Title 24-A, Title 24-A

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, §53 (RAL).] B. A prostate-spe…

1. Access and confidentiality. The superintendent or the Commissioner of Health and Human Services may require a health maintenance organization to submit its NCQA accreditation survey report. An NCQA accreditation survey report obtained by or submitted to the superintendent or t…

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 surg…

1. Coverage requirements. All health maintenance organization individual and group health contracts that provide coverage for prescription drugs or outpatient medical services must provide coverage for all prescription contraceptives, nonprescription oral hormonal contraceptives …

1. Required coverage for services upon referral of primary care provider. A health maintenance organization that issues individual and group health care contracts shall provide coverage under those contracts for services performed by a participating certified nurse practitioner, …

1. Definition. 2. Mandated offer of domestic partner benefits. All individual or group policies or contracts issued by any health maintenance organization operating pursuant to this chapter must make available to an individual or group policyholder the option for additional benef…

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…

1. Enrollee defined. For the purposes of this section, unless the context otherwise indicates, "enrollee" means a person who is covered under an individual or group contract provided by a health maintenance organization. 2. General anesthesia and associated facility charges. All …

All health maintenance organization individual and group health insurance policies, contracts and certificates must make available coverage for breast reduction surgery and symptomatic varicose vein surgery determined to be medically necessary health care as defined in section 43…

When an individual or family is eligible for MaineCare and is also eligible for health maintenance organization coverage provided by an employer through a health maintenance organization, the health maintenance organization must permit the individual or family to enroll in the he…

1. Colorectal cancer screening. For the purposes of this section, "colorectal cancer screening" means all colorectal cancer examinations and laboratory tests recommended by a health care provider in accordance with the most recently published colorectal cancer screening guideline…

1. Hearing aid; definition. For purposes of this section, "hearing aid" means a nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing, excluding batteries and cords and other assistive …

All individual and group health maintenance organization policies, contracts and certificates must provide coverage for amino acid-based elemental infant formula for children 2 years of age and under in accordance with this section. [PL 2007, c. 695, Pt. C, §16 (RAL).] 1. Determi…

1. Services provided by independent practice dental hygienist or dental hygienist. All individual and group health maintenance organization contracts that include coverage for dental services shall provide coverage for dental services performed by an independent practice dental h…

1. Definition. For purposes of this section, "children's early intervention services" means services provided by licensed occupational therapists, physical therapists, speech-language pathologists or clinical social workers working with children from birth to 36 months of age wit…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Applied behavior analysis" means the design, implementation and evaluation of environmental modifications using behavioral stimuli and consequence…

1. Enrollee defined. For the purposes of this section, unless the context otherwise indicates, "enrollee" means a person who is covered under an individual or group contract provided by a health maintenance organization. 2. No waiting period for enrollee under 19 years of age. A …

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Covered dental service" means a dental service for which reimbursement is available under an individual or group contract or for which reimburseme…

As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings. [PL 1999, c. 742, §3 (NEW).] 1. Adverse health care treatment decision. "Adverse health care treatment decision" means a health care treatment decision made by or on …

To offer or renew a health plan in this State, a carrier must comply with the following requirements. [PL 2007, c. 199, Pt. B, §2 (AMD).] 1. Description of plan. A carrier shall provide to prospective enrollees and participating providers, and to members of the public and nonpart…

A carrier offering or renewing a health plan in this State must meet the following requirements. [PL 2007, c. 199, Pt. B, §4 (AMD).] 1. Demonstration of adequate access to providers. A carrier offering or renewing a managed care plan shall provide to its members reasonable access…

1. Disclosure. At least 60 days prior to using or publicly disclosing the results of the provider profiling program, a carrier with a provider profiling program shall disclose to providers the methodologies, criteria, data and analysis used to evaluate provider quality, performan…

1. Disclosure. Upon request, a carrier shall provide to a provider to which the carrier has decided not to offer the opportunity to participate or that the carrier has decided not to include as a participating provider in any of the carrier's provider networks a written explanati…

1. Surprise bill defined. As used in this section, unless the context otherwise indicates, "surprise bill" means a bill for health care services, including, but not limited to, emergency services, received by an enrollee for covered services rendered by an out-of-network provider…

1. Requirement. A carrier shall make available provider directories in accordance with this section. A. A carrier shall post electronically a current and accurate provider directory for each of its network plans with the information and search functions described in subsection 2.…

1. Independent dispute resolution process. The superintendent shall establish an independent dispute resolution process by which a dispute for a surprise bill for emergency services or a bill for covered emergency services rendered by an out-of-network provider in accordance with…

1. Reimbursement for ambulance services. With respect to a bill for covered services rendered by an ambulance service provider, a carrier shall reimburse the ambulance service provider or enrollee, as applicable, as follows. A. If the ambulance service provider participates in th…

The following provisions govern maintenance of certification requirements. [PL 2023, c. 40, §1 (NEW); PL 2023, c. 40, §2 (AFF).] 1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Hospital" means a…

The following requirements apply to health plans doing business in this State that require prior authorization by the plan of health care services or otherwise subject payment of health care services to review for clinical necessity, appropriateness, efficacy or efficiency. A car…

1. Prior authorization for new episode of care prohibited for 12 visits. A carrier may not require prior authorization for rehabilitative or habilitative services, including, but not limited to, physical therapy services, occupational therapy services or chiropractic services, fo…

A carrier offering or renewing a health plan that subjects payment of benefits for otherwise covered services to review for clinical necessity, appropriateness, efficacy or efficiency must meet the following requirements relating to quality of care. [PL 2007, c. 199, Pt. B, §14 (…

A carrier offering or renewing a managed care plan shall allow enrollees to choose their own primary care providers, as allowed under the managed care plan's rules, from among the panel of participating providers made available to enrollees under the managed care plan's rules. A …

Notwithstanding any other requirements of this Title, a carrier offering a health plan in this State subject to the requirements of the federal Affordable Care Act: [PL 2011, c. 364, §29 (NEW).] 1. Authorization or referral not required. May not require authorization or referral …

Nothing in this chapter may be construed to: [PL 1995, c. 673, Pt. C, §1 (NEW); PL 1995, c. 673, Pt. C, §2 (AFF).] 1. Purchase services with own funds. Prohibit an individual from purchasing any health care services with that individual's own funds, whether these services are cov…

A contract between a carrier offering or renewing a health plan and a provider for the provision of services to enrollees may not require the provider to indemnify the carrier for any expenses and liabilities, including, without limitation, judgments, settlements, attorney's fees…

The superintendent shall adopt rules and establish standards for health plans in order to carry out the purposes of this chapter. Rules adopted pursuant to this chapter are major substantive rules as defined in Title 5, chapter 375, subchapter II‑A.

1. Carriers. A carrier shall comply with all applicable requirements of the federal Affordable Care Act. 2. Superintendent. The superintendent may enforce and administer this section through all powers provided under this Title and Title 24. The superintendent may adopt and amend…

1. Qualified enrollee. An enrollee is eligible for coverage for participation in an approved clinical trial if the enrollee meets the following conditions: A. The enrollee has a life-threatening illness for which no standard treatment is effective; [PL 1999, c. 742, §19 (NEW); PL…

1. Formulary. If a health plan provides coverage for prescription drugs but the coverage limits such benefits to drugs included in a formulary, a carrier shall: A. Ensure participation of participating physicians and pharmacists in the development of the formulary; [PL 2017, c. 4…

1. Access to pain management services. A carrier shall develop a plan to provide adequate coverage of and access to a broad spectrum of pain management services, including, but not limited to, nonopioid, nonnarcotic medication for pain management and nonmedication pain management…

An enrollee or the enrollee's authorized representative has the right to an independent external review of a carrier's adverse health care treatment decision made by or on behalf of a carrier offering or renewing a health plan in accordance with the requirements of this section. …

1. Duty of ordinary care; cause of action. An enrollee may maintain a cause of action against a carrier offering or renewing a health plan in accordance with the following. A. A carrier has the duty to exercise ordinary care when making health care treatment decisions that affect…

1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Eye care provider" means a participating provider who is an optometrist licensed to practice optometry pursuant to Title 32, chapter 151, or an op…

1. Required coverage. A carrier offering a health plan in this State shall provide coverage for one early refill of a prescription for eye drops if the following criteria are met: A. The enrollee requests the refill no earlier than the date on which 70% of the days of use authori…

1. Definition. As used in this section, "prosthetic device" means an artificial device to replace, in whole or in part, an arm or a leg. 2. Required coverage. A carrier shall provide coverage for prosthetic devices in all health plans that, at a minimum, equals, except as provide…