reglab/statecodes huggingface dataset:
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 830 - VALUATION OF LIFE INSURANCE POLICIES › Section 031-830-3 - Scope

Current through 2024-29, July 17, 2024
This rule shall apply to all life insurance policies, with
				  or without nonforfeiture values, issued on or after the effective date of this
				  rule, subject to the following exceptions and conditions.
A.
Exceptions
(1) This rule shall not apply to any
				individual life insurance policy issued on or after the effective date of this
				rule if the policy is issued in accordance with and as a result of the exercise
				of a reentry provision contained in the original life insurance policy of the
				same or greater face amount, issued before the effective date of this rule,
				that guarantees the premium rates of the new policy. This rule also shall not
				apply to subsequent policies issued as a result of the exercise of such a
				provision, or a derivation of the provision, in the new policy.
(2) This rule shall not apply to any
				universal life policy that meets all the following requirements:
(a) Secondary guarantee period, if any, is
				five (5) years or less;
(b)
				Specified premium for the secondary guarantee period is not less than the net
				level reserve premium for the secondary guarantee period based on the CSO
				valuation tables as defined in Section
				4(F) and the
				applicable valuation interest rate; and
(c) The initial surrender charge is not less
				than 100 percent of the first year annualized specified premium for the
				secondary guarantee period.
(3) This rule shall not apply to any variable
				life insurance policy that provides for life insurance, the amount or duration
				of which varies according to the investment experience of any separate account
				or accounts.
(4) This rule shall
				not apply to any variable universal life insurance policy that provides for
				life insurance, the amount or duration of which varies according to the
				investment experience of any separate account or accounts.
(5) This rule shall not apply to a group life
				insurance certificate unless the certificate provides for a stated or implied
				schedule of maximum gross premiums required in order to continue coverage in
				force for a period in excess of one year.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 830 - VALUATION OF LIFE INSURANCE POLICIES › Section 031-830-5 - General Calculation Requirements for Basic Reserves and Premium Deficiency Reserves

Current through 2024-29, July 17, 2024
A. At the election
				of the company for any one or more specified plans of life insurance, the
				minimum mortality standard for basic reserves may be calculated using the 1980
				CSO valuation tables with select mortality factors (or any other valuation
				mortality table adopted by the NAIC after the effective date of this rule and
				promulgated by rule by the Superintendent for this purpose). If select
				mortality factors are elected, they may be:
(1) The ten-year select mortality factors
				incorporated into the 1980 amendments to the NAIC Standard Valuation
				Law;
(2) The select mortality
				factors in the Appendix; or
Drafting Note: The select mortality factors for
				  duration 1 through 15 in the Appendix of this rule reflect the Society of
				  Actuaries' data for the years 1983 through 1986, split by sex and smoking
				  status, with fifteen years of mortality improvement, based on Society of
				  Actuaries' Projection Scale A applied. A 50% margin was added. The factors were
				  then graded to the 1980 CSO Tables over the next five durations. A 50% margin
				  was deemed appropriate to provide a reasonable margin, with little likelihood
				  that actual experience for significant blocks of business would exceed
				  it.
(3) Any other
				table of select mortality factors adopted by the NAIC after the effective date
				of this rule and promulgated by rule by the Superintendent for the purpose of
				calculating basic reserves.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 830 - VALUATION OF LIFE INSURANCE POLICIES › Section 031-830-6 - Calculation of Minimum Valuation Standard for Policies with Guaranteed Nonlevel Gross Premiums or Guaranteed Nonlevel Benefits (Other than Universal Life Policies)

Current through 2024-29, July 17, 2024
A.
Basic
				Reserves
Basic reserves shall be calculated as the greater of the
				  segmented reserves and the unitary reserves. Both the segmented reserves and
				  the unitary reserves for any policy shall use the same valuation mortality
				  table and selection factors. At the option of the insurer, in calculating
				  segmented reserves and net premiums, either of the adjustments described in
				  Paragraph (1) or (2) below may be made:
(1) Treat the unitary reserve, if greater
				than zero, applicable at the end of each segment as a pure endowment and
				subtract the unitary reserve, if greater than zero, applicable at the beginning
				of each segment from the present value of guaranteed life insurance and
				endowment benefits for each segment.
(2) Treat the guaranteed cash surrender
				value, if greater than zero, applicable at the end of each segment as a pure
				endowment; and subtract the guaranteed cash surrender value, if greater than
				zero, applicable at the beginning of each segment from the present value of
				guaranteed life insurance and endowment benefits for each segment.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 830 - VALUATION OF LIFE INSURANCE POLICIES › Section 031-830-7 - Calculation of Minimum Valuation Standard for Flexible Premium and Fixed Premium Universal Life Insurance Policies That Contain Provisions Resulting in the Ability of a Policyowner to Keep a Policy in Force Over a Secondary Guarantee Period

Current through 2024-29, July 17, 2024
A.
General
(1) Policies with a
				secondary guarantee include:
(a) A policy
				with a guarantee that the policy will remain in force at the original schedule
				of benefits, subject only to the payment of specified premiums;
(b) A policy in which the minimum premium at
				any duration is less than the corresponding one year valuation premium,
				calculated using the maximum valuation interest rate and the 1980 CSO valuation
				tables with or without ten-year select mortality factors, or any other table
				adopted after the effective date of this rule by the NAIC and promulgated by
				rule by the Superintendent for this purpose; or
(c) A policy with any combination of
				Subparagraph (a) and (b).
Drafting Note: Universal life and variable universal
				  life policies with secondary guarantees that meet the requirements of Section
				  3(A)(2) are not
				  subject to this rule.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 830 - VALUATION OF LIFE INSURANCE POLICIES › Section 031-830-8 - Effective Date

Current through 2024-29, July 17, 2024
This rule shall become effective January 1, 2000. The 2016
				  amendments are effective August 8, 2016.
(Drafting Note: The intent of the proposal is that
				  the 2016 amendments will be effective five days after filing of the final
				  adopted amendments with the Office of the Secretary of State as permitted by
				  the
Maine Administrative Procedure Act .
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 835 - DENTAL INSURANCE PLAN LOSS RATIO REPORTING › Section 031-835-1 - Purpose

Current through 2024-29, July 17, 2024
This rule establishes standards for calculating average loss
				  ratios for plans providing dental care services, reporting dental loss ratios
				  to the Superintendent, determining dental plan credibility, and establishing a
				  process to determine outlier dental plans.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 835 - DENTAL INSURANCE PLAN LOSS RATIO REPORTING › Section 031-835-2 - Scope

Current through 2024-29, July 17, 2024
This rule applies to dental plans as defined in
				  24-A
				  M.R.S.
				  §4319-B(1).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 835 - DENTAL INSURANCE PLAN LOSS RATIO REPORTING › Section 031-835-3 - Authority

Current through 2024-29, July 17, 2024
The Superintendent adopts this rule pursuant to Title 24-A
				  M.R.S. §§
									212 and
				  4319-B.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 835 - DENTAL INSURANCE PLAN LOSS RATIO REPORTING › Section 031-835-4 - Definitions

Current through 2024-29, July 17, 2024
1. "Administrative cost expenditures" means a
				carrier's financial administrative, marketing and sales, commission,
				distribution, claims operation, utilization review, network operations,
				charitable, and payroll expenses, but does not include expenses specifically
				recognized under this rule as expenses for activities that improve dental care
				quality or as community benefit expenses.
2. "Clinical Dental Services" means
				diagnostic, preventive, or corrective procedures provided by or under the
				supervision of a dentist in the practice of their profession, including
				treatment of the teeth and associated structures of the oral cavity and
				treatment for disease, injury, or impairment that may affect the oral or
				general health of the enrollee.
3.
				"Dental plan" has the same meaning as in
				24-A
				M.R.S.
				§4319-B(1)(A).
4. "Enrollee" has the same meaning as in
				24-A
				M.R.S.
				§4319-B(1)(A).
5. "Dental loss ratio" has the same meaning
				as in 24-A M.R.S.
				§4319-B(2).
6. "Market segment" means the individual,
				small group as defined by
				24-A M.
				R. S. §2808-B(1)(D), or
				large group market.
7. "Noncredible
				plan" means a plan issued by a carrier in a market segment for which the
				carrier has fewer than 12,000 Maine member months in aggregate for the
				reporting year, including each covered dependent as a separate
				member.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 835 - DENTAL INSURANCE PLAN LOSS RATIO REPORTING › Section 031-835-5 - Activities That Improve Dental Care Quality

Current through 2024-29, July 17, 2024
1. A
				carrier that offers a dental plan shall receive credit under Subparagraph
				6(1)(A)(2) for implementing and maintaining activities that improve dental care
				quality, and updating them in light of evidence-based developments in
				treatment. To qualify for recognition as activities that improve dental care
				quality, these activities must:
A. Improve
				oral and overall health and advance oral health quality, including increasing
				the likelihood of desired outcomes compared to a baseline; reducing dental
				disparities among specified populations; and improving patient safety, reducing
				medical errors, or lowering infection in ways that are capable of being
				objectively measured and of producing verifiable results;
B. Be directed toward individual enrollees,
				are incurred for the benefit of specified segments of enrollees, or provide
				oral health improvements to the population beyond those enrolled in coverage,
				as long as no credit is taken for additional costs incurred for the benefit of
				non-enrollees; and
C. Be grounded
				in the implementation, development, or improvement of evidence-based dental
				care, widely accepted best clinical practice, or criteria issued by recognized
				professional dental associations, accreditation bodies, government agencies, or
				other nationally recognized health care quality organizations.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 835 - DENTAL INSURANCE PLAN LOSS RATIO REPORTING › Section 031-835-6 - Dental Loss Ratio Calculation and Reporting

Current through 2024-29, July 17, 2024
1.
				A carrier shall calculate the dental loss ratio for its Maine plans, excluding
				any experience from noncredible plans, as follows:
A. The numerator is the sum of:
(1) The amount expended for clinical dental
				services provided to enrollees;
(2)
				The amount expended on activities that improve dental care quality;
				and
(3) The amount of claims
				payments identified as having been avoided or recaptured through fraud
				reduction efforts; and
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 835 - DENTAL INSURANCE PLAN LOSS RATIO REPORTING › Section 031-835-7 - Average Loss Ratio and Identifying Dental Plan Outliers

Current through 2024-29, July 17, 2024
A. The Superintendent shall calculate the
				average dental loss ratio for each market segment using aggregate data reported
				by carriers for the three-year period consisting of the most recent dental loss
				ratio reporting year and the two prior dental loss ratio reporting
				years.
B. The Superintendent shall
				identify as an outlier any dental plan in Maine that falls outside two standard
				deviations of the average dental loss ratio.
If the average dental loss ratio in a market segment
				  declines for two years in a row, the Superintendent may identify as an outlier
				  any dental plan that falls outside one standard deviation of the average dental
				  loss ratio for that market segment.
C. The Superintendent shall conduct a review
				of dental plans identified as outliers and require the carriers of each such
				plan to submit additional financial information necessary to evaluate the
				reasons those plans are outliers. The Superintendent may also require the
				carrier to submit a remediation plan, including without limitation measures
				such as rate revisions or benefit modifications, in a filing using the format
				prescribed by Rule
				940.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 835 - DENTAL INSURANCE PLAN LOSS RATIO REPORTING › Section 031-835-8 - Severability

Current through 2024-29, July 17, 2024
If any section, term, or provision of this rule shall be
				  deemed invalid for any reason, any remaining section, term, or provision shall
				  remain in full force and effect.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-1 - AUTHORITY

Current through 2024-29, July 17, 2024
This Rule is adopted by the Superintendent pursuant to
				   24-A M.R.S.A.
				  §§212,
				  1952 -
				  1957, and
				  2808-B(2)(F).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-2 - Purpose

Current through 2024-29, July 17, 2024
The purpose of this Rule is to supplement Chapter 18-A of
				  Title 24-A M.R.S.A. by establishing additional standards for private purchasing
				  alliances.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-3 - Scope

Current through 2024-29, July 17, 2024
This Rule applies to private purchasing alliances as defined
				  by
				  24-A M.R.S.A.
				  §1951(2) and to
				  carriers contracting with such alliances.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-4 - Definitions

Current through 2024-29, July 17, 2024
A. "
Alliance
" means a
				private purchasing alliance as defined by
				 24-A M.R.S.A.
				§1951(2).
B. "
Board
" means the Board
				of Directors of a private purchasing alliance.
C.  "
Carrier
" has the same
				meaning as in
				 24-A M.R.S.A.
				§1951(1).
D. "
Enrollee
" means an
				individual, employee, or dependent who is enrolled in a health benefit plan
				offered through the alliance by a participating carrier.
E. "
Individual
" means an
				individual not affiliated with a member employer.
F. "
Individual member
" means
				an individual who enrolls in a private purchasing alliance.
G. "
Member
" means an
				individual member or a member employer.
H. "
Late enrollee
" has the
				same meaning as in
				24-A M.R.S.A.
				§2808-B(1)(E).
I. "
Member employer
" means
				an employer that enrolls in a private purchasing alliance.
J. "
Participating carrier
"
				means a carrier that contracts with a private purchasing alliance to provide
				coverage to enrollees under a health benefit plan.
K.  "
Small employer
" means
				an "eligible group" as defined by
				 24-A M.R.S.A.
				§2808-B(1)(D).
L. "
Superintendent
" means
				the Superintendent of Insurance.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-5 - Licensure

Current through 2024-29, July 17, 2024
A. An applicant for licensure as a private
				purchasing alliance, pursuant to
				 24-A M.R.S.A.
				§1952, must file an application with the
				Superintendent, accompanied by an application fee of $400 and including the
				following information:
(1) A detailed,
				written business plan explaining how the applicant intends to meet the public
				policy objectives of reduced cost, increased access, and improved quality in
				the marketplace. Material changes in policy or operations of the business plan
				are subject to the prior approval of the Superintendent. The business plan
				shall include, but not be limited to, the following information:
(a) The specific steps planned to advance
				cost control and quality improvement, and to improve access to health insurance
				or health care services. The business plan shall demonstrate that the alliance
				will have the technical expertise and physical capacity to serve a significant
				population. There is a rebuttable presumption that ten percent of the
				population within the proposed service area is an appropriate threshold for
				measuring significance. The business plan shall demonstrate that the alliance
				will reduce cost, improve quality, and improve access to health insurance or
				health care services; and
(b) The
				scope of services to be offered in the proposed service area and the resources
				and expertise to be used to implement and administer those services. An
				alliance shall demonstrate the technical and physical capacity to serve a
				significant population over a wide territory, and to provide service quality
				throughout the entire alliance service area;
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-6 - Participating Carriers

Current through 2024-29, July 17, 2024
A. To be eligible
				as a participating carrier, a carrier must demonstrate the following operating
				characteristics to the alliance board's satisfaction:
(1) That the carrier is licensed and in good
				standing with the Superintendent. The board shall request certification from
				the Superintendent that all participating carriers are licensed carriers and
				that all carriers to be offered to small employers have filed forms and rates
				pursuant to
				 24-A M.R.S.A.
				§2808-B;
(2) The ability to administer health benefit
				plans, to provide adequate service, and to comply with all contractual
				requirements of the alliance;
(3)
				The ability to provide enrollees with reasonable access to covered
				services;
(4) The ability to
				provide coverage for enrollees in any service area in which the carrier plans
				to participate through the alliance;
(5) The ability to arrange and pay for the
				appropriate quality, level, and type of health care services;
(6) The ability to provide data required by
				the board, including information on enrollee satisfaction based on standard
				surveys and to meet reasonable satisfaction measures as the board may
				establish;
(7) Strong financial
				condition;
(8) Adequate
				administrative management;
(9) A
				procedure to address enrollee grievances and appeals;
(10) The ability to achieve satisfactory
				enrollment levels within the service area in which the carrier is licensed;
				and
(11) All other criteria
				established by the board.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-7 - Risk Pools

Current through 2024-29, July 17, 2024
A. If the alliance
				is designed to include individuals unaffiliated with an employer, all such
				individuals shall constitute a separate risk pool. Participating carriers may
				vary rates within this risk class only as would be permitted for an individual
				health plan subject to
				 24-A M.R.S.A.
				§2736-C. A carrier may offer coverage to
				individuals through the alliance even if the carrier does not offer the same
				coverage, or any coverage, through individual health plans outside the
				alliance.
B. If the alliance is to
				include small employers, all such employers shall constitute a separate risk
				pool. Participating carriers may vary rates within this risk class only as
				permitted pursuant to
				 24-A M.R.S.A.
				§2808-B.
C. The alliance and any participating carrier
				may negotiate rates for the individual or small employer risk pool which are
				less than the carrier's otherwise applicable individual or small group rates,
				but only if the reductions reflect savings derived from administrative costs,
				marketing costs, profit margins, economies of scale, or other factors unrelated
				to the pool's health status or perceived health risk. Reductions may not be
				based on any of the rating factors expressly prohibited or limited by
				 24-A M.R.S.A.
				§§2736-C(2) and
				2808-B(2).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-8 - Marketing

Current through 2024-29, July 17, 2024
A. Any marketing, advertisement, or
				educational material for health benefit plans sold through the alliance shall
				be approved by the board prior to its use.
B. A participating carrier, agent, broker, or
				contractor of a participating carrier, or an independent insurance agent,
				broker, or contractor may not engage, directly or indirectly, in an activity or
				marketing practice that would encourage member individuals, small employers, or
				eligible enrollees to:
(1) Refrain from
				enrolling in a health benefit plan offered through an alliance because of their
				health status or claims experience;
(2) Seek coverage from other participating
				carriers because of their health status or claims experience; or
(3) Enroll or fail to enroll in the alliance
				because of their health status or claims experience.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-9 - Additional Duties

Current through 2024-29, July 17, 2024
In addition to the duties set forth in
				   24-A M.R.S.A. §1954,
				  an alliance shall:
A. Provide that
				each eligible employee of any member employer is permitted to enroll in any
				health benefit plan offered to the applicable risk pool by any participating
				carrier that provides coverage where he or she works or lives;
B. Ensure that contracts with member
				individuals or employers meet the following requirements:
(1) For administrative purposes, the alliance
				will be the policyholder or contract holder of the health benefit plan on
				behalf of member individuals and employers, their eligible employees, and
				dependents;
(2) The contracts shall
				provide that the participating carrier will issue a certificate of coverage
				specifying the essential features of the health benefit plan's coverage to each
				individual member and eligible employee; and
(3) The contract shall provide that health
				benefit plans offered by the employer must be procured through the
				alliance.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-10 - Additional Restrictions

Current through 2024-29, July 17, 2024
In addition to the restrictions set forth in
				   24-A M.R.S.A.
				  §1955, an alliance shall not:
A. Commit an act constituting a rebate
				prohibited pursuant to
				 24-A M.R.S.A.
				§2160;
B. Charge a fee for activities unrelated to
				health care or otherwise not directly related to the operation of the
				alliance;
C. As a condition of
				membership, require an individual or an employer to subscribe to limited
				benefit health insurance or non-health care related products or
				services;
D. Engage in any
				competitive act or practice that results in the selection of member individuals
				based on any of the risk factors, other than geographic area, prohibited or
				limited by
				 24-A M.R.S.A.
				§2736-C(2);
E. Engage in any competitive act or practice
				that results in the selection of member small employers and enrollees based on
				any of the risk factors, other than geographic area, prohibited or limited by
				 24-A M.R.S.A.
				§2808-B(2);
				or
F. Require or take any action
				inconsistent or in conflict with applicable law.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-11 - Examination

Current through 2024-29, July 17, 2024
Financial and performance audits or examinations of the
				  alliance shall be conducted on a regular basis by the Superintendent.
				  Reasonable costs of examinations or audits are to be paid by the alliance.
				  After notice and opportunity for hearing, and for good cause shown, the
				  Superintendent may impose conditions on licensure, or continued licensure to
				  remedy compliance or performance problems; for example, the removal and
				  replacement of managerial, marketing staff, or third-party
				  contractors.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 840 - PRIVATE PURCHASING ALLIANCES › Section 031-840-12 - Effective Date

Current through 2024-29, July 17, 2024
This Rule is effective June 4, 1997. The 2002-2003 amendments
				  to this Rule are effective July 4, 2003.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 845 - STANDARDS FOR MINIMUM INTEREST PAYMENTS TO HEALTH CARE PROVIDERS ON OVERDUE CLAIMS › Section 031-845-1 - Purpose and Scope

Current through 2024-29, July 17, 2024
This Rule is adopted by the Superintendent, pursuant to
				   24-A M.R.S.A.
				  §§2436(3) and
				  212, to
				  establish minimums for interest due on overdue undisputed claims to health care
				  providers before an interest payment must be issued.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 845 - STANDARDS FOR MINIMUM INTEREST PAYMENTS TO HEALTH CARE PROVIDERS ON OVERDUE CLAIMS › Section 031-845-2 - Standards for Minimum Interest Payments

Current through 2024-29, July 17, 2024
A. A health
				insurance carrier may aggregate interest owed to a health care provider on
				overdue undisputed claims if:
1. The health
				insurance carrier aggregates interest owed on all overdue claims, including
				claims for which the interest due is less than $2.00.
2. The health insurance carrier establishes a
				mechanism to respond to written inquiries from providers within 30 days
				regarding how much interest the provider is owed.
3. The health insurance carrier pays interest
				owed to a provider at least annually if the unpaid interest at the end of the
				year exceeds $10.00. Annual interest must be paid within 30 days of the end of
				the calendar or fiscal year. Whenever the interest owed to a provider exceeds
				$50, the health insurance carrier must comply with the requirement of
				subsection
				2(A)(4).
4. The health insurance carrier pays interest
				owed to a provider at least quarterly if the aggregate interest owed at the end
				of the quarter exceeds $50.00. Quarterly interest must be paid within 30 days
				of the end of each calendar or fiscal quarter.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 845 - STANDARDS FOR MINIMUM INTEREST PAYMENTS TO HEALTH CARE PROVIDERS ON OVERDUE CLAIMS › Section 031-845-3 - Exceptions

Current through 2024-29, July 17, 2024
A. Provided interest is paid at least
				annually, nothing in this rule prohibits a health insurance carrier and a
				provider or group of providers who are paid on a capitated basis from
				contracting for minimum interest payments and payment periods that differ from
				the minimum requirements in section
				2 of this rule.
B. Provided interest is paid at least
				annually, nothing in this rule prohibits a health insurance carrier from
				contracting with a hospital for minimum interest payments and payment periods
				that differ from the parameters described in section
				2 of this rule.
C. The Superintendent may grant exceptions,
				for good cause, to the minimum interest payment and payment period requirements
				of section
				2 of this rule. Requests for
				exceptions must be signed by both the health insurance carrier and the affected
				health care provider. A request for an exception is not required for contracts
				negotiated pursuant to section 3A and 3B of this rule.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 845 - STANDARDS FOR MINIMUM INTEREST PAYMENTS TO HEALTH CARE PROVIDERS ON OVERDUE CLAIMS › Section 031-845-4 - Severability

Current through 2024-29, July 17, 2024
If any section, term, provision, or application of this Rule
				  is adjudged invalid for any reason, such judgment shall not impair or
				  invalidate any other section, term, provision, or application, and the
				  remainder of this Rule shall continue in full force and
				  effect.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 845 - STANDARDS FOR MINIMUM INTEREST PAYMENTS TO HEALTH CARE PROVIDERS ON OVERDUE CLAIMS › Section 031-845-5 - Effective Date

Current through 2024-29, July 17, 2024
This Rule is effective May 16, 2006 (filing 2006-199).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-1 - Purpose

Current through 2024-29, July 17, 2024
This rule establishes standards applicable to health
				  maintenance organizations (HMOs), as defined by Chapter 56 of the Insurance
				  Code, utilization review entities, as defined by Chapter 34 of the Insurance
				  Code, and carriers as defined by Chapter 56-A of the Insurance Code. In the
				  interest of consolidating standards applicable to carriers and adopting current
				  National Association of Insurance Commissioners (NAIC) health plan
				  accountability models, it repeals and replaces old Bureau of Insurance Rule
				  Chapter 520, Medical Utilization Review Entities, and incorporates provisions
				  of the NAIC Utilization Review Model Act, Health Carrier Grievance Procedure
				  Model Act and Health Care Professional Credentialing Verification Model Act.
				  The 2002 Amendments to Revised Rule Chapter 850 reflect amendments to the
				  Health Plan Improvement Act, Title 24-A, Chapter 56-A M.R.S.A.
				  (§§4301 et seq. ), enacted by Public Law 1999, Chapter 742, An Act to
				  Establish a Patient's Bill of Rights. The 2003 Amendments reflect amendments to
				  24-A M.R.S.A.
				  §4303, enacted by Public Law 2003,
				  Chapters 108 and 469. The 2007 Amendments to the access requirements in section
				  7 are Major Substantive Amendments
				  proposed by the Superintendent pursuant to a consensus-based rule development
				  process governed by
				  5 M.R.S.A.
				  §8051-B. The 2012 Amendments, which
				  include Major Substantive Amendments to the access requirements in section
				  7, are adopted to reflect amendments
				  to the Maine Health Plan Improvement Act enacted by Public Law 2011, Chapters
				  90 and 364, and to bring the appeal and grievance procedures in sections
				  8 through
				  10 into compliance with the
				  requirements of the federal Affordable Care Act. The 2020 Amendments are
				  Routine Technical Amendments adopted to reflect amendments to the Maine Health
				  Plan Improvement Act enacted by Public Law 2019, Chapters 171, 238, and
				  273.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-2 - Authority

Current through 2024-29, July 17, 2024
This rule is promulgated by the Superintendent pursuant to
				  Title
				  24-A M.R.S.A.
				  §§2772,
				  2774,
				  4218,
				  4218-A,
				  4222-A,
				  4303,
				  4309, and
				  4309-A.
				  The 2020 Amendments are promulgated by the Superintendent pursuant to
				  unallocated provisions in Public Law 2019, Chapters 171, 238, and 273
				  authorizing Routine Technical Amendments.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-3 - Applicability and Scope

Current through 2024-29, July 17, 2024
A. This rule shall
				apply to all health carriers, utilization review organizations and managed care
				plans as applicable. Section
				7 is applicable to any carrier
				offering a managed care plan. Section
				8 is applicable to any carrier that
				provides or performs utilization review services, any designee of the carrier
				or utilization review entity (URE) that performs utilization review functions
				on the carrier's behalf, and any URE performing utilization review on behalf of
				an employer. The requirements of section
				8 are also applicable to all "adverse
				health care treatment decisions" rendered by or on behalf of "carriers"
				offering "health plans," as defined by
				24-A M.R.S.A.
				§4301-A subsections
				1,
				3
				and
				7.
				Sections
				9 and
				10 are applicable to all carriers.
				The relationship of the appeals processes set forth in subsections
				8(G) and
				8 (G-1) to the grievance review
				procedures of section
				9 is as follows. All adverse health
				care treatment decisions denying benefits to a covered person are subject to
				the appeals procedures set forth in subsections
				8(G) and
				8 (G-1). All requests for review of
				"adverse benefit determinations," other than "adverse health care treatment
				decisions," are subject to the grievance review procedures set forth in section
				9. In the event of conflict between
				the provisions of this rule and those of any other rule promulgated by the
				Superintendent, the provisions of this rule shall be controlling. Any request
				for confidential handling of filings required by this rule must follow the
				confidentiality protocol established by the Superintendent and available from
				the Bureau of Insurance.
B. All
				group and individual health plans under which covered services are subject to
				utilization review, pre-existing condition determinations, or determinations
				regarding experimental or investigational services, are subject to the
				disclosure requirements of subsection
				8(I).
C. All group and individual health plan
				contracts must incorporate the appeal and grievance procedure description
				required by subsection
				10(B).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-4 - Affordable Care Act

Current through 2024-29, July 17, 2024
A. Pursuant to
				24-A M.R.S.A. §§
										4218-A and
				4309-A,
				carriers are required to comply with all applicable requirements of the federal
				Affordable Care Act, in addition to applicable requirements of this
				rule.
B. A carrier offering one or
				more health plans entitled to grandfathered status under the federal Affordable
				Care Act may request an exemption for its grandfathered business from certain
				requirements of this rule by submitting the following to the Superintendent for
				approval within 180 days after the effective date of this rule:
1) A letter identifying the provisions of
				this rule for which an exemption is claimed together with an explanation of why
				the exemption is permitted pursuant to
				24-A
				M.R.S.A. §4320-G and the federal
				Affordable Care Act.
2) Copies of
				notices that have been or will be provided to enrollees advising that an
				exemption has been claimed from certain requirements of this rule because of
				the health plan's grandfathered status. This requirement may be satisfied by
				including information about exemption from the requirements of this rule in the
				notices of grandfathered status provided to policyholders and enrollees
				pursuant to federal law, and providing the Bureau with a sample copy of the
				notice.
3) The number of enrollees
				impacted by the exemption.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-6 - Quality Assurance Standards

Current through 2024-29, July 17, 2024
Carriers seeking licensure in the State of Maine as a health
				  maintenance organization pursuant to the requirements of Title 24-A Chapter 56,
				  and which have received accreditation by a nationally recognized accrediting
				  organization may, as an alternative to the application requirements of Bureau
				  of Insurance Rule Chapter 191, subsection (6)(F), file for consideration by the
				  Superintendent and the Commissioner of the Department of Human Services, the
				  accrediting organization's quality assurance standards to which they are
				  subject.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-7 - Access to Services

Current through 2024-29, July 17, 2024
In addition to the requirements of Title 24-A, Chapter 56 or
				  otherwise required by rule a carrier offering a managed care plan is subject to
				  the requirements of this section.
A.
Access Plan
In addition to the requirements of
				  24-A M.R.S.A.
				  §4203(3) or
				  requirements otherwise provided by rule, a carrier's application for approval
				  of a managed care plan, application for an HMO certificate of authority, or
				  application for a Preferred Provider Arrangement registration shall include an
				  Access Plan. Carriers shall, consistent with the requirements of section
				  11 of this rule, file annual Access
				  Plan information updates reflecting any changes to previously filed
				  information, except that consistent with the requirements of Title
				  24-A M.R.S.A.
				  §4204(8), the net loss
				  of 5 or more primary care physicians in any county in any 30-day period must be
				  reported within 10 days. Access Plans must include a description of the
				  provider network, including:
1) A
				current list of all providers and facilities;
2) The projected ratio of primary care
				providers to enrollees by county;
3) Written standards for providing a network
				that is sufficient in numbers and types of providers to assure that all
				services to covered persons will be reasonably accessible without unreasonable
				delay. Standards must be realistic for the community, the delivery system, and
				clinical safety. In establishing these standards, the carrier may incorporate
				standards published by independent standard-setting organizations and approved
				by the Superintendent.
4) A
				description of the carrier's plan for providing services for rural and
				underserved populations and for developing relationships with essential
				community providers.
5) A
				description of the carrier's plan for addressing the needs of patients needing
				coordinated care, frequent services, or other needs that might impede access to
				care.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-9 - Adverse Benefit Determinations not Involving Adverse Health Care Treatment Decisions

Current through 2024-29, July 17, 2024
A .
Notice of
				Adverse Benefit Determinations not Involving Health Care Treatment
				Decisions
Adverse benefit determinations involving medical issues
				  (adverse health care treatment decisions) are subject to the written notice
				  requirements of paragraph 8(E)(5). For any adverse benefit determination that
				  does not involve medical issues, the carrier shall provide written notice that
				  includes the information required below:
1) the principal reason or reasons for the
				determination;
2) reference to the
				specific plan provisions on which the determination is based;
3) information sufficient to identify the
				claim involved (including the date of service, the health care provider, and
				the claim amount if applicable), and a statement that the diagnosis code and
				its corresponding meaning, and the treatment code and its corresponding
				meaning, will be provided upon request;
4) a description of any additional material
				or information necessary for the covered person to perfect the claim and an
				explanation as to why such material or information is necessary;
5) the instructions and time limits for
				initiating an appeal or reconsideration of the determination;
6) notice of the right to file a complaint
				with the Bureau of Insurance after exhausting any appeals under a carrier's
				internal review process. In addition, an explanation of benefits (EOB) must
				comply with the requirements of
				24-AM.R.S.A.
				§4303(13) and any rules
				adopted pursuant thereto.
7) if an
				internal rule, guideline, protocol, or other similar criterion was relied upon
				in making the adverse benefit determination, either the specific rule,
				guideline, protocol, or other similar criterion; or a statement referring to
				the rule, guideline, protocol, or other similar criterion that was relied upon
				in making the adverse determination and explaining that a copy will be provided
				free of charge to the covered person upon request;
8) a phone number the covered person may call
				for information on and assistance with initiating an appeal or reconsideration
				or requesting review criteria;
9) a
				description of the expedited review process applicable to claims involving
				exigent circumstances;
10) the
				availability of any applicable office of health insurance consumer assistance
				or ombudsman established under the federal Affordable Care Act; and 11) any
				other information required pursuant to the federal Affordable Care
				Act.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-10 - Grievance Register and Grievance Procedures

Current through 2024-29, July 17, 2024
A.
Grievance Register
1) A health
				carrier shall maintain written records to document all grievances received
				during a calendar year (the register). Standard and expedited appeals pursuant
				to subsection
				8(G)  of this rule
				shall not be considered grievances for purposes of the grievance register. For
				each grievance the register shall contain, at a minimum, the following
				information:
a) A general description of the
				reason for the grievance;
b) Date
				received;
c) Date of each review or
				hearing;
d) Resolution at each
				level of the grievance;
e) Date of
				resolution at each level; and
f)
				Name of the covered person for whom the grievance was filed.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 850 - HEALTH PLAN ACCOUNTABILITY › Section 031-850-11 - Reporting Requirements

Current through 2024-29, July 17, 2024
The annual reports to the Superintendent required of HMOs
				  pursuant to Title
				  24-A M.R.S.A.
				  §§4211 and
				  4228, and
				  of carriers pursuant to §4302(2), are due on March 1st of each year,
				  except that an HMO or carrier which has been licensed less than 6 months as of
				  March 1st shall not be required to report until the following year. The annual
				  Access Plan updates required by this rule are due on March 1st of each year,
				  except that a carrier which has filed its first access plan within 6 months of
				  March 1st shall not be required to update its plan until the following
				  year.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 851 - Clear Choice Designs for Individual and Small Group Health Plans › Section 031-851-1 - Authority and Purpose

Current through 2024-29, July 17, 2024
This rule is adopted pursuant to 24-A M.R.S. §§
									212 and
				  2793, to develop health plan cost
				  share designs as set out in 24-A M.R.S. §
									2793, for individual health plans
				  and, as applicable, for small group health plans.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 851 - Clear Choice Designs for Individual and Small Group Health Plans › Section 031-851-2 - Applicability and Scope

Current through 2024-29, July 17, 2024
This rule applies to all individual health plans subject to
				  24-A M.R.S. §
									2736-C offered in this State with
				  effective dates of coverage on or after January 1, 2022, and to all small group
				  health plans subject to 24-A M.R.S. §
									2808-B issued or renewed through
				  a pooled health insurance market on or after January 1 of the pooled market
				  implementation year.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 851 - Clear Choice Designs for Individual and Small Group Health Plans › Section 031-851-3 - Definitions

Current through 2024-29, July 17, 2024
The following definitions apply for purposes of this
				  rule:
1. "Affordable Care Act" or
				"ACA" has the same meaning as in 24-A M.R.S. §
									14.
2. "Actuarial value" or "AV" means the
				anticipated covered medical spending paid by a health plan for a standard
				population for essential health benefit coverage, as defined in 24-A M.R.S.
				§
									4320- D(2),
				computed in accordance with the plan's cost sharing, and divided by the total
				anticipated allowed charges for essential health benefit coverage provided to a
				standard population, using the most recent AV calculator published by CMS and
				any adjustments made by the carrier.
3. "Carrier" has the same meaning as in 24-A
				M.R.S. §
									4301- A(3).
4. "HSA plan" means a health plan that is
				intended to qualify as a high deductible health plan under the federal
Internal Revenue Code
for purposes of eligibility to maintain
				a tax-exempt Health Savings Account.
5. "Marketplace" means the Maine Health
				Insurance Marketplace established pursuant to 22 M.R.S. §
									5403.
6. "Pooled market implementation year" means
				the implementation year established by the Superintendent pursuant to Chapter
				856 of these rules, "Combination of the Individual and Small Business Health
				Insurance Risk Pools."