§ 24-A §4302 — Reporting requirements

Maine § 24-A §4302

• Jurisdiction: Maine
• Title 24-A: MAINE INSURANCE CODE
• Ch. 56-A: HEALTH PLAN IMPROVEMENT ACT

Text

To offer or renew a health plan in this State, a carrier must comply with the following requirements.
1.
Description of plan.
A carrier shall provide to prospective enrollees and participating providers, and to members of the public and nonparticipating providers upon request, information on the terms and conditions of the plan to enable those persons to make informed decisions regarding their choice of plan. A carrier shall provide this information annually to current enrollees, participating providers and the superintendent. This information must be presented in a standardized format acceptable to the superintendent. In adopting rules or developing standardized reporting formats, the superintendent shall consider the nature of the health plan and the extent to which rules or standardized formats are appropriate to the plan. All written and oral descriptions of the health plan must be truthful and must use appropriate and objective terms that are easy to understand. These descriptions must be consistent with standards developed for supplemental insurance coverage under the United States Social Security Act, Title XVIII, 42 United States Code, Sections 301 to 1397 (1988). Descriptions of plans under this subsection must be standardized so that enrollees may compare the attributes of the plans and be in a format that is substantially similar to the format required for a carrier pursuant to the federal Affordable Care Act as of January 1, 2019. After a carrier has provided the required information, the annual information requirement under this subsection may be satisfied by the provision of any amendments to the materials on an annual basis. A carrier shall post descriptions of its plans on its publicly accessible website and, in addition to the plan description, include a link to the health plan's certificate of coverage. Specific items that must be included in a description are as follows:
2.
Plan complaints and adverse decisions statistics.
A carrier shall provide annually to the superintendent information for each health plan that it offers or renews on plan complaints and adverse decisions statistics. This statistical information must contain, at a minimum:
2-A.
Reporting of information related to prior authorization.
In addition to the information required to be provided under subsection 2, a carrier shall annually report to the superintendent the following information related to prior authorization determinations for the prior calendar year:
2-B.
Data reporting; utilization review data.
Beginning April 1, 2025 and April 1st of each year thereafter, the superintendent shall collect the information required under subsections 2 and 2‑A, together with the utilization review information collected pursuant to section 2749, and post this information on the bureau's publicly accessible website.
3.
Acceptable methods of providing information.
A carrier may meet any of the reporting requirements set forth in this section by providing information in conformity with the requirements of the federal Health Maintenance Organization Act of 1973, 42 United States Code, Sections 280c and 300e to 300e-17 (1988), or any other applicable state or federal law or any accrediting organization recognized by the superintendent, as long as the superintendent finds that the information is substantially similar to the information required by this section and is presented in a format that provides a meaningful comparison between health plans. When the superintendent determines that it is feasible and appropriate, the information required by this section must be provided by geographic region, age, gender and type of employer or group. With respect to geographical breakdown, the information must be provided in a manner that permits comparisons between urban and rural areas.
4.
Claims data.
By February 1st of each year, a carrier that provides only administrative services for a plan sponsor shall annually file with the superintendent for the most recent complete calendar year for all covered individuals in the State the total number of claims paid for each plan sponsor and the total dollar amount of claims paid for each plan sponsor.
5.
Annual report; claims for diagnosis and treatment of Lyme disease and other tick-borne illnesses.
By February 1st of each year, all carriers shall file with the superintendent for the most recent calendar year for all covered individuals in the State the total claims made for the diagnosis and treatment of Lyme disease and other tick-borne illnesses. The filing must include information on the number of claims made for the diagnosis and treatment of Lyme disease and other tick-borne illnesses, the total dollar amount of those claims, the number of claim denials and the reasons for those denials, the number and outcome of internal appeals and the number of external appeals related to the diagnosis and treatment of Lyme disease and other tick-borne illnesses. The superintendent shall compile from all carriers this data in an annual report and submit the report by March 15th of each year to the joint standing committee of the Legislature having jurisdiction over health insurance matters. The superintendent shall consult with the Department of Health and Human Services, Maine Center for Disease Control and Prevention to determine any additional information to be collected from carriers, beginning with data for calendar year 2011.
6.
Reporting required pursuant to the Affordable Care Act.
Notwithstanding any other requirements of this Title, a carrier shall provide to the Secretary of the United States Department of Health and Human Services, and make available to the public when required by federal law, any information required by the federal Affordable Care Act. Carriers shall provide the information to the superintendent upon request.

Legislative History

PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 742, §§4,5 (AMD). PL 2001, c. 457, §23 (AMD). PL 2007, c. 199, Pt. B, §§2, 3 (AMD). PL 2007, c. 561, §2 (AMD). PL 2009, c. 439, Pt. A, §2 (AMD). PL 2009, c. 439, Pt. B, §§2-4 (AMD). PL 2009, c. 494, §5 (AMD). PL 2011, c. 364, §24 (AMD). PL 2017, c. 232, §§3-5 (AMD). PL 2019, c. 5, Pt. A, §19 (AMD). PL 2023, c. 680, Pt. B, §§1-3 (AMD). PL 2025, c. 348, §33 (AMD). PL 2025, c. 445, §13 (AMD). PL 2025, c. 445, §14 (AFF).