Source: http://www.state.me.us/pfr/insurance/review_checklists/Rate_filing_Group_Major_medical.htm
Timestamp: 2014-04-19 14:39:08
Document Index: 438652843

Matched Legal Cases: ['§4301', '§10', '§2809', '§2808', '§2850', '§4302', '§4314', '§2808', '§2820', '§2847', '§4320', '§2834', '§2837', '§2437', '§2840', '§2673', '§4303', '§2677', '§2835', '§2847', '§2826', '§4303', '§4309', '§4320', '§4320', '§2834', '§2837', '§4320', '§4303', '§2835', '§2842']

Group Major Medical - H16G : Form & Rate Filing Review Checklists : Bureau of Insurance
> Company Services > Review Checklists > H16G - Group Major Medical
H16G - Group Major Medical
Rule 755 Must comply with all applicable provisions of Rule 755 including, but not limited to, Sections 4, 5, 6(A), 6(F), and Sections 7(A), 7(B), 7(G), and 8.
Continuity on replacement of group policy
24-A M.R.S.A. §4301-A,
Sub-§10-A
Provide an extension of benefits of 6 months for a person who is totally disabled on the date the group or subgroup 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.
§2809-A Bulletin 288
30 or 31 days. Guaranteed Issue
24-A M.R.S.A. §2808-B Small group plans are guaranteed issue and renewed, community rated, and standardized plans.
24-A M.R.S.A. §2850-B
Standards in this rule include, but are not limited to, required provisions for grievance and appeal procedures, emergency services, and utilization review standards. Health Plan Improvement Act
24-A M.R.S.A. §4302 - §4314
These sections describe requirements for health plans offered in Maine. The requirements include, but are not limited to: access to clinical trials, access to prescription drugs, utilization review standards, and independent external review.
Prohibited practices 24-A M.R.S.A. §2808-B
Reasons an enrollee may not be cancelled or denied renewal: Fraud or material misrepresentation, Failure to pay the charge for coverage, When the provisions of the State's community rating law are applicable, as provided by section 2736-C, subsection 3, paragraph B and section 2808-B, subsection 4, paragraph B.
24-A M.R.S.A. §2820
There shall be a provision stating the conditions for renewal.
Application statements, notice of claim, proof of loss, assignment of benefits, renewal provisions Third Party Notice, Cancellation and Reinstatement
24-A M.R.S.A. §2847-C Rule580
COMPLIANCE WITH THE AFFORDABLE CARE ACT – See PPACA Uniform Compliance Summary for specific requirements. Affordable Care Act
24-A M.R.S.A. §4320-A Coverage of preventive health services.
Defined as 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 Children Up to Age 25
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.
May not use residency as a requirement for dependents. Dependent special enrollment period 24-A M.R.S.A. §2834-B
Coverage must be offered for domestic partners of individual policyholders or group members. This section establishes criteria defining who is an eligible domestic partner. Providers/Networks Acupuncture services 24-A M.R.S.A. §2837-B
Benefits must be made available for the services of acupuncturist if comparable services would be covered if performed by a physician. 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 and certified nurse midwifes 24-A M.R.S.A.
Chiropractic Services 24-A M.R.S.A. §2840-A
Provide benefits for care by chiropractors at least equal to benefit paid to other providers treating similar neuro-musculoskeletal conditions. Requires treatment for acute care for a limited self-referred for chiropractic benefits. Independent Practice Dental Hygienists
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. Licensed clinical Professional Counselors
Licensed pastoral counselors and marriage and family counselors 24-A M.R.S.A.
24-A M.R.S.A. §2673-A Rule 360 §4303(1)
All managed care arrangements except MEWA’s must be filed for adequacy and compliance with Rule 850 and Rule 360 access standards.
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).
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 24-A M.R.S.A. §2677-A(2)
Psychologists’ services 24-A M.R.S.A. §2835
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 M.R.S.A. §2847-I
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 Examination, autopsy 24-A M.R.S.A. §2826
A carrier may however offer a health plan that limits benefits under the health plan for specified health care services on an annual basis. Limits on priority liens/subrogation
Grievances & Appeals Grievance and appeals procedures 24-A M.R.S.A. §4303 (4) Rule 850,
Sec. 8 & 9 Specifically describes grievance & appeal procedures required in the contract, as well as the required available external review procedures Expedited request for external review
(Mandated offer) 24-A M.R.S.A.
§4309-A §4320-A
If any policy contains any provision which affects the liability of the insurer because of the insured’s use of alcohol or narcotics during the term of the policy, it shall be in the following form: The insurer shall not be liable for death, injury incurred or disease contracted while the insured is intoxicated or under the influence of narcotics or hallucinogenic drugs unless administered on the advice of a physician.
§4320-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. §2834-A
Coverage of children must be made available to unmarried women on the same basis as married women.
Benefits must be provided for screening pap tests. Screening Mammograms 24-A M.R.S.A. §2837-A §4320-A
§4303(7)(A)
Coverage required for off-label use of prescription drugs for treatment of cancer, HIV, or AIDS.
Prosthetic devices to replace an arm or leg. - Effective 1/04
A carrier may adjust an out-of-pocket limit, as long as any limit for prescription drugs for coinsurance does not exceed $3,500, to minimize any premium increase that might otherwise result from the requirements of this section. Any adjustment made by a carrier pursuant to this subsection is considered a minor modification under section 2850-B. Mental Health & substance abuse Services/COVERAGE
Must provide, at a minimum, the following benefits for a person suffering from a mental or nervous condition: inpatient services, day treatment services, outpatient services, and home health care services. For groups with more than 20 employees mental health benefits cannot be less extensive than for physical illnesses for the following mental illnesses: psychotic disorders (including schizophrenia), dissociative disorders, mood disorders, anxiety disorders, personality disorders, paraphilias, attention deficit ad disruptive behavior disorders, pervasive developmental disorders, tic disorders, eating disorders (including bulimia and anorexia), and substance abuse-related disorders.
§2835(3) Benefits must be made available for mental health services provided by licensed counselors.
Substance Abuse 24-A M.R.S.A. §2842
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) Last Updated: February 22, 2013