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This page lists some of the action toward parity compliance undertaken by Maine regulatory agencies since 2008.

Are we missing any actions taken by state regulatory agencies? Let us know at info@paritytrack.org.

Action in the Regulatory Arena

Maine’s Bureau of Insurance requires plans under its jurisdiction to complete a checklist of coverages they must provide or must offer to provide and indicate where these sections can be found in the plans. One of these checklists is about complying with the parity and autism sections of the state insurance law. This is one of the checklists for individual plans, and this is one of the checklists for small employer fully-insured plans and large employer fully-insured plans.

The Frequently Asked Questions section on the Maine’s Bureau of Insurance website contains information on mandated benefits. This section highlights that employer group health policies with more than 20 employees must provide treatment for mental illness and substance use disorders. The Bureau of Insurance also created a timeline which lists the history of mandated health insurance benefits. This table includes information on when insurers were required to cover mental illness, substance use disorders, and developmental disabilities.

7/2017

Primary Focus: Parity-General, Access to Services
Agency: Department of Professional and Financial Regulation
Title/Description: Health Maintenance Organizations
Citation: CMR 02-031-191
Summary:  A plan must provide basic health care services that include coverage for all state and federally mandated benefits, including any essential health benefits required for individual and small group plans under the federal Affordable Care Act. Mental health and substance use disorder services must be covered in all group and individual contracts in a manner consistent with state and federal mental health parity requirements.
Effective Date: July 28, 2017
Notes: July 28, 2017 – filing 2017-098 (Final adoption, major substantive)

4/2011

Maine’s Bureau of Insurance issued a market conduct examination report on Anthem health plans in the state. The examination period was from 1/2005 through 12/2008. The purpose of this report was to “evaluate whether mental health and substance abuse benefits are at least equal to those received by a person receiving medical treatment.” Specifically, the Bureau examined these 5 areas to see if Anthem complied with parity sections and other relevant sections of the state insurance law:

In performing the examinations of these 5 areas, the examiners investigated random samples of denials and reviewed whether denials were appropriate in terms of medical necessity determinations and the qualifications and expertise of Anthem’s reviewers.

The investigation found three violations. One consisted of several procedural paperwork mistakes by Anthem, another was that Anthem took more than 30 days to pay an appealed claim, and the third found that Anthem had improperly denied numerous claims for one of its enrollees on the grounds that he had reached his annual limit for outpatient visits when he had not in fact reached the limit. These improperly denied claims were eventually reprocessed by Anthem in 2010 and applied to the patient’s deductible for that year, which had not yet been met.

4/2011

Maine’s Bureau of Insurance issued a market conduct examination report about United Healthcare Insurance plans in the state. The examination period was from 1/2005 through 12/2008. The purpose of this report was to “evaluate whether mental health and substance abuse benefits are at least equal to those received by a person receiving medical treatment.” Specifically, the Bureau examined these 5 areas to see if United complied with parity sections and other relevant sections of the state insurance law:

  • Company Operations and Management
  • Claims Handling and Settlement
  • Utilization Review and Prior Authorization
  • Complaints, Appeals and Grievance Handling
  • Policyholder Services and Provider Network

In performing the examinations of these 5 areas, the examiners investigated random samples of denials and reviewed whether denials were appropriate in terms of medical necessity determinations and the qualifications and expertise of United’s reviewers.

While the Bureau’s investigation did find several very minor violations, these were not direct violations of the parity sections of the insurance law. The examination concluded United was not in violation of any of the reviewed areas relevant to parity.

7/2010

Maine’s Bureau of Insurance issued this order to Anthem Blue Cross and Blue Shield of Maine regarding their individual plan rates for 2010. Among many other things, the order noted that the Bureau had previously asked Anthem to change its rate for optional mental health coverage required of the plan. The rate had been “several times the cost of the base policy”, which resulted in no enrollee ever choosing the optional coverage. Anthem drastically lowered the rate of the optional coverage, to the Bureau’s liking, but was ordered to report in future rate filings its experience with enrollees purchasing this coverage.

5/2009

Primary Focus: Parity-General
Agency: Department of Professional and Financial Regulation
Title/Description: Individual Health Insurance Pilot Projects for Persons Under 30 Years of Age
Citation: CMR 02-031-745
Summary: Mental health and substance abuse services must be covered.  Mental health parity must be offered.
Effective Date: May 26, 2009
Notes: Secretary of State Rule Log #2009-197

1/2009

The Superintendent of Maine’s Bureau of Insurance approved MEGA Life and Health Insurance’s proposed policy rates for individual plans in 2009 after originally denying these rates in 2008. One of the reasons for denying the rates was that the Commissioner found the proposed rates for mental health coverage to be non-compliant with the parity section of the insurance law. The Commissioner finally approved the rates after MEGA changed the proposed mental health rates in December of 2008.

3/2004

Primary Focus: Parity-General
Agency: Department of Professional and Financial Regulation
Title/Description: Minimum Standards for Alcoholism and Drug Dependency Benefits
 Citation: CMR 02-031-320
Summary: All group contracts, except to the extent they cover employees of employers with 20 or fewer employees, must provide the same level of benefits for the treatment of substance abuse-related disorders as for treatment of physical illnesses. The residential treatment benefit level must be at least the greater of the same level of benefits, if any, provided for residential treatment of physical illnesses; or benefits that provide residential treatment for substance abuse of at least 30 days per calendar year or, if less, the total number of inpatient days allowed by the policy for all illnesses; and coinsurance that is at least 90 percent of the charges or, if less, the percentage applicable to inpatient benefits; and a lifetime maximum limit on the number of covered days for residential treatment of substance abuse of not less than 60 days. Inpatient services must be covered at the same benefit level as for physical illnesses.
Effective Date: Original effective date June 1, 1984
Notes: Last amended March 1, 2004 Secretary of State Rule Log # 2004-63

Primary Focus: Parity-General
Agency: Department of Professional and Financial Regulation
Title/Description: Minimum Standards for Mental Illness Benefits
Citation: CMR 02-031-330
Summary: Treatment for the mental illnesses listed must be covered at the same level of benefits as for treatment of physical illnesses (“parity”). Most mental illnesses fall into this category. The standards set forth apply to other “unlisted” mental illnesses and to all mental illnesses under policies and certificates that are subject to this rule but exempt from the parity requirement. Any policy subject to this Rule will be deemed to be in compliance if it provides, at a minimum, the specific enumerated benefits for a covered person suffering from a mental illness.If the policy contains no annual dollar maximum for other illnesses, it shall contain no annual dollar maximum for mental illness, but may include annual maximum numbers of visits if the maximum is not less than specified numbers. If the policy contains an annual dollar maximum for other illnesses, it may apply that maximum to the policy as a whole, including mental illness, or include a separate annual dollar maximum for mental illness that is no less than the annual maximum for other illnesses. If the policy contains no lifetime maximum for other illnesses, it shall contain no lifetime maximum for mental illness.  If the policy contains a lifetime maximum for other illnesses, it may apply that maximum to the policy as a whole, including mental illness, or include a separate lifetime maximum for mental illness that is no less than the lifetime maximum for other illnesses.
Effective Date: Original effective date June 1, 1984
Notes: Last amended March 1, 2004 Secretary of State Rule Log # 2004-64

Maine Parity Law

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

Behavioral Health Coverage for Certain Employer 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:

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

Mental Health Coverage for Certain Plans

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

Autism Coverage

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.

Get Support

Maine Insurance Division

Common Violations

In seeking care or services, be aware of the common ways parity rights can be violated.

Common Violations

Definition

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