24-A §4305. Quality of care - Maine Statutes

Title 24-A: MAINE INSURANCE CODE

Chapter 56-A: HEALTH PLAN IMPROVEMENT ACT HEADING: PL 1997, C. 792, §2 (RPR)

Subchapter 1: HEALTH PLAN REQUIREMENTS HEADING: PL 1997, C. 792, §2 (NEW)

§4305. Quality of care

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. [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.

[ 1995, c. 673, §1 (NEW); 1995, c. 673, §2 (AFF) .]

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.

[ 1995, c. 673, §1 (NEW); 1995, c. 673, §2 (AFF); 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.

[ 1995, c. 673, §1 (NEW); 1995, c. 673, §2 (AFF) .]

SECTION HISTORY

1995, c. 673, §C1 (NEW). 1995, c. 673, §C2 (AFF). 1999, c. 742, §14 (AMD). 2003, c. 689, §B6 (REV). 2007, c. 199, Pt. B, §14 (AMD).