§ 5 §285 — Group health plan

Maine § 5 §285

• Jurisdiction: Maine
• Title 5: ADMINISTRATIVE PROCEDURES AND SERVICES
• Part 1: STATE DEPARTMENTS
• Ch. 13: DEPARTMENT OF ADMINISTRATIVE AND FINANCIAL SERVICES

Text

A group health plan is available to state employees and other eligible persons, subject to the following provisions.
1.
Eligibility; generally.
The following persons are eligible for a group health plan:
1-A.
Eligibility; retirees.
Any person otherwise eligible pursuant to subsection 1, paragraph G, must in addition, in order to be eligible under this section:
1-B.
Ineligibility.
Except as provided in subsection 1, paragraphs K, L and M and subsection 11‑A, members of the Maine Municipal Association and active employees of counties and municipalities and instrumentalities thereof, including quasi-municipal corporations, are not eligible to participate in the group health plan under this section.
1-C.
Status of employees who have retired and returned to covered employment under Maine Public Employees Retirement System.
For purposes of participation in the state employee health insurance program pursuant to this section or in dental insurance coverage offered by the State, recipients of a service retirement benefit under the Maine Public Employees Retirement System who are retired employees and who are reemployed as state employees must be treated as retirees under subsection 1‑A for purposes of eligibility for coverage under the group plan.
2.
Coverage.
Each state employee to whom this section applies is eligible for a group health plan as provided in Title 24‑A, sections 2802 to 2812‑A, including major medical benefits or through a self-funded alternative. The provisions of the group insurance policy or policies or the self-funded alternative must be determined, insofar as the provisions are not inconsistent with terms and conditions contained in collective bargaining agreements negotiated pursuant to Title 26, chapter 9‑B, by the State Employee Health Commission as provided in section 285‑A. The master policy for the group health plan must be held by the Commissioner of Administrative and Financial Services.
3.
Enrollment.
Any employee eligible under this section may join within the first 60 days of employment or during a declared open enrollment period. The filing of necessary applications shall be the responsibility of the employer. Effective dates under this section shall be at the discretion of the commission.
3-A.
Coverage under group health insurance plan for spouse and dependents after death of state employee.
If the spouse or other dependents of an employee in any of the categories denominated in subsection 1, paragraphs A to F‑5 are covered by the group health plan and the employee dies while employed in that capacity, the spouse or dependent must have the opportunity to continue coverage under the plan after the death of the employee by making the premium payment for the cost of that coverage. In the case of underage dependent children, coverage must be available at least until the dependent children reach 19 years of age.
3-B.
Enrollment of spouse and dependents of retirees.
Effective January 1, 2003, a retiree eligible for participation in the group health insurance plan under this section may enroll a spouse and dependents in the group plan as follows:
3-C.
Retirees may decline coverage and reenroll.
A retiree eligible for a group health plan under subsection 1, paragraph G may elect to decline or to withdraw from coverage under the plan and to reenroll in the plan at a later date pursuant to the provisions of this subsection.
3-D.
Coverage under group health insurance plan for spouse and dependents after death of retiree.
If the spouse or other dependents of a retiree who is eligible pursuant to subsection 1, paragraph G and subsection 1‑A are covered by the group health plan and the retiree dies while enrolled in the group health plan, the spouse or dependents must have the opportunity to continue coverage under the plan after the death of the retiree by making the premium payment for the cost of that coverage. In the case of underage dependent children, coverage must be available at least until the dependent children reach 19 years of age.
3-E.
Employees eligible for military health coverage may decline coverage and reenroll.
An employee eligible for a group health plan under subsection 1 may elect to decline or withdraw from coverage under the plan as long as the employee demonstrates that the employee is eligible for coverage under the Civilian Health and Medical Program for the Uniformed Services, known as TRICARE, and to reenroll in the plan at a later date pursuant to the provisions of this subsection.
4.
Payroll deduction.
5.
Purchase of policies.
The commission shall purchase, by competitive bidding, from one or more insurance companies, nonprofit organizations, 3rd-party administrators or any organization necessary to administer and provide a health plan, a policy or policies or contract, to provide the benefits specified by this section. The purchase of policies by the commission must be accomplished by use of a written contract that must be fully executed within 90 calendar days of notification of bid acceptance from the commission to the insurer. In extenuating circumstances, the Commissioner of Administrative and Financial Services may grant a waiver to that 90-day limit. Notwithstanding this subsection, with the consent of the policyholder and of the insurer and at the sole discretion of the commission, existing policies of insurance covering at least 1,000 of the employees defined as eligible by this section may be amended to provide the benefits specified by this section and assigned to the Commissioner of Administrative and Financial Services for the benefit of all those eligible under this section. The company or companies or nonprofit organizations must be licensed under the laws of the State, when applicable. The policy provisions are subject to and as provided for by the insurance laws of this State, when applicable. Notwithstanding any other provisions of law, the term of a contract executed with a successful bidder may not exceed 3 years unless extended in one-year increments for up to 3 additional years.
6.
Master policy and certificates.
The insurance company, companies or nonprofit organizations or the Commissioner of Administrative and Financial Services shall furnish the usual master policy and certificates. Each covered participant must receive a certificate setting forth the benefits to which the participant is entitled, to whom payable, to whom claims must be submitted, and summarizing the provisions of the policy principally affecting the participant.
7.
Payment by State.
Except as otherwise provided in this subsection, the State, through the commission, shall pay health plan premiums in accordance with this subsection.
7-A.
Health credit premium program.
Notwithstanding subsection 7, paragraph C, the State may pay a greater proportion of the total cost of the individual premium for the standard plan identified and offered by the commission and available to the employee as authorized by the commission. The commission shall develop a health credit premium program whereby employees are provided incentives to engage in healthy behaviors in an effort to improve the health status of the state employee population and to help reduce costs to the state employee health insurance program. The commission shall define benchmarks for healthy behaviors that, if met by an individual employee, result in the State's paying a greater share of the individual premium. Adjustments to the state share of the individual premium must be applied once each year in advance of the beginning of the plan year.
7-B.
Provision for alternative cost-savings initiatives.
If the commission fails to develop and implement the health credit premium program as specified in subsection 7‑A, or if the health credit premium program fails to generate the savings required to maintain the fiscal balance in the state employee health insurance program, the commission shall develop and implement changes to the benefit structure of the standard plan in order to satisfy the need for fiscal stability.
8.
Payment by Maine State Retirement System for persons first employed before July 1, 1991.
8-A.
Payment by Maine State Retirement System for persons employed after July 1, 1991.
9.
Restrictions on self-insured programs.
The following restrictions apply to self-insured group health or dental plans.
10.
Commission not insurer.
The commission or other entity operating any self-funded plan pursuant to this section is not an insurer, reciprocal insurer, or joint underwriting association under the laws of the State. The administration of such a program by the director of the employees health insurance program does not constitute doing the business of insurance.
11.
Coverage for persons eligible under federal Trade Adjustment Assistance Reform Act of 2002.
The Department of Administrative and Financial Services, Division of Employee Health and Benefits may provide, through a qualified insurance company, a group health plan product for individuals certified to receive federal assistance in paying for health coverage under the terms of the health coverage tax credit program within the federal Trade Adjustment Assistance Reform Act of 2002, Public Law 107-210. Certification of eligibility is made by the Department of Labor. Individuals may enroll eligible dependents. Individuals eligible for enrollment in this group health plan remain eligible for enrollment and coverage through the duration of their federal trade adjustment assistance eligibility and for one month after their federal trade adjustment assistance eligibility status ends.
11-A.
Coverage for retired law enforcement officers and firefighters.
A retired county or municipal law enforcement officer or retired municipal firefighter, as defined in section 286‑M, subsection 2, who participates in an employer-sponsored retirement program and, prior to July 1, 2007, was enrolled in a self-insured health benefits plan offered by the employing county or municipality may, if the requirements of this subsection are met, enroll in a group health plan administered pursuant to this section that provides coverage for the retired county or municipal law enforcement officer or retired municipal firefighter effective no earlier than July 1, 2007.
12.
Contractual commitment to health insurance for retirees.
Effective April 1, 2004, to each vested employee as defined in this subsection, the State makes solemn contractual commitments as set forth in paragraph C, protected under the contract clauses of the Constitution of Maine, Article I, Section 11 and the United States Constitution, Article I, Section 10.
13.
Contract on pilot basis authorized.
Notwithstanding the requirements of subsection 9, paragraph G, the State may enter into a contract on a pilot basis that does not adhere to any geographic access requirements set forth in Title 24‑A or rules adopted by the Superintendent of Insurance. The department shall report annually beginning January 15, 2006 to the joint standing committee of the Legislature having jurisdiction over insurance and financial services matters on its progress in establishing and operating a pilot program pursuant to this subsection.
14.
Employees eligible for Medicare.
Notwithstanding subsection 7, if an active employee eligible for Medicare elects to enroll in Medicare, the State shall pay 100% of the employee’s share of the premiums for Medicare Part B until such time as the employee enrolls as an eligible retiree pursuant to this section.
15.
Provider profiling programs.
Notwithstanding subsection 10, the requirements of Title 24‑A, sections 2694‑A and 4303‑A apply to any provider profiling program, as defined in Title 24‑A, section 4301‑A, subsection 16‑A, developed by the commission.
16.
Dental benefit waiting period.
The requirements of Title 24‑A, sections 2766‑A, 2847‑W and 4260 that prohibit a waiting period for any dental or oral health service or treatment, except for orthodontic treatment, for an enrollee if the enrollee is under 19 years of age apply to any group health plan or dental plan purchased under subsection 5 or to any self-insured group health or dental plan provided under subsection 9.
17.
Eligibility of persons other than state employees for group health plan.
A person other than a state employee may not be granted eligibility for a group health plan pursuant to subsection 1 by legislative action to amend subsection 1 unless the person is an employee of a quasi-governmental entity that receives significant and ongoing operating funds through a General Fund appropriation.

Legislative History

PL 1967, c. 543 (NEW). PL 1969, c. 588, §§1,2 (AMD). PL 1971, c. 544, §11 (AMD). P&SL 1973, c. 625, §19 (AMD). P&SL 1975, c. 90, §§T1, 2 (AMD). PL 1975, c. 771, §52 (AMD). PL 1979, c. 653 (AMD). PL 1981, c. 178 (AMD). PL 1981, c. 270, §1 (AMD). PL 1983, c. 692, §§1,2 (AMD). PL 1985, c. 295, §2 (AMD). PL 1985, c. 391, §§1-4,7 (AMD). PL 1985, c. 507, §2 (AMD). PL 1985, c. 609 (AMD). PL 1985, c. 693, §12 (AMD). PL 1985, c. 695, §§4-7 (AMD). PL 1985, c. 785, §§A30,31 (AMD). PL 1987, c. 221, §§1-3 (AMD). PL 1987, c. 402, §A14 (AMD). PL 1987, c. 731, §§2-5 (AMD). PL 1987, c. 735, §§5,6 (AMD). PL 1987, c. 769, §A11 (AMD). PL 1989, c. 443, §6 (AMD). PL 1989, c. 483, §A8 (AMD). PL 1989, c. 502, §A12 (AMD). PL 1989, c. 776, §1 (AMD). RR 1991, c. 2, §7 (COR). PL 1991, c. 527, §§1,2 (AMD). PL 1991, c. 780, §§Y23,24 (AMD). PL 1991, c. 885, §D2 (AMD). PL 1993, c. 16, §§1,2 (AMD). P&SL 1993, c. 67, §1 (AMD). PL 1993, c. 410, §§L9-11 (AMD). PL 1995, c. 368, §§G1-4 (AMD). PL 1997, c. 24, §C1 (AMD). PL 1997, c. 80, §§1-4 (AMD). PL 1997, c. 455, §§2,3 (AMD). PL 1997, c. 652, §§1,2 (AMD). PL 1997, c. 652, §4 (AFF). PL 1997, c. 763, §1 (AMD). PL 1997, c. 763, §7 (AFF). PL 1999, c. 152, §§E1,2 (AMD). RR 2001, c. 1, §7 (COR). PL 2001, c. 239, §1 (AMD). PL 2001, c. 239, §5 (AFF). PL 2001, c. 341, §1 (AMD). PL 2001, c. 374, §1 (AMD). PL 2001, c. 439, §§XX1-5 (AMD). PL 2001, c. 641, §1 (AMD). PL 2001, c. 667, §§E1-3 (AMD). PL 2003, c. 20, §OO2 (AMD). PL 2003, c. 20, §OO4 (AFF). PL 2003, c. 214, §1 (AMD). PL 2003, c. 348, §1 (AMD). PL 2003, c. 673, §DDDD1 (AMD). PL 2003, c. 689, §B6 (REV). PL 2005, c. 12, §NNN1 (AMD). PL 2005, c. 21, §1 (AMD). PL 2005, c. 67, §1 (AMD). PL 2005, c. 279, §1 (AMD). PL 2005, c. 636, §§A1,2 (AMD). PL 2007, c. 58, §3 (REV). PL 2007, c. 134, §1 (AMD). RR 2009, c. 1, §5 (COR). PL 2009, c. 213, Pt. GG, §§1-3 (AMD). PL 2009, c. 233, §1 (AMD). PL 2009, c. 456, §1 (AMD). PL 2009, c. 571, Pt. JJJ, §1 (AMD). PL 2009, c. 571, Pt. NN, §1 (AMD). RR 2011, c. 1, §4 (COR). PL 2011, c. 1, Pt. FF, §1 (AMD). PL 2011, c. 67, §1 (AMD). PL 2011, c. 380, Pt. V, §1 (AMD). PL 2011, c. 380, Pt. V, §7 (AFF). PL 2011, c. 438, §§1-4 (AMD). PL 2011, c. 514, §1 (AMD). PL 2011, c. 540, §1 (AMD). PL 2011, c. 540, §3 (AFF). PL 2013, c. 276, §§1, 2 (AMD). PL 2013, c. 368, Pt. H, §1 (AMD). PL 2013, c. 383, §1 (AMD). PL 2015, c. 363, §1 (AMD). PL 2017, c. 56, §1 (AMD). PL 2019, c. 424, §§1-4 (AMD). PL 2019, c. 605, §1 (AMD). PL 2019, c. 669, §1 (AMD). PL 2021, c. 312, §1 (AMD). PL 2021, c. 341, §§1-3 (AMD). PL 2023, c. 20, §§1-4 (AMD). PL 2023, c. 167, §14 (AMD). PL 2023, c. 412, Pt. H, §§1-3 (AMD). PL 2023, c. 451, §1 (AMD). PL 2023, c. 607, §2 (AMD). RR 2023, c. 2, Pt. A, §§10, 11 (COR). PL 2025, c. 48, Pt. B, §1 (AMD). PL 2025, c. 278, §§1, 2 (AMD).