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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > HO4 - Blanket Accident Only Policies

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
H04 – Blanket Accident Only Policies
(Amended 11/2011)

REVIEW REQUIREMENTS

REFERENCE

DESCRIPTION OF REVIEW
STANDARDS REQUIREMENTS

LOCATION OF
STANDARD IN FILING

Required provisions

24-A M.R.S.A. §2816 - §2828

Application statements, notice of claim, proof of loss, assignment of benefits, etc.

 

Notification prior to cancellation

24-A M.R.S.A. §2847-C,
Rule 580

10 days prior notice, reinstatement required if insured has an organic brain disorder

 

Limits on priority liens

24-A M.R.S.A
§2836
  

A policy may contain a provision that allows such payments, if that provision is approved by the superintendent, and if that provision requires the prior written approval of the insured and allows such payments only on a just and equitable basis and not on the basis of a priority lien. A just and equitable basis shall mean that any factors that diminish the potential value of the insured's claim shall likewise reduce the share in the claim for those claiming payment for services or reimbursement.

 

Renewal provision

24-A M.R.S.A
§2820

Policy must contain the terms under which the policy can or cannot be renewed

 

Child coverage

24-A M.R.S.A
§2833

Defined as under 19 years of age and are children, stepchildren or adopted children of, or children placed for adoption with the policyholder, member or spouse of the policyholder or member, no financial dependency requirement, court ordered coverage

 

Penalty for failure to notify of hospitalization

24-A M.R.S.A
§2847-A
 

No penalty for hospitalization for emergency treatment

 

Notice Regarding Policies or Certificates Which are Not Medicare Supplement Policies

24-A M.R.S.A. §5013,
Rule 275, Sec. 17(D)

There must be a notice predominantly displayed on the first page of the policy that states: "THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT [POLICY OR CONTRACT]. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."

 

Coordination of benefits

24-A M.R.S.A
§2844

Medicaid is always secondary

 

Extension of Benefits

24-A M.R.S.A.
§ 2849-A

Must provide an extension of benefits of at least 6 months for a person who is totally disabled on the date the group or subgroup policy is discontinued. For a policy providing specific indemnity during hospital confinement, "extension of benefits" means that discontinuance of the policy during a disability has no effect on benefits payable for that confinement.

 

Statements in Application

24-A M.R.S.A.
§ 2828

There shall be a provision that all statements contained in any such application for insurance shall be deemed representations and not warranties.

 

Extension of coverage for dependent children with mental or physical illness

24-A M.R.S.A. §2833-A

Requires health insurance policies to continue coverage for dependent children up to 24 years of age who are unable to maintain enrollment in college due to mental or physical illness if they would otherwise terminate coverage due to a requirement that dependent children of a specified age be enrolled in college to maintain eligibility.

 

Infant Formula

24-A M.R.S.A. §2847-P

Coverage of amino acid-based elemental infant formula must be provided when a physician has diagnosed and documented one of the following:

  1. Symptomatic allergic colitis or proctitis;
  2. Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis;
  3. A history of anaphylaxis
  4. Gastroesophageal reflux disease that is nonresponsive to standard medical therapies
  5. Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider
  6. Cystic fibrosis; or
  7. Malabsorption of cow milk-based or soy milk-based formula

Medical necessity is determined when a licensed physician has submitted documentation that the amino acid-based elemental infant formula is the predominant source of nutritional intake at a rate of 50% or greater and that other commercial infant formulas, including cow milk-based and soy milk-based formulas, have been tried and have failed or are contraindicated.

Coverage for amino acid-based elemental infant formula under a policy, contract or certificate issued in connection with a health savings account may be subject to the same deductible and out-of-pocket limits that apply to overall benefits under the policy, contract or certificate.

 

Coverage for Dental Hygienists

24-A M.R.S.A. §2847-Q

 

Coverage must be provided for dental services performed by a licensed independent practice dental hygienist when those services are covered services under the contract and when they are within the lawful scope of practice of the independent practice dental hygienist.

 

Telemedicine Services

24-A M.R.S.A. §4316

 

 

A carrier offering a health plan in this State may not deny coverage on the basis that the coverage is provided through telemedicine if the health care service would be covered were it provided through in-person consultation between the covered person and a health care provider. Coverage for health care services provided through telemedicine must be determined in a manner consistent with coverage for health care services provided through in-person consultation. A carrier may offer a health plan containing a provision for a deductible, copayment or
coinsurance requirement for a health care service provided through telemedicine as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to an in-person consultation.

 

Childhood Immunizations

24-A M.R.S.A. §4302(1)(A)(5)

Childhood immunizations must be expressly covered or expressly excluded in all policies.  If childhood immunizations are a covered benefit it must be expressly stated in the benefit section.  If childhood immunizations are not a covered benefit then this must be expressly stated as an exclusion in the policy.

 

Calculation of health benefits based on actual cost

24-A M.R.S.A. §2185

Policies must comply with the requirements of 24-A §2185 which requires calculation of health benefits based on actual cost.  All health insurance policies, health maintenance organization plans and subscriber contracts or certificates of nonprofit hospital or medical service organizations with respect to which the insurer or organization has negotiated discounts with providers must provide for the calculation of all covered health benefits, including without limitation all coinsurance, deductibles and lifetime maximum benefits, on the basis of the net negotiated cost and must fully reflect any discounts or differentials from charges otherwise applicable to the services provided. With respect to policies or plans involving risk-sharing compensation arrangements, net negotiated costs may be calculated at the time services are rendered on the basis of reasonably anticipated compensation levels and are not subject to retrospective adjustment at the time a cost settlement between a provider and the insurer or organization is finalized.

 

Explanations Regarding Deductibles

24-A M.R.S.A. §2413

All policies must include clear explanations of all of the following regarding deductibles:

  1. Whether it is a calendar or policy year deductible.
  2. Clearly advise whether non-covered expenses apply to the deductible.
  3. Clearly advise whether it is a per person or family deductible or both.

 

Explanations for any Exclusion of Coverage for work related sicknesses or injuries

24-A M.R.S.A. §2413

If the policy excludes coverage for work related sicknesses or injuries, clearly explain whether the coverage is excluded if the enrollee is exempt from requirements from state workers compensation requirements or has filed an exemption from the workers compensation laws.

 

Preventative Care Services

 

24-A M.R.S.A. §4320-A

Coverage of preventive health services

 

 

 

Last Updated: August 22, 2012