Maine

Which plan do you have? Who to call first, by coverage

• Your employer pays claims itself

  Maine usually cannot help with these plans. Call the Employee Benefits Security Administration.

  Call 1-866-444-3272

• Insurance you buy, or an employer plan bought from an insurer

  Call Maine Bureau of Insurance. See the at-a-glance box.

  Call 800-300-5000

• Medicaid or children's coverage

  Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Maine.

  Medicaid in Maine

• Medicare

  Maine State Health Insurance Assistance Program (SHIP) gives free counseling. Or call 1-800-MEDICARE.

  Call 1-800-262-2232 1-800-633-4227

Who regulates health plans

If your plan is through your employer, it must be fully funded (fully insured) rather than self-funded to use the state process. The Bureau of Insurance says your human resources department can tell you which type you have, and that some trusts and self-funded plans still qualify, so contact the Bureau with questions.

• Maine Bureau of Insurance

  Health insurance policies sold in Maine (individual plans and fully insured employer plans). Most self-funded employer plans are outside its reach, although the Bureau says some trusts and self-funded plans still qualify for review.

  Phone: 800-300-5000 (toll free) or 207-624-8475. File a complaint online

Free help in Maine

• Consumers for Affordable Health Care (CAHC) Consumer Assistance HelpLine

  Free, confidential nonprofit HelpLine that helps Mainers appeal denied coverage for medically necessary care, understand bills, and apply for Marketplace coverage or MaineCare (Maine's Medicaid program).

  Phone: 1-800-965-7476

State laws that can help

• External review. You have 12 months to request a free independent external review, you may attend it and question the insurer, and the review organization must decide within 30 days (72 hours if urgent).

  Maine Revised Statutes Title 24-A, section 4312

• Prior authorization. Insurers must answer a prior authorization request within 72 hours or 2 business days, whichever is less, and if they do not the request is granted; appeals must be decided by a clinical peer.

  Maine Revised Statutes Title 24-A, section 4304

• Step therapy. Insurers must grant a step therapy exception on listed grounds (for example the required drug failed before, or you are stable on your current drug), must decide within 72 hours or 2 business days (24 hours if urgent), must cover the prescribed drug while the request is pending, and a missed deadline means the exception is granted.

  Maine Revised Statutes Title 24-A, section 4320-N

• Surprise billing. For a surprise bill from an out-of-network provider you did not knowingly choose, you can be required to pay only the cost sharing that would apply in network.

  Maine Revised Statutes Title 24-A, section 4303-C

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.