Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 865 - STANDARDS FOR FERTILITY COVERAGE
Section 031-865-7 - Benefit Mandate Defrayal

Universal Citation: 02 ME Code Rules ยง 031-865-7

Current through 2024-38, September 18, 2024

1. This section establishes the method for reporting by carriers and payment of reimbursement if some or all of the benefits required by this rule are subject to cost defrayal under the federal Affordable Care Act.

2. For the purposes of this subsection, benefits subject to cost defrayal are benefits that:

(A) Are required by and do not exceed the limitations in 24-A M.R.S. §4320-U or in this rule;

(B) Are provided by a health plan purchased on the Maine Health Insurance Marketplace;

(C) Include only the carrier's share of the claim payment required by Subsection 4(2) and not any additional amount voluntarily offered by the carrier;

(D) Were not within the scope of coverage of the benchmark plan used to define the required essential health benefits under 24-A M.R.S. § 4320-D(2), as in effect at the time of enactment of 24-A M.R.S. §4320-U; and

(E) Have been determined by the Superintendent, after consultation with the federal Centers for Medicare and Medicaid Services, to be subject to the federal Affordable Care Act's requirement to defray the cost of those benefits.

3. Reporting Process

(A) A carrier seeking reimbursement for benefits subject to cost defrayal shall, on or before April 15 of each year, submit to the Bureau a request that includes the following information for the preceding calendar year:
(1) the number of individuals who received benefits subject to defrayal during the preceding calendar year;

(2) the amounts allowed, incurred, and paid by the carrier for benefits subject to defrayal relating to services rendered during the preceding calendar year;

(3) any amounts previously incurred for benefits subject to defrayal but previously reported as unpaid;

(4) any durational limit, amount limit, deductible, copayment, and coinsurance for the fertility treatment; and

(5) any other information required by the Superintendent.

(B) A request for reimbursement shall be submitted in an electronic format prescribed by the Superintendent.

4. Rate Filing Modifications.

A carrier that expects to be eligible to receive a reimbursement under this section shall:

(A) Modify the federal rate filing template to exclude the expected reimbursement amount from the rates submitted on both the Unified Rate Review Template and the Rate Data Template;

(B) Indicate in the rate filing's actuarial memorandum:
(1) The reimbursement amount the carrier anticipates for benefits subject to defrayal; and

(2) That the cost of benefits subject to defrayal is not included in the premiums;

(C) In the Plans and Benefits Template:
(1) Indicate in the "Benefits Information" field that the carrier covers benefits subject to defrayal, and select "Not EHB" for the "EHB Variance Reason" field; and

(2) Not factor benefits subject to defrayal into the calculation for the "EHB Percent of Total Premium" field on the Plans and Benefits Template; and

(D) Benefits subject to defrayal may not include benefits subject to defrayal in the total premium from which the "EHB Percent of Total Premium" field is calculated.

5. Claims Auditing.

The Bureau may audit a carrier's reimbursement report, including its process for determining which claims are eligible for reimbursement under this section.

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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