Skip Maine state header navigation

Agencies | Online Services | Help

Skip First Level Navigation | Skip All Navigation > PFR Home > Insurance Regulation > Company Services > Review Checklists > H16I - Individual Major Medical

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
H16I - Individual Major Medical

Amended 02/2013






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.


Anesthesia for Dentistry

24-A M.R.S.A. §2760

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


Autism Spectrum Disorders

24-A M.R.S.A. § 2768

Policies and contracts must provide coverage for autism spectrum disorders for an individual covered under a policy or contract who is 5 years of age or under in accordance with the following:
1.       The policy or contract 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 or contract 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 or contract may not include any limits on the number of visits.
4.      The policy or contract 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.


Breast cancer treatment

24-A M.R.S.A. §2745-C

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


Breast reduction and symptomatic varicose vein surgery
(Mandated offer)

24-A M.R.S.A. §2761

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


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.


Certified nurse practitioners and certified nurse midwifes

24-A M.R.S.A. §2757

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


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.


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.


Chiropractic Coverage

24-A M.R.S.A. §2748

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


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(F), and Sections 7(A), 7(B), and 7(G).


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.



24-A M.R.S.A. §2756

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.


Credit toward Deductible

24-A M.R.S.A. §2723-A(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.


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.


Dependent Children Up to Age 25

24-A M.R.S.A.

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.


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.


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.


Diabetes supplies

24-A M.R.S.A. §2754

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.


Domestic Partner Coverage (Mandated offer)

24-A M.R.S.A. §2741-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.


Early Childhood Intervention

24-A M.R.S.A. §2767

All individual health insurance policies and contracts 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


Expedited request for external review

24-A M.R.S.A. §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.


Explanations for any Exclusion of Coverage for work related sicknesses or injuries

24-A M.R.S.A. §2413

24-A M.R.S.A. §4303 (15)

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

24-A M.R.S.A. §4303 (15)

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.


Eye Care Services

24-A M.R.S.A. §4314

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


Free look period

24-A M.R.S.A. §2717

10 day free look.


General format

24-A M.R.S.A. §2703

Readability, term of policy described, cost disclosed, form number in bottom left corner.


Grace Period

24-A M.R.S.A. §2707

30 days


Grievance and Appeal Procedures

24-A M.R.S.A. §2747
Rule 850

The policy must contain the procedure to follow if an insured wishes to file a grievance regarding policy provisions or denial of benefits.
All policies must contain all grievance and appeal procedures as referenced in Rule 850.


Guaranteed Issue and Renewal

24-A M.R.S.A. §2736-C

Requires guaranteed issue and renewal.


Health Plan Improvement Act

24-A M.R.S.A. §4301 - §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


Hearing aids

24-A M.R.S.A. §2762

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. 


Home healthcare coverage

24-A M.R.S.A. §2745



Hospice Care Services

24-A M.R.S.A. §2759

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 Practice Dental Hygienists

24-A M.R.S.A. §2765



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.


Infant Formula

24-A M.R.S.A. §2764


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.


Licensed clinical Professional Counselors - Effective 1/04

24-A M.R.S.A. §2744

Must include benefits for Licensed Clinical Professional Counselor services to the extent that the same services would be covered if performed by a physician.


Licensed pastoral counselors and marriage and family counselors

24-A M.R.S.A. §2744

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.


Lifetime Limits and Annual Aggregate Dollar Limits Prohibited


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.


Limitations on exclusions and waiting periods

24-A M.R.S.A. §2850

A pre-existing condition exclusion may not exceed 12 months, including the waiting period, if any. This section goes on to describe restrictions to preexisting condition exclusions.


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.


Medical food coverage for inborn error of metabolism

24-A M.R.S.A. §2745-D

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


Mental health mandated offer

24-A M.R.S.A. §2749-C

Parity with physical illness for mental health services must be offered.


Notice of Rate Increase

24-A M.R.S.A. §2735-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


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."


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

24-A M.R.S.A. §2745-E, §2745-F

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


Optional policy provisions

24-A M.R.S.A. §2718



Penalty for failure to notify of hospitalization

24-A M.R.S.A. §2749-A

No penalty for hospitalization for emergency treatment.


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.


Persons under the influence of alcohol or narcotics

24-A M.R.S.A.

Policies cannot contain the following provision: “Intoxicants and narcotics. The insurer is not liable for any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic or of any hallucinogenic drug, unless administered on the advice of a physician.”


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 non-preferred providers may not exceed 20% of the allowable charge for the service rendered.


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.


Preventative Care Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services



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.


Prostate cancer screening

24-A M.R.S.A. §2745-G

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.


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.


Registered nurse first assistants

24-A M.R.S.A. §2758

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.


Renewal provision

24-A M.R.S.A. §2738

Policy must contain the terms under which the policy can or cannot be renewed


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


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. §2745-A

If radiological procedures are covered


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.

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.


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 Notice of Cancellation

24-A M.R.S.A. §2707-A,
Rule 580

10 days prior notice, reinstatement required if insured has cognitive impairment or functional incapacity.


Timeline for second level grievance review decisions

24-A M.R.S.A.

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.


UCR Definition & 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.


Last Updated: August 5, 2014