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Maine Bureau of Insurance
Form Filing Review Requirements Checklist
H20G – Group Vision Plans

(Amended 11/05/2012)

BENEFIT/PROVISIONREQUIREMENT

REFERENCE

DESCRIPTION OF REVIEW STANDARDS REQUIREMENT

IDENTIFY LOCATION OF STANDARD IN FILING OR EXPLAIN IF REQUIREMENT IS INAPPLICABLE

Assignment of Benefits

24-A M.R.S.A.
§2827-A

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

 

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.

 

Coordination of Benefits and Evidence of Coverage

Rule 790

 

§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.

 

Dependent Children - Offer

24-A M.R.S.A. §2847-R

All group dental insurance policies, contracts and certificates that offer dependent coverage must offer the opportunity to enroll a dependent child in the dental insurance coverage during the following periods:
A. From birth to 30 days of age; and
B. Any open or annual enrollment period.

 

Dependent Children Up to Age 25

24-A M.R.S.A. §2833-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.

 

Dependent Children with mental or physical illness

§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.

 

Dependent, Definition of

24-A M.R.S.A.
§2833

Children (including stepchildren, adopted children or children placed for adoption) under the age of 19. Cannot use financial dependency as a requirement for eligibility. Adopted, or placed for adoption children are to be provided the same benefits as natural dependent children and stepchildren.

 

Domestic Partner Coverage (Mandated offer)

§2832-A

Coverage must be offered for domestic partners of individual policyholders or group members. This section establishes criteria defining who is an eligible domestic partner.

 

Emergency services

24-A M.R.S.A. §2847-A

No prior authorization can be required for emergency services.

 

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.

 

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.

 

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.

 

Grace Period

24-A M.R.S.A.
§2809-A
Bulletin 288

30 or 31 days.

 

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.

 

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.

 

Limits on priority liens/Subrogation

§2836

Does this policy have subrogation provisions?  If yes see provision below:
Subrogation requires 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. Applies to point of service contracts in the HMO but doesn’t applies to closed network arrangements.

Yes   Please provide citation for section in policy ________________________

No  

Network approval

24-A M.R.S.A. §2673-A
Rule 360

All managed care arrangements except MEWAs must be filed for adequacy & compliance with Rule 360 access standards.

 

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.

 

Notice of Rate Increase

§2808 (2-A)
§2839

§2839-A

Requires that insurers provide a minimum of 60 days written notice to affected policyholders prior to a rate filing for individual health insurance or a rate increase for group health insurance. It specifies the requirements for the notice. See these sections for more details. Reasonable notice must be provided for other types of policies.

 

 

Outline of Coverage - General Requirements

Rule 755, Sec. 7(B)

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

 

Outline of Coverage - Vision Requirements

Rule 755, Sec. 7(O)

This subsection describes the required provisions and disclosures for the Outline of Coverage for Vision Coverage.

 

PPO Benefit level differential

24-A M.R.S.A. §2677-A

There cannot be more than a 20% differential in benefits between preferred and non-preferred providers. Superintendent can grant waiver for the 20%, in particular for designated providers for cost or quality.

 

Renewal provision

24-A M.R.S.A. §2820

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

 

Required disclosure statements on policies/certificates

Rule 755, Sec. 7(A)(23)

All vision 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 vision benefits only.”

 

Third Party Notice, Cancellation and Reinstatement

24-A M.R.S.A. §2847-C
Rule 580

Third party notice of cancellation and reinstatement for cognitive impairment or functional incapacity.

 

 

Last Updated: November 7, 2012