REFERENCE

DESCRIPTION OF REVIEW STANDARDS REQUIREMENTS

LOCATION OF STANDARD IN FILING

Assignment of Benefits

24-A M.R.S.A. §4207-A
24-A M.R.S.A.
§2827-A
24-A M.R.S.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

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.

Child coverage

24-A M.R.S.A. §2833-A
24-A M.R.S.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

§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.
Medicaid is always secondary

Coverage for Dependent Children Up to Age 25

24-A M.R.S.A. §4233-B
 24-A M.R.S.A. §2833-B
24-A M.R.S.A. §2742-B

An individual or group health maintenance organization contract that offers coverage for dependent children must offer such coverage until the dependent child is 25 years of age.  Pursuant to §4233-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.
A health maintenance organization 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.

Definition of Dependent

24-A M.R.S.A. §4234
24-A M.R.S.A.
§2742
24-A M.R.S.A.
§2833

Children (including stepchildren, adopted children or children placed for adoption) under the age of 19. Cannot use financial dependency as a requirement for eligibility. Adopted, or placed for adoption children are to be provided the same benefits as natural dependent children and stepchildren

Domestic Partner Coverage (Mandated offer)

24-A M.R.S.A. §4249
§2741-A
§2832-A

Coverage must be offered for domestic partners of individual policyholders or group members. This section establishes criteria defining who is an eligible domestic partner.

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. §4233-A
§2742-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)
Bulletin 288
§2707
§2809-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 – expedited

§4312

An enrollee is not required to exhaust all levels of a carrier's internal grievance procedure before filing a request for external review if the carrier has failed to make a decision on an internal grievance within the time period required, or has otherwise failed to adhere to all the requirements applicable to the appeal pursuant to state and federal law, or the enrollee has applied for expedited external review at the same time as applying for an expedited internal appeal.

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
§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.

Network approval

24-A M.R.S.A. §2673-A, Rule 360
24-A M.R.S.A.
§4303(1)
Rule 850

All managed care arrangements except MEWAs must be filed for adequacy & compliance with Rule 850 & Rule 360 access standards

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.

Notice of Rate Increase

24-A M.R.S.A. §4222-B(15), §2808 (2-A)
§2736
§2839

§2839-A

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

Participation in Health Information Exchange.

MRS 22 §1711-C (8)

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

Health Plan Improvement Act – Plan Requirements

24-A M.R.S.A. §4302 - §4314
24-A M.R.S.A.
§4320(C)
24-A M.R.S.A.
§4320(D)

Includes requirements including, but not limited to, access to clinical trials, access to prescription drugs, independent external review, standing referral to specialists, allows for certified nurse practitioners to be PCPs. PCP include pediatricians, OB/GYNs and certified nurse practioners. Plans subject to ACA must provide comprehensive health coverage.

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.

Renewal provision

24-A M.R.S.A. §2820

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

Required disclosure statements on policies/certificates

Rule 755, Sec. 7(A)(23)

All vision 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 vision benefits only.”

Subrogation/Limits on priority liens

24-A M.R.S.A. §4243
§2729-A
§2836

Does this policy have subrogation provisions?  If yes see provision 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 applies to closed network arrangements.

Yes   Please provide citation for section in policy ________________________

No  

Third Party Notice, Cancellation and Reinstatement

Rule 580
24-A M.R.S.A. §2707-A
24-A M.R.S.A.
§2847-C
24-A M.R.S.A.
§5016

Third party notice of cancellation and reinstatement for cognitive impairment or functional incapacity

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 calendar days if the insured has not requested to appear in person before authorized representatives of the health carrier.

Vision Coverage  (Outline of Coverage)

Rule 755, Sec. 7(O)

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

Preventative Care Services

24-A M.R.S.A. §4320-A

Coverage of preventive health services