Section 031-856-5 - Operation of Pooled MarketThe provisions of this section shall apply to all pooled market health plans providing coverage in this State.
1.Guaranteed Issue and Guaranteed Renewal. Except as prohibited by federal law with respect to catastrophic plans:A. Every carrier offering any pooled market health plan must offer the same plan to all individuals and small employers within any service area where the carrier has made the plan available, subject to the network capacity limitations of 24-A M.R.S. §§2736-C(3)(A)(2) and 2808-B(4)(A)(2). Coverage for individuals, and coverage for small employers that fail to meet the carrier's approved participation requirements, shall be available only during annual open enrollment periods and designated special enrollment periods.B. No pooled market health plans may be added or discontinued after the rate and form filing deadline established by the Superintendent.C. This subsection does not require carriers to market all pooled market health plans in the same manner to all customers. A carrier may vary its marketing strategies and distribution channels, including the decision whether to offer a plan on the Maine Health Insurance Marketplace established pursuant to 22 M.R.S. §5403, between one plan and another, between one service area and another, or between individuals and small employers, as long as the carrier does not discriminate on the basis of actual or perceived health risk or other prohibited classifications.D. All pooled market health plans must be guaranteed renewable, subject to the carrier's right to discontinue or modify coverage when permitted by 24-A M.R.S. §2850-B(3) and applicable contract terms. E. This section does not prohibit differences in the administrative provisions of the policy forms issued to individuals and the coverage documents for the same plan issued to small employers and plan participants, if the variations in contract terms are reasonably related to the differences in the mode of coverage, and do not affect the plan benefits or premium rates except to the extent expressly permitted by this rule or required by controlling law.2.Unified Rating Process. Proposed rates for all pooled market health plans shall be filed and reviewed annually in accordance with 24-A M.R.S. §§2736 through 2736-C, which shall supersede any provisions of the Insurance Code that would otherwise establish different requirements or procedures for small group health plans. A. This subsection does not prohibit composite rating of small group health plans, to the extent permitted by federal law, in accordance with procedures published by the Superintendent. B. Catastrophic plans shall be adjusted for the expected impact of the special eligibility categories for these plans. Carriers may not recover this adjustment elsewhere in the rating process, because such an adjustment would remove the catastrophic plan experience from the single risk pool,3.ACA Compliance. When the Superintendent makes a final determination to implement the pooled market, the Superintendent shall promptly notify applicable federal officials, and shall make all necessary arrangements to ensure compliance with the provisions of the federal Affordable Care Act governing merged markets, including, without limitation: risk adjustment, minimum medical loss ratio requirements, and ratemaking and rate filing for pooled market health plans.02-031 C.M.R. ch. 856, § 5