Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 281 - GROUP HEALTH CONTRACTS CONVERSION RULE-REVISED › Section 031-281-3 - Similar benefits

Current through 2024-29, July 17, 2024
Conversion policies providing benefits set forth in this
				  section will be deemed to be providing benefits similar to those provided by
				  the group policy from which conversion is being made, in accordance with the
				  requirements of 24-A M.R.S.A. Section 2809-A and 24 M.R.S.A. Section 24M.R.S.A.
				  Section
				  2330.
A. Insurers other than non-profit hospital,
				medical, and health care service organizations.
(1) Hospital Surgical Expense Benefits. If
				the group insurance policy from which conversion is made insures the employee
				or member, with or without dependent coverage, for basic hospital and/or
				surgical expense insurance; the covered individuals shall be entitled to obtain
				a converted policy, or at the insurer's option a group certificate, providing
				coverage on an expense incurred basis under plans meeting the following
				requirements:
PLAN A
(a) hospital
				room and board daily expense benefits in a dollar amount approximating or equal
				to the average semi-private rate charged in metropolitan areas of this State,
				as determined by the Superintendent, for a period of seventy days per hospital
				confinement,
(b) miscellaneous
				hospital expense benefits, in the amount of ten times the room and board daily
				expense benefit, per hospital confinement, and
(c) surgical expense benefits according to a
				surgical schedule consistent with those customarily offered by the insurer
				under group or individual health insurance policies and providing a maximum
				benefit of eight hundred dollars; or
PLAN B
(a) hospital
				room and board daily expense benefits in a dollar amount equal to 75 percent of
				the dollar amount determined in Plan A, for a period of seventy days per
				hospital confinement,
(b)
				miscellaneous hospital expense benefits, in the amount of ten times the
				hospital room and board daily expense benefits, per hospital confinement,
				and
(c) surgical expense benefits
				according to a surgical schedule consistent with those customarily offered by
				the insurer under group or individual health insurance policies and providing a
				maximum benefit of six hundred dollars; or
PLAN C
(a) hospital
				room and board daily expense benefits in a dollar amount equal to 50 percent of
				the dollar amount determined for Plan A, for a period of seventy days per
				hospital confinement.
(b)
				miscellaneous hospital expense benefits, in the amount of ten times the
				hospital room and board daily expense benefit, per hospital confinement,
				and
(c) surgical expense benefits
				according to a surgical schedule consistent with those customarily offered by
				the insurer under group or individual health insurance policies and providing a
				maximum benefit of four hundred dollars.
The insurer must offer all three of these plans. The
				  individual may choose any one of the three. The average semi-private rate
				  referred to in Plan A, Subparagraph a, originally determined to be $200 in
				  Bureau Rules Chapter 280 effective October 18, 1982, shall continue to be $200
				  until July 1, 1988.
Effective July 1, 1988, this amount will increase to $240.
				  Any insurer needing to file new forms or rates in order to comply with this
				  change, must submit the filing on or before April 1, 1988. Any insurer
				  intending to use previously approved forms and rates to comply with this
				  change, must file a statement, specifying the forms and rates to be used, by
				  April 1, 1988.
The average semi-private rate referred to in Plan A,
				  Subparagraph a, may be redetermined by the Superintendent from time to time, as
				  to converted policies issued subsequent to such redetermination, but not more
				  often than once in three years. The dollar amounts in Plan A, B, and C shall be
				  rounded upward to the nearest multiple of ten dollars ($10).
For the purpose of determining the hospital room and board
				  daily expense benefits and the miscellaneous hospital expense benefits under
				  Plans A, B, and C, the policy or certificate may define recurrent hospital
				  confinements resulting from the same cause to be one continuous period of
				  confinement if the confinements are separated by a period of less than 180
				  days. If recurrent hospital confinements do not result from the same cause or
				  are separated by a period of 180 days or more, the subsequent confinement shall
				  be considered to be a separate confinement for the purpose of determining the
				  benefits payable under the policy or certificate.