REVIEW REQUIREMENTS

REFERENCE

DESCRIPTION OF REVIEW

STANDARDS REQUIREMENTS

LOCATION OF

STANDARD IN FILING

General format

24-A M.R.S.A. §2703

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

Child Coverage

24-A M.R.S.A. §2742

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

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 and Rule 755 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(L), 7(A), 7(B), 7(M), and 8.

Grace Period

24-A M.R.S.A. §2707

30 days

Notification prior to cancellation

24-A M.R.S.A. §2707-A, Rule 580

10 days prior notice, reinstatement required if insured has a 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

Notice of claim

24-A M.R.S.A. §2709

There shall be a provision that written notice of sickness or of injury must be given to the insurer within 20 days after the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim, if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.

Claim forms

24-A M.R.S.A. §2710

The insurer will furnish claim forms to the claimant. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy for filing of claim forms.

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(E)

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

24-A M.R.S.A. §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 (as applicable)

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 (as applicable)

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.

Time limit on defenses

24-A M.R.S.A. §2706

After 3 years from the date of issue of policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability, commencing after the expiration of such 3-year period.

Legal actions

24-A M.R.S.A. §2715

No action can be brought to recover on the policy prior to the expiration of sixty days after written proof of loss has been furnished in accordance with the requirements of the policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished.

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 (as applicable)

24-A M.R.S.A. 2749-A

No prior authorization can be required for emergency services

Claim Payment

24-A M.R.S.A. §2436

Payment of claim within 30 days of receipt of proof of loss

Mandated/Required Provisions

Rule 755, Sec. 9(G)

A supplemental plan is not considered a limited benefit plan if, in the judgment of the Superintendent, it is substantially similar to one of the following types of insurance:
     - Basic Hospital Expense Coverage – as defined in Rule 755, Sec. 6(B)
     - Basic Medical-Surgical Expense Coverage – as defined in Rule 755, Sec. 6(C)
     - Basic Hospital/Medical-Surgical Expense Coverage – as defined in Rule 755,  Sec. 6(D)
     - Major Medical Expense Coverage – as defined in Rule 755, Sec. 6(F)
     - Basic Medical Expense Coverage – as defined in Rule 755, Sec. 6(G)

If the supplemental plan is substantially similar to any of the above listed types of insurance then it must contain all required mandated benefits and other requirements of Maine insurance law applicable to that particular type of insurance.  (See appropriate checklist)

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 Dependent Children Up to Age 25

24-A M.R.S.A. §2742-B

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.

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.

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.

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.

Lifetime Limits and Annual Aggregate Dollar Limits Prohibited

§4317

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.