The national Medical Plans guide explains major medical design: deductibles, coinsurance, out-of-pocket maximums, HMOs, PPOs, POS plans and HSAs. This guide covers what Maine law adds. That includes individual market rating and guaranteed issue, mandated benefits, managed care consumer protections, and external review. Citations are to Title 24-A of the Maine Revised Statutes. Group-specific rules (small group, continuation) are in the Maine Group Health Insurance guide.

Individual health plans: issue and rating (24-A M.R.S. 2736-C)

• Guaranteed issue: carriers must offer individual coverage to every Maine resident except people eligible for premium-free Medicare Part A.
  • A carrier may decline someone whose coverage it ended for nonpayment in the last 91 days, or for fraud in the last 12 months.
  • A resident is someone domiciled in Maine for at least the last 60 days.
• Rating bans: premiums may not vary by gender, health status, occupation or industry, claims experience or policy duration.
• Allowed factors (within limits): age, family membership and geographic area.
  • Age bands are capped at 3 to 1 for adults 21 and older.
  • Family rating adds up individual premiums but counts no more than 3 children under 21.
  • No tobacco rating: for policies issued or renewed on or after January 1, 2024, carriers may not vary premiums for tobacco use.

Benefit protections

• No lifetime dollar limits on benefits and no annual dollar limits on essential benefits (4320).
• Preventive care: USPSTF A or B rated services are covered with no cost sharing (4320-A).
• Emergency services: no prior authorization. Out-of-network emergency care is covered with in-network cost sharing, and the enrollee is held harmless for amounts above that (4320-C).
• Rescission is barred except for fraud or intentional misrepresentation of a material fact (2850-B).

Mandated benefits and dependents

Managed care rules

• HMO alternative: an employer with more than 50 employees that offers an HMO must also offer a plan that doesn't restrict provider choice, and contribute equally to it. A point-of-service option satisfies this (4227).
• HMO open enrollment: at least one month a year after 24 months of operation (4210). Every HMO plan must cover chiropractic care (4236).
• Primary care provider: enrollees may switch at least once a year without cause, and as needed with cause (4306).
• OB/GYN: no referral or authorization needed to see a participating OB/GYN (4306-A).
• Preferred provider arrangements: the benefit difference between in-network and out-of-network can't exceed 20% of the allowable charge, unless the Superintendent waives it (2677-A). Arrangements are filed with the Bureau (2673-A).
• Utilization review entities must be licensed by the Bureau. An adverse decision notice names the reviewer (2771, 2772).
• Pharmacy benefit managers need a Bureau license (4348).

External review (24-A M.R.S. 4312)

• After a final adverse health care treatment decision, the enrollee asks the Bureau in writing for external review within 12 months.
• There's no filing fee.
• A decision is due within 30 days of the reviewer receiving the complete request, or faster when medically necessary.

Short-term and continuity rules (2849-B)

• A short-term, limited-duration policy is individual and nonrenewable. Its term can't extend past December 31 of the year it's issued.
• Continuity of coverage: a person moving between plans keeps credit if prior coverage ended within 90 days before enrolling, or 180 days in certain unemployment cases.

Underwriting limits

• Insurers may not ask whether an applicant has had an HIV test (2159(6)). Seeking AIDS-related counseling can't affect rates or insurability (Rule 490).
• Unfair discrimination between people of the same class and hazard is barred. Incentives to use particular providers are allowed (2159(2)).

Common exam traps

• Maine individual coverage is guaranteed issue, with no rating on health, gender or claims, and no tobacco rating since 2024.
• The age band is 3:1 for adults. Family premiums count at most 3 children.
• Newborn coverage starts at birth. Notice and premium are due within 31 days.
• Home health: 90 visits, with no prior hospital stay required.
• External review: request to the Bureau within 12 months, no fee.
• PPO differential: 20% maximum.