Maine Health Insurance Policy Requirements

Maine has comprehensive health insurance regulations that work alongside federal requirements. The Maine Bureau of Insurance regulates health coverage in the state under Title 24-A.

Regulatory Structure

Maine health coverage is regulated by a single agency:

HMO Regulation in Maine

Maine regulates Health Maintenance Organizations (HMOs):

• HMOs must be licensed by Bureau of Insurance
• Must meet net worth requirements
• Required to have quality assurance programs
• Must have grievance and appeals processes
• Must maintain adequate provider networks

Healthcare.gov Marketplace

Maine uses the federal Healthcare.gov marketplace:

• Only place to get premium subsidies in Maine
• Offers qualified health plans (QHPs)
• Open enrollment and special enrollment periods
• Subsidies based on income

Key Features

• Plans categorized by metal tiers (Bronze, Silver, Gold, Platinum)
• Premium tax credits based on income
• Cost-sharing reductions for Silver plans
• Special enrollment for qualifying life events

Free Look Period

Maine provides free look periods for health insurance:

• Individual health insurance policies typically have a 10-day free look
• Policyholder can return for full premium refund
• Begins when policy is delivered
• No penalty for exercising this right

Required Coverage

Maine mandates coverage for numerous benefits in accordance with ACA requirements:

Essential Health Benefits

All individual and small group ACA-compliant plans must cover:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorders
6. Prescription drugs
7. Rehabilitative services
8. Laboratory services
9. Preventive and wellness services
10. Pediatric services (including dental and vision)

Mental Health Parity

Maine requires mental health parity in health insurance:

• Mental health benefits must be equal to medical benefits
• Same copays, deductibles, and limits apply
• Covers mental illness and substance use disorders
• Applies to group and individual plans

Covered Conditions

Mental health parity applies to conditions including:

• Major depression
• Bipolar disorder
• Schizophrenia
• Anxiety disorders
• Substance use disorders
• Eating disorders

Pre-Existing Condition Protections

Maine prohibits pre-existing condition exclusions in ACA-compliant plans:

Guaranteed Issue and Renewal

Maine requires for ACA-compliant plans:

Guaranteed Issue

• Insurers must accept all applicants during open enrollment
• Cannot deny coverage based on health status
• Applies to individual and small group markets

Guaranteed Renewal

• Insurers cannot cancel coverage except for:
  • Non-payment of premium
  • Fraud or misrepresentation
  • Plan discontinuation (with notice)