REVIEW REQUIREMENTS |
REFERENCE |
DESCRIPTION OF REVIEW
STANDARDS REQUIREMENTS |
LOCATION OF
STANDARD IN FILING |
General format |
24-A M.R.S.A. §2703 |
Readibility, term of policy described, cost disclosed, form number in bottom left corner |
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Required provisions |
24-A M.R.S.A. §2704 – §2716 |
Entire contract – changes, time limit on certain defenses, reinstatement, notice of claims, payment of claims, claim forms, proof of loss, right to examine and return policy |
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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. |
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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), and 7(F). |
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Grace Period |
24-A M.R.S.A. §2707 |
30 days |
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Notification prior to cancellation |
24-A M.R.S.A. §2707-A, Rule 580 |
Third party notice of cancellation and reinstatement for cognitive impairment or functional incapacity. |
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Free look period |
24-A M.R.S.A. §2717 |
10 day free look |
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Limits on priority liens |
24-A M.R.S.A. §2729-A |
No policy for health insurance shall provide for priority over the insured of payment for any hospital, nursing, medical or surgical services |
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Renewal provision |
24-A M.R.S.A. §2738 |
Policy must contain the terms under which the policy can or cannot be renewed |
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Child coverage |
24-A M.R.S.A. §2742 |
Extension of coverage for dependent children. Certain policies subject to ACA must extend coverage to age 26. |
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Definition of Dependent |
24-A M.R.S.A. §4234
24-A M.R.S.A.
§2742
24-A M.R.S.A.
§2833 |
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 |
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Screening Mammograms |
24-A M.R.S.A. §2745-A |
If radiological procedures are covered |
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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. |
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Penalty for noncompliance with utilization review |
24-A M.R.S.A. §2749-B |
penalty of more than $500 for failure to provide notification under a utilization review program |
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Penalty for failure to notify of hospitalization |
24-A M.R.S.A. §2749-A |
No penalty for hospitalization for emergency treatment |
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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 |
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AIDS |
24-A M.R.S.A. §2750 |
may not provide more restrictive benefits for expenses resulting from Acquired Immune Deficiency Syndrome (AIDS) or related illness. |
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Notice Regarding Policies or Certificates Which are Not Medicare Supplement Policies |
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." |
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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. |
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Coverage for Dependent Children Up to Age 25 |
24-A M.R.S.A.
§2742-B |
An individual health insurance policy that offers coverage for dependent children must offer such coverage until the dependent child is 25 years of age. Pursuant to §2742-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 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. |
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Infant Formula |
24-A M.R.S.A. §2764
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Coverage of amino acid-based elemental infant formula must be provided when a physician has diagnosed and documented one of the following:
- Symptomatic allergic colitis or proctitis;
- Laboratory- or biopsy-proven allergic or eosinophilic gastroenteritis;
- A history of anaphylaxis
- Gastroesophageal reflux disease that is nonresponsive to standard medical therapies
- Severe vomiting or diarrhea resulting in clinically significant dehydration requiring treatment by a medical provider
- Cystic fibrosis; or
- 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. |
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Colorectal Cancer Screening |
24-A M.R.S.A. §2763 |
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. |
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Coverage for Dental Hygienists |
24-A M.R.S.A. §2765
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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. |
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Childhood Immunizations |
24-A M.R.S.A. §4302(1)(A)(5) |
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. |
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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. |
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Explanations Regarding Deductibles |
24-A M.R.S.A. §2413 |
All policies must include clear explanations of all of the following regarding deductibles:
- Whether it is a calendar or policy year deductible.
- Clearly advise whether non-covered expenses apply to the deductible.
- Clearly advise whether it is a per person or family deductible or both.
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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. |
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Prohibited practices |
24-A M.R.S.A. §4212(2)
24-A M.R.S.A.
§2736-C
24-A M.R.S.A.
§2808-B |
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 |
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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. |
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Newborn coverage |
24-A M.R.S.A. §4234-C
24-A M.R.S.A.
§2834
24-A M.R.S.A.
§2743 |
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. |
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Off-label use of prescription drugs for cancer, HIV or AIDS |
24-A M.R.S.A. §4234-D, §4234-E
24-A M.R.S.A.
§2745-E
24-A M.R.S.A.
§2837-F
24-A M.R.S.A.
§2837-G |
Coverage required for off-label use of prescription drugs for treatment of cancer, HIV, or AIDS. |
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Subrogation/Limits on priority liens |
24-A M.R.S.A. §4243
§2729-A
§2836 |
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 |
Coverage for services provided by registered nurse first assistants |
24-A M.R.S.A. §4246
§2758
§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. |
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Domestic Partner Coverage (Mandated offer) |
24-A M.R.S.A. §4249
§2741-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. |
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Notice of Rate Increase |
24-A M.R.S.A. §4222-B(15), §2808 (2-A)
§2736
§2839
§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. Reasonable notice must be provided for other types of policies.. |
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Coordination of Benefits and Evidence of Coverage |
Rule 191(§9-A and §9-D)
Rule 790
§2723-A
§2844 |
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 |
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Preventative Care Services |
24-A M.R.S.A. §4320-A |
Coverage of preventive health services |
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