Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 755 - HEALTH INSURANCE CLASSIFICATIONS, DISCLOSURE, AND MINIMUM STANDARDS › Section 031-755-6 - Minimum Standards for Health Insurance Benefits

Current through 2024-29, July 17, 2024
The following minimum standards for benefits are prescribed
				  for the categories of coverage noted in the following subsections. An
				  individual health insurance policy or group health insurance policy or
				  certificate shall not be delivered or issued for delivery in this state unless
				  it meets the required minimum standards for the specified categories or the
				  Superintendent finds that the policies or certificates are approvable as
				  supplemental health insurance and the outline of coverage complies with the
				  outline of coverage in Section
				  7(M) of this
				  rule.
The heading of the cover letter of any form filing subject to
				  this rule shall state the category of coverage set forth in
				   24-A M.R.S.A.
				  §2694 that the form is intended to be
				  in.
This section shall not preclude the issuance of any policy or
				  contract combining two or more categories set forth in
				   24-A M.R.S.A.
				  §2694.
The requirements set forth in this section are in addition to
				  any other applicable requirements as specified in Section
				  3(D).
A. General Rules
(1) A "noncancellable," "guaranteed
				renewable," or "noncancellable and guaranteed renewable" individual health
				insurance policy shall not provide for termination of coverage of the spouse
				solely because of the occurrence of an event specified for termination of
				coverage of the insured, other than nonpayment of premium. In addition, the
				policy shall provide that in the event of the insured's death, the spouse of
				the insured, if covered under the policy, shall become the insured.
(2)
(a) The
				terms "noncancellable," "guaranteed renewable," or "noncancellable and
				guaranteed renewable" shall not be used without further explanatory language in
				accordance with the disclosure requirements of Section 7A(4).
(b) The terms "noncancellable" or
				"noncancellable and guaranteed renewable" may be used only in an individual
				health insurance policy that the insured has the right to continue in force by
				the timely payment of premiums set forth in the policy at least until the age
				of 65 or until eligibility for Medicare, during which period the insurer has no
				right to make unilaterally any change in any provision of the policy while the
				policy is in force.
(c) An
				individual health insurance policy that provides for periodic payments, weekly
				or monthly, for a specified period during the continuance of disability
				resulting from accident or sickness must provide that the insured has the right
				to continue the policy in force at least to age 60. The policy must further
				provide that if the insured is actively and regularly employed at age 60, the
				insured has the right to continue the policy in force at least until the
				earlier of the date the insured ceases to be actively and regularly employed or
				the insured's normal retirement age under social security. If the insured is
				ineligible for social security benefits, age 65 may be substituted for the
				insured's normal retirement age under social security.
(d) A policy that is subject to the renewal
				requirements of
				 24-A M.R.S.A.
				§2850-B and that permits the insurer to
				nonrenew for any reason other than nonpayment of premiums must be labeled
				"guaranteed renewable with limited exceptions."
(e) Except as provided in subparagraph (c)
				and (d) above, the term "guaranteed renewable" may be used only in a policy
				that the insured has the right to continue in force by the timely payment of
				premiums at least until the age of 65 or until eligibility for Medicare, during
				which period the insurer has no right to make unilaterally any change in any
				provision of the policy while the policy is in force, except that the insurer
				may make changes in premium rates on a class basis.
(3) In an individual health insurance policy
				covering both husband and wife, the age of the younger spouse shall be used as
				the basis for meeting the age and durational requirements of the definitions of
				"noncancellable" or "guaranteed renewable." However, this requirement shall not
				prevent termination of coverage of the older spouse upon attainment of the
				stated age so long as the policy may be continued in force as to the younger
				spouse to the age or for the policy duration period specified in the
				policy.
(4) When accidental death
				and dismemberment coverage is part of the individual health insurance coverage
				offered under the contract, the insured shall have the option to include all
				insureds under the coverage and not just the principal insured.
(5) If a policy contains a status-type
				military service exclusion or a provision that suspends coverage during
				military service, the policy shall provide, upon written requestof the payer,
				for refund of unearned premiums as applicable to the person on a pro rata
				basisbeginning with the first day of military service. The policy must also
				provide for coverage to resume without penalty to the owner upon receipt of a
				written request within 30 days of the end of military service.
(6) In individual health insurance policies,
				coverage shall continue for a dependent child who is incapable of
				self-sustaining employment due to mental retardation or physical handicap on
				the date that the child's coverage would otherwise terminate under the policy
				due to the attainment of a specified age for children and who is chiefly
				dependent on the insured for support and maintenance.
(7) A policy may contain a provision relating
				to recurrent disabilities, but a provision relating to recurrent disabilities
				shall not specify that a recurrent disability be separated by a period greater
				than six months.
(8) Accidental
				death and dismemberment benefits shall be payable if the loss occurs within 90
				days from the date of the accident, irrespective of total disability.
				Disability coverage for loss due to an accident that occurs while the policy is
				in force may impose a time limit not to exceed 30 days on the time between the
				accidental event and commencement of the loss, but the limit must be waived if
				there is a clear cause and effect relationship between the accident and the
				subsequent loss.
(9) Specific
				dismemberment benefits shall not be in lieu of other benefits unless the
				specific benefit equals or exceeds the other benefits.
(10) If a continuous loss commences while a
				policy or certificate providing disability income benefits is in force,
				termination of the policy will not relieve the insurer of liability for that
				loss. The continuous total disability of the insured may be a condition for the
				extension of benefits beyond the period the policy was in force, limited to the
				duration of the benefit period, if any, or payment of the maximum
				benefits.
(11) A policy providing
				coverage for fractures or dislocations may not provide benefits only for "full
				or complete" fractures or dislocations.
(12) All individual policies providing
				medical expense reimbursement benefits that are not subject to the grievance
				procedure requirements of Bureau of Insurance Rule Chapter 850 must contain a
				notice of the review and arbitration rights specified in
				 24-A M.R.S.A.
				§2747.
(13) A short-term nonrenewable policy shall
				be classified in one of the categories specified in Subsections B through I, K,
				or L based on its benefits.
(14)
				For a Sickness first manifested before the policy effective date, that was
				fraudulently not disclosed or fraudulently misrepresented in answer to a
				question in an application for coverage, an insurer may void or contest the
				policy or deny a claim at any time.