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Frequently Asked Questions - Health

How much time does the company have to pay my medical claim?

An undisputed claim for medical insurance benefits is payable within 30 days after the insurance company receives all information needed to pay the claim. 24-A M.R.S.A. §2436

How much time does the company have to pay my disability claim?

Once the company has determined that a disability claim is payable, they have 30 days to pay the claim. 24-A M.R.S.A. §2436.

If the company cancels my policy for nonpayment of premiums, will it affect my ability to find coverage in the future?

If this is an individual policy, your insurance company may not be required to give you a new policy for 91 days. If that happens, any health problems that you currently have (called "pre-existing conditions") may not be covered for up to 12 months. It is better to cancel the policy yourself in writing if you cannot afford the premium so you are not penalized. Usually, you must give a 30 day advance written notice to the insurer that you want to cancel your policy. Always follow your policy’s cancellation/termination section to preserve your Continuity of Coverage rights. 24-A M.R.S.A. §2736-C(3)(A) and §2848-§2850-D.

Can I get part of my premium refunded if I cancel my policy in the middle of the month?

Sometimes. You can get a partial refund if your policy does not specifically state otherwise. Check your policy language. 24-A M.R.S.A. §2453.

What are the possible effects of concealing information from the insurance company?

You may jeopardize your coverage (a policy cancellation or nonrenewal could result) and payment for claims. Answer all questions honestly, to the best of your ability. An insurance company can request the Bureau of Insurance investigate claims of false representations on any insurance application. 24-A M.R.S.A. §2178, §2179, §2186, and §2187.

My insurance company is denying a claim because they say it's a preexisting condition. Can they do that?

Yes, under certain circumstances.  When you applied for a health insurance policy, if you did not have coverage for more than 63 (or in some cases 90) days beforehand, the insurance company may exclude claims related to a preexisting condition for up to 12 months. However, if you are switching coverage and you need to provide proof that you had insurance, you can request a Certification of Creditable Coverage from your former insurance company and the new company cannot exclude something that was covered under the old policy, as long as it is covered under the new policy.  Medicare or MaineCare (formerly Medicaid and CubCare) is also considered creditable coverage.  24-A M.R.S.A. §2849-C and §2850.

I don't want my new insurance policy. Can I give it back to the company?

This depends on the type of insurance you bought. Medicare supplement and long-term care insurance have a 30-day “free look” period during which you can cancel the coverage and have your money refunded. Many other products have at least a 10-day "free look" period when you can cancel coverage. The free look provision in your policy should be stated on the front page. 24-A M.R.S.A. §2717, Bureau of Insurance Rule Chapters 191 Section 9 M or 275 Section 7.

My health insurance plan says the treatment decisions of my doctor or primary care provider (PCP) are subject to the insurance company's "utilization review" or its "prior authorization." What do these terms mean?

"Utilization review" is the insurance company’s requirement that it reviews the recommendations of your doctor for clinical necessity and appropriateness.  The insurance company is not obligated to pay benefits until such review takes place and it approves the health care services recommended.  The insurance company can do this before or after the medical services are provided.    
           
“Prior authorization” is when your health plan agrees to pay for future medical services recommended by your doctor.

What are my options if the utilization review or prior authorization is denied?
 
If the health plan does not approve the treatment, you have two levels of internal appeals. If you lose both appeals, you might still have the right to an independent external review. 24-A M.R.S.A. § 4312 and Bureau Rule Chapter 850(8).

What is an Elimination Period?

The number of days of care that you pay out-of-pocket before the insurance company begins to pay benefits.

Does the Bureau of Insurance approve the rates the insurance company charges for my health insurance plan?

Insurance carriers offering health insurance plans to individuals and small group employers (50 or fewer employees) must file rates with the Bureau. The filing must include every rate, rating formula, and classification of risks, in addition to every modification of any formula or classification that it proposes to use.  The filing is informational (i.e., not subject to approval) if it meets the guaranteed loss ratio of 80%, and review is not required by federal law when the average increase is less than 10%.  If the Bureau has reason to believe that a rate filing for either a small group plan or an individual plan does not meet the requirements that rates not be excessive, inadequate, or unfairly discriminatory or that the filing violates any of the insurance laws, a hearing may be held.

Proposed rates for large group employers (more than 50 employees) need to be filed with the Bureau for informational purposes only.  They do not need to be reviewed or approved by the Bureau.

I need to buy health insurance for my family and myself. What can I do?

For information on the companies selling individual policies, along with a premium comparison chart, go to our Individual Health Insurance Guide.  For direct links to these companies’ websites and to see the policies go to Compare Individual and Small Group Health Insurance Policies.    

You cannot be denied an individual health insurance policy, regardless of any health problems you may have, as long as you pay the premium. 24-A M.R.S.A. §2736-C(3).

I don't make much money and I need to get insurance for my family and myself. Where can I go?

The Maine Department of Health and Human Services helps low-income families get coverage through MaineCare (formerly Medicaid and CubCare).  For more information, contact them at (877) KIDS-NOW (1-877-543-7669) or online at http://www.maine.gov/dhhs/oms/.  

In addition, you may be able to find free or reduced cost medical care through Care Partners (1-877-626-1684) or qualified health care centers.  These are only available in certain areas of the state. 

Dirigo Choice is another insurance plan available to all under age 65. Qualified individuals and families may receive discounts that reduce monthly payments and reductions in deductibles and out-of-pocket expenses based on the ability to pay.  For more information call (800) 409-7520 or visit http://www.dirigohealth.com/.

I am thinking about buying health insurance for a short period, six months or one year. What do I need to know about short-term policies?

Short-term policies do not have all of the consumer protections available under comprehensive health policies. The most important differences are pre-existing conditions and creditable coverage. Pre-existing conditions are not covered, even if you had prior coverage. The time that you are covered by this policy is not counted as creditable coverage for any individual health insurance you buy later. This can mean you will have to wait an additional year before pre-existing conditions will be covered. You cannot be insured for a period greater than 24 months with a short term plan. 24-A M.R.S.A. 2849-B(8).

I was laid off and lost my coverage, but my spouse has coverage through their employer. When do I need to apply to get on that plan?

You must apply within 30 days of losing your coverage; otherwise you may have to wait until your spouse’s employer’s plan has open enrollment (typically one month each year).  24-A M.R.S.A. §2849-B(3)

I just had a baby. Is she covered under my insurance policy?

Yes, from the moment of birth -- or in the case of an adopted child from the moment the placement papers are signed -- for 31 days. The insurance company may require you to notify them and/or pay an additional premium within that 31 days to continue coverage beyond that point. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2743, §2834 and §4234-C.

I just heard about "ABC Insurance Company" and they have rates much lower than any of the other plans I've seen. Are they a good company?

As the cost of health insurance and Medicare supplement policies continues to rise, more unauthorized insurers come into Maine. These "insurers" market seemingly low-cost plans to small business owners and individuals. They may pay a few initial claims and then leave the consumer without coverage. The only way to know whether the company you're interested in is one of these fraudulent plans is to check with the Bureau of Insurance by calling 1-800-300-5000 or by checking our website at www.maine.gov/pfr/insurance, then following the links to "Insurance Company Information" and searching for the company's name. The Bureau cannot recommend companies but can tell you whether the company is authorized to do business in Maine.

Is a discount card considered insurance?

No. Discount cards do just that - provide discounts for health care services or prescription drugs. You have to pay all costs beyond the discount. For example, compare what you would pay out-of-pocket for a prescription drug that costs $100: If your discount card provides a 25% discount, you have to pay $75; if your insurance policy has a copay, you have to pay much less. A discount card doesn't give you any of the protections of an insurance policy. If you decide to get an insurance policy in the future, any health conditions you have before buying the policy can be excluded from coverage for up to 12 months. You may wish to review the public service announcement distributed by the Maine Bureau of Insurance on discount cards.

My insurance company says my employer's health plan is "self-funded" or "self-insured." What does this mean and how does it affect my rights under the plan?

Self-funded or self-insured plans mean that your employer pays your health plan benefits from its own funds, instead of paying premiums to a health insurance company. Under such plans, employees routinely may deal with an insurer, but, because no insurance policy is involved, the insurer's participation is limited to administering benefit claims. The Maine Bureau of Insurance may not have regulatory jurisdiction of many such plans, which, however, are subject to the jurisdiction of the federal government. The specific federal agency involved is the Employee Benefits Security Administration (EBSA) of the U.S. Department of Labor. EBSA maintains a regional office in Boston, and can be contacted at toll-free (866) 444-3272. The web page is as follows: http://www.dol.gov/ebsa/.

Are there certain benefits my insurance company must provide?

For individual policies, and for group policies governed by Maine law, the law requires certain benefits, including pre- and post-natal care, certain preventive services and screenings, and breast cancer treatment. Group policies purchased by employers with more than 20 employees must also cover treatment for mental illness, alcoholism, and drug dependency. The insurance company may put limits on some of these benefits. For a list of mandated benefits in Maine law, see: Mandated Benefits.

If you have bought a new policy since September 23, 2010, federal law requires that your insurer cover certain preventive services without you having to pay a copayment or co-insurance or meet your deductible, when you obtain these services from a network provider. For a list of the covered preventive services, see: www.healthcare.gov or click here.

Can I select my obstetrician/gynecologist (OB/GYN) as my primary care provider (PCP)?

Yes, if your OB/GYN has a contract with your insurance company to provide primary care. 24-A M.R.S.A. §2847-F and §4241.

I need to see a certain kind of specialist.  What are my options?

Insurance companies using networks of participating providers must have a reasonable network of primary care, specialty care, hospitals, and behavioral health care providers. This should allow you to access care without unreasonable delay.  If the insurance company has an insufficient number or type of in-network providers, it must let you obtain the covered services at no greater cost to you than if you receive the services from an in-network provider. Bureau Rule Chapter 850, Section 7.

How long should it take my health plan to approve or disapprove a requested service (referral) from my primary care physician (PCP)?

For initial determinations, the health plan should let you and your primary care provider know of their decision within 2 working days of obtaining all necessary information. 24-A M.R.S.A. § 4304 (2).

If I go to a specialist after receiving approval from my insurance company for the referral, and the specialist then refers me to another provider, do I need to notify my primary care provider (PCP) or my insurance company to get another referral?

Yes, if you are in a plan that requires referrals. You must contact your primary care provider and receive your insurer’s authorization before seeing any other provider in order to receive the greatest benefit level.

I'm covered by 2 health insurance policies. If I have a claim, who pays first?

When you are covered under more than one health plan, “coordination of benefits” (COB) occurs. This means that the two plans will “coordinate” to see which pays first. The plan that pays benefits first is called the “primary” plan and the plan that pays the remaining benefits is called the “secondary” plan. The typical process for determining who pays first is decided under the following guidelines: 

  • If you are an active employee, the plan that covers you as an employee is usually primary (pays first). If you have another plan that covers you as a dependent, laid-off employee, retiree, or COBRA-covered person, that plan is secondary.
  • If you and your spouse have dependent children, the primary plan for your dependent children is the plan covering the parent whose birthday falls earlier in the calendar year.
  • If you and your (former) spouse are divorced or separated, the claims for your dependent children are paid in the following order (unless mandated otherwise by a court order): first, by the plan of the parent with custody; second, by the plan of the spouse of the parent with custody; third, by the plan of the parent without custody. If the parents have joint custody, the birthday rule applies.

Bureau of Insurance Rule 790 requires insurance carriers to decide the order of paying claims. The policyholder should not be subject to late or denied claims payments in the interim.

My doctor sent me a bill for what my insurance company didn't pay after I had paid my co-payment and co-insurance. Should I have to pay?

It depends. If you are enrolled in a health plan that has varying levels of coverage, i.e., 100% coverage in- network and 80% out-of-network, and you choose to see the out-of-network physician, then yes, the doctor or hospital can bill you the remaining 20%. There are many variables in insurance plans. You should review your plan. If you still have questions, you should first contact your insurance company. You can always contact the Maine Bureau of Insurance. 

Are all individual and group health insurance policies in Maine required to extend coverage for dependent children up to 26 years of age?

Because of the Federal Health Care Reform Act, as of September 23, 2010, all comprehensive individual and most group health insurance plans that offer dependent coverage must make the coverage available until a child reaches the age of 26. Both married and unmarried children qualify for this coverage. Until 2014, if an adult child has employer-based coverage available through his or her job, the parent’s plan may elect not to cover the child.

 

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Last Updated: May 7, 2014