reglab/statecodes huggingface dataset:
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4248. Coverage for services of certified nurse practitioners; certified midwives; certified nurse midwives (REALLOCATED FROM TITLE 24-A, SECTION 4245)

§4248. Coverage for services of certified nurse practitioners; certified midwives; certified nurse midwives
(REALLOCATED FROM TITLE 24-A, SECTION 4245)
1.  Required coverage for services upon referral of primary care provider.
A health maintenance organization that issues individual and group health care contracts shall provide coverage under those contracts for services performed by a participating certified nurse practitioner, participating certified midwife or participating certified nurse midwife to a patient who is referred to the participating certified nurse practitioner, participating certified midwife or participating certified nurse midwife by a primary care provider when those services are within the lawful scope of practice of the participating certified nurse practitioner, participating certified midwife or participating certified nurse midwife.
[PL 2021, c. 79, §4 (AMD).]
2.  Required coverage for self-referred services.
With respect to individual and group health care contracts that do not require the selection of a primary care provider, a health maintenance organization shall provide coverage under those contracts for services performed by a participating certified nurse practitioner, participating certified midwife or participating certified nurse midwife when those services are covered services and when they are within the lawful scope of practice of the participating certified nurse practitioner, participating certified midwife or participating certified nurse midwife.
[PL 2021, c. 79, §4 (AMD).]
3.  Limits; coinsurance; deductibles.
Any contract that provides coverage for services under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.
[RR 1999, c. 1, §38 (RAL).]
4.  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, §28 (NEW).]
SECTION HISTORY
RR 1999, c. 1, §38 (RAL). PL 2003, c. 517, §B28 (AMD). PL 2021, c. 79, §4 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4250. Coverage for hospice care services (REALLOCATED FROM TITLE 24-A, SECTION 4249)

§4250. Coverage for hospice care services
(REALLOCATED FROM TITLE 24-A, SECTION 4249)
1.  Definitions.
As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Hospice care services" means services provided on a 24-hours-a-day, 7-days-a-week basis to a person who is terminally ill and that person's family. "Hospice care services" includes, but is not limited to, physician services; nursing care; respite care; medical and social work services; counseling services; nutritional counseling; pain and symptom management; medical supplies and durable medical equipment; occupational, physical or speech therapies; volunteer services; home health care services; and bereavement services.   [RR 2001, c. 1, §36 (RAL).]
B. "Person who is terminally ill" means a person that has a medical prognosis that the person's life expectancy is 12 months or less if the illness runs its normal course.   [RR 2001, c. 1, §36 (RAL).]
[RR 2001, c. 1, §36 (RAL).]
2.  Coverage for hospice care services.
All health maintenance organization individual and group health contracts must provide coverage for hospice care services to a person who is terminally ill. Hospice care services must be provided according to a written care delivery plan developed by a hospice care provider and the recipient of hospice care services. Coverage for hospice care services must be provided whether the services are provided in a home setting or an inpatient setting.
[RR 2001, c. 1, §36 (RAL).]
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, §29 (NEW).]
SECTION HISTORY
RR 2001, c. 1, §36 (RAL). PL 2003, c. 517, §B29 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4252. Offer of coverage for breast reduction surgery and symptomatic varicose vein surgery

§4252. Offer of coverage for breast reduction surgery and symptomatic varicose vein surgery
All health maintenance organization individual and group health insurance policies, contracts and certificates must make available coverage for breast reduction surgery and symptomatic varicose vein surgery determined to be medically necessary health care as defined in section 4301‑A, subsection 10‑A.   [PL 2005, c. 128, §4 (NEW); PL 2005, c. 128, §5 (AFF).]
SECTION HISTORY
PL 2005, c. 128, §4 (NEW). PL 2005, c. 128, §5 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4253. Enrollment for individuals or families establishing eligibility for MaineCare

§4253. Enrollment for individuals or families establishing eligibility for MaineCare
When an individual or family is eligible for MaineCare and is also eligible for health maintenance organization coverage provided by an employer through a health maintenance organization, the health maintenance organization must permit the individual or family to enroll in the health maintenance organization coverage without regard to any enrollment season restrictions.   [PL 2007, c. 448, §12 (NEW).]
Revisor's Note: §4253. Coverage for hearing aids (As enacted by PL 2007, c. 452, §4 is REALLOCATED TO TITLE 24-A, SECTION 4255)
SECTION HISTORY
PL 2007, c. 448, §12 (NEW). PL 2007, c. 452, §4 (NEW). PL 2007, c. 695, Pt. A, §30 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4254. Coverage for colorectal cancer screening

§4254. Coverage for colorectal cancer screening
1.  Colorectal cancer screening.
For the purposes of this section, "colorectal cancer screening" means all colorectal cancer examinations and laboratory tests recommended by a health care provider in accordance with the most recently published colorectal cancer screening guidelines of a national cancer society.
[PL 2019, c. 86, §7 (AMD).]
2.  Required coverage.
All health maintenance organization individual and group health insurance policies, contracts and certificates must provide coverage for colorectal cancer screening for asymptomatic individuals who are:
A. At average risk for colorectal cancer according to the most recently published colorectal cancer screening guidelines of a national cancer society; or   [PL 2019, c. 86, §8 (AMD).]
B. At high risk for colorectal cancer.   [PL 2019, c. 86, §9 (AMD).]
[PL 2019, c. 86, §§8, 9 (AMD).]
3.  Billing.
If a colonoscopy is recommended by a health care provider as the colorectal cancer screening test in accordance with this section and a lesion is discovered and removed during that colonoscopy, the health care provider must bill the insurance company for a screening colonoscopy as the primary procedure.
[PL 2007, c. 516, §4 (NEW); PL 2007, c. 516, §5 (AFF).]
Revisor's Note: §4254. Coverage for medically necessary infant formula (As enacted by PL 2007, c. 595, §4 is REALLOCATED TO TITLE 24-A, SECTION 4256)
SECTION HISTORY
PL 2007, c. 516, §4 (NEW). PL 2007, c. 516, §5 (AFF). PL 2007, c. 595, §4 (NEW). PL 2007, c. 595, §5 (AFF). PL 2007, c. 695, Pt. C, §16 (RAL). PL 2019, c. 86, §§7-9 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4255. Coverage for hearing aids (REALLOCATED FROM TITLE 24-A, SECTION 4253)

§4255. Coverage for hearing aids
(REALLOCATED FROM TITLE 24-A, SECTION 4253)
1.  Hearing aid; definition.
For purposes of this section, "hearing aid" means a nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing, excluding batteries and cords and other assistive listening devices, including, but not limited to, frequency modulation systems.
[PL 2007, c. 695, Pt. A, §30 (RAL).]
2.  Required coverage.
All health maintenance organization individual and group health insurance contracts must provide coverage for the purchase of a hearing aid for each hearing-impaired ear for an individual covered under the policy, contract or certificate in accordance with the following requirements.
A. The hearing loss must be documented by a physician or audiologist licensed pursuant to Title 32, chapter 137.   [PL 2015, c. 494, Pt. A, §30 (AMD).]
B. The hearing aid must be purchased in accordance with federal and state laws, regulations and rules for the sale and dispensing of hearing aids.   [PL 2019, c. 418, §5 (AMD).]
C. The policy, contract or certificate may limit coverage to $3,000 per hearing aid for each hearing-impaired ear every 36 months.   [PL 2019, c. 418, §5 (AMD).]
[PL 2019, c. 418, §5 (AMD).]
3.  Application of coverage.
[PL 2019, c. 418, §6 (RP).]
4.  Limits; coinsurance; deductibles.
Except as otherwise provided in this section, any contract that provides coverage for services under this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.
[PL 2007, c. 695, Pt. A, §30 (RAL).]
SECTION HISTORY
PL 2007, c. 695, Pt. A, §30 (RAL). PL 2015, c. 494, Pt. A, §30 (AMD). PL 2019, c. 418, §§5, 6 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4256. Coverage for medically necessary infant formula (REALLOCATED FROM TITLE 24-A, SECTION 4254)

§4256. Coverage for medically necessary infant formula
(REALLOCATED FROM TITLE 24-A, SECTION 4254)
All individual and group health maintenance organization policies, contracts and certificates must provide coverage for amino acid-based elemental infant formula for children 2 years of age and under in accordance with this section.   [PL 2007, c. 695, Pt. C, §16 (RAL).]
1.  Determination of medical necessity.
Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has submitted documentation that the amino acid-based elemental infant formula is medically necessary health care as defined in section 4301‑A, subsection 10‑A, that the amino acid-based elemental infant formula is the predominant source of nutritional intake at a rate of 50% or greater and that other commercial infant formulas, including cow milk-based and soy milk-based formulas have been tried and have failed or are contraindicated. A licensed physician may be required to confirm and document ongoing medical necessity at least annually.
[PL 2007, c. 695, Pt. C, §16 (RAL).]
2.  Method of delivery.
Coverage for amino acid-based elemental infant formula must be provided without regard to the method of delivery of the formula.
[PL 2007, c. 695, Pt. C, §16 (RAL).]
3.  Required diagnosis.
Coverage for amino acid-based elemental infant formula must be provided when a licensed physician has diagnosed and through medical evaluation has documented one of the following conditions:
A. Symptomatic allergic colitis or proctitis;   [PL 2007, c. 695, Pt. C, §16 (RAL).]
B. Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis;   [PL 2007, c. 695, Pt. C, §16 (RAL).]
C. A history of anaphylaxis;   [PL 2007, c. 695, Pt. C, §16 (RAL).]
D. Gastroesophageal reflux disease that is nonresponsive to standard medical therapies;   [PL 2007, c. 695, Pt. C, §16 (RAL).]
E. Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider;   [PL 2007, c. 695, Pt. C, §16 (RAL).]
F. Cystic fibrosis; or   [PL 2007, c. 695, Pt. C, §16 (RAL).]
G. Malabsorption of cow milk-based or soy milk-based infant formula.   [PL 2007, c. 695, Pt. C, §16 (RAL).]
[PL 2007, c. 695, Pt. C, §16 (RAL).]
4.  Health savings accounts.
Coverage for amino acid-based elemental infant formula under a health insurance policy, contract or certificate issued in connection with a health savings account as authorized under Title XII of the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003 may be subject to the same deductible and out-of-pocket limits that apply to overall benefits under the policy, contract or certificate.
[PL 2007, c. 695, Pt. C, §16 (RAL).]
SECTION HISTORY
PL 2007, c. 695, Pt. C, §16 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4257. Coverage for services provided by independent practice dental hygienist

§4257. Coverage for services provided by independent practice dental hygienist
1.  Services provided by independent practice dental hygienist.
All individual and group health maintenance organization contracts that include coverage for dental services shall provide coverage for dental services performed by an independent practice dental hygienist licensed under Title 32, chapter 143 when those services are covered services under the contract and when they are within the lawful scope of practice of the independent practice dental hygienist.
[PL 2015, c. 429, §15 (AMD).]
2.  Limits; coinsurance; deductibles.
A contract that provides coverage for the services required by this section may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.
[PL 2009, c. 307, §4 (NEW); PL 2009, c. 307, §6 (AFF).]
3.  Coordination of benefits with dental insurance.
If an enrollee eligible for coverage under this section is eligible for coverage under a dental insurance policy or contract and a health maintenance organization policy or contract, the insurer providing dental insurance is the primary payer responsible for charges under subsection 1 and the health maintenance organization providing health coverage is the secondary payer.
[PL 2009, c. 307, §4 (NEW); PL 2009, c. 307, §6 (AFF).]
4.  Application.
The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.
[PL 2009, c. 307, §4 (NEW); PL 2009, c. 307, §6 (AFF).]
SECTION HISTORY
PL 2009, c. 307, §4 (NEW). PL 2009, c. 307, §6 (AFF). PL 2015, c. 429, §15 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4258. Coverage for children's early intervention services

§4258. Coverage for children's early intervention services
1.  Definition.
For purposes of this section, "children's early intervention services" means services provided by licensed occupational therapists, physical therapists, speech-language pathologists or clinical social workers working with children from birth to 36 months of age with an identified developmental disability or delay as described in the federal Individuals with Disabilities Education Act, Part C, 20 United States Code, Section 1411, et seq.
[PL 2009, c. 634, §4 (NEW); PL 2009, c. 634, §5 (AFF).]
2.  Required coverage.
All individual and group health maintenance organization policies, contracts and certificates must provide coverage for children's early intervention services in accordance with this subsection.
A. A referral from the child's primary care provider is required.   [PL 2009, c. 634, §4 (NEW); PL 2009, c. 634, §5 (AFF).]
B. The policy, contract or certificate may limit coverage to $3,200 per year for each child not to exceed $9,600 by the child's 3rd birthday.   [PL 2009, c. 634, §4 (NEW); PL 2009, c. 634, §5 (AFF).]
C. The policy, contract or certificate may contain provisions for maximum benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section.   [PL 2009, c. 634, §4 (NEW); PL 2009, c. 634, §5 (AFF).]
[PL 2009, c. 634, §4 (NEW); PL 2009, c. 634, §5 (AFF).]
Revisor's Note: §4258. Coverage for the diagnosis and treatment of autism spectrum disorders (As enacted by PL 2009, c. 635, §4; §6 is REALLOCATED TO TITLE 24-A, SECTION 4259)
SECTION HISTORY
PL 2009, c. 634, §4 (NEW). PL 2009, c. 634, §5 (AFF). PL 2009, c. 635, §4 (NEW). PL 2009, c. 635, §6 (AFF). PL 2011, c. 420, Pt. A, §27 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56: HEALTH MAINTENANCE ORGANIZATIONS › 24-A §4260. Dental benefit waiting period

§4260. Dental benefit waiting period
1.  Enrollee defined.
For the purposes of this section, unless the context otherwise indicates, "enrollee" means a person who is covered under an individual or group contract provided by a health maintenance organization.
[PL 2019, c. 605, §7 (NEW).]
2.  No waiting period for enrollee under 19 years of age.
A health maintenance organization that issues individual or group dental insurance or individual or group contracts that include coverage for dental services may not impose a waiting period, as defined in section 2848, subsection 5, for any dental or oral health service or treatment, except for orthodontic treatment, for an enrollee if the enrollee is under 19 years of age.
[PL 2019, c. 605, §7 (NEW).]
SECTION HISTORY
PL 2019, c. 605, §7 (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 §4301. Definitions (REPEALED)

§4301. Definitions
(REPEALED)
SECTION HISTORY
PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1997, c. 604, §A1 (AMD). PL 1999, c. 256, §A1 (AMD). PL 1999, c. 609, §19 (AMD). PL 1999, c. 742, §2 (RP). PL 2001, c. 471, §A28 (RP).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4303-B. Disclosure related to provider networks

§4303-B. Disclosure related to provider networks
1.  Disclosure.
Upon request, a carrier shall provide to a provider to which the carrier has decided not to offer the opportunity to participate or that the carrier has decided not to include as a participating provider in any of the carrier's provider networks a written explanation of the reason for the carrier's decision. The written explanation provided by the carrier must indicate whether the reason for not offering the provider the opportunity to contract or for not including the provider in any network was related to the provider's performance with respect to quality, cost or cost-efficiency.
[PL 2013, c. 535, §2 (NEW).]
2.  No right of action.
A provider has no right of action as the result of a disclosure made in accordance with this section.
[PL 2013, c. 535, §2 (NEW).]
SECTION HISTORY
PL 2013, c. 535, §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 §4303-G. Provider maintenance of certification requirements (WHOLE SECTION TEXT EFFECTIVE UNTIL 4/1/29) (WHOLE SECTION TEXT REPEALED 4/1/29)

§4303-G. Provider maintenance of certification requirements
(CONTAINS TEXT WITH VARYING EFFECTIVE DATES)
(WHOLE SECTION TEXT EFFECTIVE UNTIL 4/1/29)
(WHOLE SECTION TEXT REPEALED 4/1/29)
The following provisions govern maintenance of certification requirements.   [PL 2023, c. 40, §1 (NEW).]
1.  Definitions.
As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Hospital" means a hospital licensed and operating under Title 22, chapter 404 or 405 or the parent of such institution, or a hospital subsidiary or hospital affiliate in this State that provides medical services or medically related diagnostic and laboratory services or engages in ancillary activities supporting those services.   [PL 2023, c. 40, §1 (NEW).]
B. "Maintenance of certification program" means satisfactory participation in a program beyond the continuing medical education requirements currently in place by the Board of Licensure in Medicine or Board of Osteopathic Licensure, or initial board certification by a national or regional medical specialty board.   [PL 2023, c. 40, §1 (NEW).]
C. "Outpatient clinical practice" means any medical practice, home care or hospice organization or other nonhospital entity providing medical care through physicians.   [PL 2023, c. 40, §1 (NEW).]
D. "Physician" means an individual licensed under Title 32, chapter 36 or 48.   [PL 2023, c. 40, §1 (NEW).]
[PL 2023, c. 40, §1 (NEW).]
2.  Discrimination prohibited.
A carrier offering a health plan in this State may not:
A. Deny reimbursement to a physician, hospital or outpatient clinical practice for services rendered because a physician does not participate in a maintenance of certification program;   [PL 2023, c. 40, §1 (NEW).]
B. Provide lower reimbursement for services rendered by a physician, hospital or outpatient clinical practice because a physician does not participate in a maintenance of certification program;   [PL 2023, c. 40, §1 (NEW).]
C. Prohibit a physician, hospital or outpatient clinical practice from participating in any of the carrier's provider networks because a physician does not participate in a maintenance of certification program; or   [PL 2023, c. 40, §1 (NEW).]
D. Determine credentialing of a physician, hospital or outpatient clinical practice based on the status of a physician's, hospital's or outpatient clinical practice's participation in a maintenance of certification program.   [PL 2023, c. 40, §1 (NEW).]
[PL 2023, c. 40, §1 (NEW).]
3.  Repeal.
This section is repealed April 1, 2029.
[PL 2023, c. 40, §1 (NEW).]
SECTION HISTORY
PL 2023, c. 40, §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 §4304-A. Prior authorization for rehabilitative or habilitative services

§4304-A. Prior authorization for rehabilitative or habilitative services
1.  Prior authorization for new episode of care prohibited for 12 visits.
A carrier may not require prior authorization for rehabilitative or habilitative services, including, but not limited to, physical therapy services, occupational therapy services or chiropractic services, for the first 12 visits of each new episode of care. For purposes of this subsection, "new episode of care" means treatment for a new condition or treatment for a recurring condition for which an enrollee has not been treated within the previous 90 days.
[PL 2023, c. 275, §2 (NEW).]
2.  Intent.
This section does not limit the right of a carrier to deny a claim when an appropriate prospective or retrospective review concludes that the health care services or treatment rendered were not medically necessary.
[PL 2023, c. 275, §2 (NEW).]
SECTION HISTORY
PL 2023, c. 275, §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 §4305. Quality of care

§4305. Quality of care
A carrier offering or renewing a health plan that subjects payment of benefits for otherwise covered services to review for clinical necessity, appropriateness, efficacy or efficiency must meet the following requirements relating to quality of care.   [PL 2007, c. 199, Pt. B, §14 (AMD).]
1.  Internal quality assurance program.
A health plan must have an ongoing quality assurance program for the health care services provided or reimbursed by the health plan.
[PL 1995, c. 673, §1 (NEW); PL 1995, c. 673, §2 (AFF).]
2.  Written standards.
The standards of quality of care must be described in a written document, which must be available for examination by the superintendent or by the Department of Health and Human Services.
[PL 1995, c. 673, §1 (NEW); PL 1995, c. 673, §2 (AFF); PL 2003, c. 689, Pt. B, §6 (REV).]
3.  Coverage decisions.
Following a determination that a particular service is covered, a carrier may not deny payment for that service based on the enrollee's age, nature of disability or degree of medical dependency.
[PL 1995, c. 673, §1 (NEW); PL 1995, c. 673, §2 (AFF).]
SECTION HISTORY
PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 742, §14 (AMD). PL 2003, c. 689, §B6 (REV). PL 2007, c. 199, Pt. B, §14 (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 §4306. Enrollee choice of primary care provider

§4306. Enrollee choice of primary care provider
A carrier offering or renewing a managed care plan shall allow enrollees to choose their own primary care providers, as allowed under the managed care plan's rules, from among the panel of participating providers made available to enrollees under the managed care plan's rules. A carrier shall allow physicians, including, but not limited to, pediatricians and physicians who specialize in obstetrics and gynecology, and physician assistants licensed pursuant to Title 32, section 2594‑E or section 3270‑E and certified nurse practitioners who have been approved by the State Board of Nursing to practice advanced practice registered nursing without the supervision of a physician pursuant to Title 32, section 2102, subsection 2‑A to serve as primary care providers for managed care plans. A carrier is not required to contract with certified nurse practitioners, physician assistants or physicians as primary care providers in any manner that exceeds the access and provider network standards required in this chapter or chapter 56, or any rules adopted pursuant to those chapters. A carrier shall allow enrollees in a managed care plan to change primary care providers without good cause at least once annually and to change with good cause as necessary. When an enrollee fails to choose a primary care provider, the carrier may assign the enrollee a primary care provider located in the same geographic area in which the enrollee resides.   [PL 2019, c. 627, Pt. A, §1 (AMD).]
SECTION HISTORY
PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 396, §6 (AMD). PL 1999, c. 396, §7 (AFF). PL 1999, c. 742, §15 (AMD). PL 2007, c. 199, Pt. B, §15 (AMD). PL 2011, c. 364, §28 (AMD). PL 2019, c. 627, Pt. A, §1 (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 §4306-A. Patient access to obstetrical and gynecological care

§4306-A. Patient access to obstetrical and gynecological care
Notwithstanding any other requirements of this Title, a carrier offering a health plan in this State subject to the requirements of the federal Affordable Care Act:   [PL 2011, c. 364, §29 (NEW).]
1.  Authorization or referral not required.
May not require authorization or referral by the carrier or any other person, including a primary care provider, in the case of a female enrollee who seeks coverage for obstetrical or gynecological care provided by a participating health care professional as described in the federal Affordable Care Act who specializes in obstetrics or gynecology. The health care professional shall agree to otherwise adhere to the health plan's or carrier's policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan, if any, approved by the carrier; and
[PL 2011, c. 364, §29 (NEW).]
2.  Treated as primary care.
Shall treat the provision of obstetrical and gynecological care by a participating health care professional as described in the federal Affordable Care Act who specializes in obstetrics or gynecology, pursuant to subsection 1, as authorized by the primary care provider and the authorization of related obstetrical and gynecological items and services by that professional as the authorization of the primary care provider.
[PL 2011, c. 364, §29 (NEW).]
SECTION HISTORY
PL 2011, c. 364, §29 (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 §4307. Construction

§4307. Construction
Nothing in this chapter may be construed to:   [PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).]
1.  Purchase services with own funds.
Prohibit an individual from purchasing any health care services with that individual's own funds, whether these services are covered within the individual's benefit package or from another health care provider or plan, except as otherwise provided by federal or state law;
[PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).]
2.  Additional benefits.
Prohibit any plan sponsor from providing additional coverage for benefits, rights or protections not set out in this chapter;
[PL 1999, c. 742, §16 (AMD).]
3.  Provider participation.
Require a carrier to admit to a managed care plan a provider willing to abide by the terms and conditions of the managed care plan; or
[PL 1999, c. 742, §16 (AMD).]
4.  Treatment by religious nonmedical providers.
With respect to coverage of treatment by religious nonmedical providers:
A. Restrict or limit the right of a carrier to include a religious nonmedical provider as a participating provider in a managed care plan;   [PL 1999, c. 742, §17 (NEW).]
B. Require a carrier to:
(1) Utilize medically based eligibility standards or criteria in deciding provider status of religious nonmedical providers;
(2) Use medical professionals or criteria to decide enrollee access to religious nonmedical providers;
(3) Utilize medical professionals or criteria in making decisions in internal or external appeals regarding coverage for care by religious nonmedical providers; or
(4) Compel an enrollee to undergo a medical examination or test as a condition of receiving coverage for treatment by a religious nonmedical provider; or   [PL 1999, c. 742, §17 (NEW).]
C. Require a carrier to exclude religious nonmedical providers because the providers do not provide medical or other required data, if such data is inconsistent with the religious nonmedical treatment or nursing care provided by the provider.   [PL 1999, c. 742, §17 (NEW).]
[PL 1999, c. 742, §17 (NEW).]
SECTION HISTORY
PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 742, §§16,17 (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 §4308. Indemnification

§4308. Indemnification
A contract between a carrier offering or renewing a health plan and a provider for the provision of services to enrollees may not require the provider to indemnify the carrier for any expenses and liabilities, including, without limitation, judgments, settlements, attorney's fees, court costs and any associated charges incurred in connection with a claim or action brought against the health plan based on the carrier's own fault. Nothing in this section may be construed to remove responsibility of a carrier or provider for expenses or liabilities caused by the carrier's or provider's own negligent acts or omissions or intentional misconduct.   [PL 2007, c. 199, Pt. B, §16 (AMD).]
1.  Indemnification.
[PL 1999, c. 742, §18 (RP).]
SECTION HISTORY
PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 742, §18 (RPR). PL 2007, c. 199, Pt. B, §16 (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 §4309. Adoption of rules

§4309. Adoption of rules
The superintendent shall adopt rules and establish standards for health plans in order to carry out the purposes of this chapter. Rules adopted pursuant to this chapter are major substantive rules as defined in Title 5, chapter 375, subchapter II‑A.   [PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).]
SECTION HISTORY
PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (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 §4309-A. Compliance with the Affordable Care Act

§4309-A. Compliance with the Affordable Care Act
1.  Carriers.
A carrier shall comply with all applicable requirements of the federal Affordable Care Act.
[PL 2011, c. 364, §30 (NEW).]
2.  Superintendent.
The superintendent may enforce and administer this section through all powers provided under this Title and Title 24. The superintendent may adopt and amend rules, establish standards and enforce federal statutes and regulations in order to carry out the purposes of the federal Affordable Care Act. Rules or amendments adopted pursuant to this subsection, including amendments to major substantive rules, are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.
[PL 2011, c. 364, §30 (NEW).]
SECTION HISTORY
PL 2011, c. 364, §30 (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 §4310. Access to clinical trials

§4310. Access to clinical trials
1.  Qualified enrollee.
An enrollee is eligible for coverage for participation in an approved clinical trial if the enrollee meets the following conditions:
A. The enrollee has a life-threatening illness for which no standard treatment is effective;   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]
B. The enrollee is eligible to participate according to the clinical trial protocol with respect to treatment of such illness;   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]
C. The enrollee's participation in the trial offers meaningful potential for significant clinical benefit to the enrollee; and   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]
D. The enrollee's referring physician has concluded that the enrollee's participation in such a trial would be appropriate based upon the satisfaction of the conditions in paragraphs A, B and C.   [PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]
[PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]
2.  Coverage.
A carrier may not deny a qualified enrollee participation in an approved clinical trial or deny, limit or impose additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in the clinical trial. For the purposes of this section, "routine patient costs" does not include the costs of the tests or measurements conducted primarily for the purpose of the clinical trial involved.
[PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]
3.  Payment.
A carrier shall provide payment for routine patient costs but is not required to pay for costs of items and services that are reasonably expected to be paid for by the sponsors of an approved clinical trial. In the case of covered items and services, the carrier shall pay participating providers at the agreed upon rate and pay nonparticipating providers at the same rate the carrier would pay for comparable services performed by participating providers.
[PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]
4.  Approved clinical trial.
For the purposes of this section, "approved clinical trial" means a clinical research study or clinical investigation approved and funded by the federal Department of Health and Human Services, National Institutes of Health or a cooperative group or center of the National Institutes of Health.
[PL 1999, c. 742, §19 (NEW); PL 1999, c. 742, §21 (AFF).]
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. 517, Pt. B, §31 (NEW).]
SECTION HISTORY
PL 1999, c. 742, §19 (NEW). PL 1999, c. 742, §21 (AFF). PL 2003, c. 517, §B31 (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 §4314-A. Coverage for early refills of prescription eye drops

§4314-A. Coverage for early refills of prescription eye drops
1.  Required coverage.
A carrier offering a health plan in this State shall provide coverage for one early refill of a prescription for eye drops if the following criteria are met:
A. The enrollee requests the refill no earlier than the date on which 70% of the days of use authorized by the prescribing health care provider have elapsed;   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]
B. The prescribing health care provider indicated on the original prescription that a specific number of refills are authorized;   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]
C. The refill requested by the enrollee does not exceed the number of refills indicated on the original prescription;   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]
D. The prescription has not been refilled more than once during the period authorized by the prescribing health care provider prior to the request for an early refill; and   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]
E. The prescription eye drops are a covered benefit under the enrollee's health plan.   [PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]
[PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]
2.  Cost sharing.
A carrier may impose a deductible, copayment or coinsurance requirement for an early refill under this section as permitted under the health plan.
[PL 2015, c. 91, §1 (NEW); PL 2015, c. 91, §2 (AFF).]
SECTION HISTORY
PL 2015, c. 91, §1 (NEW). PL 2015, c. 91, §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 §4317-A. Prescription drug coverage; out-of-pocket expenses for coinsurance

§4317-A. Prescription drug coverage; out-of-pocket expenses for coinsurance
1.  Out-of-pocket expenses for coinsurance within health plan's total limit.
If a carrier that provides coverage for prescription drugs does not include prescription drugs subject to coinsurance under the total out-of-pocket limit for all benefits provided under a health plan, the carrier shall establish a separate out-of-pocket limit not to exceed $3,500 per year for prescription drugs subject to coinsurance provided under a health plan to the extent not inconsistent with the federal Affordable Care Act.
[PL 2011, c. 611, §1 (NEW); PL 2011, c. 611, §2 (AFF).]
2.  Adjustment of out-of-pocket limits.
A carrier may adjust an out-of-pocket limit, as long as any limit for prescription drugs for coinsurance does not exceed $3,500, to minimize any premium increase that might otherwise result from the requirements of this section. Any adjustment made by a carrier pursuant to this subsection is considered a minor modification under section 2850‑B.
[PL 2011, c. 611, §1 (NEW); PL 2011, c. 611, §2 (AFF).]
3.  Construction.
This section may not be construed to prohibit or limit a carrier's ability to establish specialty tiers for prescription drug coverage, to make determinations of medical necessity or to enforce procedures regarding prior authorization or utilization review in accordance with this chapter.
[PL 2011, c. 611, §1 (NEW); PL 2011, c. 611, §2 (AFF).]
4.  Terms consistent with federal law.
For the purposes of this section, the use of the terms "coinsurance" and "out-of-pocket limit" by a carrier must be consistent with the definitions of those terms as prescribed by the Secretary of the United States Department of Health and Human Services pursuant to Section 2715 of the federal Affordable Care Act.
[PL 2011, c. 611, §1 (NEW); PL 2011, c. 611, §2 (AFF).]
SECTION HISTORY
PL 2011, c. 611, §1 (NEW). PL 2011, c. 611, §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 §4317-B. Orally administered cancer therapy

§4317-B. Orally administered cancer therapy
1.  Coverage.
A carrier that provides coverage for cancer chemotherapy treatment shall provide coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells that is equivalent to the coverage provided for intravenously administered or injected anticancer medications. An increase in patient cost sharing for anticancer medications may not be used to achieve compliance with this section.
[PL 2013, c. 449, §1 (NEW); PL 2013, c. 449, §2 (AFF).]
2.  Construction.
This section may not be construed to prohibit or limit a carrier's ability to establish a prescription drug formulary or to require a carrier to cover an orally administered anticancer medication on the sole basis that it is an alternative to an intravenously administered or injected anticancer medication.
[PL 2013, c. 449, §1 (NEW); PL 2013, c. 449, §2 (AFF).]
SECTION HISTORY
PL 2013, c. 449, §1 (NEW). PL 2013, c. 449, §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 §4317-C. Coverage for prescription insulin drugs; limit on out-of-pocket costs

§4317-C. Coverage for prescription insulin drugs; limit on out-of-pocket costs
1.  Definition.
As used in this section, "insulin" has the same meaning as in Title 32, section 13786‑D, subsection 1, paragraph A.
[PL 2019, c. 666, Pt. A, §1 (NEW).]
2.  Limit on out-of-pocket costs.
A carrier that provides coverage for prescription insulin drugs may not impose any deductible, copayment, coinsurance or other cost-sharing requirement on an enrollee for that coverage that results in out-of-pocket costs to the enrollee that exceed $35 per prescription for a 30-day supply of covered prescription insulin drugs, regardless of the amount of insulin needed to fill the enrollee's insulin prescriptions.
[PL 2019, c. 666, Pt. A, §1 (NEW).]
3.  Other cost sharing.
This section does not prevent a carrier from setting an enrollee's cost-sharing requirement for one or more insulin drugs at an amount lower than the maximum amount specified in this section.
[PL 2019, c. 666, Pt. A, §1 (NEW).]
4.  Rules.
The superintendent may adopt rules to implement and administer this section to align with applicable federal requirements. Rules adopted pursuant to this section are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.
[PL 2019, c. 666, Pt. A, §1 (NEW).]
SECTION HISTORY
PL 2019, c. 666, Pt. A, §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 §4317-E. Coverage for emergency supply of chronic maintenance drugs

§4317-E. Coverage for emergency supply of chronic maintenance drugs
1.  Definition.
As used in this section, unless the context otherwise indicates, "chronic maintenance drug" has the same meaning as in Title 32, section 13786‑F, subsection 1.
[PL 2021, c. 566, §1 (NEW).]
2.  Coverage required.
A carrier offering a health plan in this State must make available coverage for an emergency supply of a chronic maintenance drug dispensed pursuant to Title 32, section 13786‑F in the same manner as coverage for other drugs under the health plan. A carrier may impose any deductible, copayment, coinsurance or other cost-sharing requirement for the chronic maintenance drug as long as the amount of the deductible, copayment, coinsurance or other cost-sharing requirement is applied in the same manner as if the chronic maintenance drug were dispensed as prescribed by a provider.
[PL 2021, c. 566, §1 (NEW).]
3.  Application.
This section does not apply to a health plan offered for use with a health savings account unless the federal Internal Revenue Service determines that the benefits required by this section are permissible benefits in a high deductible health plan as defined in the federal Internal Revenue Code, Section 223(c)(2).
[PL 2021, c. 566, §1 (NEW).]
SECTION HISTORY
PL 2021, c. 566, §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 §4318. Prohibition against maximum aggregate benefit provisions (REALLOCATED FROM TITLE 24-A, SECTION 4317) (REPEALED)

§4318. Prohibition against maximum aggregate benefit provisions
(REALLOCATED FROM TITLE 24-A, SECTION 4317)
(REPEALED)
SECTION HISTORY
RR 2009, c. 2, §70 (RAL). PL 2011, c. 364, §33 (AMD). PL 2019, c. 5, Pt. A, §22 (RP).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT › Subchapter 1: HEALTH PLAN REQUIREMENTS › 24-A §4318-B. Access to lower-priced services

§4318-B. Access to lower-priced services
1.  Services from out-of-network provider; lower prices.
Beginning January 1, 2019, if an enrollee covered under a health plan other than a health maintenance organization plan elects to obtain a covered comparable health care service as defined in section 4318‑A, subsection 1, paragraph A from an out-of-network provider at a price that is the same or less than the statewide average for the same covered health care service based on data reported on the publicly accessible health care costs website of the Maine Health Data Organization, the carrier shall allow the enrollee to obtain the service from the out-of-network provider at the provider's charge and, upon request by the enrollee, shall apply the payments made by the enrollee for that comparable health care service toward the enrollee's deductible and out-of-pocket maximum as specified in the enrollee's health plan as if the health care services had been provided by an in-network provider. A carrier may use the average price paid to a network provider for the covered comparable health care service under the enrollee's health plan in lieu of the statewide average price on the Maine Health Data Organization's publicly accessible website as long as the carrier uses a reasonable method to calculate the average price paid and the information is available to enrollees through a website accessible to the enrollee and a toll-free telephone number that provide, at a minimum, information relating to comparable health care services. The enrollee is responsible for demonstrating to the carrier that payments made by the enrollee to the out-of-network provider should be applied toward the enrollee's deductible or out-of-pocket maximum pursuant to this section. The carrier shall provide a downloadable or interactive online form to the enrollee for the purpose of making such a demonstration and may require that copies of bills and proof of payment be submitted by the enrollee. For the purposes of this section, "out-of-network provider" means a provider located in Massachusetts, New Hampshire or this State that is enrolled in the MaineCare program and participates in Medicare.
[PL 2017, c. 232, §9 (NEW).]
2.  Rules.
The superintendent may adopt rules as necessary to implement this section. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.
[PL 2017, c. 232, §9 (NEW).]
3.  Repeal.
[PL 2023, c. 224, §2 (RP).]
SECTION HISTORY
PL 2017, c. 232, §9 (NEW). PL 2023, c. 224, §2 (AMD).