Section 031-851-4 - General Provisions1. Each plan subject to this rule must be a Clear Choice Plan approved under Section 5 or an Alternative Plan approved under Section 6. 2. Each plan subject to this rule must comply with all applicable benefit and provider mandates under state law and the ACA, including all essential health benefits specified in accordance with 24-A M.R.S. §4320- D. Behavioral health benefits must comply with all applicable parity requirements. A. This rule shall not be construed as creating any new or additional benefit or provider mandates. A plan's failure to provide a particular benefit that is identified in a Clear Choice Design, if otherwise permitted by law, does not prevent that plan from conforming to that Clear Choice Design.B. Unless a federal waiver is granted, federal requirements preempt conflicting state requirements. In particular, as long as the applicable federal prohibitions remain in force and have not been waived:(1) Catastrophic Plans may not be offered to small employers or ineligible individuals;(2) Catastrophic Plans may not exempt any services from the deductible when prohibited by the ACA; and(3) HSA Plans may not exempt any services from the deductible that are not approved by the federal Internal Revenue Service for pre-deductible coverage by high deductible health plans.C. A plan's inclusion of benefits that are not identified in a Clear Choice Design does not prevent that plan from conforming to that Clear Choice Design.D. Clear Choice Designs do not address cost-sharing amounts for any out-of-network services. Plans may include any lawful cost-sharing design for out-of-network services, except when network-level cost sharing is required by law: for example, emergency services, surprise bills, and cases of network inadequacy or unavailability.E. Two plans shall be treated as different options within a single Clear Choice Design or within a single Alternative Plan Design if they differ only by characteristics that are not specified in the cost-sharing design, or that are expressly permitted to vary, including but not limited to:(1) Whether the plan includes or excludes pediatric dental benefits, to the extent permitted by law;(2) Whether the plan is a Silver plan variant providing cost-sharing reductions as determined by the carrier in accordance with the ACA;(3) Whether the plan is a preferred provider arrangement, a health maintenance organization plan, or a point-of-service health maintenance organization plan;(4) Whether the plan uses a tiered network. Tiered network plans may be offered as Clear Choice Plans as long as the specified cost sharing is offered at the broadest network tier;(5) Whether the plan includes an additional tier for low-cost generic prescription drugs, with a lower copayment than the copayment specified for generic drugs; and(6) Whether the plan incorporates a site-of-service incentive program. A site-of-service incentive benefit may, for example, apply a copayment in place of a deductible or coinsurance that would otherwise apply.3. Carriers shall discontinue all non-grandfathered small group health plans offered in the year preceding the pooled market implementation year. No such plans may be issued or renewed during the pooled market implementation year, with the exception of any existing plan that the carrier chooses to offer as an Alternative Plan pursuant to Section 6. On renewal, the carrier shall map each policyholder with a discontinued plan to its most similar plan offered in the pooled market in the pooled market implementation year. A. Except as provided in Paragraph B, the replacement shall be considered a benefit modification required by law in accordance with 24-A M.R.S. §2850- B(3)(I)(3).B. The carrier must demonstrate, in accordance with 24-A M.R.S. §2850- B(3)(G)(2) or (I)(4), that the discontinuance and replacement is a minor modification or is otherwise in the best interest of policyholders if: (1) The carrier chooses not to offer a Clear Choice design that is more similar to a discontinued plan than the carrier's designated replacement;(2) The carrier chooses to map a non-HMO policyholder into an HMO plan, or to map an HMO enrollee that has a point-of-service benefit into an HMO plan without a point-of-service benefit; or(3) The carrier chooses to map an HMO enrollee into non-HMO coverage.C. The requirement to discontinue small group plans and replace them with plans approved under this rule does not apply to plans issued to small employers through an association or trustee group that is excluded from the pooled market pursuant to 24-A M.R.S. §2808- B(2)(E)(2) and applicable provisions of the ACA.4. The discontinuance or modification of a health plan is also considered a benefit modification required by law in accordance with 24 A M.R.S. §2850- B(3) (I)(3) if: A. The Superintendent discontinues or materially modifies a Clear Choice design and the carrier maps enrollees to a new Clear Choice plan designated by the Superintendent as an appropriate replacement; orB. The carrier offers new Alternative Plans in the pooled market implementation year that are specifically designed to be marketed to small employers, must discontinue or materially modify one or more existing Alternative Plans in order to do so, and maps those policyholders to new plans in a manner that does not exceed the restrictions set forth in Subsection 3, Paragraph B.02-031 C.M.R. ch. 851, § 4