1. Continuation of coverage by other carriers. In the event of an insolvency of a health maintenance organization and if satisfactory arrangements for the performance of its obligations have not been made as provided for in section 4214, all other carriers that made an offer of coverage to any group contract holder of the insolvent health maintenance organization at the most recent purchase or renewal of coverage, upon order of the superintendent, shall offer the enrollees in the group covered by that contract a 30-day enrollment period that begins on the date of insolvency.
Each carrier shall offer the group’s enrollees the same coverage and rates that the carrier had offered to those enrollees at the most recent purchase or renewal of coverage prior to the insolvency, except that a successor health maintenance organization may increase the group’s rate to the extent justified by including the new enrollees in a recalculation of rates using the existing method of rate calculation of the successor carrier or, if the group was covered under a multiple-year contract, to the extent justified to take into account increased health care costs, as approved by the superintendent.

[PL 2001, c. 88, §8 (AMD).]

Terms Used In Maine Revised Statutes Title 24-A Sec. 4231

  • Carrier: means a health maintenance organization, an insurer, a nonprofit hospital, a medical service corporation or any other entity responsible for the payment of benefits or provision of services under a group contract. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Contract: A legal written agreement that becomes binding when signed.
  • Group contract holder: means an entity or person that has purchased coverage from a health maintenance organization that provides, at a minimum, basic health care services to enrollees. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Health care services: means any services included in the furnishing of medical care, dental care or hospitalization to an individual, or any services incident to the furnishing of that care or hospitalization, as well as the furnishing of any other services to an individual to prevent, alleviate, cure or heal human illness or injury. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Health maintenance organization: means a public or private organization that is organized under the laws of the Federal Government, this State, another state or the District of Columbia or a component of such an organization, and that:
A. See Maine Revised Statutes Title 24-A Sec. 4202-A
  • Superintendent: means the Superintendent of Insurance. See Maine Revised Statutes Title 24-A Sec. 4202-A
    • 2. Allocation of enrollees. If no other carrier had offered coverage to a group contract holder in the insolvent health maintenance organization, or if the superintendent determines that the other health benefit plan or plans lack sufficient health care delivery resources to ensure that health care services will be available and reasonably accessible to all of that group’s enrollees in the insolvent health maintenance organization, then the superintendent shall allocate equitably the insolvent health maintenance organization’s group contracts among all health maintenance organizations that operate within a portion of the insolvent health maintenance organization’s service area, taking into consideration the health care delivery resources of each health maintenance organization. Each health maintenance organization to which a group or groups are so allocated shall offer such group or groups the health maintenance organization’s existing coverage that is most similar to each group’s coverage with the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization’s existing rating methodology.

    [PL 1989, c. 842, §18 (NEW).]

    3. Nongroup enrollees.

    [PL 1995, c. 332, Pt. O, §10 (RP).]

    4. Allocation upon withdrawal. If any group contract holder of a withdrawing health maintenance organization is unable to obtain replacement coverage subsequent to a withdrawal pursuant to section 415?A, the superintendent may allocate equitably the withdrawing health maintenance organization’s group contract holders among all health maintenance organizations that operate within a portion of the withdrawing health maintenance organization’s service area in accordance with subsection 2.

    [PL 2001, c. 88, §9 (NEW).]

    SECTION HISTORY

    PL 1989, c. 842, §18 (NEW). PL 1995, c. 332, §O10 (AMD). PL 2001, c. 88, §§8,9 (AMD).
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