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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > H21 - Group Basic Medical Expense

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
H21 – Group Basic Medical Expense

(Amended 11/2011)

REVIEW REQUIREMENTS

REFERENCE

DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS LOCATION OF STANDARD IN FILING

Guaranteed Issue

24-A M.R.S.A. §2808-B

Small group plans are guaranteed issue and renewed, community rated, and standardized plans.

 

Dependent coverage

24-A M.R.S.A. §2809

May not use residency as a requirement for dependents.

 

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.

 

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(G), 7(A), 7(B), 7(G), and 8.

 

Coverage of licensed pastoral counselors and marriage and family counselors

24-A M.R.S.A. §2835

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

24-A M.R.S.A. §2847-L

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

 

Credit toward Deductible

24-A M.R.S.A. §2844(3)

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.

 

Continuation of group coverage

24-A M.R.S.A. §2809-A(11)

If the termination of an individual's group insurance coverage is a result of the member or employee being temporarily laid off or losing employment because of an injury or disease that the employee claims to be compensable under Workers Compensation, the insurer shall allow the member or employee to elect to continue coverage under the group policy at no higher level than the level of benefits or coverage received by the employee immediately before termination and at the member's or employee's expense or, at the member's or employee's option, to convert to a policy of individual coverage without evidence of insurability in accordance with this section. See complete details in §2809-A(11).

 

PPOs – Payment for Non-preferred Providers

24-A M.R.S.A. §2677-A(2)

The benefit level differential between services rendered by preferred providers and nonpreferred providers may not exceed 20% of the allowable charge for the service rendered. Superintendent can grant waiver for the 20%, in particular for designated providers for cost or quality.

 

Required provisions

24-A M.R.S.A. §2816 thru §2828

Application statements, notice of claim, proof of loss, assignment of benefits, renewal provisions

 

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

 

Child coverage

24-A M.R.S.A. §2833-A
§4320-B

Extension of coverage for dependent children.

 

Newborn coverage

24-A M.R.S.A. §2834

Newborns are automatically covered under the plan from the moment of birth for the first 31 days

 

Maternity and newborn care

24-A M.R.S.A. §2834-A
§4320-A

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.

 

Dependent enrollment

24-A M.R.S.A. §2834-B

Enrollment for qualifying events.

 

Limits on priority liens

24-A M.R.S.A. §2836

No policy for health insurance shall provide for priority over the insured of payment for any hospital, nursing, medical or surgical services

 

Screening Mammograms

24-A M.R.S.A. §2837-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. 

 

Coverage for breast cancer treatment

24-A M.R.S.A. §2837-C

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

 

Coverage for Psychologists

24-A M.R.S.A. §2835

Must include benefits for psychologists’ services to the extent that the same services would be covered if performed by a physician.

 

Coverage of Optometrists

24-A M.R.S.A. §2841

Benefits must be made available for the services of optometrists if the same services would be covered if performed by  physician.

 

Social Workers/Psychiatric Nurses

24-A M.R.S.A. §2835

Benefits must be included for the services of social workers and  psychiatric nurses to the extent that the same services would be covered if performed by a physician.

 

Medical food coverage for inborn error of metabolism

24-A M.R.S.A. §2837-D

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

 

Coverage for Pap tests

24-A M.R.S.A. §2837-E
§4320-A

Benefits must be provided for screening Pap tests

 

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

24-A M.R.S.A. §2837-F, §2837-G

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

 

Coverage for prostate cancer screening

24-A M.R.S.A. §2837-H
§4320-A

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.

 

Chiropractic Coverage

24-A M.R.S.A. §2840-A

Provide benefits for care by chiropractors at least equal to benefit paid to other providers treating similar neuro-musculoskeletal conditions.

 

Substance Abuse

24-A M.R.S.A. §2842, Rule 320

Mandated coverage at minimum levels defined in the Rule.

 

Coordination of benefits

24-A M.R.S.A. §2844

Medicaid is always secondary

 

AIDS

24-A M.R.S.A. §2846

may not provide more restrictive benefits for expenses resulting from Acquired Immune Deficiency Syndrome (AIDS) or related illness.

 

Penalty for failure to notify of hospitalization

24-A M.R.S.A. §2847-A

No penalty for hospitalization for emergency treatment

 

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

 

Penalty for noncompliance with utilization review

24-A M.R.S.A. §2847-D

May not have a penalty of more than $500 for failure to provide notification under a utilization review program

 

Coverage for diabetes supplies

24-A M.R.S.A. §2847-E

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.

 

Gynecological and obstetrical services

24-A M.R.S.A. §2847-F
§4320-A

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

 

Gynecological and obstetrical services

24-A M.R.S.A. §2847-F
§4241

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

 

Coverage for contraceptives (as applicable)

24-A M.R.S.A. §2847-G
§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 of certified nurse practitioners and certified nurse midwifes

24-A M.R.S.A. §2847-H

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

 

Coverage for services provided by registered nurse first assistants

24-A M.R.S.A. §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.

 

Continuity on replacement of group policy

24-A M.R.S.A. §2849

Continuity of coverage to persons who were covered under the replaced contract any time during the 90 days before the discontinuance of the replaced contract or policy.

 

Extension of Benefits

24-A M.R.S.A. §2849-A

Provide an extension of benefits of 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.

 

Continuity for individual who changes groups

24-A M.R.S.A. §2849-B

A person is provided continuity of coverage if the person was covered under the prior policy and the prior policy terminated Within 180 days before the date the person enrolls or is eligible to enroll in the succeeding policy, or within 90 days before the date the person enrolls or is eligible to enroll in the succeeding contract. The succeeding carrier must waive any medical underwriting or preexisting conditions exclusion to the extent that benefits would have been payable under a prior contract or policy if the prior contract or policy were still in effect.

 

Limitations on exclusions and waiting periods

24-A M.R.S.A. §2850

No preexisting exclusion for children under age 19. A preexisting condition exclusion may not exceed 12 months, including the waiting period, if any. This section goes on to describe restrictions to preexisting condition exclusions.

 

Guaranteed Renewal

24-A M.R.S.A. §2850-B

Renewal must be guaranteed to all individuals, to all groups and to all eligible members and their dependents in those groups except for failure to pay premiums, fraud or intentional misrepresentation.

 

Health plan accountability

Rule 850

Standards in this rule include, but are not limited to, required provisions for grievance and appeal procedures, emergency services, and utilization review standards.

 

Definition of UCR

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.

 

Hospice Care Services

24-A M.R.S.A. §2847-J

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.

 

Domestic Partner Coverage (Mandated offer)

24-A M.R.S.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.

 

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.

 

Anesthesia for Dentistry

24-A M.R.S.A. §2847-K

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

 

Eye Care Services

24-A M.R.S.A. §4314

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

 

Health Plan Improvement Act

24-A M.R.S.A. §4301-A - §4314
§4320-C
§4320-D

These sections describe requirements for health plans offered in Maine. The requirements include, but are not limited to: access to clinical trials, access to prescription drugs, utilization review standards, and independent external review

 

Notice of Rate Increase

24-A M.R.S.A. §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.

 

UCR Required Disclosure

24-A M.R.S.A. §4303(8)(A)

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.

 

Coverage of prosthetic devices to replace an arm or leg. - Effective 1/04

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.

 

Coverage of Licensed clinical Professional Counselors - Effective 1/04

24-A M.R.S.A. §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.

 

Mental Health Coverage

24-A M.R.S.A. §2843, Rule 330

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. For groups with more than 20 employees mental health benefits can not be less extensive than for physical illnesses for the following mental illnesses: psychotic disorders (including schizophrenia), dissociative disorders, mood disorders, anxiety disorders, personality disorders, paraphilias, attention deficit ad disruptive behavior disorders, pervasive developmental disorders, tic disorders, eating disorders (including bulimia and anorexia), and substance abuse-related disorders.
Mandated offer of parity for small groups – mental health benefits cannot be less extensive than for physical illnesses for the following mental illnesses:  schizophrenia, bipolar disorder, pervasive developmental disorder (or autism), paranoia, panic disorder, obsessive compulsive disorder, and major depressive disorder.

 

Prohibition against Absolute Discretion Clauses  Effective 9/13/03

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.

 

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:

  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.

 

Colorectal Cancer Screening

24-A M.R.S.A. §2847-N
§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.

 

Coverage for Dental Hygienists

24-A M.R.S.A. §2847-Q

 

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.

 

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.

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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.

 

Continuity of Prescription Drugs

24-A M.R.S.A.
§4303 (7)(A)

 

If an enrollee has been undergoing a course of treatment with a prescription drug by prior authorization of a carrier and the enrollee’s coverage with one carrier is replaced with coverage from another carrier pursuant to section 2849-B, the replacement carrier shall honor the prior authorization for that prescription drug and provide coverage in the same manner as the previous carrier until the replacement carrier conducts a review of the prior authorization for that prescription drug with the enrollee’s prescribing provider. Policies must include a notice of the carrier’s right to request a review with the enrollee’s provider, and the replacing carrier must honor the prior carrier’s authorization for a period not to exceed 6 months if the enrollee’s provider participates in the review and requests the prior authorization be continued. The replacing carrier is not required to provide benefits for conditions or services not otherwise covered under the replacement policy, and cost sharing may be based on the copayments and coinsurance requirements of the replacement policy.

 

Continuity on replacement of group policy – Preexisting condition exclusions

24-A M.R.S.A. §2849

An insurer or health maintenance organization may impose a preexisting condition exclusion period on a person who was subject to a preexisting condition exclusion under the replaced contract or policy. The preexisting condition exclusion period under the replacement policy or contract must end no later than the date the preexisting condition exclusion period would have ended under the replaced contract or policy.

 

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.

 

Autism Spectrum Disorders

24-A M.R.S.A. § 2847-T

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.

 

Early Childhood Intervention

24-A M.R.S.A. §2847-S

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/uscode-cgi/fastweb.exe?getdoc+uscview+t17t20+4099+0++%28%29%20%20A.

 

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.

 

Compliance with ACA

§4309-A

Must comply with the ACA

 

Preventative Care Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services

 

 

Last Updated: August 22, 2012