Mandated Health Insurance Benefits

Mandated Health Insurance Benefits: A mandated benefit is coverage that your health insurance company is required by Maine law to provide. These benefits typically pertain to a specific disease or condition. For example, coverage for diabetes supplies and services. A health policy that provides coverage for the mandate as required may contain provisions for maximum benefits and coinsurance and limitations, deductibles and exclusions to the same extent that these provisions are applicable to all coverage and are not inconsistent with the requirements of the particular mandate.

Please note that these mandated benefits only apply to the fully insured market and do not apply to self-funded plans, MaineCare, or Medicare.

 

History of Mandated Benefits for Health Insurance

Year Enacted	Benefit	Contracts Affected	Type of Mandate	Statutory Reference		ET*
				Title 24	Title 24-A
1975	Maternity benefits provided to married women must also be provided to unmarried women.	All Contracts excluding HMOs	Mandated Coverage	§2318	§2741, §2832,	Y
1975	Coverage of children must be made available to unmarried women on the same basis as married women	All Contracts excluding HMOs	Mandated Offer	§2318	§2742, §2833, §4234	Y
1975	Must include benefits for dentists' services to the extent that the same services would be covered if performed by a physician.	All Contracts excluding HMOs	Mandated Provider		§2437	N
1975	Family Coverage must cover any children born while coverage is in force from the moment of birth, including treatment of congenital defects.	All Contracts	Mandated Coverage	§2319	§2743, §2834, §4234-C	Y
1975	Must include benefits for psychologists' services to the extent that the same services would be covered if performed by a physician.	All Contracts excluding HMOs	Mandated Provider		§2744, §2835	Y
1977	Benefits must be made available for home health care services.	All Contracts excluding HMOs	Mandated Offer	§2320	§2745, §2837	N
1979	Benefits must be made available for outpatient health care services of certified rural health clinics.	Nonprofit Hospital & Medical Service Organizations	Mandated Offer	§2324		N
1981	Benefits must be made available for the services of optometrists if the same services would be covered if performed by a physician.	All Groups excluding HMOs	Mandated Offer	§2331	§2841	N
1981 1983 2018	Benefits must include for treatment of substance use disorder, subject to "reasonable limitations".	Groups of more than 20 excluding HMOs	Mandated Coverage	§2329	§2842	Y
1983 1995 2003 2019	Benefits must be included for Mental Health Services, subject to "reasonable limitations". Requires coverage of listed conditions at levels not less extensive than for physical illnesses.	All Contracts	Mandated Coverage	§2325-A	§2749-C, §2843, §4234-A	Y
1983	Benefits must be included for the services of social workers and psychiatric nurses to the extent that the same services would be covered if performed by a physician.	All Contracts excluding HMOs	Mandated Provider		§2744, §2835	Y
1986	Benefits must be included for the services of chiropractors to the extent that the same services would be covered by a physician. Benefits must be included for therapeutic, adjustive and manipulative services.	All Contracts	Mandated Provider and Coverage		§2840-A, §2748, §4236	N
1987	Benefits must be made available for cardiac rehabilitation expenses.	Groups of 20 or more	Mandated Offer		§2845	N
1990	Benefits must be included for AIDS, AIDS Related Complex (ARC) or HIV related diseases to the extent that any other sickness or disabling condition is covered.	All Contracts	Mandated Coverage	§2332-B	§2750, §2846, §4229	Y
1990 1997	Benefits must be made available for screening mammography.	All Contracts	Mandated Coverage	§2320-A	§2837-A, §2745-A, §4237-A	Y
1992	Benefits must be made available for the services of acupuncturist if comparable services would be covered if performed by a physician.	All Contracts	Mandated Provider	§2320-B	§2837-B, §2745-B	Y
1994 1995 1997	Provide benefits for care by chiropractors at least equal to benefit paid to other providers treating similar neuro-musculoskeletal conditions. Requires treatment for acute care for a limited self referred for chiropractic benefits.	HMO Only	Mandated Provider and Coverage		§4236	N
1995	Must provide coverage for reconstruction of both breasts to produce symmetrical appearance according to patient and physician wishes.	All Contracts	Mandated Coverage	§2320-C	§2745-C, §2837-C, §4237	Y**
1995	Must provide coverage for metabolic formula and up to $3,000 per year for prescribed modified low-protein food products.	All Contracts	Mandated Coverage	§2320-D	§2745-D, §2837-D, §4238	Y
1996	Benefits must be provided for maternity (length of stay) and newborn care, in accordance with "Guidelines for Perinatal Care" as determined by attending provider and mother.	All Contracts including HMOs	Mandated Coverage	§2318-A	§2743-A, §2834-A, §4234-B	Y**
1996	Benefits must be provided for medically necessary equipment and supplies used to treat diabetes (insulin, oral hypoglycemic agents, monitors, test strips, syringes and lancets) and approved self-management and education training.	All Contracts	Mandated Coverage	§2332-F	§2754, §2847-E, §4240	Y
1996	Benefits must be provided for screening Pap tests.	Group, and all HMO contracts	Mandated Coverage	§2320-E	§2837-E, §4242	Y
1996	Benefits must be provided for annual gynecological exam without prior approval of primary care physician.	Group managed care	Mandated Coverage	§2332-G	§2847-F, §4241	Y
1996	Benefits must be made available for mental health services provided by licensed counselors.	All Contracts	Mandated Offer		§2744(3), §2835(3), §4234-A(8-A)	N
1997	Benefits provided for breast cancer treatment for a medically appropriate period of time determined by the physician in consultation with the patient.	All Contracts	Mandated Coverage	§2320-C	§2745-C, §2837-C, §4237	Y
1998	Coverage required for off-label use of prescription drugs for treatment of cancer, HIV, or AIDS.	All Contracts	Mandated Coverage	§2320-F, §2320-G	§2745-E, §2745-F, §2837-F, §2837-G, §4234-D, §4234-E	Y
1998	Coverage required for prostate cancer screening: Digital rectal examinations and prostate-specific antigen tests covered if recommended by a physician, at least once a year for men 50 years of age or older until age 72.	All Contracts	Mandated Coverage	§2325-C	§2745-G, §2837-H, §4244	Y
1999	Coverage of nurse practitioners and nurse midwives and allows nurse practitioners to serve as primary care providers.	All Contracts	Mandated Provider	§2332-K	§2757, §2847-H, §4248	Y
1999	Prescription drug coverage must include contraceptives. Effective 2019 coverage must be provided without any deductible, coinsurance, copay or other cost-sharing requirement. Coverage must be provided for dispensing of prescribed coverage for 12 months.	All Contracts	Mandated Coverage	§2332-J	§2756, §2847-G, §4247	Y
1999	Coverage of registered nurse first assistants.	All Contracts	Mandated Provider and Coverage	§2332-L	§2758, §2847-I, §4246	Y
2000	Access to clinical trials.	All Contracts	Mandated Coverage		§4310	Y
2000	Access to prescription drugs for contracts that provide coverage for prescription drugs and medical devices.	All Managed Care Contracts	Mandated Coverage		§4311	Y
2001	Coverage of hospice care services	All Contracts	Mandated Coverage		§2759, §2847-J, §4250	Y
2001	Coverage of general anesthesia for dentistry. Effective 1/02	All Contracts	Mandated Coverage	§2332-M	§2760, §2847-K, §4251	Y
2001	Access to eye care providers. Effective 1/02	All Managed Care Contracts	Mandated Coverage		§4314	Y
2003 2010	Coverage of prosthetic devices to replace an arm or leg. Effective 1/2004. Exclusion for micro-processors removed effective 1/2011.	All Contracts	Mandated Coverage		§4315	Y
2003	Coverage of licensed clinical professional counselors. Effective 1/04 See Bulletin 335 (PDF)	All Contracts	Mandated Provider		§2744, §2835, §4234-A (8)	Y
2005	Coverage of licensed pastoral counselors and marriage & family therapists. Effective 1/06 See Bulletin 335 (PDF)	All Contracts	Mandated Provider		§2744, §2835, §4234-A (8)	Y
2005	Benefits must be made available for breast reduction and symptomatic varicose vein surgery. Effective 1/06	All Contracts	Mandated Offer	§2332-N	§2761, §2847-L, §4252	Y
2007 2019	Hearing Aids - Children currently mandated. Adults effective 1/2020. The dollar limit changes to $3,000 effective 1/2020.	All Contracts	Mandated Coverage		§2762, §2847-O, §4255	Y
2008	Coverage for amino acid-based elemental infant formulas for children 2 years and under, regardless of delivery method. Effective 1/09.	All Contracts	Mandated Coverage		§2764, §2847-P, §4256	Y
2008 2019	Coverage for colorectal cancer screening - Colorectal cancer examinations and laboratory tests recommended by a health care provider in accordance with the most recently published colorectal cancer screening guidelines of a national cancer society or at high risk for colorectal cancer.	All Contracts	Mandated Coverage		§2763, §2847-N, §4254	Y
2009	An insurer that issues individual dental insurance or health insurance that includes coverage for dental services shall provide coverage for dental services performed by an independent practice dental hygienist. Effective 1/2010.	All Contracts	Mandated Provider		§2765, §2847-Q, §4257	Y
2010	Coverage for autism spectrum disorders for individuals 5 years of age or under. May be limited for applied behavior analysis to $36,000 per year. Effective 1/2011	All Contracts	Mandated Coverage		§2768, §2847-T, §4259	Y
2010	Coverage for children’s early intervention services from birth to 36 months for a child identified with a developmental disability or delay. May be limited to $3,200 per year. Effective 1/2011	All Contracts	Mandated Coverage		§2767, §2847-S, §4258	Y
2014	Coverage for autism spectrum disorders expanded to age 10. Effective 1/2015	All Contracts	Mandated Coverage		§2768, §2847-T, §4259	Y
2014	Policies that provide chemotherapy treatment must provide coverage for prescribed orally administered anticancer medications equivalent to the coverage for IV or injected anticancer medication. Effective 1/2015	All Contracts	Mandated Coverage		§4317-B	Y
2014	Reimbursement for human leukocyte antigen testing to register as a bone marrow donor. Limited to $150 per lifetime. May not be applied to any deductible or other cost share. Effective 1/2015	All Contracts	Mandated Coverage		§4320-I	Y
2014	Coverage for services provided by a dental hygiene therapist for policies with dental coverage. Effective 1/2015	All Contracts	Mandated Provider		§2847-U, §2765-A	Y
2015	Coverage for abuse-deterrent opioid analgesic drugs on a basis not less favorable than that for opioid analgesic drugs that are not abuse-deterrent and are covered by the health plan.	All Contracts	Mandated Coverage		§4320-J	N
2018	Coverage for preventive health services including evidence-based items or services with a rating of A or B in the United States Preventive Services Task Force or equivalent, preventive care and screenings and immunizations supported by the federal DHHS.	All Contracts	Mandated Coverage		§4320-A	Y
2018	Coverage for services provided by a naturopathic doctor when those services are covered when provided by any other health care provided and within the lawful scope of practice of the naturopathic doctor.	All Contracts	Mandated Provider		§4320-K	Y
2019	Coverage for Telehealth provided for any medically necessary health care service delivered through telehealth including telemonitoring and telephonic services.	All Contracts effective 1/2020	Mandated Coverage		§4316
2019	Abortion Services - A carrier offering a health plan in this State that provides coverage for maternity services shall provide coverage for abortion services.	Effective 1/2020	Mandated Coverage		§4320-M	Y
2021	Coverage for certified registered nurse anesthetists (CRNA).	All Health Plans Effective 1/2022	Mandated Provider		§4320-P	Y
2021	Coverage for certified midwives.	All Contracts Effective 1/2022	Mandated Provider		§2757, §2847-H, §4248	Y
2021	Coverage for HIV prevention drugs. Limits on prior authorization and step therapy requirements.	All Health Plans Effective 1/2022	Mandated Coverage		§4317-D	Y
2022	Coverage for mental health services that use evidence-based practices and are determined to be medically necessary health care for individuals 21 years of age or younger	All Contracts Effective 4/14/2022	Mandated Coverage		§2749-C, sub-§1, §2843,  §4234-A, sub-§6	Y
2022	Expanded coverage for all prescription contraceptives without cost-sharing	All Contracts Effective 1/2023	Mandated Coverage		§2756, sub-§3, §2847-G, sub-§4,  §4247, sub-§4	Y
2022	Expanded coverage for postpartum care including pelvic floor surgery	All Contracts Effective 1/2023	Mandated Coverage		§2743-B	Y
2022	Coverage for fertility care	All Contracts Effective 1/2024	Mandated Coverage		§4320-U	Y
2022	Coverage for medically necessary prosthetic needs of enrollees under 18 years of age for recreational purposes	All Contracts Effective 1/2024	Mandated Coverage		§4315, sub-§2	Y
2022	Coverage for medically necessary dental procedures for cancer patients	All Contracts Effective 1/2024	Mandated Coverage		§4320-S	Y
2023	Coverage for donor breastmilk for infants when medically necessary	All Contracts Effective 1/2024	Mandated Coverage		§4320-V (PL 229)	Y
2023	First dollar coverage for diagnostic breast examination including mammography, MRI or ultrasound	All Contracts Effective 1/2024	Mandated Coverage		§2745-A, §2837-A, and §4237-A (PL 338)	Y

*ET (Extra-territorial) This column states whether the mandate applies to certificates issued in Maine through group policies that are issued outside of Maine.

** Similar mandate in Federal law.

*** 24-A MRSA Section 704 - Mandates enacted after 2011, unless specifically stated otherwise, do not apply to these types of insurance: accidental injury, specified disease, hospital indemnity, dental, vision, disability income, long-term care, Medicare supplement or other limited benefit health insurance.