Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 851 - Clear Choice Designs for Individual and Small Group Health Plans
Section 031-851-5 - Clear Choice Plans

Universal Citation: 02 ME Code Rules ยง 031-851-5

Current through 2024-38, September 18, 2024

1. The Superintendent shall develop and publish a series of Clear Choice Designs, including at least one at each metal level. A health plan may only be approved as a Clear Choice Plan if the Superintendent determines that it conforms to one of the Clear Choice Designs.

A. The Superintendent shall annually review market experience with the Clear Choice designs, and shall solicit stakeholder input on changes that might be desirable, including potential amendments to this rule. The Superintendent shall consider AV requirements, stakeholder input, value-based plan design, and the need for meaningful differences between plans offered by the same carrier in a given service area. For years in which the individual and small group health markets are pooled, the Superintendent shall ensure the availability of a range of designs intended to meet the needs of individuals and small employers. The Superintendent shall expose any proposed revisions to the Clear Choice designs for public comment, and shall publish the final version in time for carriers to use it in their rate and form filings.

B. If changes to the actuarial value calculator, maximum permissible out-of-pocket expenses, or other federal or state requirements require adjustments to one or more Clear Choice Designs after they have been finalized, and a waiver of the new requirements is not granted, the Superintendent shall make adjustments as necessary to remain in compliance.

C. To facilitate comparison between plans, each Clear Choice Design shall be designated by its metal level, or the term "Catastrophic," and a short descriptive term, except for levels with only one Clear Choice Design.
(1) The descriptive name of any HSA plan design shall include "HSA" and the descriptive name of any Off-Marketplace plan design shall include "Off-Marketplace."

(2) The Superintendent shall develop a comparative table of Clear Choice Plans approved to be offered in Maine, grouped by their respective Clear Choice Designs. The table of plans for the upcoming year shall be published on the Bureau of Insurance website after rates are approved and shall be furnished to the Marketplace.

(3) Carriers may use their own branding for Clear Choice Plans as long as they also identify the applicable Clear Choice Design.

2. Except as otherwise provided in this subsection, any Clear Choice Design or approved Alternative Plan Design may be incorporated into a Qualified Health Plan offered by a carrier on the Marketplace.

A. If a carrier participates in the individual Marketplace, its lowest-price Marketplace Silver plan in any service area must be a Clear Choice Plan.

B. The Superintendent shall develop at least one Silver Clear Choice Design which shall be designated as an Off-Marketplace Plan and which may not be offered on the Marketplace by any carrier. Off-Marketplace Clear Choice Designs shall be developed to provide affordable options for Silver-level coverage for non-subsidized individuals, and, if applicable, for small employers. An Off-Marketplace Clear Choice Design, and any other Silver Clear Choice Design that a carrier chooses not to offer on the Marketplace, shall not be subject to "silver-loading" to reflect the anticipated cost of unreimbursed cost-sharing reductions.

3. A carrier submitting a plan for approval as a Clear Choice Plan shall identify the applicable Clear Choice Design and describe all cost-sharing features not fully specified in that Clear Choice design. The carrier shall provide its AV snapshot calculations as part of the filing submission to demonstrate compliance with the ACA and any necessary adjustments for unique plan design.

4. No new individual or pooled market health plans may be introduced after the deadline announced by the Superintendent for rate and form filings.

5. Clear Choice Plans shall be subject to the following terms and conditions:

A. The specified primary care office visit copayment may be separate from any related laboratory charge from the visit.

B. The plan's deductible shall be applicable to all benefits except as otherwise specified in this rule.
(1) A plan providing family or dependent coverage must provide that if actual charges paid toward the deductible during the year for the entire family meet a family deductible equal to two times the individual deductible, the deductible will be considered satisfied for all family members. The out-of-pocket maximum will work in a similar manner.

(2) Primary care and behavioral health office visits shall be exempt from the deductible to the extent provided in 24-A M.R.S. §4320- A(3), unless an exception is required by Section 4(2)(B).

(3) For all services with a copayment that are not subject to the deductible, the copayment shall accumulate toward the plan's maximum out-of-pocket expense, but not toward the deductible except as required by 24-A M.R.S. §4320- A(3) for primary care and behavioral health office visits.

(4) For services that are subject to both a deductible and a copayment, the full amount of out-of-pocket spending shall accrue toward the deductible until the deductible is satisfied. The copayment shall apply only to services provided after the deductible has been satisfied, or in cases where the amount remaining on the deductible is less than the copayment.

C. Preventive care services shall be covered without copayment, coinsurance, or deductible as required under the ACA. In Clear Choice Designs for HSA plans, if a carrier elects to provide pre-deductible coverage for preventive services beyond the applicable requirements of 24-A M.R.S. §4320- A, it shall include all covered services that the federal Internal Revenue Service has determined to qualify as preventive care for tax purposes, including prescription drugs for certain chronic conditions classified as preventive care for someone with that chronic condition.

D. Office visits for the treatment of mental health, behavioral health, or substance use disorder conditions shall be categorized as Behavioral Health Outpatient Services, regardless of provider type. Outpatient services may be subclassified into office visits and all other outpatient items and services.

E. For prescription drugs in any tier, the cost-share defined is for a standard 30-day supply. Other options for mail order or network pharmacies are acceptable as long as the basic coverage in the Clear Choice plan is offered.

F. Unless otherwise noted, carriers are permitted to assign a service not specified in the rule to the appropriate benefit category if permissible under state and federal law.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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