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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > H07G - Group Specified Disease

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
H07G - Group Specified Disease

(Amended 12/2011)

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.

 

Policy Definitions

Rule 755, Sec. 4

This section of Rule 755 contains required definitions for:  Accident, Convalescent Nursing Home/Extended Care Facility/Skilled Nursing Facility, Hospital, Medicare, Nurse, One Period of Confinement, Partial Disability, Physician, Pre-existing Condition, Residual Disability, Sickness, and Total Disability.

 

Probationary or Waiting Periods

Rule 755, Sec. 5(A)

A policy shall not contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy, except:

(1)        A policy may specify a probationary or waiting period for sickness not to exceed 30 days from the effective date of the coverage of the insured person; and

(2)        A policy may specify a probationary or waiting period not to exceed six months for specified diseases or conditions and losses resulting from disease or condition related to hernia, disorder of reproduction organs, varicose veins, adenoids, appendix, and tonsils. However, the permissible six-month exception shall not be applicable where the specified diseases or conditions are treated on an emergency basis.

 

 

Pre-existing Condition Exclusions

Rule 755, Sec. 5(B)

 

Rule 755, Sec. 7(A)(8)

A policy shall not exclude coverage for a loss, due to a preexisting condition, that occurs beyond the 12 months following the issuance of the policy or certificate where the application or enrollment form for the insurance does not seek disclosure of prior illness, disease, physical conditions, medical care, or treatment and where the preexisting condition is not specifically excluded by the terms of the policy or certificate.

If a policy or certificate contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy or certificate and be labeled as “Preexisting Condition Limitations.”

 

Limitations and Exclusions

Rule 755, Sec. 5(E)

A policy shall not limit or exclude coverage except as provided in this subsection.

 

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.

 

General Rules for Minimum Standards

Rule 755, Sec. 6(A)

The requirements set forth in this section are in addition to any other requirements contained in any other applicable statutes and rules including, but not limited to, 24-A M.R.S.A. Chapters 27, 32, 33, 35, 36 and 56-A and Rules 140, 320, 330, 360, 530, 590, 600, 850 and 940.

 

Minimum Standards for Specified Disease Coverage

Rule 755, Sec. 6(J)

Policy must meet all minimum standards in Rule 755, Sec. 6(J)(1) – Sec. 6(J)(6).

 

REQUIRED DISCLOSURE PROVISIONS INCLUDING, BUT NOT LIMITED TO:

Renewal, Continuation, or Nonrenewal Provisions

 

 

Required disclosure statements on policies/certificates

 

 

 

General Outline of Coverage Requirements

Specified Disease Coverage (Outline of Coverage)

Rule 755, Sec. 7

Rule 755, Sec. 7(A)(4)

 

 

Rule 755, Sec. 7(A)(15)

 

 

 

Rule 755, Sec. 7(B)

 

Rule 755, Sec. 7(K)

Each policy shall contain all appropriate provisions contained in this section including, but not limited to the following:

 

Each policy of individual health insurance and group health insurance shall include a renewal, continuation, or nonrenewal provision. The language or specification of the provision shall be consistent with the type of contract to be issued. The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.

 

All specified disease policies and certificates shall contain on the first page 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], a prominent statement as follows: Notice to Buyer: This is a specified disease [policy] [certificate].This [policy] [certificate] provides limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses. [If the policy covers cancer, include the following sentence.] Read your [policy] [certificate] carefully with the outline of coverage and the Buyer’s Guide to Cancer Insurance.

 

This subsection contains general requirements and disclosures for Outlines of Coverage.

 

This subsection describes the required provisions and disclosures for the Outline of Coverage for Specified Disease coverage.

 

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 notifiy 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,§17(D)
Rule 755, Sec. 7(A)13

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."

 

Coordintion 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.

 

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.

 

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.

 

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.

 

Coverage for Dependent Children Up to Age 25

24-A M.R.S.A. §4233-B
 24-A M.R.S.A. §2833-B
24-A M.R.S.A. §2742-B

 

An individual or group health maintenance organization contract that offers coverage for dependent children must offer such coverage until the dependent child is 25 years of age.  Pursuant to §4233-B the child must be unmarried, have no dependent of their own, be a resident of Maine or be enrolled as a full-time student, and not have coverage under any other health policy/contract or federal or state government program.
A health maintenance organization shall provide notice to policyholders regarding the availability of dependent coverage under this section upon each renewal of coverage or at lease once annually, whichever occurs more frequently.  Notice provided under this subsection must include information about enrolment periods and notice of the insurer’s definition of and benefit limitations for preexisting conditions.

 

 

 

 

 

 

Assignment of Benefits

24-A M.R.S.A. §4207-A
24-A M.R.S.A.
§2827-A
24-A M.R.S.A.
§2755

Permits insureds to assign benefits directly to their provider of care.  Applies to medical and dental expense incurred plans. Does not include indemnity plans.

 

Off-label use of prescription drugs for cancer, HIV or AIDS

24-A M.R.S.A. §4234-D, §4234-E
24-A M.R.S.A.
§2745-E
24-A M.R.S.A.
§2745-F

24-A M.R.S.A.
§2837-F
24-A M.R.S.A.
§2837-G

Coverage required for off-label use of prescription drugs for treatment of cancer, HIV, or AIDS.

 

Coverage for diabetes supplies

24-A M.R.S.A. §4240
§2754
§2847-E

Benefits must be provided for medically necessary equipment and supplies used to treat diabetes (insulin, oral hypoglycemic agents, monitors, test strips, syringes and lancets) and approved self-management and education training.

 

Coordination of Benefits and Evidence of Coverage

Rule 191(§9-A and §9-D)
 Rule 790

§2723-A

§2844

Lists items that are required to be placed in an Evidence of Coverage.  Also §9 states:
Evidences of coverage may contain a provision for coordination of benefits, provided that such provision shall not relieve an HMO of its duty to provide or arrange for a covered health care service to an enrollee solely because the enrollee is entitled to coverage under any other contract, policy or plan, including coverage provided under government programs.
Medicaid is always secondary

 

Extension of coverage for dependent children with mental or physical illness

24-A M.R.S.A. §4233-A
§2742-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.

 

Calculation of health benefits based on actual cost

24-A M.R.S.A. §2185

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.

 

Preventative Care Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services

 

 

Last Updated: December 17, 2013