2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 87: DIRIGO HEALTH › Subchapter 1: GENERAL PROVISIONS › 24-A §6910. Dirigo Health Program

§6910. Dirigo Health Program
1.  Dirigo Health Program.
Dirigo Health shall arrange for the provision of health benefits coverage through the Dirigo Health Program not later than October 1, 2004. The Dirigo Health Program must comply with all relevant requirements of this Title. Dirigo Health Program coverage may be offered by health insurance carriers that apply to the board and meet qualifications described in this section and any additional qualifications set by the board or may be provided through the Dirigo Health Self-administered Plan pursuant to section 6981.
[PL 2007, c. 447, §9 (AMD).]
2.  Legislative approval of nonprofit health care plan or expansion of public plan.
If health insurance carriers do not apply to offer and deliver Dirigo Health Program coverage, the board may have Dirigo Health provide access to health insurance by proposing the establishment of a nonprofit health care plan organized under Title 13‑B and authorized pursuant to Title 24, chapter 19 or by proposing the expansion of an existing public plan. If the board proposes the establishment of a nonprofit health care plan or the expansion of an existing public plan, the board shall submit its proposal, including, but not limited to, a funding mechanism to capitalize a nonprofit health care plan and any recommended legislation to the joint standing committee of the Legislature having jurisdiction over health insurance matters. Dirigo Health may not provide access to health insurance by establishing a nonprofit health care plan or through an existing public plan without specific legislative approval.
[PL 2005, c. 400, Pt. C, §8 (AMD).]
3.  Carrier participation requirements.
To qualify as a carrier of Dirigo Health Program coverage, a health insurance carrier must:
A. Provide the comprehensive health services and benefits as determined by the board, including a standard benefit package that meets the requirements for mandated coverage for specific health services, specific diseases and for certain providers of health services under Title 24 and this Title and any supplemental benefits the board wishes to make available; and   [PL 2003, c. 469, Pt. A, §8 (NEW).]
B. Ensure that:
(1) Providers contracting with a carrier contracted to provide coverage to plan enrollees do not charge plan enrollees or 3rd parties for covered health care services in excess of the amount allowed by the carrier the provider has contracted with, except for applicable copayments, deductibles or coinsurance or as provided in section 4204, subsection 6;
(2) Providers contracting with a carrier contracted to provide coverage to plan enrollees do not refuse to provide services to a plan enrollee on the basis of health status, medical condition, previous insurance status, race, age, religion, ancestry or national origin, citizenship status, sex, sexual orientation, gender identity, disability or marital status. This subparagraph may not be construed to require a provider to furnish medical services that are not within the scope of that provider's license; and
(3) Providers contracting with a carrier contracted to provide coverage to plan enrollees are reimbursed at the negotiated reimbursement rates between the carrier and its provider network.   [PL 2021, c. 553, §17 (AMD).]
Health insurance carriers that seek to qualify to provide Dirigo Health Program coverage must also qualify as health plans in Medicaid.
[PL 2021, c. 553, §17 (AMD).]
4.  Contracting authority.
Dirigo Health has contracting authority and powers to administer Dirigo Health Insurance as set out in this subsection.
A. Dirigo Health may contract with health insurance carriers licensed to sell health insurance in this State or other private or public third-party administrators to provide Dirigo Health Program coverage. In addition:
(1) Dirigo Health shall issue requests for proposals from health insurance carriers;
(2) Dirigo Health may include quality improvement, disease prevention, disease management and cost-containment provisions in the contracts with participating health insurance carriers or may arrange for the provision of such services through contracts with other entities;
(3) Dirigo Health shall require participating health insurance carriers to offer a benefit plan identical to the Dirigo Health Program, for which no Dirigo Health subsidies are available, in the general small group market;
(4) Dirigo Health shall make payments to participating health insurance carriers under a Dirigo Health Program contract to provide Dirigo Health Program benefits to plan enrollees not enrolled in MaineCare;
(5) Dirigo Health may set allowable rates for administration and underwriting gains for the Dirigo Health Program;
(6) Dirigo Health may administer continuation benefits for eligible individuals from employers with 20 or more employees who have purchased health insurance coverage through Dirigo Health for the duration of their eligibility periods for continuation benefits pursuant to the federal Consolidated Omnibus Budget Reconciliation Act, Public Law 99-272, Title X, Private Health Insurance Coverage, Sections 10001 to 10003; and
(7) Dirigo Health may administer or contract to administer the United States Internal Revenue Code of 1986, Section 125 plans for employers and employees participating in Dirigo Health, including medical expense reimbursement accounts and dependent care reimbursement accounts.   [PL 2005, c. 400, Pt. C, §8 (AMD).]
B. Dirigo Health shall contract with eligible businesses seeking assistance from Dirigo Health in arranging for health benefits coverage by the Dirigo Health Program for their employees and dependents as set out in this paragraph.
(1) Dirigo Health may establish contract and other reporting forms and procedures necessary for the efficient administration of contracts.
(2) Dirigo Health shall collect payments from participating employers and plan enrollees to cover the cost of:
(a) The Dirigo Health Program for enrolled employees and dependents in contribution amounts determined by the board;
(b) Dirigo Health's quality assurance, disease prevention, disease management and cost-containment programs;
(c) Dirigo Health's administrative services; and
(d) Other health promotion costs.
(3) Dirigo Health shall establish the minimum required contribution levels, not to exceed 60%, to be paid by employers toward the aggregate payment in subparagraph (2) and establish an equivalent minimum amount to be paid by employers or plan enrollees and their dependents who are enrolled in MaineCare. The minimum required contribution level to be paid by employers must be prorated for employees that work less than the number of hours of a full-time equivalent employee as determined by the employer. Dirigo Health may establish a separate minimum contribution level to be paid by employers toward coverage for dependents of the employers' enrolled employees.
(4) Dirigo Health shall require participating employers to certify that at least 75% of their employees that work 30 hours or more per week and who do not have other creditable coverage are enrolled in the Dirigo Health Program and that the employer group otherwise meets the minimum participation requirements specified by section 2808‑B, subsection 4, paragraph A.
(5) Dirigo Health shall reduce the payment amounts for plan enrollees eligible for a subsidy under section 6912 accordingly. Dirigo Health shall return any payments made by plan enrollees also enrolled in MaineCare to those enrollees.
(6) Dirigo Health shall require participating employers to pass on any subsidy in section 6912 to the plan enrollee qualifying for the subsidy, up to the amount of payments made by the plan enrollee.
(7) Dirigo Health may establish other criteria for participation.
(8) Dirigo Health may limit the number of participating employers.   [PL 2005, c. 400, Pt. C, §8 (AMD).]
C. Dirigo Health may permit eligible individuals to purchase Dirigo Health Program coverage for themselves and their dependents as set out in this paragraph.
(1) Dirigo Health may establish contract and other reporting forms and procedures necessary for the efficient administration of contracts.
(2) Dirigo Health may collect payments from eligible individuals participating in the Dirigo Health Program to cover the cost of:
(a) Enrollment in the Dirigo Health Program for eligible individuals and dependents;
(b) Dirigo Health's quality assurance, disease prevention, disease management and cost-containment programs;
(c) Dirigo Health's administrative services; and
(d) Other health promotion costs.
(3) Dirigo Health shall reduce the payment amounts for individuals eligible for a subsidy under section 6912 accordingly.
(4) Dirigo Health may require that eligible individuals certify that all their dependents are enrolled in the Dirigo Health Program or are covered by another creditable plan.
(5) Dirigo Health may require an eligible individual who is currently employed by an eligible employer that does not offer health insurance to certify that the current employer did not provide access to an employer-sponsored benefits plan in the 12-month period immediately preceding the eligible individual's application.
(6) Dirigo Health may limit the number of plan enrollees.
(7) Dirigo Health may establish other criteria for participation.   [PL 2005, c. 400, Pt. C, §8 (AMD).]
[PL 2005, c. 400, Pt. C, §8 (AMD).]
5.  Enrollment in Dirigo Health Program.
Dirigo Health shall perform, at a minimum, the following functions to facilitate enrollment in the Dirigo Health Program.
A. Dirigo Health shall publicize the availability of the Dirigo Health Program to businesses, self-employed individuals and others eligible to enroll in the Dirigo Health Program.   [PL 2005, c. 400, Pt. C, §8 (AMD).]
B. Dirigo Health shall screen all eligible individuals and employees for eligibility for subsidies under section 6912 and eligibility for MaineCare. To facilitate the screening and referral process, Dirigo Health shall provide a single application form for Dirigo Health and MaineCare. The application materials must inform applicants of subsidies available through Dirigo Health and of the additional coverage available through MaineCare. It must allow an applicant to choose on the application form to apply or not to apply for MaineCare or for a subsidy. It must allow an applicant to provide household financial information necessary to determine eligibility for MaineCare or a subsidy. Except when the applicant has declined to apply for MaineCare or a subsidy, an application must be treated as an application for Dirigo Health, for a subsidy and for MaineCare. MaineCare must make the final determination of eligibility for MaineCare.   [PL 2003, c. 469, Pt. A, §8 (NEW).]
C. Except as provided in this paragraph, the effective date of coverage for a new enrollee in the Dirigo Health Program is the first day of the month following receipt of the fully completed application for that enrollee by the carrier contracting with Dirigo Health or the first day of the next month if the fully completed application is received by the carrier within 10 calendar days of the end of the month. If a new enrollee in the Dirigo Health Program had prior coverage through an individual or small group policy, coverage under the Dirigo Health Program must take effect the day following termination of that enrollee's prior coverage.   [PL 2005, c. 400, Pt. C, §8 (AMD).]
[PL 2005, c. 400, Pt. C, §8 (AMD).]
6.  Quality improvement, disease management and cost containment.
Dirigo Health shall promote quality improvement, disease prevention, disease management and cost-containment programs as part of its administration of the Dirigo Health Program.
[PL 2005, c. 400, Pt. C, §8 (AMD).]
SECTION HISTORY
RR 2003, c. 1, §22 (COR). PL 2003, c. 469, §A8 (NEW). PL 2005, c. 400, §C8 (AMD). PL 2007, c. 447, §9 (AMD). PL 2021, c. 366, §29 (AMD). PL 2021, c. 553, §17 (AMD).