REVIEW REQUIREMENTS |
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. |
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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. |
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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. |
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Claim forms |
24-A M.R.S.A. §2710 |
The insurer will furnish claim forms to the claimant. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this policy for filing of claim forms. |
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Compliance with ACA |
§4309-A |
Must comply with the ACA |
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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 |
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Coverage for Dental Hygienists |
24-A M.R.S.A. §4257
§2765
§2847-Q
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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. |
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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
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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. |
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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 |
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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. |
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Dental Coverage for Children - Offer |
24-A M.R.S.A. §2766 |
All individual dental insurance policies and contracts 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. |
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Emergency services |
24-A M.R.S.A. §2749-A |
No prior authorization can be required for emergency services |
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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. |
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Explanations Regarding Deductibles |
24-A M.R.S.A. §2413 |
All policies must include clear explanations of all of the following regarding deductibles:
- Whether it is a calendar or policy year deductible.
- Clearly advise whether non-covered expenses apply to the deductible.
- Clearly advise whether it is a per person or family deductible or both.
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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. |
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Free look period |
24-A M.R.S.A. §2717 |
10 day free look |
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General Outline of Coverage Requirements |
Rule 755, Sec. 7(B) |
This subsection contains general requirements and disclosures for Outlines of Coverage. |
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Grace Period |
Rule 191, Sec. 9(K)
Bulletin 288
§2707
§2809-A
§4209 (6) |
30 or 31 days. |
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Grievance & appeals procedures |
24-A M.R.S.A. §4303 (4) and Rule 850, Sec. 8 & 9 |
Specifically describes grievance & appeal procedures required in the contract, as well as the required available external review procedures |
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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. |
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Legal actions |
24-A M.R.S.A. §2715
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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. |
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Lifetime Limits and Annual Aggregate Dollar Limits Prohibited |
§4318
§4320
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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. |
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Limits on priority liens |
24-A M.R.S.A. §2729-A
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A policy may contain a provision that allows such payments, if that provision is approved by the superintendent, and if that provision requires the 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. A just and equitable basis shall mean that any factors that diminish the potential value of the insured's claim shall likewise reduce the share in the claim for those claiming payment for services or reimbursement. |
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Misstatement of age |
24-A M.R.S.A. §2720 |
Misstatement of age: If the age of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age |
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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 |
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Notice of claim |
24-A M.R.S.A. §2709 |
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. |
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Notification prior to cancellation |
24-A M.R.S.A. §2707-A, Rule 580 |
10 days prior notice, reinstatement required if insured has an organic brain disorder |
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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.. |
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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. |
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Plan Requirements |
§4303 |
Must meet all the requirements of this section. |
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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:
- Whether it is a calendar or policy year deductible.
- Clearly advise whether non-covered expenses apply to the deductible.
- Clearly advise whether it is a per person or family deductible or both.
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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. |
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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. |
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Renewal provision |
24-A M.R.S.A. §2738 |
Policy must contain the terms under which the policy can or cannot be renewed |
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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.” |
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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 |
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Time limit on defenses |
24-A M.R.S.A. §2706 |
After 3 years from the date of issue of policy no misstatements, except fraudulent misstatements, made by the applicant in the application for such policy shall be used to void the policy or to deny a claim for loss incurred or disability, commencing after the expiration of such 3-year period. |
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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. |
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Preventative Care Services |
24-A M.R.S.A. §4320-A |
Coverage of preventive health services |
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