Source: http://www.maine.gov/pfr/insurance/review_checklists/Rate_filing_Blanket_Studentonly.html
Timestamp: 2014-03-08 22:10:10
Document Index: 104021979

Matched Legal Cases: ['§2817', '§2849', '§2844', '§2723', '§2826', '§2707', '§2850', '§2736', '§4320', '§2703', '§2707', '§4309', '§2833', '§2834', '§2437', '§2765', '§2673', '§4318', '§2823', '§2847', '§2749', '§2846', '§2745', '§4306', '§2832', '§2837', '§2745', '§2834', '§2745', '§2744']

HO4.001 - Blanket Accident and Sickness Policies : Form & Rate Filing Review Checklists : Bureau of Insurance
> Company Services > Review Checklists > HO4.001 - Blanket Accident and Sickness Policies
(H04.001) - Blanket Accident/Sickness - STUDENT ONLY
(45 CFR 147 defines student health insurance as individual coverage and applies to policy years beginning on or after July 1, 2012.)
Amended 09/2012
Certification: This product will be sold to Students only: ___Yes ___No
If No, USE: HO4 – Blanket Accident and Sickness Policy Checklist.
General Policy Provisions Applicant's statements – applies to Master Policy, not certificate.
24-A M.R.S.A. §2817
Continuity for individual who changes groups Continuity on replacement of group policy
24-A M.R.S.A. §2849-B (3-B)
This section provides continuity of coverage to persons who were covered under the replaced contract or policy at any time during the 90 days before the discontinuance of the replaced contract or policy.
Coordination of Benefits 24-A M.R.S.A. §2844
§2723-A(3)
Blanket health insurance is the form of health insurance covering groups of persons cited in this section (i.e. schools, religious groups, common carrier, sports group, camp, etc.) Definition of Medically Necessary
Coverage must be offered for domestic partners of individual policyholders or group members. This section establishes criteria defining who is an eligible domestic partner. Examination, Autopsy 24-A M.R.S.A. §2826
There shall be a provision that the insurer has the right to examine the insured as often as it may reasonably require during the pendency of claim and also has the right to make an autopsy in case of death where it is not prohibited by law. Explanations for any Exclusion of Coverage for work related sicknesses or injuries
Must provide an extension of benefits of at least 6 months for a person who is totally disabled on the date the group policy is discontinued, or on the date coverage for a subgroup in the policy is discontinued. For a policy providing specific indemnity during hospital confinement, "extension of benefits" means that discontinuance of the policy during a disability has no effect on benefits payable for that confinement. Grace Period 24-A M.R.S.A. §2707
30 days Guaranteed Issue & Renewal - Applies to Master Policy, not certificate
24-A M.R.S.A. §2850-B §2736-C(3)
§4320-H
A preexisting condition exclusion may not exceed 12 months, including the waiting period, if any. This section goes on to describe restrictions to preexisting condition exclusions. Notice of Rate Increase
Required provisions 24-A M.R.S.A.
§2703-2768
Entire contract – changes, time limit on certain defenses, reinstatement, notice of claims, payment of claims, claim forms, proof of loss, right to examine and return policy Third Party Notice, Cancellation and Reinstatement
§2707-A
No action of law shall be brought to recover on the policy prior to the expiration of 60 days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought at all, unless brought within 2 years from the expiration of the time within which proof of loss is required by the policy. COMPLIANCE WITH THE AFFORDABLE CARE ACT – See PPACA Uniform Compliance Summary for specific requirements.
24-A M.R.S.A. §4309-A, , A carrier shall comply with all applicable requirements of the ACA.
Coverage of preventive health services. For plans subject to the ACA. See separate checklist for specific requirements.
Child coverage 24-A M.R.S.A. §2833
Under 19 years of age and are children, stepchildren or adopted children of, or children placed for adoption with the policyholder, member or spouse of the policyholder or member, no financial dependency requirement, court ordered coverage Dependent special enrollment period 24-A M.R.S.A. §2834-B
Enrollment for qualifying events. Dependent children with mental or physical illness
Requires health insurance policies to continue coverage for dependent children up to the age at which coverage for students terminates under the terms of the policy 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. Note: If this is a blanket policy that does not qualify as a group policy this provision might not apply. Providers/Networks
Benefits for dentists 24-A M.R.S.A. §2437
Must include benefits for dentists’ services to the extent that the same services would be covered if performed by a physician. Certified nurse practitioners; certified nurse midwives 24-A M.R.S.A.
Benefits must be included for the services of chiropractors to the extent that the same services would be covered by a physician. Benefits must be included for therapeutic, adjustive and manipulative services. Independent Practice Dental Hygienists
§2765 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. Network adequacy 24-A M.R.S.A. §2673-A Rule 360
If the policy uses a network, the network(s) need to have been approved by the Bureau for adequacy and access standards (i.e. physician, hospital, and ancillary service networks) Optional coverage for optometric services
Benefits must be made available for the services of optometrists if the same services would be covered if performed by a physician. PPOs – Payment for Non-preferred Providers
Psychologists’ services 24-A M.R.S.A.
Must include benefits for psychologists’ services to the extent that the same services would be covered if performed by a physician. Registered nurse first assistants
24-A .R.S.A.
Coverage for registered nurse first assistants Services of social workers 24-A M.R.S.A.
Benefits must be included for the services of social workers and psychiatric nurses to the extent that the same services would be covered if performed by a physician. Claims & Utilization Review
24-A M.R.S.A. §4318
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. Notice of claim 24-A M.R.S.A. §2823
All benefits shall generally be payable to the person insured, or to his designated beneficiary or beneficiaries, or to his estate. Penalty for noncompliance with utilization review 24-A M.R.S.A. §2847-D
§2749-B
All policies must contain all grievance and appeal procedures as referenced in Rule 850. The policy must contain the procedure to follow if an insured wishes to file a grievance regarding policy provisions or denial of benefits.
General Health Care Treatment/Coverage
24-A M.R.S.A. §2846
May not provide more restrictive benefits for expenses resulting from Acquired Immune Deficiency Syndrome (AIDS) or related illness.
(Mandated Coverage) 24-A M.R.S.A. §2745-C
Breast reduction and symptomatic varicose vein surgery (Mandated Offer) 24-A M.R.S.A.
Coverage must be offered for breast reduction surgery and symptomatic varicose vein surgery determined to be medically necessary.
Benefits must be made available for home health care services. Hospice Care Services
Prostate cancer screening 24-A M.R.S.A.
Coverage required for prostate cancer screening: Digital rectal examinations and prostate-specific antigen tests covered if recommended by a physician, at least once a year for men 50 years of age or older until age 72. Treatment of alcoholism
Benefits must be made available for treatment of alcoholism by licensed or certified treatment facilities subject "reasonable limitations". This is mandated coverage for groups of 20 or more (mandated offer for groups under 20) Women & Maternity/Children/Infants
Gynecological and obstetrical services 24-A M.R.S.A.
§4306-A
Benefits must be provided for annual gynecological exam without prior approval of primary care physician. Maternity and newborn care 24-A M.R.S.A.
Benefits must be provided for maternity (length of stay) and newborn care, in accordance with "Guidelines for Perinatal Care" as determined by attending provider and mother. Maternity benefits for unmarried women
24-A M.R.S.A. §2832
Maternity benefits provided to married women must also be provided to unmarried women. Coverage of children must be made available to unmarried women on the same basis as married women.
Pap tests 24-A M.R.S.A. §2837-E
Benefits must be provided for screening Pap tests Screening mammograms
24-A M.R.S.A. §2745-A
Must provide coverage for screening mammography. A screening mammogram also includes an additional radiologic procedure recommended by a provider when the results of an initial radiologic procedure are not definitive. Provision in the ACA may prohibit cost sharing provisions for some preventative services. Autism Spectrum Disorders
“Children's early intervention services” means services provided by licensed occupational therapists, physical therapists, speech-language pathologists or clinical social workers working with children from birth to 36 months of age with an identified developmental disability or delay as described in the federal Individuals with Disabilities Education Act, Part C, 20 US Code, Section 1411 http://uscode.house.gov/uscode-cgi/fastweb.exe?getdoc+uscview+t17t20+4099+0++%28%29%20%20A.
Coverage is required for the purchase of hearing aids for each hearing-impaired ear for the following individuals:
From birth to 5 years of age if the individual is covered under a policy or contract that is issued or renewed on or after January 1, 2008.
Medical food coverage for inborn error of metabolism 24-A M.R.S.A.
Must provide coverage for metabolic formula and up to $3,000 per year for prescribed modified low-protein food products. Newborn coverage 24-A M.R.S.A. §2834
Must cover any children born while coverage is in force from the moment of birth, including treatment of congenital defects. Prescription Drugs/Supplies/Devices
If an enrollee has been undergoing a course of treatment with a prescription drug by prior authorization of a carrier and the enrollee’s coverage with one carrier is replaced with coverage from another carrier pursuant to section 2849-B, the replacement carrier shall honor the prior authorization for that prescription drug and provide coverage in the same manner as the previous carrier until the replacement carrier conducts a review of the prior authorization for that prescription drug with the enrollee’s prescribing provider. Policies must include a notice of the carrier’s right to request a review with the enrollee’s provider, and the replacing carrier must honor the prior carrier’s authorization for a period not to exceed 6 months if the enrollee’s provider participates in the review and requests the prior authorization be continued. The replacing carrier is not required to provide benefits for conditions or services not otherwise covered under the replacement policy, and cost sharing may be based on the copayments and coinsurance requirements of the replacement policy. Contraceptives
Prescription drug coverage must include contraceptives Diabetes supplies 24-A M.R.S.A.
Benefits must be provided for medically necessary equipment and supplies used to treat diabetes (insulin, oral hypoglycemic agents, monitors, test strips, syringes and lancets) and approved self-management and education training. Off-label use of prescription drugs for cancer, HIV, or AIDS
24-A M.R.S.A. §2745-E
Specialty tiered drugs - Adjustment of out-of-pocket limits
A carrier offering a health plan in this State may not deny coverage on the basis that the coverage is provided through telemedicine if the health care service would be covered were it provided through in-person consultation between the covered person and a health care provider. Coverage for health care services provided through telemedicine must be determined in a manner consistent with coverage for health care services provided through in-person consultation. A carrier may offer a health plan containing a provision for a deductible, copayment or coinsurance requirement for a health care service provided through telemedicine as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to an in-person consultation. Mental Health Services/COVERAGE
Mandated Officer - Individual
Rule 330 applies to only certain policies. Mandated offer of parity for individuals – mental health benefits cannot be less extensive than for physical illnesses for the following mental illnesses: schizophrenia, bipolar disorder, pervasive developmental disorder (or autism), paranoia, panic disorder, obsessive compulsive disorder, and major depressive disorder.
Minimum Standards for Mental Illness Benefits.
Mental health services provided by counseling professionals.
§2744(3)
Benefits must be made available for mental health services provided by licensed counselors. Last Updated: December 17, 2013