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Maine.gov > PFR Home > Insurance Regulation > FAQ > Health

Frequently Asked Questions - Health

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

Regarding health, policy language would dictate a time frame for providers to submit claims. Proof of loss would be required in any disability claim, and a death certificate would be required for claim payments in life policies. It may be an unfair trade practice if the insurance company fails to acknowledge with reasonable promptness pertinent written communications with respect to claims arising under its policies. 24-A M.R.S.A. S 2164-D SS 3B.

What effect will cancellation for nonpayment have on 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 for 91 days. If that happens, any health problems that you currently have (called "pre-existing conditions") may not be covered for up to 12 months. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2736-C(3)(A).

Can I get part of my premium refunded if I cancel my policy in the middle of the month?

Sometimes. 24-A M.R.S.A. S 2453 provides that "Life and health insurance policies that do not provide for any refund of premium when a policyholder requests cancellation prior to the end of the period for which premiums have been paid must state that no refund is payable and that the cancellation will take effect at the end of the period for which premiums have been paid unless the policyholder requests an earlier cancellation date." Therefore, you may be able to get a refund if your policy does not specifically state otherwise.

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. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2178, §2179, §2186, and §2187.

My insurance company is denying a claim because they say it's a preexisting condition. Can they do that?

When you applied for a health insurance policy, if you did not have coverage for more than 63 (or in some cases 90) days beforehand, it is possible that the insurance company can exclude claims related to a preexisting condition for up to 12 months. However, if you are switching coverage - even from Medicare or MaineCare (formerly Medicaid and CubCare) -- the new company cannot exclude something that was covered under the old policy. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2850.

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 period during which you can cancel the coverage and have your money refunded. 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. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2717, Bureau of Insurance Rule Chapters 191 Section 9 M or 275 Section 7.

My health insurance plan says the treatment decisions of my doctor or primary care provider (PCP) are subject to the insurance company's "utilization review" or its "prior authorization." What do these terms mean?

If the policy allows the insurer to conduct utilization review or requires its prior authorization for medical services, the insurance company is not obligated to pay benefits until such review or authorization takes place and it approves the medical treatment your doctor recommends. The review or authorization can be take place not only before, but also during or after, you receive the service in question. If the insurer does not approve the treatment, you have two levels of internal appeal in which you can seek to persuade the insurer to reverse its decision. In many cases where you lose both appeals, you still may pursue what is called independent external review, one of the "Patient's Bill of Rights." To see exactly what Maine law says on this issue, see 24-A MRSA SS 4303-04 and Bureau of Insurance Rule Chapter 850(8) and (9).

What is an Elimination Period?

The number of days of care that you pay out-of-pocket before the insurance company begins to pay benefits.

Does the Bureau of Insurance determine the rates the insurance company charges for my employer's plan?

No. The Bureau of Insurance approves rates for individual policies, but not for small or large groups. Employers negotiate group rates with the insurance companies. For groups with 50 or fewer employees, this will change beginning July 1, 2004. The Bureau will have approval authority over small group rates unless the insurer agrees to refund premiums if claims paid turn out to be less than 78% of the premium. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2808-B(2) and §2736-C (2) through (2-C).

I need to buy health insurance for my family and myself. What can I do?

For information on the companies providing individual insurance policies, along with their premiums, go to: Guide to Individual Health Insurance. You cannot be denied the chance to buy individual insurance, regardless of any health problem you may have, as long as you pay the premium. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2736-C(3).

I don't make much money and I need to get insurance for my family and myself. Where can I go?

The Maine Department of Human Services helps low-income families get coverage through MaineCare (formerly Medicaid and CubCare). For more information, contact them toll-free at 1-877-KIDS-NOW (1-877-543-7669) or http://www.maine.gov/dhhs/bms/.

Dirigo Choice is another insurance plan that provides a competitive alternative to existing health insurance products on the market. Qualifying individuals and families will receive discounts that reduce monthly payments and reductions in deductibles and out-of-pocket expenses based on ability to pay. Dirigo Health pools small business, self-employed and individuals into a large group to better bargain for good prices. As the plan grows over time, so will its capacity to bargain for competitive prices for its members. For more information call: 1-800-409-7520 or http://www.dirigohealth.com/.

I am thinking about buying health insurance for a short period, six months or one year. What do I need to know about short-term policies?

Short-term policies do not have all the consumer protections available under comprehensive health policies. The most important differences are: preexisting conditions are not covered even if you had prior coverage; the time when you are covered by this policy is not counted as creditable coverage for any individual health insurance you buy later, which can mean you will have to wait an additional year before preexisting conditions will be covered; and you cannot be insured for more than one year with a short-term plan. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2849-B(8).

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

You must apply within 30 days of losing your coverage; otherwise, you will need to wait until your spouse's employer's plan has open enrollment (typically for one month each year). To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2849-B(3).

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. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2743, §2834 and §4234-C.

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. These "insurers" market seemingly low-cost plans to small business owners and individuals. They may pay a few initial claims and then leave the consumer without coverage. 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 checking our website at www.maine.gov/insurance, then following the links to "Insurance Company Information" 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.

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 have to pay much less. A discount card doesn't give you any of the protections of an insurance policy. If you decide to get an insurance policy in the future, any health conditions you have before buying the policy can be excluded from coverage for up to 12 months. You may wish to review the public service announcement distributed by the Maine Bureau of Insurance on discount cards.

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, employees routinely may deal with an insurer, but, because no insurance policy is involved, the insurer's participation is limited to administering benefit claims. The Maine Bureau of Insurance may not have regulatory jurisdiction of many such plans, which, however, 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 1-866-444-3272. The web page is as follows: http://www.dol.gov/ebsa/.

Are there certain benefits my insurance company must provide?

Yes. For individual and group policies, the State mandates certain benefits, including screening mammograms, breast cancer treatment, prostate cancer screening, medical food for inborn errors of metabolism, and chiropractic services. Group policies issued to employers with more than 20 employees must also cover treatment for mental illness, alcoholism and drug dependency. The insurance company may put limits on some of these benefits. For a list of mandated benefits, see: Mandated Benefits.

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

You may select a participating OB/GYN as your PCP if he or she has a contract with your insurance company to provide primary care. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §2847-F and §4241.

I need to see a certain kind of specialist, and the only one who participates in my insurance company's network is 2 hours away. What can I do?

If there is no participating specialist within a 60-minute drive from your house and there is a closer non-participating specialist, your health plan must allow you to see the non-participating specialist at no greater cost to you than if that specialist did participate in the network. This 60-minute drive maximum also applies to hospitals; for primary care physicians, the maximum is a 30-minute drive. To see exactly what Maine law says on this issue, see: Bureau of Insurance Rule Chapter 850, Section 7.

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 PCP know of their decision within 2 working days of obtaining all necessary information. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. § 4304 (2) or Bureau of Insurance Rule Chapter 850, Section 8(E).

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

If you are in a managed care plan that requires referrals, yes. You must contact your PCP and receive your health plan's authorization before seeing any other provider in order to receive the greatest benefit level from your health plan.

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

"Coordination of benefits" is the way 2 or more health plans coordinate their respective benefits so that the total benefit paid is not more than 100% of the charges. Maine does not have rules governing coordination of benefits, but the typical process is as follows:

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

(2) If you and your spouse are not divorced or separated, the primary plan for your dependent children is the plan covering the parent whose birthday falls earlier in the calendar year.

(3) If you and your (former) spouse are divorced or separated, the claims for your dependent children are paid in the following order (unless mandated 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.

My doctor sent me a bill for what my insurance company didn't pay. Is that OK?

In managed care, whether your doctor can "balance bill" depends on whether he/she participates in your insurance company's network. Doctors who do participate in the network cannot bill for the balance between their charge and what the insurance companies pay, except for limited copays; doctors who do not participate in the network can charge their regular fee. However, if you're seeing a non-participating doctor because there are no participating doctors within your area (see the question above on specialists), then you cannot be balance billed. To see exactly what Maine law says on this issue, see: Title 24-A M.R.S.A. §4204 (6).

Are all individual and group health insurance policies in Maine required to extend coverage for dependent children up to 25 years of age?

No, health insurance carriers are only required to "offer" you the opportunity to purchase an individual policy that provides for extended coverage up to 25 years of age. Similarly, in Maine health insurance carriers are required to "offer" your employer the opportunity to purchase a group health insurance policy that provides extended coverage for dependent children up to 25 years of age. However, your employer is not required to purchase a policy that provides extended coverage for dependent children up to 25 years of age. You can ask your employer to consider purchasing extended coverage for all employees covered under the health insurance plan, but many employers decline to do so because of the increased premium required.

Is the insurance carrier required to permit your employer to purchase extended coverage for your dependent children up to 25 years of age without providing the same extended coverage for the dependent children of all of the other employees.

No, in general employers must offer similar benefits to all employees.

If your employer chooses to purchase extended health insurance coverage for dependent children up to 25 years of age, what requirements may apply.

1. The dependent is unmarried.
2. The dependent has no dependent children of the child's own.
3. The dependent is either a resident of the State or enrolled as a full-time student at an accredited public or private institution of higher education.
4. A person seeking coverage for a dependent child must provide written documentation on an annual basis that the dependent child meets the above requirements.

 

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Last Updated: December 8, 2011