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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > H16G - Group Major Medical

H16G - Group Major Medical

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
Guaranteed Issue 24-A M.R.S.A. §2808-B Small group plans are quaranteed 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(B), 7(A), 7(B), 7(C), and 8.  
Prescription Drug Coverage Rule 755, Sec. 6(F)(1)(i) Must provide coverage for out-of-hospital prescription drugs and medications. Cost sharing for the drug benefit shall not exceed 50% on average. If there is a separate maximum for this benefit, it shall be at least $1,500 per year.  
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.  
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 §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  
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 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  
Home healthcare coverage 24-A M.R.S.A. §2837    
Screening Mammograms 24-A M.R.S.A. §2837-A If radiological procedures are covered  
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.  
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 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 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 Benefits must be provided for annual gynecological exam without prior approval of primary care physician.  
Coverage for contraceptives 24-A M.R.S.A. §2847-G 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 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.  
Standardized plans 24-A M.R.S.A. §2808-B, Rule 750 Carriers in the small group market must have these plans available for purchase. Benefit levels defined in the Rule.  
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 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.  
Coverage for hearing aids 24-A M.R.S.A. §2847-O

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 Dependent Children Up to Age 25 24-A M.R.S.A. §2833-B

An group health insurance policy that offers coverage for dependent children must offer such coverage until the dependent child is 25 years of age.  Pursuant to §2833-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.

  
Screening mammograms 24-A M.R.S.A. §2837-A Benefits must be made available for screening mammography.  A screening mammogram also includes an additional radiologic procedure recommended by a provider when the results of an initial radiologic procedure are not definitive.   
Timeline for second level grievance review decisions 24-A M.R.S.A. §4303(4) Decisions for second level grievance reviews must be issued within 30 calendar days if the insured has not requested to appear in person before authorized representatives of the health carrier.  
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

 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.  

Last Updated: October 31, 2008