Supplemental Order Regarding Telehealth/Remote Delivery of Health Services
March 31, 2020
On March 20, 2020, the Bureau of Insurance published a supplemental order relating to remote delivery of health services, also sometimes referred to as “telehealth.” Maine law requires parity between coverage of in-person services and telehealth services. The order clarifies that “telehealth” includes audio-only telephone (something that was excluded from the Maine statutory definition of telehealth). The order also directs carriers to ensure that rates of payment to in-network providers for services delivered via telehealth and other remote modalities are not lower than the rates of payment established by the carrier for services delivered in person.
The order contains no new employer compliance obligations. Maine employers should work with their carrier regarding any questions on telehealth coverage, including parity in coverage of telehealth and in-person visits. Employers may see an uptick in this telehealth coverage issue, as more employees seek telehealth services as they practice social distancing.
Supplemental Order on Remote Delivery of Health Services »
Supplemental Order Regarding Continuation of Group Health Coverage
March 31, 2020
On March 27, 2020, the Bureau of Insurance published a supplemental order regarding continuation of group health coverage. According to the supplemental order, carriers (when requested by an employer) must suspend the application of any group health plan contract provision that terminates coverage when an eligible employee is no longer actively employed by the employer, provided that the employer’s continued coverage is made to all affected employees on a nondiscriminatory basis. In other words, the carrier must allow furloughed (or other inactive) employees to remain on the group health plan during the COVID-19 related pandemic.
Maine employers with fully insured plans should work with their carriers and review plan documents to determine if they will continue health insurance eligibility during a furlough.
Supplemental Order Regarding Continuation of Group Health Coverage »
Coronavirus Public Health Emergency Guidance
March 17, 2020
On March 12, 2020, Superintendent of Insurance Cioppa released Bulletin 442, which is an insurance emergency response order to be followed by all insurance carriers pursuant to the governor’s designation of the impact of COVID-19 as an insurance emergency. Pursuant to this declaration, Maine insurers must provide COVID-19 screening and testing without cost sharing and without prior authorization requirements. When an immunization becomes available, insurers must also provide the vaccine with no cost sharing.
In addition to prohibiting cost sharing for COVID-19 screening and testing, the order:
- Reminds insurers that emergency services must be provided with the same cost-sharing for in-network and out-of-network claims. They must also be provided without prior authorization being required.
- Prepares health carriers for the chance that networks may be overloaded, and requires that services from all providers be treated the same as coverage from participating providers. Likewise, patients must be protected from surprise billing.
- Highlights parity between coverage of telehealth and in-person services.
- Requires insurers to provide a one-time refill of participants’ prescription medications before the scheduled refill date. (Exceptions can be made for drug classes subject to misuse, such as opioids, benzodiazepines and stimulants.)
- Encourages expeditious claims adjudication, utilization review and appeals process.
- Mandates that insurers provide prompt and accurate information to participants, providers and the public on an ongoing basis, including posting a prominent notice that they are providing COVID-19 screening and testing without cost sharing.
This insurance emergency response order does not provide any additional guidance to employers, but they should familiarize themselves with the requirements so that they can provide additional information to employees who may have questions.
Bulletin 442 »
Bulletin on Interaction Between Medicare and Small Group Health Plans
January 22, 2020
On November 27, 2019, the Bureau of Insurance published Bulletin 440, which is meant to remind small group health carriers of the importance of providing employers and health plan enrollees with accurate information relating to Medicare, especially when the employer has fewer than 20 employees. According to the bulletin, Medicare is secondary to group coverage for active employees (and their spouses) if the employer has 20 or more employees. However, if the employer has fewer than 20 employees, Medicare is primary and the employer’s plan is secondary. This results in the carrier coordinating benefits, so that its responsibility for payment cannot exceed the portion of the bill that Medicare does not pay.
In addition, Maine law also permits carriers to coordinate benefits if the employee is eligible for Medicare but did not enroll in Part B. As a result, if the employee is Part B-eligible, but chooses to delay enrollment, and the group has fewer than 20 employees, the group plan may decline to cover any portion of a bill that Part B would cover, as long as the insured employee, retiree, or dependent has received prominent notice (which must be both in the certificate of coverage and when the insured becomes eligible for Medicare due to age). Carriers must clearly articulate in plain, unambiguous language whether the carrier is the primary or secondary payer for Medicare-eligible individuals and provide examples to explain the difference (if any) for actively employed individuals and retirees covered under the small group plan.
The bulletin contains no new employer compliance obligations; but employers with small group plans sitused in Maine should be aware of the coordination rules, and the carrier’s obligation to distribute notices.
Bulletin 440 »
New Bulletin Revises Counting Methodology for Small and Large Group Markets in Maine
August 20, 2019
On July 23, 2019, the Bureau of Insurance published Bulletin 436, which supersedes Bulletin 409. According to the bulletin, whether a particular employer is considered "large" or "small" depends on the counting methodology; the bulletin withdraws previous guidance (issued under Bulletin 409) and reinstates the so-called "head count" methodology formerly used in Maine.
As background, Maine's small group health plan law applies to all employers with 50 or fewer eligible employees. By contrast, ACA and CMS rules require carriers offering small group health plans on the SHOP exchange to determine eligibility by using full-time equivalent (FTE) counting methodology for part-time employees. Thus, it would be possible for a business that has a significant number of employees, but only a few of them working enough hours to be eligible for coverage, to be a "small" employer under pre-ACA Maine law, but ineligible to participate in the SHOP exchange because it's a large employer under the ACA and CMS rules.
According to an example, if an employer has 10 full-time employees and 75 employees working 20 hours per week, it has 10 eligible employees but has 60 or more FTE employees. Use of the FTE methodology means that this employer is ineligible for community rated small group coverage and must be individually rated, even if there can never be more than 10 covered employees on the plan. According to the bulletin, it's unfair to both the employer and the carrier to require experience rating when the employer's risk pool is too small to generate any credible loss history — employers, producers, and carriers have all expressed concerns to the Bureau.
As a result, the Bureau is using its discretion to reinstate the old methodology, which accounts for part-time employees by including them if and only if they are eligible for coverage under the group health insurance policy. All employers with in-force policies are entitled to maintain that coverage until the end of the current policy term, if they choose, and carriers can honor all outstanding offers of small or large group coverage.
Except for employers with offers of new or renewal coverage outstanding or in progress, or employers applying for coverage through the SHOP exchange, carriers should transition at the earliest date (and no later than September 1, 2019) to consistent application of the "eligible employee" counting methodology for purposes of access to community-rated coverage under Maine's small group health plan law.
Bulletin 436 »
ACA Consumer Protections Incorporated into Maine Law
August 20, 2019
On July 23, 2019, the Maine Bureau of Insurance published Bulletin 437, which relates to incorporation of the ACA's consumer protections into Maine law. According to the bulletin, Public Law 2019, Chapter 5 (LD 1), preserves some of the ACA's major consumer protections by incorporating them into Maine law and harmonizes state and federal laws in areas where Maine law was already similar to the ACA.
According to the bulletin, Maine law now incorporates ACA and additional protections on the following items:
- Rating restrictions
- Dependent child coverage up to age 26
- Pre-existing condition exclusion prohibitions
- Prohibition on rescissions of coverage
- Plan descriptions — similar to the ACA's SBC rules
- Prescription drugs — prohibits carriers from reducing or terminating benefits for an ongoing course of treatment during the course of an appeal
- Minimum medical loss ratio rules
- Guaranteed issue
- Prohibition on lifetime and annual limits on essential health benefits
- Nondiscrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, age, or disability.
- Mental health coverage.
For employers with fully insured plans in Maine, the new law and bulletin signals Maine's intent to solidify the ACA's protections through Maine law. The guidance contains no new employer obligations; employers should work with carriers on any questions relating to the bulletin.
Bulletin 437 »
New Paid Sick Time Law
June 11, 2019
On May 28, 2019, Gov. Mills signed into law LD 369, which is a new paid sick leave law. Effective January 1, 2021, the new law requires employers with 10 or more employees to provide an hour of paid sick leave for every 40 hours worked, up to a maximum of 40 hours of paid leave per year. Accrual of leave begins at the start of employment, although the employer is not required to permit use of the leave until the employee has worked 120 days. During the leave, employees must be paid at least the same base rate of pay that the employee received immediately prior to taking the paid leave, and must receive the same benefits as those provided to employees under other types of paid leave. Employees can use paid sick leave to take care of their own illness or serious condition or that of a family member. Employees are expected to provide advanced notice to employers, where possible.
We anticipate the Maine government and regulatory agencies providing additional detail on this new law prior to the 2021 effective date; we’ll continue to monitor any developments and report them here in Compliance Corner.
LD 369 »
Guidance for Short-Term Health Insurance
October 16, 2018
On Sept. 20, 2018, Superintendent Cioppa released Bulletin 431 to remind carriers and producers issuing policies in Maine of the state insurance requirements for short-term health insurance. This bulletin was intended to remind carriers doing business in the state that state law isn’t preempted regarding short-term health insurance and, thus, carriers doing business in ME must continue to comply with state law.
As background, the federal government issued a rule in Aug. 2018 that extended the initial contract term of short-term policies issued on or after Oct. 2, 2018, to be no more than 12 months while limiting renewals or extension of such policies to no more than 36 months. Similar to the federal rule, ME law limits a short-term policy to a term that is less than 12 months. However, in ME, short-term policies are nonrenewable and the combined term of successive short-term policies can be no more than 24 months, regardless of whether the policies are issued by the same carrier or a different carrier.
The bulletin also mentions that although federal law doesn’t require short-term policies to meet the essential health benefit requirements of the ACA, these policies are still subject to ME’s mandated benefits for individual health insurance. In addition, short-term policies are subject to more requirements for health plans in ME, such as preventive health services and the prohibition against aggregate dollar limits on coverage.
The bulletin highlights that short-term policies may be appropriate for some consumers, but producers should keep in mind that the federal regulation expressly describes short-term coverage as “a type of health insurance coverage that was primarily designed to fill temporary gaps in coverage that may occur when an individual is transitioning from one plan or coverage to another plan or coverage.” A producer has a duty of competence to ensure that consumers considering these policies are fully advised of the terms, benefits and limitations of the coverage.
This bulletin was for informational purposes only and employers need not take any action at this time. The intent was to remind carriers that ME insurance law continues to apply to short-term health insurance and carriers must factor in ME policies before issuing a product in response to the federal guidelines.
Bulletin 431 »
HHS Approves Maine Section 1332 Waiver
August 21, 2018
On July 30, 2018, HHS and the Department of the Treasury approved ME’s state innovation waiver, which requested a waiver from certain health insurance requirements under the ACA. Specifically, ME sought waiver of the ACA’s requirement that all enrollees in the individual market be rated under a single risk pool in order to reinstate the ME Guaranteed Access Reinsurance Association (the state-operated reinsurance program) from 2019 through 2023. The Departments believe that the waiver will achieve lower individual premiums in the state and lower premium tax credits (PTC) provided to ME residents.
The waived provisions are effective from Jan. 1, 2019 through Dec. 31, 2023, unless the waiver is extended. Superintendent Cioppa has 30 days (from July 30, 2018) to accept the terms and conditions of the Departments’ approval. If approved, the estimated PTC savings will be provided to the state to be used for implementation of the state’s reinsurance program.
The approval of this innovation waiver doesn’t impact employers directly, since it’s related to the individual market. However, employers may want to familiarize themselves with the approval in order to understand the waiver’s effect on the individual market.
Waiver Approval »
Out-Of-Network Provider Referrals Must Be Accepted
August 07, 2018
On July 13, 2018, Superintendent of Insurance Cioppa issued Bulletin 430 to clarify the legislative intent behind a recently enacted law that prohibits a carrier from denying payment for any covered health care service solely on the basis that the referral was made by a provider that was not a member of the carrier's provider network. The bulletin is in response to questions the bureau received about the interpretation and scope of the law change, including whether it prohibits so-called "gatekeeper" plans, which are typical for HMOs, from requiring all referrals to be made by the enrollee's designated primary care provider (PCP).
As background, effective Jan. 1, 2018, Gov. LePage signed 24-A M.R.S. §4303(22) into law. This law prohibits a carrier from denying an enrollee's referral for a covered service solely because it is from an out-of-network provider. The law applies to all carriers including HMOs and also limits carriers using tiered networks or other incentive programs that require the use of particular designated providers and exclude "non-designated" network providers from making referrals.
The bulletin clarifies that the law doesn't mean carriers must honor all referrals made by out-of-network providers, or that carriers can't impose reasonable restrictions that don't distinguish between referring providers on the basis of network membership. For example, a carrier may still deny the referral if the proposed service doesn't meet the carrier's documented clinical review criteria, to the extent otherwise permitted by law. The law does, however, prohibit any "gatekeeper" procedure traditionally used by HMOs.
This bulletin is intended for informational purposes and is primarily focused on carriers. So, fully insured employers don't need to take any action.
Bulletin 430 »
24-A M.R.S. §4303(22) »