1. Each plan
subject to this rule must be a Clear Choice Plan approved under Section 5 or an
Alternative Plan approved under Section
6.
2. Each plan subject to this rule must comply
with all applicable benefit and provider mandates under state law and the ACA,
including all essential health benefits specified in accordance with 24-A
M.R.S. §4320- D. Behavioral health benefits must comply with all
applicable parity requirements.
A. This rule
shall not be construed as creating any new or additional benefit or provider
mandates. A plan's failure to provide a particular benefit that is identified
in a Clear Choice Design, if otherwise permitted by law, does not prevent that
plan from conforming to that Clear Choice Design.
B. Unless a federal waiver is granted,
federal requirements preempt conflicting state requirements. In particular, as
long as the applicable federal prohibitions remain in force and have not been
waived:
(1) Catastrophic Plans may not be
offered to small employers or ineligible individuals;
(2) Catastrophic Plans may not exempt any
services from the deductible when prohibited by the ACA; and
(3) HSA Plans may not exempt any services
from the deductible that are not approved by the federal Internal Revenue
Service for pre-deductible coverage by high deductible health
plans.
C. A plan's
inclusion of benefits that are not identified in a Clear Choice Design does not
prevent that plan from conforming to that Clear Choice Design.
D. Clear Choice Designs do not address
cost-sharing amounts for any out-of-network services. Plans may include any
lawful cost-sharing design for out-of-network services, except when
network-level cost sharing is required by law: for example, emergency services,
surprise bills, and cases of network inadequacy or unavailability.
E. Two plans shall be treated as different
options within a single Clear Choice Design or within a single Alternative Plan
Design if they differ only by characteristics that are not specified in the
cost-sharing design, or that are expressly permitted to vary, including but not
limited to:
(1) Whether the plan includes or
excludes pediatric dental benefits, to the extent permitted by law;
(2) Whether the plan is a Silver plan variant
providing cost-sharing reductions as determined by the carrier in accordance
with the ACA;
(3) Whether the plan
is a preferred provider arrangement, a health maintenance organization plan, or
a point-of-service health maintenance organization plan;
(4) Whether the plan uses a tiered network.
Tiered network plans may be offered as Clear Choice Plans as long as the
specified cost sharing is offered at the broadest network tier;
(5) Whether the plan includes an additional
tier for low-cost generic prescription drugs, with a lower copayment than the
copayment specified for generic drugs; and
(6) Whether the plan incorporates a
site-of-service incentive program. A site-of-service incentive benefit may, for
example, apply a copayment in place of a deductible or coinsurance that would
otherwise apply.
3. Carriers shall discontinue all
non-grandfathered small group health plans offered in the year preceding the
pooled market implementation year. No such plans may be issued or renewed
during the pooled market implementation year, with the exception of any
existing plan that the carrier chooses to offer as an Alternative Plan pursuant
to Section
6. On renewal, the carrier shall map
each policyholder with a discontinued plan to its most similar plan offered in
the pooled market in the pooled market implementation year.
A. Except as provided in Paragraph B, the
replacement shall be considered a benefit modification required by law in
accordance with 24-A M.R.S. §2850- B(3)(I)(3).
B. The carrier must demonstrate, in
accordance with 24-A M.R.S. §2850- B(3)(G)(2) or (I)(4), that the
discontinuance and replacement is a minor modification or is otherwise in the
best interest of policyholders if:
(1) The
carrier chooses not to offer a Clear Choice design that is more similar to a
discontinued plan than the carrier's designated replacement;
(2) The carrier chooses to map a non-HMO
policyholder into an HMO plan, or to map an HMO enrollee that has a
point-of-service benefit into an HMO plan without a point-of-service benefit;
or
(3) The carrier chooses to map
an HMO enrollee into non-HMO coverage.
C. The requirement to discontinue small group
plans and replace them with plans approved under this rule does not apply to
plans issued to small employers through an association or trustee group that is
excluded from the pooled market pursuant to 24-A M.R.S. §2808- B(2)(E)(2)
and applicable provisions of the ACA.
4. The discontinuance or modification of a
health plan is also considered a benefit modification required by law in
accordance with 24 A M.R.S. §2850- B(3) (I)(3) if:
A. The Superintendent discontinues or
materially modifies a Clear Choice design and the carrier maps enrollees to a
new Clear Choice plan designated by the Superintendent as an appropriate
replacement; or
B. The carrier
offers new Alternative Plans in the pooled market implementation year that are
specifically designed to be marketed to small employers, must discontinue or
materially modify one or more existing Alternative Plans in order to do so, and
maps those policyholders to new plans in a manner that does not exceed the
restrictions set forth in Subsection 3, Paragraph B.
