Terms Used In Maine Revised Statutes Title 24-A Sec. 4320-C

  • Carrier: means :
A. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • Enrollee: 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
  • Provider: means a practitioner or facility licensed, accredited or certified to perform specified health care services consistent with state law. See Maine Revised Statutes Title 24-A Sec. 4301-A
  • If a carrier offering a health plan provides or covers any benefits with respect to services in an emergency facility or setting, the plan must cover emergency services without prior authorization. Cost-sharing requirements, such as a deductible, copayment amount or coinsurance rate, for out-of-network services are the same as requirements that would apply if such services were provided in network, and any payment made by an enrollee pursuant to this section must be applied to the enrollee’s in-network cost-sharing limit. The enrollee’s responsibility for payment for covered out-of-network emergency services must be limited so that if the enrollee has paid the enrollee’s share of the charge as specified in the plan for in-network services, the carrier shall hold the enrollee harmless from any additional amount owed to an out-of-network provider for covered emergency services and make payment to the out-of-network provider in accordance with section 4303?C or, if there is a dispute, in accordance with section 4303?E. A carrier offering a health plan in this State shall also comply with the requirements of section 4304, subsection 5. [PL 2019, c. 668, §4 (AMD).]
    SECTION HISTORY

    PL 2011, c. 364, §34 (NEW). PL 2019, c. 238, §3 (AMD). PL 2019, c. 668, §4 (AMD).