2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 36: CONTINUITY OF HEALTH INSURANCE COVERAGE › 24-A §2848. Definitions

§2848. Definitions
As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings.   [PL 1993, c. 349, §52 (RPR).]
1.  Evidence of individual insurability.
"Evidence of individual insurability" means medical information or other information that indicates health status, such as whether the individual is actively at work, used to determine whether coverage of an individual within the group is to be limited or excluded.
[PL 1993, c. 349, §52 (RPR).]
1-A.  COBRA continuation provision.
"COBRA continuation provision" means any of the following:
A. Section 4980B of the Internal Revenue Code of 1986, other than Subsection (f)(1) as it relates to pediatric vaccines;   [PL 1997, c. 445, §20 (NEW); PL 1997, c. 445, §32 (AFF).]
B. Part 6 of Subtitle B of Title I of the federal Employee Retirement Income Security Act of 1974, 29 United States Code, Section 1161, other than Section 609; or   [PL 1997, c. 445, §20 (NEW); PL 1997, c. 445, §32 (AFF).]
C. Title XXII of the federal Public Health Service Act, 42 United States Code, Section 201.   [PL 1997, c. 445, §20 (NEW); PL 1997, c. 445, §32 (AFF).]
[PL 1997, c. 445, §20 (NEW); PL 1997, c. 445, §32 (AFF).]
1-B.  Federally creditable coverage.
"Federally creditable coverage" is defined as follows.
A. "Federally creditable coverage" means health benefits or coverage provided under any of the following:
(1) An employee welfare benefit plan as defined in Section 3(1) of the federal Employee Retirement Income Security Act of 1974, 29 United States Code, Section 1001, or a plan that would be an employee welfare benefit plan but for the "governmental plan" or "nonelecting church plan" exceptions, if the plan provides medical care as defined in subsection 2‑A, and includes items and services paid for as medical care directly or through insurance, reimbursement or otherwise;
(2) Benefits consisting of medical care provided directly, through insurance or reimbursement and including items and services paid for as medical care under a policy, contract or certificate offered by a carrier;
(3) Part A or Part B of Title XVIII of the Social Security Act, Medicare;
(4) Title XIX of the Social Security Act, Medicaid, other than coverage consisting solely of benefits under Section 1928 of the Social Security Act;
(4-A) A state children's health insurance program under Title XXI of the Social Security Act;
(5) The Civilian Health and Medical Program for the Uniformed Services, CHAMPUS, 10 United States Code, Chapter 55;
(6) A medical care program of the federal Indian Health Care Improvement Act, 25 United States Code, Section 1601 et seq. or of a tribal organization;
(7) A state health benefits risk pool;
(8) A health plan offered under the federal Employees Health Benefits Amendments Act, 5 United States Code, Chapter 89;
(9) A public health plan as defined in federal regulations authorized by the federal Public Health Service Act, Section 2701(c)(1)(I), as amended by Public Law 104-191; or
(10) A health benefit plan under Section 5(e) of the Peace Corps Act, 22 United States Code, Section 2504(e).   [PL 2013, c. 588, Pt. A, §27 (AMD).]
B. "Federally creditable coverage" does not include coverage consisting solely of one or more of the following:
(1) Coverage for accident or disability income insurance or any combination of those coverages;
(2) Liability insurance, including general liability insurance and automobile liability insurance;
(3) Coverage issued as a supplement to liability insurance;
(4) Workers' compensation or similar insurance;
(5) Automobile medical payment insurance;
(6) Credit insurance;
(7) Coverage for on-site medical clinics; or
(8) Other similar insurance coverage, specified in federal regulations issued pursuant to Public Law 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits.   [PL 1999, c. 256, Pt. L, §2 (AMD).]
C. "Federally creditable coverage" does not include the following benefits if those benefits are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan:
(1) Limited scope dental or vision benefits;
(2) Benefits for long-term care, nursing home care, home health care, community-based care or any combination of those benefits; and
(3) Other similar, limited benefits as specified in federal regulations issued pursuant to Public Law 104-191.   [PL 1999, c. 256, Pt. L, §2 (AMD).]
D. "Federally creditable coverage" does not include the following benefits if the benefits are provided under a separate policy, certificate or contract of insurance, and if no coordination exists between the provision of the benefits and any exclusion of benefits under a group health plan maintained by the same plan sponsor and those benefits are paid for an event without regard to whether benefits are provided for that event under a group health plan maintained by the same plan sponsor:
(1) Coverage only for a specified disease or illness; and
(2) Hospital indemnity or other fixed indemnity insurance.   [PL 1999, c. 256, Pt. L, §2 (AMD).]
E. "Federally creditable coverage" does not include the following if it is offered as a separate policy, certificate or contract of insurance:
(1) Medicare supplemental health insurance under the Social Security Act, Section 1882(g)(1);
(2) Coverage supplemental to the coverage provided under the Civilian Health and Medical Program of the Uniformed Services, CHAMPUS, 10 United States Code, Chapter 55; and
(3) Similar supplemental coverage under a group health plan.   [PL 1999, c. 256, Pt. L, §2 (AMD).]
For purposes of this subsection, a "period of continuing federally creditable coverage" means a period in which an individual has maintained federally creditable coverage through one or more plans or programs, with no break in coverage exceeding 63 days. In calculating the aggregate length of a period of continuing federally creditable coverage that includes one or more breaks in coverage, only the time actually covered is counted. A waiting period is not counted as a break in coverage, but is not counted as a period of actual coverage unless the individual has other federally creditable coverage during this period. For purposes of this subsection and subsection 1‑C, "group health plan" has the same meaning as specified in the federal Public Health Service Act, Title XXVII, Section 2791(a).
[PL 2013, c. 588, Pt. A, §27 (AMD).]
1-C.  Federally eligible individual.
"Federally eligible individual" means an individual:
A. Who has had a period of continuing federally creditable coverage, as defined in subsection 1‑B, ending not more than 63 days before applying for an individual health plan, with an aggregate length of federally creditable coverage, as defined in subsection 1‑B, of at least 18 months;   [PL 1999, c. 256, Pt. L, §3 (AMD).]
B. Whose most recent prior federally creditable coverage was under a group health plan, governmental plan, church plan or health insurance coverage offered in connection with any such plan;   [PL 1999, c. 256, Pt. L, §3 (AMD).]
C. Who is not eligible for coverage under a group health plan, Part A or Part B of Title XVIII of the Social Security Act, Medicare, or a state plan under Title XIX, Medicaid or any successor program and who does not have other health insurance coverage;   [PL 1997, c. 445, §20 (NEW); PL 1997, c. 445, §32 (AFF).]
D. Whose most recent federally creditable coverage was not terminated based on nonpayment of premiums, fraud or intentional misrepresentation of material fact; and   [PL 1999, c. 256, Pt. L, §3 (AMD).]
E. Who, if offered the option of continuation of coverage under a COBRA continuation provision, as defined by subsection 1‑A, or under a similar state program, elected continuation of coverage and has exhausted that coverage. For purposes of this paragraph, an individual is considered to have exhausted COBRA continuation coverage when the individual no longer resides, lives or works in a service area of a managed care plan and there is no other COBRA continuation coverage available to the individual.   [PL 2001, c. 258, Pt. D, §2 (AMD).]
[PL 2001, c. 258, Pt. D, §2 (AMD).]
1-D.  Governmental plan.
"Governmental plan" has the meaning given under Section 3(32) of the federal Employee Retirement Income Security Act of 1974 or any federal governmental employee plan.
[PL 1997, c. 445, §20 (NEW); PL 1997, c. 445, §32 (AFF).]
2.  Group.
"Group" means any of the types of groups under sections 2804 to 2808.
[PL 1993, c. 349, §52 (RPR).]
2-A.  Medical care.
Medical care includes the amounts paid for:
A. The diagnosis, care, mitigation, treatment or prevention of disease, or the amounts paid for the purpose of affecting a structure or function of the body;   [PL 1997, c. 445, §21 (NEW); PL 1997, c. 445, §32 (AFF).]
B. Transportation primarily for, and essential to, medical care under paragraph A; and   [PL 1997, c. 445, §21 (NEW); PL 1997, c. 445, §32 (AFF).]
C. Insurance coverage for medical care under paragraphs A and B.   [PL 1997, c. 445, §21 (NEW); PL 1997, c. 445, §32 (AFF).]
[PL 1997, c. 445, §21 (NEW); PL 1997, c. 445, §32 (AFF).]
3.  Preexisting condition exclusion.
[PL 1997, c. 445, §22 (RP); PL 1997, c. 445, §32 (AFF).]
4.  Subgroup.
"Subgroup" means an employer covered under a contract issued to a multiple employer trust or to an association.
[PL 1993, c. 349, §52 (RPR).]
5.  Waiting period.
"Waiting period" means a period of time after the date of enrollment during which a health insurance plan excludes coverage for the diagnosis or treatment of any or all medical conditions.
[PL 1999, c. 256, Pt. L, §4 (AMD).]
SECTION HISTORY
PL 1989, c. 767, §4 (NEW). PL 1989, c. 801, §3 (NEW). PL 1989, c. 867, §§8,10 (NEW). PL 1991, c. 695, §6 (RPR). PL 1991, c. 824, §A52 (RPR). PL 1993, c. 349, §52 (RPR). PL 1997, c. 445, §§20-22 (AMD). PL 1997, c. 445, §32 (AFF). PL 1997, c. 683, §A13 (AMD). PL 1997, c. 777, §B4 (AMD). PL 1999, c. 256, §§L2-4 (AMD). PL 2001, c. 258, §§D2,E5 (AMD). PL 2005, c. 121, §H1 (AMD). PL 2011, c. 238, Pt. E, §1 (AMD). PL 2013, c. 588, Pt. A, §27 (AMD).