Maine

There are several sections of the state insurance law about parity for behavioral health conditions. There are also several identical sections about coverage for autism coverage. For the sake of clarity, these sections will be summarized as follows:

• Behavioral Health coverage requirements for large employer fully-insured plans and small employer fully-insured plans with 21 or more employees
• Mental health coverage requirements for individual plans and small employer fully-insured plans with 20 or fewer employees
• Autism coverage requirements for all affected plans

This section requires large employer fully-insured plans and small employer fully-insured plans with 21 or more employees to cover behavioral health services. These plans must cover “medically necessary health care for a person suffering from mental illness.” This includes:

• Inpatient care
• Outpatient care
• Partial hospitalization
• Home health services

There are further coverage requirements for treatment of the following behavioral health conditions:

• Psychotic disorders, including schizophrenia
• Dissociative disorders
• Mood disorders
• Anxiety disorders
• Personality disorders
• Paraphilias
• Attention deficit and disruptive behavior disorders
• Pervasive developmental disorders
• Tic disorders
• Eating disorders, including bulimia and anorexia
• Substance use disorders

For these conditions services must be covered on “terms and conditions no less extensive” than services for other medical conditions. Also required are:

• Plans cannot have annual maximums, lifetime maximums, deductibles, coinsurance amounts, and other out-of-pocket yearly dollar limits that are different from those used for other medical services
• Plans cannot have different visit limits for outpatient care for behavioral health services
• Copayments cannot be greater for behavioral health services than those used for other medical services
• Medical necessity determinations for behavioral health coverage must follow the same criteria as what is in place for other medical coverage
• Coverage of office visits for medication management must be the same for behavioral health treatment and other medical treatment

Subsection 5-D of this section requires small employer fully-insured plans with 20 or fewer employees to offer optional mental health coverage. This section has identical requirements for individual plans.

This section applies to the following conditions:

• Schizophrenia
• Bipolar disorder
• Pervasive developmental disorder, or autism
• Paranoia
• Panic disorder
• Obsessive-compulsive disorder
• Major depressive disorder

Plans are required to do the following if the plan covers the above conditions:

• Coverage for mental health services must be “on the same terms and conditions and no less extensive” than coverage for other medical services
• Medical necessity determinations for mental health coverage must follow the same criteria as what is in place for other medical coverage
• File an annual report with the Maine Bureau of Insurance about the cost of covering these conditions broken into cost by inpatient care, outpatient care, and partial hospitalization

This section requires small employer fully-insured plans, and large employer fully-insured plans to cover autism services for children through age 10. This section is identical and applies to individual plans.

Autism spectrum disorders are defined as “any of the pervasive developmental disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, published by the American Psychiatric Association, including autistic disorder, Asperger’s disorder and pervasive developmental disorder not otherwise specified.”

Treatment of autism is defined as “Habilitative or rehabilitative services, including applied behavior analysis or other professional or counseling services necessary to develop, maintain and restore the functioning of an individual to the extent possible.”

There cannot be any visit limits for outpatient care and plans must cover a $36,000 annual maximum for applied behavior analysis.