Title 24-A, Title 24-A

1. The governing body of any health maintenance organization may include providers, other individuals, or both. 2. Such governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of policy and operation through the establishment of…

1. Every person who has enrolled as a legal resident of this State in a health maintenance organization is entitled to evidence of coverage. If the enrollee obtains coverage under a health maintenance organization through an insurance policy or contract whether by option or other…

1. Product design; mandatory requirements. A point-of-service product, filed and approved for use subject to the requirements of section 4207, subsection 4, at a minimum must: A. Provide all services required by law to be provided by health maintenance organizations as in-plan co…

1. Every health maintenance organization shall file annual and quarterly financial statements substantially similar to those required of health insurers under sections 423, 423‑A and 423‑D, verified by at least 3 principal officers, and shall provide a copy of each statement to t…

1. Information provided annually. Every health maintenance organization must annually provide to its enrollees: A. The most recent annual statement of financial condition including a balance sheet and a statement of operations; [PL 1989, c. 842, §15 (NEW).] B. A description of th…

1. After a health maintenance organization has been in operation 24 months, it shall have an annual open enrollment period of at least one month during which it accepts enrollees up to the limits of its capacity, as determined by the health maintenance organization, in the order …

1. Every health maintenance organization shall establish and maintain a complaint system which has been approved by the superintendent, after consultation with the Commissioner of Health and Human Services, to provide reasonable procedures for the resolution of written complaints…

1. No health maintenance organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purposes of this chapter: …

The superintendent may, after notice and hearing pursuant to the Maine Administrative Procedure Act, Title 5, chapter 375, subchapter II, promulgate such reasonable rules and regulations as are necessary to provide for the licensing of agents. An agent means a person directly or …

1. Subject to the provisions of sections 222, 3479 to 3482 and chapters 13 and 13‑A, an insurance company licensed in this State or a nonprofit hospital, medical or health care service organization may establish, maintain, own, merge with, organize and operate a health maintenanc…

1. The superintendent may make an examination of the affairs of any health maintenance organization as often as the superintendent considers it necessary for the protection of the interests of the people of this State, but not less frequently than once every 3 years. The superint…

1. Notwithstanding Title 4, chapter 5 and Title 5, section 10051, the superintendent may suspend or revoke a certificate of authority issued to a health maintenance organization under this chapter if the superintendent finds that any of the following conditions exist after a hear…

Any rehabilitation, liquidation or conservation of a health maintenance organization must be deemed to be the rehabilitation, liquidation or conservation of an insurance company and must be conducted under the supervision of the superintendent pursuant to the laws governing the r…

The superintendent may, after notice and hearing pursuant to the Maine Administrative Procedure Act, Title 5, chapter 375, subchapter II, promulgate reasonable rules and regulations as are necessary or proper to carry out this chapter. Such rules and regulations shall be subject …

The superintendent may adopt and amend rules, establish standards and enforce federal statutes and regulations in order to carry out the purposes of the federal Affordable Care Act. Rules or amendments to rules adopted pursuant to this section, including amendments to major subst…

1. When the superintendent has cause to believe that grounds exist for the suspension or revocation of a certificate of authority, the superintendent shall notify the health maintenance organization and the Commissioner of Health and Human Services in writing specifically stating…

1. Every health maintenance organization subject to this chapter shall pay to the superintendent the following fees: A. For filing an initial application for a certificate of authority, $500; [PL 1975, c. 503 (NEW).] B. For filing each annual report, $50. [PL 1975, c. 503 (NEW).]…

1. The superintendent may levy an administrative penalty in an amount not less than $100 nor more than $500, if reasonable notice in writing is given of the intent to levy the penalty and the health maintenance organization has a reasonable time within which to remedy the defect …

1. Except as otherwise specifically provided, provisions of the insurance law and the laws relating to hospital or medical service corporations do not apply to a health maintenance organization granted a certificate of authority under this chapter. This provision does not apply t…

Subject to the applicable requirements and procedures of the Maine Administrative Procedure Act, Title 5, chapter 375, subchapter II, the superintendent may make, adopt, amend and rescind reasonable rules to aid the administration or effectuation of any provisions of this chapter…

1. Every health maintenance organization licensed under this chapter is considered an insurer for purposes of those provisions of the insurance laws that do not expressly reference health maintenance organizations, but are applicable to health maintenance organizations under this…

All applications, filings and reports required under this chapter shall be treated as public documents subject to limitations and exceptions provided in Title 1, chapter 13, subchapter I.

1. Confidentiality. Any data or information pertaining to the diagnosis, treatment or health of an enrollee or applicant obtained from that enrollee or applicant or a provider by a health maintenance organization must be held in confidence and may not be disclosed to any person e…

The Commissioner of Health and Human Services, in carrying out the commissioner's obligations under section 4204, subsection 1, paragraph B; section 4215; and section 4216, subsection 1, may contract with qualified persons to make recommendations concerning the determinations req…

Nothing in this chapter shall prohibit any health maintenance organization from meeting the requirements of any federal law which would authorize such health maintenance organization to receive federal financial assistance or certification or to enroll beneficiaries assisted by f…

Any employer of more than 50 employees who offers a health maintenance organization, as defined in section 4202‑A, shall also offer its employees, at the time of offering and renewal of the health maintenance organization, the option of selecting alternative health benefits cover…

1. Report required. On or before April 1st of each year, each health maintenance organization which issues a program of contract in this State that contains a provision whereby in nonemergency cases the insured is required to be prospectively evaluated through a prehospital admis…

No policy, contract or certificate delivered or issued for delivery in this State may provide more restrictive coverage for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex or HIV related diseases than for any other disease or sickness or exclude coverage for AIDS…

1. Continuation of coverage by other carriers. In the event of an insolvency of a health maintenance organization and if satisfactory arrangements for the performance of its obligations have not been made as provided for in section 4214, all other carriers that made an offer of c…

1. Group hospital, medical or surgical expenses, or service benefits. Any insurer or nonprofit health insurance plan that issues replacement coverage with respect to group hospital, medical or surgical expenses or service benefits within a period of 60 days from the date of disco…

1. 2. Every domestic health maintenance organization is subject to the requirements of section 221‑A. At the superintendent's request, a domestic health maintenance organization must make available to the superintendent the audit work papers of any accountant who has audited that…

An individual or group health maintenance organization contract that provides coverage for a dependent child at certain ages only if the child is a student must continue that coverage if the child is unable to remain enrolled in school on a full-time basis due to a mental or phys…

1. Dependent child; definition. As used in this section, "dependent child" means the child of a person covered under an individual or group health maintenance organization contract. A. [PL 2019, c. 5, Pt. A, §18 (RP).] B. [PL 2019, c. 5, Pt. A, §18 (RP).] C. [PL 2019, c. 5, Pt. A…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Dependent child" has the same meaning as in section 4233‑B, subsection 1. [PL 2021, c. 520, §6 (NEW).] B. "Disability" means a physical, mental, i…

1. Definitions. For the purposes of this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Dependent children" means children who are under 19 years of age and are children, stepchildren or adopted children of, or children place…

1. Findings. The Legislature finds that: A. Mental illness affects nearly 170,000 people of this State each year, resulting in anguish, grief, desperation, fear, isolation and a sense of hopelessness of significant levels among victims and families; [PL 1995, c. 407, §10 (NEW).] …

Individual and group contracts and certificates issued by a health maintenance organization that provide maternity benefits, including benefits for childbirth, shall provide coverage for services related to maternity and routine newborn care, including coverage for hospital stay,…

All individual and group health maintenance organization contracts must provide that benefits are payable with respect to a newly born child from the moment of birth. [PL 1997, c. 604, Pt. C, §4 (NEW).] The coverage for newly born children must consist of coverage of injury, sick…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Medically accepted indication" includes any use of a drug that has been approved by the federal Food and Drug Administration and includes another …

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Off-label use" means the prescription and use of drugs for indications other than those stated in the labeling approved by the federal Food and Dr…

A health maintenance organization that issues individual and group contracts providing maternity benefits shall provide coverage for 12 months following childbirth for postpartum care services and support necessary to transition a patient to a healthy and stable condition that me…

All health maintenance organizations providing payment or reimbursement for diagnosis or treatment of a condition or a complaint by a licensed health care practitioner must accept the current standardized claim form for professional services approved by the Federal Government and…

Every health maintenance organization shall include in every plan for health care services chiropractic services delivered by qualified chiropractic providers in accordance with this section. [PL 1993, c. 669, §6 (NEW).] 1. Qualifications of chiropractic providers. The health mai…

1. Inpatient care. All individual and group coverage subject to this chapter that provides coverage for medical and surgical benefits must ensure that inpatient coverage with respect to the treatment of breast cancer is provided for a period of time determined by the attending ph…

1. Definition. 1-A. Definitions. For the purposes of this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Cost-sharing requirements" means a deductible, coinsurance, copayment or out-of-pocket expense and any maximum limitatio…

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 a…