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

Third Party Notice, Cancellation and Reinstatement

Rule 580
24-A M.R.S.A. §2707-A
24-A M.R.S.A.
§2847-C
24-A M.R.S.A.
§5016

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

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.

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(E), 7(A), 7(B), 7(F), and 8.

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-A

Extension of coverage for dependent children. Certain policies subject to ACA must extend coverage to age 26.

Screening Mammograms

24-A M.R.S.A. §2837-A

If radiological procedures are covered

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(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.

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.

Child coverage

24-A M.R.S.A. §2833-A
§4320-B

Extension of coverage for dependent children. Certain policies subject to ACA must extend coverage to age 26.

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.