reglab/statecodes huggingface dataset:
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4319. Rebates

§4319. Rebates
1.  Rebates required.
Carriers must provide rebates in the large group, small group and individual markets if the medical loss ratio under subsection 2 is less than the minimum medical loss ratio under subsection 3.
[PL 2019, c. 5, Pt. A, §23 (AMD).]
2.  Medical loss ratio.
For purposes of this section, the medical loss ratio is the ratio of the numerator to the denominator as described in paragraphs A and B, respectively, plus any credibility adjustment. For the purposes of this subsection:
A. The numerator is the amount expended on reimbursement for clinical services provided to enrollees and activities that improve health care quality; and   [PL 2011, c. 90, Pt. D, §5 (NEW).]
B. The denominator is the total amount of premium revenue excluding federal and state taxes and licensing and regulatory fees paid and after accounting for payments or receipts for risk adjustment, risk corridors and reinsurance pursuant to federal law.   [PL 2011, c. 90, Pt. D, §5 (NEW).]
[PL 2019, c. 5, Pt. A, §23 (AMD).]
3.  Minimum medical loss ratio.
The minimum medical loss ratio is:
A. In the large group market, 85%;   [PL 2011, c. 90, Pt. D, §5 (NEW).]
B. In the small group market, 80%; and   [PL 2011, c. 90, Pt. D, §5 (NEW).]
C. In the individual market, 80%.   [PL 2019, c. 5, Pt. A, §23 (AMD).]
[PL 2019, c. 5, Pt. A, §23 (AMD).]
4.  Rules.
The superintendent may adopt rules to implement this section in a substantially similar manner as required under the federal Affordable Care Act in effect as of January 1, 2019, including, but not limited to, rules establishing the period for which the medical loss ratio is calculated. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.
[PL 2019, c. 5, Pt. A, §23 (NEW).]
SECTION HISTORY
PL 2011, c. 90, Pt. D, §5 (NEW). PL 2019, c. 5, Pt. A, §23 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4319-A. Guaranteed issue

§4319-A. Guaranteed issue
A carrier offering a health plan in this State in the individual, small group or large group market must offer to an individual or group in the State all health plans that are approved for sale in the applicable market and must accept any individual or group that applies for any of those health plans in accordance with the requirements of section 2736‑C, subsection 3 and section 2808‑B, subsection 4 and section 2850‑B.   [PL 2019, c. 5, Pt. A, §24 (NEW).]
SECTION HISTORY
PL 2019, c. 5, Pt. A, §24 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320. No lifetime or annual limits on health plans

§4320. No lifetime or annual limits on health plans
A carrier offering a health plan in the individual, small group or large group market, as those markets are defined under applicable federal law, may not:   [PL 2019, c. 5, Pt. A, §25 (AMD).]
1.  Establish lifetime limits.
Establish lifetime limits on the dollar value of benefits for any participant or beneficiary; or
[PL 2011, c. 364, §34 (NEW).]
2.  Establish annual limits.
Establish annual limits on the dollar value of essential benefits.
[PL 2019, c. 5, Pt. A, §25 (AMD).]
3.  Application.
This section applies to health plans offered or renewed in this State in the individual, small group and large group markets, as those markets are defined under applicable federal law. A health plan may contain annual dollar limits to the extent allowed under the federal Affordable Care Act as of January 1, 2019 if the plan has been continuously renewed since that date, but the plan may not impose any new limits or reduce any existing limit in effect as of January 1, 2019.
[PL 2019, c. 5, Pt. A, §25 (NEW).]
Revisor's Note: §4320. Payment reform pilot projects (As enacted by PL 2011, c. 270, §2 is REALLOCATED TO TITLE 24-A, SECTION 4320-H)
SECTION HISTORY
RR 2011, c. 1, §43 (RAL). PL 2011, c. 270, §2 (NEW). PL 2011, c. 364, §34 (NEW). PL 2019, c. 5, Pt. A, §25 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-B. Extension of dependent coverage

§4320-B. Extension of dependent coverage
A carrier offering a health plan subject to the requirements of the federal Affordable Care Act that provides dependent coverage of children shall continue to make such coverage available for an adult child until the child turns 26 years of age, consistent with the federal Affordable Care Act, and offer coverage for a dependent child with a disability in accordance with section 4320‑R.   [PL 2021, c. 520, §7 (AMD).]
SECTION HISTORY
PL 2011, c. 364, §34 (NEW). PL 2021, c. 520, §7 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-C. Emergency services

§4320-C. Emergency services
If a carrier offering a health plan provides or covers any benefits with respect to services in an emergency facility or setting, the plan must cover emergency services without prior authorization. Cost-sharing requirements, such as a deductible, copayment amount or coinsurance rate, for out-of-network services are the same as requirements that would apply if such services were provided in network, and any payment made by an enrollee pursuant to this section must be applied to the enrollee's in-network cost-sharing limit. The enrollee's responsibility for payment for covered out-of-network emergency services must be limited so that if the enrollee has paid the enrollee's share of the charge as specified in the plan for in-network services, the carrier shall hold the enrollee harmless from any additional amount owed to an out-of-network provider for covered emergency services and make payment to the out-of-network provider in accordance with section 4303‑C or, if there is a dispute, in accordance with section 4303‑E. A carrier offering a health plan in this State shall also comply with the requirements of section 4304, subsection 5.   [PL 2019, c. 668, §4 (AMD).]
SECTION HISTORY
PL 2011, c. 364, §34 (NEW). PL 2019, c. 238, §3 (AMD). PL 2019, c. 668, §4 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-E. Reinsurance, risk corridors and risk adjustment

§4320-E. Reinsurance, risk corridors and risk adjustment
1.  Transitional reinsurance program.
The superintendent shall establish a transitional reinsurance program for calendar years 2014, 2015 and 2016 as required by Section 1341 of the federal Affordable Care Act.
[PL 2011, c. 364, §34 (NEW).]
2.  Risk corridors.
A carrier shall make any payments required under the risk corridors program established by the Secretary of the United States Department of Health and Human Services for calendar years 2014, 2015 and 2016 as required by Section 1342 of the federal Affordable Care Act.
[PL 2011, c. 364, §34 (NEW).]
3.  Risk adjustment.
The superintendent shall establish a risk adjustment program as required by Section 1343 of the federal Affordable Care Act.
[PL 2011, c. 364, §34 (NEW).]
SECTION HISTORY
PL 2011, c. 364, §34 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-F. Oversight of plans offered on the American Health Benefit Exchange and the SHOP Exchange

§4320-F. Oversight of plans offered on the American Health Benefit Exchange and the SHOP Exchange
1.  Superintendent's authority preserved.
Except as otherwise expressly provided by applicable law, the requirements established by this Title, Title 24 and rules adopted by the superintendent continue to apply to carriers and health plans and are not extinguished or modified in any way by:
A. Certification of a health plan as a qualified health plan or any other determination made by the American Health Benefit Exchange or the SHOP Exchange pursuant to the federal Affordable Care Act; or   [PL 2011, c. 364, §34 (NEW).]
B. Recognition by the applicable federal agency of a carrier as a qualified nonprofit health insurance issuer or as an issuer of multistate qualified health plans, or of a health plan as a multistate qualified health plan, pursuant to the federal Affordable Care Act.   [PL 2011, c. 364, §34 (NEW).]
[PL 2011, c. 364, §34 (NEW).]
2.  Coordination with exchanges.
The superintendent has all additional powers and duties conferred upon a state insurance regulator with respect to the American Health Benefit Exchange and the SHOP Exchange by the federal Affordable Care Act. The superintendent may enter into agreements with the American Health Benefit Exchange and the SHOP Exchange relating to coordination of responsibilities, and such agreements may provide for the superintendent to assume additional authority relating to the certification of qualified health plans or the authorization of a carrier to participate in the American Health Benefit Exchange or the SHOP Exchange.
[PL 2011, c. 364, §34 (NEW).]
SECTION HISTORY
PL 2011, c. 364, §34 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-G. Applicability to health plans grandfathered under the Affordable Care Act

§4320-G. Applicability to health plans grandfathered under the Affordable Care Act
A health plan that is exempt from certain requirements of the federal Affordable Care Act because it has grandfathered status is also exempt, to the same extent, from substantially similar provisions in this Title and Title 24 enacted after January 1, 2011, except to the extent that those provisions state that they apply to grandfathered health plans.   [PL 2011, c. 364, §34 (NEW).]
SECTION HISTORY
PL 2011, c. 364, §34 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-I. Coverage for the cost of testing for bone marrow donation suitability

§4320-I. Coverage for the cost of testing for bone marrow donation suitability
1.  Required coverage.
A carrier offering a health plan in this State shall provide coverage for laboratory fees up to $150 arising from human leukocyte antigen testing performed to establish bone marrow transplantation suitability in accordance with the following requirements:
A. The enrollee covered under the health plan must meet the criteria for testing established by the National Marrow Donor Program, or its successor organization;   [PL 2013, c. 603, §1 (NEW); PL 2013, c. 603, §2 (AFF).]
B. The testing must be performed in a facility that is accredited by a national accrediting body with requirements that are substantially equivalent to or more stringent than those of the College of American Pathologists and is certified under the federal Clinical Laboratories Improvement Act of 1967, 42 United States Code, Section 263a;   [PL 2013, c. 603, §1 (NEW); PL 2013, c. 603, §2 (AFF).]
C. At the time of the testing, the enrollee covered under the health plan must complete and sign an informed consent form that authorizes the results of the test to be used for participation in the National Marrow Donor Program, or its successor organization, and acknowledges a willingness to be a bone marrow donor if a suitable match is found; and   [PL 2013, c. 603, §1 (NEW); PL 2013, c. 603, §2 (AFF).]
D. The carrier may limit each enrollee to one test per lifetime.   [PL 2013, c. 603, §1 (NEW); PL 2013, c. 603, §2 (AFF).]
[PL 2013, c. 603, §1 (NEW); PL 2013, c. 603, §2 (AFF).]
2.  Prohibition on cost-sharing.
A carrier may not impose any deductible, copayment, coinsurance or other cost-sharing requirement on an enrollee for the coverage required under this section.
[PL 2013, c. 603, §1 (NEW); PL 2013, c. 603, §2 (AFF).]
SECTION HISTORY
PL 2013, c. 603, §1 (NEW). PL 2013, c. 603, §2 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-J. Coverage for abuse-deterrent opioid analgesic drug products

§4320-J. Coverage for abuse-deterrent opioid analgesic drug products
1.  Definitions.
As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Abuse-deterrent opioid analgesic drug product" means a brand or generic opioid analgesic drug product approved by the federal Food and Drug Administration with abuse-deterrent labeling claims that indicate the drug product is expected to result in a meaningful reduction in abuse.   [PL 2015, c. 371, §1 (NEW); PL 2015, c. 371, §2 (AFF).]
B. "Cost sharing" means any coverage limit, copayment, coinsurance, deductible or other out-of-pocket expense associated with a health plan.   [PL 2015, c. 371, §1 (NEW); PL 2015, c. 371, §2 (AFF).]
C. "Opioid analgesic drug product" means a drug product in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release, long-acting form and whether or not combined with other drug substances to form a single drug product or dosage form.   [PL 2015, c. 371, §1 (NEW); PL 2015, c. 371, §2 (AFF).]
[PL 2015, c. 371, §1 (NEW); PL 2015, c. 371, §2 (AFF).]
2.  Required coverage.
A carrier offering a health plan in this State shall provide coverage for abuse-deterrent opioid analgesic drug products listed on any formulary, preferred drug list or other list of drugs used by the carrier on a basis not less favorable than that for opioid analgesic drug products that are not abuse-deterrent and are covered by the health plan. An increase in enrollee cost sharing to achieve compliance with this section may not be implemented.
[PL 2015, c. 371, §1 (NEW); PL 2015, c. 371, §2 (AFF).]
SECTION HISTORY
PL 2015, c. 371, §1 (NEW). PL 2015, c. 371, §2 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-K. Coverage for services provided by a naturopathic doctor

§4320-K. Coverage for services provided by a naturopathic doctor
1.  Services provided by a naturopathic doctor.
A carrier offering a health plan in this State shall provide coverage for health care services performed by a naturopathic doctor licensed under Title 32, chapter 113‑B, subchapter 3 when those services are covered services under the health plan when performed by any other health care provider and when those services are within the lawful scope of practice of the naturopathic doctor.
[PL 2017, c. 340, §1 (NEW).]
2.  Limits; deductible; copayment; coinsurance.
A carrier may offer a health plan containing a provision for a deductible, copayment or coinsurance requirement for a health care service provided by a naturopathic doctor as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to the same service provided by other health care providers.
[PL 2017, c. 340, §1 (NEW).]
3.  Network participation.
A carrier shall demonstrate that the carrier's provider network includes reasonable access, in accordance with section 4303, to all covered services that are within the lawful scope of practice of a naturopathic doctor. A carrier may not exclude a provider from participation in the carrier's provider network solely because the provider is a naturopathic doctor as long as the provider is willing to meet the same terms and conditions as other participating providers. This subsection does not require a carrier to contract with all naturopathic doctors or require a carrier to provide coverage under a health plan for any service provided by a participating naturopathic doctor that is not within the health plan's scope of coverage.
[PL 2017, c. 340, §1 (NEW).]
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 2017, c. 340, §1 (NEW).]
SECTION HISTORY
PL 2017, c. 340, §1 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-L. Nondiscrimination

§4320-L. Nondiscrimination
1.  Nondiscrimination.
An individual may not, on the basis of race, color, national origin, sex, sexual orientation, gender identity, age or disability, be excluded from participation in, be denied benefits of or otherwise be subjected to discrimination under any health plan offered in accordance with this Title. A carrier may not in offering, providing or administering a health plan:
A. Deny, cancel, limit or refuse to issue or renew a health plan or other health-related coverage, deny or limit coverage of a claim or impose additional cost sharing or other limitations or restrictions on coverage on the basis of race, color, national origin, sex, sexual orientation, gender identity, age or disability;   [PL 2019, c. 5, Pt. C, §2 (NEW).]
B. Have or implement marketing practices or benefit designs that discriminate on the basis of race, color, national origin, sex, sexual orientation, gender identity, age or disability in a health plan or other health-related coverage;   [PL 2019, c. 5, Pt. C, §2 (NEW).]
C. Deny or limit coverage, deny or limit coverage of a claim or impose additional cost sharing or other limitations or restrictions on coverage for any health services that are ordinarily or exclusively available to individuals of one sex to a transgender individual based on the fact that the individual's sex assigned at birth, gender identity or gender otherwise recorded is different from the one to which such health services are ordinarily or exclusively available;   [PL 2019, c. 5, Pt. C, §2 (NEW).]
D. Have or implement a categorical coverage exclusion or limitation for all health services related to gender transition; or   [PL 2019, c. 5, Pt. C, §2 (NEW).]
E. Otherwise deny or limit coverage, deny or limit coverage of a claim or impose additional cost sharing or other limitations or restrictions on coverage for specific health services related to gender transition if such denial, limitation or restriction results in discrimination against a transgender individual.   [PL 2019, c. 5, Pt. C, §2 (NEW).]
Nothing in this subsection is intended to determine or restrict a carrier from determining whether a particular health service is medically necessary or otherwise meets applicable coverage requirements in any individual case.
[PL 2019, c. 5, Pt. C, §2 (NEW).]
2.  Meaningful access for individuals with limited English proficiency.
A carrier shall take reasonable steps to provide meaningful access to each enrollee or prospective enrollee under a health plan who has limited proficiency in English.
[PL 2019, c. 5, Pt. C, §2 (NEW).]
3.  Effective communication for persons with disabilities.
A carrier shall take reasonable steps to ensure that communication with an enrollee or prospective enrollee in a health plan who is an individual with a disability is as effective as communication with other enrollees or prospective enrollees.
[PL 2019, c. 5, Pt. C, §2 (NEW).]
SECTION HISTORY
PL 2019, c. 5, Pt. C, §2 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-O. Coverage for services provided by a physician assistant

§4320-O. Coverage for services provided by a physician assistant
1.  Services provided by a physician assistant.
A carrier offering a health plan in this State shall provide coverage for health care services performed by a physician assistant licensed under Title 32, section 2594‑E or 3270‑E when those services are covered services under the health plan when performed by any other health care provider and when those services are within the lawful scope of practice of the physician assistant.
[PL 2019, c. 627, Pt. A, §2 (NEW).]
2.  Limits; deductible; copayment; coinsurance.
A carrier may offer a health plan containing a provision for a deductible, copayment or coinsurance requirement for a health care service provided by a physician assistant as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to the same service provided by other health care providers.
[PL 2019, c. 627, Pt. A, §2 (NEW).]
3.  Network participation.
A carrier shall demonstrate that the carrier's provider network includes reasonable access, in accordance with section 4303, to all covered services that are within the lawful scope of practice of a physician assistant. A carrier may not exclude a provider from participation in the carrier's provider network solely because the provider is a physician assistant as long as the provider is willing to meet the same terms and conditions as other participating providers. This subsection does not require a carrier to contract with all physician assistants or require a carrier to provide coverage under a health plan for any service provided by a participating physician assistant that is not within the health plan's scope of coverage.
[PL 2019, c. 627, Pt. A, §2 (NEW).]
4.  Billing.
A carrier shall authorize a physician assistant to bill the carrier and receive direct payment for a medically necessary service the physician assistant provides to an enrollee and identify the physician assistant as provider in the billing and claims process for payment of the service. A carrier may not impose on a physician assistant a practice, education or collaboration requirement that is inconsistent with or more restrictive than a requirement of state law or board or agency rules.
[PL 2019, c. 627, Pt. A, §2 (NEW).]
SECTION HISTORY
PL 2019, c. 627, Pt. A, §2 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-Q. Coverage for services provided by a certified registered nurse anesthetist (REALLOCATED FROM TITLE 24-A, SECTION 4320-P)

§4320-Q. Coverage for services provided by a certified registered nurse anesthetist
(REALLOCATED FROM TITLE 24-A, SECTION 4320-P)
1.  Services provided by a certified registered nurse anesthetist.
A carrier offering a health plan in this State shall provide coverage for health care services performed by a certified registered nurse anesthetist licensed under Title 32, chapter 31 when those services are covered services under the health plan when performed by any other health care provider and when those services are within the lawful scope of practice of the certified registered nurse anesthetist.
[PL 2021, c. 39, §1 (NEW); RR 2021, c. 1, Pt. A, §23 (RAL).]
2.  Limits; deductible; copayment; coinsurance.
A carrier may offer a health plan containing a provision for a deductible, copayment or coinsurance requirement for a health care service provided by a certified registered nurse anesthetist as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to the same service provided by other health care providers.
[PL 2021, c. 39, §1 (NEW); RR 2021, c. 1, Pt. A, §23 (RAL).]
3.  Network participation.
A carrier may not prohibit a certified registered nurse anesthetist from participating in the carrier's provider network or billing the carrier directly solely because the provider is a certified registered nurse anesthetist as long as the provider is willing to meet the same terms and conditions as other participating providers. This subsection does not require a carrier to contract with all certified registered nurse anesthetists or require a carrier to provide coverage under a health plan for any service provided by a participating certified registered nurse anesthetist that is not a covered service under the plan.
[PL 2021, c. 39, §1 (NEW); RR 2021, c. 1, Pt. A, §23 (RAL).]
4.  Claim submission.
Services billed by a certified registered nurse anesthetist must be submitted using the current standardized claim form for professional services approved by the Federal Government and submitted electronically.
[PL 2021, c. 39, §1 (NEW); RR 2021, c. 1, Pt. A, §23 (RAL).]
SECTION HISTORY
PL 2021, c. 39, §1 (NEW). RR 2021, c. 1, Pt. A, §23 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-R. Mandatory offer of coverage for certain adults with disabilities

§4320-R. Mandatory offer of coverage for certain adults with disabilities
1.  Definitions.
As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Dependent child" has the same meaning as in section 4233‑B, subsection 1.   [PL 2021, c. 520, §8 (NEW).]
B. "Disability" means a physical, mental, intellectual or developmental disability that renders a person incapable of self-sustaining employment.   [PL 2021, c. 520, §8 (NEW).]
[PL 2021, c. 520, §8 (NEW).]
2.  Offer of coverage.
A health plan subject to the requirements of the federal Affordable Care Act that offers coverage for a dependent child must offer such coverage, at the option of the parent, for a dependent child with a disability, regardless of age.
[PL 2021, c. 520, §8 (NEW).]
3.  Proof of disability.
A parent shall furnish proof of a dependent child's disability to the carrier within 31 days of the dependent child's attainment of the limiting age established in section 4320‑B and subsequently as may be required by the carrier, but the carrier may not require proof more frequently than annually after the 2-year period following the dependent child's attainment of the limiting age.
[PL 2021, c. 520, §8 (NEW).]
Revisor's Note: §4320-R. Implementation of federal mental health parity laws (As enacted by PL 2021, c. 638, §4 is REALLOCATED TO TITLE 24-A, SECTION 4320-T)
SECTION HISTORY
PL 2021, c. 520, §8 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-S. Coverage for dental services for cancer patients

§4320-S. Coverage for dental services for cancer patients
1.  Required coverage.
Except as provided in subsection 2, a carrier offering a health plan in this State shall provide coverage for medically necessary dental procedures in accordance with the following for an enrollee who has been diagnosed with cancer.
A. Coverage must be provided for fluoride treatment and dental procedures that are medically necessary to reduce the risk of infection or eliminate infection or to treat tooth loss or decay in an enrollee prior to beginning cancer treatment, including chemotherapy, biological therapy or radiation therapy treatment.   [PL 2021, c. 683, §1 (NEW).]
B. Coverage must be provided for dental procedures that are medically necessary to reduce the risk of infection or eliminate infection or to treat tooth loss or decay that are the direct or indirect result of cancer treatment, including chemotherapy, biological therapy or radiation therapy treatment.   [PL 2021, c. 683, §1 (NEW).]
C. Coverage required under this subsection must include coverage for laboratory assessments, medications and treatments.   [PL 2021, c. 683, §1 (NEW).]
[PL 2021, c. 683, §1 (NEW).]
2.  Routine preventive dental care not required.
A carrier is not required to provide coverage for routine preventive dental care, including cleaning and sealants.
[PL 2021, c. 683, §1 (NEW).]
Revisor's Note: §4320-S. Coverage for fertility services (As enacted by PL 2021, c. 692, §1 is REALLOCATED TO TITLE 24-A, SECTION 4320-U)
SECTION HISTORY
PL 2021, c. 683, §1 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4320-V. Coverage for donor breast milk

§4320-V. Coverage for donor breast milk
1.  Required coverage.
A carrier offering a health plan in this State shall provide coverage for pasteurized donor breast milk provided to an infant eligible for coverage under the health plan if a physician or physician assistant licensed under Title 32, chapter 36 or 48 or an advanced practice registered nurse licensed under Title 32, chapter 31 signs an order stating that:
A. The infant is medically or physically unable to receive maternal breast milk or participate in breastfeeding or the infant's parent is medically or physically unable to produce maternal breast milk in quantities sufficient for the infant; and   [PL 2023, c. 229, §1 (NEW).]
B. The infant:
(1) Was born at a birth weight of less than 1,500 grams;
(2) Has a gastrointestinal anomaly or metabolic or digestive disorder or is recovering from intestinal surgery and the infant's digestive needs require additional support;
(3) Is not appropriately gaining weight or growing;
(4) Has formula intolerance and is experiencing weight loss or difficulty feeding;
(5) Has low blood sugar;
(6) Has congenital heart disease;
(7) Has received or will receive an organ transplant; or
(8) Has another serious medical condition for which donor breast milk is medically necessary.   [PL 2023, c. 229, §1 (NEW).]
[PL 2023, c. 229, §1 (NEW).]
SECTION HISTORY
PL 2023, c. 229, §1 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 2: CONSUMER HEALTH CARE DIVISION › 24-A §4322. Consumer Health Care Division Advisory Council (REPEALED)

§4322. Consumer Health Care Division Advisory Council
(REPEALED)
SECTION HISTORY
PL 1997, c. 792, §3 (NEW). PL 2003, c. 689, §B7 (REV). PL 2005, c. 294, §24 (RP).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 2-A: HEALTH INSURANCE CONSUMER ASSISTANCE PROGRAM › 24-A §4326. Health Insurance Consumer Assistance Program

§4326. Health Insurance Consumer Assistance Program
1.  Establishment.
The Health Insurance Consumer Assistance Program, referred to in this section as "the consumer assistance program," is established to provide support for consumers, including prospective consumers, of health insurance, referred to in this section as "consumers," and to customer assistance programs and public and private health insurance assistance programs.
[PL 2019, c. 522, §1 (NEW).]
2.  Consumer assistance program services.
The services provided by the consumer assistance program may include:
A. Assisting consumers with filing complaints and appeals with a group health plan, health insurance carrier or independent review organization and providing information about the internal and external appeal and grievance processes of a group health plan, health insurance carrier or independent review organization;   [PL 2019, c. 522, §1 (NEW).]
B. Collecting, tracking and quantifying inquiries regarding health insurance and problems encountered by consumers;   [PL 2019, c. 522, §1 (NEW).]
C. Educating consumers on their rights and responsibilities with respect to health insurance coverage;   [PL 2019, c. 522, §1 (NEW).]
D. Assisting consumers with obtaining health insurance coverage by providing information, referrals or other assistance;   [PL 2019, c. 522, §1 (NEW).]
E. Assisting with obtaining federal health insurance premium tax credits under Section 36B of the United States Internal Revenue Code of 1986, as amended; and   [PL 2019, c. 522, §1 (NEW).]
F. Providing information to the public about the services of the consumer assistance program through a comprehensive outreach program and a toll-free telephone number.   [PL 2019, c. 522, §1 (NEW).]
[PL 2019, c. 522, §1 (NEW).]
3.  Contract for operation.
The Attorney General shall contract with a nonprofit, independent health insurance consumer assistance entity, which may not be an insurer, to operate the consumer assistance program.
[PL 2019, c. 522, §1 (NEW).]
4.  Report.
The operator of the consumer assistance program shall report to the Attorney General, according to the requirements of the contract under subsection 1, on aggregate data relevant to the services provided by and activities of the consumer assistance program, and annually, by January 15th, the Attorney General shall report to the joint standing committee of the Legislature having jurisdiction over health insurance matters on the aggregate data.
[PL 2019, c. 522, §1 (NEW).]
5.  Funding.
The State shall provide necessary funding for the consumer assistance program.
[PL 2021, c. 206, §1 (NEW).]
SECTION HISTORY
PL 2019, c. 522, §1 (NEW). PL 2021, c. 206, §1 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 3: DOWNSTREAM RISK › 24-A §4332. Safe harbor and waiver

§4332. Safe harbor and waiver
1.  Authority for safe harbor.
Notwithstanding any other provisions of this Title or Title 24, including, without limitation, sections 4341 and 4342, an arrangement between a carrier and a downstream entity with which the carrier has contracted to provide or arrange for the provision of services that allows the downstream entity to accept a limited degree of insurance risk is permitted and such a risk arrangement is deemed not to be engaging in the business of insurance by the downstream entity if:
A. The arrangement does not involve substantial insurance risk or substantial enrollment risk as described in section 4334; and   [PL 1999, c. 609, §20 (NEW).]
B. The arrangement meets the requirements of sections 4335 and 4336.   [PL 1999, c. 609, §20 (NEW).]
[PL 1999, c. 609, §20 (NEW).]
2.  Waiver for downstream risk arrangements that exceed risk threshold described in section 4334.
Carriers and downstream entities that wish to develop downstream risk arrangements that exceed the risk threshold described in section 4334 may jointly request that the superintendent grant a waiver that allows the downstream entity to accept a limited degree of insurance risk without being licensed as an insurer, a health maintenance organization or an insurance administrator. The joint request for a waiver must include a plan for managing financial exposure, based upon reasonable enrollment and utilization projections and upon the contracts, parties and features proposed, sufficient to quantify in dollars per quarter and per annum all elements of downstream risk to be assumed by the downstream entity. All other risk arrangements are prohibited unless the arrangements meet the appropriate licensing standards or are expressly permitted by the superintendent.
[PL 1999, c. 609, §20 (NEW).]
3.  Continuing obligation to subscribers.
A carrier contracting with a downstream entity remains obligated to its subscribers for the delivery of health care benefits consistent with existing state law. The carrier remains responsible for compliance with all applicable laws.
[PL 1999, c. 609, §20 (NEW).]
4.  Certain incentives prohibited.
A downstream risk arrangement may not contain incentives for the downstream entity or participating provider to limit or deny medically necessary care to enrollees.
[PL 1999, c. 609, §20 (NEW).]
5.  Requirements still applicable.
The application of the safe harbor provisions in subsection 1 or a waiver of licensing requirements granted pursuant to this section does not exempt the downstream entity from any other licensure or prior approval requirements applicable to activities conducted by the downstream entity, including, but not limited to, utilization review licensure, insurance administrator licensure or preferred provider arrangement registration.
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 3: DOWNSTREAM RISK › 24-A §4333. Requirements for downstream risk arrangements

§4333. Requirements for downstream risk arrangements
1.  Permissible downstream risk arrangements.
Downstream entities that do not exceed the risk threshold described in section 4334 may enter into downstream risk arrangements only if:
A. The requirements of section 4332, subsection 1 and sections 4335 and 4336 are met; and   [PL 1999, c. 609, §20 (NEW).]
B. No specific payment is made directly or indirectly under the plan to a provider as an inducement to reduce or limit medically necessary services furnished to an enrollee.   [PL 1999, c. 609, §20 (NEW).]
[PL 1999, c. 609, §20 (NEW).]
2.  Prohibited downstream risk payments.
A specific payment of any kind may not be made directly or indirectly under the incentive plan to a downstream entity as an inducement to reduce or limit covered medically necessary services under the carrier's contract furnished to an enrollee. Indirect payments include offerings of monetary value such as stock options or waivers of debt measured in the present or future.
[PL 1999, c. 609, §20 (NEW).]
3.  Applicability.
This section applies to risk arrangements between carriers and downstream entities with which they contract to provide medical services to enrollees. This section also applies to subcontracting arrangements.
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 3: DOWNSTREAM RISK › 24-A §4334. Substantial insurance risk; substantial enrollment risk

§4334. Substantial insurance risk; substantial enrollment risk
1.  Substantial insurance risk.
Substantial insurance risk is risk based on the use or costs of referral services only, when the downstream entity is at risk for more than 25% of potential payments by the carrier to the downstream entity.
[PL 1999, c. 609, §20 (NEW).]
2.  Substantial enrollment risk.
Substantial enrollment risk exists when a carrier enters into a risk arrangement with a downstream entity involving more than 25% of the enrollees served by the carrier in the State unless the risk arrangement is a risk-sharing arrangement.
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 3: DOWNSTREAM RISK › 24-A §4336. Disclosure requirements for organizations with downstream risk arrangements

§4336. Disclosure requirements for organizations with downstream risk arrangements
1.  Disclosure to superintendent.
Each carrier shall provide information concerning the carrier's downstream risk arrangements as required or requested by the superintendent. The disclosure must contain the following information in sufficient detail to enable the superintendent to determine whether the risk arrangement complies with the following requirements:
A. Whether services not furnished by the downstream entity are covered by the risk arrangement. If the services furnished by the downstream entity are covered by the risk arrangement, disclosure of other aspects of the plan need not be made;   [PL 1999, c. 609, §20 (NEW).]
B. The type of risk arrangement; for example, withhold, bonus, capitation;   [PL 1999, c. 609, §20 (NEW).]
C. If the risk arrangement involves a withhold or bonus, the percent of the withhold or bonus;   [PL 1999, c. 609, §20 (NEW).]
D. The panel size, the number of enrollees covered by the downstream entity and the total number of enrollees covered by the carrier in the State; and   [PL 1999, c. 609, §20 (NEW).]
E. In the case of capitated downstream entities, capitation payments paid to primary care providers for the most recent year broken down by percent for primary care services, referral services to specialists, hospital services and other types of provider services, including, but not limited to, nursing home and home health agency services.   [PL 1999, c. 609, §20 (NEW).]
[PL 1999, c. 609, §20 (NEW).]
2.  Annual disclosure.
A carrier shall provide this information to the superintendent at least annually. A carrier shall provide the capitation data required under subsection 1 for the previous calendar year to the superintendent by April 1st of each year.
[PL 1999, c. 609, §20 (NEW).]
3.  Disclosure to enrollees.
A carrier shall provide the following information to any enrollee upon request:
A. Whether the prepaid plan uses a downstream risk arrangement that affects the use of referral services; and   [PL 1999, c. 609, §20 (NEW).]
B. The type of risk arrangement.   [PL 1999, c. 609, §20 (NEW).]
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 3: DOWNSTREAM RISK › 24-A §4337. Requirements related to subcontracting arrangements

§4337. Requirements related to subcontracting arrangements
1.  Physician groups.
A carrier that contracts with a downstream entity that places the individual physician members at substantial financial risk for services they do not furnish shall disclose to the superintendent any incentive plan between the downstream entity and the entity's individual physicians that bases compensation to the physician on the use or cost of services furnished to enrollees. The disclosure must include the information specified in section 4336, subsection 1.
[PL 1999, c. 609, §20 (NEW).]
2.  Intermediate entities.
A carrier that contracts with a downstream entity, other than a physician group, for the provision of services to enrollees shall disclose to the superintendent any risk arrangement between the entity and a physician or physician group that bases compensation to the physician or physician group on the use or cost of services furnished to enrollees. The disclosure must include the information required to be disclosed under section 4336, subsection 1.
[PL 1999, c. 609, §20 (NEW).]
3.  Sanctions against the carrier.
The superintendent may apply intermediate sanctions if the superintendent determines that a carrier fails to comply with the requirements of this section.
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 3: DOWNSTREAM RISK › 24-A §4338. Downstream risk arrangements that exceed risk threshold described in section 4334

§4338. Downstream risk arrangements that exceed risk threshold described in section 4334
The superintendent may waive downstream risk arrangements from licensure requirements that exceed the risk threshold described in section 4334 if the downstream risk arrangement meets the contractual and disclosure requirements established under section 4332 and the criteria set forth in sections 4339 to 4342 and is determined by the superintendent not to prejudice enrollee interests.   [PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 3: DOWNSTREAM RISK › 24-A §4339. Contractual provisions to demonstrate financial viability

§4339. Contractual provisions to demonstrate financial viability
If a carrier applies for a waiver under section 4332, subsection 2, the carrier may demonstrate the financial viability and condition of the downstream entity through the terms of the contract, including one or more of the following:   [PL 1999, c. 609, §20 (NEW).]
1.  Books, accounts and records.
A contractual provision authorizing the carrier to access the downstream entity's books, accounts and records according to terms and conditions on which the carrier and the downstream entity agree;
[PL 1999, c. 609, §20 (NEW).]
2.  Financial statements.
A contractual provision requiring the downstream entity to provide to the carrier interim unaudited financial statements on a regular and ongoing basis as well as an annual financial statement, accompanied by a certified public accountant's opinion, appropriate to the magnitude of risk involved;
[PL 1999, c. 609, §20 (NEW).]
3.  Reserves.
A contractual provision authorizing the carrier to receive information regarding the downstream entity's reserves;
[PL 1999, c. 609, §20 (NEW).]
4.  Letter of credit.
A contractual provision requiring the downstream entity to post a letter of credit or other acceptable financial security;
[PL 1999, c. 609, §20 (NEW).]
5.  Fees.
A contractual provision under which the carrier withholds fees payable to the downstream entity or to the providers for which it acts;
[PL 1999, c. 609, §20 (NEW).]
6.  General liability insurance.
A contractual provision requiring the downstream entity to carry general liability insurance and requiring participating providers to carry professional liability insurance in an amount and from an insurer mutually acceptable to the carrier and the downstream entity;
[PL 1999, c. 609, §20 (NEW).]
7.  Surety bond.
A contractual provision requiring the downstream entity to secure a surety bond to cover the downstream entity's performance under the contract; or
[PL 1999, c. 609, §20 (NEW).]
8.  Excess of loss insurance.
A contractual provision requiring the downstream entity to secure excess of loss insurance or reinsurance in an amount and from an insurer mutually acceptable to the carrier and the downstream entity.
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 3: DOWNSTREAM RISK › 24-A §4340. Financial viability

§4340. Financial viability
Each carrier and downstream entity requesting a waiver shall file with the superintendent a plan for managing financial exposure under those downstream risk arrangement contracts and thereafter operate in substantial conformance with the terms of that plan and of the corresponding waiver. At least 60 days before any material change in a filed and approved exposure management plan, the carrier and downstream entity shall file for the superintendent's review and approval a modified plan, along with any changes in related contracts.   [PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 3: DOWNSTREAM RISK › 24-A §4341. Limitations on premium transfer

§4341. Limitations on premium transfer
The superintendent may deny a request for waiver based on any of the following characteristics:   [PL 1999, c. 609, §20 (NEW).]
1.  Transfer of 30% of annual aggregate premium.
A contract by which 30% or more of the carrier's annual aggregate premium with respect to a contract, plan or product is transferred to a single downstream entity. This transfer is the sum of capitated payments plus the sum of amounts returnable to the carrier through incentive payments or other risk adjustments; or
[PL 1999, c. 609, §20 (NEW).]
2.  Transfer of 75% of annual aggregate premium.
Multiple contracts by which 75% or more of the carrier's annual aggregate premium with respect to a contract, plan or product is transferred to one or more downstream entities. This transfer is the sum of capitated payments plus the sum of amounts returnable to the carrier through incentive payments or other risk adjustments.
[PL 1999, c. 609, §20 (NEW).]
SECTION HISTORY
PL 1999, c. 609, §20 (NEW).