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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > Individual Dental Plans - H10I

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
H10I – Individual Dental 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. §2755

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.

 

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.

 

Coordination of Benefits and Evidence of Coverage

24-A M.R.S.A.
§2723-A

Rule 790

 

 

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. §2766

All individual dental insurance policies and contracts 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. §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.

 

Dependent children with mental or physical illness

§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.

 

Dependent, Definition of

24-A M.R.S.A.
§2742

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.

 

Emergency services

24-A M.R.S.A. §2749-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.

 

Free look period

24-A M.R.S.A. §2717

10 day free look.

 

Grace Period

24-A M.R.S.A.
§2707
Bulletin 288

30 or 31 days.

 

Independent Practice Dental Hygienists

24-A M.R.S.A.
§2765

 

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.

 

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 (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

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.

 

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

 

Network approval

24-A M.R.S.A. §2673-A, Rule 360
Rule 850

All managed care arrangements except MEWAs must be filed for adequacy & compliance with Rule 850 & Rule 360 access standards.

 

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 (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.

 

Outline of Coverage - Dental Requirements

Rule 755, Sec. 7(N)

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

 

Outline of Coverage - General Requirements

Rule 755, Sec. 7(B)

This subsection contains general requirements and disclosures for Outlines of 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. §2738

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)(22)

All dental 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 dental benefits only.”

 

Limits on priority liens/Subrogation

§2729-A

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 apply to closed network arrangements.

Yes   Please provide citation for section in policy ________________________

No  

Third Party Notice, Cancellation and Reinstatement

24-A M.R.S.A. §2707-A
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. §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.

 

 

Last Updated: December 17, 2013