Section 031-745-7 - MINIMUM PLAN REQUIREMENTS FOR PERSONS UNDER 30 YEARS OF AGE1. 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. (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 servicesB. 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. (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.(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(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.
02-031 C.M.R. ch. 745, § 7