Bulletin 485

2025 Legislative Changes Affecting Insurance in Maine

Health Insurance

The following acts relating to health insurance in Maine were enacted during the First Regular Session of the 132nd Legislature.  All of these acts are effective on September 24, 2025, except where otherwise noted.  Licensees should take appropriate steps in advance of the effective dates of these laws to ensure full compliance.  Licensees are also encouraged to contact the appropriate Bureau work unit with any questions.

• An Act Regarding Coverage for Step Therapy for Metastatic Cancer[1]

This act prohibits a carrier from requiring a member with metastatic cancer (spread from the original site to other areas of the body) to go through step therapy (i.e., prove a history of failure of other prescription drugs before providing coverage of the requested drug).  This prohibition applies to medications for treating the cancer and any associated conditions, symptoms, or side effects resulting from the cancer treatment. 

• An Act to Clarify the Requirements for Accessing Nonformulary Drugs and Drugs Used to Treat Serious Mental Illness[2]

This act provides coverage of an equivalent nonformulary drug if a drug shortage makes the formulary drug unavailable, and rectifies an inconsistency between two prescription drug sections of the Insurance Code, one of which could have been interpreted as requiring carriers to cover all behavioral health drugs regardless of whether the drug was on the carrier’s formulary and one that required an approval process for off-formulary drugs.

• An Act to Clarify and Increase Access to HIV Prevention Medications[3]

This act requires carriers to reimburse pharmacists, beginning no later than January 1, 2027, for prescribing, dispensing, and administering HIV prevention drugs and allows pharmacists to bill commercial insurers for payment directly.  It also provides that each long-acting injectable drug with a different duration constitutes a separate method of administration.  The effect is to require a carrier to cover each duration of long-acting injectables for at least one approved drug with no out-of-pocket cost, no prior authorizations, and no step therapy requirements.

• An Act to Require Health Insurance Coverage for Federally Approved Nonprescription Oral Hormonal Contraceptives and Nonprescription Emergency Contraceptives[4]

This act requires coverage for all nonprescription oral hormonal contraceptives and nonprescription emergency contraceptives approved by the FDA without any deductible, coinsurance, copayment, or other cost-sharing, beginning January 1, 2026.  It also prohibits requiring a prescription for coverage of an over-the-counter contraceptive.  Each health carrier must establish a mechanism to ensure that enrollees who purchase nonprescription contraceptives have the option to either make the purchase at an in-network pharmacy with zero cost-sharing at the point of sale or make the purchase at an out-of-network retail establishment that will require a payment at the point of sale and then submit a claim to the health carrier requesting reimbursement.

• An Act to Require Insurance Coverage for Covered Dental Services Provided by Licensed Dental Hygienists[5]

This act requires dental insurance and health insurance that includes coverage for dental services to cover services lawfully provided by dental hygienists if those same services are covered when provided by a dentist.

• An Act to Improve Accountability and Understanding of Data in Insurance Transactions[6]

This act provides sponsors of self-insured health benefit plans the right to audit claims payments by their third-party administrators and pharmacy benefits managers (PBMs), and to obtain information about claims in excess of $100,000 before the claim is paid.  Violations are punishable under the Maine Unfair Trade Practices Act.[7]

• Resolve, Regarding Legislative Review of Portions of Chapter 850: Health Plan Accountability, a Major Substantive Rule of the Department of Professional and Financial Regulation, Bureau of Insurance[8]

This resolve approves changes made by the Bureau to Rule 850, which were provisionally adopted on December 10, 2024 but required legislative approval to take effect.  The amendments:

• Reflect amendments to the Maine Health Plan Improvement Act as enacted by P.L. 2023, Chapter 680 (“An Act Concerning Prior Authorizations for Health Care Provider Services”), and P.L. 2021, Chapter 603 (“An Act Regarding Reporting on Spending for Behavioral Health Care Services and to Clarify Requirements for Credentialing by Health Insurance Carriers”),
• Comply with new federal requirements included in the U.S. Department of Health and Human Services Notice of Benefit and Payment Parameters for 2025, and
• Delete the requirement that a written adverse health care treatment decision for a claim under appeal identify reviewers by name and title in appeal decisions and replaces it with a requirement that the decision attest to the credentials of those evaluating an appeal and that they were not involved in the initial decision, and a point of contact, including name, address, and telephone number, to answer specific questions from the enrollee.

• An Act Regarding Reimbursements by Health Insurance Carriers or Pharmacy Benefits Managers to Pharmacies[9]

This act prohibits a carrier or PBM under contract with a carrier from paying a pharmacy provider less for a prescription drug or pharmacy service than it would have paid if that pharmacy provider were affiliated with that carrier or PBM.

• An Act to Protect Healthcare for Rural and Underserved Areas by Prohibiting Discrimination by Participants in a Federal Drug Discount Program[10]

This act allows hospitals and federally qualified community health centers (FQHCs) participating in the federal 340B program to contract with pharmacies outside the hospitals or FQHCs without those pharmacies being treated differently by carriers and payors.

The 340B program requires pharmaceutical manufacturers to provide discounts for all drugs covered by Medicaid to all designated “covered entities,” such as safety-net hospitals, which were chosen because they serve disadvantaged populations, and FQHCs.[11]

The act also requires additional 340B reporting from hospitals to the Maine Health Data Organization, and clarifies that the language prohibiting discrimination does not extend to the use of preferred networks by health insurance carriers and pharmacy benefits managers.  It requires that pharmacies and health care providers participating in the program must contract, to the extent possible and as permitted under federal law and regulation, with pharmacies located in this State.  The Maine Unfair Trade Practices Act is the exclusive enforcement mechanism.

• An Act to Expand Direct Health Care Service Arrangements[12]

This act allows direct care agreements for specialists in the same manner as currently available for primary care providers.  It also prohibits carriers from denying payment for a service solely because an enrollee’s referral for the service was obtained from a direct health care provider who was not part of the carrier’s provider network.

• An Act to Clarify the Availability of Alternative Claims Payment Methods to Dental Care Providers[13]

Currently, some insurers make claim payments to providers via credit card, and the credit card company charges a fee to the provider.  The Insurance Code requires the insurer to provide a method for paying claims, on request, via an electronic funds transfer through the automated clearing house network, where the fee would be paid by the insurer rather than the provider.  This act amends 24-A M.R.S. § 2436(1-A) to clarify that dental insurers and dental providers are included within the scope of this requirement.

• An Act to Require Health Insurance Carriers to Provide Contact Information for Employees Responsible for Negotiating Health Care Provider Contracts[14]

This act requires health insurance carriers to provide contact information for employees responsible for negotiating health care provider contracts.

• An Act to Prohibit Health Care Entities Providing Dental Plans from Requiring a Dental Provider to Charge Fees for Uncovered Dental Services[15]

This act prohibits carriers offering dental plans from requiring that a dental practitioner who provides a service to an enrollee of the dental plan that is not covered by the plan do so at a rate set or approved by the entity offering the plan.

• An Act to Prohibit Carriers and Pharmacy Benefits Managers from Using Spread Pricing[16]

This act prohibits PBMs from engaging in spread pricing, which is defined as any amount charged by a PBM to the plan sponsor that exceeds the ingredient cost of a prescription drug plus dispensing fee paid to the pharmacy on behalf of the carrier minus the agreed-upon PBM fee.  The bill includes a sunset clause, repealing the section as of January 1, 2031.

• An Act to Amend the Laws Governing Insurance Coverage of Preventive and Primary Health Services[17]

This act provides that if a large group health plan’s only cost sharing takes the form of copayments, with no deductible and no coinsurance, then the plan is exempt from the requirement to provide coverage without cost sharing for the first primary care office visit and first behavioral health office visit in each plan year.

Property and Casualty Insurance

The following acts relating to property and casualty insurance in Maine were enacted during the First Regular Session of the 132^nd Legislature:

• An Act to Increase Storm Preparedness for Maine’s Communities, Homes and Infrastructure[18]

Part A of this act creates the HoME Resiliency Program within the Bureau of Insurance to make grants to Maine residents for roof replacements and making homes more flood resilient.

The roofing program uses building standards developed by the Insurance Institute for Business and Home Safety (“IBHS”) and is known as “FORTIFIED” roofs.  These standards have the potential to reduce water entry by as much as 95%.  The Maine program, which is modeled after successful programs initiated by state insurance departments in several southeastern states, is designed to address specific perils facing Maine homeowners. 

The roof replacement initiative would help homeowners upgrade their roofs to withstand straight line winds and driving rains, as well as reduce the potential for ice dams. The second initiative focuses on flood and water resilience.  The grant funds will be used to help fund home improvements such as elevating utility connections above ground level, sealing foundations, and installing sump pumps to minimize the damage from water seepage into the home.

These programs will help Maine residents harden their homes to deal with more frequent and intense storms and foster a broader culture of preparedness. 

• An Act to Strengthen the Requirements for Medical Payments Coverage[19]

This act allows the assignment of medical payments benefits only via written authorization by the insured on a form prescribed or approved by the Superintendent of Insurance.  Medical payments is a category of auto coverage that provides limited payments to insured drivers and their passengers for medical expenses they may incur due to an auto accident.  Covered expenses commonly include copayments and deductibles under the terms of a health insurance policy.  Financial responsibility laws require motorists to have at least $2,000 in “med pay” coverage but they will often carry more.

• An Act to Align Intrastate Commercial Motor Vehicle Insurance Requirements with Federal Standards[20]

This act sets a combined single limit of $750,000 for “intrastate commercial vehicles” and makes the new combined single limit applicable to commercial motor vehicle policies executed, delivered, issued for delivery, continued, or renewed in this State on or after January 1, 2026.

General Insurance Matters

The following acts relating to general insurance matters in Maine were enacted during the First Regular Session of the 132^nd Legislature.

• An Act to Amend the Laws Affecting Insurance[21]

The act makes a number of changes to Maine’s insurance code:

• Corrects the inadvertent omission of breast cancer screening from some health plan requirements;
• Updates a civil penalty to comply with National Association of Insurance Commissioners (NAIC) accreditation requirements;
• Conforms the Maine Holding Company Act to NAIC Model 440 regarding voting securities;
• Conforms wet signature requirements to NAIC best practices;
• Incorporates an annual report fee into the annual renewal fee to streamline the process for both companies and the Bureau;
• Conforms the Surplus Lines chapter to NAIC Model 870;
• Clarifies the requirements for Insurance Data Security Act compliance when third-party contractors enter into subcontracting arrangements;
• Allows for a raw number instead of a percentage in reporting enrollee and carrier disenrollments because the carriers do not have enough information on out-of-network providers to calculate the denominator;
• Creates confidentiality for independent dispute resolution in the same manner as for external review;
• Conforms the property and casualty guaranty fund law to NAIC Model 540; and
• Corrects some typos and other small errors and obsolete provisions.
• An Act to Establish an Apprentice Insurance Producer License[22]

The act allows the Bureau of Insurance to issue apprentice producer licenses beginning January 1, 2026.  In addition to application requirements, the apprentice must have a supervising sponsor who assumes legal responsibility for the actions of the apprentice.  The license is intended to be temporary, while the apprentice works to pass a producer licensing examination. The license duration is 180 days and is not renewable.  The activities of the person with an apprentice license are limited to those which do not require additional training, authorizations, or the selling of complex financial products.  Activities involving the sales of life, long-term care, annuities and ACA health policies are not permitted. 

• An Act Regarding Pre-need Funeral Insurance[23]

The act eliminates a prohibition against funeral practitioners being licensed to sell insurance and authorizes the sale of pre-need insurance to fund funeral arrangements with guardrails such as required disclosures and a requirement that the face amount of the policy may not exceed the amount of the goods and services contracted for in the funeral arrangement.

• An Act to Amend the Provisions of the Maine Workers’ Compensation Act of 1992 Governing Requirements for Self-insurers[24]

This act makes the following changes to the laws regulating workers’ compensation self-insurance:

• With the approval of the Superintendent, allows the entire safety margin in excess of claims expected to be secured by a letter of credit.
• Clarifies the notice period for nonrenewal of an irrevocable standby letter of credit. As currently written, the law requires the notice be sent on an exact date and not by the deadline, as intended. 
• Repeals provisions requiring the triggering events for a draw on a letter of credit to be incorporated as conditions within the letter of credit. This eliminates an inappropriate impediment to drawing the funds when needed, clarifying that the issuing bank’s obligation is unconditional and that the bank cannot second-guess the treasurer’s authority to draw.
• Fixes an error related to fully funded trusts. This requires the same standard for dividends as for assessments. 
• Adds a requirement that the Bureau notify the Workers’ Compensation Board if an authorization for self-insurance is terminated or suspended.
• An Act to Protect Federal Home Loan Banks That Lend Money to Insurer Members That Become Delinquent[25]

The act gives preferential treatment to Federal Home Loan Bank (FHLB)-backed arrangements in the rare event of a member insurer’s insolvency, enabling favorable loan terms for insurance companies that are FLHB members.

• An Act to Eliminate the Provision of the Maine Workers’ Compensation Act of 1992 That Allows an Employer Member of a Group Self-insurer to Insure Its Employees Through a Fronting Arrangement[26]

The act repeals the statutes that authorize group self-insurers to establish fronting companies to insure their out-of-state workers’ compensation exposure.

July 25, 2025                                     

NOTE:  This Bulletin is intended solely for informational purposes.  It is not intended to set forth legal rights, duties, or privileges, nor is it intended to provide legal advice.  Readers should consult applicable statutes and rules and contact the Bureau of Insurance if additional information is needed.

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