REFERENCE

DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

LOCATION OF STANDARD IN FILING

Required provisions

24-A M.R.S.A. §2816

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

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 and Rule 755 that the form is intended to be in.

Classification, Disclosure, and Minimum Standards

Rule 755

Must comply with all applicable provisions of Rule 755 including, but not limited to, Sections 4, 5, 6(A), 6(L), 7(A), 7(B), and 7(M)

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. §2738

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 noncompliance with utilization review

24-A M.R.S.A. §2847-D

penalty of more than $500 for failure to provide notification under a utilization review program

Penalty for failure to notify of hospitalization

24-A M.R.S.A. §2847-A

No penalty for hospitalization for emergency treatment

AIDS

24-A M.R.S.A. §2846

may not provide more restrictive benefits for expenses resulting from Acquired Immune Deficiency Syndrome (AIDS) or related illness.

Notice Regarding Policies or Certificates Which are Not Medicare Supplement Policies

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

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 (as applicable)

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.

Representations on Applications

24-A M.R.S.A. §2818

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

Mandated/Required Provisions

Rule 755, Sec. 9(G)

A supplemental plan is not considered a limited benefit plan if, in the judgment of the Superintendent, it is substantially similar to one of the following types of insurance:
     - Basic Hospital Expense Coverage – as defined in Rule 755, Sec. 6(B)
     - Basic Medical-Surgical Expense Coverage – as defined in Rule 755, Sec. 6(C)
     - Basic Hospital/Medical-Surgical Expense Coverage – as defined in Rule 755,  Sec. 6(D)
     - Major Medical Expense Coverage – as defined in Rule 755, Sec. 6(F)
     - Basic Medical Expense Coverage – as defined in Rule 755, Sec. 6(G)

If the supplemental plan is substantially similar to any of the above listed types of insurance then it must contain all required mandated benefits and other requirements of Maine insurance law applicable to that particular type of insurance.  (See appropriate checklist)

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 Dependent Children Up to Age 25

24-A M.R.S.A. §2833-B

A group health insurance policy that offers coverage for dependent children must offer such coverage until the dependent child is 25 years of age.  Pursuant to §2833-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.
An insurer 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.

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.

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.

Lifetime Limits and Annual Aggregate Dollar Limits Prohibited

§4318
§4320

An individual or group health plan may not include a provision in a policy, contract, certificate or agreement that purports to terminate payment of any additional claims for coverage of health care services after a defined maximum aggregate dollar amount of claims for coverage of health care services on an annual, lifetime or other basis has been paid under the health plan for coverage of an insured individual, family or group.

A carrier may however offer a health plan that limits benefits under the health plan for specified health care services on an annual basis.
May not establish dollar limits on essential benefits.

Preventative Care Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services