Maine Regulations

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.

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:

• 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 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.

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.

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.

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.