Source: https://www1.maine.gov/pfr/insurance/review_checklists/Rate_filing_Group_hospital_surgicalt_medical_expense.htm
Timestamp: 2015-03-04 00:37:18
Document Index: 763504944

Matched Legal Cases: ['§2817', '§2827', '§2849', '§2849', '§2844', '§2849', '§2707', '§2850', '§2808', '§4301', '§4314', '§2850', '§2847', '§2820', '§2847', '§2707', '§2828', '§4320', '§4320', '§4320', '§4319', '§4320', '§2833', '§2833', '§2809', '§2834', '§2847', '§2840', '§2437', '§2835', '§2841', '§2835', '§2847', '§2835', '§2826', '§2825', '§2836', '§2823', '§2814', '§2847', '§2824', '§4303', '§4303', '§4303', '§2846', '§2837', '§4237', '§4310', '§2847', '§4320', '§2837', '§2829', '§2837', '§2847', '§4320', '§4241', '§2834', '§2832', '§2837', '§2837', '§4320', '§4302', '§4320', '§2847', '§2847', '§2837', '§2837', '§4317', '§2843', '§2843', '§2835', '§2842', '§2842']

> Company Services > Review Checklists > H14G - Group Hospital Surgical Medical Expense
H15G - Group Hospital/Surgical/Medical Expense Amended 09/2012 BENEFIT/PROVISION
Applicant's statements 24-A M.R.S.A. §2817
No statement made by the applicant for insurance shall void the insurance or reduce benefits unless contained in the written application signed by the applicant; and a provision that no agent has authority to change the policy or to waive any of its provisions; and that no change in the policy shall be valid unless approved by an officer of the insurer and evidenced by endorsement on the policy, or by amendment to the policy signed by the policyholder and the insurer Assignment of benefits 24-A M.R.S.A.
§2827-A
Must comply with all applicable provisions of Rule 755 including, but not limited to, Sections 4, 5, 6(A), 6(G), 7(A), 7(B), 7(G), and 8. Continuation of group coverage
Continuity for individual who changes groups 24-A M.R.S.A. §2849-B
A person is provided continuity of coverage if the person was covered under the prior policy and the prior policy terminated Within 180 days before the date the person enrolls or is eligible to enroll in the succeeding policy, or within 90 days before the date the person enrolls or is eligible to enroll in the succeeding contract. The succeeding carrier must waive any medical underwriting or preexisting conditions exclusion to the extent that benefits would have been payable under a prior contract or policy if the prior contract or policy were still in effect. Continuity on replacement of group policy 24-A M.R.S.A. §2849
Continuity of coverage to persons who were covered under the replaced contract any time during the 90 days before the discontinuance of the replaced contract or policy. Continuity on replacement of group policy – Preexisting condition exclusions
24-A M.R.S.A. §2844 Medicaid is always secondary.
Extension of Benefits 24-A M.R.S.A. §2849-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. §2707
30 days. Guaranteed Issue & Renewal
24-A M.R.S.A. §2850-B §2808-B
Renewal must be guaranteed to all individuals, to all groups and to all eligible members and their dependents in those groups except for failure to pay premiums, fraud or intentional misrepresentation.
Small group plans are guaranteed issue and renewed, community rated, and standardized plans. Health plan accountability Rule 850
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. §4301-A - §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 Limitations on exclusions and waiting periods 24-A M.R.S.A. §2850
No preexisting exclusion for children under age 19. 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
10 days prior notice, reinstatement required if insured has an organic brain disorder Penalty for failure to notify of hospitalization 24-A M.R.S.A. §2847-A
Renewal of policy 24-A M.R.S.A. §2820
There shall be a provision stating the conditions for renewal Representations in Applications
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 §2707-A
Time limit on defenses 24-A M.R.S.A. §2828
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. Affordable Care Act
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.
24-A M.R.S.A. §4320-C
The plan must cover emergency services in accordance with the requirements of the ACA, including requirements that emergency services be covered without prior authorization and that cost-sharing requirements, expressed as a copayment amount or coinsurance rate, for out-of-network services are the same as requirements that would apply if such services were provided in network.
24-A M.R.S.A. §4320-B
A health insurance policy that offers coverage for dependent children must offer such coverage until the dependent child is 26 years of age. An insurer shall provide notice to policyholders regarding the availability of dependent coverage under this section upon each renewal of coverage or at least 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.
24-A M.R.S.A. §4320
No lifetime or annual limits on health plans subject to the Affordable Care Act
24-A M.R.S.A. §4319
Carriers must provide rebates in the large group, small group and individual markets to the extent required by the ACA.
24-A M.R.S.A. §4320-D
A carrier offering a health plan subject to the requirements of the ACA shall, at a minimum, provide coverage that incorporates essential benefits and cost-sharing limitations consistent with the requirements of the ACA.
Eligibility/Enrollment Child coverage 24-A M.R.S.A. §2833
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 Coverage for Dependent Children Up to Age 25
Dependent children with mental or physical illness. 24-A M.R.S.A. §2833-A
Dependent coverage 24-A M.R.S.A. §2809
May not use residency as a requirement for dependents. Dependent enrollment 24-A M.R.S.A. §2834-B
Enrollment for qualifying events. Domestic Partner Coverage (Mandated offer)
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 Certified nurse practitioners and certified nurse midwifes 24-A M.R.S.A. §2847-H
Coverage of nurse practitioners and nurse midwives and allows nurse practitioners to serve as primary care providers Chiropractic Services
(Mandated Provider & Coverage)
24-A M.R.S.A. §2840-A
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. 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 - Effective 1/04
Licensed pastoral counselors and marriage and family counselors 24-A M.R.S.A. §2835
Optional Coverage for Optometric Services
24-A M.R.S.A. §2841 Benefits must be made available for the services of optometrists if the same services would be covered if performed by physician.
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 provided for coverage for surgical first assisting benefits or services shall provide coverage and payment under those contracts to a registered nurse first assistant who performs services that are within the scope of a registered nurse first assistant's qualifications. Social workers/Psychiatric nurses
24-A M.R.S.A. §2835 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
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. 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 Lifetime Limits and Annual Aggregate Dollar Limits Prohibited
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 24-A M.R.S.A. §2836
No policy for health insurance shall provide for priority over the insured of payment for any hospital, nursing, medical or surgical services 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 30 days 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. Payment of Benefits 24-A M.R.S.A. §2814
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 May not have a penalty of more than $500 for failure to provide notification under a utilization review program
Proof of Loss 24-A M.R.S.A. §2824
Written proof of loss must be furnished to the insurer within 30 days after the commencement of the period for which the insurer is liable UCR Definition & Required Disclosure 24-A M.R.S.A. §4303(8)
§4303(8)(A)
Grievances & Appeals Grievance & 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
Enrollees have the right to waive the right to a second level appeal/grievance and request an external review after the first level appeal decision.
GeneraL health care treatment/coverage AIDS 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. Anesthesia for Dentistry
(Mandated Coverage)
24-A M.R.S.A. §2837-C §4237
Must provide coverage for reconstruction of both breasts to produce symmetrical appearance according to patient and physician wishes. Benefits provided for breast cancer treatment for a medically appropriate period of time determined by the physician in consultation with the patient. Effective 1/98
Breast reduction and symptomatic varicose vein surgery
(Mandated offer)
24-A M.R.S.A. §4310
Provide access to clinical trials.
24-A M.R.S.A. §2847-N §4320-A
Home health care benefits 24-A M.R.S.A. §2837
Benefits must be made available for home health care services.
Persons under the influence of alcohol or narcotics
24-A M.R.S.A. §2829-3
Policies cannot contain the following provision: “Intoxicants and narcotics. The insurer is not liable for any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic or of any hallucinogenic drug, unless administered on the advice of a physician.”
Prostate cancer screening 24-A M.R.S.A. §2837-H
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. Telemedicine Services
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. woman & Maternity/Infants/Children Gynecological and obstetrical services 24-A M.R.S.A. §2847-F
§4320-A §4241
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
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
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. §2837-A §4320-A
If radiological procedures are covered. Benefits must be made available for screening mammography at least once a year for women 40 years of age and over. A screening mammogram also includes an additional radiologic procedure recommended by a provider when the results of an initial radiologic procedure are not definitive. Autism Spectrum Disorders
The policy, contract or certificate must provide coverage for any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder. The policy, contract or certificate must provide coverage for the treatment of autism spectrum disorders when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary.
24-A M.R.S.A. §4302(1)(A)(5) §4320-A
Newborns are automatically covered under the plan from the moment of birth for the first 31 days.
Prescription Drugs Continuity of Prescription Drugs
24-A M.R.S.A. §2847-G
All contracts that provide coverage for prescription drugs or outpatient medical services must provide coverage for all prescription contraceptives or for outpatient contraceptive services, respectively, to the same extent that coverage is provided for other prescription drugs or outpatient medical services. Diabetes supplies 24-A M.R.S.A. §2847-E
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 and HIV or AIDS 24-A M.R.S.A.
§2837-F §2837-G
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
Coverage must be provided, at a minimum, for prosthetic devices to replace, in whole or in part, an arm or leg to the extent that they are covered under the Medicare program. Coverage for repair or replacement of a prosthetic device must also be included. Exclusion for micro-processors was removed effective 1/2011.
24-A M.R.S.A. §4317-A
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 to the extent not inconsistent with the federal Affordable Care Act.
Mental Health & substance abuse Services/COVERAGE
Mental Health Coverage 24-A M.R.S.A. §2843
Mental health services (groups of 20 or less) 24-A M.R.S.A. §2843
Mental health services provided by counseling professionals. 24-A M.R.S.A. §2835(3)
Benefits must be made available for mental health services provided by licensed counselors. Substance Abuse 24-A M.R.S.A. §2842 Rule 320
Mandated coverage at minimum levels defined in the Rule. Treatment of alcoholism
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: December 17, 2013