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 031-851-4 - General Provisions

Current through 2024-29, July 17, 2024
1. Each plan
				subject to this rule must be a Clear Choice Plan approved under Section
				5 or an Alternative Plan approved
				under Section
				6.
2. Each plan subject to this rule must comply
				with all applicable benefit and provider mandates under state law and the ACA,
				including all essential health benefits specified in accordance with 24-A
				M.R.S. §
									4320- D. Behavioral health
				benefits must comply with all applicable parity requirements.
A. This rule shall not be construed as
				creating any new or additional benefit or provider mandates. A plan's failure
				to provide a particular benefit that is identified in a Clear Choice Design, if
				otherwise permitted by law, does not prevent that plan from conforming to that
				Clear Choice Design.
B. Unless a
				federal waiver is granted, federal requirements preempt conflicting state
				requirements. In particular, as long as the applicable federal prohibitions
				remain in force and have not been waived:
(1)
				Catastrophic Plans may not be offered to small employers or ineligible
				individuals;
(2) Catastrophic Plans
				may not exempt any services from the deductible when prohibited by the ACA;
				and
(3) HSA Plans may not exempt
				any services from the deductible that are not approved by the federal Internal
				Revenue Service for pre-deductible coverage by high deductible health
				plans.
C. A plan's
				inclusion of benefits that are not identified in a Clear Choice Design does not
				prevent that plan from conforming to that Clear Choice Design.
D. Clear Choice Designs do not address
				cost-sharing amounts for any out-of-network services. Plans may include any
				lawful cost-sharing design for out-of-network services, except when
				network-level cost sharing is required by law: for example, emergency services,
				surprise bills, and cases of network inadequacy or unavailability.
E. Two plans shall be treated as different
				options within a single Clear Choice Design or within a single Alternative Plan
				Design if they differ only by characteristics that are not specified in the
				cost-sharing design, or that are expressly permitted to vary, including but not
				limited to:
(1) Whether the plan includes or
				excludes pediatric dental benefits, to the extent permitted by law;
(2) Whether the plan is a Silver plan variant
				providing cost-sharing reductions as determined by the carrier in accordance
				with the ACA;
(3) Whether the plan
				is a preferred provider arrangement, a health maintenance organization plan, or
				a point-of-service health maintenance organization plan;
(4) Whether the plan uses a tiered network.
				Tiered network plans may be offered as Clear Choice Plans as long as the
				specified cost sharing is offered at the broadest network tier;
(5) Whether the plan includes an additional
				tier for low-cost generic prescription drugs, with a lower copayment than the
				copayment specified for generic drugs; and
(6) Whether the plan incorporates a
				site-of-service incentive program. A site-of-service incentive benefit may, for
				example, apply a copayment in place of a deductible or coinsurance that would
				otherwise apply.