Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 755 - HEALTH INSURANCE CLASSIFICATIONS, DISCLOSURE, AND MINIMUM STANDARDS › Section 031-755-7 - Required Disclosure Provisions

Current through 2024-29, July 17, 2024
The requirements set forth in this section are in addition to
				  any other applicable requirements as specified in Section
				  3(D).
A. General Rules
(1) All applications for coverages specified
				in Sections 6B, C, D, E, G, I, J, K and L shall contain a prominent statement
				by type, stamp or other appropriate means in either contrasting color or in
				boldface type at least equal to the size type used for the headings or captions
				of sections of the application and in close conjunction with the applicant's
				signature block on the application as follows:
"The [policy] [certificate] provides limited benefits. Review
				  your [policy][certificate] carefully."
(2) All applications for dental plans shall
				contain a prominent statement by type, stamp or other appropriate means in
				either contrasting color or in boldface type at least equal to the size type
				used for the headings or captions of sections of the application and in close
				conjunction with the applicant's signature block on the application as follows:
"The [policy] [certificate] provides dental benefits only.
				  Review your [policy] [certificate] carefully."
(3) All applications for vision plans shall
				contain a prominent statement by type, stamp or other appropriate means in
				either contrasting color or in boldface type at least equal to the size type
				used for the headings or captions of sections of the application and in close
				conjunction with the applicant's signature block on the application as follows:
"The [policy] [certificate] provides vision benefits only.
				  Review your [policy] [certificate] carefully."
(4) Each policy of individual health
				insurance and group health insurance shall include a renewal, continuation, or
				nonrenewal provision. The language or specification of the provision shall be
				consistent with the type of contract to be issued. The provision shall be
				appropriately captioned, shall appear on the first page of the policy, and
				shall clearly state the duration, where limited, of renewability and the
				duration of the term of coverage for which the policy is issued and for which
				it may be renewed.
(5) The
				following requirements apply to riders or endorsements added to a policy after
				date of issue, except as provided in subparagraph (e).
(a) Except for riders or endorsements by
				which the insurer effectuates a request made in writing by the policyholder or
				exercises a specifically reserved right under the policy, all riders or
				endorsements added to a policy after date of issue or at reinstatement or
				renewal that reduce or eliminate benefits or coverage in the policy shall
				require signed acceptance by the policyholder.
(b) After date of policy issue, any rider or
				endorsement that increases benefits or coverage with a concomitant increase in
				premium during the policy term must be agreed to in writing signed by the
				policyholder, except if the increased benefits or coverage is required by
				law.
(c) After date of policy
				issue, any rider or endorsement added to a guaranteed renewable policy that
				increases benefits or coverage must be agreed to in writing signed by the
				policyholder, except if the increased benefits or coverage is required by law
				or if the insurer certifies to the Superintendent that claims paid under the
				rider or endorsement will be excluded when determining the need for future rate
				increases.
(d) The signature
				requirements in this paragraph also apply to group health insurance
				certificates where the certificateholder pays the entire premium to the
				carrier.
(e) The requirements of
				this paragraph do not apply to policies that are "guaranteed renewable with
				limited exceptions" as described in section
				6(A)(2)(d) if the
				policy's renewal provision does not restrict the insurer's right to
				unilaterally modify benefits and the modification is otherwise consistent with
				 24-A M.R.S.A.
				§2850-B. The requirements of this
				paragraph do not apply to product replacements pursuant to
				 24-A M.R.S.A.
				§2850-B(3)(G).
(6) Where a separate additional
				premium is charged for benefits provided in connection with riders or
				endorsements, the premium charge shall be set forth in the policy or
				certificate.
(7) A policy or
				certificate under which the insured may be subject to balance billing when
				charges exceed a maximum considered "usual and customary," "reasonable and
				customary," or words of similar import must comply with the following
				requirements:
(a) It must include a definition
				of the terms and an explanation of the terms in its accompanying outline of
				coverage;
(b) It must clearly
				disclose that the insured or enrollee may be subject to balance billing as a
				result of claims adjustment;
(c) It
				must provide a toll-free number that an insured or enrollee may call prior to
				receiving services to determine the maximum allowable charge permitted by the
				carrier for a specified service.
(d) The carrier must provide to the
				Superintendent on request complete information on the methodology and specific
				data used by the carrier or any 3rd party on behalf of the carrier in adjusting
				any claim submitted by or on behalf of the insured or enrollee. In considering
				the reasonableness of the methodology for calculating maximum allowable
				charges, the Superintendent shall consider whether the methodology takes into
				account relevant data specific to this State if there is sufficient data to
				constitute a representative sample of charge data for the same or comparable
				service.
(8) If a policy
				or certificate contains any limitations with respect to preexisting conditions,
				the limitations shall appear as a separate paragraph of the policy or
				certificate and be labeled as "Preexisting Condition Limitations."
(9) All accident-only policies and
				certificates shall contain a prominent statement on the first page of the
				policy or certificate, in either contrasting color or in boldface type at least
				equal to the size of type used for headings or captions of sections in the
				policy or certificate, a prominent statement as follows:
"Notice to Buyer: This is an accident-only
				  [policy][certificate] and it does not pay benefits for loss from sickness.
				  Review your [policy][certificate] carefully."
Accident-only [policies][certificates] that provide coverage
				  for hospital or medical care shall contain the following statement in addition
				  to the Notice to Buyer above: "This [policy][certificate] provides limited
				  benefits. Benefits provided are supplemental and are not intended to cover all
				  medical expenses."
(10) All
				individual policies, except nonrenewable accident policies, shall have a notice
				prominently printed on the first page of the policy or certificate or attached
				to it stating in substance that the policyholder or certificateholder shall
				have the right to return the policy or certificate within ten days of its
				delivery and to have the premium refunded if, after examination of the policy
				or certificate, the policyholder or certificateholder is not satisfied for any
				reason. Ten days is a minimum; longer periods are permitted.
(11) If age is to be used as a determining
				factor for reducing the maximum aggregate benefits made available in the policy
				or certificate as originally issued, that fact shall be prominently set forth
				in the outline of coverage.
(12) If
				a policy or certificate contains a conversion privilege, it shall comply, in
				substance, with the following: The caption of the provision shall be
				"Conversion Privilege" or words of similar import. The provision shall indicate
				the persons eligible for conversion, the circumstances applicable to the
				conversion privilege, including any limitations on the conversion, and the
				person by whom the conversion privilege may be exercised. The provision shall
				specify the benefits to be provided on conversion or may state that the
				converted coverage will be as provided on a policy form then being used by the
				insurer for that purpose.
(13)
(a) Outlines of coverage delivered in
				connection with policies defined in this rule as hospital confinement indemnity
				(Section 6E ), specified disease (Section 6J ), or supplemental health
				coverages (Section 6L ) to persons eligible for Medicare by reason of age shall
				contain, in addition to the requirements of Subsections F and J, the following
				language, which shall be printed on or attached to the first page of the
				outline of coverage:
This IS NOT A MEDICARE SUPPLEMENT policy. If you are eligible
				  for Medicare, review the Guide to Health Insurance for People With Medicare
				  available from the company.
(b) An insurer shall deliver to persons
				eligible for Medicare any notice required under Bureau of Insurance Rule
				Chapter 275(17)(D).
(14)
				Insurers, except direct response insurers, shall give a person applying for
				specified disease insurance that covers cancer the NAIC Buyer's Guide to Cancer
				Insurance at the time of application enrollment and shall obtain the
				recipient's written acknowledgement of the guide's delivery. Direct response
				insurers shall provide the Buyer's Guide upon request, but not later than the
				time that the policy or certificate is delivered.
(15) All specified disease policies and
				certificates shall contain on the first page or attached to it in either
				contrasting color or in boldface type at least equal to the size type used for
				headings or captions of sections in the [policy][certificate], a prominent
				statement as follows: Notice to Buyer: This is a specified disease [policy]
				[certificate].This [policy] [certificate] provides limited benefits. Benefits
				provided are supplemental and are not intended to cover all medical expenses.
				[If the policy covers cancer, include the following sentence.] Read your
				[policy] [certificate] carefully with the outline of coverage and the Buyer's
				Guide to Cancer Insurance.
(16) All
				hospital confinement indemnity policies and certificates shall display
				prominently by type, stamp, or other appropriate means on the first page of the
				policy or certificate, or attached to it, in either contrasting color or in
				boldface type at least equal to the size type used for headings or captions of
				sections in the [policy][certificate] the following:
"Notice to Buyer: This is a hospital confinement indemnity
				  [policy][certificate]. This [policy][certificate] provides limited benefits.
				  Benefits provided are supplemental and are not intended to cover all medical
				  expenses."
(17) All
				supplemental health policies and certificates shall display prominently by
				type, stamp, or other appropriate means on the first page of the policy or
				certificate, or attached to it, in either contrasting color or in boldface type
				at least equal to the size type used for headings or captions of sections in
				the [policy][certificate] the following:
"Notice to Buyer: This is a supplemental health
				  [policy][certificate]. This [policy][certificate] provides limited benefits.
				  Benefits provided are supplemental and are not intended to cover all medical
				  expenses."
(18) All basic
				hospital expense policies and certificates shall display prominently by type,
				stamp, or other appropriate means on the first page of the policy or
				certificate, or attached to it, in either contrasting color or in boldface type
				at least equal to the size type used for headings or captions of sections in
				the [policy][certificate] the following:
"Notice to Buyer: This is a basic hospital expense
				  [policy][certificate]. This [policy][certificate] provides limited benefits and
				  should not be considered a substitute for comprehensive health insurance
				  coverage."
(19) All basic
				medical-surgical expense policies and certificates shall display prominently by
				type, stamp, or other appropriate means on the first page of the policy or
				certificate, or attached to it, in either contrasting color or in boldface type
				at least equal to the size type used for headings or captions of sections in
				the [policy][certificate] the following:
"Notice to Buyer: This is a basic medical-surgical expense
				  [policy][certificate]. This [policy][certificate] provides limited benefits and
				  should not be considered a substitute for comprehensive health insurance
				  coverage."
(20) All basic
				hospital/medical-surgical expense policies and certificates shall display
				prominently by type, stamp, or other appropriate means on the first page of the
				policy or certificate, or attached to it, in either contrasting color or in
				boldface type at least equal to the size type used for headings or captions of
				sections in the [policy][certificate] the following:
"Notice to Buyer: This is a basic hospital/medical-surgical
				  expense [policy][certificate]. This [policy][certificate] provides limited
				  benefits and should not be considered a substitute for comprehensive health
				  insurance coverage."
(21)
				All basic medical expense policies shall display prominently by type, stamp, or
				other appropriate means on the first page of the policy, or attached to it, in
				either contrasting color or in boldface type at least equal to the size type
				used for headings or captions of sections in the policy the following:
"Notice to Buyer: This is a basic medical expense policy.
				  This policy provides benefits that are not as comprehensive as major medical
				  expense coverage and should not be considered a substitute for comprehensive
				  health insurance coverage."
(22) All dental plan policies and
				certificates shall display prominently by type, stamp or other appropriate
				means on the first page of the policy or certificate, or attached to it, in
				either contrasting color or in boldface type at least equal to the size type
				used for headings or captions of sections in the [policy][certificate] the
				following:
"Notice to Buyer: This [policy] [certificate] provides dental
				  benefits only."
(23) All
				vision plan policies and certificates shall display prominently by type, stamp,
				or other appropriate means on the first page of the policy or certificate, or
				attached to it, in either contrasting color or in boldface type at least equal
				to the size type used for headings or captions of sections in the
				[policy][certificate] the following:
"Notice to Buyer: This [policy] [certificate] provides vision
				  benefits only."