For more information, visit our section on Health Insurance - http://www.maine.gov/pfr/insurance/consumer/individuals_families/health/index.html

Health Insurance FAQs
Topic Frequently Asked Questions
Billing - After Co-Pay and Co-Insurance I underwent elective surgery at a Maine hospital in my network but received a bill from an out-of-network anesthesiologist for what my insurance company didn’t pay after I had paid my co-payment and co-insurance.  Should I have to pay?
Buying Health Insurance Shopping for Health Insurance
Buying Health Insurance with Low Income Can't Afford Insurance?
Buying Health Insurance for a Short Period of Time I am thinking about buying health insurance for a short period, What do I need to know about short-term policies?
Cancellation for Nonpayment If the company cancels my policy for nonpayment of premiums, will it affect my ability to find coverage in the future?
Change of Mind After Purchasing Policy I don't want my new insurance policy. Can I give it back to the company?
Checking on an Insurance Company I just heard about "ABC Insurance Company" and they have rates much lower than any of the other plans I've seen. Are they a good company?
Claim Processing - Time to Pay Disability Claim How much time does the company have to pay my disability claim?
Claim Processing - Time to Pay Medical Claim How much time does the company have to pay my medical claim?
Concealing Information from Insurer What are the possible effects of concealing information from the insurance company?
Coverage for a New Baby I just had a baby. Is she covered under my insurance policy?
Coverage for Dependent Children Up to Age 26 Are all individual and group health insurance policies in Maine required to extend coverage for dependent children up to 26 years of age?
Coverage on Spouses Plan I was laid off and lost my coverage, but my spouse has coverage through her employer. When do I need to apply to get on that plan?
Discount Cards Is a discount card considered insurance?
Double Coverage - Who Pays First? I'm covered by 2 health insurance policies. If I have a claim, who pays first?
OB/GYN as Primary Care Provider (PCP) Can I select my obstetrician/gynecologist (OB/GYN) as my primary care provider (PCP)?
Referrals (Requests for Service) Approvals/Disapprovals How long should it take my health plan to approve or disapprove a requested service (referral) from my primary care physician (PCP)?
Referrals When a Specialist Refers You to Another Provider If I go to a specialist after receiving approval from my insurance company for the referral, and the specialist then refers me to another provider, do I need to notify my primary care provider (PCP) or my insurance company to get another referral?
Required Benefits Are there certain benefits my insurance company must provide?
Review of Rates Does the Bureau of Insurance approve the rates the insurance company charges for my health insurance plan?
Self-Funded or Self-Insured Health Plans My insurance company says my employer's health plan is "self-funded" or "self-insured." What does this mean and how does it affect my rights under the plan?
Specialist Options I need to see a certain kind of specialist.  What are my options?
Utilization Review and Prior Authorization
Utilization Review and Prior Authorization Denied Health Insurance Appeals

 

I underwent elective surgery at a Maine hospital in my network but received a bill from an out-of-network anesthesiologist for what my insurance company didn’t pay after I had paid my co-payment and co-insurance.  Should I have to pay?co-payment and co-insurance. Should I have to pay?

This is an example of “balance billing.”  Beginning January 1, 2018, unless you knowingly elected to obtain the services of the out-of-network anesthesiologist when an in-network anesthesiologist was available, you should not be balance billed by this provider.  In addition, if your insurance company’s provider network was inadequate for this service, you should not be responsible for this balance bill.  In both instances, your insurance company is responsible for resolving the balance billing issue with the anesthesiologist.  On the other hand, if you knowingly elected to obtain this out-of-network anesthesiologist’s services when an in-network provider was available, the anesthesiologist is not prohibited from balance billing.  You should contact your insurance company.  You can always contact the Maine Bureau of Insurance. See 24-A M.R.S.   4303-C; 22 M.R.S.   1718-D. [back to top]

I am thinking about buying health insurance for a short period. What do I need to know about short-term policies?

Short-term policies do not have all of the consumer protections available under comprehensive health policies. The most important differences are pre-existing conditions and creditable coverage. Pre-existing conditions are not covered, even if you had prior coverage. The time that you are covered by this policy is not counted as creditable coverage for any individual health insurance you buy later. This can mean you will have to pay a tax penalty. [back to top]

If the company cancels my policy for nonpayment of premiums, will it affect my ability to find coverage in the future?

If this is an individual policy, your insurance company may not be required to give you a new policy until the next open enrollment. You may also be subject to a tax penalty for lack of coverage. [back to top]

I don't want my new insurance policy. Can I give it back to the company?

This depends on the type of insurance you bought. Medicare supplement and long-term care insurance have a 30-day “free look” period during which you can cancel the coverage and have your money refunded. Many other products have at least a 10-day "free look" period when you can cancel coverage. The free look provision in your policy should be stated on the front page. 24-A M.R.S,A, §2717, Bureau of Insurance Rule Chapters 191 Section 9 M or 275 Section 7. [back to top]

I just heard about "ABC Insurance Company" and they have rates much lower than any of the other plans I've seen. Are they a good company?

As the cost of health insurance and Medicare supplement policies continues to rise, more unauthorized insurers come into Maine. The only way to know whether the company you're interested in is one of these fraudulent plans is to check with the Bureau of Insurance by calling 1-800-300-5000 or by using the "Licensee Lookup" tool in the left menu of our website and searching for the company's name. The Bureau cannot recommend companies but can tell you whether the company is authorized to do business in Maine. [back to top]

How much time does the company have to pay my disability claim?

Once the company has determined that a disability claim is payable, it has 30 days to pay the claim. 24-A M.R.S.A. §2436. [back to top]

How much time does the company have to pay my medical claim?

An undisputed claim for medical insurance benefits is payable within 30 days after the insurance company receives all information needed to pay the claim. 24-A M.R.S.A. §2436[back to top]

What are the possible effects of concealing information from the insurance company?

You may jeopardize your coverage (a policy cancellation or nonrenewal could result) and payment for claims. Answer all questions honestly, to the best of your ability. An insurance company can request the Bureau of Insurance investigate claims of false representations on any insurance application. 24-A M.R.S.A. §2178, §2179, §2186, and §2187. [back to top]

I just had a baby. Is she covered under my insurance policy?

Yes, from the moment of birth -- or in the case of an adopted child from the moment the placement papers are signed -- for 31 days. The insurance company may require you to notify them and/or pay an additional premium within that 31 days to continue coverage beyond that point. Title 24-A M.R.S.A. §2743, §2834 and §4234-C. [back to top]

Are all individual and group health insurance policies in Maine required to extend coverage for dependent children up to 26 years of age?

Because of the Federal Health Care Reform Act, all comprehensive individual and most group health insurance plans that offer dependent coverage must make the coverage available until a child reaches the age of 26. Both married and unmarried children qualify for this coverage, even if they have coverage through an employer. [back to top]

I was laid off and lost my coverage, but my spouse has coverage through her employer. When do I need to apply to get on that plan?

You must apply within 30 days of losing your coverage; otherwise you may have to wait until your spouse’s employer’s plan has open enrollment (typically one month each year).  24-A M.R.S.A. §2849-B(3) [back to top]

Is a discount card considered insurance?

No. Discount cards do just that - provide discounts for health care services or prescription drugs. You have to pay all costs beyond the discount. For example, compare what you would pay out-of-pocket for a prescription drug that costs $100: If your discount card provides a 25% discount, you have to pay $75; if your insurance policy has a copay, you may pay less.  Prescriptions purchased with a discount card may not apply to your deductible.  [back to top]

I'm covered by 2 health insurance policies. If I have a claim, who pays first?

When you are covered under more than one health plan, “coordination of benefits” (COB) occurs. This means that the two plans will “coordinate” to see which pays first. The plan that pays benefits first is called the “primary” plan and the plan that pays the remaining benefits is called the “secondary” plan. The typical process for determining who pays first is decided under the following guidelines:

If you are an active employee, the plan that covers you as an employee is usually primary (pays first). If you have another plan that covers you as a dependent, laid-off employee, retiree, or COBRA-covered person, that plan is secondary.

If you and your spouse have dependent children, the primary plan for your dependent children is the plan covering the parent whose birthday falls earlier in the calendar year.

If you and your (former) spouse are divorced or separated, the claims for your dependent children are paid in the following order (unless mandated otherwise by a court order): first, by the plan of the parent with custody; second, by the plan of the spouse of the parent with custody; third, by the plan of the parent without custody. If the parents have joint custody, the birthday rule applies.

Bureau of Insurance Rule 790 requires insurance carriers to decide the order of paying claims. The policyholder should not be subject to late or denied claims payments in the interim. [back to top]

Can I select my obstetrician/gynecologist (OB/GYN) as my primary care provider (PCP)?

Yes, if your OB/GYN has a contract with your insurance company to provide primary care. 24-A M.R.S.A. §2847-F and §4241. [back to top]

How long should it take my health plan to approve or disapprove a requested service (referral) from my primary care physician (PCP)?

For initial determinations, the health plan should let you and your primary care provider know of their decision within 2 working days of obtaining all necessary information. 24-A M.R.S.A. § 4304 (2). [back to top]

If I go to a specialist after receiving approval from my insurance company for the referral, and the specialist then refers me to another provider, do I need to notify my primary care provider (PCP) or my insurance company to get another referral?

Yes, if you are in a plan that requires referrals. You must contact your primary care provider and receive your insurer’s authorization before seeing any other provider in order to receive the greatest benefit level.[back to top]

Are there certain benefits my insurance company must provide?

For individual policies, and for group policies governed by Maine law, the law requires certain benefits. See the list of Maine's mandated benefits.

Qualified Health Plans sold to individuals and small groups are also required by federal law to provide certain healthcare benefits.

In addition, Federal law requires your insurer to cover certain preventive services without you having to pay a copayment or co-insurance or meet your deductible, when you obtain these services from a network provider. See a list of the covered preventive services. -- [back to top]

Does the Bureau of Insurance approve the rates the insurance company charges for my health insurance plan?

Insurance carriers offering health insurance plans to individuals and small group employers (50 or fewer employees) must file rates each year with the Bureau for review and approval. The filing must include every rate, rating formula, and classification of risks, in addition to every modification of any formula or classification that it proposes to use. When the average increase for individual plans is more than 10% or the Bureau has reason to believe that a rate filing for either a small group plan or an individual plan does not meet the requirements that rates not be excessive, inadequate, or unfairly discriminatory or that the filing violates any of the insurance laws, a hearing may be held.

Proposed rates for large group employers (more than 50 employees) need to be filed with the Bureau for informational purposes only. They do not need to be reviewed or approved by the Bureau. [back to top]

My insurance company says my employer's health plan is "self-funded" or "self-insured." What does this mean and how does it affect my rights under the plan?

Self-funded or self-insured plans mean that your employer pays your health plan benefits from its own funds, instead of paying premiums to a health insurance company. Under such plans, the insurer's participation is limited to administering benefit claims. The Maine Bureau of Insurance may not have regulatory jurisdiction over these plans as many are subject to the jurisdiction of the federal government. The specific federal agency involved is the Employee Benefits Security Administration (EBSA) of the U.S. Department of Labor. EBSA maintains a regional office in Boston, and can be contacted at toll-free (866) 444-3272. The web page is as follows: http://www.dol.gov/ebsa/. [back to top]

I need to see a certain kind of specialist.  What are my options?

Contact your insurance company first for a list of their in-network providers.  Insurance companies using networks of participating providers must have a reasonable network of primary care, specialty care, hospitals, and behavioral health care providers. This should allow you to access care without unreasonable delay. If the insurance company has an insufficient number or type of in-network providers, it must let you obtain the covered services at no greater cost to you than if you receive the services from an in-network provider. Bureau Rule Chapter 850, Section 7. [back to top]