Current through 2024-38, September 18, 2024
This section applies only to contracts that are subject to
this rule but are not subject to the parity requirements of Title
24 M.R.S.A.,
Section2325-A(5-C). Most
contracts subject to this rule will be subject to the parity requirements and
not to this section. The exception is group contracts other than employee
groups, such as association groups, to the extent they cover employees of
employers with 20 or fewer employees. For purposes of this Rule, group
contracts issued jointly by a nonprofit hospital service corporation and a
nonprofit medical service corporation will be considered as one
contract.
Any group contract subject to this section will be deemed to
be in compliance with
24M.R.S.A. Section2329, if it provides, at a
minimum, the following benefits for a covered person suffering from substance
abuse:
A. Residential Treatment and
Non-residential Day Treatment.
(1) Annual
Maximum. The contract must provide residential treatment benefits for substance
abuse of at least 30 days per calendar year. However, in no case need the total
number of inpatient days allowed by the contract for all illnesses be exceeded.
Two days of non-residential day treatment shall be counted as one day of
residential treatment.
(2)
Coinsurance. The minimum level of benefits provided for substance abuse must be
at least the lesser of 90 percent of the charges or the level of benefits
provided for any other illness. The coinsurance provision, if any, shall be
administered uniformly regardless of whether services are rendered in a
hospital or other residential or non-residential facility.
(3) Maximum Lifetime Residential Benefits.
The contract may contain a lifetime maximum limit on the number of covered days
for residential treatment of substance abuse of not less than 60 days. Two days
of non-residential treatment shall be counted as one day of residential
treatment. Services for each admission shall be according to a treatment
plan.
B. Outpatient Care
Other than Non-residential Day Treatment.
(1)
Annual Maximum. The contract must provide an annual benefit of at least $1,500
for outpatient care for substance abuse other than non-residential day
treatment.
(2) Coinsurance. The
minimum level of benefits provided for outpatient care of substance abuse other
than non-residential day treatment must be at least 80 percent of the usual,
customary and reasonable charge, or, if less, the coinsurance amount under the
contract for other illnesses. An amount based on a relative value scale or
other reasonable methodology may be substituted for the usual, customary, and
reasonable charge. In the case of either a preferred provider or a
non-preferred provider under a preferred provider arrangement approved pursuant
to Title 24, Section 2337 or Title
24-A M.R.S.A.,
Section2675, the allowable charge may be
substituted for the usual, customary, and reasonable charge.
C. Deductible. The contract may
contain a deductible for substance abuse benefits in one of the following ways:
(1) If the contract contains a contract
deductible applicable to all benefits, substance abuse benefits may be subject
to that deductible and no separate deductible for substance abuse may be
required.
(2) Alternatively, the
contract may contain a separate deductible for substance abuse benefits not to
exceed $150 per calendar year, regardless of whether the policy contains a
deductible for other illnesses.
D. Maximum Lifetime Benefits. The contract
may contain a maximum lifetime benefit for substance abuse benefits of not less
than $25,000 except the contract total maximum benefit, if any, need not be
exceeded.
