a registered nurse first assistant who performed those services is used as a substitute.   [PL 1999, c. 412, §4 (NEW).] 4.  Limits; coinsurance; deductibles.  Any contract that provides coverage for the services required by this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.   [PL 1999, c. 412, §4 (NEW).] 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. 617, Pt. B, §26 (NEW).] SECTION HISTORY PL 1999, c. 412, §4 (NEW). PL 2003, c. 517, §B26 (AMD).