Plan requirements - Me. Rev. Stat. tit. 24-A, § 4303

Maine has enacted a Health Care Bill of Rights that provides patients with certain basic rights when obtaining health insurance.  Included in this Bill of Rights is:

• Publication of Policies by Carriers – Insurance carriers must publish at least 5 individual health plans and 5 small group health plans with the highest level of enrollment on the carrier’s public website.
• Explanation of Benefits – Insurance carriers must provide individual policyholders and group certificate holders with clear written explanations of benefit documents in response to the filing of any claim providing for coverage of hospital or medical expenses.
• Policy Terms – The Maine superintendent has the ability define standard policy terms that must be used in all policies issued by carriers offering health plans in the State.
• Description of Review Procedures – Before offering a new plan in the State, a carrier must provide a description of the independent external review procedures and the circumstances when an enrollee is entitled to independent external review.
• Description of Clinical Trial Costs – Insurance carriers must provide a description of the routine costs of clinical trials, and information on the manner in which enrollees may qualify for the compassionate use program of the federal FDA.
• Description of Provider Profiling Programs – Insurance carriers must provide a description of any provider profiling program that may be part of the health plan, including the location of the performance ratings in the plan materials or on a publicly accessible website, information explaining the provider rating system and the basis upon which provider performance is measured, the limitations of the data used to measure provider performance, the process for selecting providers, and a statement that such ratings should only be used as a guide for choosing a provider.
• Filing of Rate Information – Every insurer must file for approval by the superintendent every rate, rating formula, classification or risks and every modification of any formula or classification that it proposes to use in connection with individual health insurance policies, and certain group policies.
• Continuity of Prescriptions – If an enrollee has been receiving a course of treatment with a prescription drug by prior authorization of one carrier, any newer carrier must continue the coverage of that prescription drug.