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Maine.gov > PFR Home > Insurance Regulation > Company Services > Review Checklists > H07I - Individual Specified Disease

Maine Bureau of Insurance
Form Filing Review Requirements Checklist
H07I - Individual Specified Disease

(Amended 11/2011)

REVIEW REQUIREMENTS

REFERENCE

DESCRIPTION OF REVIEW

STANDARDS REQUIREMENTS

LOCATION OF

STANDARD IN FILING

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.

 

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

 

Policy Definitions

Rule 755, Sec. 4

This section of Rule 755 contains required definitions for:  Accident, Convalescent Nursing Home/Extended Care Facility/Skilled Nursing Facility, Hospital, Medicare, Nurse, One Period of Confinement, Partial Disability, Physician, Pre-existing Condition, Residual Disability, Sickness, and Total Disability.

 

Probationary or Waiting Periods

Rule 755, Sec. 5(A)

A policy shall not contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy, except:

(1)        A policy may specify a probationary or waiting period for sickness not to exceed 30 days from the effective date of the coverage of the insured person; and

(2)        A policy may specify a probationary or waiting period not to exceed six months for specified diseases or conditions and losses resulting from disease or condition related to hernia, disorder of reproduction organs, varicose veins, adenoids, appendix, and tonsils. However, the permissible six-month exception shall not be applicable where the specified diseases or conditions are treated on an emergency basis.

 

Pre-existing Condition Exclusions

Rule 755, Sec. 5(B)

 

Rule 755, Sec. 7(A)(8)

A policy shall not exclude coverage for a loss, due to a preexisting condition, that occurs beyond the 12 months following the issuance of the policy or certificate where the application or enrollment form for the insurance does not seek disclosure of prior illness, disease, physical conditions, medical care, or treatment and where the preexisting condition is not specifically excluded by the terms of the policy or certificate.

If a policy or certificate contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy or certificate and be labeled as “Preexisting Condition Limitations.”

 

Limitations and Exclusions

Rule 755, Sec. 5(E)

A policy shall not limit or exclude coverage except as provided in this subsection.

 

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.

 

General Rules for Minimum Standards

Rule 755, Sec. 6(A)

The requirements set forth in this section are in addition to any other requirements contained in any other applicable statutes and rules including, but not limited to, 24-A M.R.S.A. Chapters 27, 32, 33, 35, 36 and 56-A and Rules 140, 320, 330, 360, 530, 590, 600, 850 and 940.

 

Minimum Standards for Specified Disease Coverage

Rule 755, Sec. 6(J)

Policy must meet all minimum standards in Rule 755, Sec. 6(J)(1) – Sec. 6(J)(6).

 

REQUIRED DISCLOSURE PROVISIONS INCLUDING, BUT NOT LIMITED TO:

Renewal, Continuation, or Nonrenewal Provisions

 

 

Required disclosure statements on policies/certificates

 

 

 

Free Look Period

 

 

 

General Outline of Coverage Requirements

Specified Disease Coverage (Outline of Coverage)

Rule 755, Sec. 7

Rule 755, Sec. 7(A)(4)

 

 

Rule 755, Sec. 7(A)(15)

 

 

 

Rule 755,Sec. 7(A)(10)

 

 

 

Rule 755, Sec. 7(B)

Rule 755, Sec. 7(K)

Each policy shall contain all appropriate provisions contained in this section including, but not limited to the following:

 

Each policy of individual health insurance and group health insurance shall include a renewal, continuation, or nonrenewal provision. The language or specification of the provision shall be consistent with the type of contract to be issued. The provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration, where limited, of renewability and the duration of the term of coverage for which the policy is issued and for which it may be renewed.

All specified disease policies and certificates shall contain on the first page or attached to it in either contrasting color or in boldface type at least equal to the size type used for headings or captions of sections in the [policy][certificate], a prominent statement as follows: Notice to Buyer: This is a specified disease [policy] [certificate].This [policy] [certificate] provides limited benefits. Benefits provided are supplemental and are not intended to cover all medical expenses. [If the policy covers cancer, include the following sentence.] Read your [policy] [certificate] carefully with the outline of coverage and the Buyer’s Guide to Cancer Insurance.

All individual policies, except nonrenewable accident policies, shall have a notice prominently printed on the first page of the policy or certificate or attached to it stating in substance that the policyholder or certificateholder shall have the right to return the policy or certificate within ten days of its delivery and to have the premium refunded if, after examination of the policy or certificate, the policyholder or certificateholder is not satisfied for any reason. Ten days is a minimum; longer periods are permitted.

 

 

This subsection contains general requirements and disclosures for Outlines of Coverage.

 

This subsection describes the required provisions and disclosures for the Outline of Coverage for Specified Disease coverage.

 

Requirements for Replacement of Individual Health Insurance

Rule 755, Sec. 8

Requirements and notifications for individual health insurance

 

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.

 

Renewal provision

24-A M.R.S.A. §2738

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

 

Free look period

24-A M.R.S.A. §2717

10 day free look except nonrenewable accident policies

 

Notice Regarding Policies or Certificates Which are Not Medicare Supplement Policies

24-A M.R.S.A. §5013 and 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. If you have a Medicare supplement policy or major medical policy, this coverage may be more than you need. For information call the Bureau of Insurance at 1-800-300-5000."

 

Misstatement of age

§2720

Misstatement of age: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age

 

Limits on priority liens

24-A M.R.S.A. §2729-A

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.

 

Assignment of benefits

24-A M.R.S.A. §2755

All policies providing benefits for medical or dental care on an expense-incurred basis must contain a provision permitting the insured to assign benefits for such care to the provider of the care. An assignment of benefits under this section does not affect or limit the payment of benefits otherwise payable under the policy.

 

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

 

Emergency services

24-A M.R.S.A. §2749-A

No prior authorization can be required for emergency services

 

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.

 

Coverage for 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.

 

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.

 

Preventative Care Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services

 

 

Last Updated: August 22, 2012