reglab/statecodes huggingface dataset:
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2834-C. Compliance with federal law

§2834-C. Compliance with federal law
1.  Application.
This section applies to all group and blanket medical insurance policies issued by nonprofit hospital or medical service organizations, insurers or health maintenance organizations except hospital indemnity, accidental injury, specified disease and long-term care policies.
[PL 2009, c. 244, Pt. E, §1 (NEW).]
2.  Requirement.
Policies subject to this section must comply with the federal Children's Health Insurance Program Reauthorization Act of 2009, Section 311 concerning special enrollment periods in case of termination of coverage under a Medicaid plan or a state child health plan or eligibility for assistance in the purchase of employment-based coverage.
[PL 2009, c. 244, Pt. E, §1 (NEW).]
SECTION HISTORY
PL 2009, c. 244, Pt. E, §1 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2834-D. Maternity and postpartum care

§2834-D. Maternity and postpartum care
An insurer that issues 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, §2 (NEW).]
SECTION HISTORY
PL 2021, c. 691, §2 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2836. Limits on priority liens

§2836. Limits on priority liens
No group or blanket policy shall provide for priority over the insured member of payment for any hospital, nursing, medical or surgical services, or of any expenses paid or reimbursed under the policy, in the event the insured member is entitled to receive payment reimbursement from any other person as a result of legal action or claim, except as provided in this section.   [PL 1975, c. 770, §108 (NEW).]
A policy may contain a provision that allows such payments, if that provision is approved by the superintendent, and if that provision requires the prior written approval of the insured member 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 shall mean that any factors that diminish the potential value of the insured member's claim shall likewise reduce the share in the claim for those claiming payment for services or reimbursement. Such factors shall include, but are not limited to:   [PL 1975, c. 770, §108 (NEW).]
1.  Legal defenses.
Questions of liability and comparative negligence or other legal defenses;
[PL 1975, c. 770, §108 (NEW).]
2.  Exigencies of trial.
Exigencies of trial that reduce a settlement or award in order to resolve the claim; and
[PL 1975, c. 770, §108 (NEW).]
3.  Limits of coverage.
Limits on the amount of applicable insurance coverage that reduce the claim to an amount recoverable by the insured member.
[PL 1975, c. 770, §108 (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, the dispute shall 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 1975, c. 770, §108 (NEW).]
SECTION HISTORY
PL 1975, c. 770, §108 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2837-B. Acupuncture services

§2837-B. Acupuncture services
All group insurance policies and certificates providing coverage for acupuncture must provide coverage for those services when performed by an acupuncturist licensed pursuant to Title 32, chapter 113‑B, subchapter 2, under the same conditions that apply to the services of a licensed physician.   [PL 2003, c. 517, Pt. B, §14 (AMD).]
SECTION HISTORY
PL 1991, c. 647, §3 (NEW). PL 1995, c. 671, §10 (AMD). PL 2003, c. 517, §B14 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2837-C. Coverage for breast cancer treatment

§2837-C. Coverage for breast cancer treatment
1.  Inpatient care.
All group health policies providing coverage for medical and surgical benefits, except accidental injury, specified disease, hospital indemnity, Medicare supplement, long-term care and other limited benefit health insurance policies and contracts, 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, a group health policy 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 group health policies 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, §3 (AMD); PL 2015, c. 227, §5 (AFF).]
2.  Reconstruction.
All group health policies providing 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, §6 (NEW); PL 1997, c. 408, §8 (AFF).]
3.  Application.
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. B, §15 (NEW).]
SECTION HISTORY
RR 1995, c. 1, §17 (COR). PL 1995, c. 295, §4 (NEW). PL 1995, c. 369, §3 (NEW). PL 1997, c. 408, §6 (RPR). PL 1997, c. 408, §8 (AFF). PL 2003, c. 517, §B15 (AMD). PL 2015, c. 227, §3 (AMD). PL 2015, c. 227, §5 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2837-D. Medical food coverage for inborn error of metabolism

§2837-D. 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, §3 (NEW).]
2.  Required coverage.
All group insurance policies and contracts, except accidental injury, specified disease, hospital indemnity, Medicare supplement, long-term care and other limited benefit health insurance policies and 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 policies and contracts must reimburse:
A. For metabolic formula; and   [PL 1995, c. 369, §3 (NEW).]
B. Up to $3,000 per year for special modified low-protein food products.   [PL 1995, c. 369, §3 (NEW).]
[PL 1995, c. 369, §3 (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, §3 (NEW).]
SECTION HISTORY
RR 1995, c. 1, §17 (RNU). PL 1995, c. 369, §3 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2837-E. Coverage for Pap tests

§2837-E. Coverage for Pap tests
All group health insurance policies, contracts and certificates must provide coverage for screening Pap tests recommended by a physician.   [PL 2003, c. 517, Pt. A, §7 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).]
SECTION HISTORY
PL 1995, c. 617, §3 (NEW). PL 1995, c. 617, §6 (AFF). PL 2003, c. 517, §A7 (AMD). PL 2003, c. 517, §A13 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2837-H. Coverage for prostate cancer screening (REALLOCATED FROM TITLE 24-A, SECTION 2837-F)

§2837-H. Coverage for prostate cancer screening
(REALLOCATED FROM TITLE 24-A, SECTION 2837-F)
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, §52 (RAL).]
B. A prostate-specific antigen test.   [RR 1997, c. 2, §52 (RAL).]
[RR 1997, c. 2, §52 (RAL).]
2.  Required coverage for prostate cancer screening.
All group insurance policies and contracts except accidental injury, specified disease, hospital indemnity, Medicare supplement, long-term care and other limited benefit health insurance policies and 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, §52 (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, §52 (RAL).]
SECTION HISTORY
RR 1997, c. 2, §52 (RAL).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2838. Community health service coverage (REPEALED)

§2838. Community health service coverage
(REPEALED)
SECTION HISTORY
PL 1979, c. 419, §2 (NEW). PL 1979, c. 558, §10 (NEW). PL 1979, c. 663, §148 (AMD). PL 1979, c. 663, §149 (RAL). PL 1983, c. 515, §5 (RP).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2839. Rates filed

§2839. Rates filed
A policy of group or blanket health insurance may not be delivered in this State until a copy of the rates to be used in calculating the premium for these policies has been filed for informational purposes with the superintendent. The filing must include the base rates and a description of any procedures to be used to adjust the base rates to reflect factors including but not limited to age, gender, health status, claims experience, group size and coverage of dependents. Notwithstanding this section, rates for group Medicare supplement, nursing home care or long-term care insurance contracts and for certain association groups and other groups specified in section 2701, subsection 2, paragraph C must be filed in accordance with section 2736. Rates for small group health insurance subject to section 2808‑B are subject to the additional filing requirements specified in that section. A filing required under this section must be made electronically in a format required by the superintendent unless exempted by rule adopted by the superintendent. Rules adopted pursuant to this section are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.   [PL 2011, c. 238, Pt. C, §1 (AMD).]
SECTION HISTORY
PL 1979, c. 558, §10 (NEW). PL 1979, c. 663, §149 (RAL). PL 1985, c. 648, §11 (AMD). PL 2003, c. 428, §E2 (AMD). PL 2009, c. 14, §5 (AMD). PL 2011, c. 238, Pt. C, §1 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2839-A. Notice of rate increase

§2839-A. Notice of rate increase
1.  Notice of rate increase on existing policies.
An insurer offering group health insurance, except for accidental injury, specified disease, hospital indemnity, disability income, Medicare supplement, long-term care or other limited benefit group health insurance, must provide written notice by mail or electronically of a rate increase to all affected policyholders or others who are directly billed for group coverage at least 60 days before the effective date of any increase in premium rates. An increase in premium rates may not be implemented until 60 days after the notice is provided. For small group health plan rates subject to section 2808‑B, subsection 2‑B, if the increase is pending approval at the time of notice, the disclosure must state that the increase is subject to regulatory approval.
[PL 2011, c. 90, Pt. F, §2 (AMD).]
1-A.  Notice of rate increase on existing policies renewed in calendar year 2006.
[PL 2005, c. 400, Pt. A, §2 (NEW); MRSA T. 24-A §2839-A, sub-§1-A (RP).]
2.  Notice of rate increase on new business.
When an insurer offering group health insurance, except for accidental injury, specified disease, hospital indemnity, disability income, Medicare supplement, long-term care or other limited benefit group health insurance, quotes a rate for new business, it must disclose any rate increase that the insurer anticipates implementing within the following 90 days. If the quote is in writing, the disclosure must also be in writing. If such disclosure is not provided, an increase may not be implemented until at least 90 days after the date the quote is provided. For small group health plan rates subject to section 2808‑B, subsection 2‑B, if the increase is pending approval at the time of notice, the disclosure must state that the increase is subject to regulatory approval.
[PL 2005, c. 121, Pt. F, §1 (AMD).]
3.  Notice of rate increase on new business for calendar year 2006.
[PL 2005, c. 400, Pt. A, §2 (NEW); MRSA T. 24-A §2839-A, sub-§3 (RP).]
SECTION HISTORY
PL 2001, c. 432, §7 (NEW). PL 2005, c. 121, §F1 (AMD). PL 2005, c. 400, §A2 (AMD). PL 2011, c. 90, Pt. F, §2 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2839-B. Large group rates

§2839-B. Large group rates
1.  Application.
This section applies to group health insurance offered in the large group market as defined in section 2850‑B, except insurance covering only accidental injury, specified disease, hospital indemnity, dental, vision, disability income, long-term care, Medicare supplement or other limited benefit health insurance.
[PL 2003, c. 469, Pt. E, §17 (NEW).]
2.  Annual filing.
Every carrier offering group health insurance specified in subsection 1 shall annually file with the superintendent on or before April 30th a certification signed by a member in good standing of the American Academy of Actuaries or a successor organization that the carrier's rating methods and practices are in accordance with generally accepted actuarial principles and with the applicable actuarial standards of practice as promulgated by an actuarial standards board. The filing also must state the number of policyholders, certificate holders and dependents, as of the close of the preceding calendar year, enrolled in large group health insurance plans offered by the carrier. A filing and supporting information are public records except as provided by Title 1, section 402, subsection 3.
[PL 2023, c. 59, §8 (AMD).]
3.  Documentation.
Every carrier shall maintain at its principal place of business a complete and detailed description of its rating practices, including information and documentation that demonstrates that its rating methods and practices are in accordance with generally accepted actuarial principles and with the applicable actuarial standards of practice as promulgated by an actuarial standards board.
[PL 2003, c. 469, Pt. E, §17 (NEW).]
SECTION HISTORY
PL 2003, c. 469, §E17 (NEW). PL 2007, c. 629, Pt. M, §11 (AMD). PL 2023, c. 59, §8 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2840. Optional coverage for chiropractic services (REALLOCATED FROM TITLE 24-A, SECTION 2746) (REPEALED)

§2840. Optional coverage for chiropractic services
(REALLOCATED FROM TITLE 24-A, SECTION 2746)
(REPEALED)
SECTION HISTORY
PL 1979, c. 663, §145 (RAL). PL 1981, c. 282, §2 (AMD). PL 1985, c. 516, §4 (RP).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2840-A. Coverage for chiropractic services

§2840-A. Coverage for chiropractic services
1.  Therapeutic, adjustive and manipulative services.
Notwithstanding any other provisions of this chapter, every insurer which issues group or blanket health care contracts providing coverage for the services of a "physician" or "doctor" to residents of this State shall provide coverage to any subscriber or other person covered under those contracts for those services when performed by a chiropractor, to the extent that the services are within the lawful scope of practice of a chiropractor licensed to practice in this State. Therapeutic, adjustive and manipulative services shall be covered whether performed by an allopathic, osteopathic or chiropractic doctor.
[PL 1985, c. 516, §5 (NEW).]
2.  Limits; coinsurance; deductibles.
Any contract which 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 1985, c. 516, §5 (NEW).]
3.  Reports to the Superintendent of Insurance.
Every insurer subject to this section shall report its experience for each calendar year to the Superintendent of Insurance not later than April 30th of the following year. The report must be in a form prescribed by the superintendent and include the amount of claims paid in this State for the services required by this section and the total amount of claims paid in this State for health care contracts. The report must include complaints concerning access to services under this section and the results of those complaints. The superintendent shall compile this data for all insurers in an annual report.
[PL 1993, c. 669, §3 (AMD).]
4.  Application; expiration.
[PL 1989, c. 141, §6 (RP).]
5.  Reimbursement; discrimination.
An insurer subject to this section may not refuse to reimburse a chiropractic provider who participates in the insurer's provider network for providing a health care service or procedure covered by the insurer as long as the chiropractic provider is acting within the lawful scope of that provider's license in the delivery of the covered service or procedure. Consistent with reasonable medical management techniques specified under the insurer's contract with respect to the method, treatment or setting for a covered service or procedure, the insurer may not discriminate based on the chiropractic provider's license. This subsection does not require an insurer to accept all chiropractic providers into a network or govern the amount of the reimbursement paid to a chiropractic provider.
[PL 2015, c. 111, §2 (NEW); PL 2015, c. 111, §4 (AFF).]
SECTION HISTORY
PL 1985, c. 516, §5 (NEW). PL 1989, c. 141, §§5,6 (AMD). PL 1993, c. 669, §3 (AMD). PL 2015, c. 111, §2 (AMD). PL 2015, c. 111, §4 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2841. Optional coverage for optometric services

§2841. Optional coverage for optometric services
1.  Coverage required to be made available.
Every insurer which issues for delivery in this State group health policies which provide coverage on an expense-incurred basis for the services of a "physician" or "doctor" to residents of this State shall make available to all groups coverage for such services when performed by an optometrist, to the extent the services are within the scope of the practice of an optometrist licensed to practice in this State.
[PL 1981, c. 254, §2 (NEW).]
2.  Policy.
The group or blanket policy making available coverage for the services referred to in this section shall contain provisions for maximum benefits and coinsurance, and reasonable limitations, deductibles and exclusions.
[PL 1981, c. 254, §2 (NEW).]
SECTION HISTORY
PL 1981, c. 254, §§2,3 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2845. Cardiac rehabilitation coverage

§2845. Cardiac rehabilitation coverage
1.  Requirement.
Every insurer which issues group health care contracts providing coverage for hospital care to residents of this State shall make available to groups of 20 or more persons, at the option of the policyholder, benefits as required by this section to any certificate holder or other person covered under those contracts for the expense of cardiac rehabilitation.
[PL 1987, c. 293, §2 (NEW).]
2.  Cardiac rehabilitation.
"Cardiac rehabilitation" means multidisciplinary, medically necessary treatment of persons with documented cardiovascular disease, which shall be provided in either a hospital or other setting. That treatment shall include outpatient treatment which is initiated within 26 weeks after the diagnosis of that disease and physician-recommended continuance of Phase II rehabilitation services for up to 36 sessions in a hospital or community-based setting and up to 36 Phase III sessions in a community-based setting.
[PL 1987, c. 293, §2 (NEW).]
3.  Limitations.
Benefits required to be made available pursuant to this section may be made subject to any reasonable limitation, maximum benefit, coinsurance, deductible or exclusion provisions applicable to overall benefits under the policy or certificate.
[PL 1987, c. 293, §2 (NEW).]
4.  Application.
The requirements of this section shall apply to all policies and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 1988. For purposes of this section only, all group policies shall be deemed to be renewed no later than the next yearly anniversary of the contract date.
[PL 1987, c. 293, §2 (NEW).]
SECTION HISTORY
PL 1987, c. 293, §2 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2846. Acquired Immune Deficiency Syndrome

§2846. Acquired Immune Deficiency Syndrome
A group health insurance policy or certificate delivered or issued for delivery in this State may not provide more restrictive benefits for sickness or disablement or the related expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or HIV related diseases than for any other sickness or disabling condition or exclude benefits for AIDS, ARC or HIV related diseases except through an exclusion under which all sicknesses and diseases are treated the same. This section does not apply to a policy providing benefits for specific diseases or accidental injury only.   [PL 2003, c. 517, Pt. B, §17 (AMD).]
SECTION HISTORY
PL 1989, c. 176, §6 (NEW). PL 2003, c. 517, §B17 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847. Utilization review data

§2847. Utilization review data
1.  Report required.
On or before April 1st of each year, any insurer or 3rd-party administrator which issues or administers a program or contract in this State providing coverage for hospital care 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 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. 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;   [PL 1989, c. 556, Pt. C, §3 (NEW).]
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 insurer;   [PL 1989, c. 556, Pt. C, §3 (NEW).]
C. The number and result of any appeals by the patients or their physicians as a result of initial review decisions to reduce benefits for services as determined through prospective evaluations; and   [PL 1989, c. 556, Pt. C, §3 (NEW).]
D. Any complaints filed in a court of competent jurisdiction and served upon an insurer filing under this section stating a cause of action against that insurer on the basis of damages to patients alleged to have been approximately caused by a delay, reduction or denial of medical benefits by the insurer, as determined through prospective evaluations, and the determination of liability or other disposition of the complaint.   [PL 1989, c. 556, Pt. C, §3 (NEW).]
[PL 1989, c. 556, Pt. C, §3 (NEW).]
2.  Residents.
This section is applicable to evaluations, appeals and complaints relating to residents of this State only.
[PL 1989, c. 556, Pt. C, §3 (NEW).]
3.  Confidentiality.
Any information provided pursuant to this section shall not identify the patients.
[PL 1989, c. 556, Pt. C, §3 (NEW).]
SECTION HISTORY
PL 1989, c. 556, §C3 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-A. Penalty for failure to notify of hospitalization

§2847-A. Penalty for failure to notify of hospitalization
An insurance policy may not include a provision permitting the insurer to impose a penalty for the failure of any person to notify the insurer of an insured person's hospitalization for emergency treatment. For purposes of this section, "emergency treatment" has the same meaning as defined in Title 22, section 1829.   [PL 1991, c. 695, §5 (NEW); PL 1991, c. 824, Pt. A, §51 (NEW).]
This section applies to policies and certificates executed, delivered, issued for delivery, continued or renewed in this State after the effective date of this section. For purposes of this section, all policies are deemed to be renewed no later than the next yearly anniversary of the contract date.   [PL 1991, c. 695, §5 (NEW); PL 1991, c. 824, Pt. A, §51 (NEW).]
SECTION HISTORY
PL 1991, c. 695, §5 (NEW). PL 1991, c. 824, §A51 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-B. Jury service

§2847-B. Jury service
1.  Prohibition.
An insurer that issues group or blanket health care contracts providing coverage for medical care to residents of this State may not terminate coverage for any person covered under those contracts because the person has been summonsed for or is engaged in jury service under Title 14, chapter 305, subchapter I‑A.
[PL 1991, c. 695, §5 (NEW); PL 1991, c. 824, Pt. A, §51 (NEW).]
2.  Application.
This section applies to all policies and any certificate executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 1991. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.
[PL 1991, c. 695, §5 (NEW); PL 1991, c. 824, Pt. A, §51 (NEW).]
SECTION HISTORY
PL 1991, c. 695, §5 (NEW). PL 1991, c. 824, §A51 (NEW).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-C. Notification prior to cancellation; restrictions on cancellation, termination or lapse due to cognitive impairment or functional incapacity

§2847-C. Notification prior to cancellation; restrictions on cancellation, termination or lapse due to cognitive impairment or functional incapacity
An insurer shall provide for notification of the insured person and another person, if designated by the insured, prior to cancellation of a health insurance certificate for nonpayment of premium.   [PL 2011, c. 123, §3 (AMD); PL 2011, c. 123, §5 (AFF).]
Within 90 days after cancellation due to nonpayment of premium, a policyholder, a person authorized to act on behalf of the policyholder or a dependent of the policyholder covered under a health insurance policy or certificate may request reinstatement on the basis that the loss of coverage was a result of the policyholder's cognitive impairment or functional incapacity. An insurer may require a medical demonstration that the policyholder suffered from cognitive impairment or functional incapacity at the time of cancellation. If the medical demonstration is waived or substantiates the existence of a cognitive impairment or functional incapacity at the time of policy cancellation to the satisfaction of the insurer, the policy must be reinstated. The medical demonstration may be at the expense of the policyholder.   [PL 2011, c. 123, §3 (NEW); PL 2011, c. 123, §5 (AFF).]
A policy reinstated pursuant to this section must cover any loss or claim occurring from the date of the cancellation. Within 15 days after request from an insurer, a policyholder of a policy reinstated pursuant to this section shall pay any unpaid premium from the date of the last premium payment at the rate that would have been in effect had the policy remained in force. If the premium is not paid as required, the policy may not be reinstated and the insurer is not responsible for claims incurred after the initial date of cancellation. If an insurer denies a request for reinstatement, the insurer shall notify the policyholder that the policyholder may request a hearing before the superintendent.   [PL 2011, c. 123, §3 (NEW); PL 2011, c. 123, §5 (AFF).]
The superintendent may adopt rules to implement the requirements of this section. The rules may include, but are not limited to, definitions, minimum disclosure requirements, notice provisions and the right of reinstatement. Rules adopted pursuant to this section are routine technical rules as defined in Title 5, chapter 375, subchapter 2‑A.   [PL 2011, c. 123, §3 (AMD); PL 2011, c. 123, §5 (AFF).]
The requirements of this section apply to all policies and certificates executed, delivered, issued for delivery, continued or renewed in this State.   [PL 1991, c. 695, §5 (NEW); PL 1991, c. 824, Pt. A, §51 (NEW).]
SECTION HISTORY
PL 1991, c. 695, §5 (NEW). PL 1991, c. 824, §A51 (NEW). PL 2011, c. 123, §3 (AMD). PL 2011, c. 123, §5 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-D. Penalty for noncompliance with utilization review programs

§2847-D. Penalty for noncompliance with utilization review programs
A policy or certificate issued or renewed after April 8, 1994 may not contain a provision that permits, upon retroactive review and confirmation of medical necessity, the imposition of a penalty of more than $500 for failure to provide notification under a utilization review program. This section does not limit the right of insurers to deny a claim when appropriate prospective or retroactive review concludes that services or treatment rendered were not medically necessary.   [PL 1995, c. 332, Pt. M, §9 (AMD).]
SECTION HISTORY
PL 1993, c. 645, §B5 (NEW). PL 1995, c. 332, §M9 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-E. Coverage for diabetes supplies

§2847-E. Coverage for diabetes supplies
All group insurance policies, 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, §8 (AMD); PL 2003, c. 517, Pt. A, §13 (AFF).]
1.  Certification of medical necessity.
The insured'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, §3 (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, §3 (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, §8 (NEW); PL 2003, c. 517, Pt. A, §13 (AFF).]
SECTION HISTORY
PL 1995, c. 592, §3 (NEW). PL 2003, c. 517, §A8 (AMD). PL 2003, c. 517, §A13 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-F. Gynecological and obstetrical services (REALLOCATED FROM TITLE 24-A, SECTION 2850-A)

§2847-F. Gynecological and obstetrical services
(REALLOCATED FROM TITLE 24-A, SECTION 2850-A)
1.  Coverage in managed care plans.
With respect to managed care plans that require group members to select primary care physicians, an insurer that issues group health insurance policies, contracts and certificates must meet the following requirements.
A. The insurer must permit a physician who specializes in obstetrics and gynecology to serve as a primary care physician if the physician qualifies under the insurer's credentialling policy.   [PL 1997, c. 370, Pt. H, §1 (RAL).]
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 1997, c. 370, Pt. H, §1 (RAL).]
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 1997, c. 370, Pt. H, §1 (RAL).]
[PL 2003, c. 517, Pt. A, §9 (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, §9 (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 1997, c. 370, Pt. H, §1 (RAL).]
SECTION HISTORY
PL 1997, c. 370, §H1 (RAL). PL 2003, c. 517, §A9 (AMD). PL 2003, c. 517, §A13 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-H. Coverage for services of certified nurse practitioners; certified midwives; certified nurse midwives (REALLOCATED FROM TITLE 24-A, SECTION 2847-G)

§2847-H. Coverage for services of certified nurse practitioners; certified midwives; certified nurse midwives
(REALLOCATED FROM TITLE 24-A, SECTION 2847-G)
1.  Required coverage for services upon referral of primary care provider.
An insurer that issues group health insurance policies and contracts shall provide coverage under those contracts for services performed by a certified nurse practitioner, certified midwife or certified nurse midwife to a patient who is referred to the certified nurse practitioner, certified midwife or certified nurse midwife by a primary care provider when those services are within the lawful scope of practice of the certified nurse practitioner, certified midwife or certified nurse midwife.
[PL 2021, c. 79, §3 (AMD).]
2.  Required coverage for self-referred services.
With respect to group health insurance policies and contracts that do not require the selection of a primary care provider, an insurer shall provide coverage under those contracts for services performed by a certified nurse practitioner, certified midwife or certified nurse midwife when those services are covered services and when they are within the lawful scope of practice of the certified nurse practitioner, certified midwife or certified nurse midwife.
[PL 2021, c. 79, §3 (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, §34 (RAL).]
4.  Application.
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. B, §19 (NEW).]
SECTION HISTORY
RR 1999, c. 1, §34 (RAL). PL 2003, c. 517, §B19 (AMD). PL 2021, c. 79, §3 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-I. Coverage for services provided by registered nurse first assistants (REALLOCATED FROM TITLE 24-A, SECTION 2847-G)

§2847-I. Coverage for services provided by registered nurse first assistants
(REALLOCATED FROM TITLE 24-A, SECTION 2847-G)
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.   [RR 1999, c. 1, §35 (RAL).]
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.   [RR 1999, c. 1, §35 (RAL).]
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.   [RR 1999, c. 1, §35 (RAL).]
[RR 1999, c. 1, §35 (RAL).]
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.
[RR 1999, c. 1, §35 (RAL).]
3.  Required coverage for services.
Notwithstanding any other provisions of this chapter, an insurer that issues group health insurance policies and 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. This section does not apply to policies or contracts that cover only specified diseases.
[RR 1999, c. 1, §35 (RAL).]
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.
[RR 1999, c. 1, §35 (RAL).]
5.  Application.
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. B, §20 (NEW).]
SECTION HISTORY
RR 1999, c. 1, §35 (RAL). PL 2003, c. 517, §B20 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-J. Coverage for hospice care services

§2847-J. Coverage for hospice care services
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.   [PL 2001, c. 358, Pt. LL, §3 (NEW); PL 2001, c. 358, Pt. LL, §5 (AFF).]
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.   [PL 2001, c. 358, Pt. LL, §3 (NEW); PL 2001, c. 358, Pt. LL, §5 (AFF).]
[PL 2001, c. 358, Pt. LL, §3 (NEW); PL 2001, c. 358, Pt. LL, §5 (AFF).]
2.  Coverage for hospice care services.
All group insurance policies and 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.
[PL 2001, c. 358, Pt. LL, §3 (NEW); PL 2001, c. 358, Pt. LL, §5 (AFF).]
3.  Application.
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. B, §21 (NEW).]
Revisor's Note: §2847-J. Coverage for general anesthesia for dentistry (As enacted by PL 2001, c. 423, §3 and affected by §5 is REALLOCATED TO TITLE 24-A, SECTION 2847-K)
SECTION HISTORY
RR 2001, c. 1, §33 (RAL). PL 2001, c. 358, §LL3 (NEW). PL 2001, c. 358, §LL5 (AFF). PL 2001, c. 423, §3 (NEW). PL 2001, c. 423, §5 (AFF). PL 2003, c. 517, §B21 (AMD).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-L. Offer of coverage for breast reduction surgery and symptomatic varicose vein surgery

§2847-L. Offer of coverage for breast reduction surgery and symptomatic varicose vein surgery
All 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, §3 (NEW); PL 2005, c. 128, §5 (AFF).]
SECTION HISTORY
PL 2005, c. 128, §3 (NEW). PL 2005, c. 128, §5 (AFF).
2023 Maine Revised Statutes › TITLE 24-A: MAINE INSURANCE CODE › Chapter 35: GROUP AND BLANKET HEALTH INSURANCE › 24-A §2847-M. Enrollment for individuals or families establishing eligibility for MaineCare

§2847-M. Enrollment for individuals or families establishing eligibility for MaineCare
When an individual or family is eligible for MaineCare and is also eligible for health insurance coverage provided by an employer, the insurer must permit the individual or family to enroll in the health insurance coverage without regard to any enrollment season restrictions.   [PL 2007, c. 448, §11 (NEW).]
Revisor's Note: §2847-M. Coverage for hearing aids (As enacted by PL 2007, c. 452, §3 is REALLOCATED TO TITLE 24-A, SECTION 2847-O)
SECTION HISTORY
PL 2007, c. 448, §11 (NEW). PL 2007, c. 452, §3 (NEW). PL 2007, c. 695, Pt. A, §29 (RAL).