Current through 2024-38, September 18, 2024
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.
Treatment for the mental illnesses listed in
24 M.R.S.A.
§2325-A(5-C) must be
covered at the same level of benefits as for treatment of physical illnesses
("parity"). Most mental illnesses fall into this category. The standards set
forth in this section apply to other "unlisted" mental illnesses and to all
mental illnesses under contracts and certificates that are subject to this rule
but exempt from the parity requirement. Contracts subject to this rule but
exempt from the parity requirement are group contracts other than employee
groups, such as association groups, to the extent they cover employees of
employers with 20 or fewer employees. With respect to these unlisted conditions
and exempt contracts and certificates, any group contract subject to this Rule
will be deemed to be in compliance with
24 M.R.S.A.
§2325-A, if it provides, at a minimum,
the following benefits for a covered person suffering from mental illness or
nervous condition:
A. Inpatient and
Day Treatment Care.
1. Annual Maximum. The
contract must provide inpatient benefits for mental illness 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. For purposes of this
paragraph, two days of day treatment will be considered equivalent to one day
of inpatient care.
2. Coinsurance.
The minimum level of benefits provided for mental illness must be at least the
lesser of 80% of the charges or the highest level of benefits provided for
other covered illnesses.
B. Outpatient Care.
1. Annual Maximum. The contract must provide
an annual benefit of at least $1,500 for outpatient care for mental illness. In
the large group market, the policy must contain no annual maximum except as
permitted by Section
11.
2. Coinsurance. The minimum level of benefits
provided for mental illness must be at least 50% of the usual, customary and
reasonable charge. 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 nonpreferred
provider under a preferred provider arrangement approved pursuant to 24 §
2337 or
24-A M.R.S.A.
§2675, the allowable charge may be
substituted for the usual, customary, and reasonable charge.
C. Home Health Care Services.
1. Annual Maximum. The contract must provide
an annual benefit of at least $1,500 for home health care services for mental
illness. In the large group market, the policy must contain no annual maximum
except as permitted by Section
11.
2. Coinsurance. The minimum level of benefits
provided for mental illness must be at least 50% of the usual, customary and
reasonable charge. 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 nonpreferred
provider under a preferred provider arrangement approved pursuant to 24 §
2337 or
24-A M.R.S.A.
§2675, the allowable charge may be
substituted for the usual, customary, and reasonable charge.
D. Deductible. The contract may
contain a deductible for mental illness benefits in one of the following ways:
1. If the contract contains a contract
deductible applicable to all benefits, mental illness benefits may be subject
to that deductible and no separate deductible for mental illness may be
required.
2. Alternatively, the
contract may contain a separate deductible for mental illness benefits not to
exceed $150 per calendar year, regardless of whether the policy contains a
deductible for other illnesses.
E. Maximum Lifetime Benefit. Except for
coverage applicable to a large employer, the contract may contain a separate
maximum lifetime benefit for mental illness if the maximum benefit is at least
$50,000 except the contract total maximum benefit, if any, need not be
exceeded. The maximum applies to benefits actually paid, net of any applicable
discount. Coverage applicable to large employers may only contain a lifetime
maximum to the extent permitted by Section
11.
