Maine Revised Statutes Title 24-A Sec. 4305 – Quality of care
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A carrier offering or renewing a health plan that subjects payment of benefits for otherwise covered services to review for clinical necessity, appropriateness, efficacy or efficiency must meet the following requirements relating to quality of care. [PL 2007, c. 199, Pt. B, §14 (AMD).]
1. Internal quality assurance program. A health plan must have an ongoing quality assurance program for the health care services provided or reimbursed by the health plan.
[PL 1995, c. 673, §1 (NEW); PL 1995, c. 673, §2 (AFF).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 4305
- Carrier: means :
A. See Maine Revised Statutes Title 24-A Sec. 4301-AEnrollee: means an individual who is enrolled in a health plan or a managed care plan. See Maine Revised Statutes Title 24-A Sec. 4301-A Health plan: means a plan offered or administered by a carrier that provides for the financing or delivery of health care services to persons enrolled in the plan, other than a plan that provides only accidental injury, specified disease, hospital indemnity, Medicare supplement, disability income, long-term care or other limited benefit coverage not subject to the requirements of the federal Affordable Care Act. See Maine Revised Statutes Title 24-A Sec. 4301-A
2. Written standards. The standards of quality of care must be described in a written document, which must be available for examination by the superintendent or by the Department of Health and Human Services.
[PL 1995, c. 673, §1 (NEW); PL 1995, c. 673, §2 (AFF); PL 2003, c. 689, Pt. B, §6 (REV).]
3. Coverage decisions. Following a determination that a particular service is covered, a carrier may not deny payment for that service based on the enrollee‘s age, nature of disability or degree of medical dependency.
[PL 1995, c. 673, §1 (NEW); PL 1995, c. 673, §2 (AFF).]
SECTION HISTORY
PL 1995, c. 673, §C1 (NEW). PL 1995, c. 673, §C2 (AFF). PL 1999, c. 742, §14 (AMD). PL 2003, c. 689, §B6 (REV). PL 2007, c. 199, Pt. B, §14 (AMD).