Section 031-330-5 - Minimum BenefitsTreatment for the mental illnesses listed in 24-A M.R.S.A. §2843(5-C) 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 policies and certificates that are subject to this rule but exempt from the parity requirement. Policies subject to this rule but exempt from the parity requirement are group policies other than employee groups, such as association groups, to the extent they cover employees of employers with 20 or fewer employees. With respect to these unlisted conditions and exempt policies and certificates, and except as provided by Section 6, any policy subject to this Rule will be deemed to be in compliance with the requirements of 24-A M.R.S.A. §2843 if it provides, at a minimum, the following benefits for a covered person suffering from a mental illness or nervous condition:
A. Inpatient and Day Treatment Care.1. Annual Minimum. The policy must provide inpatient benefits for mental illness of at least 30 days per calendar year. However in no case need the total number of inpatient days allowed by the policy for all illnesses be exceeded. For purposes of this paragraph, two days of day treatment will be considered equivalent to one day of inpatient care.2. Coinsurance. The minimum level of benefits provided for mental illness must be at least the lesser of 80% of the charges or the highest level of benefits provided for other covered illnesses.B. Outpatient Care. 1. Annual Maximum. The policy must provide an annual benefit of at least $1,500 for outpatient care for mental illness. In the large group market, the policy must contain no annual maximum except as permitted by Section 11. 2. Coinsurance. The minimum level of benefits provided for mental illness must be at least 50% of the usual, customary and reasonable charge. An amount based on a relative value scale or other reasonable methodology may be substituted for the usual, customary and reasonable charge. In the case of either a preferred provider or a nonpreferred provider under a preferred provider arrangement approved pursuant to 24-A M.R.S.A. §2675, the allowable charge may be substituted for the usual, customary, and reasonable charge.C. Home Health Care Services. 1. Annual Maximum. The policy must provide an annual benefit of at least $1,500 for home health care services for mental illness. In the large group market, the policy must contain no annual maximum except as permitted by Section 11. 2. Coinsurance. The minimum level of benefits provided for mental illness must be at least 50% of the usual, customary and reasonable charge. An amount based on a relative value scale or other reasonable methodology may be substituted for the usual, customary and reasonable charge. In the case of either a preferred provider or a nonpreferred provider under a preferred provider arrangement approved pursuant to 24-A M.R.S.A. §2675, the allowable charge may be substituted for the usual, customary, and reasonable charge.D. Deductible. The policy may contain a deductible for mental illness benefits in one of the following ways: 1. If the policy contains a policy deductible applicable to all benefits, mental illness benefits may be subject to that deductible and no separate deductible for mental illness may be required.2. Alternatively, the policy may contain a separate deductible for mental illness benefits not to exceed $150 per calendar year, regardless of whether the policy contains a deductible for other illnesses.E. Maximum Lifetime Benefit. Except for coverage applicable to a large employer, the policy may contain a separate maximum lifetime benefit for mental illness if the maximum benefit is at least $50,000 except the policy 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. 02-031 C.M.R. ch. 330, § 5