REFERENCE

DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

LOCATION OF STANDARD IN FILING

Assignment of Benefits

24-A M.R.S.A. §4207-A
§2827-A
§2755

Permits insureds to assign benefits directly to their provider of care.  Applies to medical and dental expense incurred plans. Does not include indemnity plans. 

Calculation of health benefits based on actual cost

24-A M.R.S.A. §2185

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.

Child coverage

24-A M.R.S.A. §2833-A
§4320-B

Extension of coverage for dependent children. Certain policies subject to ACA must extend coverage to age 26.

Compliance with ACA

§4309-A

Must comply with the ACA

Coordination of Benefits and Evidence of Coverage

Rule 191(§9-A and §9-D)
Rule 790

Rule 790
§2723-A
§2844

Lists items that are required to be placed in an Evidence of Coverage.  Also §9 states:
Evidences of coverage may contain a provision for coordination of benefits, provided that such provision shall not relieve an HMO of its duty to provide or arrange for a covered health care service to an enrollee solely because the enrollee is entitled to coverage under any other contract, policy or plan, including coverage provided under government programs.

Coverage for Dental Hygienists

24-A M.R.S.A. §2847-Q

Coverage must be provided for dental services performed by a licensed independent practice dental hygienist when those services are covered services under the contract and when they are within the lawful scope of practice of the independent practice dental hygienist.

Dental Coverage  (Outline of Coverage)

Rule 755, Sec. 7(N)

This subsection describes the required provisions and disclosures for the Outline of Coverage for Dental Coverage

Dental Coverage for Children - Offer

24-A M.R.S.A. §2847-R

All group dental insurance policies, contracts and certificates that offer dependent coverage must offer the opportunity to enroll a dependent child in the dental insurance coverage during the following periods:
A. From birth to 30 days of age; and
B. Any open or annual enrollment period.

Emergency services

24-A M.R.S.A. §2847-A

No prior authorization can be required for emergency services

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.

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.

Extension of coverage for dependent children with mental or physical illness

24-A M.R.S.A. §2833-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.

Forms for proof of loss

24-A M.R.S.A. §2825

There shall be a provision that the insurer will furnish to the policyholder such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished before the expiration of 15 days after the insurer received notice of any claim under the policy, the person making such claim shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, character and extent of the loss for which claim is made

General Outline of Coverage Requirements

Rule 755, Sec. 7(B)

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

Grace Period

Rule 191, Sec. 9(K)
Rule 191(§9-A and §9-D)
Bulletin 288
24-A M.R.S.A. §2825
24-A M.R.S.A. §2707
24-A M.R.S.A. §2809-A
24-A M.R.S.A. §4209 (6)

30 or 31 days.

Grievance procedure

24-A M.R.S.A. §2816 (non-ERISA group plans only)

The policy must contain the procedure to follow if an insured wishes to file a grievance regarding policy provisions or denial of benefits

Independent external review

24-A M.R.S.A. §4312

Must comply with all requirements of §4312 and the ACA.

Legal actions

24-A M.R.S.A. §2828

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 (for individual plans) (2 years for group plans) after the time written proof of loss is required to be furnished.

Lifetime Limits and Annual Aggregate Dollar Limits Prohibited

§4318
24-A M.R.S.A. §4320

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.
May not establish dollar limits on essential benefits.

Notice of Rate Increase

24-A M.R.S.A. §4222-B(15), §2736
24-A M.R.S.A. §2839

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. Reasonable notice must be provided for other types of policies.

Notification prior to cancellation

24-A M.R.S.A. §2847-C, Rule 580

10 days prior notice, reinstatement required if insured has an organic brain disorder

Notice of claim

24-A M.R.S.A. §2823

There shall be a provision that written notice of sickness or of injury must be given to the insurer within 20 days (30 days for group) 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.

Participation in Health Information Exchange.

22 M.R.S.A. §1711-C (8))

Insurance carrier must not deny a benefit based on patient’s decision not to participate in health information exchange.

Plan Requirements

24-A M.R.S.A. §4303

Must meet all the requirements of this section.

Policy terms must be clear - by way of example - Explanations Regarding Deductibles

24-A M.R.S.A. §2413

Example_-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.

Policy terms must be clear - by way of example Explanations for any Exclusion of Coverage for work related sicknesses or injuries

24-A M.R.S.A. §2413

Example- 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.

PPO Benefit level differential

24-A M.R.S.A. §2677-A

There cannot be more than a 20% differential in benefits between preferred and non-preferred providers. Superintendent can grant waiver for the 20%, in particular for designated providers for cost or quality.

Required disclosure statements on policies/certificates

Rule 755, Sec. 7(A)(22)

All dental plan policies and certificates shall display prominently by type, stamp or other appropriate means on the first page of the policy or certificate, 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] the following:
“Notice to Buyer: This [policy] [certificate] provides dental benefits only.”

Renewal provision

24-A M.R.S.A. §2820

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

Subrogation / Limits on priority liens

24-A M.R.S.A. §4243
24-A M.R.S.A. §2729-A
24-A M.R.S.A. §2836

Does this policy have subrogation provisions? If yes see provisions below:
Subrogation requires 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. Applies to point of service contracts in the HMO but doesn’t apply to closed network arrangements.

Yes   Please provide citation for section in policy ________________________

No  

Timeline for second level grievance review decisions

24-A M.R.S.A. §4303(4)
Rule 850

Decisions for second level grievance reviews must be issued within 30  days if the insured has not requested to appear in person before authorized representatives of the health carrier.

Preventative Care Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services