reglab/statecodes huggingface dataset:
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-3 - Applicability and scope

Current through 2024-29, July 17, 2024
(A) Except as
				otherwise specifically provided, this Rule shall apply to all Medicare
				supplement insurance policies, subscriber contracts, and certificates, as
				defined in
				 24-A M.R.S.A.
				§5001, delivered or issued for delivery
				in this State after the effective date of this Rule.
(B) The disclosure provisions in Section
				13(A)(5) of this
				Rule and Section
				19 of this Rule shall apply to all
				individual and group accident and health insurance policies and subscriber
				contracts, and all certificates issued thereunder, which provide hospital or
				medical expense coverage on an expense incurred or indemnity basis, other than
				incidentally, delivered or issued for delivery in this State to persons
				eligible for Medicare by reason of age on or after the effective date of this
				Rule.
(C) This Rule shall not apply
				to:
(1) individual policies issued pursuant
				to a conversion privilege under a group or individual insurance policy that
				includes provisions inconsistent with the requirements of this Rule;
				or
(2) Medicare supplement policies
				issued to employees or members of franchise plans in existence on the effective
				date of this Rule.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-4 - Definitions

Current through 2024-29, July 17, 2024
For purposes of this Rule:
(A) "Applicant" means:
(1) in the case of an individual Medicare
				supplement policy, the person who seeks to contract for benefits; and
(2) in the case of a group Medicare
				supplement policy, the proposed certificate holder.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-5 - Policy definitions and terms

Current through 2024-29, July 17, 2024
No insurance policy may be advertised, solicited, or issued
				  for delivery in this State as a Medicare supplement policy unless the
				  definitions of terms in that policy conform to the requirements of this
				  section.
(A) "Accident," "Accidental
				Injury," or "Accidental Means" shall be defined to employ "result" language and
				shall not include words which establish an accidental means test or use words
				such as "external, violent, visible wounds" or similar words of description or
				characterization.
(1) The definition shall
				not be more restrictive than the following:
Injury or injuries for which benefits are provided means
				  accidental bodily injury sustained by the insured which is the direct result of
				  an accident, independent of disease or bodily infirmity or any other cause, and
				  which occurs while insurance coverage is in force.
(2) The definition may, however, exclude
				injuries for which benefits are provided or available under any workers'
				compensation, employer's liability, or similar law, or motor vehicle no-fault
				plan, unless prohibited by law.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-6 - Prohibited policy provisions

Current through 2024-29, July 17, 2024
(A) A Medicare
				supplement policy may impose reasonable territorial limitations consistent with
				those imposed by Medicare but may otherwise limit or exclude coverage only for
				the following services and conditions:
(1)
				foot care in connection with corns, calluses, flat feet, fallen arches, weak
				feet, chronic foot strain, or symptomatic complaints of the feet;
(2) alcoholism, drug addiction, and mental or
				emotional disorders other than Alzheimer's Disease and related
				dementias;
(3) illness, medical
				condition, or treatment, arising out of:
(a)
				war or act of war (whether declared or undeclared), service in the armed forces
				or units auxiliary thereto, or participation in a felony, riot, or
				insurrection;
(b) suicide (sane or
				insane), attempted suicide, or intentionally self-inflicted injury;
(c) aviation;
(4) cosmetic surgery, other than
				reconstructive surgery that is incidental to or follows surgery resulting from
				trauma, infection, or other diseases of the involved part;
(5) treatment provided in a government
				hospital; any expense to the extent of benefits provided under Medicare, any
				state or federal workers' compensation, employer's liability, or occupational
				disease law, any motor vehicle no-fault law, or any other governmental program
				except Medicaid; services performed by a member of the covered person's
				immediate family; and services for which no charge is normally made in the
				absence of insurance;
(6) dental
				care or treatment;
(7) eye glasses,
				hearing aids, and examination and prescription for the fitting thereof;
				and
(8) rest cures, custodial care,
				transportation, and routine physical examinations;
Limitations or exclusions falling within the foregoing
				  descriptions are permitted, but only to the extent consistent with the mandated
				  benefit requirements of Subparagraph 8(B)(8) below and the other minimum
				  benefit standards set forth in this Rule, provided further that no limitations
				  of the types enumerated in subsections (1), (6), or (8) above may be more
				  restrictive than those of Medicare.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-7 - Benefit conversion requirements

Current through 2024-29, July 17, 2024
(A) Benefits
				eliminated by operation of the Medicare Catastrophic Coverage Act of 1988
				transition provisions shall be restored.
(B) Medicare supplement policies subject to
				the minimum standards adopted by the states pursuant to the Medicare
				Catastrophic Coverage Act of 1988 shall provide at least the minimum benefits
				set forth below in Subsection
				8(B).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-9 - Standards for claims payment

Current through 2024-29, July 17, 2024
(A) Every entity
				providing Medicare supplement policies shall comply with all provisions of
				Section 4081 of the United States Omnibus Reconciliation Act of 1987 ( P.L.
				100-203 ).
(B) Compliance with the
				requirements of Subsection A must be certified on the Medicare supplement
				insurance experience reporting form.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-10 - Prohibited solicitation practices

Current through 2024-29, July 17, 2024
In any advertisement or solicitation of a person eligible for
				  Medicare by reason of age to apply for a Medicare supplement policy, no
				  insurer, agent, or broker shall:
(A)
				represent or imply that the policy, insurer, agent, or broker is sponsored by
				or affiliated with the Federal Government, the Medicare Program, or the Social
				Security Administration; or
(B) use
				any title or initials which represent or imply that the policy, insurer, agent,
				or broker is affiliated with or sponsored by the Federal Government, the
				Medicare Program, or the Social Security Administration.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-11 - Loss ratio standards

Current through 2024-29, July 17, 2024
As soon as practicable, but prior to the effective date of
				  Medicare benefit changes, every insurer or other entity providing Medicare
				  supplement insurance policies or certificates in this State shall file with the
				  Superintendent in accordance with the applicable filing procedures of this
				  State:
(A) Appropriate premium
				adjustments necessary to produce loss ratios as originally anticipated for the
				applicable policies or certificates. Supporting documents as necessary to
				justify the adjustments shall accompany the rate filing; and
(B) Any appropriate riders, endorsements, or
				policy forms needed to accomplish the Medicare supplement insurance
				modifications necessary to eliminate benefit duplications with Medicare. Any
				such riders, endorsements, or policy forms shall provide a clear description of
				the Medicare supplement benefits provided by the policy or
				certificate.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-12 - Permitted compensation arrangements

Current through 2024-29, July 17, 2024
(A) An insurer
				or other entity may provide commission or other compensation to an agent or
				other representative for the sale of a Medicare supplement policy or
				certificate only if the first year commission or other first year compensation
				is no more than 200 percent (200%) of the commission or other compensation paid
				for selling or servicing the policy or certificate in the second year or
				period.
(B) The commission or other
				compensation provided in subsequent (renewal) years must be the same as that
				provided in the second year or period and must be provided for a reasonable
				number of renewal years.
(C) If an
				existing policy or certificate is replaced, no entity shall provide to its
				agents or other producers, and no agent or producer shall receive, compensation
				greater than the renewal compensation payable by the replacing insurer on
				renewal policies or certificates, unless benefits of the new policy or
				certificate are clearly and substantially greater than the benefits under the
				replaced policy.
(D) For purposes
				of this section, "compensation" includes pecuniary or non-pecuniary
				remuneration of any kind relating to the sale or renewal of the policy or
				certificate, including but not limited to bonuses, gifts, prizes, awards and
				finder's fees.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-14 - Requirements for replacement

Current through 2024-29, July 17, 2024
(A) Application
				forms shall include the following questions designed to elicit information as
				to whether the applicant has another Medicare supplement insurance policy or
				certificate in force, as of the date of the application, or whether a Medicare
				supplement policy or certificate is intended to replace any other accident and
				sickness policy or certificate. This requirement may be satisfied through use
				of a supplementary application or other form to be signed by the applicant and,
				except where the coverage is sold without an agent, by the agent:
(1) Do you have another Medicare supplement
				insurance policy or certificate in force (including health care service
				contract or health maintenance organization contract)"
(2) Did you have another Medicare supplement
				policy or certificate in force during the last twelve (12) months"
(a) If so, with which company:
(b) If that policy lapsed, when did it
				lapse"
(3) Are you
				covered by Medicaid"
(4) Do you
				intend to replace any of your medical or health insurance coverage with this
				policy (certificate)"
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-15 - Standards for marketing

Current through 2024-29, July 17, 2024
(A) Every insurer,
				health care service plan, or other entity marketing Medicare supplement
				insurance coverage in this State, directly or through its producers, shall:
(1) Establish marketing procedures to assure
				that any comparison of policies by its agents or other producers will be fair
				and accurate;
(2) Establish
				marketing procedures to assure that excessive insurance is not sold or issued.
				The procedures shall include a specific standard for persons covered by
				Medicaid;
(3) Establish marketing
				procedures which set forth a mechanism or formula for determining whether a
				replacement policy or certificate contains benefits clearly and substantially
				greater than the benefits under the replaced policy;
(4) Display prominently by type, stamp, or
				other appropriate means, on the first page of the outline of coverage and
				policy the following:
"Notice to buyer: This policy may not cover all of the costs
				  associated with medical care incurred by the buyer during the period of
				  coverage. The buyer is advised to review carefully all policy
				  limitations."
(5) Inquire
				and otherwise make every reasonable effort to identify whether a prospective
				applicant or enrollee for Medicare supplement insurance already has accident
				and sickness insurance and the types and amounts of any such insurance;
				and
(6) Establish auditable
				procedures for verifying compliance with the foregoing standards.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-16 - Appropriateness of recommended purchase and excessive insurance

Current through 2024-29, July 17, 2024
(A) In recommending the purchase or
				replacement of any Medicare supplement policy or certificate an agent shall
				make reasonable efforts to determine the appropriateness of a recommended
				purchase or replacement.
(B) Any
				sale of Medicare supplement coverage which will provide an individual more than
				one Medicare supplement policy or certificate is prohibited; provided, however,
				that additional Medicare supplement coverage may be sold if, when combined with
				that individual's health coverage already in force, it would insure no more
				than 100 percent of the individual's actual medical expenses covered under the
				combined policies.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-17 - Reporting of multiple policies

Current through 2024-29, July 17, 2024
On or before March 1 of each year, every insurer or other
				  entity providing Medicare supplement insurance coverage in this state shall
				  inform the Superintendent of every individual resident of this State for which
				  the insurer has in force more than one Medicare supplement insurance policy or
				  certificate. For each such individual, the insurer shall report all policy and
				  certificate numbers and dates of issuance.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-18 - Prohibition against pre-existing conditions, waiting periods, elimination periods, and probationary periods in replacement policies or certificates

Current through 2024-29, July 17, 2024
If a Medicare supplement policy or certificate replaces
				  another Medicare supplement policy or certificate or is offered as a conversion
				  or continuation from a group health insurance plan, the replacing insurer shall
				  waive any time periods applicable to pre-existing conditions, waiting periods,
				  elimination periods, and probationary periods in the new Medicare supplement
				  policy for similar benefits to the extent such time was spent under the
				  original policy.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-19 - Limited benefit health coverage

Current through 2024-29, July 17, 2024
Any limited benefit health insurance policy or certificate,
				  as defined in Section
				  4(C) of this Rule,
				  issued in Maine to persons eligible for Medicare by reason of age, shall notify
				  insureds that the policy is not a Medicare supplement policy or contract. Such
				  notice shall either be printed or attached to the first page of an outline of
				  coverage, if any, delivered to insureds or to the first page of the policy or
				  certificate delivered to insureds. Such notice shall be in no less than twelve
				  (12) point type and shall contain the following language:
"THIS [POLICY, CERTIFICATE OR SUBSCRIBER CONTRACT] IS NOT A
				  MEDICARE SUPPLEMENT [POLICY OR CERTIFICATE]. If you are eligible for Medicare
				  review the Medicare Supplement Buyer's Guide available from the [company or
				  plan].
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-20 - Transition rules

Current through 2024-29, July 17, 2024
Prior to advertising, marketing, issuing, or delivering for
				  issuance any policy as Medicare supplement insurance following the effective
				  date of this revised Rule, all insurers, health maintenance organizations,
				  nonprofit hospital and medical service plans, and nonprofit health care plans
				  shall file with the Superintendent a statement of all forms previously approved
				  for use in Maine which they intend to use in marketing Medicare supplement
				  insurance after the effective date of this Rule. The statement shall identify
				  all such products by form number and indicate the date each such form was
				  approved by the Maine Bureau of Insurance for use in Maine.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-21 - Severability

Current through 2024-29, July 17, 2024
If any provision of this Rule or the application thereof to
				  any person or circumstance is for any reason held to be invalid, the remainder
				  of the Rule and the application of such provision to other persons or
				  circumstances shall not be affected thereby.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-22 - Buyer's guide

Current through 2024-29, July 17, 2024
No insurer, health maintenance organization, or nonprofit
				  hospital or medical service plan shall make use of or otherwise disseminate any
				  Buyer's Guide or informational brochure which does not accurately outline
				  current Medicare benefits.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-23 - Transitional form and rate filing requirements

Current through 2024-29, July 17, 2024
(A) As soon as practicable, and no later than
				forty-five (45) days after the effective date of substantive Medicare benefit
				changes, every insurer, health maintenance organization, and nonprofit hospital
				or medical service plan providing Medicare supplement coverage in this State
				shall file with the Superintendent, in accordance with the applicable filing
				procedures of this State:
(1) Appropriate
				premium adjustments necessary to produce loss ratios as originally anticipated
				for the applicable policies or the adjustment shall accompany the
				filing.
(2) Any appropriate riders,
				endorsements, or policy forms needed to accomplish the Medicare supplement
				insurance modifications necessary to eliminate benefit duplications with
				Medicare and to provide the minimum required benefits. Any such riders,
				endorsements, or policy forms shall provide a clear description of the Medicare
				supplement benefits provided by the policy.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 270 - MEDICARE SUPPLEMENT INSURANCE RULE - REVISED › Section 031-270-24 - Effective date

Current through 2024-29, July 17, 2024
The revised Rule shall be effective August 15, 1990. This
				  Rule does not apply to policies or certificates issued for delivery on or after
				  the effective date of Bureau of Insurance Rule Chapter 275.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 271 - Repealed › Section 031-271-1 - Purpose

Current through 2024-29, July 17, 2024
The purpose of this Rule is to clarify the requirements of
				  reinstitution of Medicare supplemental coverage effective following repeal of
				  the Medicare Catastrophic Coverage Act of 1988 for those insurers which failed
				  to provide reinstitution on a timely basis.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 271 - Repealed › Section 031-271-2 - AUTHORITY

Current through 2024-29, July 17, 2024
This Rule is issued pursuant to the authority vested in the
				  Superintendent of Insurance under Title
				  
				  24 M.R.S.A. §2328 and Title
				   24-A M.R.S.A.
				  §§212,
				  5002,
				  and
				  5003.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 271 - Repealed › Section 031-271-3 - Offer of reinstitution of coverage

Current through 2024-29, July 17, 2024
(A) Except as
				provided in subsection B, in the case of an individual who had in effect, as of
				December 31, 1988, a Medicare supplemental policy with an insurer (as a
				policyholder or, in the case of a group policy, as a certificate holder) and
				the individual terminated coverage under such policy before the date of the
				enactment of the repeal of the Medicare Catastrophic Coverage Act of 1988, the
				insurer shall:
(1) Provide written notice no
				later than December 30, 1990, to the policyholder or certificate holder (at the
				most recent available address) of the offer described below, and
(2) Offer the individual, during a period of
				at least sixty (60) days beginning not later than January 1, 1991,
				reinstitution of coverage (with coverage effective as of January 1, 1990),
				under terms which:
(a) Do not provide for any
				waiting period with respect to treatment of preexisting conditions;
(b) Provide for coverage which is
				substantially equivalent to coverage in effect before the date of termination;
				and
(c) Provide for classification
				of premiums on terms which are at least as favorable to the policyholder or
				certificate holder as the premium classification terms that would have applied
				to the policyholder or certificate holder had the coverage never
				terminated.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 271 - Repealed › Section 031-271-4 - Previous offer

Current through 2024-29, July 17, 2024
An insurer which has previously offered to reinstitute
				  coverage consistent with the requirements of this Rule need not provide an
				  additional opportunity for reinstitution of coverage.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-1 - Purpose

Current through 2024-29, July 17, 2024
The purpose of this Rule is to provide for the reasonable
				  standardization of coverage and simplification of terms and benefits of
				  Medicare supplement policies; to facilitate public understanding and comparison
				  of such policies; to eliminate provisions contained in such policies which may
				  be misleading or confusing in connection with the purchase of such policies or
				  with the settlement of claims; and to provide for full disclosures in the sale
				  of accident and sickness insurance coverages to persons eligible for
				  Medicare.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-2 - Authority

Current through 2024-29, July 17, 2024
This Rule is issued pursuant to the authority vested in the
				  Superintendent of Insurance under
				  24 M.R.S.A. §
										2317-B and 24-A M.R.S.A. §§ 212,
				  2413(1)(F),
				  4207(9), 5002-A, 5002-B, 5005, 5010-A, 5011, and Resolve 2013 Chapter
				  19.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-3 - Applicability and Scope

Current through 2024-29, July 17, 2024
A. Except as
				otherwise specifically provided in Sections
				13,
				14,
				17 and
				22, this Rule shall apply to:
(1) All Medicare supplement policies
				delivered or issued for delivery in this State on or after the effective date
				of this Rule, and
(2) All
				certificates issued under group Medicare supplement policies which certificates
				have been delivered or issued for delivery in this State.
Drafting Note:
For
				  policies or certificates issued or delivered prior to January 1, 1992 see
				  Bureau of Insurance Rule 270, in addition to any applicable sections of this
				  Rule 275.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-4 - Definitions

Current through 2024-29, July 17, 2024
For purposes of this Rule:
A. "Applicant" means:
(1) In the case of an individual Medicare
				supplement policy, the person who seeks to contract for benefits; and
(2) In the case of a group Medicare
				supplement policy, the proposed certificate holder.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-5 - Policy Definitions and Terms

Current through 2024-29, July 17, 2024
No policy or certificate may be advertised, solicited or
				  issued for delivery in this State as a Medicare supplement policy or
				  certificate unless such policy or certificate contains definitions or terms
				  which conform to the requirements of this section.
A. "Accident," "Accidental Injury," or
				"Accidental Means" shall be defined to employ "result" language and shall not
				include words which establish an accidental means test or use words such as
				"external, violent, visible wounds" or similar words of description or
				characterization.
(1) The definition shall
				not be more restrictive than the following: "Injury or injuries for which
				benefits are provided means accidental bodily injury sustained by the insured
				which is the direct result of an accident, independent of disease or bodily
				infirmity or any other cause, and occurs while insurance coverage is in
				force."
(2) The definition may,
				however, exclude injuries for which benefits are provided or available under
				any workers' compensation, employer's liability, or similar law, or motor
				vehicle no-fault plan, unless prohibited by law.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-6 - Policy Provisions

Current through 2024-29, July 17, 2024
A. Except for
				permitted preexisting condition clauses as described in Section
				8 and in Sections
				8(A)(1) and
				8.1(A)(1) of this
				Rule, no policy or certificate may be advertised, solicited, or issued for
				delivery in this State as a Medicare supplement policy if the policy or
				certificate contains limitations or exclusions on coverage that are more
				restrictive than those of Medicare.
B. No Medicare supplement policy or
				certificate may use waivers to exclude, limit or reduce coverage or benefits
				for specifically named or described preexisting diseases or physical
				conditions.
C. No Medicare
				supplement policy or certificate in force in the State shall contain benefits
				which duplicate benefits provided by Medicare.
D.
(1)
				Subject to Sections
				8(A)(4), and
				8(A)(5) of this Rule,
				a Medicare supplement policy with benefits for outpatient prescription drugs in
				existence prior to January 1, 2006 shall be renewed for current policyholders
				who do not enroll in Part D at the option of the policyholder.
(2) A Medicare supplement policy with
				benefits for outpatient prescription drugs shall not be issued after December
				31, 2005.
(3) After December 31,
				2005, a Medicare supplement policy with benefits for outpatient prescription
				drugs may not be renewed after the policyholder enrolls in Medicare Part D
				unless:
a. The policy is modified to eliminate
				outpatient prescription coverage for expenses of outpatient prescription drugs
				incurred after the effective date of the individual's coverage under a Part D
				plan, and;
b. Premiums are adjusted
				to reflect the elimination of outpatient prescription drug coverage at the time
				of Medicare Part D enrollment, accounting for any claims paid, if
				applicable.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-9.1 - Standard Medicare Supplement Benefit Plans for 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery with an Effective Date of Coverage on or After June 1, 2010

Current through 2024-29, July 17, 2024
The following standards are applicable to all Medicare
				  supplement policies or certificates delivered or issued for delivery in this
				  State with an effective date of coverage on or after June 1, 2010. No policy or
				  certificate may be advertised, solicited, delivered, or issued for delivery in
				  this State as a Medicare supplement policy or certificate unless it complies
				  with these benefit plan standards. Benefit plan standards applicable to
				  Medicare supplement policies and certificates issued with an effective date of
				  coverage before June 1, 2010 remain subject to the requirements of Section
				  9.
A.
(1) An
				issuer shall make available to each prospective policyholder and certificate
				holder a policy form or certificate form containing only the basic (core)
				benefits, as defined in Section
				8.1(B) of this
				Rule.
(2) If an issuer makes
				available any of the additional benefits described in Section
				8.1(C), or offers
				standardized benefit Plans K or L (as described in Sections 9.1(E)(8) and (9)
				of this Rule), then the issuer shall make available to each prospective
				policyholder and certificateholder, in addition to a policy form or certificate
				form with only the basic (core) benefits as described in Subsection A(1) above,
				a policy form or certificate form containing either standardized benefit Plan C
				(as described in Section 9.1(E)(3) of this Rule) or standardized benefit Plan F
				(as described in 9.1(E)(5) of this Rule).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-10 - Medicare Select Policies and Certificates

Current through 2024-29, July 17, 2024
A.
(1) This section shall apply to Medicare
				Select policies and certificates, as defined in this section.
(2) No policy or certificate may be
				advertised as a Medicare Select policy or certificate unless it meets the
				requirements of this section.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-11 - Open Enrollment

Current through 2024-29, July 17, 2024
A. Each Medicare
				beneficiary shall be entitled to a 6-month open enrollment period beginning on
				the date he or she first enrolls for benefits under Medicare Part B, and each
				individual enrolled for benefits under Medicare Part B before turning 65 shall
				be entitled to an additional 6-month open enrollment period beginning on his or
				her 65th birthday. An issuer shall not deny or condition the issuance or
				effectiveness of any Medicare supplement policy or certificate available for
				sale in this State, nor discriminate in the pricing of such a policy or
				certificate because of the applicant's health status, claims experience,
				receipt of health care, or medical condition, if the application date falls
				during the applicant's open enrollment period or during the preceding 60 days.
				In the case of an application preceding the open enrollment period, the issuer
				may defer the effective date of the Medicare supplement policy until the first
				day of the open enrollment period. Each Medicare supplement policy and
				certificate currently available from an issuer shall be made available to all
				applicants who qualify under this subsection without regard to age.
B.
(1) If
				an applicant qualifies under Subsection A and submits an application during the
				time period referenced in Subsection A and, as of the date of application, has
				had a continuous period of creditable coverage of at least six (6) months, the
				issuer shall not exclude benefits based on a preexisting condition.
(2) If the applicant qualifies under
				Subsection A and submits an application during the time period referenced in
				Subsection A and, as of the date of application, has had a continuous period of
				creditable coverage that is less than six (6) months, the issuer shall reduce
				the period of any preexisting condition exclusion by the aggregate of the
				period of creditable coverage applicable to the applicant as of the enrollment
				date. For example, if a beneficiary did not have creditable coverage prior to
				enrolling in Medicare Part A and Part B at age 65 and then purchases a Medicare
				supplement policy with a six-month preexisting condition exclusion at month 5
				of the open enrollment period, the preexisting condition exclusion period must
				be reduced to one month because Medicare is creditable coverage. This example
				pertains only to Subsections A and B and does not preclude the insurer from
				underwriting or refusing to issue a policy if the insured does not elect a
				Medicare supplement policy during the 6-month period described in Subsection A
				or is otherwise provided for in Subsection B and Sections
				12 and
				23.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-12 - Guaranteed Issue for Eligible Persons

Current through 2024-29, July 17, 2024
A.
				Guaranteed Issue
(1) Eligible persons are
				those individuals described in Subsection B who apply to enroll under the
				policy not later than ninety (90) days after the date of the termination of
				enrollment described in Subsection B, and who submit evidence of the date of
				termination, disenrollment, or Medicare Part D enrollment with the application
				for a Medicare supplement policy, or within a reasonable time after the date of
				the application. In case of an individual described in Subsection 12(B)(1), the
				guaranteed issue period begins on the later of:
(i) the date the individual receives a notice
				of termination or cessation of some or all supplemental health benefits (or if
				a notice is not received, notice that a claim has been denied because of such a
				termination or cessation); or
(ii)
				the date that the applicable coverage terminates or ceases; and ends 90 days
				thereafter.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-13 - Standards for Claims Payment

Current through 2024-29, July 17, 2024
A. An issuer shall
				comply with Section 1882(c)(3) of the Social Security Act (as enacted by
				Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA)
				1987, Pub. L. No. 100-203 ) by:
(1) Accepting
				a notice from a Medicare carrier on dually assigned claims submitted by
				participating physicians and suppliers as a claim for benefits in place of any
				other claim form otherwise required and making a payment determination on the
				basis of the information contained in that notice;
(2) Notifying the participating physician or
				supplier and the beneficiary of the payment determination;
(3) Paying the participating physician or
				supplier directly;
(4) Furnishing,
				at the time of enrollment, each enrollee with a card listing the policy name,
				number, and a central mailing address to which notices from a Medicare carrier
				may be sent;
(5) Paying user fees
				for claim notices that are transmitted electronically or otherwise;
				and
(6) Providing to the Secretary
				of Health and Human Services, at least annually, a central mailing address to
				which all claims may be sent by Medicare carriers.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-14 - Loss Ratio Standards and Refund or Credit of Premium

Current through 2024-29, July 17, 2024
A. Loss Ratio Standards.
(1)
a. A
				Medicare supplement policy form or certificate form shall not be delivered or
				issued for delivery unless the policy form or certificate form can be expected,
				as estimated for the entire period for which rates are computed to provide
				coverage, to return to policyholders and certificate holders in the form of
				aggregate benefits (not including anticipated refunds or credits) provided
				under the policy form or certificate form:
i.
				At least seventy-five percent (75%) of the aggregate amount of premiums earned
				in the case of group policies, or
ii. At least sixty-five percent (65%) of the
				aggregate amount of premiums earned in the case of individual
				policies.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-15 - Filing and Approval of Policies and Certificates and Premium Rates

Current through 2024-29, July 17, 2024
The requirements of this Rule have extraterritorial
				  applicability. The form and rate requirements apply to certificates issued in
				  Maine pursuant to out-of-state group policies.
A. An issuer shall not deliver or issue for
				delivery a policy or certificate to a resident of this State unless the policy
				form or certificate form has been filed with and approved by the Superintendent
				in accordance with filing requirements and procedures prescribed by law. An
				issuer shall file any riders or amendments to policy or certificate forms to
				delete outpatient prescription drug benefits as required by the Medicare
				Prescription Drug, Improvement, and Modernization Act of 2003 only in the state
				in which the policy or certificate was issued.
B. An issuer shall not use or change premium
				rates for a Medicare supplement policy or certificate unless the rates, rating
				schedule and supporting documentation have been filed with and approved by the
				Superintendent in accordance with the filing requirements and procedures
				prescribed by Subsection G.
C.
(1) Except as provided in Paragraph (2) of
				this subsection, an issuer shall not file for approval more than one form of a
				policy or certificate of each type for each standard Medicare supplement
				benefit plan.
(2) An issuer may
				offer, with the approval of the Superintendent, up to two (2) alternative
				policy forms or certificate forms of the same type for the same standard
				Medicare supplement benefit plan, one for each of the following cases:
a. The inclusion of new or innovative
				benefits;
b. The addition of either
				direct response or producer marketing methods.
(3) For the purposes of this section, a
				"type" means an individual policy, a group policy, an individual Medicare
				Select policy, or a group Medicare Select policy.
(4) An issuer filing proposed rate increases
				for 1990 standardized Medicare supplement benefit plans must describe the
				relationship of the rates filed to those renewal rates for comparable 2010
				standardized Medicare supplement benefit plans.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-16 - Permitted Compensation Arrangements

Current through 2024-29, July 17, 2024
A. An issuer or
				other entity may provide commission or other compensation to a producer or
				other representative for the sale of a Medicare supplement policy or
				certificate only if the first year commission or other first year compensation
				is no more than two-hundred percent (200%) of the commission or other
				compensation paid for selling or servicing the policy or certificate in the
				second year or period.
B. The
				commission or other compensation provided in subsequent (renewal) years must be
				the same as that provided in the second year or period and must be provided for
				no fewer than five (5) renewal years.
C. No issuer or other entity shall provide to
				its producers, and no producer shall receive, compensation greater than the
				renewal compensation payable by the replacing issuer on renewal policies or
				certificates if an existing policy or certificate is replaced.
D. The commission or other compensation
				provided to a producer or other representative for the sale of a Medicare
				supplement policy or certificate must be the same regardless of age of the
				individual when issuance is guaranteed.
E. For purposes of this section,
				"compensation" includes pecuniary or non-pecuniary remuneration of any kind
				relating to the sale or renewal of the policy or certificate including but not
				limited to bonuses, gifts, prizes, awards, and finder's fees.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-19 - Filing Requirements for Advertising

Current through 2024-29, July 17, 2024
An issuer shall provide a copy of any Medicare supplement
				  advertisement intended for use in this State, whether through written, radio or
				  television medium, to the Superintendent for approval at least 30 days prior to
				  the date the advertisement will be used in this State.
All advertising materials shall specifically disclose the
				  availability of Medicare supplemental products to those persons eligible for
				  Medicare because of disability.
Producer or broker advertisements that do not identify
				  Medicare supplement issuers by name are not subject to this
				  section.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-20 - Standards for Marketing

Current through 2024-29, July 17, 2024
A. An issuer,
				directly or through its producers, shall:
(1)
				Establish marketing procedures to assure that any comparison of policies by its
				producers will be fair and accurate.
(2) Establish marketing procedures to assure
				excessive insurance is not sold or issued.
(3) Display prominently by type, stamp or
				other appropriate means, on the first page of the policy the following:
"Notice to buyer: This policy may not cover all of your
				  medical expenses."
(4)
				Inquire and otherwise make every reasonable effort to identify whether a
				prospective applicant or enrollee for Medicare supplement insurance already has
				accident and sickness insurance and the types and amounts of any such
				insurance.
(5) Establish auditable
				procedures for verifying compliance with this Subsection A.
(6) If applicable, develop and document the
				implementation of procedures to monitor and assess the accuracy of information
				provided to consumers by outside entities or associations, with particular
				attention to guaranteed issue rights and other state-specific issues that
				cannot be addressed accurately by uniform nationwide materials. Carriers must
				make the procedures and written assessments available to the Bureau of
				Insurance upon request.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-21 - Appropriateness of Recommended Purchase and Excessive Insurance

Current through 2024-29, July 17, 2024
A. In recommending the purchase or
				replacement of any Medicare supplement policy or certificate a producer shall
				make reasonable efforts to determine the appropriateness of a recommended
				purchase or replacement.
B. Any
				sale of a Medicare supplement policy or certificate that will provide an
				individual more than one Medicare supplement policy or certificate is
				prohibited.
C. An issuer shall not
				issue a Medicare supplement policy or certificate to an individual enrolled in
				Medicare Part C unless the effective date of the coverage is after the
				termination date of the individual's Part C coverage.
D. A producer recommending the replacement of
				a Medicare supplement policy with a Medicare Advantage plan shall provide the
				beneficiary with a written notice advising that if the individual is
				terminating the Medicare supplement policy to enroll in a Medicare Advantage
				plan for the first time, the individual may be entitled to obtain a Medicare
				supplement policy in the state of Maine if he or she returns to original
				Medicare Part A and Part B within three years. The notice shall specifically
				advise that the right to return to original Medicare Part A and Part B is
				governed by federal law and that for many enrollees federal law only permits
				Medicare beneficiaries to return to original Medicare Part A and Part B during
				an annual enrollment period. The notice shall specifically advise that Medicare
				Advantage enrollees may need to return to original Medicare Part A and Part B
				in less than three years in order to obtain a Medicare supplement policy on a
				guaranteed issue basis.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 275 - Medicare Supplement Insurance › Section 031-275-22 - Reporting of Multiple Policies

Current through 2024-29, July 17, 2024
A. On or before
				March 1 of each year, an issuer shall report the following information for
				every individual resident of this State for which the issuer has in force more
				than one Medicare supplement policy or certificate, or has in force both a
				Medicare Advantage plan and a Medicare supplement policy or certificate:
(1) Policy and certificate number,
				and
(2) Date of issuance