Sec. H-1. 24-A MRSA §1951, sub-§2, as corrected by RR 2001, c. 2, Pt. B, §42 and affected by §58, is amended to read:
2. Private purchasing alliance. "Private purchasing alliance" or "alliance" means a corporation licensed pursuant to this section established under former Title 13-A, Title 13-B or Title 13-C to provide health insurance to its members through one or more participating carriers.
Sec. H-2. 24-A MRSA §1952, as enacted by PL 1995, c. 673, Pt. A, §3, is amended to read:
A person or entity private purchasing alliance may not market, sell, offer or arrange for a package of one or more health benefit plans underwritten by 2 one or more carriers without first being licensed by the superintendent. The superintendent shall specify by rule standards and procedures for the issuance and renewal of licenses for private purchasing alliances. A rule may require an application fee of not more than $400 and an annual license fee of not more than $100. A license may not be issued until the rulemaking required by this chapter has been undertaken and all required rules are in effect.
Sec. H-3. 24-A MRSA §2736-C, sub-§5, as enacted by PL 1993, c. 477, Pt. C, §1 and affected by Pt. F, §1, is amended to read:
5. Loss ratios. For all policies and certificates issued on or after the effective date of this section, the superintendent shall disapprove any premium rates filed by any carrier, whether initial or revised, for an individual health policy unless it is anticipated that the aggregate benefits estimated to be paid under all the individual health policies maintained in force by the carrier for the period for which coverage is to be provided will return to policyholders at least 65% of the aggregate premiums collected for those policies, as determined in accordance with accepted actuarial principles and practices and on the basis of incurred claims experience and earned premiums.
Sec. H-4. 24-A MRSA §2747, sub-§1, as enacted by PL 1981, c. 205, §2, is amended to read:
1. Any insurer denying medical expense reimbursement benefits on any of the grounds specified in subsection 2 for a claim filed pursuant to a policy issued under this chapter, other than a policy that is subject to section 4312, shall provide the policy or certificate holder with an opportunity to have the denial reviewed by the insurer and to arbitrate the denial if not satisfied after review. The right to review and arbitrate shall must be prominently set forth in any written notice sent to the policy or certificate holder denying the claim. The arbitration shall be is nonbinding and shall must be carried out in accordance with procedures established by the insurer.
Sec. H-5. 24-A MRSA §2808-B, sub-§1, ¶D, as amended by PL 2001, c. 258, Pt. E, §3 and c. 400, §1 and affected by §2, is repealed and the following enacted in its place:
D. "Eligible group" means any person, firm, corporation, partnership, association or subgroup engaged actively in a business that employed an average of 50 or fewer eligible employees during the preceding calendar year.
(1) If an employer was not in existence throughout the preceding calendar year, the determination must be based on the average number of employees that the employer is reasonably expected to employ on business days in the current calendar year.
(2) In determining the number of eligible employees, companies that are affiliated companies or that are eligible to file a combined tax return for purposes of state taxation are considered one employer.
(3) A group is not an eligible group if there is any one other state where there are more eligible employees than are employed within this State and the group had coverage in that state or is eligible for guaranteed issuance of coverage in that state.
(4) An employer qualifies as an eligible group for 2-person coverage if the employer provides a carrier with the following information demonstrating that the employer's business and employees meet the minimum qualifications for group coverage in paragraph C:
(a) A copy of the most recent quarterly combined filing for income tax withholding and unemployment contributions, Form 941/C1-ME;
(b) For an employee claimed to be an employee eligible for group coverage whose name is not listed on Form 941/C1-ME, a copy of the employer's payroll records for the most recent 3 months showing tax withholding or a wage report from a payroll company showing wages paid to that employee for the most recent quarter with tax withholding;
(c) If an employer is exempt from filing Form 941/C1-ME for group coverage, documentation of that exemption and a copy of the employer's payroll records for the most recent 3 months showing tax withholding or a wage report from a payroll company showing wages paid to that employee for the most recent quarter with tax withholding; or
(d) If the name of the business owner or employee does not appear on Form 941/C1-ME, a copy of one of the following:
(i) Federal income tax Form Schedule C or Schedule F;
(ii) Federal income tax Form 1120S, Schedule K-1;
(iii) Federal income tax Form 1065, Schedule K-1;
(iv) A workers' compensation insurance audit or evidence of a waiver of benefits under Title 39-A;
(v) A description of operations in a commercial general liability insurance policy or equivalent insurance policy providing coverage for the business; or
(vi) A signature card from a financial institution or credit union authorizing the employee to sign checks on a business checking or share draft account that is at least 6 months old; a notarized affidavit from the employer describing the duties of the employee and the average number of hours worked by the employee and attesting that the employer is not defrauding the carrier and is aware of the consequences of committing fraud or making a material misrepresentation to the carrier, including a loss of coverage and benefits; and, if the group coverage is purchased through a producer, a notarized affidavit from the producer affirming the producer's belief that the employer qualifies as an eligible group for coverage.
In determining if a new business or a business that adds an owner or a new employee to payroll during the course of a year qualifies as an eligible group for 2-person coverage under this subparagraph, the employer must submit an affidavit stating that all employees meet the criteria in this subpara-graph and that the documentation and forms required under this subparagraph will be provided to the carrier when payroll records become available, when ownership distribution forms become available or the first renewal date of the coverage, whichever date is earlier. A false affidavit or misrepresentation on an affidavit submitted by an employer may result in the loss of group coverage and repayment of claims paid. This subparagraph may not be construed to prohibit a carrier from recognizing an employer as an eligible group if the employer has not produced the documentation required in this subparagraph.
This subparagraph applies only to an employer applying for group health insurance coverage as a 2-person group on or after October 1, 2001.
Sec. H-6. 24-A MRSA §4331, sub-§4, as enacted by PL 1999, c. 609, §20, is amended to read:
4. Downstream risk arrangement. "Downstream risk arrangement" means any compensation an arrangement between that transfers insurance risk from a carrier and to a downstream entity that may directly or indirectly have the effect of reducing or limiting services furnished to enrollees of the carrier.
Sec. H-7. 24-A MRSA §5011, sub-§2, as enacted by PL 1991, c. 740, §13, is amended to read:
2. Discounts. Issuers that do not vary rates for a standardized plan based on age, gender, health status, claims experience, policy duration, industry or occupation, and that do not refuse issue of that plan to any individual or group based on health status, may provide discounts on that plan to individuals who purchase coverage during their initial period of eligibility for enrollment in Medicare Part A by reason of age B at or after 65 years of age, subject to approval by the superintendent. The superintendent may adopt rules governing the appropriate use of discounts.
| Revisor of Statutes Homepage | Subject Index | Search | 121st Laws of Maine | Maine Legislature |
