All Rate and Form Filings submitted to the Bureau of Insurance for
review must be accompanied by the completed appropriate transmittal
Document as well as the completed appropriate rate/form review checklist.
The checklist must be completed by the company submitting the filing
and must reference, for each item on the checklist, the location of
each specific item in the filing. The transmittal Document takes the
place of the cover letter requirement. Blank transmittal documents are
attached here for your use.
| REVIEW
REQUIREMENTS |
REFERENCE
|
DESCRIPTION
OF REVIEW
STANDARDS REQUIREMENTS |
LOCATION OF
STANDARD IN FILING |
| Child Coverage |
24-A
M.R.S.A. §2833 |
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 |
|
| Grace Period |
Bulletin
288 |
30 days, policy must be kept in force during grace
period |
|
| 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 |
|
| Renewal provision |
24-A
M.R.S.A. §2820 |
Policy must contain the terms under which the policy
can or cannot be renewed |
|
| Designation of
Classification of Coverage |
Rule
755, Sec. 6 |
The heading of the cover letter of any form filing
subject to this rule shall state the category of coverage set forth
in 24-A M.R.S.A. § 2694 that the form is intended to be in. |
|
| Required disclosure statements on policies/certificates |
Rule
755, Sec. 7(A)(22) |
All dental plan policies and certificates shall display
prominently by type, stamp or other appropriate means on the first
page of the policy or certificate, or attached to it, in either contrasting
color or in boldface type at least equal to the size type used for
headings or captions of sections in the [policy][certificate] the
following:
“Notice to Buyer: This [policy] [certificate] provides dental
benefits only.”
|
|
| General Outline of Coverage Requirements |
Rule
755, Sec. 7(B) |
This subsection contains general requirements and disclosures
for Outlines of Coverage. |
|
| Dental Coverage (Outline of Coverage) |
Rule
755, Sec. 7(N) |
This subsection describes the required provisions and
disclosures for the Outline of Coverage for Dental Coverage |
|
| Notice of claim |
24-A
M.R.S.A. §2823 |
There shall be a provision that written notice of sickness
or of injury must be given to the insurer within 20 days (30 days
for group) after the date when such sickness or injury occurred. Failure
to give notice within such time shall not invalidate nor reduce any
claim, if it shall be shown not to have been reasonably possible to
give such notice and that notice was given as soon as was reasonably
possible. |
|
| Forms for proof of loss |
24-A
M.R.S.A. §2825 |
There shall be a provision that the insurer will furnish
to the policyholder such forms as are usually furnished by it for
filing proof of loss. If such forms are not furnished before the expiration
of 15 days after the insurer received notice of any claim under the
policy, the person making such claim shall be deemed to have complied
with the requirements of the policy as to proof of loss upon submitting
within the time fixed in the policy for filing proof of loss, written
proof covering the occurrence, character and extent of the loss for
which claim is made |
|
| 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. |
|
| Assignment of benefits |
24-A
M.R.S.A. §2827-A |
All policies providing benefits for medical or dental
care on an expense-incurred basis must contain a provision permitting
the insured to assign benefits for such care to the provider of the
care. An assignment of benefits under this section does not affect
or limit the payment of benefits otherwise payable under the policy. |
|
| Legal actions |
24-A
M.R.S.A. §2828 |
No action can be brought to recover on the policy prior
to the expiration of sixty days after written proof of loss has been
furnished in accordance with the requirements of the policy. No such
action shall be brought after the expiration of 3 years (for individual
plans) (2 years for group plans) after the time written proof of loss
is required to be furnished. |
|
| Grievance procedure |
24-A
M.R.S.A. §2816 (non-ERISA group plans only) |
The policy must contain the procedure to follow if
an insured wishes to file a grievance regarding policy provisions
or denial of benefits |
|
| Emergency services |
24-A
M.R.S.A. §2847-A |
No prior authorization can be required for emergency
services |
|
| 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. |
|
| 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. |
|
