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An Act To Ensure That DirigoChoice Is Affordable
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §6910, sub-§3, ¶A,  as enacted by PL 2003, c. 469, Pt. A, §8, is amended to read:
 
A. Provide the comprehensive health services and benefits as determined by the board in accordance with subsection 3-A, including a standard benefit package that meets the requirements for mandated coverage for specific health services, specific diseases and for certain providers of health services under Title 24 and this Title and any supplemental benefits the board wishes to make available; and
Sec. 2. 24-A MRSA §6910, sub-§3-A  is enacted to read:
 
3-A.  Comprehensive and affordable benefits; standards.     The health services and benefits provided through Dirigo Health Program coverage must be determined by the board to meet standards for a comprehensive and affordable benefit package in accordance with the following.
 
A.  Comprehensive benefits must, at a minimum, include coverage for preventive care services, medically necessary services and covered services required by Bureau of Insurance Rule Chapter 750 except to the extent that services covered under the Dirigo Health Program on the effective date of this subsection exceed services required by Rule Chapter 750. To the extent that covered services contained in Rule Chapter 750 deviate from or are lesser than the clinical practice guidelines established by the federal Agency for Healthcare Research and Quality, a nationally recognized professional medical or health association or the National Quality Forum, or a successor organization, the services required under the clinical practice guidelines adopted by the federal Agency for Healthcare Research and Quality, a nationally recognized professional medical or health association or the National Quality Forum, or a successor organization, apply.
 
For the purposes of this paragraph, "medically necessary services" means a service that is reasonably expected to prevent, diagnose, prevent the worsening of, alleviate, correct or cure conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap or result in illness or infirmity. "Medically necessary services" includes inpatient and outpatient services as mandated under Title XIX of the federal Social Security Act.
 
B.  Comprehensive benefits may not include any lifetime maximum limits, coinsurance rates that exceed 20% or any dollar caps on certain services.
 
C.  Comprehensive benefits may not include deductibles within any income bracket that exceeds 10% of income within that bracket and the total out-of-pocket maximum amount on any enrollee may not exceed the maximum contribution required for that enrollee.
 
D.  The total out-of-pocket expenses required to be paid by individual enrollees may not exceed the following maximum amounts based on an enrollee’s income:
 
(1) An enrollee with a household income at or below 250% of the federal poverty level may not be required to contribute any out-of-pocket amount;
 
(2) An enrollee with a household income between 251% and 300% of the federal poverty level may not be required to contribute more than 0.5% of taxable income;
 
(3) An enrollee with a household income between 301% and 350% of the federal poverty level may not be required to contribute more than 1% of taxable income;
 
(4) An enrollee with a household income between 351% and 400% of the federal poverty level may not be required to contribute more than 2% of taxable income;
 
(5) An enrollee with a household income between 401% and 500% of the federal poverty level may not be required to contribute more than 3% of taxable income;
 
(6) An enrollee with a household income between 501% and 600% of the federal poverty level may not be required to contribute more than 4% of taxable income;
 
(7) An enrollee with a household income between 601% and 700% of the federal poverty level may not be required to contribute more than 5% of taxable income;
 
(8) An enrollee with a household income between 701% and 800% of the federal poverty level may not be required to contribute more than 6% of taxable income; and
 
(9) An enrollee with a household income above 800% of the federal poverty level may not be required to contribute more than 10% of taxable income.
 
SUMMARY
This bill requires that Dirigo Health Program coverage meet certain standards for a comprehensive and affordable health benefit package. The bill also limits the amount of contributions required by enrollees in the Dirigo Health Program based on an enrollee’s income.