Designation of Classification of Coverage The heading of the cover letter of any form filing subject to this rule shall state the category of coverage set forth in 24-A M.R.S.A. §2694 that the form is intended to be in. ☐ Disclosure 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.” Explanations for any Exclusion of Coverage for work related sicknesses or injuries If the policy excludes coverage for work related sicknesses or injuries, clearly explain whether the coverage is excluded if the enrollee is exempt from requirements from state workers compensation requirements or has filed an exemption from the workers compensation laws. ☐ Explanations Regarding Deductibles All policies must include clear explanations of all of the following regarding deductibles: Whether it is a calendar or policy year deductible. Clearly advise whether non-covered expenses apply to the deductible. Clearly advise whether it is a per person or family deductible or both. ☐ Extension of Benefits 24-A M.R.S.A. Provide an extension of benefits of 6 months for a person who is totally disabled on the date the group or subgroup policy is discontinued. For a policy providing specific indemnity during hospital confinement, "extension of benefits" means that discontinuance of the policy during a disability has no effect on benefits payable for that confinement. For purposes of determining eligibility for extension of benefits, "total disability" shall be defined no more restrictively than: A. in the case of an insured who was gainfully employed prior to disability, "the inability to engage in any gainful occupation for which ☐
nursing without the supervision of a physician pursuant to to serve as primary care providers for managed care plans. Essential Health Care Providers (Rural health clinics) (7) Benefits must be made available for outpatient health care services of certified rural health clinics. ☐ Independent Practice Dental Hygienists 24-A M.R.S.A. §2847-Q Coverage must be provided for dental services performed by a licensed independent practice dental hygienist when those services are covered services under the contract and when they are within the lawful scope of practice of the independent practice dental hygienist. ☐ Network adequacy 24-A M.R.S.A. ) (7) All managed care arrangements except MEWA’s must be filed for adequacy and compliance with Rule 850 and Rule 360 access standards. If the policy uses a network, the network(s) need to have been approved by the Bureau for adequacy and access standards (i.e. physician, hospital, and ancillary service networks). Must provide a copy of network approval. ☐ Optional coverage for optometric services 24-A M.R.S.A. Benefits must be made available for the services of optometrists if the same services would be covered if performed by a physician. ☐ Pastoral counselors and marriage and family therapists Must include benefits for licensed pastoral counselors and marriage and family therapists for mental health services to the extent that the same services would be covered if performed by a physician. ☐ Pharmacy Providers – “Any Willing Pharmacy” A carrier that provides coverage for prescription drugs as part of a health plan may not refuse to contract with a pharmacy provider that is qualified and is willing to meet the terms and conditions of the carrier's criteria for pharmacy participation as stipulated in the carrier's contractual agreement with its pharmacy providers. ☐ PPOs – Payment for Non-preferred Providers 24-A M.R.S.A. The benefit level differential between services rendered by preferred providers and non-preferred providers may not exceed 20% of the allowable charge for the service rendered. ☐ Provider directories Pursuant to 24-A M.R.S. § 4303-D: 1. Requirement. A carrier shall make available provider directories in accordance with this section. ☐
Carriers must also provide an explanation as to why certain benefits are not being covered in the space provided (e.g., do not provide dependent coverage, do not provide dental, no RX coverage unless group purchases, etc.). Abuse-deterrent opioid analgesic drug products 24-A M.R.S.A. §4320-J A carrier offering a health plan in this State shall provide coverage for abuse-deterrent opioid analgesic drug products listed on any formulary, preferred drug list or other list of drugs used by the carrier on a basis not less favorable than that for opioid analgesic drug products that are not abuse-deterrent and are covered by the health plan. An increase in enrollee cost sharing to achieve compliance with this section may not be implemented. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings. A. "Abuse-deterrent opioid analgesic drug product" means a brand or generic opioid analgesic drug product approved by the federal Food and Drug Administration with abuse-deterrent labeling claims that indicate the drug product is expected to result in a meaningful reduction in abuse. B. "Cost sharing" means any coverage limit, copayment, coinsurance, deductible or other out-of-pocket expense associated with a health plan. C. "Opioid analgesic drug product" means a drug product in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release, form and whether or not combined with other drug substances to form a single drug product or dosage form. ☐ Anesthesia for Dentistry 24-A M.R.S.A. Anesthesia & associated facility charges for dental procedures are mandated benefits for certain vulnerable persons. ☐ Autism Spectrum Disorders All group health insurance policies, contracts and certificates must provide coverage for autism spectrum disorders for an individual covered under a policy, contract or certificate in accordance with the following. ☐
Colorectal Cancer Screening 24-A M.R.S.A. §4309-A Coverage must be provided for colorectal cancer screening (including colonoscopies if recommended by a health care provider as the colorectal cancer screening test) for asymptomatic individuals who are fifty years of age or older; or less than 50 years of age and at high risk for colorectal cancer. If a colonoscopy is recommended as the colorectal cancer screening and a lesion is discovered and removed during the colonoscopy benefits must be paid for the screening colonoscopy as the primary procedure. Must clearly disclose preventive screenings vs diagnostic services. ☐ Continuity of Prescription Drugs 24-A M.R.S.A. §4303(7)(A) If an enrollee has been undergoing a course of treatment with a prescription drug by prior authorization of a carrier and the enrollee’s coverage with one carrier is replaced with coverage from another carrier pursuant to section 2849-B, the replacement carrier shall honor the prior authorization for that prescription drug and provide coverage in the same manner as the previous carrier until the replacement carrier conducts a review of the prior authorization for that prescription drug with the enrollee’s prescribing provider. Policies must include a notice of the carrier’s right to request a review with the enrollee’s provider, and the replacing carrier must honor the prior carrier’s authorization for a period not to exceed 6 months if the enrollee’s provider participates in the review and requests the prior authorization be continued. The replacing carrier is not required to provide benefits for conditions or services not otherwise covered under the replacement policy, and cost sharing may be based on the copayments and coinsurance requirements of the replacement policy. ☐ Contraceptives 24-A M.R.S.A. 24-A M.R.S.A. §2847-G(4) All contracts that provide coverage for prescription drugs or outpatient medical services must provide coverage for all prescription contraceptives or for outpatient contraceptive services, respectively, to the same extent that coverage is provided for other prescription drugs or outpatient medical services. Coverage required under this section must include coverage for contraceptive supplies in accordance with the following requirements. ☐
Medical food coverage for inborn error of metabolism 24-A M.R.S.A. Must provide coverage for metabolic formula and up to the actuarial equivalent of $3,000 per year for prescribed modified low-protein food products. ☐ Mental Health Coverage 24-A M.R.S.A. Must provide, at a minimum, the following benefits for a person suffering from a mental or nervous condition: inpatient services, day treatment services, outpatient services, and home health care services. For groups with more than 20 employees mental health benefits cannot be less extensive than for physical illnesses for the following mental illnesses: psychotic disorders (including schizophrenia), dissociative disorders, mood disorders, anxiety disorders, personality disorders, paraphilias, attention deficit ad disruptive behavior disorders, pervasive developmental disorders, tic disorders, eating disorders (including bulimia and anorexia), and substance abuse-related disorders. ☐ Mental health services (groups of 20 or less) Mandated offer of parity for small groups – mental health benefits cannot be less extensive than for physical illnesses for the following mental illnesses: schizophrenia, bipolar disorder, pervasive developmental disorder (or autism), paranoia, panic disorder, obsessive compulsive disorder, and major depressive disorder. ☐ Mental health services provided by counseling professionals. Benefits must be made available for mental health services provided by licensed counselors. ☐ Obstetrical and gynecological care 24-A M.R.S.A. Benefits must be provided for annual gynecological exam without prior approval of primary care physician. A group health plan, or health insurance issuer offering group or individual health insurance coverage, described in paragraph (2) may not require authorization or referral by the plan, issuer, or any person (including a primary care provider described in paragraph (2)(B)) in the case of a female participant, beneficiary, or enrollee who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology. ☐ Off-label use of prescription drugs for 24-A M.R.S.A. Coverage required for off-label use of prescription drugs for treatment of cancer, HIV, or AIDS. ☐