‘An Act To Establish the Maine Health Benefit Marketplace’
HP1099 LD 1498 |
Second Regular Session - 125th Maine Legislature C "A", Filing Number H-867, Sponsored by
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LR 394 Item 2 |
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Bill Tracking, Additional Documents | Chamber Status |
Amend the bill by striking out the title and substituting the following:
‘An Act To Establish the Maine Health Benefit Marketplace’
Amend the bill by striking out everything after the enacting clause and before the summary and inserting the following:
‘Sec. 1. 2 MRSA §6, sub-§1, as repealed and replaced by PL 2005, c. 397, Pt. A, §1, is amended to read:
Sec. 2. 5 MRSA §934-C is enacted to read:
§ 934-C. Maine Health Benefit Marketplace
The position of executive director is a major policy-influencing position within the Maine Health Benefit Marketplace established pursuant to Title 24-A, chapter 93. Notwithstanding any other provision of law, this position and any successor position are subject to this chapter.
Sec. 3. 5 MRSA §12004-G, sub-§14-I is enacted to read:
Health Care | Board of Directors of the Maine Health Benefit Marketplace | $100 per diem and expenses | 24-A MRSA §7204 |
Sec. 4. 24-A MRSA c. 93 is enacted to read:
CHAPTER 93
MAINE HEALTH BENEFIT MARKETPLACE ACT
§ 7201. Short title
This chapter may be known and cited as "the Maine Health Benefit Marketplace Act."
§ 7202. Definitions
As used in this chapter, unless the context otherwise indicates, the following terms have the following meanings.
(1) Coverage only for accident or disability income insurance or any combination thereof;
(2) Coverage issued as a supplement to liability insurance;
(3) Liability insurance, including general liability insurance and automobile liability insurance;
(4) Workers' compensation or similar insurance;
(5) Automobile medical payment insurance;
(6) Credit-only insurance;
(7) Coverage for on-site medical clinics; or
(8) Insurance coverage similar to any coverage listed in subparagraphs (1) to (7), as specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, under which benefits for health care services are secondary or incidental to other insurance benefits.
(1) Limited-scope dental or vision benefits;
(2) Benefits for long-term care, nursing home care, home health care, community-based care or any combination thereof; or
(3) Limited benefits similar to benefits listed in subparagraphs (1) and (2) as specified in federal regulations issued pursuant to the federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191.
(1) Coverage only for a specified disease or illness; or
(2) Hospital indemnity or other fixed indemnity insurance.
(1) Medicare supplemental health insurance as defined under the United States Social Security Act, Section 1882(g)(1);
(2) Coverage supplemental to the coverage provided under 10 United States Code, Chapter 55; or
(3) Supplemental coverage similar to coverage listed in subparagraphs (1) and (2) provided under a group health plan.
§ 7203. Maine Health Benefit Marketplace established; declaration of necessity
§ 7204. Board of Directors of Maine Health Benefit Marketplace
The Board of Directors of the Maine Health Benefit Marketplace, as established in Title 5, section 12004-G, subsection 14-I, shall supervise the marketplace.
(1) Three members appointed by the Governor;
(2) Two members appointed by the President of the Senate;
(3) Two members appointed by the Speaker of the House;
(4) One member appointed by the President of the Senate upon recommendation from the leader of the minority in the Senate; and
(5) One member appointed by the Speaker of the House upon recommendation from the leader of the minority in the House of Representatives.
(1) The Commissioner of Professional and Financial Regulation or the commissioner's designee;
(2) The Commissioner of Health and Human Services or the commissioner's designee;
(3) The Commissioner of Administrative and Financial Services or the commissioner's designee; and
(4) The Treasurer of State or the treasurer's designee.
(1) Health care purchasing;
(2) Individual health insurance coverage;
(3) Small group health insurance coverage;
(4) The MaineCare program;
(5) Health benefit plan or dental benefit plan administration;
(6) Administering a public or private health care delivery system;
(7) Health care financing; and
(8) Health policy and law.
(1) One member who serves as the chair of the Medicaid advisory committee within the Department of Health and Human Services;
(2) One member representing a federally recognized Indian tribe; and
(3) Two members representing consumers, including either one employee who receives health care coverage through a commercially insured product or one representative of organized labor and either one representative of a consumer health advocacy organization or one representative of the uninsured or Medicaid recipients.
(1) A member or staff member of the board may not make, participate in making or in any way attempt to use that member's or staff member's official position to influence the making of any decision that the member or staff member knows or has reason to know will have a reasonably foreseeable material financial effect, distinguishable from its effect on the public generally, on that member or staff member or a member of that member's or staff member's immediate family, or on either of the following:
(a) Any source of income, other than gifts and other than loans by a commercial lending institution in the regular course of business on terms available to the public without regard to official status, aggregating $250 or more in value provided to, received by or promised to the member or staff member within 12 months prior to the time when the decision is made; or
(b) Any business entity in which the member or staff member is a director, officer, partner, trustee or employee or holds any position of management.
(2) If a member or staff member of the board has a conflict of interest in a matter before the board requiring member or staff action, the member or staff member shall recuse that member's or staff member's self from the matter and may not vote on or attempt to influence the outcome of the matter. Whether or not recusal is required under this subparagraph, a member or staff member of the board shall consider recusing that member's or staff member's self from any matter that would give rise to an appearance of a conflict of interest.
§ 7205. Limitation on liability
§ 7206. Prohibited interests of board members and employees
Board members and employees of the marketplace and their spouses and dependent children may not receive any direct personal benefit from the activities of the marketplace in assisting any private entity, except that they may participate in the marketplace on the same terms as others may under this chapter. This section does not prohibit corporations or other entities with which board members are associated by reason of ownership or employment from participating in activities of the marketplace or receiving services offered by the marketplace as long as the ownership or employment is made known to the board and, if applicable, the board members abstain from voting on matters relating to that participation.
§ 7207. Records
Except as provided in subsections 1 and 2, information obtained by the marketplace under this chapter is a public record within the meaning of Title 1, chapter 13, subchapter 1.
§ 7208. Executive director
§ 7209. Availability of coverage
§ 7210. Powers and duties of the Maine Health Benefit Marketplace
(1) Fairly and affirmatively offer, market and sell all products made available to individuals in the marketplace to individuals purchasing coverage outside the marketplace; and
(2) Fairly and affirmatively offer, market and sell all products made available to small employers in the marketplace to small employers purchasing coverage outside the marketplace;
(1) There is no affordable qualified health plan available through the marketplace, or the individual's employer, covering the individual; or
(2) The individual meets the requirements for any other exemption from the individual responsibility requirement or penalty;
(1) A list of the individuals who are issued a certification under paragraph P, including the name and taxpayer identification number of each individual;
(2) The name and taxpayer identification number of each individual who was an employee of an employer but who was determined to be eligible for the premium tax credit under Section 1401 of the federal Affordable Care Act because:
(a) The employer did not provide the minimum essential coverage; or
(b) The employer provided the minimum essential coverage, but it was determined under Section 1401 of the federal Affordable Care Act to either be unaffordable to the employee or not provide the required minimum actuarial value; and
(3) The name and taxpayer identification number of:
(a) Each individual who notifies the marketplace under Section 1411(b)(4) of the federal Affordable Care Act that the individual has changed employers; and
(b) Each individual who ceases coverage under a qualified health plan during a plan year and the effective date of that cessation;
(1) Conduct public education activities to raise awareness of the availability of qualified health plans and qualified stand-alone dental benefit plans;
(2) Distribute fair and impartial information concerning enrollment in qualified health plans and qualified stand-alone dental benefit plans and the availability of premium tax credits under Section 1401 of the federal Affordable Care Act and cost-sharing reductions under Section 1402 of the federal Affordable Care Act;
(3) Facilitate enrollment in qualified health plans and qualified stand-alone dental benefit plans;
(4) Provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under the federal Public Health Service Act, 42 United States Code, Section 300gg-93 (2010), or any other appropriate state agency or agencies, for an enrollee with a grievance, complaint or question regarding a health benefit plan or stand-alone dental benefit plan or coverage or a determination under that plan or coverage; and
(5) Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the marketplace.
An individual licensed as an insurance producer pursuant to chapter 16 may serve as a navigator to qualified individuals in the marketplace and in the SHOP exchange in accordance with Section 1311(i) of the federal Affordable Care Act;
(1) Educated health care consumers who are enrollees in qualified health plans and qualified stand-alone dental benefit plans;
(2) Individuals and entities with experience in facilitating enrollment in qualified health plans and qualified stand-alone dental benefit plans;
(3) Representatives of small businesses and self-employed individuals;
(4) Representatives of the MaineCare program; and
(5) Advocates for enrolling hard-to-reach populations;
(1) Investigate the affairs of the marketplace;
(2) Examine the properties and records of the marketplace; and
(3) Require periodic reports in relation to the activities undertaken by the marketplace; and
§ 7211. Health benefit plan certification
(1) The marketplace has determined that at least one qualified stand-alone dental benefit plan is available to supplement the plan's coverage; and
(2) The carrier makes prominent disclosure at the time it offers the plan, in a form approved by the marketplace, that the plan does not provide the full range of essential pediatric dental benefits and that qualified stand-alone dental benefit plans providing those benefits and other dental benefits not covered by the plan are offered through the marketplace;
(1) Is licensed and in good standing to offer health insurance coverage in this State;
(2) Offers at least one qualified health plan in the silver level and at least one plan in the gold level as described in Section 1302(d)(1)(B) and (d)(1)(C) of the federal Affordable Care Act through each component of the marketplace in which the carrier participates. As used in this subparagraph, "component" means the SHOP exchange and the marketplace;
(3) Offers at least one qualified health plan that provides the essential health benefits package described in Section 1302(a) of the federal Affordable Care Act without benefits that duplicate the minimum dental benefits of stand-alone dental benefit plans, if the marketplace has determined that at least one qualified stand-alone dental benefit plan is available through the marketplace to supplement the qualified health plan's coverage;
(4) Charges the same premium rate for each qualified health plan without regard to whether the plan is offered through the marketplace and without regard to whether the plan is offered directly from the carrier or through an insurance producer;
(5) Does not charge any fees or penalties for termination of coverage in violation of section 7209, subsection 4; and
(6) Complies with the regulations developed by the secretary under Section 1311(c) of the federal Affordable Care Act and such other requirements as the marketplace may establish;
(1) Claims payment policies and practices;
(2) Periodic financial disclosures;
(3) Data on enrollment;
(4) Data on disenrollment;
(5) Data on the number of claims that are denied;
(6) Data on rating practices;
(7) Information on cost sharing and payments with respect to any out-of-network coverage;
(8) Information on enrollee and participant rights under Title I of the federal Affordable Care Act; and
(9) Other information as determined appropriate by the secretary.
The information required in this paragraph must be provided in plain language, as that term is defined in Section 1311(e)(3)(B) of the federal Affordable Care Act;
(1) Is licensed and in good standing to offer dental coverage in this State. The carrier need not be licensed to offer other health benefits;
(2) Offers at least one stand-alone dental benefit plan that includes only the essential pediatric dental benefit requirement of Section 1302(b)(1)(J) of the federal Affordable Care Act, as long as this requirement does not limit a carrier from providing other stand-alone dental benefit plans that are certified by the marketplace;
(3) Charges the same premium rate for each stand-alone dental benefit plan without regard to whether the plan is offered through the marketplace and without regard to whether the plan is offered directly from the carrier or through an insurance producer;
(4) Submits the premium rates and contract language to the superintendent for approval;
(5) Does not charge any fees or penalties for termination of coverage in violation of section 7209, subsection 4; and
(6) Complies with any regulations adopted by the secretary under Section 1311(d) of the federal Affordable Care Act and any rules adopted by the marketplace pursuant to this chapter.
§ 7212. Navigators
A navigator may not be an insurer or receive any consideration directly or indirectly from any insurer in connection with the enrollment of any qualified individual or employees of a qualified employer in a qualified health plan.
§ 7213. Carrier participation
§ 7214. The Maine Health Benefit Marketplace Enterprise Fund
The Maine Health Benefit Marketplace Enterprise Fund is created as an enterprise fund for the deposit of any funds advanced for initial operating expenses, payments made by employers and individuals, federal funds and any funds received from any public or private source. The fund may not lapse, but must be carried forward to carry out the purposes of this chapter.
§ 7215. Maine Health Benefit Marketplace Business Advisory Council
The Maine Health Benefit Marketplace Business Advisory Council, referred to in this chapter as "the advisory council," is established to advise the marketplace. Except as provided in section 7207, subsection 2, information obtained by the advisory council is a public record as provided by Title 1, chapter 13, subchapter 1.
Prior to making appointments to the advisory council, the Governor shall seek nominations from the public statewide associations representing the interests under paragraphs A to F and other entities as appropriate.
§ 7216. Relation to other laws
This chapter, and any action taken by the marketplace pursuant to this chapter, may not be construed to preempt or supersede the authority of the superintendent to regulate the business of insurance within this State. Except as expressly provided to the contrary in this chapter, all health carriers offering qualified health plans or qualified stand-alone dental benefit plans in this State shall comply fully with all applicable health insurance laws of this State and rules adopted and orders issued by the superintendent.
Sec. 5. Staggered terms; Board of Directors of the Maine Health Benefit Marketplace. Notwithstanding the Maine Revised Statutes, Title 24-A, section 7204, subsection 3, of the initial voting members appointed to the Board of Directors of the Maine Health Benefit Marketplace, 2 members must be appointed to serve initial terms of one year, 3 members must be appointed to serve initial terms of 2 years and 4 members must be appointed to serve initial terms of 3 years.
Sec. 6. Staggered terms; Maine Health Benefit Marketplace Business Advisory Council. Notwithstanding the Maine Revised Statutes, Title 24-A, section 7215, subsection 2, of the initial members appointed to the Maine Health Benefit Marketplace Business Advisory Council, 3 members must be appointed to serve initial terms of 3 years, 3 members must be appointed to serve initial terms of 4 years and 2 members must be appointed to serve initial terms of 5 years.
Sec. 7. Transition. The following provisions apply to the establishment of the Maine Health Benefit Marketplace pursuant to the Maine Revised Statutes, Title 24-A, chapter 93.
1. Board appointed. Within 30 days of the effective date of this Act, the Governor shall post nominations for the appointment of the members of the Board of Directors of the Maine Health Benefit Marketplace. As soon as practicable after Senate confirmation of board members, the board shall appoint the Executive Director of the Maine Health Benefit Marketplace pursuant to Title 24-A, section 7208.
2. Initial staffing; Dirigo Health. Upon request from the Board of Directors of the Maine Health Benefit Marketplace, the Executive Director of Dirigo Health shall provide initial staffing assistance to the marketplace in the initial phases of its operations until the appointment of the Executive Director of the Maine Health Benefit Marketplace. The Executive Director of the Maine Health Benefit Marketplace shall hire staff and contract for services to implement this Act. In hiring and contracting, the Executive Director of the Maine Health Benefit Marketplace may give preference to state employees and contractors who are employed by Dirigo Health.
3. Grant funding. As soon as practicable after Senate confirmation of board members, the Board of Directors of the Maine Health Benefit Marketplace shall submit an application to the Secretary of the United States Department of Health and Human Services for any grant funding made available to states for exchange planning and implementation pursuant to the federal Patient Protection and Affordable Care Act, Public Law 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, Public Law 111-152.
4. Report. Beginning 90 days after the effective date of this Act and until June 30, 2014, the Executive Director of the Maine Health Benefit Marketplace shall report on a quarterly basis to the joint standing committee of the Legislature having jurisdiction over insurance and financial services matters on the actions taken by the Board of Directors of the Maine Health Benefit Marketplace and the initial operations of the Maine Health Benefit Marketplace.
Sec. 8. Maine Health Benefit Marketplace funding mechanism; report. The Board of Directors of the Maine Health Benefit Marketplace shall consider how to ensure that the marketplace is financially sustainable by 2015 as required by federal law, including, but not limited to:
1. A recommended plan for the budget of the marketplace; and
2. The funding mechanism recommended by the marketplace to fund its operations. Any funding mechanism recommended by the marketplace must be broad-based, may not disadvantage health benefit plans offered inside the marketplace and must minimize adverse selection.
On or before February 1, 2014, the Board of Directors of the Maine Health Benefit Marketplace shall submit a report, including suggested legislation, with its recommended funding mechanism to the joint standing committee of the Legislature having jurisdiction over insurance matters. The joint standing committee of the Legislature having jurisdiction over insurance matters may submit a bill based on the report to the Second Regular Session of the 126th Legislature.
Sec. 9. Impact of adverse selection on the Maine Health Benefit Marketplace; report. The Board of Directors of the Maine Health Benefit Marketplace, in consultation with any advisory committees established pursuant to the Maine Revised Statutes, Title 24-A, chapter 93 and with other stakeholders, shall study and make recommendations regarding the rules under which health benefit plans should be offered inside and outside the marketplace in order to mitigate adverse selection and encourage enrollment in the marketplace, including:
1. Whether any benefits should be required of qualified health plans beyond those mandated by the federal Affordable Care Act, as defined in the Maine Revised Statutes, Title 24-A, section 14, and whether any such additional benefits should be required of health benefit plans offered outside the marketplace; and
2. Whether carriers offering health benefit plans outside the marketplace should be required to offer either all the same health benefit plans inside the marketplace or, alternatively, at least one health benefit plan inside the marketplace.
On or before April 1, 2013, the Board of Directors of the Maine Health Benefit Marketplace shall submit a report, including any suggested legislation, with its recommendations to the joint standing committee of the Legislature having jurisdiction over insurance matters. The joint standing committee of the Legislature having jurisdiction over insurance matters may submit a bill based on the report to the First Regular Session of the 126th Legislature.
Sec. 10. Appropriations and allocations. The following appropriations and allocations are made.
HEALTH BENEFIT MARKETPLACE
Maine Health Benefit Marketplace Fund N136
Initiative: Allocates funds for the salary, benefits and related costs of the Executive Director, Maine Health Benefit Marketplace position.
MAINE HEALTH BENEFIT MARKETPLACE ENTERPRISE FUND | 2011-12 | 2012-13 |
POSITIONS - LEGISLATIVE COUNT
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0.000 | 1.000 |
Personal Services
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$0 | $158,003 |
All Other
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$0 | $5,000 |
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MAINE HEALTH BENEFIT MARKETPLACE ENTERPRISE FUND TOTAL | $0 | $163,003 |
SUMMARY
This amendment reflects the recommendations of the minority of the committee. The amendment makes the following changes to the bill.
1. It designates the position of Executive Director of the Maine Health Benefit Marketplace as a major policy-influencing position under state law and establishes the salary range for the position.
2. It makes changes to strengthen the conflict of interest provisions related to members and staff of the Board of Directors of the Maine Health Benefit Marketplace.
3. It authorizes the marketplace to offer qualified stand-alone dental benefit plans and other dental benefit plans.
4. It authorizes the board to standardize health plan coverage to be offered through the marketplace and also requires carriers to offer certain levels of coverage both through the marketplace and outside of the marketplace.
5. It requires the board to consult with the Department of Health and Human Services and the MaineCare Advisory Committee when considering whether to establish a basic health program and requires the board to submit its recommendation to the Legislature by April 1, 2013.
6. It establishes standards for the participation of navigators through the marketplace and authorizes insurance producers to act as navigators with respect to both individuals and small employers.
7. It removes the provisions in the bill that eliminate the Dirigo Health program effective January 1, 2014 and transfer the health access payment from Dirigo Health, since the health access payment is eliminated as of January 1, 2014 pursuant to Public Law 2011, chapter 380, Part BBB. The amendment requires the board to report to the Legislature and the Governor with recommendations for how the marketplace can be self-sustaining by 2015 and also requires the board to study the effect of adverse selection on the marketplace.
8. It removes the provisions in the bill making changes to the Maine Insurance Code that preserve the authority of the Superintendent of Insurance to enforce the federal Patient Protection and Affordable Care Act since substantially similar provisions were enacted by Public Law 2011, chapter 364.
9. It removes the provision in the bill requiring the Department of Professional and Financial Regulation, Bureau of Insurance to review the minimum essential benefits package to be determined by the Secretary of the United States Department of Health and Human Services in comparison with existing state mandated health insurance benefit laws.
10. It allocates funds for the Executive Director of the Maine Health Benefit Marketplace.