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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > H14G - Group Hospital Surgical Medical Expense

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
H15G - Group Hospital/Surgical/Medical Expense

Amended 09/2012

BENEFIT/PROVISION

REQUIREMENT

REFERENCE

DESCRIPTION OF REVIEW

STANDARDS REQUIREMENT

IDENTIFY LOCATION OF STANDARD IN FILING OR EXPLAIN IF REQUIREMENT

 IS INAPPLICABLE

General Policy Provisions

Applicant's statements

24-A M.R.S.A. §2817

No statement made by the applicant for insurance shall void the insurance or reduce benefits unless contained in the written application signed by the applicant; and a provision that no agent has authority to change the policy or to waive any of its provisions; and that no change in the policy shall be valid unless approved by an officer of the insurer and evidenced by endorsement on the policy, or by amendment to the policy signed by the policyholder and the insurer

 

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.

 

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.

 

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(G), 7(A), 7(B), 7(G), and 8.

 

Continuation of group coverage

24-A M.R.S.A. §2809-A(11)

If the termination of an individual's group insurance coverage is a result of the member or employee being temporarily laid off or losing employment because of an injury or disease that the employee claims to be compensable under Workers Compensation, the insurer shall allow the member or employee to elect to continue coverage under the group policy at no higher level than the level of benefits or coverage received by the employee immediately before termination and at the member's or employee's expense or, at the member's or employee's option, to convert to a policy of individual coverage without evidence of insurability in accordance with this section. See complete details in §2809-A(11).

 

 

 

 

 

 

 

Continuity for individual who changes groups

24-A M.R.S.A. §2849-B

A person is provided continuity of coverage if the person was covered under the prior policy and the prior policy terminated Within 180 days before the date the person enrolls or is eligible to enroll in the succeeding policy, or within 90 days before the date the person enrolls or is eligible to enroll in the succeeding contract. The succeeding carrier must waive any medical underwriting or preexisting conditions exclusion to the extent that benefits would have been payable under a prior contract or policy if the prior contract or policy were still in effect.

 

Continuity on replacement of group policy

24-A M.R.S.A. §2849

Continuity of coverage to persons who were covered under the replaced contract any time during the 90 days before the discontinuance of the replaced contract or policy.

 

Continuity on replacement of group policy – Preexisting condition exclusions

24-A M.R.S.A. §2849

An insurer or health maintenance organization may impose a preexisting condition exclusion period on a person who was subject to a preexisting condition exclusion under the replaced contract or policy. The preexisting condition exclusion period under the replacement policy or contract must end no later than the date the preexisting condition exclusion period would have ended under the replaced contract or policy.

 

Coordination of benefit

24-A M.R.S.A. §2844

Medicaid is always secondary.

 

Credit toward Deductible

24-A M.R.S.A. §2844(3)

 

When an insured is covered under more than one expense-incurred health plan, payments made by the primary plan, payments made by the insured and payments made from a health savings account or similar fund for benefits covered under the secondary plan must be credited toward the deductible of the secondary plan.  This subsection does not apply if the secondary plan is designed to supplement the primary plan.

 

 

 

 

 

 

Definition of Medically Necessary

24-A M.R.S.A. §4301-A, Sub-§10-A

Forms that use the term "medically necessary" or similar terms must include this new definition verbatim.

 

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.

 

Extension of Benefits

24-A M.R.S.A. §2849-A

Provide an extension of benefits of 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.

 

Grace Period

24-A M.R.S.A. §2707

30 days.

 

Guaranteed Issue & Renewal

24-A M.R.S.A. §2850-B


§2808-B

Renewal must be guaranteed to all individuals, to all groups and to all eligible members and their dependents in those groups except for failure to pay premiums, fraud or intentional misrepresentation.
Small group plans are guaranteed issue and renewed, community rated, and standardized plans.

 

Health plan accountability

Rule 850

Standards in this rule include, but are not limited to, required provisions for grievance and appeal procedures, emergency services, and utilization review standards.

 

Health Plan Improvement Act

24-A M.R.S.A. §4301-A - §4314
§4320-C
§4320-D

These sections describe requirements for health plans offered in Maine. The requirements include, but are not limited to: access to clinical trials, access to prescription drugs, utilization review standards, and independent external review

 

Limitations on exclusions and waiting periods

24-A M.R.S.A. §2850

No preexisting exclusion for children under age 19.  A preexisting condition exclusion may not exceed 12 months, including the waiting period, if any. This section goes on to describe restrictions to preexisting condition exclusions.

 

Notice of Rate Increase

24-A M.R.S.A. §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.

 

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

 

Penalty for failure to notify of hospitalization

24-A M.R.S.A. §2847-A

No penalty for hospitalization for emergency treatment

 

Prohibition against Absolute Discretion Clauses  Effective 9/13/03

24-A M.R.S.A. §4303(11)

Carriers are prohibited from including or enforcing absolute discretion provisions in health plan contracts, certificates, or agreements.

 

Renewal of policy

24-A M.R.S.A. §2820

There shall be a provision stating the conditions for renewal

 

Representations in 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.

 

Required provisions

24-A M.R.S.A. §2816 thru §2828

Application statements, notice of claim, proof of loss, assignment of benefits, renewal provisions.

 

Third Party Notice, Cancellation and Reinstatement

24-A M.R.S.A. §2847-C

§2707-A

§5016

Rule 580

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

 

Time limit on defenses

24-A M.R.S.A. §2828

No action of law shall be brought to recover on the policy prior to the expiration of 60 days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought at all, unless brought within 2 years from the expiration of the time within which proof of loss is required by the policy.

 

COMPLIANCE WITH THE AFFORDABLE CARE ACT – See PPACA Uniform Compliance Summary for specific requirements.

Affordable Care Act

§4309-A

A carrier shall comply with all applicable requirements of the ACA.

 

Coverage of Preventative Health Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services. For plans subject to the ACA, see separate checklist for specific requirements.

 

Emergency services

24-A M.R.S.A. §4320-C

The plan must cover emergency services in accordance with the requirements of the ACA, including requirements that emergency services be covered without prior authorization and that cost-sharing requirements, expressed as a copayment amount or coinsurance rate, for out-of-network services are the same as requirements that would apply if such services were provided in network.

 

Extension of dependent coverage

24-A M.R.S.A. §4320-B

A health insurance policy that offers coverage for dependent children must offer such coverage until the dependent child is 26 years of age. 
An insurer shall provide notice to policyholders regarding the availability of dependent coverage under this section upon each renewal of coverage or at least 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.

 

Lifetime or Annual Limits

24-A M.R.S.A. §4320

No lifetime or annual limits on health plans subject to the Affordable Care Act

 

Rebates

24-A M.R.S.A. §4319

Carriers must provide rebates in the large group, small group and individual markets to the extent required by the ACA.

 

Comprehensive Health Coverage

24-A M.R.S.A. §4320-D

A carrier offering a health plan subject to the requirements of the ACA shall, at a minimum, provide coverage that incorporates essential benefits and cost-sharing limitations consistent with the requirements of the ACA.

 

Eligibility/Enrollment

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

 

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 least 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.

 

Dependent children with mental or physical illness.

24-A M.R.S.A. §2833-A
§4320-B

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 coverage

24-A M.R.S.A. §2809

May not use residency as a requirement for dependents.

 

Dependent enrollment

24-A M.R.S.A. §2834-B

Enrollment for qualifying events.

 

Domestic Partner Coverage (Mandated offer)

24-A M.R.S.A. §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.

 

Providers/Networks

Certified nurse practitioners and certified nurse midwifes

24-A M.R.S.A. §2847-H

Coverage of nurse practitioners and nurse midwives and allows nurse practitioners to serve as primary care providers

 

Chiropractic Services
(Mandated Provider & Coverage)

24-A M.R.S.A. §2840-A

Provide benefits for care by chiropractors at least equal to benefit paid to other providers treating similar neuro-musculoskeletal conditions.

 

Dentists

24-A M.R.S.A. §2437

Must include benefits for dentists’ services to the extent that the same services would be covered if performed by a physician.

 

Independent Practice 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.

 

Licensed Clinical Professional Counselors - Effective 1/04

24-A M.R.S.A. §2835

Must include benefits for Licensed Clinical Professional Counselor services to the extent that the same services would be covered if performed by a physician.

 

Licensed pastoral counselors and marriage and family counselors

24-A M.R.S.A. §2835

Must include benefits for licensed pastoral counselors and marriage and family therapists for mental health services to the extent that the same services would be covered if performed by a physician.

 

Optional Coverage for Optometric Services

24-A M.R.S.A. §2841

Benefits must be made available for the services of optometrists if the same services would be covered if performed by physician.

 

PPOs – Payment for Non-preferred Providers

24-A M.R.S.A. §2677-A(2)

The benefit level differential between services rendered by preferred providers and nonpreferred providers may not exceed 20% of the allowable charge for the service rendered. Superintendent can grant waiver for the 20%, in particular for designated providers for cost or quality.

 

Psychologists’ Services

24-A M.R.S.A. §2835

Must include benefits for psychologists’ services to the extent that the same services would be covered if performed by a physician.

 

Registered nurse first assistants

24-A M.R.S.A. §2847-I

Benefits must be provided for coverage for surgical first assisting benefits or services shall provide coverage and payment under those contracts to a registered nurse first assistant who performs services that are within the scope of a registered nurse first assistant's qualifications.

 

Social workers/Psychiatric nurses

24-A M.R.S.A. §2835

Benefits must be included for the services of social workers and psychiatric nurses to the extent that the same services would be covered if performed by a physician.

 

 

 

Claims & Utilization Review

Examination, Autopsy

24-A M.R.S.A. §2826

There shall be a provision that the insurer has the right to examine the insured as often as it may reasonably require during the pendency of claim and also has the right to make an autopsy in case of death where it is not prohibited by law.

 

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

 

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.

 

Limits on priority liens

24-A M.R.S.A. §2836

No policy for health insurance shall provide for priority over the insured of payment for any hospital, nursing, medical or surgical services

 

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 30 days 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.

 

Payment of Benefits

24-A M.R.S.A. §2814

All benefits shall generally be payable to the person insured, or to his designated beneficiary or beneficiaries, or to his estate.

 

Penalty for noncompliance with utilization review

24-A M.R.S.A. §2847-D

May not have a penalty of more than $500 for failure to provide notification under a utilization review program

 

Proof of Loss

24-A M.R.S.A. §2824

Written proof of loss must be furnished to the insurer within 30 days after the commencement of the period for which the insurer is liable

 

UCR Definition & Required Disclosure

24-A M.R.S.A. §4303(8)


§4303(8)(A)

The data used to determine this charge must be Maine specific and relative to the region where the claim was incurred.
Clearly disclose that the insured or enrollee may be subject to balance billing as a result of claims adjustment and provide a toll-free number that an insured or enrollee may call prior to receiving services to determine the maximum allowable charge permitted by the carrier for a specified service.

 

Grievances & Appeals

Grievance & appeals procedures

24-A M.R.S.A. §4303 (4)
 Rule 850,
Sec. 8 & 9

Specifically describes grievance & appeal procedures required in the contract, as well as the required available external review procedures

 

Expedited request for external review

24-A M.R.S.A. §4312

An enrollee is not required to exhaust all levels of a carrier's internal grievance procedure before filing a request for external review if the carrier has failed to make a decision on an internal grievance within the time period required, or has otherwise failed to adhere to all the requirements applicable to the appeal pursuant to state and federal law, or the enrollee has applied for expedited external review at the same time as applying for an expedited internal appeal.

 

 

 

 

 

Right to waive the right to a second level appeal/grievance

 

24-A M.R.S.A. §4312

Enrollees have the right to waive the right to a second level appeal/grievance and request an external review after the first level appeal decision.

 

Timeline for second level grievance review decisions

24-A M.R.S.A. §4303(4)

Decisions for second level grievance reviews must be issued within 30 calendar days if the insured has not requested to appear in person before authorized representatives of the health carrier.

 

 

GeneraL health care treatment/coverage

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.

 

Anesthesia for Dentistry

24-A M.R.S.A. §2847-K

Anesthesia & associated facility charges for dental procedures are mandated benefits for certain vulnerable persons.

 

Breast cancer treatment
(Mandated Coverage)

24-A M.R.S.A. §2837-C
§4237

Must provide coverage for reconstruction of both breasts to produce symmetrical appearance according to patient and physician wishes.
Benefits provided for breast cancer treatment for a medically appropriate period of time determined by the physician in consultation with the patient. Effective 1/98

 

Breast reduction and symptomatic varicose vein surgery
(Mandated offer)

24-A M.R.S.A. §2847-L

Coverage must be offered for breast reduction surgery and symptomatic varicose vein surgery determined to be medically necessary

 

Clinical Trials

24-A M.R.S.A. §4310

Provide access to clinical trials.

 

Colorectal Cancer Screening

24-A M.R.S.A. §2847-N
§4320-A

Coverage must be provided for colorectal cancer screening (including colonoscopies if recommended by a health care provider as the colorectal cancer screening test) for asymptomatic individuals who are fifty years of age or older; or less than 50 years of age and at high risk for colorectal cancer.  If a colonoscopy is recommended as the colorectal cancer screening and a lesion is discovered and removed during the colonoscopy benefits must be paid for the screening colonoscopy as the primary procedure.

 

Eye Care Services

24-A M.R.S.A. §4314

Patient access to eye care provisions when the plan provides eye care services

 

Home health care benefits

24-A M.R.S.A. §2837

Benefits must be made available for home health care services.

 

Hospice Care Services

24-A M.R.S.A. §2847-J

Hospice care services must be provided to a person who is terminally ill (life expectancy of 12 months or less). Must be provided whether the services are provided in a home setting or an inpatient setting. See section for further requirements.

 

Persons under the influence of alcohol or narcotics

24-A M.R.S.A. §2829-3
§2728

Policies cannot contain the following provision: “Intoxicants and narcotics. The insurer is not liable for any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic or of any hallucinogenic drug, unless administered on the advice of a physician.”

 

Prostate cancer screening

24-A M.R.S.A. §2837-H
§4320-A

Coverage required for prostate cancer screening: Digital rectal examinations and prostate-specific antigen tests covered if recommended by a physician, at least once a year for men 50 years of age or older until age 72.

 

Telemedicine Services

24-A M.R.S.A. §4316

 

 

A carrier offering a health plan in this State may not deny coverage on the basis that the coverage is provided through telemedicine if the health care service would be covered were it provided through in-person consultation between the covered person and a health care provider. Coverage for health care services provided through telemedicine must be determined in a manner consistent with coverage for health care services provided through in-person consultation. A carrier may offer a health plan containing a provision for a deductible, copayment or
coinsurance requirement for a health care service provided through telemedicine as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to an in-person consultation.

 

woman & Maternity/Infants/Children

Gynecological and obstetrical services

24-A M.R.S.A. §2847-F
§4320-A
§4241

Benefits must be provided for annual gynecological exam without prior approval of primary care physician.

 

Maternity and newborn care

24-A M.R.S.A. §2834-A
§4320-A

Benefits must be provided for maternity (length of stay) and newborn care, in accordance with "Guidelines for Perinatal Care" as determined by attending provider and mother.

 

Maternity benefits for unmarried women

24-A M.R.S.A. §2832

Coverage of children must be made available to unmarried women on the same basis as married women

 

Pap tests

24-A M.R.S.A. §2837-E
§4320-A

Benefits must be provided for screening Pap tests

 

Screening Mammograms

24-A M.R.S.A. §2837-A
§4320-A

If radiological procedures are covered.   Benefits must be made available for screening mammography at least once a year for women 40 years of age and over.  A screening mammogram also includes an additional radiologic procedure recommended by a provider when the results of an initial radiologic procedure are not definitive. 

 

Autism Spectrum Disorders

24-A M.R.S.A. § 2847-T

All group health insurance policies, contracts and certificates must provide coverage for autism spectrum disorders for an individual covered under a policy, contract or certificate who is 5 years of age or under in accordance with the following.

  1. The policy, contract or certificate must provide coverage for any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder.
  2. The policy, contract or certificate must provide coverage for the treatment of autism spectrum disorders when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary.
  3. The policy, contract or certificate may not include any limits on the number of visits.
  4. The policy, contract or certificate may limit coverage for applied behavior analysis to $36,000 per year.  An insurer may not apply payments for coverage unrelated to autism spectrum disorders to any maximum benefit established under this paragraph.
  5. Coverage for prescription drugs for the treatment of autism spectrum disorders must be determined in the same manner as coverage for prescription drugs for the treatment of any other illness or condition.

 

Childhood Immunizations

24-A M.R.S.A. §4302(1)(A)(5)
§4320-A

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.

 

Early Childhood Intervention

24-A M.R.S.A. §2847-S

All group health insurance policies, contracts and certificates must provide coverage for children's early intervention services in accordance with this subsection.  A referral from the child's primary care provider is required.  The policy or contract may limit coverage to $3,200 per year for each child not to exceed $9,600 by the child's 3rd birthday.

“Children's early intervention services” means services provided by licensed occupational therapists, physical therapists, speech-language pathologists or clinical social workers working with children from birth to 36 months of age with an identified developmental disability or delay as described in the federal Individuals with Disabilities Education Act, Part C, 20
United States Code, Section 1411
http://uscode.house.gov/uscode-cgi/fastweb.exe?getdoc+uscview+t17t20+4099+0++%28%29%20%20A.

 

Hearing aids

24-A M.R.S.A. §2847-O

Coverage is required for the purchase of hearing aids for each hearing-impaired ear for the following individuals:

  1. From birth to 5 years of age if the individual is covered under a policy or contract that is issued or renewed on or after January 1, 2008.
  2. From 6 to 13 years of age if the individual is covered under a policy or contract that is issued or renewed on or after January 1, 2009.
  3. From 14 to 18 years of age if the individual is covered under a policy or contract that is issued or renewed on or after January 1, 2010.

 

Infant Formula

24-A M.R.S.A. §2847-P

Coverage of amino acid-based elemental infant formula must be provided when a physician has diagnosed and documented one of the following:

  1. Symptomatic allergic colitis or proctitis;
  2. Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis;
  3. A history of anaphylaxis
  4. Gastroesophageal reflux disease that is nonresponsive to standard medical therapies
  5. Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider
  6. Cystic fibrosis; or
  7. Malabsorption of cow milk-based or soy milk-based formula

Medical necessity is determined when a licensed physician has submitted documentation that the amino acid-based elemental infant formula is the predominant source of nutritional intake at a rate of 50% or greater and that other commercial infant formulas, including cow milk-based and soy milk-based formulas, have been tried and have failed or are contraindicated.

Coverage for amino acid-based elemental infant formula under a policy, contract or certificate issued in connection with a health savings account may be subject to the same deductible and out-of-pocket limits that apply to overall benefits under the policy, contract or certificate.

 

Medical food coverage for inborn error of metabolism

24-A M.R.S.A. §2837-D

Must provide coverage for metabolic formula and up to $3,000 per year for prescribed modified low-protein food products.

 

Newborn coverage

24-A M.R.S.A. §2834

Newborns are automatically covered under the plan from the moment of birth for the first 31 days.

 

 

Prescription Drugs

Continuity of Prescription Drugs

24-A M.R.S.A.
§4303 (7)(A)

 

 

If an enrollee has been undergoing a course of treatment with a prescription drug by prior authorization of a carrier and the enrollee’s coverage with one carrier is replaced with coverage from another carrier pursuant to section 2849-B, the replacement carrier shall honor the prior authorization for that prescription drug and provide coverage in the same manner as the previous carrier until the replacement carrier conducts a review of the prior authorization for that prescription drug with the enrollee’s prescribing provider. Policies must include a notice of the carrier’s right to request a review with the enrollee’s provider, and the replacing carrier must honor the prior carrier’s authorization for a period not to exceed 6 months if the enrollee’s provider participates in the review and requests the prior authorization be continued. The replacing carrier is not required to provide benefits for conditions or services not otherwise covered under the replacement policy, and cost sharing may be based on the copayments and coinsurance requirements of the replacement policy.

 

Contraceptives

24-A M.R.S.A. §2847-G
§4320-A

All contracts that provide coverage for prescription drugs or outpatient medical services must provide coverage for all prescription contraceptives or for outpatient contraceptive services, respectively, to the same extent that coverage is provided for other prescription drugs or outpatient medical services.

 

Diabetes supplies

24-A M.R.S.A. §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.

 

 

 

 

 

 

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

24-A M.R.S.A.
§2837-F
§2837-G

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

 

 

 

Prosthetic devices to replace an arm or leg. - Effective 1/04

24-A M.R.S.A. §4315

Coverage must be provided, at a minimum, for prosthetic devices to replace, in whole or in part, an arm or leg to the extent that they are covered under the Medicare program.  Coverage for repair or replacement of a prosthetic device must also be included.  Exclusion for micro-processors was removed effective 1/2011.

 

Specialty tiered drugs - Adjustment of out-of-pocket limits – Effective 8/30/2012.  Applies to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in Maine on or after 1/1/2013.

24-A M.R.S.A. §4317-A
(Temporary link)

A carrier may adjust an out-of-pocket limit, as long as any limit for prescription drugs for coinsurance does not exceed $3,500, to minimize any premium increase that might otherwise result from the requirements of this section to the extent not inconsistent with the federal Affordable Care Act.

 

Mental Health & substance abuse Services/COVERAGE

Mental Health Coverage

24-A M.R.S.A. §2843

Must provide, at a minimum, the following benefits for a person suffering from a mental or nervous condition: inpatient services, day treatment services, outpatient services, and home health care services. For groups with more than 20 employees mental health benefits can not be less extensive than for physical illnesses for the following mental illnesses: psychotic disorders (including schizophrenia), dissociative disorders, mood disorders, anxiety disorders, personality disorders, paraphilias, attention deficit ad disruptive behavior disorders, pervasive developmental disorders, tic disorders, eating disorders (including bulimia and anorexia), and substance abuse-related disorders.

 

 

 

 

 

 

 

 

 

 

 

Mental health services (groups of 20 or less)

24-A M.R.S.A. §2843

Mandated offer of parity for small groups – mental health benefits cannot be less extensive than for physical illnesses for the following mental illnesses:  schizophrenia, bipolar disorder, pervasive developmental disorder (or autism), paranoia, panic disorder, obsessive compulsive disorder, and major depressive disorder.

 

Mental health services provided by counseling professionals.

24-A M.R.S.A. §2835(3)

Benefits must be made available for mental health services provided by licensed counselors.

 

Substance Abuse

24-A M.R.S.A. §2842
Rule 320

Mandated coverage at minimum levels defined in the Rule.

 

Treatment of alcoholism

24-A M.R.S.A. §2842

Benefits must be made available for treatment of alcoholism by licensed or certified treatment facilities subject "reasonable limitations". This is mandated coverage for groups of 20 or more (mandated offer for groups under 20)

 

 

Last Updated: December 17, 2013