REFERENCE

DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

LOCATION OF STANDARD IN FILING

Child Coverage

24-A M.R.S.A. §2742

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

Grace Period

24-A M.R.S.A. §2707

30 days

Notification prior to cancellation

24-A M.R.S.A. §2707-A, Rule 580

10 days prior notice, reinstatement required if insured has an organic brain disorder

Renewal provision

24-A M.R.S.A. §2738

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

Notice of claim

24-A M.R.S.A. §2709

There shall be a provision that written notice of sickness or of injury must be given to the insurer within 20 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.

Claim forms

24-A M.R.S.A. §2710

The insurer will furnish claim forms to the claimant. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy for filing of claim forms.

Free look period

24-A M.R.S.A. §2717

10 day free look except nonrenewable accident policies

Definition of “Accident”, “Accidental Injury”, “Accidental Means”

Rule 755, Sec. 4(C)

Shall be defined to employ “result” language and shall not include words that establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization. The definition shall not be more restrictive than the following: “accident,” “accidental injury,” or “accidental means” means accidental bodily injury sustained by the insured person that is the direct cause of the condition for which benefits are provided and that occurs while the insurance is in force.

Probationary or Waiting Periods Not Allowed

Rule 755, Sec. 5(A)

Accident policies shall not contain probationary or waiting periods.

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 “Accident Only Coverage” and “Specified Accident Coverage”

Rule 755, Sec. 6(I)

“Accident only coverage” is a policy that provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident. Accidental death and double dismemberment amounts under the policy shall be at least $2,000 and a single dismemberment amount shall be at least $1,000.

REQUIRED DISCLOSURE PROVISIONS INCLUDING, BUT NOT LIMITED TO:

Renewal, Continuation, or Nonrenewal Provisions

Required disclosure statements on policies/certificates

General Outline of Coverage Requirements

Accident-Only Coverage (Outline of Coverage)

Rule 755, Sec. 7

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

Rule 755, Sec. 7(A)(9) and Sec. 7(A)(10)

Rule 755, Sec. 7(B)

Rule 755, Sec. 7(J)

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.

See this section for required disclosure statements to be placed prominently on the first page of the policy/certificate.

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 Accident-Only coverage.

Notice Regarding Policies or Certificates Which are Not Medicare Supplement Policies

24-A M.R.S.A. §5013, and 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. If you have a Medicare supplement policy or major medical policy, this coverage may be more than you need. For information call the Bureau of Insurance at 1-800-300-5000."

Misstatement of age

24-A M.R.S.A. §2720

Misstatement of age: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age

Limits on priority liens

24-A M.R.S.A. §2729-A

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.

Assignment of benefits

24-A M.R.S.A. §2755

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.

Time limit on defenses

24-A M.R.S.A. §2706

After 3 years from the date of issue of policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability, commencing after the expiration of such 3-year period.

Legal actions

24-A M.R.S.A. §2715

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 after the time written proof of loss is required to be furnished.

Grievance procedure

24-A M.R.S.A. §2747

The policy must contain the procedure to follow if an insured wishes to file a grievance regarding policy provisions or denial of benefits

Emergency services

24-A M.R.S.A. 2749-A

No prior authorization can be required for emergency services

Claim Payment

24-A M.R.S.A. §2436

Payment of claim within 30 days of receipt of proof of loss

Extension of coverage for dependent children with mental or physical illness

24-A M.R.S.A. §2742-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. §2765

Coverage must be provided for dental services performed by a licensed independent practice dental hygienist services under the contract and when they are when those services are covered 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.