reglab/statecodes huggingface dataset:
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2758. Coverage for services provided by registered nurse first assistants (REALLOCATED FROM TITLE 24-A, SECTION 2756)

§2758. Coverage for services provided by registered nurse first assistants
(REALLOCATED FROM TITLE 24-A, SECTION 2756)
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.   [RR 1999, c. 1, §33 (RAL).]
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.   [RR 1999, c. 1, §33 (RAL).]
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.   [RR 1999, c. 1, §33 (RAL).]
[RR 1999, c. 1, §33 (RAL).]
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.
[RR 1999, c. 1, §33 (RAL).]
3.  Required coverage for services.
Notwithstanding any other provisions of this chapter, an insurer that issues individual health insurance policies and 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. This section does not apply to policies or contracts that cover only specified diseases.
[RR 1999, c. 1, §33 (RAL).]
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.
[RR 1999, c. 1, §33 (RAL).]
SECTION HISTORY
RR 1999, c. 1, §33 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2759. Coverage for hospice care services

§2759. Coverage for hospice care services
1.  Definitions.
As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Hospice care services" means services provided on a 24-hours-a-day, 7-days-a-week basis to a person who is terminally ill and that person's family. "Hospice care services" includes, but is not limited to, physician services; nursing care; respite care; medical and social work services; counseling services; nutritional counseling; pain and symptom management; medical supplies and durable medical equipment; occupational, physical or speech therapies; volunteer services; home health care services; and bereavement services.   [PL 2001, c. 358, Pt. LL, §2 (NEW); PL 2001, c. 358, Pt. LL, §5 (AFF).]
B. "Person who is terminally ill" means a person that has a medical prognosis that the person's life expectancy is 12 months or less if the illness runs its normal course.   [PL 2001, c. 358, Pt. LL, §2 (NEW); PL 2001, c. 358, Pt. LL, §5 (AFF).]
[PL 2001, c. 358, Pt. LL, §2 (NEW); PL 2001, c. 358, Pt. LL, §5 (AFF).]
2.  Coverage for hospice care services.
All individual health policies must provide coverage for hospice care services to a person who is terminally ill. Hospice care services must be provided according to a written care delivery plan developed by a hospice care provider and the recipient of hospice care services. Coverage for hospice care services must be provided whether the services are provided in a home setting or an inpatient setting.
[PL 2001, c. 358, Pt. LL, §2 (NEW); PL 2001, c. 358, Pt. LL, §5 (AFF).]
Revisor's Note: §2759. Coverage for general anesthesia for dentistry (As enacted by PL 2001, c. 423, §2 and affected by § 5 is REALLOCATED TO TITLE 24-A, SECTION 2760)
SECTION HISTORY
RR 2001, c. 1, §31 (RAL). PL 2001, c. 358, §LL2 (NEW). PL 2001, c. 358, §LL5 (AFF). PL 2001, c. 423, §2 (NEW). PL 2001, c. 423, §5 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2761. Offer of coverage for breast reduction surgery and symptomatic varicose vein surgery

§2761. Offer of coverage for breast reduction surgery and symptomatic varicose vein surgery
All individual health insurance policies, contracts and certificates must make available coverage for breast reduction surgery and symptomatic varicose vein surgery determined to be medically necessary health care as defined in section 4301‑A, subsection 10‑A.   [PL 2005, c. 128, §2 (NEW); PL 2005, c. 128, §5 (AFF).]
SECTION HISTORY
PL 2005, c. 128, §2 (NEW). PL 2005, c. 128, §5 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2762. Coverage for hearing aids

§2762. Coverage for hearing aids
1.  Hearing aid; definition.
For purposes of this section, "hearing aid" means a nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing, excluding batteries and cords and other assistive listening devices, including, but not limited to, frequency modulation systems.
[PL 2007, c. 452, §2 (NEW).]
2.  Required coverage.
All individual health policies and contracts must provide coverage for the purchase of a hearing aid for each hearing-impaired ear for an individual covered under the policy or contract in accordance with the following requirements.
A. The hearing loss must be documented by a physician or audiologist licensed pursuant to Title 32, chapter 137.   [PL 2015, c. 494, Pt. A, §28 (AMD).]
B. The hearing aid must be purchased in accordance with federal and state laws, regulations and rules for the sale and dispensing of hearing aids.   [PL 2019, c. 418, §1 (AMD).]
C. The policy or contract may limit coverage to $3,000 per hearing aid for each hearing-impaired ear every 36 months.   [PL 2019, c. 418, §1 (AMD).]
[PL 2019, c. 418, §1 (AMD).]
3.  Application of coverage.
[PL 2019, c. 418, §2 (RP).]
4.  Limits; coinsurance; deductibles.
Except as otherwise provided in this section, any policy or contract that provides coverage for services under 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 2007, c. 452, §2 (NEW).]
SECTION HISTORY
PL 2007, c. 452, §2 (NEW). PL 2015, c. 494, Pt. A, §28 (AMD). PL 2019, c. 418, §§1, 2 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2763. Coverage for colorectal cancer screening

§2763. Coverage for colorectal cancer screening
1.  Colorectal cancer screening.
For the purposes of this section, "colorectal cancer screening" means all colorectal cancer examinations and laboratory tests recommended by a health care provider in accordance with the most recently published colorectal cancer screening guidelines of a national cancer society.
[PL 2019, c. 86, §1 (AMD).]
2.  Required coverage.
All individual health insurance policies and contracts must provide coverage for colorectal cancer screening for asymptomatic individuals who are:
A. At average risk for colorectal cancer according to the most recently published colorectal cancer screening guidelines of a national cancer society; or   [PL 2019, c. 86, §2 (AMD).]
B. At high risk for colorectal cancer.   [PL 2019, c. 86, §3 (AMD).]
[PL 2019, c. 86, §§2, 3 (AMD).]
3.  Billing.
If a colonoscopy is recommended by a health care provider as the colorectal cancer screening test in accordance with this section and a lesion is discovered and removed during that colonoscopy, the health care provider must bill the insurance company for a screening colonoscopy as the primary procedure.
[PL 2007, c. 516, §2 (NEW); PL 2007, c. 516, §5 (AFF).]
Revisor's Note: §2763. Coverage for medically necessary infant formula (As enacted by PL 2007, c. 595, §2 is REALLOCATED TO TITLE 24-A, SECTION 2764)
SECTION HISTORY
RR 2007, c. 2, §11 (RAL). PL 2007, c. 516, §2 (NEW). PL 2007, c. 516, §5 (AFF). PL 2007, c. 595, §2 (NEW). PL 2007, c. 595, §5 (AFF). PL 2019, c. 86, §§1-3 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2764. Coverage for medically necessary infant formula (REALLOCATED FROM TITLE 24-A, SECTION 2763)

§2764. Coverage for medically necessary infant formula
(REALLOCATED FROM TITLE 24-A, SECTION 2763)
All individual health insurance policies, contracts and certificates must provide coverage for amino acid-based elemental infant formula for children 2 years of age and under in accordance with this section.   [RR 2007, c. 2, §11 (RAL).]
1.  Determination of medical necessity.
Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has submitted documentation that the amino acid-based elemental infant formula is medically necessary health care as defined in section 4301‑A, subsection 10‑A, that the amino acid-based elemental infant formula is the predominant source of nutritional intake at a rate of 50% or greater and that other commercial infant formulas, including cow milk-based and soy milk-based formulas have been tried and have failed or are contraindicated. A licensed physician may be required to confirm and document ongoing medical necessity at least annually.
[RR 2007, c. 2, §11 (RAL).]
2.  Method of delivery.
Coverage for amino acid-based elemental infant formula must be provided without regard to the method of delivery of the formula.
[RR 2007, c. 2, §11 (RAL).]
3.  Required diagnosis.
Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has diagnosed and through medical evaluation has documented one of the following conditions:
A. Symptomatic allergic colitis or proctitis;   [RR 2007, c. 2, §11 (RAL).]
B. Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis;   [RR 2007, c. 2, §11 (RAL).]
C. A history of anaphylaxis;   [RR 2007, c. 2, §11 (RAL).]
D. Gastroesophageal reflux disease that is nonresponsive to standard medical therapies;   [RR 2007, c. 2, §11 (RAL).]
E. Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider;   [RR 2007, c. 2, §11 (RAL).]
F. Cystic fibrosis; or   [RR 2007, c. 2, §11 (RAL).]
G. Malabsorption of cow milk-based or soy milk-based infant formula.   [RR 2007, c. 2, §11 (RAL).]
[RR 2007, c. 2, §11 (RAL).]
4.  Health savings accounts.
Coverage for amino acid-based elemental infant formula under a health insurance policy, contract or certificate issued in connection with a health savings account as authorized under Title XII of the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003 may be subject to the same deductible and out-of-pocket limits that apply to overall benefits under the policy, contract or certificate.
[RR 2007, c. 2, §11 (RAL).]
SECTION HISTORY
RR 2007, c. 2, §11 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2765. Coverage for services provided by independent practice dental hygienist

§2765. Coverage for services provided by independent practice dental hygienist
1.  Services provided by independent practice dental hygienist.
An insurer that issues individual dental insurance or health insurance that includes coverage for dental services shall provide coverage for dental services performed by an independent practice dental hygienist licensed under Title 32, chapter 143 when those services are covered services under the contract and when they are within the lawful scope of practice of the independent practice dental hygienist.
[PL 2015, c. 429, §11 (AMD).]
2.  Limits; coinsurance; deductibles.
A 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 2009, c. 307, §2 (NEW); PL 2009, c. 307, §6 (AFF).]
3.  Coordination of benefits with dental insurance.
If an enrollee eligible for coverage under this section is eligible for coverage under a dental insurance policy or contract and a health insurance policy or contract, the insurer providing dental insurance is the primary payer responsible for charges under subsection 1 and the insurer providing individual health insurance is the secondary payer.
[PL 2009, c. 307, §2 (NEW); PL 2009, c. 307, §6 (AFF).]
4.  Application.
The requirements of this section apply 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 2009, c. 307, §2 (NEW); PL 2009, c. 307, §6 (AFF).]
SECTION HISTORY
PL 2009, c. 307, §2 (NEW). PL 2009, c. 307, §6 (AFF). PL 2015, c. 429, §11 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2765-A. Coverage for services provided by dental therapist

§2765-A. Coverage for services provided by dental therapist
1.  Services provided by dental therapist.
An insurer that issues individual dental insurance or health insurance that includes coverage for dental services shall provide coverage for dental services performed by a dental therapist licensed under Title 32, chapter 143 when those services are covered services under the contract and when they are within the lawful scope of practice of the dental therapist.
[PL 2019, c. 388, §3 (AMD).]
2.  Limits; coinsurance; deductibles.
A 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 2013, c. 575, §5 (NEW); PL 2013, c. 575, §10 (AFF).]
3.  Coordination of benefits with dental insurance.
If an enrollee eligible for coverage under this section is eligible for coverage under a dental insurance policy or contract and a health insurance policy or contract, the insurer providing dental insurance is the primary payer responsible for charges under subsection 1 and the insurer providing individual health insurance is the secondary payer.
[PL 2013, c. 575, §5 (NEW); PL 2013, c. 575, §10 (AFF).]
4.  Application.
The requirements of this section apply 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 2013, c. 575, §5 (NEW); PL 2013, c. 575, §10 (AFF).]
SECTION HISTORY
PL 2013, c. 575, §5 (NEW). PL 2013, c. 575, §10 (AFF). PL 2015, c. 429, §12 (AMD). PL 2019, c. 388, §3 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2766. Enrollment of dependent children in dental coverage

§2766. Enrollment of dependent children in dental coverage
1.  Offer of dependent coverage; enrollment period.
All individual dental insurance policies and contracts that offer dependent coverage must offer the opportunity to enroll a dependent child in the dental insurance coverage at appropriate rates during the following periods:
A. From birth to 30 days of age; and   [PL 2009, c. 578, §2 (NEW); PL 2009, c. 578, §4 (AFF).]
B. Any open or annual enrollment period.   [PL 2009, c. 578, §2 (NEW); PL 2009, c. 578, §4 (AFF).]
Revisor's Note: §2766. Coverage for children's early intervention services (As enacted by PL 2009, c. 634, §2; §5 is REALLOCATED TO TITLE 24-A, SECTION 2767)
Revisor's Note: §2766. Coverage for the diagnosis and treatment of autism spectrum disorders (As enacted by PL 2009, c. 635, §2; §6 is REALLOCATED TO TITLE 24-A, SECTION 2768)
[PL 2009, c. 578, §2 (NEW); PL 2009, c. 578, §4 (AFF).]
SECTION HISTORY
PL 2009, c. 578, §2 (NEW). PL 2009, c. 578, §4 (AFF). PL 2009, c. 634, §2 (NEW). PL 2009, c. 634, §5 (AFF). PL 2009, c. 635, §2 (NEW). PL 2009, c. 635, §6 (AFF). PL 2011, c. 420, Pt. A, §23 (RAL). PL 2011, c. 420, Pt. A, §24 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2766-A. Dental benefit waiting period

§2766-A. Dental benefit waiting period
1.  Enrollee defined.
For the purposes of this section, unless the context otherwise indicates, "enrollee" means a person who is covered under an individual policy or contract provided by an insurer.
[PL 2019, c. 605, §5 (NEW).]
2.  No waiting period for enrollee under 19 years of age.
An insurer that issues individual dental insurance or health insurance that includes coverage for dental services may not impose a waiting period, as defined in section 2848, subsection 5, for any dental or oral health service or treatment, except for orthodontic treatment, for an enrollee if the enrollee is under 19 years of age.
[PL 2019, c. 605, §5 (NEW).]
SECTION HISTORY
PL 2019, c. 605, §5 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2767. Coverage for children's early intervention services (REALLOCATED FROM TITLE 24-A, SECTION 2766)

§2767. Coverage for children's early intervention services
(REALLOCATED FROM TITLE 24-A, SECTION 2766)
1.  Definition.
For purposes of this section, "children's early intervention services" means services provided by licensed occupational therapists, physical therapists, speech-language pathologists or clinical social workers working with children from birth to 36 months of age with an identified developmental disability or delay as described in the federal Individuals with Disabilities Education Act, Part C, 20 United States Code, Section 1411, et seq.
[PL 2011, c. 420, Pt. A, §23 (RAL).]
2.  Required coverage.
All individual health insurance policies, contracts and certificates must provide coverage for children's early intervention services in accordance with this subsection.
A. A referral from the child's primary care provider is required.   [PL 2011, c. 420, Pt. A, §23 (RAL).]
B. The policy, contract or certificate may limit coverage to $3,200 per year for each child not to exceed $9,600 by the child's 3rd birthday.   [PL 2011, c. 420, Pt. A, §23 (RAL).]
C. The policy, contract or certificate 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 2011, c. 420, Pt. A, §23 (RAL).]
[PL 2011, c. 420, Pt. A, §23 (RAL).]
SECTION HISTORY
PL 2011, c. 420, Pt. A, §23 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2769. Prescription synchronization

§2769. Prescription synchronization
1.  Synchronization.
If a health plan provides coverage for prescription drugs, a carrier:
A. Shall permit and apply a prorated daily cost-sharing rate to a prescription that is dispensed by a pharmacist in the carrier's network for less than a 30-day supply if the prescriber or pharmacist determines that filling or refilling the prescription for less than a 30-day supply is in the best interest of the patient and the patient requests or agrees to less than a 30-day supply in order to synchronize the refilling of that prescription with the patient's other prescriptions;   [PL 2015, c. 93, §1 (NEW); PL 2015, c. 93, §2 (AFF).]
B. May not deny coverage for the dispensing of a medication prescribed for the treatment of a chronic illness that is made in accordance with a plan developed by the carrier, the insured, the prescriber and a pharmacist to synchronize the filling or refilling of multiple prescriptions for the insured. The carrier shall allow a pharmacy to override any denial codes indicating that a prescription is being refilled too soon in order to synchronize the patient's prescriptions; and   [PL 2015, c. 93, §1 (NEW); PL 2015, c. 93, §2 (AFF).]
C. May not use payment structures incorporating prorated dispensing fees. Dispensing fees for partially filled or refilled prescriptions must be paid in full for each prescription dispensed, regardless of any prorated copay for the insured or fee paid for alignment services.   [PL 2015, c. 93, §1 (NEW); PL 2015, c. 93, §2 (AFF).]
[PL 2015, c. 93, §1 (NEW); PL 2015, c. 93, §2 (AFF).]
2.  Application; exclusion.
The requirements of this section do not apply to a prescription for:
A. Solid oral doses of antibiotics; or   [PL 2015, c. 93, §1 (NEW); PL 2015, c. 93, §2 (AFF).]
B. Solid oral doses that are dispensed in their original container as indicated in the federal Food and Drug Administration Prescribing Information or are customarily dispensed in their original packaging to assist a patient with compliance.   [PL 2015, c. 93, §1 (NEW); PL 2015, c. 93, §2 (AFF).]
[PL 2015, c. 93, §1 (NEW); PL 2015, c. 93, §2 (AFF).]
SECTION HISTORY
PL 2015, c. 93, §1 (NEW). PL 2015, c. 93, §2 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 33: HEALTH INSURANCE CONTRACTS › 24-A §2770. Absolute discretion clauses

§2770. Absolute discretion clauses
An individual health insurance policy, contract or certificate, including, but not limited to, a disability income insurance policy, contract or certificate, may not contain a provision purporting to reserve sole or absolute discretion to the insurer to interpret the terms of the contract, to provide standards of interpretation or review, to determine eligibility for benefits, to determine the amount of benefits or to resolve factual disputes. An insurer may not enforce a provision in a policy, contract or certificate that was offered, executed, delivered or issued for delivery in this State and has been continued or renewed by an individual policy holder in this State that purports to reserve sole or absolute discretion to the insurer to interpret the terms of the contract, to provide standards of interpretation or review, to determine eligibility for benefits, to determine the amount of benefits or to resolve factual disputes.   [PL 2019, c. 179, §1 (NEW).]
SECTION HISTORY
PL 2019, c. 179, §1 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 34: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES › 24-A §2772. Minimum standards

§2772. Minimum standards
A utilization review program of the applicant must meet the following minimum standards.   [PL 1989, c. 556, Pt. C, §2 (NEW).]
1.  Notification of adverse decisions.
Notification of an adverse decision by the utilization review agent must be provided to the insured or other party designated by the insured within a time period to be determined by the superintendent through rulemaking and must include the name of the utilization review agent who made the decision.
[PL 1993, c. 602, §5 (AMD).]
2.  Reconsideration of determinations.
All licensees shall maintain a procedure by which insureds, patients or providers may seek reconsideration of determinations of the licensee.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
3.  Accessibility of representatives.
A representative of the licensee must be accessible by telephone to insureds, patients or providers and the superintendent may adopt standards of accessibility by rule.
[RR 2015, c. 1, §27 (COR).]
3-A.  Medical utilization review criteria.
The licensee must have written medical utilization review criteria to be employed in the review process. The criteria must be available for review as a part of any review conducted pursuant to section 2774, subsection 1 and a copy of the criteria must be provided to the bureau upon request.
[PL 1995, c. 332, Pt. M, §7 (NEW).]
4.  Information materials; confidentiality.
A copy of the materials designed to inform applicable patients of the requirements of the utilization plan and the responsibilities and rights of patients under the plan and an acknowledgment that all applicable state and federal laws to protect the confidentiality of individual medical records are followed must be filed with the bureau.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
5.  Penalty for noncompliance with utilization review programs.
A medical utilization review program may not recommend or implement a penalty of more than $500 for failure to provide notification. This subsection does not limit the right of insurers to deny a claim when appropriate prospective or retroactive review concludes that services or treatment rendered were not medically necessary.
[PL 1995, c. 332, Pt. M, §8 (AMD).]
6.  Prohibited activities.
A medical utilization review entity shall ensure that an employee does not perform medical utilization review services involving a health care provider or facility in which that employee has a financial interest.
[RR 1993, c. 2, §15 (RNU).]
SECTION HISTORY
PL 1989, c. 556, §C2 (NEW). RR 1993, c. 2, §15 (COR). PL 1993, c. 602, §§5,6 (AMD). PL 1993, c. 645, §B4 (AMD). PL 1995, c. 332, §§M7,8 (AMD). RR 2015, c. 1, §27 (COR).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 34: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES › 24-A §2773. Utilization review services

§2773. Utilization review services
As used in this chapter, unless the context indicates otherwise, "utilization review services" or "medical utilization review services" means a program or process by which a person, partnership or corporation, on behalf of an insurer, nonprofit service organization, 3rd-party administrator, health maintenance organization, preferred provider organization or employer that is a payor for or that arranges for payment of medical services, seeks to review the utilization, appropriateness or quality of medical services provided to a person whose medical services are paid for, partially or entirely, by that insurer, nonprofit service organization, 3rd-party administrator, health maintenance organization, preferred provider organization or employer. The terms include these programs or processes whether they apply prospectively or retrospectively to medical services. Utilization review services include, but are not limited to, the following:   [PL 1993, c. 602, §7 (AMD).]
1.  Second opinion programs.
Second opinion programs;
[PL 1989, c. 556, Pt. C, §2 (NEW).]
2.  Prehospital admission certification.
Prehospital admission certification;
[PL 1989, c. 556, Pt. C, §2 (NEW).]
3.  Preinpatient service eligibility certification.
Preinpatient service eligibility certification; and
[PL 1989, c. 556, Pt. C, §2 (NEW).]
4.  Concurrent hospital review.
Concurrent hospital review to determine appropriate length of stay.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
SECTION HISTORY
PL 1989, c. 556, §C2 (NEW). PL 1993, c. 602, §7 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 34: LICENSURE OF MEDICAL UTILIZATION REVIEW ENTITIES › 24-A §2774. Enforcement

§2774. Enforcement
The following provisions govern enforcement of this chapter.   [PL 1989, c. 556, Pt. C, §2 (NEW).]
1.  Periodic reviews.
The superintendent may conduct periodic reviews of the operations of the entities licensed pursuant to this chapter to ensure that they continue to meet the minimum standards set forth in section 2772 and any applicable rules adopted by the superintendent. The superintendent may perform periodic telephone audits of licensees to determine if representatives of the licensee are reasonably accessible, as required by section 2772.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
2.  Action against licensee.
The superintendent is authorized to take appropriate action against a licensee which fails to meet the standards of this chapter or any rules adopted by the superintendent, or who fails to respond in a timely manner to corrective actions ordered by the superintendent. The superintendent may impose a civil penalty not to exceed $1,000 for each violation, as permitted by section 12‑A, or may deny, suspend or revoke the license.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
3.  Opportunity to provide information and request hearing.
Before taking the actions authorized by this section to deny, suspend or revoke the license, the superintendent shall provide the licensee with reasonable time to supply additional information demonstrating compliance with the requirements of this chapter and the opportunity to request a hearing to be held consistent with the provisions of the Maine Administrative Procedure Act, Title 5, chapter 375.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
4.  Authority to adopt rules.
The superintendent may adopt rules necessary to implement the provisions of this chapter.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
5.  Rulings on appropriateness of medical judgments not authorized.
Nothing in this chapter requires or authorizes the superintendent to rule on the appropriateness of medical decisions or judgments rendered by review entities and their agents.
[PL 1989, c. 556, Pt. C, §2 (NEW).]
SECTION HISTORY
PL 1989, c. 556, §C2 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 34-A: STATE-FEDERAL HEALTH COVERAGE PARTNERSHIPS › 24-A §2781. State-federal health coverage partnerships

§2781. State-federal health coverage partnerships
1.  Partnerships authorized.
The State may enter into state-federal health coverage partnerships that support the availability of affordable health coverage in the State in accordance with this section. As used in this chapter, "state-federal health coverage partnership" means a program established or authorized under federal law that provides or reallocates federal funding or that provides for the waiver or modification of otherwise applicable provisions of federal laws governing health insurance. "State-federal health coverage partnership" includes, but is not limited to, innovation waivers under Section 1332 of the federal Affordable Care Act.
[PL 2019, c. 653, Pt. B, §1 (NEW).]
2.  Application.
Unless the applicable federal laws, regulations or administrative guidelines require a different state official to be the applicant, the superintendent may apply to the appropriate federal agency or agencies to establish or participate in a state-federal health coverage partnership or to modify the terms and conditions of an existing partnership if the superintendent determines that the application, if approved, is likely to improve the affordability, availability or quality of health coverage in this State and the Governor approves the submission of the application.
[PL 2019, c. 653, Pt. B, §1 (NEW).]
3.  Notice and consultation.
The superintendent shall ensure that all federally required notices and opportunities for consultation with respect to a state-federal health coverage partnership or proposed partnership are provided. The superintendent shall take any additional measures that may be necessary to identify persons and constituencies likely to be materially affected by a state-federal health coverage partnership or proposed partnership and to provide such persons and constituencies with reasonable notice and opportunity for input.
[PL 2019, c. 653, Pt. B, §1 (NEW).]
4.  MaineCare program and Maine Health Insurance Marketplace.
A state-federal health coverage partnership may coordinate with the MaineCare program or the Maine Health Insurance Marketplace established in Title 22, chapter 1479 and incorporate provisions affecting these programs, including but not limited to a joint Medicaid Section 1115 demonstration waiver and state innovation waiver, with the approval or joint application of the Commissioner of Health and Human Services.
[PL 2019, c. 653, Pt. B, §1 (NEW).]
SECTION HISTORY
PL 2019, c. 653, Pt. B, §1 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 34-B: POOLED MARKET AND CLEAR CHOICE DESIGN › 24-A §2791. Definitions

§2791. Definitions
As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings.   [PL 2019, c. 653, Pt. B, §2 (NEW).]
1.  Individual health plan.
"Individual health plan" has the same meaning as in section 2736‑C, subsection 1, paragraph C.
[PL 2019, c. 653, Pt. B, §2 (NEW).]
2.  Small group health plan.
"Small group health plan" has the same meaning as in section 2808‑B, subsection 1, paragraph G.
[PL 2019, c. 653, Pt. B, §2 (NEW).]
SECTION HISTORY
PL 2019, c. 653, Pt. B, §2 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 34-B: POOLED MARKET AND CLEAR CHOICE DESIGN › 24-A §2793. Clear choice designs

§2793. Clear choice designs
The superintendent shall develop clear choice designs for health plans in order to reduce consumer confusion and provide meaningful choices for consumers by promoting a level playing field on which carriers compete on the basis of price and quality.   [PL 2021, c. 361, §3 (AMD).]
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.
[PL 2021, c. 361, §3 (AMD).]
2.  Development of clear choice designs.
The superintendent shall develop clear choice designs in consultation with working groups consisting of consumers, carriers, health policy experts and other interested persons. The superintendent shall adopt rules for clear choice designs, taking into consideration the ability of plans to conform to actuarial value ranges, consumer needs and promotion of benefits with high value and return on investment. The superintendent shall develop at least one clear choice design for each tier of health insurance plan designated as bronze, silver, gold and platinum in accordance with the federal Affordable Care Act. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A. Clear choice designs apply to all individual health plans offered in this State with effective dates of coverage on or after January 1, 2022 and to all small group health plans offered through the pooled market under section 2792.
[PL 2021, c. 361, §3 (AMD).]
3.  Annual review.
The superintendent shall consider annually whether to revise, discontinue or add any clear choice designs for use by carriers in the following calendar year, including but not limited to considering whether deductible and copayment levels should be changed to reflect medical inflation and conform with actuarial value and annual maximum out-of-pocket limits.
[PL 2019, c. 653, Pt. B, §2 (NEW).]
4.  Alternative plan designs.
In addition to one or more health plans that include cost-sharing parameters consistent with a clear choice design developed pursuant to this section, a carrier may offer up to 3 health plan designs that modify one or more specific cost-sharing parameters in a clear choice design if the carrier submits an actuarial certification to the satisfaction of the superintendent that the alternative plan design offers significant consumer benefits and does not result in adverse selection. An alternative plan design may be offered only in a service area where the carrier offers at least one clear choice design plan at the same tier.
[PL 2021, c. 361, §3 (AMD).]
SECTION HISTORY
PL 2019, c. 653, Pt. B, §2 (NEW). PL 2021, c. 361, §3 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2801. Scope of chapter -- short title

§2801. Scope of chapter -- short title
1.
This chapter applies only to group health insurance contracts and to blanket health insurance contracts as herein provided. Nothing in this chapter pertains to legal services insurance as described in chapter 38, except to the extent expressly permitted in that chapter.
[PL 1983, c. 801, §10 (AMD).]
2.
This chapter may be cited as the "Group or Blanket Health Insurance Law."
[PL 1969, c. 132, §1 (NEW).]
SECTION HISTORY
PL 1969, c. 132, §1 (NEW). PL 1983, c. 801, §10 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2802. Group insurance defined

§2802. Group insurance defined
1.
Any policy or contract of insurance against death or injury resulting from accident or from accidental means which covers more than one person, except blanket accident policies as defined in section 2813 and family accident and sickness policies conforming to section 2703, shall be deemed a group accident insurance policy.
[PL 1969, c. 177, §48 (AMD).]
2.
Any policy or contract which insures against disablement, disease or sickness of the insured, excluding disablement which results from accident or from accidental means, and which covers more than one person, except blanket sickness insurance policies as defined in section 2813 and family accident and sickness policies conforming to section 2703, shall be deemed a group sickness insurance policy or contract.
[PL 1969, c. 132, §1 (NEW).]
3.
Any policy or contract of insurance which combines the coverage of group accident insurance and of group sickness insurance shall be deemed a group accident and sickness insurance policy.
[PL 1969, c. 132, §1 (NEW).]
4.
Any reference hereinafter to group health insurance shall mean group accident, group sickness and group accident and sickness insurance as herein defined.
[PL 1969, c. 132, §1 (NEW).]
SECTION HISTORY
PL 1969, c. 132, §1 (NEW). PL 1969, c. 177, §48 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2803. Requirements

§2803. Requirements
A policy of group health insurance may not be delivered in this State, nor may any certificate of group health insurance that derives from a policy issued in another state be delivered in this State unless the group policyholder conforms to one of the descriptions set forth in sections 2804 to 2808.   [PL 2011, c. 238, Pt. G, §1 (AMD).]
SECTION HISTORY
PL 1969, c. 132, §1 (NEW). PL 1981, c. 147, §1 (RPR). PL 1993, c. 171, §C2 (AMD). PL 2011, c. 238, Pt. G, §1 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2804. Employee groups

§2804. Employee groups
A group of individuals may be insured under a policy issued to an employer or to the trustees of a fund established by an employer, which employer or trustees shall be deemed the policyholder, to insure employees of the employer for the benefit of persons other than the employer, subject to the following requirements.   [PL 1981, c. 147, §2 (RPR).]
1.
The employees eligible for insurance under the policy must be all of the employees of the employer, or all of any class or classes thereof. The policy may provide that the term "employees" includes the employees of one or more subsidiary corporations and the employees, individual proprietors, and partners of one or more affiliated corporations, proprietorships or partnerships if the business of the employer and of the affiliated corporations, proprietorships or partnerships is under common control. The policy may provide that the term "employees" includes the individual proprietor or partners if the employer is an individual proprietorship or partnership. The policy may provide that the term "employees" includes retired employees and directors of a corporate employer. A policy issued to insure the employees of a public body may provide that the term "employees" includes elected or appointed officials. If authorized by the school boards of the alternative organizational structure's member school administrative units pursuant to Title 20‑A, section 1001, an alternative organizational structure established pursuant to Title 20‑A, section 1461‑B may contract for group health insurance that is offered to all eligible employees and retirees of the alternative organizational structure and its member school administrative units and their dependents in one or more employment classifications.
[PL 2015, c. 420, §3 (AMD).]
2.
The premium for the policy shall be paid either from the employer's funds or from funds contributed by the insured employees, or from both. Except as provided in subsection 3, a policy on which no part of the premium is to be derived from funds contributed by the insured employees must insure all eligible employees, except those who reject such coverage in writing.
[PL 1981, c. 147, §2 (RPR).]
3.
Except as provided in section 2736‑C, section 2808‑B and chapter 36, an insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer.
[PL 1999, c. 256, Pt. G, §1 (AMD).]
4.
[PL 1981, c. 147, §2 (RP).]
SECTION HISTORY
PL 1969, c. 132, §1 (NEW). PL 1969, c. 177, §49 (AMD). PL 1981, c. 147, §2 (RPR). PL 1989, c. 867, §§2,10 (AMD). PL 1999, c. 256, §G1 (AMD). PL 2015, c. 420, §3 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2804-A. Private purchasing alliances

§2804-A. Private purchasing alliances
A group of individuals may be insured under a policy issued to a private purchasing alliance meeting the requirements of chapter 18‑A.   [PL 1995, c. 673, Pt. A, §4 (NEW).]
SECTION HISTORY
PL 1995, c. 673, §A4 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2804-B. Group disability income protection plan

§2804-B. Group disability income protection plan
An employer may offer its employees an employer-sponsored group disability income protection plan in accordance with the requirements of section 2804. As used in this section, "disability income protection plan" means a group short-term disability policy or a group long-term disability policy instituted by an employer that provides income benefits to an employee who is unable to work for an extended period of time because of sickness or an accident. For the purpose of Title 26, section 629, subsection 1, the premium paid by an employee for an employer-sponsored group disability income protection plan issued pursuant to this section is considered a premium that the employee has agreed to pay if the group disability income protection plan provides for appropriate disclosure regarding the plan chosen by the employer, a method of enrollment that allows employees to opt out of coverage and an appropriate time period for employees to voluntarily terminate coverage. An employee must be provided information regarding the employer-sponsored group disability income protection plan at least 30 days prior and a 2nd time at least 10 days prior to the initial payroll deduction of that employee's premiums. The information provided must include a statement of the employee's right to opt out of coverage, the process by which the employee may exercise the right to opt out of coverage and any deadline to opt out of coverage.   [PL 2015, c. 490, §1 (NEW).]
SECTION HISTORY
PL 2015, c. 490, §1 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2805. Labor union groups

§2805. Labor union groups
A group of individuals may be insured under a policy issued to a labor union or similar employee organization, which shall be deemed to be the policyholder, to insure members of that union or organization for the benefit of persons other than the union or organization or any of its officials, representatives or agents, subject to the following requirements.   [PL 1981, c. 147, §3 (RPR).]
1.
The members eligible for insurance under the policy shall be all of the members of the union or organization or all of any class or classes thereof.
[PL 1981, c. 147, §3 (RPR).]
2.
The premium for the policy shall be paid either from funds of the union or organization, or from funds contributed by the insured members specifically for their insurance, or from both. Except as provided in subsection 3, a policy on which no part of the premium is to be derived from funds contributed by the insured members specifically for their insurance must insure all eligible members, except those who reject such coverage in writing.
[PL 1981, c. 147, §3 (RPR).]
3.
Except as provided in section 2736‑C, section 2808‑B and chapter 36, an insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer.
[PL 1999, c. 256, Pt. G, §2 (AMD).]
4.
[PL 1981, c. 147, §3 (RP).]
SECTION HISTORY
PL 1969, c. 132, §1 (NEW). PL 1981, c. 147, §3 (RPR). PL 1989, c. 867, §§3,10 (AMD). PL 1999, c. 256, §G2 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2805-A. Association groups

§2805-A. Association groups
A group of individuals may be insured under a policy issued to an association or to a trust or to the trustees of a fund established, created or maintained for the benefit of members of one or more associations. The association or associations shall have at the outset a minimum of 50 persons; shall have been organized and maintained in good faith for purposes other than that of obtaining insurance; shall have been in active existence for at least 2 years; and shall have a constitution and bylaws which provides that: The association or associations hold regular meetings not less than annually to further purposes of the members; except for credit unions, the association or associations collect dues or solicit contributions from members; and the members have voting privileges and representation on the governing board and committees. The policy is subject to the following requirements.   [PL 1981, c. 147, §4 (NEW).]
1.
The policy may insure members of the association or associations, employees thereof or employees of members or one or more of the preceding or all of any class or classes thereof for the benefit of persons other than the employees' employer.
[PL 1981, c. 147, §4 (NEW).]
2.
The premium for the policy shall be paid from funds contributed by the association or associations or by employer members, or by both, or from funds contributed by the covered persons or from both the covered persons and the association, associations or employer members.
[PL 1981, c. 147, §4 (NEW).]
3.
Except as provided in subsection 4, a policy on which no part of the premium is to be derived from funds contributed by the covered persons specifically for their insurance must insure all eligible persons, except those who reject that coverage in writing.
[PL 1981, c. 147, §4 (NEW).]
4.
Except as provided in section 2736‑C, section 2808‑B and chapter 36, an insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer.
[PL 1999, c. 256, Pt. G, §3 (AMD).]
SECTION HISTORY
PL 1981, c. 147, §4 (NEW). PL 1989, c. 867, §§4,10 (AMD). PL 1999, c. 256, §G3 (AMD).