reglab/statecodes huggingface dataset:
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 851 - Clear Choice Designs for Individual and Small Group Health Plans › Section 031-851-5 - Clear Choice Plans

Current through 2024-29, July 17, 2024
1. The
				Superintendent shall develop and publish a series of Clear Choice Designs,
				including at least one at each metal level. A health plan may only be approved
				as a Clear Choice Plan if the Superintendent determines that it conforms to one
				of the Clear Choice Designs.
A. The
				Superintendent shall annually review market experience with the Clear Choice
				designs, and shall solicit stakeholder input on changes that might be
				desirable, including potential amendments to this rule. The Superintendent
				shall consider AV requirements, stakeholder input, value-based plan design, and
				the need for meaningful differences between plans offered by the same carrier
				in a given service area. For years in which the individual and small group
				health markets are pooled, the Superintendent shall ensure the availability of
				a range of designs intended to meet the needs of individuals and small
				employers. The Superintendent shall expose any proposed revisions to the Clear
				Choice designs for public comment, and shall publish the final version in time
				for carriers to use it in their rate and form filings.
B. If changes to the actuarial value
				calculator, maximum permissible out-of-pocket expenses, or other federal or
				state requirements require adjustments to one or more Clear Choice Designs
				after they have been finalized, and a waiver of the new requirements is not
				granted, the Superintendent shall make adjustments as necessary to remain in
				compliance.
C. To facilitate
				comparison between plans, each Clear Choice Design shall be designated by its
				metal level, or the term "Catastrophic," and a short descriptive term, except
				for levels with only one Clear Choice Design.
(1) The descriptive name of any HSA plan
				design shall include "HSA" and the descriptive name of any Off-Marketplace plan
				design shall include "Off-Marketplace."
(2) The Superintendent shall develop a
				comparative table of Clear Choice Plans approved to be offered in Maine,
				grouped by their respective Clear Choice Designs. The table of plans for the
				upcoming year shall be published on the Bureau of Insurance website after rates
				are approved and shall be furnished to the Marketplace.
(3) Carriers may use their own branding for
				Clear Choice Plans as long as they also identify the applicable Clear Choice
				Design.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 851 - Clear Choice Designs for Individual and Small Group Health Plans › Section 031-851-6 - Alternative Plan Designs

Current through 2024-29, July 17, 2024
1. A carrier may
				request approval, in accordance with this section, to offer up to three
				Alternative Plan Designs in any plan year.
2. The carrier's application shall be
				submitted no later than the deadline announced by the Superintendent for rate
				and form filings, and shall include:
A. An
				actuarial certification, including an explanation why the Alternative Plan
				Design is not expected to promote adverse selection, a description of the
				significant consumer benefits that are anticipated, and an explanation why
				those benefits are not available from any Clear Choice Design or from any of
				the carrier's other Alternative Plan Designs;
B. Copies of all policy forms the carrier
				proposes to use in conformance with the Alternative Plan Design, and if there
				are multiple forms, optional endorsements, or variable language, an explanation
				why the variations should not be considered distinct plan designs for purposes
				of this rule; and
C. If the carrier
				is proposing to modify or discontinue an Alternative Plan Design already in
				use, an explanation why the modification or discontinuance is permitted under
				24-A M.R.S. §
										2850- B(3)(G) or (I), including a
				proposed mapping for existing policyholders.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 851 - Clear Choice Designs for Individual and Small Group Health Plans › Section 031-851-7 - Severability

Current through 2024-29, July 17, 2024
If any section, term, or provision of this rule shall be
				  deemed invalid for any reason, any remaining section, provision, or definition
				  shall remain in full force and effect.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 851 - Clear Choice Designs for Individual and Small Group Health Plans › Section 031-851-8 - Effective date

Current through 2024-29, July 17, 2024
This rule is effective June 8, 2021. The 2022 amendments are
				  effective December 4, 2022.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 855 - HEALTH INSURANCE PAYMENT REFORM PILOT PROJECTS › Section 031-855-1 - Authority and Purpose

Current through 2024-29, July 17, 2024
This rule is adopted pursuant to
				   24-A M.R.S.A.
				  §§212 and
				  4320-H
				  and
				  2011
				  Public Law Chapter 270 §
									4, to establish procedures and
				  policies for authorization of pilot projects relating to health insurance
				  provider payment reform strategies.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 855 - HEALTH INSURANCE PAYMENT REFORM PILOT PROJECTS › Section 031-855-2 - Definitions

Current through 2024-29, July 17, 2024
For purposes of this rule, the following terms have the
				  following meanings:
A. "Accountable
				care organization" means a group of health care providers operating under a
				payment agreement to provide health care services to a defined set of
				individuals with established benchmarks for the quality and cost of those
				health care services consistent with federal law and regulations.
B. "Carrier" and "health plan" have the
				meanings set forth in
				 24-A M.R.S.A.
				§§4301-A(3) &
				(7).
C. "Pilot project" means a
				project that allows a health insurance carrier that offers health plans in this
				State to implement payment reform strategies with providers through an
				accountable care organization to reduce costs and improve the quality of
				patient care, but does not include projects otherwise permitted by
				law.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 855 - HEALTH INSURANCE PAYMENT REFORM PILOT PROJECTS › Section 031-855-3 - Authorization of Health Insurance Payment Reform Pilot Projects

Current through 2024-29, July 17, 2024
A. A carrier that offers health plans in this
				State may seek authorization from the Superintendent to conduct a pilot project
				that implements payment reform strategies with providers through an accountable
				care organization to reduce costs and improve the quality of patient care.
B. In order to be approved, a
				pilot project application must:
1. include a
				detailed project narrative including, where appropriate a work planand project
				timeline, including project commencement and conclusion dates;
2. demonstrate consistency with the payment
				reform principles set forth in Section
				4 of this Rule;
3. include copies of all contracts, written
				agreements, memoranda of understanding, or other similar documents pertinent to
				the program.Forms to be used in multiple agreements should be submitted in
				blank;
4. demonstrate compliance
				with all applicable Maine laws;
5.
				include a methodology for periodic measurement and evaluation of the results of
				the pilot project.The methodology shall include identification of the baseline
				data or information to be analyzed and the analysis of project costs, project
				benefits, the effect of the project in reducing health care costs, any effect
				on insurance premiums, and any effect on the quality of care;
6. provide for reporting to the
				Superintendent by May 31 of each year the pilot project results as of December
				31 of the preceding year, or on such other schedule as may be agreed to by the
				carrier and the Superintendent; and
7. have received accreditation status from
				the National Council on Quality Accreditation (NCQA) or provided such other
				assurances of quality as the Superintendent may determine acceptable.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 855 - HEALTH INSURANCE PAYMENT REFORM PILOT PROJECTS › Section 031-855-4 - Payment Reform Principles

Current through 2024-29, July 17, 2024
Pilot projects must demonstrate consistency with the
				  following payment reform principles:
A. Support for integrated, efficient, and
				effective systems of care delivery and payment;
B. Promotion of a patient-centered approach
				to service payment and delivery;
C.
				Encouragement and reward for the prevention and management of
				disease;
D. Incentives that do not
				reward the denial or restriction of medically necessary care;
E. Promotion of the value of care over volume
				to measurably lower costs; and
F.
				Support for payments and processes that are transparent, easy to understand,
				and simple to administer for patients, providers, purchasers, and other
				stakeholders. If a health insurance carrier implements a pilot project that
				restricts provider participation on the basis of cost and/or quality
				benchmarks, those benchmarks should be transparent to the provider community.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 855 - HEALTH INSURANCE PAYMENT REFORM PILOT PROJECTS › Section 031-855-5 - Compliance with Other Laws

Current through 2024-29, July 17, 2024
Pilot projects authorized under this Rule and complying with
				  the payment reform principles set forth in Section
				  4 shall not be considered prohibited
				  financial incentives under
				   24-A M.R.S.A.
				  §4303(3-B). Pilot
				  projects are subject to all other applicable Maine statutes and rules.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 855 - HEALTH INSURANCE PAYMENT REFORM PILOT PROJECTS › Section 031-855-6 - Confidentiality

Current through 2024-29, July 17, 2024
Any information contained in an application for authorization
				  of a pilot project or in other documents filed with the Superintendent pursuant
				  to this Rule shall be treated by the Superintendent as a "public record" within
				  the meaning of the Maine Freedom of Access Act,
				   1 M.R.S.A.
				  §§401
et seq
.,
				  unless a legal basis for confidentiality exists. Any applicant who seeks to
				  assert the confidentiality of any document or documents filed pursuant to this
				  Rule shall clearly state the basis for the assertion at the time of filing and
				  shall provide both redacted and unredacted originals of the documents to which
				  the assertion relates. Unredacted documents subject to an assertion of
				  confidentiality shall be clearly identified as confidential. The cover letter
				  to the filing shall identify information subject to a confidentiality assertion
				  and where it is located within the filing.
There shall be a rebuttable presumption that any documents
				  that are subject to an assertion of confidentiality are confidential.If a
				  request for the documents is received, or if the Superintendent determines that
				  the filing party has not adequately supported the assertion of confidentiality,
				  the filing party shall be provided an opportunity to provide the
				  Superintendent, and the requesting party if applicable, detailed legal support
				  for the basis for the assertion according to Maine law then in effect. The
				  requesting party shall be provided an opportunity to provide responsive legal
				  support for the document request. The Superintendent shall then notify both the
				  filing party and the requesting party of his or her determination as to
				  confidentiality of the documents in question. Should the Superintendent
				  determine that the documents or any portion of the documents are not entitled
				  to confidential treatment, the filing party shall be provided an opportunity to
				  seek judicial review before their release.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 856 - Combination of the Individual and Small Business Health Insurance Risk Pools › Section 031-856-1 - Authority and Purpose

Current through 2024-29, July 17, 2024
This rule is adopted pursuant to
				  24-A M.R.S.
				  §§212 and
				  2792(5),
				  to establish the necessary conditions and procedures for implementation of the
				  pooled individual and small group health insurance market, and the extension of
				  Maine Guaranteed Access Reinsurance Association coverage to small group health
				  insurance.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 856 - Combination of the Individual and Small Business Health Insurance Risk Pools › Section 031-856-2 - Applicability and Scope

Current through 2024-29, July 17, 2024
This rule shall apply to all individual health plans, as
				  defined in
				  24-A M.R.S.
				  §2736-C(1)(C), and to
				  all small group health plans, as defined in
				  24-A M.R.S.
				  §2808-B(1)(G), issued
				  or renewed as pooled market health plans on or after January 1, 2023. Section 6
				  applies to the operations of the Maine Guaranteed Access Reinsurance
				  Association on and after January 1, 2022.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 856 - Combination of the Individual and Small Business Health Insurance Risk Pools › Section 031-856-3 - Definitions

Current through 2024-29, July 17, 2024
The following definitions apply for purposes of this
				  rule:
1. "Carrier" has the same
				meaning as in
				24-A M.R.S.
				§4301-A(3).
2. "Innovation waiver amendment" means a
				revision of the state innovation waiver that was granted to the State of Maine
				under Section 1332 of the federal Affordable Care Act and is in force on the
				effective date of this rule, or any substitute or replacement of that waiver
				issued or applied for under Section 1332 or a successor federal
				program.
3. "Maine Guaranteed
				Access Reinsurance Association" or "Association" has the same meaning as in
				 24-A M.R.S.
				§3952(1).
4. "Implementation year" means the first
				calendar year in which the individual and small group markets are pooled
				pursuant to this rule.
5. "Pooled
				market health plan" means any individual or small group health plan, as defined
				in
				24-A M.R.S. §§
										2736-C(1)(C) and
				2808-B(1)(G),
				issued or renewed in this State during or after the implementation year, other
				than a multiple-employer plan that has been approved as a separate rating pool
				under
				24-A M.R.S.
				§2808-B(2)(E).
6. "Provisional implementation year" means
				2023 or, if applicable, the alternative provisional implementation year most
				recently established by the Superintendent pursuant to subsection
				6(B).
7. "Retrospective reinsurance
				program" means a reinsurance program under which all eligible policies are
				covered by the Association, without regard for an insured individual's health
				condition and without requiring any advance designation for
				reinsurance.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 856 - Combination of the Individual and Small Business Health Insurance Risk Pools › Section 031-856-4 - Establishment of Pooled Market

Current through 2024-29, July 17, 2024
1.
Review of
				Expected Savings.
The Superintendent shall commence the implementation
				process by evaluating the expected premium savings, if any, resulting from the
				implementation of the pooled market and the Association's reinsurance program.
A. The Superintendent shall conduct an
				actuarial analysis of the expected premium impact of the pooled market and the
				reinsurance program, and shall consider any other analyses that may be provided
				by the Association or by members of the public. The Association shall provide
				its estimate of the impact of pooling the market on anticipated reinsurance
				parameters for the provisional implementation year, including attachment
				points, coinsurance percentages, and any reinsurance caps and ceding
				premiums.
B. The Superintendent
				shall solicit public input on the expected impact of the pooled market and the
				reinsurance program, and suggestions for additional or alternate initiatives to
				improve the stability and affordability of the small group market.
C. The Superintendent shall hold at least one
				forum where the public may provide comments and ask questions. This requirement
				may be satisfied by a forum or hearing held in connection with the preliminary
				application process for an innovation waiver amendment under subsection 3.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 856 - Combination of the Individual and Small Business Health Insurance Risk Pools › Section 031-856-5 - Operation of Pooled Market

Current through 2024-29, July 17, 2024
The provisions of this section shall apply to all pooled
				  market health plans providing coverage in this State.
1.
Guaranteed Issue and Guaranteed
				Renewal.
Except as prohibited by federal law with respect to
				catastrophic plans:
A. Every carrier offering
				any pooled market health plan must offer the same plan to all individuals and
				small employers within any service area where the carrier has made the plan
				available, subject to the network capacity limitations of
				24-A M.R.S.
				§§2736-C(3)(A)(2)
				and
				2808-B(4)(A)(2).
				Coverage for individuals, and coverage for small employers that fail to meet
				the carrier's approved participation requirements, shall be available only
				during annual open enrollment periods and designated special enrollment
				periods.
B. No pooled market health
				plans may be added or discontinued after the rate and form filing deadline
				established by the Superintendent.
C. This subsection does not require carriers
				to market all pooled market health plans in the same manner to all customers. A
				carrier may vary its marketing strategies and distribution channels, including
				the decision whether to offer a plan on the Maine Health Insurance Marketplace
				established pursuant to
				22 M.R.S.
				§5403, between one plan and another,
				between one service area and another, or between individuals and small
				employers, as long as the carrier does not discriminate on the basis of actual
				or perceived health risk or other prohibited classifications.
D. All pooled market health plans must be
				guaranteed renewable, subject to the carrier's right to discontinue or modify
				coverage when permitted by
				24-A M.R.S.
				§2850-B(3) and
				applicable contract terms.
E. This
				section does not prohibit differences in the administrative provisions of the
				policy forms issued to individuals and the coverage documents for the same plan
				issued to small employers and plan participants, if the variations in contract
				terms are reasonably related to the differences in the mode of coverage, and do
				not affect the plan benefits or premium rates except to the extent expressly
				permitted by this rule or required by controlling law.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 856 - Combination of the Individual and Small Business Health Insurance Risk Pools › Section 031-856-6 - Reinsurance Coverage by the Association

Current through 2024-29, July 17, 2024
1.
Pooled Reinsurance Program.
During and after the
				implementation year, the Association shall administer a retrospective
				reinsurance program for pooled market health plans.
2.
Amendments to Plan of
				Operation.
Within 45 days after the Superintendent issues a final
				decision to implement the pooled market, the Association shall file with the
				Superintendent all amendments to its Plan of Operation that the Association's
				board determines to be necessary, including, without limitation:
A. The number of layers of coverage, the
				attachment point and coinsurance percentage for each layer, and the cap, if
				any, for the top layer of coverage;
B. The ceding premium, if any, to be
				charged;
C. The accumulation of
				claims for participants enrolled in non-calendar-year small group plans; and D.
				Any other material terms of coverage.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 856 - Combination of the Individual and Small Business Health Insurance Risk Pools › Section 031-856-7 - Severability

Current through 2024-29, July 17, 2024
If any section, term, or provision of this rule shall be
				  deemed invalid for any reason, any remaining section, provision, or definition
				  shall remain in full force and effect.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-1 - Authority and Purpose

Current through 2024-29, July 17, 2024
This rule is adopted pursuant to
				  24-A M.R.S.
				  §212 and P.L. 2021, c. 483, Part C,
An Act To Provide Allocations for the Distribution of State Fiscal
				  Recovery Funds
, to implement the Small Business Health Insurance
				  Premium Support Program (the "program"). The purpose of the program is to
				  temporarily reduce insurance premium costs for small employers and their
				  employees. The Superintendent will carry out the purpose of the program by
				  allocating the funds provided for the program through the duration of the
				  program to the small group health insurance carriers, based on actual credits
				  made monthly by each carrier, and by auditing the carriers for compliance and
				  to ensure that the administrative costs of the program do not result in
				  increased premiums to policyholders.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-2 - Applicability and Scope

Current through 2024-29, July 17, 2024
This rule shall apply to all small group health insurance
				  carriers and eligible small businesses doing business in Maine during the
				  duration of the program.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-3 - Definitions

Current through 2024-29, July 17, 2024
The following definitions apply for purposes of this
				  rule:
1. "Small Group Health Insurance
				Carrier" means a carrier as defined in
				24-A M.R.S.
				§2808-B(1)(A).
2. "Eligible Small Business" means an
				employer that purchases fully-insured small group health coverage, either
				directly or as a subgroup, offered by a small group health insurance carrier
				and rated as part of the carrier's single statewide small group risk
				pool.
3. "Eligible Employee" has
				the same meaning as defined in
				24-A M.R.S.
				§2808-B(1)(C).
4. "Enrolled Eligible Employee"
				means an eligible employee who is enrolled in an eligible small business group
				plan at any time during the duration of the program. Enrolled eligible
				employee" does not include an employee who stopped participating in an eligible
				employer's group health coverage before November 1, 2021 or a former employee,
				including a former employee eligible for COBRA or mini-COBRA
				coverage.
5. "Eligible Group" has
				the same meaning as in
				24-A M.R.S.
				§2808-B(1)(D).
6. "Premium Relief Credits" means
				monthly premium credits provided to eligible small businesses through the
				program.
7. "Duration of the
				Program" means November 1, 2021 through April 30, 2023.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-5 - Reimbursement of Premium Relief Credits and Administrative Costs

Current through 2024-29, July 17, 2024
1. Based on the information provided in
				Section 8, the program shall reimburse small group health insurance carriers
				for all premium relief credits provided to policyholders in accordance with
				this rule.
A. Reimbursement amounts shall be
				subject to adjustment if it is subsequently determined that credits were
				inaccurately reported or erroneously granted or denied, or if subsequent
				changes to the underlying premium bills result in changes to the applicable
				credits. Overpayments or underpayments of reimbursements shall be charged or
				credited as offsets in a subsequent reimbursement, and if necessary, a final
				reconciliation payment shall be made to the carrier or collected from the
				carrier after the end of the program.
B. Eligibility for reimbursement of a premium
				relief credit shall be based on whether the carrier provided coverage during
				that month to the employee and beneficiaries, and the employer owed premium for
				that coverage to the carrier, regardless of whether the premium owed was
				ultimately collected. No credit shall be reimbursed for months entirely
				preceding the inception date of the employee's coverage or entirely following
				the termination date of the employee's coverage.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-6 - Monthly Premium Relief Credits and Adjustments

Current through 2024-29, July 17, 2024
1.
				Small group health carriers shall reflect the premium relief credits in the
				monthly invoices they send to eligible small businesses. Each monthly invoice
				to an eligible small business must itemize the monthly premium relief credit
				provided to each enrolled eligible employee.
2. Small group health insurance carriers are
				permitted to make reasonable adjustments to the timing of these credits if
				necessary to minimize administrative costs. An example of reasonable adjustment
				is providing the first premium relief credit in the second month after a small
				group begins a new plan or a subscriber joins a plan. Any such adjustment must
				be clearly explained to the eligible small business in the corresponding
				invoice.
3. If necessary to
				minimize administrative costs, a small group health insurance carrier may
				utilize an alternative method of communicating the information in paragraphs
				(1) and (2) to eligible small businesses. The alternative method must meet the
				following minimum requirements:
(a) The
				alternative method must provide the information to the eligible small business
				within five business days of a request.
(b) The alternative method must be clearly
				communicated to eligible small businesses.
(c) The alternative method must be submitted
				to and approved by the Superintendent.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-7 - Notices to Small Group Policyholders

Current through 2024-29, July 17, 2024
1. Before
				November 1, 2021 or with the first premium invoice issued to a new
				policyholder, small group health insurance carriers must provide a notice
				explaining the program to all policyholders that are eligible small businesses,
				including an explanation of the purpose of the program and the duration of the
				program. This notice must include a request that copies of the notice be
				provided to employees, and that the notice be posted prominently in the
				employer's workplace, in locations where other employment notices are posted.
				This notice must also include an explanation that the premium relief credits
				must be divided with the enrolled eligible employee in an amount that is in at
				least the same proportion as the employee's premium contribution.
2. A similar notice must be provided with
				each subsequent monthly premium invoice sent to an eligible small
				business.
3. The Superintendent
				shall provide sample language to be included in these notices.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-8 - Reporting of Program-related Information

Current through 2024-29, July 17, 2024
1. Small
				group health insurance carriers shall provide the Superintendent with a
				spreadsheet each month through the duration of the program and any required
				time period following the end of the program showing details of the prior
				month's eligible small business premium billings and premium relief credits by
				subscriber number and showing total enrollment numbers. The report shall
				include the following data:
For each subscriber
* Subscriber type (employee-only, employee + spouse/partner,
				  etc.),
* Subscriber number
* Number of covered lives per subscriber
* Policy number
* Product/plan name
* Coverage period
* Billed premium
* Invoice date
* Premium credits (including any corrections for prior months
				  due to timing of reporting of employee or dependent adds/drops)
Monthly totals
* Total number of small groups
* Total number of each subscriber type
* Total number of covered lives
* Total amount of credits provided for each subscriber type
2. The Superintendent shall
				notify small group health insurance carriers of the requirements for this
				reporting, including the reporting format, and any additional required data
				elements.
3. Small group health
				insurance carriers shall also report information necessary to reimburse
				reasonable administrative costs on a monthly basis in a format prescribed by
				the Superintendent. The Superintendent shall review the submitted documentation
				and facilitate payment to the small group health insurance carriers under the
				terms of an agreement between the Superintendent and each small group health
				insurance carrier.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-9 - Prohibition Against Premium Increases

Current through 2024-29, July 17, 2024
A small group health insurance carrier may not raise small
				  group premiums throughout the duration of the program or at a renewal following
				  the end of the program due to costs, whether reimbursed or not, resulting from
				  the carrier's participation in the program.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-10 - Examination

Current through 2024-29, July 17, 2024
1. The Superintendent will monitor carriers'
				compliance with the prohibition against premium increases throughout the
				duration of the program. The Superintendent will also verify carriers'
				compliance with this prohibition after the termination of the program. Small
				group health insurance carriers must provide any information requested by the
				Superintendent for the purpose of verifying compliance with this prohibition.
2. To the extent that any amounts
				paid to carriers for premium credit reimbursements or administrative expense
				reimbursements under this program are determined to be overpayments upon
				examination, such overpayments shall be returned to the program.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 857 - Small Business Health Insurance Premium Support Program › Section 031-857-11 - Severability

Current through 2024-29, July 17, 2024
If any section, term, or provision of this rule shall be
				  deemed invalid for any reason, any remaining section, provision, or definition
				  shall remain in full force and effect.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 860 - ALIEN INSURERS; PORT OF ENTRY › Section 031-860-1 - Authority

Current through 2024-29, July 17, 2024
This Rule is adopted pursuant to the authority of
				   24-A M.R.S.A.
				  §§212 and
				  413-A.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 860 - ALIEN INSURERS; PORT OF ENTRY › Section 031-860-2 - Definitions

Current through 2024-29, July 17, 2024
For purposes of this Rule, the following terms have the
				  following meanings:
A. "Non U.S.
				Insurer" or "Alien Insurer' means an insurer organized under the laws of any
				country other than the United States of America, or its states, districts,
				territories, commonwealths and possessions.
B. "United States Branch" or "U.S. Branch"
				means the business unit through which business is transacted within the United
				States by a non-U.S. insurer and the assets and liabilities of the insurer
				within the United States pertaining to such business.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 860 - ALIEN INSURERS; PORT OF ENTRY › Section 031-860-3 - Scope

Current through 2024-29, July 17, 2024
This Rule applies to a U.S. branch using the State of Maine
				  as a port of entry to transact insurance in the United States. The U.S. branch
				  shall also be subject to all state laws applicable to an insurer domiciled in
				  this state unless otherwise provided.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 860 - ALIEN INSURERS; PORT OF ENTRY › Section 031-860-4 - Authorization of Entry

Current through 2024-29, July 17, 2024
A. A non-U.S.
				insurer may use this state as a port of entry to transact insurance in the
				United States through a U.S. branch by:
(1)
				Qualifying as an insurer licensed to do business in this state; and
(2) Establishing a trust account, pursuant to
				a trust agreement approved by the Superintendent with a U.S. Bank approved by
				the Superintendent, in an amount at least equal to the greater of the minimum
				capital and surplus r authorized control level risk based capital required to
				be maintained by a domestic insurer licensed to do the same kind of
				insurance.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 860 - ALIEN INSURERS; PORT OF ENTRY › Section 031-860-5 - Maintenance of Trust Account

Current through 2024-29, July 17, 2024
The assets in the trust account shall be known as "trusteed
				  assets" and shall at all times be in an amount equal to the U.S. branch's
				  reserves and other liabilities plus the greater of the minimum capital and
				  surplus or authorized control level risk based capital required to be
				  maintained by a domestic insurer licensed to do the same kind of
				  insurance.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 860 - ALIEN INSURERS; PORT OF ENTRY › Section 031-860-6 - Requirements for Trust Agreement

Current through 2024-29, July 17, 2024
A. The deed of
				trust and all amendments thereto shall be authenticated in such form and manner
				as the Superintendent may prescribe and shall not be effective unless approved
				by the Superintendent upon a finding that:
(1) A deed of trust or its amendments are
				sufficient in form and in conformity with law;
(2) The trustee or trustees are eligible as
				such; and
(3) The deed of trust is
				adequate to protect the interests of the beneficiaries of the trust.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 860 - ALIEN INSURERS; PORT OF ENTRY › Section 031-860-8 - Additional Requirements for U.S. Branch License

Current through 2024-29, July 17, 2024
A.
				Before issuing any new or renewal license to any U.S. branch, the
				Superintendent will require satisfactory proof, either in the non-U.S.
				insurer's charter or by an agreement evidenced by a duly certified resolution
				of its board of directors, or otherwise as the Superintendent may require, that
				the insurer will not engage in any insurance business in contravention of the
				provisions of the section or not authorized by its charter.
B. The Superintendent will issue a renewal
				license to any U.S. branch if satisfied, by such proof as required, that the
				insurer is not delinquent with respect to any requirement imposed by Title 24-A
				M.R.S.A. or this Rule and that its continuance in business in this state will
				not be hazardous or prejudicial to the best interests of the people of this
				state.
C. No U.S. branch shall be
				licensed to do in this state any kind of insurance business, or any combination
				of kinds of insurance business, which are not permitted to be done by domestic
				insurers licensed under the provisions of title 24-A M.R.S.A..
D. Except as otherwise specifically provided,
				no U.S. branch, entering through this state or another state, shall be or
				continue to be authorized to do an insurance business in this state if it fails
				to comply substantially with any requirement or limitation of Title 24-A
				M.R.S.A., applicable to similar domestic insurers hereafter organized, which in
				the judgment of the Superintendent is reasonably necessary to protect the
				interest of the policyholders.
E.
				No U.S. branch which does any kind or combination of kinds of insurance
				business outside of this state not permitted to be done in this state by
				similar domestic insurers hereafter organized, shall be or continue to be
				authorized to do an insurance business in this state, unless in the judgment of
				the Superintendent the doing of such kind or combination of kinds of insurance
				business will not be prejudicial to the best interests of the people of this
				state.
F. No U.S. branch shall be
				or continue to be authorized to do an insurance business in this state if it
				fails to keep full and correct entries of its transactions, which shall at all
				times be open to the inspection of persons invested by law with the rights of
				inspection and be maintained in its principal office within this
				state.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 860 - ALIEN INSURERS; PORT OF ENTRY › Section 031-860-9 - Authority of Superintendent

Current through 2024-29, July 17, 2024
Whenever it appears to the Superintendent from any annual or
				  quarterly statement or trusteed surplus statement or any other report that a
				  U.S. branch's trusteed surplus is reduced below the greater of minimum capital
				  and surplus or the authorized control level risk based capital required to be
				  maintained by a domestic insurer licensed to transact the same kinds of
				  insurance, the Superintendent may proceed against the insurer pursuant to the
				  provisions of Chapters 5 and 57 of Title 24-A M.R.S.A. as an insurer whose
				  condition is such that its further transaction of business in the United States
				  will be hazardous to its policyholders, its creditors or the public in the
				  United States.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 865 - STANDARDS FOR FERTILITY COVERAGE › Section 031-865-1 - Authority and Purpose

Current through 2024-29, July 17, 2024
The Superintendent adopts this rule pursuant to
				  24-A
				  M.R.S. §§212 and
				  4320-U(5) to
				  implement the fertility care coverage requirements of
				  24-A
				  M.R.S. §4320-U.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 865 - STANDARDS FOR FERTILITY COVERAGE › Section 031-865-2 - Applicability and Scope

Current through 2024-29, July 17, 2024
This rule applies to all policies, contracts, riders, and
				  endorsements delivered, issued, executed or renewed in this State on and after
				  January 1, 2025 by a carrier as defined in this rule. Section 7 also applies to
				  claims paid under coverage issued or renewed in 2024.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 865 - STANDARDS FOR FERTILITY COVERAGE › Section 031-865-4 - Coverage Requirements

Current through 2024-29, July 17, 2024
1. In making
				coverage available under this rule, a carrier shall not discriminate against
				any class of enrollees protected by the Maine Human Rights Act, Title 5 M.R.S.
				Chapter 337. In particular, carriers shall make coverage available regardless
				of sexual orientation, gender identity or expression, and family composition,
				including single parents.
2. A
				carrier shall adopt and use guidelines no less favorable than those established
				and adopted by a standard-setting organization, including without limitation
				guidelines for:
(A) identifying experimental
				fertility procedures and treatments not covered for the diagnosis and treatment
				of infertility or for fertility preservation;
(B) identifying the required training,
				experience, and other standards for health care providers to provide fertility
				diagnostic care, fertility treatment, and fertility preservation services;
				and
(C) determining appropriate
				candidates for fertility care, including without limitation:
(1) enrollees with a medical need for
				fertility preservation services, including patients who expect to undergo
				treatment, as designated in the guidelines, that may directly or indirectly
				cause a risk of iatrogenic infertility, and
(2) enrollees who have been diagnosed by a
				physician as having a genetic trait associated with certain conditions that
				include, at a minimum, all those specified by the standard-setting organization
				designated by the carrier.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 865 - STANDARDS FOR FERTILITY COVERAGE › Section 031-865-5 - Required Benefits

Current through 2024-29, July 17, 2024
Fertility coverage shall include, at a minimum, payment of
				  benefits for the following services and procedures for fertility patients,
				  subject to the limitations permitted by Section 6, when the service or
				  procedure is recognized as medically appropriate, in light of the fertility
				  patient's medical history, under guidelines adopted in compliance with this
				  rule:
1. Intrauterine or vaginal
				insemination;
2. Assisted
				hatching;
3. Diagnosis and
				diagnostic tests;
4. Laboratory
				testing;
5. Ultrasounds and other
				imaging procedures;
6. Physical
				examinations;
7. Fresh and frozen
				embryo transfer, including the transfer of donor embryos;
8. Egg retrievals, including, when a live
				donor is used in an egg retrieval, the donor's associated medical costs until
				the donor is released from treatment by the reproductive endocrinologist;
				covered medical costs include without limitation physical examination,
				laboratory screening, psychological screening, prescription drugs, monitoring
				follicle development, the retrieval procedure, and treatment of any direct
				medical complications of covered procedures;
9. Gamete intrafallopian tube transfer and
				zygote intrafallopian tube transfer;
10. Intracytoplasmic sperm
				injections;
11. In vitro
				fertilization, including in vitro fertilization using donor eggs and in vitro
				fertilization where the embryo is transferred to a gestational carrier or
				surrogate;
12. Medications,
				including injectable fertility medications, even if the contract or policy does
				not provide prescription drug benefits. Where a contract or policy provides
				both prescription drug and medical and hospital benefits, fertility drugs shall
				be covered under the prescription drug coverage;
13. Ovulation induction;
14. Surgery, including but not limited to
				microsurgical sperm aspiration or extraction; and
15. Costs associated with cryopreservation
				and storage of embryos, eggs, sperm, ovarian tissue, and testicular tissue for
				up to five years.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 865 - STANDARDS FOR FERTILITY COVERAGE › Section 031-865-6 - Permissible Benefit Limitations and Exclusions

Current through 2024-29, July 17, 2024
1.
				Benefits for intrauterine or vaginal insemination may be limited to three
				lifetime cycles.
2. Benefits for
				egg retrieval may be subject to a lifetime limit of four completed egg
				retrievals.
3. Benefits for any
				combination of gamete intrafallopian transfer (GIFT), zygote intrafallopian
				transfer (ZIFT), or fresh or frozen embryo transfer (FET) may be limited to two
				lifetime cycles.
4. In calculating
				any lifetime limit permitted by this rule, procedures where the cost was not
				covered by any carrier, self-insured health plan, or governmental program shall
				not count toward the limit, and a covered procedure shall only be counted
				against the lifetime limit for the individual fertility patient who filed the
				claim.
5. This rule does not
				prohibit coverage exclusions for the following services:
(A) Reversal of voluntary
				sterilization;
(B) Nonmedical costs
				of an egg or sperm donor, gestational carrier, or surrogate;
(C) Maternity care and prenatal care
				services, or services to treat complications of pregnancy or childbirth,
				rendered to a gestational carrier or surrogate who is not covered by the
				carrier's policy or contract;
(D)
				Experimental fertility procedures;
(E) Ovulation kits and sperm testing kits and
				supplies designed for home use;
(F)
				In vitro fertilization, gamete intrafallopian tube transfer, and zygote
				intrafallopian tube transfer for persons who have not used all reasonable less
				expensive and medically appropriate treatments for infertility;
(G) In vitro fertilization or gamete
				intrafallopian tube transfer involving eggs that were collected from a
				fertility patient who had exceeded the limit of four covered completed egg
				retrievals; and
(H) In vitro
				fertilization when the resulting embryos are to be transferred to a fertility
				patient who has exceeded the limit of two covered embryo transfer
				cycles.