reglab/statecodes huggingface dataset:
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4219. Administrative procedures

§4219. Administrative procedures
1.
When the superintendent has cause to believe that grounds exist for the suspension or revocation of a certificate of authority, the superintendent shall notify the health maintenance organization and the Commissioner of Health and Human Services in writing specifically stating the grounds for suspension or revocation. The Commissioner of Health and Human Services, or the commissioner's designated representative, shall participate in any disciplinary proceedings. In the process of determining whether grounds for suspension or revocation exist the findings of the commissioner with respect to matters relating to the quality of health care services provided are conclusive and binding upon the Superintendent of Insurance. The duration of and conditions attached to any suspension are determined by the superintendent after a hearing held in accordance with Title 5, chapter 375, subchapter IV.
[PL 1997, c. 592, §72 (AMD); PL 2003, c. 689, Pt. B, §7 (REV).]
2.
The Superintendent of Insurance, acting in concert with the Commissioner of Health and Human Services, has the authority to amend, modify or refuse to renew any certificate of authority for cause, pursuant to the Maine Administrative Procedure Act, Title 5, chapter 375, subchapter IV.
[PL 1977, c. 694, §436 (RPR); PL 2003, c. 689, Pt. B, §7 (REV).]
SECTION HISTORY
PL 1975, c. 503 (NEW). PL 1977, c. 694, §436 (RPR). PL 1997, c. 592, §72 (AMD). PL 2003, c. 689, §B7 (REV).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4220. Fees

§4220. Fees
1.
Every health maintenance organization subject to this chapter shall pay to the superintendent the following fees:
A. For filing an initial application for a certificate of authority, $500;   [PL 1975, c. 503 (NEW).]
B. For filing each annual report, $50.   [PL 1975, c. 503 (NEW).]
[PL 1975, c. 503 (NEW).]
2.
Fees charged under this section shall be distributed as follows: 50% to the superintendent and 50% to the Commissioner of Health and Human Services.
[PL 1975, c. 503 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).]
SECTION HISTORY
PL 1975, c. 293, §4 (AMD). PL 1975, c. 503 (NEW). PL 2003, c. 689, §B7 (REV).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4221. Penalties and enforcement

§4221. Penalties and enforcement
1.
The superintendent may levy an administrative penalty in an amount not less than $100 nor more than $500, if reasonable notice in writing is given of the intent to levy the penalty and the health maintenance organization has a reasonable time within which to remedy the defect in its operations that gave rise to the penalty citation. The superintendent may augment this penalty by an amount equal to the sum that the superintendent calculates to be the damages suffered by enrollees or other members of the public.
[RR 2021, c. 1, Pt. B, §349 (COR).]
2.
If the superintendent or the Commissioner of Health and Human Services shall for any reason have cause to believe that any violation of this chapter has occurred or is threatened, the superintendent or Commissioner of Health and Human Services may give notice to the health maintenance organization and to the representatives, or other persons who appear to be involved in such suspected violation, to arrange a conference with the alleged violators or their authorized representatives for the purpose of attempting to ascertain the facts relating to such suspected violation and, in the event it appears that any violation has occurred or is threatened, to arrive at an adequate and effective means of correcting or preventing such violation.
Proceedings under this subsection shall not be governed by any formal procedural requirements and may be conducted in such manner as the superintendent or the Commissioner of Health and Human Services may deem appropriate under the circumstances.
[PL 1975, c. 503 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).]
3.
The superintendent may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of this chapter.
Within 10 days after service of the order of cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of this chapter have occurred.
[PL 1975, c. 503 (NEW).]
4.
In the case of any violation under this chapter, if the superintendent elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order issued pursuant to this section, the superintendent may apply to the Superior Court to issue an injunction restraining the company in whole or in part from proceeding further with its business, or the superintendent may apply for an order of the court to command performance consistent with contractual obligations of the health maintenance organization.
[RR 2021, c. 1, Pt. B, §350 (COR).]
SECTION HISTORY
PL 1975, c. 293, §5 (AMD). PL 1975, c. 503 (NEW). PL 1977, c. 694, §437 (AMD). PL 2003, c. 689, §B7 (REV). RR 2021, c. 1, Pt. B, §§349, 350 (COR).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4222. Statutory construction and relationship to other laws

§4222. Statutory construction and relationship to other laws
1.
Except as otherwise specifically provided, provisions of the insurance law and the laws relating to hospital or medical service corporations do not apply to a health maintenance organization granted a certificate of authority under this chapter. This provision does not apply to an insurer or hospital or medical service corporation licensed and regulated pursuant to the insurance laws of this State except with respect to its health maintenance organization activities, whether those activities are conducted through a subsidiary or as a division or line of business, authorized and regulated pursuant to this chapter.
[PL 1993, c. 702, Pt. A, §16 (AMD).]
2.
Solicitation of enrollees by a health maintenance organization granted a certificate of authority or its representatives shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.
[PL 1975, c. 503 (NEW).]
3.
Any health maintenance organization authorized under this chapter is not deemed to be practicing medicine and is exempt from provisions of law relating to the practice of medicine, except that this subsection may not be asserted by a health maintenance organization as a defense to any action brought by an enrollee pursuant to section 4313.
[PL 1999, c. 742, §1 (AMD).]
4.
[PL 1995, c. 625, Pt. A, §26 (RP).]
SECTION HISTORY
PL 1975, c. 503 (NEW). PL 1991, c. 861, §3 (AMD). PL 1991, c. 861, §4 (AFF). PL 1993, c. 702, §A16 (AMD). PL 1995, c. 332, §§L2,O7 (AMD). PL 1995, c. 625, §A26 (AMD). PL 1999, c. 742, §1 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4222-A. Rules

§4222-A. Rules
Subject to the applicable requirements and procedures of the Maine Administrative Procedure Act, Title 5, chapter 375, subchapter II, the superintendent may make, adopt, amend and rescind reasonable rules to aid the administration or effectuation of any provisions of this chapter.   [PL 1993, c. 702, Pt. A, §17 (NEW).]
SECTION HISTORY
PL 1993, c. 702, §A17 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4223. Filings and reports as public documents

§4223. Filings and reports as public documents
All applications, filings and reports required under this chapter shall be treated as public documents subject to limitations and exceptions provided in Title 1, chapter 13, subchapter I.   [PL 1985, c. 704, §7 (AMD).]
SECTION HISTORY
PL 1975, c. 503 (NEW). PL 1985, c. 704, §7 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4224-A. Loss information (REPEALED)

§4224-A. Loss information
(REPEALED)
SECTION HISTORY
PL 1995, c. 71, §3 (NEW). PL 1997, c. 370, §E7 (AMD). PL 2001, c. 410, §B4 (RP).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4225. Commissioner of Health and Human Services' authority to contract

§4225. Commissioner of Health and Human Services' authority to contract
The Commissioner of Health and Human Services, in carrying out the commissioner's obligations under section 4204, subsection 1, paragraph B; section 4215; and section 4216, subsection 1, may contract with qualified persons to make recommendations concerning the determinations required to be made by the commissioner. Such recommendations may be accepted in full or in part by the commissioner.   [RR 2021, c. 2, Pt. A, §79 (COR).]
SECTION HISTORY
PL 1975, c. 293, §4 (AMD). PL 1975, c. 503 (NEW). PL 2003, c. 689, §B7 (REV). RR 2021, c. 1, Pt. B, §351 (COR). RR 2021, c. 2, Pt. A, §79 (COR).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4226. Federal legislation

§4226. Federal legislation
Nothing in this chapter shall prohibit any health maintenance organization from meeting the requirements of any federal law which would authorize such health maintenance organization to receive federal financial assistance or certification or to enroll beneficiaries assisted by federal funds.   [PL 1975, c. 503 (NEW).]
SECTION HISTORY
PL 1975, c. 503 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4227. Choice of alternative coverage

§4227. Choice of alternative coverage
Any employer of more than 50 employees who offers a health maintenance organization, as defined in section 4202‑A, shall also offer its employees, at the time of offering and renewal of the health maintenance organization, the option of selecting alternative health benefits coverage that does not restrict the ability of the covered persons to obtain health care services from the providers of their choice.   [PL 1991, c. 709, §8 (AMD).]
Any employer subject to this section shall contribute to the alternative health benefits coverage to the same extent as it contributes to the health maintenance organization.   [PL 1985, c. 704, §8 (NEW).]
An employer may not be required to pay more for health benefits as a result of the application of this section than would otherwise be paid.   [PL 1991, c. 709, §8 (AMD).]
An employer may satisfy the requirements of this section by offering a point-of-service option but may not satisfy the requirements of this section by contributing to the cost of an individual health plan.   [PL 1997, c. 370, Pt. B, §4 (AMD).]
SECTION HISTORY
PL 1985, c. 704, §8 (NEW). PL 1991, c. 709, §8 (AMD). PL 1997, c. 370, §B4 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4228. Utilization review data

§4228. Utilization review data
1.  Report required.
On or before April 1st of each year, each health maintenance organization which issues a program of contract in this State that contains a provision whereby in nonemergency cases the insured is required to be prospectively evaluated through a prehospital admission certification, preinpatient service eligibility program or any similar preutilization review or screening procedure prior to the delivery of contemplated hospitalization, inpatient or outpatient health care or medical services which are prescribed or ordered by a duly licensed physician shall file a report on the results of that evaluation for the preceding year with the superintendent which shall contain the following:
A. The number and type of evaluations performed.
(1) For the purposes of this section, the term "type of evaluations" means the following preutilization review categories: presurgical inpatient days; setting of medical service, such as inpatient or outpatient services; and the number of days of service.
(2) The report must separately identify the number of evaluations performed in which the health care services requested or provided include chiropractic services and the results of those evaluations;   [PL 1993, c. 669, §5 (AMD).]
B. The result of the evaluation, such as whether the medical necessity of the level of service contemplated by the patient's physician was agreed to or whether benefits paid for the service were reduced by the health maintenance organization;   [PL 1987, c. 168, §5 (NEW).]
C. The number and result of any appeals by patients or their physicians as a result of initial review decisions to reduce benefits for services as determined through prospective evaluations; and   [PL 1987, c. 168, §5 (NEW).]
D. Any complaints filed in a court of competent jurisdiction and served upon a health maintenance organization filing under this section stating a cause of action against that organization on the basis of damages to patients alleged to have been proximately caused by a delay, reduction or denial of medical benefits by the organization, as determined through prospective evaluations, and the determination of liability or other disposition of the complaint.   [PL 1987, c. 168, §5 (NEW).]
[PL 1993, c. 669, §5 (AMD).]
2.  Maine residents.
This section is applicable to evaluations, appeals and complaints relating to Maine residents only.
[PL 1987, c. 168, §5 (NEW).]
3.  Confidentiality.
Any information provided pursuant to this section shall not identify the names of patients.
[PL 1987, c. 168, §5 (NEW).]
SECTION HISTORY
PL 1987, c. 168, §5 (NEW). PL 1993, c. 669, §5 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4229. Acquired Immune Deficiency Syndrome

§4229. Acquired Immune Deficiency Syndrome
No policy, contract or certificate delivered or issued for delivery in this State may provide more restrictive coverage for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex or HIV related diseases than for any other disease or sickness or exclude coverage for AIDS, ARC or HIV related diseases except through an exclusion under which all sicknesses and diseases are treated the same.   [PL 1989, c. 176, §9 (NEW).]
SECTION HISTORY
PL 1989, c. 176, §9 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4230. Trade practices and frauds (REPEALED)

§4230. Trade practices and frauds
(REPEALED)
SECTION HISTORY
PL 1989, c. 345, §2 (NEW). PL 1995, c. 332, §O9 (RP).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4232. Replacement coverage

§4232. Replacement coverage
1.  Group hospital, medical or surgical expenses, or service benefits.
Any insurer or nonprofit health insurance plan that issues replacement coverage with respect to group hospital, medical or surgical expenses or service benefits within a period of 60 days from the date of discontinuance of a prior health maintenance organization contract or policy providing the hospital, medical or surgical expenses or service benefits shall immediately cover all enrollees who were validly covered under the previous health maintenance organization contract or policy at the date of discontinuance and who would otherwise be eligible for coverage under the succeeding insurer's or nonprofit health insurance plan's contract, regardless of any provisions in that contract relating to active employment, hospital confinement or pregnancy.
[PL 1989, c. 842, §18 (NEW).]
2.  Preexisting conditions.
No provision in a succeeding insurer's or nonprofit hospital or medical service corporation's contract of replacement coverage may reduce or exclude benefits to enrollees covered under the prior health maintenance organization's contract on the date of discontinuance, on the basis that the condition giving rise to benefits preexisted the effective date of the succeeding contract, except to the extent that benefits for the condition would have been reduced or excluded under the prior contract.
[PL 1989, c. 842, §18 (NEW).]
SECTION HISTORY
PL 1989, c. 842, §18 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4233. Registration, regulation and supervision of holding company systems

§4233. Registration, regulation and supervision of holding company systems
1.
[PL 1995, c. 332, Pt. O, §11 (RP).]
2.
Every domestic health maintenance organization is subject to the requirements of section 221‑A. At the superintendent's request, a domestic health maintenance organization must make available to the superintendent the audit work papers of any accountant who has audited that health maintenance organization.
Upon timely notice to a health maintenance organization, the superintendent may review, photocopy or otherwise record the audit work papers generated by any accountant who has audited that health maintenance organization.
Health maintenance organization work papers under the superintendent's custody or control are confidential and not subject to public inspection.
The work papers of a health maintenance organization's parent, subsidiaries or other corporate affiliates are deemed to be the work papers of that health maintenance organization to the extent the work papers affect the health maintenance organization's final equity determination and reference any transaction between the health maintenance organization and its parent, subsidiaries or corporate affiliates.
As a condition of engaging an auditing accountant, the health maintenance organization shall require the accountant to:
A. Retain for a period of at least 6 years any work papers prepared in connection with the accountant's audit of that health maintenance organization; and   [PL 1993, c. 313, §36 (NEW).]
B. Provide, at the request of the health maintenance organization, the original or copies of any work papers created by the accountant in connection with an audit of that health maintenance organization.   [PL 1993, c. 313, §36 (NEW).]
For purposes of this subsection, the term "work papers" includes, but is not limited to, originals or copies of any schedules, analyses, reconciliations, abstracts, memoranda, narratives, flow charts, company records or other documents prepared or obtained by the accountant and the accountant's employees in the course of conducting an audit of the health maintenance organization.
[PL 1993, c. 313, §36 (NEW).]
SECTION HISTORY
PL 1989, c. 842, §18 (NEW). PL 1993, c. 313, §36 (RPR). PL 1995, c. 332, §O11 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4233-A. Extension of coverage for dependent children

§4233-A. Extension of coverage for dependent children
An individual or group health maintenance organization contract that provides coverage for a dependent child at certain ages only if the child is a student must continue that coverage if the child is unable to remain enrolled in school on a full-time basis due to a mental or physical illness or an accidental injury. This coverage may be terminated at the age at which coverage for students terminates under the terms of the contract. A health maintenance organization may require, as a condition of eligibility for continued coverage in accordance with this section, that the student provide written documentation from a health care provider and the student's school that the student is no longer enrolled in school on a full-time basis due to a mental or physical illness or accidental injury.   [PL 2007, c. 115, §3 (AMD); PL 2007, c. 115, §5 (AFF).]
SECTION HISTORY
PL 2005, c. 532, §3 (NEW). PL 2007, c. 115, §3 (AMD). PL 2007, c. 115, §5 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4233-B. Mandatory offer to extend coverage for dependent children up to 26 years of age

§4233-B. Mandatory offer to extend coverage for dependent children up to 26 years of age
1.  Dependent child; definition.
As used in this section, "dependent child" means the child of a person covered under an individual or group health maintenance organization contract.
A. [PL 2019, c. 5, Pt. A, §18 (RP).]
B. [PL 2019, c. 5, Pt. A, §18 (RP).]
C. [PL 2019, c. 5, Pt. A, §18 (RP).]
D. [PL 2007, c. 514, §13 (RP).]
[PL 2019, c. 5, Pt. A, §18 (AMD).]
2.  Offer of coverage.
An individual or group health maintenance organization contract that offers coverage for a dependent child must offer such coverage, at the option of the parent, until the dependent child attains 26 years of age. If the dependent child has a disability, the contract must offer coverage in accordance with section 4233‑C.
[PL 2021, c. 520, §5 (AMD).]
3.  Notice.
[PL 2007, c. 514, §15 (NEW); MRSA T. 24-A §4233-B, sub-§3 (RP).]
SECTION HISTORY
PL 2007, c. 115, §4 (NEW). PL 2007, c. 115, §5 (AFF). PL 2007, c. 514, §§11-15 (AMD). PL 2019, c. 5, Pt. A, §18 (AMD). PL 2021, c. 520, §5 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4233-C. Mandatory offer of coverage for certain adults with disabilities

§4233-C. 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, §6 (NEW).]
B. "Disability" means a physical, mental, intellectual or developmental disability that renders a person incapable of self-sustaining employment.   [PL 2021, c. 520, §6 (NEW).]
[PL 2021, c. 520, §6 (NEW).]
2.  Offer of coverage.
An individual or group health maintenance organization contract 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, §6 (NEW).]
3.  Proof of disability.
A parent shall furnish proof of a dependent child's disability to the insurer within 31 days of the dependent child's attainment of the limiting age established in section 4233‑B, subsection 2 and subsequently as may be required by the insurer, but the insurer 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, §6 (NEW).]
SECTION HISTORY
PL 2021, c. 520, §6 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4234-B. Maternity and routine newborn care

§4234-B. Maternity and routine newborn care
Individual and group contracts and certificates issued by a health maintenance organization that provide maternity benefits, including benefits for childbirth, shall provide coverage for services related to maternity and routine newborn care, including coverage for hospital stay, in accordance with the attending physician's or attending certified nurse midwife's determination in conjunction with the mother that the mother and newborn meet the criteria outlined in the "Guidelines for Perinatal Care," published by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology. For the purposes of this section, "routine newborn care" does not include any services provided after the mother has been discharged from the hospital. For the purposes of this section, "attending physician" includes the obstetrician, pediatrician or other physician attending the mother and newborn. Benefits for routine newborn care required by this section are part of the mother's benefit. The mother and the newborn are treated as one person in calculating the deductible, coinsurance and copayments for coverage required by this section.   [PL 2003, c. 517, Pt. B, §23 (AMD).]
SECTION HISTORY
PL 1995, c. 615, §4 (NEW). PL 2001, c. 258, §A4 (AMD). PL 2003, c. 517, §B23 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4234-C. Newborn children coverage

§4234-C. Newborn children coverage
All individual and group health maintenance organization contracts must provide that benefits are payable with respect to a newly born child from the moment of birth.   [PL 1997, c. 604, Pt. C, §4 (NEW).]
The coverage for newly born children must consist of coverage of injury, sickness or other benefits provided by the contract, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.   [PL 1997, c. 604, Pt. C, §4 (NEW).]
If payment of a specific premium or subscription fee is required to provide coverage for a child, the contract may require that notification of birth of a newly born child and payment of the required fees must be furnished to the nonprofit hospital or medical service organization within 31 days after the date of birth in order to have the coverage continue beyond that 31-day period. The payment may be required to be retroactive to the date of birth. Benefits required by section 4234‑B must be paid regardless of whether coverage under this section is elected.   [PL 1997, c. 604, Pt. C, §4 (NEW).]
The requirements of this section apply to all contracts delivered or issued for delivery in this State on or after the effective date of this Act.   [PL 1997, c. 604, Pt. C, §4 (NEW).]
SECTION HISTORY
PL 1997, c. 604, §C4 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4234-F. Maternity and postpartum care

§4234-F. Maternity and postpartum care
A health maintenance organization that issues individual and group contracts providing maternity benefits shall provide coverage for 12 months following childbirth for postpartum care services and support necessary to transition a patient to a healthy and stable condition that meets the recommendations of the American College of Obstetricians and Gynecologists outlined in the "Optimizing Postpartum Care" opinion published May 2018. The postpartum care services and support provided in accordance with this section must include coverage for development of a postpartum care plan; contact with the patient within 3 weeks of the end of pregnancy; a comprehensive postpartum visit, including a full assessment of the patient's physical, social and psychological well-being; treatment of complications of pregnancy and childbirth, including pelvic floor disorders and postpartum depression; assessment of risk factors for cardiovascular disease; and care related to pregnancy loss.   [PL 2021, c. 691, §3 (NEW).]
SECTION HISTORY
PL 2021, c. 691, §3 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4235. Standardized claim forms

§4235. Standardized claim forms
All health maintenance organizations providing payment or reimbursement for diagnosis or treatment of a condition or a complaint by a licensed health care practitioner must accept the current standardized claim form for professional services approved by the Federal Government and submitted electronically. All health maintenance organizations providing payment or reimbursement for diagnosis or treatment of a condition or a complaint by a licensed hospital must accept the current standardized claim form for professional or facility services, as applicable, approved by the Federal Government and submitted electronically. A health maintenance organization may not be required to accept a claim submitted on a form other than the applicable form specified in this section and may not be required to accept a claim that is not submitted electronically, except from a health care practitioner who is exempt pursuant to Title 24, section 2985. All services provided by a health care practitioner in an office setting must be submitted on the standardized federal form used by noninstitutional providers and suppliers. Services in a nonoffice setting may be billed as negotiated between the health maintenance organization and health care practitioner. For purposes of this section, "office setting" means a location where the health care practitioner routinely provides health examinations, diagnosis and treatment of illness or injury on an ambulatory basis whether or not the office is physically located within a facility.   [PL 2005, c. 97, §4 (AMD).]
SECTION HISTORY
PL 1993, c. 477, §D12 (NEW). PL 1993, c. 477, §F1 (AFF). PL 2003, c. 218, §8 (AMD). PL 2003, c. 469, §D8 (AMD). PL 2003, c. 469, §D9 (AFF). PL 2005, c. 97, §4 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4237. Coverage for breast cancer treatment

§4237. Coverage for breast cancer treatment
1.  Inpatient care.
All individual and group coverage subject to this chapter that provides coverage for medical and surgical benefits must ensure that inpatient coverage with respect to the treatment of breast cancer is provided for a period of time determined by the attending physician, after providing notice to the patient regarding the coverage required by this subsection and in consultation with the patient, to be medically appropriate following a mastectomy, a lumpectomy or a lymph node dissection for the treatment of breast cancer.
Nothing in this subsection may be construed to require the provision of inpatient coverage if the attending physician and patient determine that a shorter period of hospital stay is appropriate.
In implementing the requirements of this subsection, an individual or group coverage contract may not modify the terms and conditions of coverage based on the determination by any enrollee to request less than the minimum coverage required under this subsection.
All individual and group coverage subject to this subsection must provide written notice to each enrollee under the contract regarding the coverage required by this subsection. The notice must be prominently positioned in any literature or correspondence made available or distributed by the plan and must be transmitted in the next mailing made by the plan to the enrollee or as part of any yearly information packet sent to the enrollee, whichever is earlier. The notice must also be made available to any physician participating in the insurer's provider network.
[PL 2015, c. 227, §4 (AMD); PL 2015, c. 227, §5 (AFF).]
2.  Reconstruction.
All individual and group coverage subject to this chapter that provides coverage for mastectomy surgery must provide coverage for reconstruction of the breast on which surgery has been performed and surgery and reconstruction of the other breast to produce a symmetrical appearance if the patient elects reconstruction and in the manner chosen by the patient and the physician.
[PL 1997, c. 408, §7 (NEW); PL 1997, c. 408, §8 (AFF).]
3.  Application.
The requirements of this section apply to all individual and group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.
[PL 2003, c. 517, Pt. B, §24 (NEW).]
SECTION HISTORY
RR 1995, c. 1, §19 (COR). RR 1995, c. 1, §21 (COR). PL 1995, c. 295, §5 (NEW). PL 1995, c. 369, §4 (NEW). PL 1995, c. 418, §C4 (NEW). PL 1997, c. 408, §7 (RPR). PL 1997, c. 408, §8 (AFF). PL 2003, c. 517, §B24 (AMD). PL 2015, c. 227, §4 (AMD). PL 2015, c. 227, §5 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4238. Medical food coverage for inborn error of metabolism

§4238. Medical food coverage for inborn error of metabolism
1.  Inborn error of metabolism; special modified low-protein food product.
As used in this section, "inborn error of metabolism" means a genetically determined biochemical disorder in which a specific enzyme defect produces a metabolic block that may have pathogenic consequences at birth or later in life. As used in this section, "special modified low-protein food product" means food formulated to reduce the protein content to less than one gram of protein per serving and does not include foods naturally low in protein.
[PL 1995, c. 369, §4 (NEW).]
2.  Required coverage.
All health maintenance organization individual and group contracts must provide coverage for metabolic formula and special modified low-protein food products that have been prescribed by a licensed physician for a person with an inborn error of metabolism. The contracts must reimburse:
A. For metabolic formula; and   [PL 1995, c. 369, §4 (NEW).]
B. Up to $3,000 per year for special modified low-protein food products.   [PL 1995, c. 369, §4 (NEW).]
[PL 1995, c. 369, §4 (NEW).]
3.  Application.
The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 1996. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.
[PL 1995, c. 369, §4 (NEW).]
SECTION HISTORY
RR 1995, c. 1, §19 (RNU). PL 1995, c. 369, §4 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4239. Medical child support

§4239. Medical child support
A health maintenance organization must comply with 42 United States Code, Section 1396g‑1.   [PL 1995, c. 418, Pt. C, §4 (NEW).]
SECTION HISTORY
RR 1995, c. 1, §21 (RNU). PL 1995, c. 418, §C4 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4240. Coverage for diabetes supplies

§4240. Coverage for diabetes supplies
All health maintenance organization individual and group health contracts and certificates must provide coverage for the medically appropriate and necessary equipment, limited to insulin, oral hypoglycemic agents, monitors, test strips, syringes and lancets, and the out-patient self-management training and educational services used to treat diabetes, if:   [PL 2003, c. 517, Pt. A, §10 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).]
1.  Certification of medical necessity.
The enrollee's treating physician or a physician who specializes in the treatment of diabetes certifies that the equipment and services are necessary; and
[PL 1995, c. 592, §4 (NEW).]
2.  Provision of medical services.
The diabetes out-patient self-management training and educational services are provided through ambulatory diabetes education facilities authorized by the State's Diabetes Control Project within the Bureau of Health.
[PL 1995, c. 592, §4 (NEW).]
The requirements of this section apply to all group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.   [PL 2003, c. 517, Pt. A, §10 (NEW); PL 2003, c. 517, Pt. A, §13 (AFF).]
Revisor's Note: §4240. Coverage for Pap tests (As enacted by PL 1995, c. 617, §5 is REALLOCATED TO TITLE 24-A, SECTION 4242)
SECTION HISTORY
RR 1995, c. 2, §53 (RAL). PL 1995, c. 592, §4 (NEW). PL 1995, c. 617, §5 (NEW). PL 1995, c. 617, §6 (AFF). PL 2003, c. 517, §A10 (AMD). PL 2003, c. 517, §A13 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4241. Gynecological and obstetrical services

§4241. Gynecological and obstetrical services
1.  Coverage in managed care plans.
With respect to managed care plans that require enrollees to select primary care physicians, a health maintenance organization that issues group policies, contracts and certificates must meet the following requirements.
A. The health maintenance organization must permit a physician who specializes in obstetrics and gynecology to serve as a primary care physician if the physician qualifies under the organization's credentialling policy.   [PL 1995, c. 617, §5 (NEW); PL 1995, c. 617, §6 (AFF).]
B. All group plan contracts must provide coverage for an annual gynecological examination, including routine pelvic and clinical breast examinations, performed by a physician, certified nurse practitioner or certified nurse midwife participating in the plan, without requiring the prior approval of the primary care physician.   [PL 1995, c. 617, §5 (NEW); PL 1995, c. 617, §6 (AFF).]
C. If the examination specified in paragraph B reveals a gynecological condition for which another visit to the physician participating in the plan is medically required and appropriate, or for any gynecological care beyond the annual examination, the carrier may require the patient or the examining physician, certified nurse practitioner or certified nurse midwife to secure from the patient's primary care physician a referral to the participating physician, certified nurse practitioner or certified nurse midwife from whom such care may be obtained.   [PL 1995, c. 617, §5 (NEW); PL 1995, c. 617, §6 (AFF).]
[PL 2003, c. 517, Pt. A, §11 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).]
2.  Application.
This section applies to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.
[PL 2003, c. 517, Pt. A, §11 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).]
This section does not prohibit a carrier from requiring a physician, certified nurse practitioner or certified nurse midwife participating in the plan to inform a woman's primary care physician prior to each treatment pursuant to this section.   [PL 1995, c. 617, §5 (NEW); PL 1995, c. 617, §6 (AFF).]
SECTION HISTORY
PL 1995, c. 617, §5 (NEW). PL 1995, c. 617, §6 (AFF). PL 2003, c. 517, §A11 (AMD). PL 2003, c. 517, §A13 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4242. Coverage for Pap tests (REALLOCATED FROM TITLE 24-A, SECTION 4240)

§4242. Coverage for Pap tests
(REALLOCATED FROM TITLE 24-A, SECTION 4240)
All health maintenance organization plan contracts and certificates must provide coverage for screening Pap tests recommended by a physician.   [PL 2003, c. 517, Pt. A, §12 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).]
SECTION HISTORY
RR 1995, c. 2, §53 (RAL). PL 2003, c. 517, §A12 (AMD). PL 2003, c. 517, §A13 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4243. Limits on priority liens; subrogation

§4243. Limits on priority liens; subrogation
An individual or group contract subject to this chapter may not provide for subrogation or priority over the enrollee of payment for any hospital, nursing, medical or surgical services or of any expenses paid or reimbursed under the coverage, in the event the enrollee is entitled to receive payment or reimbursement from any other person as a result of legal action or claim, except as provided in this section.   [PL 1997, c. 369, §3 (NEW).]
The coverage may contain a provision that allows the payments, if that provision is approved by the superintendent and if that provision required the prior written approval of the insured and allows such payments only on a just and equitable basis and not on the basis of a priority lien. A "just and equitable basis" means that any factors that diminish the potential value of the enrollee's claim may likewise reduce the share in the claim for those claiming payment for services or reimbursement. Such factors include, but are not limited to:   [PL 1997, c. 369, §3 (NEW).]
1.  Legal defenses.
Questions of liability and comparative negligence or other legal defenses;
[PL 1997, c. 369, §3 (NEW).]
2.  Exigencies of trial.
Exigencies of trial that reduce a settlement or award in order to resolve the claim; and
[PL 1997, c. 369, §3 (NEW).]
3.  Limits of coverage.
Limits on the amount of applicable insurance coverage that reduce the claim to an amount recoverable by the insured.
[PL 1997, c. 369, §3 (NEW).]
In the event of a dispute as to the application of any such provision or the amount available for payment to those claiming payment for services or reimbursement, that dispute must be determined, if the action is pending, before the court in which it is pending; or if no action is pending, by filing an action in any court for determination of the dispute.   [PL 1997, c. 369, §3 (NEW).]
Revisor's Note: §4243. Coverage for prostate cancer screening (As enacted by PL 1997, c. 754, §4 is REALLOCATED TO TITLE 24-A, SECTION 4244)
SECTION HISTORY
RR 1997, c. 2, §53 (RAL). PL 1997, c. 369, §3 (NEW). PL 1997, c. 754, §4 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4244. Coverage for prostate cancer screening (REALLOCATED FROM TITLE 24-A, SECTION 4243)

§4244. Coverage for prostate cancer screening
(REALLOCATED FROM TITLE 24-A, SECTION 4243)
1.  Definition.
As used in this section, "services for the early detection of prostate cancer" means the following procedures provided to a man for the purpose of early detection of prostate cancer:
A. A digital rectal examination; and   [RR 1997, c. 2, §53 (RAL).]
B. A prostate-specific antigen test.   [RR 1997, c. 2, §53 (RAL).]
[RR 1997, c. 2, §53 (RAL).]
2.  Required coverage for prostate cancer screening.
All health maintenance organization individual and group contracts must provide coverage for services for the early detection of prostate cancer. The contracts must reimburse for services for the early detection of prostate cancer, if recommended by a physician, at least once a year for men 50 years of age or older until a man reaches the age of 72.
[RR 1997, c. 2, §53 (RAL).]
3.  Application.
The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after September 1, 1998. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.
[RR 1997, c. 2, §53 (RAL).]
SECTION HISTORY
RR 1997, c. 2, §53 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4245. NCQA accreditation survey report

§4245. NCQA accreditation survey report
1.  Access and confidentiality.
The superintendent or the Commissioner of Health and Human Services may require a health maintenance organization to submit its NCQA accreditation survey report. An NCQA accreditation survey report obtained by or submitted to the superintendent or the Commissioner of Health and Human Services is confidential, is not subject to subpoena and may not be made public by the superintendent or the Commissioner of Health and Human Services except as otherwise provided in this section.
[PL 1999, c. 256, Pt. Q, §2 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).]
2.  Use in examination.
In conducting an examination of a health maintenance organization pursuant to section 4215, the superintendent or the Commissioner of Health and Human Services has the discretion to adopt relevant findings in the NCQA accreditation survey report in whole or in part as the examiner's conclusions, if the examiner determines that the NCQA survey, by itself or in combination with the examiner's own findings, sufficiently demonstrates that the health maintenance organization has satisfied the pertinent requirements of this chapter. If the NCQA accreditation survey report indicates that the health maintenance organization may not be in compliance with one or more requirements of this chapter, the examiner may investigate and make independent findings.
[PL 1999, c. 256, Pt. Q, §2 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).]
3.  Examination report.
The information from the NCQA accreditation survey report that sufficiently demonstrates that the health maintenance organization has satisfied the pertinent requirements of this section as adopted by the superintendent or the Commissioner of Health and Human Services pursuant to subsection 2 may be incorporated into an examination report, which is a public record except for any information relating to an individual applicant or enrollee.
[PL 1999, c. 256, Pt. Q, §2 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).]
4.  Use of information for regulatory purposes.
The confidentiality of the NCQA accreditation survey report does not prohibit its use by the superintendent or the Commissioner of Health and Human Services for regulatory or law enforcement purposes subject to the restrictions of section 216, subsection 5 and section 226, subsection 7.
[PL 1999, c. 256, Pt. Q, §2 (NEW); PL 2003, c. 689, Pt. B, §7 (REV).]
Revisor's Note: §4245. Coverage for contraceptives (As enacted by PL 1999, c. 341, §4 and affected by §5 is REALLOCATED TO TITLE 24-A, SECTION 4247)
Revisor's Note: §4245. Coverage for services of certified nurse practitioners; certified nurse midwives (As enacted by PL 1999, c. 396, §4 and affected by §7 is REALLOCATED TO TITLE 24-A, SECTION 4248)
SECTION HISTORY
RR 1999, c. 1, §§37,38 (RAL). PL 1999, c. 256, §Q2 (NEW). PL 1999, c. 341, §4 (NEW). PL 1999, c. 341, §5 (AFF). PL 1999, c. 396, §4 (NEW). PL 1999, c. 396, §7 (AFF). PL 2003, c. 689, §B7 (REV).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4246. Coverage for services provided by registered nurse first assistants

§4246. Coverage for services provided by registered nurse first assistants
1.  Definitions.
As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Perioperative nursing" means a practice of nursing in which the nurse provides preoperative, intraoperative and postoperative nursing care to surgical patients.   [PL 1999, c. 412, §4 (NEW).]
B. "Recognized program" means a program that addresses all content of the core curriculum for registered nurse first assistants as established by the Association of Operating Room Nurses or its successor organization.   [PL 1999, c. 412, §4 (NEW).]
C. "Registered nurse first assistant," or "RNFA," means a person who:
(1) Is licensed as a registered nurse under Title 32, chapter 31;
(2) Is experienced in perioperative nursing; and
(3) Has successfully completed a recognized program.   [PL 1999, c. 412, §4 (NEW).]
[PL 1999, c. 412, §4 (NEW).]
2.  Institutional powers.
Each health care institution, as defined in Title 22, chapter 405, may establish specific procedures for the appointment and reappointment of registered nurse first assistants and for granting, renewing and revising their clinical privileges.
[PL 1999, c. 412, §4 (NEW).]
3.  Required coverage for services.
Notwithstanding any other provisions of this chapter, a health maintenance organization that issues individual and group health care contracts that provide coverage for surgical first assisting benefits or services shall provide coverage and payment under those contracts to a registered nurse first assistant who performs services that are within the scope of a registered nurse first assistant's qualifications. The provisions of this subsection apply only if reimbursement for an assisting physician would be covered and a registered nurse first assistant who performed those services is used as a substitute.
[PL 1999, c. 412, §4 (NEW).]
4.  Limits; coinsurance; deductibles.
Any contract that provides coverage for the services required by this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.
[PL 1999, c. 412, §4 (NEW).]
5.  Application.
The requirements of this section apply to all individual and group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.
[PL 2003, c. 617, Pt. B, §26 (NEW).]
SECTION HISTORY
PL 1999, c. 412, §4 (NEW). PL 2003, c. 517, §B26 (AMD).