1. A plan issued pursuant to this Rule must
provide coverage for medically necessary hospital, medical, and surgical
expenses, subject to the minimum benefit requirements set forth in this
section. Carriers may offer pilot project plans with greater benefits.
A. The first three office visits must be
covered prior to the application of any plan deductible.
(1) The first three office visits may be
subject to cost sharing not greater than a $25 copayment or 20% of eligible
charges for a participating provider. Additional services other than charges
for the office visit may be subject to the plan deductible or to higher cost
sharing, even if performed during one of the first three office
visits.
(2) Enrollees may use the
first three office visits for medically necessary services including, but not
limited to, the following types of services.
(a) Routine care
(b) Preventive care
(c) Sick visits
(d) Eye examinations
(e) Family planning
(f) Consultations with a specialist
(g) Physical, speech, and occupational
therapies
(h) Care by a
chiropractor
(i) Outpatient mental
health services
(j) Outpatient drug
rehabilitation services
(k)
Outpatient alcohol rehabilitation services
B. Prescription drug expenses must be
covered.
(1) Prescription drug expenses may
not be subject to any plan deductible.
(2) The first $1,500 of eligible prescription
drug expenses may be subject to cost sharing not greater than:
(a) $25 copayment for a 30 day supply,
or
(b) 20% of eligible
charges.
(3) After the
first $1,500 in eligible prescription drug charges, actuarially expected
aggregate cost sharing may not exceed 50% of eligible charges, excluding
out-of-pocket expenses incurred after the enrollee has reached any maximum
benefit limitations included in the plan.
C. Prescription contraceptives must be
covered to the same extent that coverage is provided for other prescription
drugs.
D. Diabetes supplies, blood
glucose monitors, insulin pumps and supplies, and infusion devices may not be
subject to any plan deductible. Cost sharing may not exceed 50% of eligible
charges.
E. Ambulance service and
emergency room care must be covered and may not be subject to any plan
deductible. Copayments or coinsurance may not exceed $150 for ambulance or $150
for emergency room care.
F.
Coverage for prosthetic devices must be covered and may not be subject to any
plan deductible.
G. At a minimum,
the following preventive services must be covered prior to the application of
any plan deductible.
(1) Screening
Mammograms
(2) Prostate Cancer
Screening
(3) Colorectal Cancer
Screening
Actuarially expected cost sharing for in-network preventive
services in the form of copayments or coinsurance may not exceed 50% of
eligible charges.
H. Inpatient services must be covered.
Cost sharing for in-network inpatient services, after
satisfaction of any applicable deductible, may not exceed 50% of eligible
charges.
I. Outpatient
services must be covered.
Cost sharing for in-network outpatient services, after
satisfaction of any applicable deductible, may not exceed 50% of eligible
charges.
J. Mental health
and substance abuse services must be covered.
Actuarially expected aggregate cost sharing for in-network
services, after satisfaction of any applicable deductible, may not exceed 50%
of eligible charges.
K.
Mental health parity must be offered.
Mental health benefits must be offered pursuant to
24-A
M.R.S.A. §2749-C.
L. Physical therapy must be covered.
Actuarially expected aggregate cost sharing, after
satisfaction of any applicable deductible, may not exceed 50% of eligible
charges.
M. Exclusions
The plan may contain exclusions generally permitted under
State law. Additional exclusions may be permitted if determined by the
Superintendent to provide affordable individual health plans for persons under
30 years of age. Maternity benefits may be excluded only after the first three
office visits. Pilot project plans offered by HMOs are not subject to the cost
sharing requirements of Bureau of Insurance Rule Chapter 750. Except as
otherwise provided in this Rule, HMOs may request exclusions generally
permitted for non-HMO plans.
2. Additional Cost Sharing Limitations.
A. Deductible
(1) The plan may contain an annual plan year
deductible not greater than $2,000.
(2) The plan must provide that actual charges
paid toward the deductible during the last three months of a plan year, if
applied to that year's deductible, will also be applied to the next year's
deductible.
(3) The following
services may be, but are not required to be, subject to a deductible.
(a) Services performed by the enrollee's
physician during office visits (including the first three office visits) such
as taking x-rays, performing lab tests, outpatient surgery services,
detoxification or psychological testing. During the first three office visits
the procedure but not the office visit may be subject to the
deductible.
(b) X rays and lab
tests
(c) Hospital outpatient
department services
(d) Outpatient
surgery services
(e) Maternity care
(except during the first three office visits)
(f) The fourth and subsequent medical office
visits per individual
(g)
Detoxification
(h) Psychological
testing.
B.
Annual Out-of-Pocket Maximum
(1) The plan
must include an annual out-of-pocket maximum. Total cost sharing for covered
services in the form of copayments, coinsurance and any plan deductible may not
exceed $10,000 per year.
(2)
Medical expenses which exceed any annual per condition or sickness maximum,
lifetime maximum, prescription drug maximum or other internal plan benefit
maximum are not required to be applicable towards satisfying the out-of-pocket
maximum.
C. Annual Per
Condition or Sickness Limitations
The plan may contain a maximum annual benefit per accident or
sickness, which may not be less than $50,000 per year.
D. Maximum Lifetime Benefit
The plan may contain a maximum lifetime benefit, which may
not be less than $250,000, unless the plan pays at least 80% of in-network
benefits for most types of covered services. Plans that pay at least 80% of
in-network benefits may contain a maximum lifetime benefit not less than
$100,000.
E. Aggregate Cost
Sharing
Actuarially expected aggregate cost sharing for all
in-network services, after satisfaction of any applicable deductible but prior
to exceeding any per condition or sickness limitation or maximum lifetime
benefit, may not exceed 50% of eligible charges.
