Maine Bureau of Insurance Form Filing Requirements Checklist INDIVIDUAL MAJOR MEDICAL PLANS (H16I) (NON-GRANDFATHERED) Inside and Outside the Marketplace For Plans Issued On or After January 1, 2019 (Revised 9/27/2018) Carriers must confirm compliance and IDENTIFY the LOCATION (Page number, Section, Paragraph, etc.) of the standard in the form in the last column. N/A: Check this box if a contract does not have to meet this requirement carriers must EXPLAIN WHY in the last column. State Benefit/Provision and/or ACA Requirement State Law/ Rule and/or Federal Law State Description of Requirement and/or ACA Description of Requirement N/A CONFIRM COMPLIANCE AND IDENTIFY LOCATION OF STANDARD IN FILING MUST EXPLAIN IF REQUIREMENT IS INAPPLICABLE General Submission Requirements Electronic (SERFF) Submission Requirements All filings must be filed electronically, using the NAIC System for Electronic Rate and Form Filing (SERFF). See . ☐ FILING FEES $20.00 for Rate filings, rating rules filings, insurance policy, forms, riders, endorsements and certificates. See General Instructions page in SERFF for additional information on filing fee structure. Filing fees must be submitted by EFT in SERFF at the time of submission of the filing. All filings require a filing fee unless specifically excluded per 24-A M.R.S.A. §4222(1), and/or are a required annual report. ☐ Grounds for disapproval Seven categories of the grounds for disapproving a filing. ☐ Readability Minimum of 50. Riders, endorsements, applications all must be scored. They may be scored either individually or in conjunction with the policy/certificate to which they will be attached. Exceptions: Federally mandated forms/language, Groups > 1000, Group Annuities ☐
Genetic information (GINA), coverage is not based on PHSA §2753 (74 Fed Reg 51664, 45 CFR §148.180) An issuer is not allowed to: Adjust premiums based on genetic information; Request/require genetic testing; Collect genetic information from an individual prior to/in connection with enrollment in a plan, or at any time for underwriting purposes. ☐ Period 24-A M.R.S.A. There shall be a provision that a grace period of 31 days will be granted for the payment of each premium falling due after the first premium, during which grace period the policy shall continue in force. ☐ Guaranteed issue and renewal Guaranteed renewable 24-A M.R.S.A. PHSA §2702 (45 CFR §148.122) Requires guaranteed issue and renewal. May only non-renew or cancel coverage for nonpayment of premiums, fraud, market exit, movement outside of service area, or cessation of bona-fide association membership. ☐ Health plan accountability Standards in this rule include, but are not limited to, required provisions for grievance and appeal procedures, emergency services, access and utilization review standards. ☐ Legal actions No action at law or in equity shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of 3 years after the time written proof of loss is required to be furnished. Limitations & Exclusions 45 CFR 156.115 Limitations and exclusions must be substantially similar or more favorable to the insured as found in the Maine EHB benchmark plan. ☐ Notice of Policy Changes and Modifications Notice of Policy Changes PHSA 2715 (75 Fed Reg 41760) A carrier may make minor modifications to the coverage, terms and conditions of the policy consistent with other applicable provisions of state and federal laws as long as the modifications meet the conditions specified in this paragraph and are applied uniformly to all policyholders of the same product. Provide 60 days advance notice to enrollees before the effective date of any material modification including changes in preventive benefits. ☐ Notice of Rate Increase 24-A M.R.S.A. Requires that insurers provide a minimum of 60 days written notice to affected policyholders prior to a rate filing for individual health ☐
insurance or a rate increase for group health insurance. It specifies the requirements for the notice. See these sections for more details Penalty for failure to notify of hospitalization 24-A M.R.S.A. No penalty for hospitalization for emergency treatment. ☐ Persons under the influence of alcohol or narcotics Policies cannot contain the following provision: “Intoxicants and narcotics. The insurer is not liable for any loss sustained or contracted in consequence of the insured’s being intoxicated or under the influence of any narcotic or of any hallucinogenic drug, unless administered on the advice of a physician.” ☐ 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. ☐ Pre-existing condition exclusions for child under age 19 Pre-existing condition exclusions PHSA §2704 PHSA §1255 (75 Fed Reg 45 CFR §147.108) Prohibits the imposition of a preexisting condition exclusion by all group plans and nongrandfathered individual market plans. ☐ Prohibited practices Rescissions prohibited 2850-B(3) PHSA§2712 (75 Fed Reg 37188, 45 CFR §147.128) An enrollee may not be cancelled or denied renewal except for or material misrepresentation and/or failure to pay premiums for coverage. Rescissions are prohibited except in cases of fraud or intentional misrepresentation of material fact. Coverage may not be cancelled except with 30 days prior notice to each enrolled person who would be affected. ☐ Prohibition against Absolute Discretion Clauses Carriers are prohibited from including or enforcing absolute discretion provisions in health plan contracts, certificates, or agreements. ☐ Prohibition on Discrimination 45 CFR §156.1259(a) An issuer does not provide EHB if its benefit design, or the implementation of its benefit design, discriminates based on an individual's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions. ☐
Preventive health services Preventive health services without requirements including deductibles, and 24-A M.R.S.A. PHSA §2713 (75 Fed Reg 45 CFR §147.130) Must, at a minimum, provide coverage for, and may not impose requirements for, the following preventive services: The evidence-based items or services that have a rating of A or B in the recommendations of the USPSTF or equivalent rating from a successor organization; With respect to the individual insured, immunizations that have a recommendation from the federal DHHS, CDC, Advisory Committee on Immunization Practices; With respect to infants, children and adolescents, preventive care and screenings provided for in the most recent version of the comprehensive guidelines supported by the federal DHHS, HRSA; and With respect to such additional preventive care and screenings not described in paragraph A, provided for in the comprehensive guidelines supported by the federal DHHS, HRSA women's preventive services guidelines. If one of the recommendations referenced above is changed during a plan year, a carrier is not required to make changes to that health plan during the plan year. SEE SEPARATE CHECKLIST FOR SPECIFIC SERVICES. ☐ Prostate cancer screening 24-A M.R.S.A. Coverage required for prostate cancer screening: Digital rectal examinations and prostate-specific antigen tests covered if recommended by a physician, at least once a year for men 50 years of age or older until age 72. ☐ Reconstructive surgery after mastectomy 24-A M.R.S.A. PHSA §2727 If covers mastectomy, then must also cover reconstructive surgery in a manner determined in consultation with provider and patient. Coverage must include: Reconstruction of the breast on which the mastectomy was performed (all stages); ☐ ☐ sharing