Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 330 - MINIMUM STANDARDS FOR MENTAL ILLNESS BENEFITS - REVISED
Section 031-330-8 - Health Maintenance Organizations
Current through 2024-38, September 18, 2024
Treatment for certain mental illnesses listed in 24-A M.R.S.A. §4234-A(6) 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 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-A M.R.S.A. §4234-A, if it provides, at a minimum, benefit levels described in Section 5 or 7, or the following benefits for a covered person suffering from mental illness or nervous condition:
A. Inpatient and Day Treatment Care. The contract must provide inpatient treatment up to a maximum of 30 days in a calendar year subject to the same copayment that applies for other illnesses. Two days of day treatment will be considered one day of inpatient treatment. Day treatment is subject to a copayment of no more than 50% of the copayment applicable to inpatient treatment and may be applied only once per course of treatment.
B. Outpatient Care. The contract must provide outpatient services up to a maximum benefit of $1,500 in a calendar year and subject to a copayment of $10 per visit or the copayment applicable to other illnesses. In the large group market, the contract must contain no annual maximum except as permitted by Section 11.
C. Home Health Care Services. The contract must provide home health care services up to a maximum benefit of $1,500 in a calendar year and subject to a copayment of $10 per visit or the copayment applicable to other illnesses. In the large group market, the contract must contain no annual maximum except as permitted by Section 11.
D. 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.
E. Point-of Service-Plans. For a point-of-service plan, the standards in subsections A through D apply to the in-network benefit level.
