All Rate and Form Filings submitted to the Bureau of Insurance for review must be accompanied by the appropriate rate and/or form review checklists for the product being submitted. The checklists must be completed and must reference, for each requirement on the checklist, the location (i.e. form, page number, paragraph, etc.) of each standard in the filing.
If you have any questions about the Health and Life checklists, please contact Kim Jalbert, Insurance Contract Examiner, at Kimberly.Jalbert@maine.govor call
Plan Year QHP & SADP Requirements Checklists
Please review the SERFF General Instructions page and Plan Management General Instructions Page on SERFF as they have been updated for new plan submissions.
New Legislation from the 131st Legislature.
QHP Forms
- Small Group Major Medical Plans (DOCX) - NON-GRANDFATHERED (updating)
- Individual Major Medical Plans (DOCX) - NON-GRANDFATHERED (updating)
- Small Group HMO and Individual HMO Plans (DOCX) - NON-GRANDFATHERED (updating)
- Maine's Benchmark Essential Health Benefits Chart (PDF) - (updating)
SADP Forms
- Qualified Stand Alone Small Group & Individual Dental (DOCX) 4/8/24
- Maine's Benchmark Pediatric Dental Checklist (PDF) - (updating)
- FEDVIP Benchmark Pediatric Dental Services Chart (PDF) - (updating)
Rates
- Individual Health Policies including Qualified SADP (DOCX) Subject to Title 24-A M.R.S.A § 2736-C - (H15I, H16I.005B, H16I.005C, HOrg02I.005B, HOrg02I.005C) REVISED 4/24/24
- Small Group Health Plans including Qualified SADP Policies (DOCX) - (H15G.003, H16G.003A, H16G.003D,H16G.003G, HOrg02G.004E, H24G.003, H25G.003) REVISED 4/24/24
- Student Health Policies (H04) Health - Blanket Accident/Sickness (DOCX)
- URRT Supplement Template (XLSX) REVISED 4/24/24
- Major Medical Data Collection (XLSX) 4/24/24
The documents on this page are also available in hard copy by contacting the Bureau.