02-031 C.M.R. ch. 755
| Section 1. | Purpose | 2 |
|---|---|---|
| Section 2. | Authority | 2 |
| Section 3. | Applicability and Scope | 2 |
| Section 4. | Policy Definitions | 3 |
| Section 5. | Prohibited Policy Provisions | 6 |
| Section 6. | Minimum Standards for Health Insurance Benefits | 8 |
| A. | General Rules | 8 |
| B. | Basic Hospital Expense Coverage | 10 |
| C. | Basic Medical-Surgical Expense Coverage | 11 |
| D. | Basic Hospital/Medical-Surgical Expense Coverage | 12 |
| E. | Hospital Confinement Indemnity Coverage | 12 |
| F. | Major Medical Expense Coverage | 12 |
| G. | Basic Medical Expense Coverage | 14 |
| H. | Individual Disability Income Protection Coverage | 15 |
| I. | Accident Only Coverage | 16 |
| J. | Specified Disease Coverage | 16 |
| K. | Specified Accident Coverage | 22 |
| L. | Supplemental Health Coverage | 22 |
| Section 7. | Required Disclosure Provisions | 22 |
| A. | General Rules | 22 |
| B. | Outline of Coverage Requirements | 27 |
| C. | Basic Hospital Expense Coverage (Outline of Coverage) | 28 |
| D. | Basic Medical-Surgical Expense Coverage (Outline of Coverage) | 29 |
| E. | Basic Hospital/Medical-Surgical Expense Coverage (Outline of Coverage) | 30 |
| F. | Hospital Confinement Indemnity Coverage (Outline of Coverage) | 31 |
| G. | Major Medical Expense Coverage (Outline of Coverage) | 32 |
| H. | Basic Medical Expense Coverage (Outline of Coverage) | 33 |
| I. | Individual Disability Income Protection Coverage (Outline of Coverage) | 35 |
| J. | Accident-Only Coverage (Outline of Coverage) | 35 |
| K. | Specified Disease Coverage (Outline of Coverage) | 36 |
| L. | Specified Accident Coverage (Outline of Coverage) | 37 |
| M. | Supplemental Health Coverage (Outline of Coverage) | 38 |
| N. | Dental Plans (Outline of Coverage) | 39 |
| O. | Vision Plans (Outline of Coverage) | 39 |
| Section 8. | Requirements for Replacement of Individual Health Insurance | 40 |
| Section 9. | Limited Benefit Health Insurance | 42 |
| Section 10. | Transition | 43 |
| Section 11. | Separability | 43 |
| Section 12. | Effective Date | 43 |
The purpose of this rule is to implement 24-A M.R.S.A. Chapter 32-A to standardize and simplify the
terms and coverages of individual health insurance policies, and group health insurance policies and certificates. This rule is also intended to: facilitate public understanding and comparison of coverage; eliminate provisions contained in individual and group health insurance policies that may be misleading or confusing in connection with either the purchase of the coverages or the settlement of claims; and provide for full disclosure in the marketing and sale of individual and group health insurance. This rule is also intended to clarify the meaning of limited benefits health insurance as referred to in 24-A M.R.S.A. chapters 33, 35 and 56-A.
This rule is adopted by the Superintendent pursuant to 24-A M.R.S.A. §§ 212 and 2717 and 24-A M.R.S.A. Chapter 32-A.
D. The requirements contained in this rule shall be in addition to those contained in any other applicable statutes and rules including, but not limited to, 24-A M.R.S.A. Chapters 27, 32, 33, 35, 36 and 56-A and Rules 140, 320, 330, 360, 530, 590, 600, 850 and 940.
A. Except as provided in this rule, an individual health insurance policy or group health insurance policy or certificate delivered or issued for delivery to any person in this state and to which this rule applies shall contain definitions respecting the matters set forth below that comply with the requirements of this section. Definitions may need to be modified to comply with other requirements specified in Section 3(D).B. The Superintendent may approve any substitute definition that is, in his or her opinion, not less favorable in any particular to the insured or beneficiary than the provisions otherwise required.C. 'Accident,' 'accidental injury,' and 'accidental means' shall be defined to employ 'result' language and shall not include words that establish an accidental means test or use words such as 'external, violent, visible wounds' or similar words of description or characterization. The definition shall not be more restrictive than the following: 'accident,' 'accidental injury,' or 'accidental means' means accidental bodily injury sustained by the insured person that is the direct cause of the condition for which benefits are provided and that occurs while the insurance is in force.D. 'Convalescent nursing home,' 'extended care facility,' or 'skilled nursing facility' shall be defined in relation to its status, facility, and available services.1. (1) A definition of the home or facility shall not be more restrictive than one requiring that it:
1. (a) Be operated pursuant to law;
2. (b) Be approved for payment of Medicare benefits or be qualified to receive approval for payment of Medicare benefits, if so requested;
3. (c) Be primarily engaged in providing, in addition to room and board accommodations, skilled nursing care under the supervision of a duly licensed physician;
4. (d) Provide continuous twenty-four-hour-a-day nursing service by or under the supervision of a registered nurse; and
5. (e) Maintain a daily medical record of each patient.
2. (2) The definition of the home or facility may provide that the term shall not be inclusive of:
1. (a) A home, facility, or part of a home or facility used primarily for rest;
2. (b) A home or facility for ~~the aged~~ older adults or for the care of ~~drug addicts or alcoholics~~ those suffering from substance use disorder; or
3. (c) A home or facility primarily used for custodial or educational care.
E. “Hospital” may be defined in relation to its status, facilities, and available services or to reflect its accreditation by the Joint Commission on Accreditation of Healthcare Organizations.1. (1) The definition of the term “hospital” shall not be more restrictive than one requiring that the hospital:
1. (a) Be an institution licensed to operate as a hospital pursuant to law;
2. (b) Be primarily and continuously engaged in providing or operating (either on its premises or in facilities available to the hospital on a prearranged basis and under the supervision of a staff of licensed physicians) medical, diagnostic, and major surgical facilities for the medical care and treatment of sick or injured persons on an in-patient basis for which a charge is made; and
3. (c) Provide twenty-four-hour-a-day nursing service by or under the supervision of registered nurses.
2. (2) The definition of the term “hospital” may state that the term shall not be inclusive of:
1. (a) Convalescent homes or convalescent, rest, or nursing facilities;
2. (b) Facilities affording primarily custodial, educational, or rehabilitative care;
3. (c) Facilities for the aged, drug addicts or alcoholics older adults or those suffering from substance use disorder; or
4. (d) A military or veterans’ hospital, a soldiers’ home, or a hospital contracted for or operated by any national government or government agency for the treatment of members or ex-members of the armed forces, except for services rendered on an emergency basis where a legal liability for the patient exists for charges made to the individual for the services.F. “Medicare” means The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as then constituted or later amended.G. “Nurse” may be defined so that the description of nurse is restricted to a type of nurse, such as registered nurse or a licensed practical nurse. If the words “nurse,” “trained nurse,” or “registered nurse” are used without specific instruction, then the use of these terms requires the insurer to recognize the services of any individual who qualifies under the terminology in accordance with the applicable statutes or administrative rules of the licensing or registry board of the state.H. “One period of confinement” means consecutive days of in-hospital service received as an in-patient, or successive confinements for the same or related causes when discharge from and readmission to the hospital occurs within a period of time not more than six months.I. “Partial disability” shall be defined in relation to the individual’s inability to perform one or more, but not all, of the “major,” “important,” or “essential” duties of employment or occupation, or in relation to a percentage of time worked, to a specified number of hours worked, or to compensation earned.
J. “Physician” may be defined by including words such as “qualified physician” or “licensed physician.” The use of these terms requires an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when the services are within the scope of the provider’s licensed authority and are provided pursuant to applicable laws.
K. “Preexisting condition” shall not be defined more broadly than the following: “Preexisting condition means the existence of symptoms that would cause an ordinarily prudent person to seek diagnosis, care, or treatment within a 24-month period preceding the effective date of the coverage of the insured person or a condition for which medical advice or treatment was recommended by a physician or received from a physician within a 24-month period preceding the effective date of the coverage of the insured person.”
L. “Residual disability” shall be defined in relation to the individual’s reduction in earnings and may be related either to the inability to perform some part of the “major,” “important” or “essential duties” of employment or occupation, or to the inability to perform all usual business duties for as long as is usually required. A policy that provides for residual disability benefits may require a qualification period, during which the insured must be continuously totally disabled before residual disability benefits are payable. The qualification period for residual benefits may be longer than the elimination period for total disability. In lieu of the term “residual disability,” the insurer may use “proportionate disability” or other term of similar import that in the opinion of the Superintendent adequately and fairly describes the benefit.
M. “Sickness” shall not be defined to be more restrictive than the following: “Sickness means illness or disease of an insured person.”
N. “Total disability”
(1) A general definition of total disability shall not be more restrictive than one requiring that the insured, as a result of the covered sickness or accident, is unable to engage in any employment or occupation for which he or she is or becomes qualified by reason of education, training, or experience, and is not, in fact, engaged in any employment or occupation for wage or profit.
(2) Total disability may be defined in relation to the inability of the person to perform duties, but the definition must not require that an individual be unable to:
(a) Perform “any occupation whatsoever,” “any occupational duty,” or “any and every duty of his occupation”; or
(b) Engage in a training or rehabilitation program.
(3) An insurer may require the complete inability of the person to perform all of the substantial and material duties of his or her regular occupation or words of similar import, provided that “regular occupation” or similar words are clearly defined in the policy.
The restrictions set forth in this section are in addition to any other applicable restrictions as specified in Section 3(D).
A. A policy shall not contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy, except:
(1) A policy may specify a probationary or waiting period for sickness not to exceed 30 days from the effective date of the coverage of the insured person; and
(2) A policy may specify a probationary or waiting period not to exceed six months for specified diseases or conditions and losses resulting from disease or condition related to hernia, disorder of reproduction organs, varicose veins, adenoids, appendix, and tonsils. However, the permissible six-month exception shall not be applicable where the specified diseases or conditions are treated on an emergency basis.
Accident policies shall not contain probationary or waiting periods. Nothing in this subsection is intended to restrict the use of elimination periods for disability income benefits.
B. A policy shall not exclude coverage for a loss, due to a preexisting condition, that occurs beyond the 12 months following the issuance of the policy or certificate where the application or enrollment form for the insurance does not seek disclosure of prior illness, disease, physical conditions, medical care, or treatment and where the preexisting condition is not specifically excluded by the terms of the policy or certificate.
C. Unless the Superintendent specifically finds that it is in the best interest of the insureds, no policy subject to this rule shall provide a return of premium or cash value benefit, except: return of unearned premium upon termination or suspension of coverage; retroactive waiver of premium paid during disability; payment of dividends on participating policies; or experience rating refunds.
D. Policies providing hospital confinement indemnity coverage shall not contain provisions excluding coverage because of confinement in a hospital operated by the state or federal government or because the insured is not liable for hospital charges.
E. A policy shall not limit or exclude coverage by type of illness, accident, treatment, or medical condition, except as provided in this subsection. Exclusions and limitations may be further limited by other applicable restrictions as specified in Section 3(D). A policy may contain coverage limitations or exclusions deemed reasonable by the Superintendent including but not limited to the following:
(1) Preexisting conditions, except for congenital anomalies of a dependent child covered at birth;
(2) Mental or emotional disorders, alcoholism, or drug addiction;
(3) Pregnancy, except for complications of pregnancy;
(4) Illness, treatment, or medical condition arising out of war or act of war (whether declared or undeclared), participation in a felony, riot, or insurrection, or service in the armed forces or units auxiliary to it;
(5) Illness or medical condition arising out of Suicide (sane or insane), attempted suicide or intentionally self-inflicted injury, except that this exclusion must not apply to benefits for medical expenses;
(6) Illness, treatment, or medical condition arising out of Aviation, other than as a
ticketed passenger on a commercial airline;
The following minimum standards for benefits are prescribed for the categories of coverage noted in the following subsections. An individual health insurance policy or group health insurance policy or certificate shall not be delivered or issued for delivery in this state unless it meets the required minimum standards for the specified categories or the Superintendent finds that the policies or certificates are approvable as supplemental health insurance and the outline of coverage complies with the outline of coverage in Section 7(M) of this rule.
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.
This section shall not preclude the issuance of any policy or contract combining two or more categories set forth in 24-A M.R.S.A. § 2694.
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) A “noncancellable,” “guaranteed renewable,” or “noncancellable and guaranteed renewable” individual health insurance policy shall not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than nonpayment of premium. In addition, the policy shall provide that in the event of the insured’s death, the spouse of the insured, if covered under the policy, shall become the insured.
(2) (a) The terms “noncancellable,” “guaranteed renewable,” or “noncancellable and guaranteed renewable” shall not be used without further explanatory language in accordance with the disclosure requirements of Section 7A(4).
(b) The terms “noncancellable” or “noncancellable and guaranteed renewable” may be used only in an individual health insurance policy that the insured has the right to continue in force by the timely payment of premiums set forth in the policy at least until the age of 65 or until eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force.
(c) An individual health insurance policy that provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from accident or sickness must provide that the insured has the right to continue the policy in force at least to age 60. The policy must further provide that if the insured is actively and regularly employed at age 60, the insured has the right to continue the policy in force at least until the earlier of the date the insured ceases to be actively and regularly employed or the insured’s normal retirement age under social security. If the insured is ineligible for social security benefits, age 65 may be substituted for the insured’s normal retirement age under social security.
(d) A policy that is subject to the renewal requirements of 24-A M.R.S.A. § 2850-B and that permits the insurer to nonrenew for any reason other than nonpayment of premiums must be labeled “guaranteed renewable with limited exceptions.”
(e) Except as provided in subparagraph (c) and (d) above, the term “guaranteed renewable” may be used only in a policy that the insured has the right to continue in force by the timely payment of premiums at least until the age of 65 or until eligibility for Medicare, during which period the insurer has no right to make unilaterally any change in any provision of the policy while the policy is in force, except that the insurer may make changes in premium rates on a class basis.(3) In an individual health insurance policy covering both husband and wife, the age of the younger spouse shall be used as the basis for meeting the age and durational requirements of the definitions of “noncancellable” or “guaranteed renewable.” However, this requirement shall not prevent termination of coverage of the older spouse upon attainment of the stated age so long as the policy may be continued in force as to the younger spouse to the age or for the policy duration period specified in the policy.(4) When accidental death and dismemberment coverage is part of the individual health insurance coverage offered under the contract, the insured shall have the option to include all insureds under the coverage and not just the principal insured.(5) If a policy contains a status-type military service exclusion or a provision that suspends coverage during military service, the policy shall provide, upon written request of the payer, for refund of unearned premiums as applicable to the person on a pro rata basis beginning with the first day of military service. The policy must also provide for coverage to resume without penalty to the owner upon receipt of a written request within 30 days of the end of military service.(6) In individual health insurance policies, coverage shall continue for a dependent child who is incapable of self-sustaining employment due to ~~mental retardation~~ cognitive disability or physical ~~handicap~~ disability on the date that the child’s coverage would otherwise terminate under the policy due to the attainment of a specified age for children and who is chiefly dependent on the insured for support and maintenance.(7) A policy may contain a provision relating to recurrent disabilities, but a provision relating to recurrent disabilities shall not specify that a recurrent disability be separated by a period greater than six months.(8) Accidental death and dismemberment benefits shall be payable if the loss occurs within 90 days from the date of the accident, irrespective of total disability. Disability coverage for loss due to an accident that occurs while the policy is in force may impose a time limit not to exceed 30 days on the time between the accidental event and commencement of the loss, but the limit must be waived if there is a clear cause and effect relationship between the accident and the subsequent loss.(9) Specific dismemberment benefits shall not be in lieu of other benefits unless the specific benefit equals or exceeds the other benefits.(10) If a continuous loss commences while a policy or certificate providing disability income benefits is in force, termination of the policy will not relieve the insurer of liability for that loss. The continuous total disability of the insured may be a condition for the extension of benefits beyond the period the policy was in force, limited to the duration of the benefit period, if any, or payment of the maximum benefits.
(11) A policy providing coverage for fractures or dislocations may not provide benefits only for “full or complete” fractures or dislocations.
(12) All individual policies providing medical expense reimbursement benefits that are not subject to the grievance procedure requirements of Bureau of Insurance Rule Chapter 850 must contain a notice of the review and arbitration rights specified in 24-A M.R.S.A. § 2747.
(13) A short-term nonrenewable policy shall be classified in one of the categories specified in Subsections B through I, K, or L based on its benefits.
(14) For a Sickness first manifested before the policy effective date, that was fraudulently not disclosed or fraudulently misrepresented in answer to a question in an application for coverage, an insurer may void or contest the policy or deny a claim at any time.
B. Basic Hospital Expense Coverage
“Basic hospital expense coverage” is a policy of health insurance that provides coverage, for a period of not less than 31 days during any one period of confinement for each person insured under the policy, for expense incurred for medically necessary treatment and services rendered as a result of accident or sickness for at least the following:
(1) Daily hospital room and board in an amount not less than the lesser of:
(a) 80% of the charges for semiprivate room accommodations or
(b) $500 per day;
(2) Miscellaneous hospital services for expenses incurred for the charges made by the hospital for services and supplies that are customarily rendered by the hospital and provided for use only during any one period of confinement in an amount not less than either 80% of the charges incurred up to at least $5,000 or ten times the daily hospital room and board benefits; and
(3) Hospital outpatient services consisting of:
(a) Hospital services on the day surgery is performed,
(b) Hospital services rendered within 72 hours after injury, in an amount not less than $1,000; and
(c) X-ray and laboratory tests in an amount not less than $500.
(4) Benefits provided under this subsection may be provided subject to a combined deductible amount not in excess of $500.
C. Basic Medical-Surgical Expense Coverage
“Basic medical-surgical expense coverage” is a policy of health insurance that provides coverage for each person insured under the policy for the expenses incurred for the medically necessary services rendered by a physician for treatment of an injury or sickness for at least the following:
(1) Surgical services: (a) In amounts not less than those provided on a fee schedule based on the relative values contained in a fee schedule up to a maximum of at least $5,000 for one procedure; or (b) Not less than 80% of the usual, customary and reasonable charges, as determined consistent with § 7(A)(7); or (c) Not less than 80% of a maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions. (2) Anesthesia services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical service rendered by a physician other than the physician (or the physician assistant) performing the surgical services: (a) In an amount not less than 80% of the usual, customary and reasonable charges, as determined consistent with § 7(A)(7); or (b) Not less than 80% of a maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions.; or (c) 15% of the surgical service benefit. (3) In-hospital medical services, consisting of physician services rendered to a person who is a bed patient in a hospital for treatment of sickness or injury other than that for which surgical care is required, in an amount not less than: (a) 80% of the usual, customary and reasonable charges, as determined consistent with § 7(A)(7); or (b) 80% of a maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions; or (c) $100 per day for not less than 21 days during one period of confinement. D. Basic Hospital/Medical-Surgical Expense Coverage “Basic hospital/medical-surgical expense coverage” is a combined coverage and must meet the requirements of both Subsections B and C. E. Hospital Confinement Indemnity Coverage (1) “Hospital confinement indemnity coverage” is a policy of health insurance that provides daily benefits for hospital confinement on an indemnity basis in an amount not less than $50 per day and not less than 31 days during any one period of confinement for each person insured under the policy. (2) Coverage shall not be excluded due to a preexisting condition for a period greater than 12 months following the effective date of coverage of an insured person unless
the preexisting condition is specifically and expressly excluded.
(3) Except as permitted under 24-A M.R.S.A. § 2723, benefits shall be paid regardless of other coverage.
(1) "Major medical expense coverage" is a health insurance policy that provides coverage for medically necessary hospital, medical, and surgical expenses, subject to a lifetime maximum of not less than $1,000,000 per covered person, a coinsurance percentage not to exceed 50% of covered charges, provided that the coinsurance out-of-pocket maximum per covered person after any deductibles shall not exceed $10,000 per year, and a deductible stated on a per person, per family, per illness, per benefit period, or per year basis, or a combination of these bases not to exceed 5% of the lifetime maximum limit under the policy for each covered person, for at least:
(a) Daily hospital room and board expenses subject only to limitations based on average daily cost of the semiprivate room rate in the area where the insured resides;
(b) Miscellaneous hospital services;
(c) Surgical services;
(d) Anesthesia services;
(e) In-hospital medical services;
(f) Out-of-hospital care, consisting of physicians' services rendered on an ambulatory basis for diagnosis and treatment of sickness or injury, diagnostic x-ray, laboratory services, radiation therapy, and hemodialysis ordered by a physician; and
(g) Diagnosis and treatment by a radiologist or physiotherapist;
(h) Treatment for functional nervous disorders and mental and emotional disorders; and
(i) Out-of-hospital prescription drugs and medications. Cost sharing for the drug benefit shall not exceed 50% on average. If there is a separate maximum for this benefit, it shall be at least $1,500 per year.
(2) If the policy is written to complement underlying basic hospital expense and basic medical-surgical expense coverage, the deductible may be increased by the amount of the benefits provided by the underlying coverage.
(3) The minimum benefits required by Section 6(F)(1) may be subject to all applicable deductibles, coinsurance, and general policy exceptions and limitations. A major medical expense policy may also have special or internal limitations for prescription drugs, nursing facilities, intensive care facilities, mental health treatment, alcohol or substance abuse treatment, transplants, experimental treatments, mandated benefits required by law, and other such special or internal limitations as are authorized or approved by the Superintendent. Except as authorized by this subsection through the
application of special or internal limitations, a major medical expense policy must be designed to cover, after any deductibles or coinsurance provisions are met:
(a) The usual, customary, and reasonable charges, as determined consistent with § 7(A)(7); or
(b) A maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions; or
(c) Another rate agreed to between the insurer and provider, for covered services up to the lifetime policy maximum.
G. Basic Medical Expense Coverage
(1) “Basic medical expense coverage” is a health insurance policy that provides coverage for medically necessary hospital, medical, and surgical expenses, subject to a lifetime maximum of not less than $250,000 per covered person, a coinsurance percentage not to exceed 50% of covered charges, provided that the coinsurance out-of-pocket maximum after any deductibles shall not exceed $25,000 per covered person per year, and a deductible stated on a per person, per family, per illness, per benefit period, or per year basis, or a combination of these bases not to exceed 10% of the lifetime maximum limit under the policy for each covered person, for at least:
(a) Daily hospital room and board expenses subject only to limitations based on average daily cost of the semiprivate room rate in the area where the insured resides or such other rate agreed to between the insurer and provider for a maximum period of not less than 31 days during any one period of confinement;
(b) Miscellaneous hospital services;
(c) Surgical services;
(d) Anesthesia services;
(e) In-hospital medical services;
(f) Out-of-hospital care, consisting of physicians’ services rendered on an ambulatory basis for diagnosis and treatment of sickness or injury, diagnostic x-ray, laboratory services, radiation therapy, and hemodialysis ordered by a physician; and
(g) Not fewer than three (3) of the following additional benefits:
(i) In-hospital private duty registered nurse services;
(ii) Convalescent nursing home care;
(iii) Diagnosis and treatment by a radiologist or physiotherapist;
(iv) Rental of special medical equipment, as defined by the insurer in the policy;
(v) Artificial limbs or eyes, casts, splints, trusses, or braces;
(vi) Treatment for functional nervous disorders and mental and emotional disorders; or
(vii) Out-of-hospital prescription drugs and medications.
(2) If the policy is written to complement underlying basic hospital expense and basic medical-surgical expense coverage, the deductible may be increased by the amount of the benefits provided by the underlying coverage.
(3) The minimum benefits required by 6G(1) may be subject to all applicable deductibles, coinsurance, and general policy exceptions and limitations. A basic medical expense policy may also have special or internal limitations for prescription drugs, nursing facilities, intensive care facilities, mental health treatment, alcohol or substance abuse treatment, transplants, experimental treatments, mandated benefits required by law, and those services covered under 6G(1)(g) and other such special or internal limitations as are authorized or approved by the Superintendent. Except as authorized by this subsection through the application of special or internal limitations, a basic medical expense policy must be designed to cover, after any deductibles or coinsurance provisions are met:
(a) The usual, customary, and reasonable charges, as determined consistently by the carrier and as subject to approval by the Superintendent; or
(b) A maximum allowance based on the Medicare Resource Based Relative Value Scale with appropriate adjustments for market conditions; or
(c) Another rate agreed to between the insurer and provider, for covered services up to the lifetime policy maximum.
“Individual disability income protection coverage” provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from either sickness or injury or a combination of them. The requirements of this subsection do not apply to policies providing business buy-out coverage.
(1) Policies shall not contain an elimination period greater than:
(a) 90 days in the case of a coverage providing a benefit of one year or less;
(b) 180 days in the case of coverage providing a benefit of more than one year but not greater than two (2) years; or
(c) 730 days in all other cases during the continuance of disability resulting from sickness or injury;
(2) The maximum benefit period shall be at least three months except a maximum benefit period of one month is permitted for normal pregnancy and normal childbirth or for miscarriage.
(3) No reduction in benefits shall be put into effect because of an increase in Social
Security or similar benefits during a benefit period.
(4) An insurer may condition total disability benefits on care by a physician other than the insured or a member of the insured's immediate family.
I. Accident Only Coverage
"Accident only coverage" is a policy that provides coverage, singly or in combination, for death, dismemberment, disability, or hospital and medical care caused by accident. Accidental death and double dismemberment amounts under the policy shall be at least $2,000 and a single dismemberment amount shall be at least $1,000.
J. Specified Disease Coverage
(1) "Specified disease coverage" pays benefits based on diagnosis and/or treatment of a specifically named disease or diseases. A specified disease policy must meet the following rules and one of the following sets of minimum standards for benefits:
(a) Insurance covering cancer only or cancer in conjunction with other conditions or diseases must meet the standards of Paragraph (4), (5) or (6) of this subsection.
(b) Insurance covering only specified diseases other than cancer must meet the standards of Paragraph (3) or (6) of this subsection.
(2) General Rules
The following rules shall apply to specified disease coverages in addition to all other rules imposed by this Rule. In cases of conflict between the following and other rules, the following rules shall govern.
(a) Policies covering a single specified disease or combination of specified diseases may not be sold or offered for sale other than as specified disease coverage under this section.
(b) Any policy issued pursuant to this section that conditions payment upon pathological diagnosis of a covered disease shall also provide that if the pathological diagnosis is medically inappropriate, a clinical diagnosis will be accepted instead.
(c) Notwithstanding any other provision of this rule, specified disease policies shall provide benefits, with the exception of any lump-sum benefit based on diagnosis of a specified disease, to any covered person not only for the specified diseases but also for any other conditions or diseases, directly caused or aggravated by the specified diseases or the treatment of the specified disease.
(d) Individual specified disease coverage shall be guaranteed renewable or noncancellable.
(e) A specified disease policy may contain a waiting or probationary period of no more than 30 days following the issue or reinstatement date of the policy or certificate.
(ii) Hospice care is an optional benefit. However, if a specified disease insurance product offers coverage for hospice care, it shall meet the following minimum standards:
(II) A fixed-sum payment of at least \$50 per day; and
person not to exceed 20% of covered charges. The requirements of this paragraph apply unless the Superintendent approves different minimum benefits based on a determination that the minimum benefits provided by the insurer are in the interest of the consumer.
(III) It is available to provide the care needed in the home seven days a week and has telephone answering service available 24 hours per day;
(IV) It provides, either directly or through contract, the services of a coordinator responsible for case discovery and planning and for assuring that the covered person receives the services ordered by the physician;
(i) A fixed-sum payment of at least \$100 for each day of hospital confinement for at least 365 days;
(ii) A fixed-sum payment equal to one half the hospital inpatient benefit for each day of hospital or nonhospital outpatient surgery, chemotherapy, and radiation therapy, for at least 365 days of treatment; and
“Specified accident coverage” is a policy that provides coverage for a specifically identified kind of accident (or accidents) for each person insured under the policy for accidental death or accidental death and dismemberment combined. The benefit amount shall not be less than $2,000 for accidental death, $2,000 for double dismemberment, and $1,000 for single
dismemberment.
“Supplemental health coverage” is a policy or contract, other than a policy or contract covering only a specified disease or diseases, that provides benefits that are less than the minimum standards for benefits required under Subsections B, C, D, E, F, G, I and K. These policies or contracts may be delivered or issued for delivery in this state only if the outline of coverage required by Section 7(M) of this rule is completed and delivered as required by Section 7(B) of this rule and the policy or certificate is clearly labeled as a supplemental policy or certificate as required by Section 7(A)(17). A policy covering a single specified disease or combination of diseases shall meet the requirements of Section 6(J) and shall not be offered for sale as a “limited” or “supplemental” coverage.
The requirements set forth in this section are in addition to any other applicable requirements as specified in Section 3(D).
(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.
(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.”
(1) An insurer shall deliver an outline of coverage to an applicant or enrollee in the sale of individual health insurance, group health insurance, dental plans, and vision plans as required in 24-A M.R.S.A. § 2695. This requirement shall not apply to group major medical policies and certificates issued to employer groups as described in 24-A M.R.S.A. § 2804 and labor union groups as described in 24-A M.R.S.A. § 2805. Except as provided in Section 10, all outlines of coverage used in this state require the approval of the Superintendent.
(2) If an outline of coverage was delivered at the time of application or enrollment and the policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and contain the following statement in no less than twelve (12) point type, immediately above the company name:
“NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon [application][enrollment], and the coverage originally applied for has not been issued.”
(3) In any case where the prescribed outline of coverage is inappropriate for the coverage provided by the policy or certificate, an alternate outline of coverage shall be submitted to the Superintendent for prior approval.
(4) An outline of coverage may take the form or an advertisement provided that it satisfies the standards specified for outlines of coverage in 24-A M.R.S.A. § 2695(8) as well as this rule.
C. Basic Hospital Expense Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Section 6(B) of this rule, but not meeting the standards of Sections 6(C) (basic medical-surgical), 6(F) (major medical) or 6(G) (basic medical). The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
BASIC HOSPITAL EXPENSE COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS AND SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR COMPREHENSIVE HEALTH INSURANCE COVERAGE
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate] Carefully—This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR [POLICY][CERTIFICATE] CAREFULLY!
(2) Basic hospital coverage is designed to provide coverage for hospital expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, and hospital outpatient services, subject to any limitations, deductibles, and copayment requirements set forth in the policy. Coverage is NOT provided for physicians’ or surgeons’ fees or for out-of-hospital prescription drugs.
(3) [A brief specific description of the benefits, including dollar amounts and number of days duration where applicable, contained in this policy, in the following order:
The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described.]
D. Basic Medical-Surgical Expense Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Section 6(C) of this rule but not meeting the standards of Sections 6(B) (basic hospital), 6(F) (major medical) or 6(G) (basic medical). The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
BASIC MEDICAL-SURGICAL EXPENSE COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS AND SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR COMPREHENSIVE HEALTH INSURANCE COVERAGE
OUTLINE OF COVERAGE
(a) Surgical services; (b) Anesthesia services; (c) In-hospital medical services; and (d) Other benefits, if any.
The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described.]
(4) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (3) above.] (5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.]
E. Basic Hospital/Medical-Surgical Expense Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Sections 7(B) and 7(C) of this rule but not meeting the standards of Section 6(F) (major medical) or 6(G) (basic medical). The items included in the outline of coverage must appear in the sequence prescribed.
[COMPANY NAME]
BASIC HOSPITAL/MEDICAL-SURGICAL EXPENSE COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS AND SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR COMPREHENSIVE HEALTH INSURANCE COVERAGE
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate] Carefully—This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore important that you READ YOUR [POLICY] [CERTIFICATE] CAREFULLY! (2) Basic hospital/medical-surgical expense coverage is designed to provide, to persons insured, coverage for hospital expenses and for physicians' and surgeons' fees incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, hospital outpatient services, surgical services, anesthesia services, and in-hospital medical services, subject to any limitations, deductibles, and copayment requirements set forth in the policy. Coverage is not provided for unlimited hospital or medical surgical expenses. No coverage is provided for out-of-hospital prescription drugs.
(3) [A brief specific description of the benefits, including dollar amounts and number of days duration where applicable, contained in this policy, in the following order: (a) Daily hospital room and board; (b) Miscellaneous hospital services; (c) Hospital outpatient services; (d) Surgical services; (e) Anesthesia services; (f) In-hospital medical services; and (g) Other benefits, if any.
The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described.]
(4) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (3) above.] (5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.]
F. Hospital Confinement Indemnity Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Section 6(E) of this rule. The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
HOSPITAL CONFINEMENT INDEMNITY COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate] Carefully—This outline of coverage provides a very brief description of the important features of coverage. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR [POLICY] [CERTIFICATE] CAREFULLY! (2) Hospital confinement indemnity coverage is designed to provide coverage in the
form of a fixed daily benefit during periods of hospitalization resulting from a covered accident or sickness, subject to any limitations set forth in the policy. Coverage is not provided for any benefits other than the fixed daily indemnity for hospital confinement and any additional benefit described below.
(3) [A brief specific description of the benefits in the following order: (a) Daily benefit payable during hospital confinement; and (b) Duration of benefit described in (a).
The description of benefits shall be stated clearly and concisely.]
(4) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefit, described in Paragraph (3) above.] (5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.] (6) [Any benefits provided in addition to the daily hospital benefit.]
An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Section 6(F) of this rule. This requirement does not apply to group policies and certificates issued to employer groups as described in 24-A M.R.S.A. § 2804 and labor union groups as described in 24-A M.R.S.A. § 2805. The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
(1) Read Your Policy Carefully—This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!] (2) Major medical expense coverage is designed to provide comprehensive coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, out-of-hospital care, and prescription drugs, subject to any deductibles, copayment provisions, or other limitations that may be set forth in the policy. (3) [A brief specific description of the benefits, including dollar amounts, contained in this policy, in the following order: (a) Daily hospital room and board;
The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described.]
An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Section 6(G) of this rule but not meeting the standards of Section 6(F) (major medical). The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care, subject to any deductibles, copayment provisions, or other limitations that may be set forth in the policy. No coverage is provided for out-of-hospital prescription drugs.
(3) [A brief specific description of the benefits, including dollar amounts, contained in this policy, in the following order: (a) Daily hospital room and board; (b) Miscellaneous hospital services, (c) Surgical services; (d) Anesthesia services; (e) In-hospital medical services, (f) Out-of-hospital care; (g) Maximum dollar amount for covered charges; and (h) Other benefits, if any
The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described.]
(4) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (3) above.] (5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.]
I. Individual Disability Income Protection Coverage (Outline of Coverage)
An outline of coverage, in the form prescribed below, shall be issued in connection with policies meeting the standards of Section 6(H) of this rule. The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
DISABILITY INCOME PROTECTION COVERAGE
OUTLINE OF COVERAGE
(1) Read Your Policy Carefully—This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It
is, therefore, important that you READ YOUR POLICY CAREFULLY!
(2) Disability income protection is designed to replace part of your earned income every month if you become unable to work due to a covered accident or sickness, subject to any limitations set forth in the policy. No coverage is provided for medical expenses.
(3) [A brief specific description of the benefits contained in this policy. The description of benefits shall be stated clearly and concisely.]
(4) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (3) above.]
(5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.]
J. Accident-Only Coverage (Outline of Coverage)
An outline of coverage in the form prescribed below shall be issued in connection with policies meeting the standards of Section 6(I) of this rule. The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
ACCIDENT-ONLY COVERAGE
THIS [POLICY][CERTIFICATE] PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND NOT INTENDED TO COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
(1) Read Your [Policy][Certificate] Carefully—This outline of coverage provides a very brief description of the important features of the coverage. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR [POLICY][CERTIFICATE] CAREFULLY!
(2) Accident-only coverage is designed to provide coverage for certain losses resulting from a covered accident ONLY, subject to any limitations contained in the policy. Coverage is not provided for medical expenses.
(3) [A brief specific description of the benefits. The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described. If benefits vary according to the type of accidental cause, the outline of coverage shall prominently set forth the circumstances under which benefits are payable that are less than the maximum amount payable under the policy.]
(4) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in
Paragraph (3) above.]
(5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.]
K. Specified Disease Coverage (Outline of Coverage)
An outline of coverage in the form prescribed below shall be issued in connection with policies or certificates meeting the standards of Sections 7(J) of this rule. The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
SPECIFIED DISEASE COVERAGE
THIS [POLICY] [CERTIFICATE] PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES
OUTLINE OF COVERAGE
(1) This coverage is designed only as a supplement to a comprehensive health insurance policy and should not be purchased unless you have this underlying coverage. [If the policy covers cancer, include the following sentence.] Persons covered under Medicaid should not purchase it. Read the Buyer's Guide to Cancer Insurance to review the possible limits on benefits in this type of coverage.
(2) Read Your [policy] [certificate] Carefully—This outline of coverage provides a very brief description of the important features of coverage. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR [POLICY] [CERTIFICATE] CAREFULLY!
(3) Specified disease coverage is designed to provide restricted coverage paying benefits ONLY when certain losses occur as a result of specified diseases. Coverage is NOT provided for other diseases or accidents.
(4) [A brief specific description of the benefits, including dollar amounts. The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provisions applicable to the benefits described.]
(5) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (4) above.]
(6) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.]
L. Specified Accident Coverage (Outline of Coverage)
An outline of coverage in the form prescribed below shall be issued in connection with policies or certificates meeting the standards of Sections 7(K) of this rule. The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
THIS [POLICY] [CERTIFICATE] PROVIDES LIMITED BENEFITS
BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES
(1) Read Your [Policy][Certificate] Carefully—This outline of coverage provides a very brief description of the important features of the coverage. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR [POLICY][CERTIFICATE] CAREFULLY!
(2) Specified accident coverage is designed to provide, to persons insured, restricted coverage paying benefits ONLY when certain losses occur as a result of specified accidents. Coverage is not provided for other accidents or for illness.
(3) [A brief specific description of the benefits. The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provision applicable to the benefits described. If benefits vary according to the type of accidental cause, the outline of coverage shall prominently set forth the circumstances under which benefits are payable that are less than the maximum amount payable under the policy.]
(4) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (3) above.]
(5) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.]
An outline of coverage, in the form prescribed below, shall be issued in connection with policies or certificates that do not meet the minimum standards of Sections 7B, C, D, E, F, G, I and K of this rule. The items included in the outline of coverage must appear in the sequence prescribed:
[COMPANY NAME]
BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES
(1) Read Your [Policy][Certificate] Carefully—This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR[POLICY][CERTIFICATE] CAREFULLY!
(2) Supplemental health coverage is designed to provide limited or supplemental coverage.
(3) [A brief specific description of the benefits, including dollar amounts. The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provisions applicable to the benefits described. If benefits vary according to the type of accidental cause, the outline of coverage shall prominently set forth the circumstances under which benefits are payable that are less than the maximum amount payable under the policy.]
(4) [A description of any provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (3) above.]
(5) [A description of provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.]
An outline of coverage in the form prescribed below shall be issued in connection with dental plan policies and certificates. The items included in the outline of coverage must appear in the sequence prescribed:
(1) Read Your [Policy][Certificate] Carefully—This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR[POLICY][CERTIFICATE] CAREFULLY!
(2) [A brief specific description of the benefits. The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provisions applicable to the benefits described.]
(3) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (2) above.]
(4) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.]
An outline of coverage in the form prescribed below shall be issued in connection with vision plan policies and certificates. The items included in the outline of coverage must appear in the sequence prescribed:
(1) Read Your [Policy][Certificate] Carefully—This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR[POLICY][CERTIFICATE] CAREFULLY!
(2) [A brief specific description of the benefits. The description of benefits shall be stated clearly and concisely, and shall include a description of any deductible or copayment provisions applicable to the benefits described.]
(3) [A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or, in any other manner, operate to qualify payment of the benefits described in Paragraph (2) above.]
(4) [A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.]
A. An application form for individual health insurance shall include a question designed to elicit information as to whether the insurance to be issued is intended to replace any other health insurance presently in force. A supplementary application or other form to be signed by the applicant containing the question may be used.
B. Upon determining that a sale will involve replacement, an insurer, other than a direct response insurer, or its agent shall furnish the applicant, prior to issuance or delivery of the policy, the notice described in Subsection C below. The insurer shall retain a copy of the notice. A direct response insurer shall deliver to the applicant upon issuance of the policy, the notice described in Subsection D below. In no event, however, will the notices be required in the solicitation of the following types of policies: accident-only and single-premium nonrenewable policies.
C. The notice required by Subsection B above for an insurer, other than a direct response insurer, shall provide, in substantially the following form:
According to [your application] [information you have furnished], you intend to lapse or otherwise terminate existing health insurance and replace it with a policy to be issued by [insert company name] Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy.
(1) Health conditions that you may presently have, (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or
delay of a claim for benefits present under the new policy, whereas a similar claim might have been payable under your present policy. [This subsection may be modified or omitted if preexisting conditions are covered under the new policy.]
(2) You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage.
(3) Do not cancel your present policy until you have actually received your new policy and are sure you want to keep it.
(4) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded.
The above “Notice to Applicant” was delivered to me on:
(Date)
(Applicant’s Signature)
D. The notice required by Subsection B of this section for a direct response insurer shall be as follows:
OF HEALTH INSURANCE
According to [your application] [information you have furnished] you intend to lapse or otherwise terminate existing health insurance and replace it with the policy delivered herewith issued by [insert company name] Insurance Company. Your new policy provides ten [insert higher number if the policy provides a longer period] days within which you may decide without cost whether you desire to keep the policy. For your own information and protection you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy.
(1) Health conditions that you may presently have, (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy. [This subsection may be modified or omitted if preexisting conditions are covered under the new policy.]
(2) You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in
replacing your present coverage.
(3) Do not cancel your present policy until you have actually received your new policy and are sure you want to keep it.
(4) [To be included only if the application is attached to the policy]. If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, read the copy of the application attached to your new policy and be sure that all questions are answered fully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to [insert company name and address] within ten days if any information is not correct and complete, or if any past medical history has been left out of the application.
[COMPANY NAME]
"Limited benefit health insurance" or "limited benefit coverage," as used in 24-A M.R.S.A. Chapters 33, 35, and 56-A, means only the following types of coverage:
A. Coverage designed to supplement TRICARE or the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) (Chapter 55, title 10 of the United States Code);
B. Policies that cover only dental or vision care;
C. Hospital confinement indemnity coverage as defined in Section 6, Subsection E;
D. Accident only coverage as defined in Section 6, Subsection I;
E. Specified disease coverage as defined in Section 6, Subsection J;
F. Specified accident coverage as defined in Section 6, Subsection K; and
G. Supplemental coverage as defined in Section 6, Subsection L, except that supplemental coverage is not limited benefit health insurance if it is substantially similar to one of the following types of coverage:
(1) Basic hospital expense coverage as defined in Section 6, Subsection B;
(2) Basic medical-surgical expense coverage as defined in Section 6, Subsection C;
(3) Basic hospital/medical-surgical expense coverage as defined in Section 6, Subsection D;
(4) Major medical expense coverage as defined in Section 6, Subsection F; or
(5) Basic medical expense coverage as defined in Section 6, Subsection G.
For purposes of this subsection, "substantially similar" means that, in the judgment of the Superintendent, there are only minor differences between the supplemental coverage and coverage that would meet the minimum standards of Section 6, Subsections B, C, D, F, or G.
Two or more policies sold as a package are not limited benefit health insurance if the combined benefits are substantially similar to one of the types of coverage listed in paragraphs (1) thorough (5) above.
The following requirements apply to any form approved prior to the effective date of this rule that the carrier intends to offer in this state on or after January 1, 2005.
A. On or before October 1, 2004, the carrier must submit to the Superintendent a list of previously approved forms that the carrier intends to continue offering and that are in compliance with this rule.
B. For previously approved forms that the carrier intends to continue offering and that do not comply with this rule, the carrier must submit, on or before October 1, 2004, for approval by the Superintendent, any amendments needed to bring the forms into compliance with this rule.
C. On or before December 31, 2004, the carrier must submit to the Superintendent, for each form on the list specified in Subsection A and each form amended pursuant to Subsection B, outlines of coverage that comply with Section 7 of this rule. Outlines of coverage submitted pursuant to this subsection do not require approval and may be used unless disapproved by the Superintendent.
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 the provision to other persons or circumstances shall not be affected thereby.
This rule shall be effective on June 11, 2004.
STATUTORY AUTHORITY: 24-A M.R.S.A. §§ 212 and 2717 and 24-A M.R.S.A. Chapter 32-A
EFFECTIVE DATE:
June 11, 2004 - filing 2004-155 (major substantive)
NONSUBSTANTIVE CORRECTIONS (terminology updates):
March 31, 2026