Sec. B-1. 24-A MRSA §2803-A, sub-§§2 and 3, as enacted by PL 1995, c. 71, §2, are amended to read:
2. Disclosure of basic loss information. Upon written request, every insurer shall provide loss information concerning a group policy or contract to its policyholder at least 60 days prior to renewal of the policy or contract and again 6 months from the date the policy becomes effective within 21 business days of the date of the request.
3. Transmittal of request. If a policyholder requests loss information from an An insurance agent producer or other authorized representative, the representative or agent who receives a request for loss information in accordance with this section shall transmit the request for loss information to the insurer within 4 working business days.
Sec. B-2. 24-A MRSA §2803-A, sub-§4, as amended by PL 1997, c. 370, Pt. E, §5, is further amended to read:
4. Exception. An insurer is not required to provide the loss information described in this section to for a group that is eligible for small group coverage pursuant to section 2808-B.
Sec. B-3. 24-A MRSA §4222-B, sub-§§17 to 19 are enacted to read:
17. Section 2803-A, relating to disclosure of loss information, applies to health maintenance organizations.
18. The requirement of section 2809-A, subsection 11 to continue group coverage under certain circumstances applies to health maintenance organizations.
19. Section 12-A, relating to penalties, applies to health maintenance organizations.
Sec. B-4. 24-A MRSA §4224-A, as amended by PL 1997, c. 370, Pt. E, §7, is repealed.
Sec. B-5. 24-A MRSA §4303, sub-§8 is enacted to read:
8. Maximum allowable charges. All policies, contracts and certificates executed, delivered and issued by a carrier under which the insured or enrollee may be subject to balance billing when charges exceed a maximum considered usual, customary and reasonable by the carrier or that contain contractual language of similar import must be subject to the following.
A. If benefits for covered services are limited to a maximum amount based on any combination of usual, customary and reasonable charges or other similar method, the carrier must:
(1) Clearly disclose that the insured or enrollee may be subject to balance billing as a result of claims adjustment; and
(2) Provide a toll-free number that an insured or enrollee may call prior to receiving services to determine the maximum allow-able charge permitted by the carrier for a specified service.
B. The carrier must provide to the superintendent on request complete information on the methodology and specific data used by the carrier or any 3rd party on behalf of the carrier in adjusting any claim submitted by or on behalf of the insured or enrollee. In considering the reasonableness of the methodology for calculating maximum allowable charges, the superintendent shall consider whether the methodology takes into account relevant data specific to this State if there is sufficient data to constitute a representative sample of charge data for the same or comparable service.
Sec. B-6. 24-A MRSA §4304, sub-§6 is enacted to read:
6. Notice. A notice issued by a carrier or its contracted utilization review entity in response to a request by or on behalf of an insured or enrollee for authorization of medical services that advises that the requested service has been determined to be medically necessary must also advise whether the service is covered under the policy or contract under which the insured or enrollee is covered. Nothing in this subsection requires a carrier to provide coverage for services performed when the insured or enrollee is no longer covered by the health plan.
Sec. B-7. 24-A MRSA §5002-B, sub-§2-A is enacted to read:
2-A. Low-cost drugs for the elderly or disabled program. An issuer that offers standardized plans that include prescription drug benefits shall permit an insured who has a plan from the same issuer without prescription drug benefits to purchase a plan with prescription drug benefits under the following circumstances:
A. The insured was covered under the low-cost drugs for the elderly or disabled program established by Title 22, section 254;
B. The insured applies for a plan with prescription drug coverage within 90 days after losing eligibility for the low-cost drugs for the elderly or disabled program established by Title 22, section 254; and
C. The insured either:
(1) Had a Medicare supplement plan with prescription drug benefits from the same issuer prior to enrolling in the low-cost drugs for the elderly or disabled program established by Title 22, section 254; or
(2) Is entitled to continuity of coverage pursuant to subsection 1 and has had prescription drug benefits, through either a Medicare supplement plan or the low-cost drugs for the elderly or disabled program established by Title 22, section 254, since the insured's open enrollment period with no gap in prescription drug coverage in excess of 90 days.
The purchase of a plan with prescription drug benefits by an insured pursuant to this subsection does not affect eligibility for coverage under the low-cost drugs for the elderly or disabled program established by Title 22, section 254 if the insured is not covered by a Medicare supplement plan with prescription drug benefits at the time of reapplying for coverage under the low-cost drugs for the elderly or disabled program established by Title 22, section 254.
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