HO4 - Blanket Accident Only Policies
All Rate and Form Filings submitted to the Bureau of Insurance for
review must be accompanied by the completed appropriate transmittal
Document as well as the completed appropriate rate/form review checklist.
The checklist must be completed by the company submitting the filing
and must reference, for each item on the checklist, the location of
each specific item in the filing. The transmittal Document takes the
place of the cover letter requirement. Blank transmittal documents are
attached here for your use.
| REVIEW REQUIREMENTS |
REFERENCE |
DESCRIPTION OF REVIEW
STANDARDS REQUIREMENTS |
LOCATION OF
STANDARD IN FILING |
| Required provisions |
24-A
M.R.S.A. §2816 - §2828 |
Application statements, notice of claim, proof of
loss, assignment of benefits, etc. |
|
| 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 |
|
| Limits on Priority Liens |
24-A
M.R.S.A. §2836 |
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. |
|
| Renewal provision |
24-A
M.R.S.A. §2820 |
Policy must contain the terms under which the policy
can or cannot be renewed |
|
| 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 |
|
| Penalty for failure to notify
of hospitalization |
24-A
M.R.S.A. §2847-A |
No penalty for hospitalization for emergency treatment |
|
| Notice Regarding Policies
or Certificates Which are Not Medicare Supplement Policies |
24-A
M.R.S.A. §5013,
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." |
|
| Coordination of benefits |
24-A
M.R.S.A
§2844 |
Medicaid is always secondary |
|
| Extension of Benefits |
24-A
M.R.S.A.
§ 2849-A |
Must provide an extension of benefits of at least 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. |
|
| Statements in Application |
24-A
M.R.S.A.
§ 2828 |
There shall be a provision that all statements contained
in any such application for insurance shall be deemed representations
and not warranties. |
|
| Extension of coverage for dependent children
with mental or physical illness |
24-A
M.R.S.A. §2833-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. |
|
| 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:
- 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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