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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > HOrg02I - Individual HMO/POS Plans

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
HOrg02I – Individual HMO/POS Plans

Amended 02/2013

BENEFIT/PROVISIONREQUIREMENT

REFERENCE

DESCRIPTION OF REVIEW STANDARDS REQUIREMENT

IDENTIFY LOCATION OF STANDARD IN FILING

Anesthesia for Dentistry

24-A M.R.S.A.
 
§4251

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

 

Assignment of Benefits

24-A M.R.S.A.
§4207-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.

 

Autism Spectrum Disorders

24-A M.R.S.A.
§4259

 

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.

 

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.

 

 

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.

 

 

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.

 

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.

 

Chiropractic Coverage

24-A M.R.S.A. §4236

Provide benefits for care by chiropractors at least equal to benefit paid to other providers treating similar neuro-musculoskeletal conditions. Requires treatment for acute care for a limited self referred for chiropractic benefits. For HMO’s see self-referred requirements.

 

Colorectal Cancer Screening

24-A M.R.S.A. §4254
§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.

 

Continuity law

24-A M.R.S.A. §4222-B and Chapter 36

This section provides continuity of coverage for a person who seeks coverage under an individual or a group insurance policy or health maintenance organization policy.

 

Coordination of Benefits and Evidence of Coverage

Rule 191(§9-A and §9-D)
 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

 

Coverage for breast cancer treatment

24-A M.R.S.A. §4237

Must provide coverage for reconstruction of both breasts to produce symmetrical appearance according to patient and physician wishes.

 

Coverage for breast reduction and symptomatic varicose vein surgery         (Mandated offer)

24-A M.R.S.A. §4252

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

 

Coverage for contraceptives

24-A M.R.S.A. §4247
§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.

 

Coverage for Dental Hygienists

24-A M.R.S.A. §4257

 

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.

 

Coverage for Dependent Children Up to Age 25

24-A M.R.S.A. §4233-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.

 

Coverage for diabetes supplies

24-A M.R.S.A. §4240

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.

 

Coverage for hearing aids

24-A M.R.S.A. §4255

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.

 

Coverage for Pap tests

24-A M.R.S.A. §4242
§4320-A

Benefits must be provided for screening Pap tests

 

Coverage for prostate cancer screening

24-A M.R.S.A. §4244

Coverage required for prostrate 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.

 

Coverage for services provided by registered nurse first assistants

24-A M.R.S.A. §4246

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.

 

Coverage of certified nurse practitioners and certified nurse midwifes

24-A M.R.S.A. §4248

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

 

Coverage of Licensed clinical Professional Counselors

24-A M.R.S.A. §4234-A(8)
§2744
§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.

 

Coverage of licensed pastoral counselors and marriage and family counselors

24-A M.R.S.A. §§4234-A (8)

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.

 

Coverage of prosthetic devices to replace an arm or leg

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.

 

Credit toward Deductible

24-A M.R.S.A. §4222-B(21)

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.

 

Def. Of Emergency Services &  Med. Condition

Rule 850, Sec. 5(O) & 5(P)

Acute symptoms that if not medically attended to could result in placing the health, physical or mental, of the individual (or unborn child) in serious jeopardy; serious impairment of bodily functions; serious dysfunction of bodily organ or part; for pregnant women if having contractions and there is inadequate time to transfer to another hospital or there is a safety issue involved.  Includes prudent layperson language

 

Definition of Dependent

24-A M.R.S.A. §4234

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

 

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.

 

Definition of UCR/Maximum allowable charge UCR required disclosure

24-A M.R.S.A. §4303(8)

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.

 

Domestic Partner Coverage (Mandated offer)

24-A M.R.S.A. §4249

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

 

Early Childhood Intervention

24-A M.R.S.A. §4258

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/view.xhtml?req=granuleid:USC-prelim-title20-section1432&num=0&edition=prelim

 

Emergency care

Rule 850, Subsection H
24-A M.R.S.A.§4320-C

Cannot require precertification for emergency treatment. Cost sharing must be same for in and out of network.

 

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 coverage for dependent children with mental or physical illness

24-A M.R.S.A. §4233-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.

 

Eye Care Services

24-A M.R.S.A. §4314

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

 

Grace Period

Rule 191, Sec. 9(K)
Bulletin 288
§4209 (6)

30 or 31 days.

 

Grievance & appeals procedures

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

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

 

Gynecological and obstetrical services

24-A M.R.S.A. §4306-A
24-A M.R.S.A.
§4320

No referral or authorization for gynecological exam without prior approval of primary care physician.

 

Gynecological and obstetrical services

24-A M.R.S.A§4320-A

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

 

Health Plan Improvement Act – Plan Requirements

24-A M.R.S.A. §4302 - §4314
24-A M.R.S.A.
§4320(C)
24-A M.R.S.A.
§4320(D)

Includes requirements including, but not limited to, access to clinical trials, access to prescription drugs, independent external review, standing referral to specialists, allows for certified nurse practitioners to be PCPs. PCP include pediatricians, OB/GYNs and certified nurse practioners. Plans subject to ACA must provide comprehensive health coverage.

 

Health Plan Improvement Act Definitions

24-A M.R.S.A. §4301-A

Provides definitions for terms used throughout sections of §4301-A - §4320

 

Hospice Care Services

24-A M.R.S.A. §4250

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.

 

Independent External Review – expedited

§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.

 

Independent External Review – expedited

§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.

 

Infant Formula

24-A M.R.S.A. §4256

 

 

 

 

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.

 

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.
May not establish dollar limits on essential benefits.

 

Maternity benefits

24-A M.R.S.A. §4234
§4234-B

Maternity benefits provided to married women must also be provided to unmarried women
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.

 

Medical food coverage for inborn error of metabolism

24-A M.R.S.A. §4238

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

 

Mental Health Benefits

24-A M.R.S.A. §4234-A
§2749-C
§2843
Rule 330 applies to only certain policies

This section includes, but is not limited to, mandated coverage for the following: Each group contract 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.
Mandated coverage for large groups >20:  The level of benefits for the 11 listed mental illnesses of  psychotic disorders (including schizophrenia), dissociative disorders, mood disorders, anxiety disorders, personality disorders, paraphilias, attention deficit and disruptive behavior disorders, pervasive developmental disorders, tic disorders, eating disorders (9including bulimia and anorexia), and substance abuse-related disorders can not be less extensive than for physical illnesses
Mandated offer for small groups:  The level of benefits for the 7 listed mental illneses of schizophrenia, bipolar disorders, pervasive developmental disorders (or autism), paranoia, panic disorders, obsessive compulsive disorders, and major depressive disorders cannot be less extensive than for physical illnesses

 

Network approval

24-A M.R.S.A. §2673-A, Rule 360
24-A M.R.S.A.
§4303(1)
Rule 850

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

 

Newborn coverage

24-A M.R.S.A. §4234-C

Newborns are automatically covered under the plan from the moment of birth for the first 31 days including coverage for congenital defects and birth abnormalities.

 

Non-Standard & Non-Basic Plans

Rule 750, Part II

If an HMO plan is not a standard or basic plan, it then must meet all minimum benefit levels noted in Rule 750, Part II.

 

Notice of Rate Increase

24-A M.R.S.A. §4222-B(15),

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..

 

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

24-A M.R.S.A. §4234-D, §4234-E

 

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

 

Pre-existing condition limitations

24-A M.R.S.A. §2850(2)

Pre-existing conditions do not include pregnancy for federally eligible individuals. Policies subject to ACA: no preexisting exclusion for children under age 19

 

Preventative Care Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services

 

Prohibited practices

24-A M.R.S.A. §4212(2)

Reasons an enrollee may not be cancelled or denied renewal: Fraud or material misrepresentation, Failure to pay the charge for coverage, When the provisions of the State's community rating law are applicable, as provided by section 2736-C, subsection 3, paragraph B and section 2808-B, subsection 4, paragraph B

 

Prohibition against Absolute Discretion Clauses 

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.

 

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.  

 

Screening Mammograms

24-A M.R.S.A.
§4237-A
24-A M.R.S.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.  ACA preventative benefit no deductible or copayment.

 

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

 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. Any adjustment made by a carrier pursuant to this subsection is considered a minor modification under section 2850-B.

 

Standard & Basic Plans

Rule 750, Part I

If the plan is a Standard or Basic Plan, it must comply with the product structure and benefit level requirements noted in Rule 750, Part I

 

Subrogation/Limits on priority liens

24-A M.R.S.A. §4243

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  

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.

 

Third Party Prescription Program Act

Title 32, §13771 - §13777

Any changes in benefits or provisions in any contract may not be made unilaterally by either the program administrator or the pharmacy. Any change in a contract offered to one pharmacy shall be offered to all the state pharmacies participating in the program.

 

Last Updated: August 5, 2014