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USA Statutes : maine
Title : Title 24-A. MAINE INSURANCE CODE
Chapter : Chapter 35. GROUP AND BLANKET HEALTH INSURANCE
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Title 24-A - §2802. Group insurance defined
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2802. Group insurance defined
1. Any policy or contract of insurance against death or injury resulting from accident or from accidental means which covers
more than one person, except blanket accident policies as defined in section 2813 and family accident and sickness policies
conforming to section 2703, shall be deemed a group accident insurance policy.
[1969, c. 177, § 48 (amd).]
2. Any policy or contract which insures against disablement, disease or sickness of the insured, excluding disablement which
results from accident or from accidental means, and which covers more than one person, except blanket sickness insurance policies
as defined in section 2813 and family accident and sickness policies conforming to section 2703, shall be deemed a group sickness
insurance policy or contract.
[1969, c. 132, § 1 (new).]
3. Any policy or contract of insurance which combines the coverage of group accident insurance and of group sickness insurance
shall be deemed a group accident and sickness insurance policy.
[1969, c. 132, § 1 (new).]
4. Any reference hereinafter to group health insurance shall mean group accident, group sickness and group accident and sickness
insurance as herein defined.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2803-A. Loss information
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2803-A. Loss information
1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Insurance policy" means the insurance policy relating to the loss information requested pursuant to this section.
[1995, c. 71, §2 (new).]
B. "Loss information" means the aggregate claims experience of the group insurance policy or contract. "Loss information"
includes the amount of premium received, the amount of claims paid and the loss ratio. "Loss information" does not include
any information or data pertaining to the medical diagnosis, treatment or health status that identifies an individual covered
under the group contract or policy.
[1995, c. 71, §2 (new).]
C. "Loss ratio" means the ratio between the amount of premium received and the amount of claims paid by the insurer under the
group insurance contract or policy.
[1995, c. 71, §2 (new).]
[1995, c. 71, §2 (new).]
2. Disclosure of basic loss information. Upon written request, every insurer shall provide loss information concerning a group policy or contract to its policyholder
or former policyholder within 21 business days of the date of the request. This subsection does not apply to a former policyholder
whose coverage terminated more than 18 months prior to the date of a request.
[2003, c. 428, Pt. D, §1 (amd).]
3. Transmittal of request. An insurance producer or other authorized representative who receives a request for loss information in accordance with
this section shall transmit the request for loss information to the insurer within 4 business days.
[2001, c. 410, Pt. B, §1 (amd).]
4. Exception. An insurer is not required to provide the loss information described in this section for a group that is eligible for small
group coverage pursuant to section 2808-B.
[2001, c. 410, Pt. B, §2 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2803. Requirements
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2803. Requirements
A policy of group health insurance may not be delivered in this State, nor may any certificate of group health insurance that
derives from a policy issued in another state be delivered in this State unless the group policyholder conforms to one of
the descriptions set forth in sections 2804 to 2809.
[1993, c. 171, Pt. C, §2 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2804-A. Private purchasing alliances
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2804-A. Private purchasing alliances
A group of individuals may be insured under a policy issued to a private purchasing alliance meeting the requirements of chapter
18-A.
[1995, c. 673, Pt. A, §4 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2804. Employee groups
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2804. Employee groups
A group of individuals may be insured under a policy issued to an employer or to the trustees of a fund established by an
employer, which employer or trustees shall be deemed the policyholder, to insure employees of the employer for the benefit
of persons other than the employer, subject to the following requirements.
[1981, c. 147, §2 (rpr).]
1. The employees eligible for insurance under the policy shall be all of the employees of the employer, or all of any class
or classes thereof. The policy may provide that the term "employees" includes the employees of one or more subsidiary corporations
and the employees, individual proprietors, and partners of one or more affiliated corporations, proprietorships or partnerships
if the business of the employer and of the affiliated corporations, proprietorships or partnerships is under common control.
The policy may provide that the term "employees" includes the individual proprietor or partners if the employer is an individual
proprietorship or partnership. The policy may provide that the term "employees" includes retired employees and directors of
a corporate employer. A policy issued to insure the employees of a public body may provide that the term "employees" includes
elected or appointed officials.
[1981, c. 147, §2 (rpr).]
2. The premium for the policy shall be paid either from the employer's funds or from funds contributed by the insured employees,
or from both. Except as provided in subsection 3, a policy on which no part of the premium is to be derived from funds contributed
by the insured employees must insure all eligible employees, except those who reject such coverage in writing.
[1981, c. 147, §2 (rpr).]
3. Except as provided in section 2736-C, section 2808-B and chapter 36, an insurer may exclude or limit the coverage on any
person as to whom evidence of individual insurability is not satisfactory to the insurer.
[1999, c. 256, Pt. G, §1 (amd).]
4.
[1981, c. 147, §2 (rp).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2805-A. Association groups
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2805-A. Association groups
A group of individuals may be insured under a policy issued to an association or to a trust or to the trustees of a fund established,
created or maintained for the benefit of members of one or more associations. The association or associations shall have at
the outset a minimum of 50 persons; shall have been organized and maintained in good faith for purposes other than that of
obtaining insurance; shall have been in active existence for at least 2 years; and shall have a constitution and bylaws which
provides that: The association or associations hold regular meetings not less than annually to further purposes of the members;
except for credit unions, the association or associations collect dues or solicit contributions from members; and the members
have voting privileges and representation on the governing board and committees. The policy is subject to the following requirements.
[1981, c. 147, §4 (new).]
1. The policy may insure members of the association or associations, employees thereof or employees of members or one or more
of the preceding or all of any class or classes thereof for the benefit of persons other than the employees' employer.
[1981, c. 147, §4 (new).]
2. The premium for the policy shall be paid from funds contributed by the association or associations or by employer members,
or by both, or from funds contributed by the covered persons or from both the covered persons and the association, associations
or employer members.
[1981, c. 147, §4 (new).]
3. Except as provided in subsection 4, a policy on which no part of the premium is to be derived from funds contributed by
the covered persons specifically for their insurance must insure all eligible persons, except those who reject that coverage
in writing.
[1981, c. 147, §4 (new).]
4. Except as provided in section 2736-C, section 2808-B and chapter 36, an insurer may exclude or limit the coverage on any
person as to whom evidence of individual insurability is not satisfactory to the insurer.
[1999, c. 256, Pt. G, §3 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2805. Labor union groups
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2805. Labor union groups
A group of individuals may be insured under a policy issued to a labor union or similar employee organization, which shall
be deemed to be the policyholder, to insure members of that union or organization for the benefit of persons other than the
union or organization or any of its officials, representatives or agents, subject to the following requirements.
[1981, c. 147, §3 (rpr).]
1. The members eligible for insurance under the policy shall be all of the members of the union or organization or all of any
class or classes thereof.
[1981, c. 147, §3 (rpr).]
2. The premium for the policy shall be paid either from funds of the union or organization, or from funds contributed by the
insured members specifically for their insurance, or from both. Except as provided in subsection 3, a policy on which no part
of the premium is to be derived from funds contributed by the insured members specifically for their insurance must insure
all eligible members, except those who reject such coverage in writing.
[1981, c. 147, §3 (rpr).]
3. Except as provided in section 2736-C, section 2808-B and chapter 36, an insurer may exclude or limit the coverage on any
person as to whom evidence of individual insurability is not satisfactory to the insurer.
[1999, c. 256, Pt. G, §2 (amd).]
4.
[1981, c. 147, §3 (rp).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2806. Trustee groups
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2806. Trustee groups
A group of individuals may be insured under a policy issued to a trust or to the trustee or trustees of a fund established
by 2 or more employers, or by one or more labor unions or similar employee organizations, or by one or more employers and
one or more labor unions or similar employee organizations, which trust or trustee or trustees shall be deemed the policyholder,
to insure employees of the employers or members of the unions or organizations for the benefit of persons other than the employers
or the unions or organizations, subject to the following requirements.
[1981, c. 147, §5 (rpr).]
1. The persons eligible for insurance shall be all of the employees of the employers or all of the members of the unions or
organizations, or all of any class or classes thereof. The policy may provide that the term "employees" includes retired employees,
the individual proprietor or partners if an employer is an individual proprietorship or a partnership and directors of a corporate
employer. The policy may provide that the term "employees" includes the trustees or their employees, or both, if their duties
are principally connected with that trusteeship.
[1981, c. 147, §5 (rpr).]
2. The premium for the policy shall be paid from funds contributed by the employer or employers of the insured persons or by
the union or unions or similar employee organizations, or by both, or from funds contributed by the insured persons or from
both the insured persons and the employer or union or similar employee organization. Except as provided in subsection 3, a
policy on which no part of the premium is to be derived from funds contributed by the insured persons specifically for their
insurance must insure all eligible person, except those who reject such coverage in writing.
[1981, c. 147, §5 (rpr).]
3. Except as provided in section 2736-C, section 2808-B and chapter 36, an insurer may exclude or limit the coverage on any
person as to whom evidence of individual insurability is not satisfactory to the insurer.
[1999, c. 256, Pt. G, §4 (amd).]
4.
[1981, c. 147, §5 (rp).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2807-A. Credit union groups
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2807-A. Credit union groups
A group of individuals may be insured under a policy issued to a credit union or to a trustee or trustees or agent designated
by 2 or more credit unions, which credit union, trustee, trustees or agent is considered the policyholder, to insure members
of the credit union or credit unions for the benefit of persons other than the credit union or credit unions, trustee or trustees
or agent or any of their officials, subject to the following requirements.
[1981, c. 147, §7 (new).]
1. The members eligible for insurance are all of the members of the credit union or credit unions or all of any class or classes
thereof.
[1981, c. 147, §7 (new).]
2. The premium for the policy shall be paid either from funds of the credit union or from funds contributed by the insured
members specifically for their insurance, or from both. Except as provided in subsection 3, a policy on which no part of the
premium is to be derived from funds contributed by the insured members specifically for their insurance must insure all eligible
members, except those who reject the coverage in writing.
[1981, c. 147, §7 (new).]
3. Except as provided in section 2736-C, section 2808-B and chapter 36, an insurer may exclude or limit the coverage on any
member as to whom evidence of individual insurability is not satisfactory to the insurer.
[1999, c. 256, Pt. G, §5 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2807. Debtor groups
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2807. Debtor groups
A group of individuals may be insured under a policy issued to a creditor, or its parent holding company or to a trustee or
trustees or agent designated by 2 or more creditors, which creditor, holding company, affiliate, trustee, trustees or agent
shall be deemed the policyholder, to insure debtors of the creditor or creditors, as the case may be, all as defined and set
forth under section 2604-A, provided that the amount of indemnity payable with respect to any person insured thereunder shall
not at any time exceed the aggregate of the periodic scheduled unpaid installments, including, with respect to mortgage indebtedness,
such real estate taxes and insurance costs incident to the mortgaged property as may become due during the scheduled period
and provided that nothing in this paragraph may be construed or deemed to apply to or affect disability benefit provisions
in group credit life insurance policies as authorized under section 2604-A.
[1981, c. 698, § 109 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2808-A. Rating practices in group health insurance (REPEALED)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2808-A. Rating practices in group health insurance (REPEALED)
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2808-B. Small group health plans
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2808-B. Small group health plans
1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Carrier" means any insurance company, nonprofit hospital and medical service organization or health maintenance organization
authorized to issue small group health plans in this State. For the purposes of this section, carriers that are affiliated
companies or that are eligible to file consolidated tax returns are treated as one carrier and any restrictions or limitations
imposed by this section apply as if all small group health plans delivered or issued for delivery in this State by affiliated
carriers were issued by one carrier. For purposes of this section, health maintenance organizations are treated as separate
organizations from affiliated insurance companies and nonprofit hospital and medical service organizations.
[1991, c. 861, §2 (new).]
B. "Community rate" means the rate to be charged to all eligible groups for small group health plans prior to any adjustments
pursuant to subsection 2, paragraphs C and D.
[1991, c. 861, §2 (new).]
C. "Eligible employee" means an employee who works on a full-time basis, with a normal work week of 30 hours or more. "Eligible
employee" includes a sole proprietor, a partner of a partnership or an independent contractor, but does not include employees
who work on a temporary or substitute basis. An employer may elect to treat as eligible employees part-time employees who
work a normal work week of 10 hours or more as long as at least one employee works a normal work week of 30 hours or more.
An employer may elect to treat as eligible employees employees who retire from the employer's employment.
[1999, c. 256, Pt. P, §1 (amd).]
D. "Eligible group" means any person, firm, corporation, partnership, association or subgroup engaged actively in a business
that employed an average of 50 or fewer eligible employees during the preceding calendar year.
(1) If an employer was not in existence throughout the preceding calendar year, the determination must be based on the average
number of employees that the employer is reasonably expected to employ on business days in the current calendar year.
(2) In determining the number of eligible employees, companies that are affiliated companies or that are eligible to file
a combined tax return for purposes of state taxation are considered one employer.
(3) A group is not an eligible group if there is any one other state where there are more eligible employees than are employed
within this State and the group had coverage in that state or is eligible for guaranteed issuance of coverage in that state.
(4) An employer qualifies as an eligible group for 2-person coverage if the employer provides a carrier with the following
information demonstrating that the employer's business and employees meet the minimum qualifications for group coverage in
paragraph C:
(a) A copy of the most recent quarterly combined filing for income tax withholding and unemployment contributions, Form
941C1-ME;
(b) For an employee claimed to be an employee eligible for group coverage whose name is not listed on Form 941C1-ME, a
copy of the employer's payroll records for the most recent 3 months showing tax withholding or a wage report from a payroll
company showing wages paid to that employee for the most recent quarter with tax withholding;
(c) If an employer is exempt from filing Form 941C1-ME for group coverage, documentation of that exemption and a copy of
the employer's payroll records for the most recent 3 months showing tax withholding or a wage report from a payroll company
showing wages paid to that employee for the most recent quarter with tax withholding; or
(d) If the name of the business owner or employee does not appear on Form 941C1-ME, a copy of one of the following:
(i) Federal income tax Form Schedule C or Schedule F;
(ii) Federal income tax Form 1120S, Schedule K-1;
(iii) Federal income tax Form 1065, Schedule K-1;
(iv) A workers' compensation insurance audit or evidence of a waiver of benefits under Title 39-A;
(v) A description of operations in a commercial general liability insurance policy or equivalent insurance policy providing
coverage for the business; or
(vi) A signature card from a financial institution or credit union authorizing the employee to sign checks on a business
checking or share draft account that is at least 6 months old; a notarized affidavit from the employer describing the duties
of the employee and the average number of hours worked by the employee and attesting that the employer is not defrauding the
carrier and is aware of the consequences of committing fraud or making a material misrepresentation to the carrier, including
a loss of coverage and benefits; and, if the group coverage is purchased through a producer, a notarized affidavit from the
producer affirming the producer's belief that the employer qualifies as an eligible group for coverage.
In determining if a new business or a business that adds an owner or a new employee to payroll during the course of a year
qualifies as an eligible group for 2-person coverage under this subparagraph, the employer must submit an affidavit stating
that all employees meet the criteria in this subparagraph and that the documentation and forms required under this subparagraph
will be provided to the carrier when payroll records become available, when ownership distribution forms become available
or the first renewal date of the coverage, whichever date is earlier. A false affidavit or misrepresentation on an affidavit
submitted by an employer may result in the loss of group coverage and repayment of claims paid. This subparagraph may not
be construed to prohibit a carrier from recognizing an employer as an eligible group if the employer has not produced the
documentation required in this subparagraph.
This subparagraph applies only to an employer applying for group health insurance coverage as a 2-person group on or after
October 1, 2001.
[2003, c. 428, Pt. H, §5 (rpr).]
E. "Late enrollee" means an eligible employee or dependent who requests enrollment in a small group health plan following the
initial minimum 30-day enrollment period provided under the terms of the plan, except that, an eligible employee or dependent
is not considered a late enrollee if the eligible employee or dependent meets the requirements of section 2849-B, subsection
3, paragraph A, B, C-1 or D.
[1997, c. 777, Pt. B, §2 (amd).]
F. "Premium rate" means the rate charged to an eligible group or eligible individual for a small group health plan.
[1991, c. 861, §2 (new).]
G. "Small group health plan" means any hospital and medical expense-incurred policy; health, hospital or medical service corporation
plan contract; or health maintenance organization subscriber contract covering an eligible group. "Small group health plan"
does not include the following types of insurance:
(1) Accident;
(2) Credit;
(3) Disability;
(4) Long-term care or nursing home care;
(5) Medicare supplement;
(6) Specified disease;
(7) Dental or vision;
(8) Coverage issued as a supplement to liability insurance;
(9) Workers' compensation;
(10) Automobile medical payment; or
(11) Insurance under which benefits are payable with or without regard to fault and that is required statutorily to be contained
in any liability insurance policy or equivalent self-insurance.
[1991, c. 861, §2 (new).]
H. "Subgroup" means an employer with 50 or fewer employees within an association, a multiple employer trust, a private purchasing
alliance or any similar subdivision of a larger group covered by a single group health policy or contract.
[1997, c. 445, §13 (amd); §32 (aff).]
[2003, c. 428, Pt. H, §5 (amd).]
2. Rating practices. The following requirements apply to the rating practices of carriers providing small group health plans. This subsection
does not apply to policies issued before January 1, 1998 to eligible groups that employed, on average, 25 to 50 eligible employees
until their first renewal date on or after January 1, 1998.
A.
[2003, c. 469, Pt. E, §14 (rp).]
B. A carrier may not vary the premium rate due to the gender, health status, claims experience or policy duration of the eligible
group or members of the group.
[1993, c. 477, Pt. B, §1 (amd); Pt. F, §1 (aff).]
C. A carrier may vary the premium rate due to family membership, smoking status, participation in wellness programs and group
size. The superintendent may adopt rules setting forth appropriate methodologies regarding rate discounts pursuant to this
paragraph. Rules adopted pursuant to this paragraph are routine technical rules as defined in Title 5, chapter 375, subchapter
II-A.
[2001, c. 410, Pt. A, §3 (amd); §10 (aff).]
D. A carrier may vary the premium rate due to age, occupation or industry and geographic area only under the following schedule
and within the listed percentage bands.
(1) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed
in this State between July 15, 1993 and July 14, 1994, the premium rate may not deviate above or below the community rate
filed by the carrier by more than 50%.
(2) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed
in this State between July 15, 1994 and July 14, 1995, the premium rate may not deviate above or below the community rate
filed by the carrier by more than 33%.
(3) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed
in this State after July 15, 1995, the premium rate may not deviate above or below the community rate filed by the carrier
by more than 20%, except as provided in paragraph D-1.
[2001, c. 410, Pt. A, §4 (amd); §10 (aff).]
D-1. With respect to eligible groups that employed, on average, 25 to 50 eligible employees in the preceding calendar year, a
carrier may vary the premium rate due to age, occupation or industry and geographic area only under the following schedule
and within the listed percentage bands.
(1) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed
in this State in 1998, the premium rate may not deviate above or below the community rate filed by the carrier by more than
40%.
(2) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed
in this State in 1999, the premium rate may not deviate above or below the community rate filed by the carrier by more than
30%.
(3) For all policies, contracts or certificates that are executed, delivered, issued for delivery, continued or renewed
in this State after January 1, 2000, the premium rate may not deviate above or below the community rate filed by the carrier
by more than 20%.
[2001, c. 410, Pt. A, §5 (amd); §10 (aff).]
D-2. Notwithstanding the requirements of paragraph D, rates with respect to employees whose work site is not in this State may
be based on area adjustment factors appropriate to that location.
[RR 1997, c. 1, §22 (ral).]
E. The superintendent may authorize a carrier to establish a separate community rate for an association group organized pursuant
to section 2805-A or a trustee group organized pursuant to section 2806, as long as association group membership or eligibility
for participation in the trustee group is not conditional on health status, claims experience or other risk selection criteria
and all small group health plans offered by the carrier through that association or trustee group:
(1) Are otherwise in compliance with the premium rate requirements of this subsection; and
(2) Are offered on a guaranteed issue basis to all eligible employers that are members of the association or are eligible
to participate in the trustee group except that a professional association may require that a minimum percentage of the eligible
professionals employed by a subgroup be members of the association in order for the subgroup to be eligible for issuance or
renewal of coverage through the association. The minimum percentage must not exceed 90%. For purposes of this subparagraph,
"professional association" means an association that:
(a) Serves a single profession that requires a significant amount of education, training or experience or a license or certificate
from a state authority to practice that profession;
(b) Has been actively in existence for 5 years;
(c) Has a constitution and bylaws or other analogous governing documents;
(d) Has been formed and maintained in good faith for purposes other than obtaining insurance;
(e) Is not owned or controlled by a carrier or affiliated with a carrier;
(g) Has a least 1,000 members if it is a national association; 200 members if it is a state or local association;
(h) All members and dependents of members are eligible for coverage regardless of health status or claims experience; and
(i) Is governed by a board of directors and sponsors annual meetings of its members.
Producers may only market association memberships, accept applications for membership or sign up members in the professional
association where the individuals are actively engaged in or directly related to the profession represented by the professional
association.
[2001, c. 258, Pt. E, §4 (amd).]
F. Premium rates charged to a private purchasing alliance, as defined by chapter 18-A, may be reduced in accordance with rules
adopted pursuant to that chapter.
[1995, c. 673, Pt. A, §6 (new).]
G.
[2003, c. 469, Pt. E, §15 (rp).]
[2003, c. 469, Pt. E, §§14, 15 (amd).]
2-A. Rate filings. A carrier offering small group health plans shall file with the superintendent the community rates for each plan and every
rate, rating formula and classification of risks and every modification of any formula or classification that it proposes
to use.
A. Every filing must state the effective date of the filing. Every filing must be made not less than 60 days in advance of
the stated effective date, unless the 60-day requirement is waived by the superintendent. The effective date may be suspended
by the superintendent for a period of time not to exceed 30 days. In the case of a filing that meets the criteria in subsection
2-B, paragraph E, the superintendent may suspend the effective date for a longer period not to exceed 30 days from the date
the carrier satisfactorily responds to any reasonable discovery requests.
[2003, c. 469, Pt. E, §16 (new).]
B. A filing and supporting information are public records except as provided by Title 1, section 402, subsection 3 and become
part of the official record of any hearing held pursuant to subsection 2-B, paragraphs B or F.
[2003, c. 469, Pt. E, §16 (new).]
C. Rates for small group health plans must be filed in accordance with this section and subsections 2-B and 2-C for premium
rates effective on or after July 1, 2004, except that the filing of rates for small group health plans are not required to
account for any savings offset payment or any recovery of that offset payment pursuant to subsection 2-B, paragraph D and
section 6913 for rates effective before July 1, 2005.
[2003, c. 469, Pt. E, §16 (new).]
[2003, c. 469, Pt. E, §16 (new).]
2-B. Rate review and hearings. Except as provided in subsection 2-C, rate filings are subject to this subsection.
A. The superintendent shall disapprove any premium rates filed by any carrier, whether initial or revised, for a small group
health plan unless it is anticipated that the aggregate benefits estimated to be paid under all the small group health plans
maintained in force by the carrier for the period for which coverage is to be provided will return to policyholders at least
75% of the aggregate premiums collected for those policies, as determined in accordance with accepted actuarial principles
and practices and on the basis of incurred claims experience and earned premiums. For the purposes of this calculation, any
savings offset payments paid pursuant to section 6913 must be treated as incurred claims.
[2003, c. 469, Pt. E, §16 (new).]
B. If at any time the superintendent has reason to believe that a filing does not meet the requirements that rates not be excessive,
inadequate or unfairly discriminatory or that the filing violates any of the provisions of chapter 23, the superintendent
shall cause a hearing to be held. Hearings held under this subsection must conform to the procedural requirements set forth
in Title 5, chapter 375, subchapter 4. The superintendent shall issue an order or decision within 30 days after the close
of the hearing or of any rehearing or reargument or within such other period as the superintendent for good cause may require,
but not to exceed an additional 30 days. In the order or decision, the superintendent shall either approve or disapprove
the rate filing. If the superintendent disapproves the rate filing, the superintendent shall establish the date on which
the filing is no longer effective, specify the filing the superintendent would approve and authorize the insurer to submit
a new filing in accordance with the terms of the order or decision.
[2003, c. 469, Pt. E, §16 (new).]
C. When a filing is not accompanied by the information upon which the carrier supports the filing or the superintendent does
not have sufficient information to determine whether the filing meets the requirements that rates not be excessive, inadequate,
unfairly discriminatory or not in compliance with section 6913, the superintendent shall require the carrier to furnish the
information upon which it supports the filing.
[2003, c. 469, Pt. E, §16 (new).]
D. A carrier that adjusts its rate shall account for the savings offset payment or any recovery of that savings offset payment
in its experience consistent with this section and section 6913.
[2003, c. 469, Pt. E, §16 (new).]
E. Any filing of rates, rating formulas and modifications that satisfies the criteria set forth in this paragraph is subject
to the provisions of paragraph F:
(1) The proposed rate for any group or subgroup does not include a unit cost change that exceeds the index of inflation
multiplied by 1.5, excluding any approved rate differential based on age. For the purposes of this subparagraph, "index of
inflation" means the rate of increase in medical costs for a section of the United States selected by the superintendent that
includes this State for the most recent 12-month period immediately preceding the date of the filing for which data are available;
and
(2) The carrier demonstrates in accordance with generally accepted actuarial principles and practices consistently applied
that, as of a date no more than 210 days prior to the filing, the ratio of benefits incurred to premiums earned averages no
less than 78% for the previous 36-month period.
[2003, c. 469, Pt. E, §16 (new).]
F. Any rate hearing conducted with respect to filings that meet the criteria in paragraph E is subject to this paragraph.
(1) A person requesting a hearing shall provide the superintendent with a written statement detailing the circumstances
that justify a hearing, notwithstanding the satisfaction of the criteria in paragraph E.
(2) If the superintendent decides to hold a hearing, the superintendent shall issue a written statement detailing the circumstances
that justify a hearing, notwithstanding the satisfaction of the criteria in paragraph E.
(3) In any hearing conducted under this paragraph, the bureau and any party asserting that the rates are excessive have
the burden of establishing that the rates are excessive. The burden of proving that rates are adequate, not unfairly discriminatory
and in compliance with the requirements of section 6913 remains with the carrier.
[2003, c. 469, Pt. E, §16 (new).]
[2003, c. 469, Pt. E, §16 (new).]
2-C. Optional guaranteed loss ratio. Notwithstanding subsection 2-B, at the carrier's option, rate filings for a credible block of small group health plans may
be filed in accordance with this subsection instead of subsection 2-B. Rates filed in accordance with this subsection are
filed for informational purposes.
A. A block of small group health plans is considered credible if the anticipated average number of members during the period
for which the rates will be in effect is at least 1,000 or if it meets credibility standards adopted by the superintendent
by rule. The rate filing must state the anticipated average number of members during the period for which the rates will be
in effect and the basis for the estimate. If the superintendent determines that the number of members is likely to be less
than 1,000 and the block does not satisfy any alternative credibility standards adopted by rule, the filing is subject to
subsection 2-B, except as provided in paragraph A-1.
[2005, c. 121, Pt. E, §1 (amd).]
A-1. A carrier that elected to file rates in accordance with this subsection prior to September 1, 2004 may continue to file rates
in accordance with this subsection as long as the anticipated number of member months for a 12-month period is at least 1,000.
[2005, c. 121, Pt. E, §2 (new).]
B. On an annual schedule as determined by the superintendent, the carrier shall file a report with the superintendent showing
aggregate earned premiums and incurred claims for the period the rates were in effect. Incurred claims must include claims
paid to a date 6 months after the end of the annual reporting period determined by the superintendent and an estimate of unpaid
claims. The report must state how the unpaid claims estimate was determined.
[2003, c. 469, Pt. E, §16 (new).]
C. If incurred claims were less than 78% of aggregate earned premiums over a continuous 36-month period, the carrier shall
refund a percentage of the premium to the current in-force policyholder. For the purposes of calculating this loss-ratio
percentage, any savings offset payments paid pursuant to section 6913 must be treated as incurred claims. The excess premium
is the amount of premium above that amount necessary to achieve a 78% loss ratio for all of the carrier's small group policies
during the same 36-month period. The refund must be distributed to policyholders in an amount reasonably calculated to correspond
to the aggregate experience of all policyholders holding policies having similar benefits. The total of all refunds must equal
the excess premiums.
(1) For determination of loss-ratio percentages in 2005, actual aggregate incurred claims expenses include expenses incurred
in 2005 and projected expenses for 2006 and 2007. For determination of loss-ratio percentages in 2006, actual incurred claims
expenses include expenses in 2005 and 2006 and projected expenses for 2007.
(2) The superintendent may waive the requirement for refunds during the first 3 years after the effective date of this subsection.
[2003, c. 469, Pt. E, §16 (new).]
D. The superintendent may require further support for the unpaid claims estimate and may require refunds to be recalculated
if the estimate is found to be unreasonably large.
[2003, c. 469, Pt. E, §16 (new).]
E. The superintendent may adopt rules setting forth appropriate methodologies regarding reports, refunds and credibility standards
pursuant to this subsection. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5,
chapter 375, subchapter 2-A.
[2003, c. 469, Pt. E, §16 (new).]
[2005, c. 121, Pt. E, §§1, 2 (amd).]
3. Coverage for late enrollees. In providing coverage to late enrollees, small group health plan carriers are allowed to exclude or limit coverage for a
late enrollee subject to the limitations set forth in section 2849-B, subsection 3.
[1999, c. 256, Pt. L, §1 (amd).]
4. Guaranteed issuance and guaranteed renewal. Carriers providing small group health plans must meet the following requirements on issuance and renewal.
A. Any small group health plan offered to any eligible group or subgroup must be offered to all eligible groups that meet the
carrier's minimum participation requirements, which may not exceed 75%, to all eligible employees and their dependents in
those groups. In determining compliance with minimum participation requirements, eligible employees and their dependents
who have existing health care coverage may not be considered in the calculation. If an employee declines coverage because
the employee has other coverage, any dependents of that employee who are not eligible under the employee's other coverage
are eligible for coverage under the small group health plan. A carrier may deny coverage under a managed care plan, as defined
by section 4301-A:
(1) To employers who have no employees who live, reside or work within the approved service area of the plan; and
(2) To employers if the carrier has demonstrated to the superintendent's satisfaction that:
(a) The carrier does not have the capacity to deliver services adequately to additional enrollees within all or a designated
part of its service area because of its obligations to existing enrollees; and
(b) The carrier is applying this provision uniformly to individuals and groups without regard to any health-related factor.
A carrier that denies coverage in accordance with this subparagraph may not enroll individuals residing within the area subject
to denial of coverage, or groups or subgroups within that area for a period of 180 days after the date of the first denial
of coverage.
[RR 2001, c. 1, §32 (cor).]
B. Renewal is guaranteed under section 2850-B.
[1997, c. 445, §17 (rpr); §32 (aff).]
[RR 2001, c. 1, §32 (cor).]
5. Cessation of business.
[1997, c. 445, §18 (rp); §32 (aff).]
6. Fair marketing standards. Carriers providing small group health plans must meet the following standards of fair marketing.
A. Each carrier must actively market small group health plan coverage to eligible groups in this State.
[2001, c. 410, Pt. A, §6 (amd).]
B. A carrier or representative of the carrier may not directly or indirectly engage in the following activities:
(1) Encouraging or directing eligible groups to refrain from filing an application for coverage with the carrier because
of any of the rating factors listed in subsection 2; and
(2) Encouraging or directing eligible groups to seek coverage from another carrier because of any of the rating factors
listed in subsection 2.
[1991, c. 861, §2 (new).]
C. A carrier may not directly or indirectly enter into any contract, agreement or arrangement with a representative of the
carrier that provides for or results in the compensation paid to the representative for the sale of a small group health plan
to be varied because of the rating factors listed in subsection 2. A carrier may enter into a compensation arrangement that
provides compensation to a representative of the carrier on the basis of percentage of premium, provided that the percentage
does not vary because of the rating factors listed in subsection 2.
[1991, c. 861, §2 (new).]
D. A carrier may not terminate, fail to renew or limit its contract or agreement of representation with a representative for
any reason related to the rating factors listed in subsection 2.
[1991, c. 861, §2 (new).]
E. A carrier or representative of the carrier may not induce or otherwise encourage an eligible group to separate or otherwise
exclude an employee from small group health plan coverage or benefits.
[1991, c. 861, §2 (new).]
F. Denial by a carrier of an application for coverage from an eligible group must be in writing and must state the reason or
reasons for the denial.
[1991, c. 861, §2 (new).]
G. The superintendent may establish rules setting forth additional standards to provide for the fair marketing and broad availability
of small group health plans in this State.
[1991, c. 861, §2 (new).]
H. A violation of this section by a carrier or a representative of the carrier is an unfair trade practice under chapter 23.
If a carrier enters into a contract, agreement or other arrangement with a 3rd-party administrator to provide administrative,
marketing or other services related to the offering of small group health plans in this State, the 3rd-party administrator
is subject to this section as if it were a carrier.
[1991, c. 861, §2 (new).]
I. Notwithstanding any other provision of this section, a carrier may choose whether it will offer to groups having only one
member coverage under the carrier's individual health policies offered to other individuals in this State in accordance with
section 2736-C or coverage under a small group health plan in accordance with this section, or both, but the carrier need
not offer to groups of one both small group and individual health coverage.
[1993, c. 477, Pt. B, §3 (new); Pt. F, §1 (aff).]
[2001, c. 410, Pt. A, §6 (amd).]
7. Applicability. This section applies to all policies, plans, contracts and certificates executed, delivered, issued for delivery, continued
or renewed in this State on or after July 15, 1993. For purposes of this section, all contracts are deemed renewed no later
than the next yearly anniversary date of the policy, plan, contract or certificate.
[1995, c. 332, Pt. D, §4 (amd).]
8. Standardized plans.
[2001, c. 410, Pt. A, §7 (rp).]
9. Reinsurance mechanism. Small group carriers, except nonprofit hospital and medical service organizations, may form a reinsurance pool for the purpose
of reinsuring small group risks. This pool may not become operative until the superintendent has approved a plan of operation.
The superintendent may approve a plan only after the superintendent determines that the plan is in the public interest and
is consistent with this section. The participants in the plan of operation of the pool shall guarantee, without limitation,
the solvency of the pool. That guarantee constitutes a permanent financial obligation of each participant on a pro rata basis.
[1993, c. 325, §1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2808. Other groups
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2808. Other groups
Group health insurance offered to a resident of this State under a group health insurance policy issued to a group other than
one described in sections 2804 to 2807-A is subject to the following requirements.
[1981, c. 147, §8 (rpr).]
1. No group health insurance policy may be delivered in this State, pursuant to this section, unless the superintendent finds
that:
A. The policyholder is a bona fide group formed for purposes other than procurement of insurance;
[1987, c. 476, §4 (amd).]
B. The issuance of the group policy would be actuarially sound;
[1981, c. 147, §8 (new).]
C. The issuance of the group policy would result in economies of acquisition or administration; and
[1987, c. 476, §4 (amd).]
D. The benefits are reasonable in relation to the premiums charged.
[1981, c. 147, §8 (new).]
[1987, c. 476, §4 (amd).]
2. No group health insurance coverage may be offered in this State, pursuant to this section, by an insurer under a policy
issued in another state, unless the superintendent has made a determination that the requirements of subsection 1, paragraphs
A, B, C and D have been met.
[1987, c. 476, §5 (rpr).]
2-A. Notwithstanding subsections 1 and 2, an employee leasing company registered pursuant to Title 32, chapter 125 qualifies
as an eligible group for purposes of the purchase of group health insurance as provided in this section.
[1997, c. 393, Pt. A, §26 (amd).]
3. The premium for the policy shall be paid either from the policyholder's funds or from funds contributed by the covered persons,
or from both.
[1981, c. 147, §8 (new).]
4. Except as provided in section 2736-C, section 2808-B and chapter 36, an insurer may exclude or limit the coverage on any
person as to whom evidence of individual insurability is not satisfactory to the insurer.
[1999, c. 256, Pt. G, §6 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2809-A. Conversion on termination of policy or eligibility
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2809-A. Conversion on termination of policy or eligibility
1. A group policy issued prior to January 1, 1996, that provides hospital, surgical or major medical expense insurance or any
combination thereof, other than a policy that provides benefits for specific diseases or accidental injuries only, must contain
a provision that if the insurance on an employee or member ceases because of termination of employment or termination of the
policy or any portion of a policy, and the person has been continuously insured for a period of at least 3 months under the
group policy or under the group policy and any prior group policy or contract providing similar benefits that it replaces,
that person is entitled to have issued to that person by the insurer, without evidence of insurability, an individual policy
or, at the insurer's option, a group certificate of health insurance, provided that application is made and the first premium
paid to the insurer within 90 days after that termination. At the option of the employee or member, the converted policy
may cover the employee or member, the employee or member and the employee or member's dependents or the dependents of the
employee or member if, in the latter 2 cases, the dependents have been covered for a period of at least 3 months under the
group policy, unless the dependent persons were not eligible for coverage until after the beginning of the 3-month period.
The insurer has the option to provide the required coverage upon conversion through either a group or individual policy,
and may issue a separate converted policy to cover any dependent. An insurer is not required to provide a conversion privilege
if termination of insurance under the group policy occurred because the employee or member failed to pay any required contribution
or if any discontinued group coverage is replaced by continuous and substantially similar group coverage within 31 days.
[1995, c. 332, Pt. A, §8 (amd).]
1-A. Notification of cancellation. An insurer may not cancel or refuse to renew any policy for hospital, surgical, dental or major medical expense insurance
until the insurer has provided by first class mail at least 10 days' prior notification according to this section. The notice
must include the date of cancellation of coverage and, if applicable, the time period for exercising policy conversion rights.
The notice also must include an explanation of any applicable grace period. Notification is not required when the insurer
has received written notice from the group policyholder that replacement coverage has been obtained.
A. Notice must be mailed to the group policyholder or subgroup sponsor.
[1995, c. 625, Pt. A, §25 (rpr).]
B.
[2003, c. 156, §2 (rp).]
B-1. At the time of notification under paragraph A, notice must be mailed to the certificate holder at the last address provided
to the insurer by the subgroup sponsor, the group policyholder or the certificate holder. If the insurer does not have an
address on file for the certificate holder, the notice must be mailed to the office of the subgroup sponsor, if any, or the
group policy holder. The notice must also include information to the certificate holder about the availability of individual
coverage as described in subsection 1-B.
[2003, c. 428, Pt. B, §2 (amd).]
C.
[2003, c. 428, Pt. B, §2 (rp).]
[2003, c. 428, Pt. B, §2 (amd).]
1-B. Notification of availability of individual coverage. An insurer must provide forms to group policyholders and certificate holders as required in subsection 1-A for the purpose
of informing terminating group members of their right to purchase any individual health plan available in this State. An
adequate supply of forms must be provided to each group policyholder when the policy is issued and at least annually thereafter.
The superintendent may prescribe the content of the form by routine technical rule pursuant to Title 5, chapter 375, subchapter
2-A. The form must include at least the following:
A. A statement that all state residents not eligible for Medicare have a right to purchase any individual health plan available
in this State;
[1997, c. 604, Pt. B, §3 (new).]
B. A statement that in order to avoid a gap in coverage, the individual should apply for individual coverage prior to termination
of group coverage;
[1997, c. 604, Pt. B, §3 (new).]
C. A statement that if more than 90 days pass between the time the group coverage ends and the time individual coverage begins,
the individual coverage may exclude preexisting conditions for one year; and
[1997, c. 604, Pt. B, §3 (new).]
D. A statement that information concerning individual coverage is available from the Bureau of Insurance. The bureau's toll-free
telephone number must also be provided.
[1997, c. 604, Pt. B, §3 (new).]
[2003, c. 156, §4 (amd).]
2. If a conversion privilege is applicable pursuant to subsection 1, it must also be available:
A. Upon the death of an employee or member, to the surviving spouse with respect to the spouse and the children whose coverage
terminates by reason of that death, or if there is no surviving spouse to each surviving child whose coverage so terminates.
If the group policy provides for continuation of dependents' coverage upon the death of the employee or member, the conversion
privilege must be made available at the end of that continuation;
[1995, c. 332, Pt. A, §10 (amd).]
B. To the spouse of a member or employee upon termination of coverage by reason of ceasing to be a qualified family member
under the group policy whether by divorce or otherwise, whether or not the employee or member remains insured, with respect
to the spouse and the children whose coverage terminates at the same time;
[1981, c. 606, §2 (new).]
C. To a child upon termination of coverage by reason of ceasing to be a qualified family member under the group policy if a
conversion privilege is not otherwise provided with respect to that child in this subsection; or
[1995, c. 332, Pt. A, §10 (amd).]
D. To an employee or member whose coverage would otherwise continue under the group policy upon retirement prior to eligibility
for coverage under Medicare,"United States Insurance for the Aged Act," Title XVIII of the Social Security Amendments of 1965,
Public Law 89-97, as amended, at the option of that employee or member in lieu of continued coverage under the group policy.
[1981, c. 606, §2 (new).]
[1995, c. 332, Pt. A, §10 (amd).]
3. The insurer shall not be required to issue a converted policy covering an otherwise eligible person:
A. If:
(1) That person is eligible for Medicare; or
(2) That person:
(a) Is covered for similar benefits by any other plan or program;
(b) Is eligible for similar benefits under any group coverage arrangement whether on an insured or uninsured basis; or
(c) Has similar benefits provided for or available to him pursuant to requirements of any state or federal law; and
[1981, c. 606, §2 (new).]
B. The benefits as described in paragraph A, subparagraph 2, division (a) (b) or (c) provided for or available to the person
together with the benefits provided by the converted policy would result in overinsurance according to standards which have
been filed by the insurer prior to denial of coverage and approved by the superintendent.
[1981, c. 606, §2 (new).]
[1981, c. 606, §2 (new).]
3-A. Policies issued or renewed on or after January 1, 1996. An insurer that offers individual health plans pursuant to section 2736-C is permitted, but not required, to include a conversion
privilege in group policies issued or renewed on or after January 1, 1996. If the insurer does include a conversion privilege
in those policies, individuals exercising these rights must be offered a choice of any individual health plan offered by the
insurer. An insurer that does not offer individual health plans pursuant to section 2736-C may not include a conversion privilege
in group policies issued or renewed on or after January 1, 1996.
[1995, c. 332, Pt. A, §11 (new).]
4. The premium on the converted policy must be determined in accordance with premium rates applicable to individually underwritten
standard risks for the age and class of risk of each person to be covered and the type and amount of insurance provided.
Experience under converted policies is not an acceptable basis for establishing rates for converted policies, except to the
extent permitted by rules adopted by the superintendent.
The superintendent may establish maximum rates by rule for standard benefit options.
Maximum rates do not apply if all of the following conditions are met:
A. Conversion is provided through a form that is also issued to members of the general public applying for an individual health
plan pursuant to section 2736-C;
[1995, c. 332, Pt. A, §12 (amd).]
B. The rates for that form comply with section 2736-C; and
[1995, c. 332, Pt. A, §12 (amd).]
C. The rates have been filed pursuant to section 2736.
[1991, c. 668, §2 (new).]
[1995, c. 332, Pt. A, §12 (amd).]
5. The effective date of the converted policy shall be the date of termination of the individual's insurance under the group
policy.
[1981, c. 606, §2 (new).]
6. A converted policy issued under this section must conform to rules adopted by the superintendent. These rules must ensure
that continuity of coverage with similar benefits as determined by the superintendent is offered. The rules must also specify
plans with more limited benefits that must be offered, but may not require an insurer to provide benefits in excess of those
provided under the group policy from which conversion is made.
[1991, c. 668, §2 (amd).]
7. Notice. Notice of the conversion privilege, if one is applicable, must be included in each certificate of coverage.
[1995, c. 332, Pt. A, §13 (amd).]
8. A converted policy issued pursuant to this section which is delivered outside this State may be on such form as the insurer
may then be offering for that conversion in the jurisdiction where the delivery is to be made.
[1981, c. 606, §2 (new).]
9. Refusal to renew. A policy issued pursuant to the conversion privilege provided by this section may provide that the insurer may refuse to
renew the policy or coverage of any person insured only as permitted by section 2736-C.
A.
[1995, c. 332, Pt. A, §13 (rp).]
B.
[1995, c. 332, Pt. A, §13 (rp).]
[1995, c. 332, Pt. A, §13 (amd).]
10. Additional conversion period for injured workers.
[1995, c. 332, Pt. A, §14 (rp).]
11. Continued group coverage; certain circumstances. Notwithstanding this section, if the termination of an individual's group insurance coverage is a result of the member
or employee being temporarily laid off or losing employment because of an injury or disease that the employee claims to be
compensable under former Title 39 or Title 39-A, the insurer shall allow the member or employee to elect, within the time
period prescribed by paragraph B, to continue coverage under the group policy at no higher level than the level of benefits
or coverage received by the employee immediately before termination and at the member's or employee's expense or, at the member's
or employee's option, to convert to a policy of individual coverage without evidence of insurability in accordance with this
section.
A. For the purposes of this subsection, the term "member or employee" includes only those persons who have been a member or
employee for at least 6 months.
[1985, c. 684, §2 (new).]
B.
[1989, c. 447, §2 (rp).]
B-1. The member or employee has 31 days from the termination of coverage in which to elect and make the initial payment under
this subsection.
[1991, c. 885, Pt. E, §30 (amd); §47 (aff).]
C. An insurer is not required to continue coverage under a group policy if the member or employee meets the conditions set
out in subsection 3, paragraph A.
[1985, c. 684, §2 (new).]
D. The payment amount for continued group coverage under this subsection may not exceed 102% of the group rate in effect for
a group member, including an employer's contribution, if any.
[1987, c. 25, §3 (amd).]
E. At the option of the member or employee, the continued group coverage may cover the member or employee, the member or employee
and any dependents or only the dependents of the member or employee; provided that, in the latter 2 cases, the dependents
have been covered for a period of at least 3 months under the group policy, unless the dependents were not eligible for coverage
until after the beginning of the 3-month period.
[1989, c. 447, §2 (amd).]
F. Except as provided in paragraph G, coverage provided under this section continues and may not be terminated until one year
from the last day of work.
[1991, c. 885, Pt. E, §30 (amd); §47 (aff).]
G. Coverage provided under this section may be terminated sooner than provided under paragraph F if:
(1) The member or employee fails to make timely payment of a required premium amount;
(2) The member or employee becomes eligible for coverage under another group policy; or
(3) The Workers' Compensation Board determines that the injury or disease that entitles the employee to continue coverage
under this section is not compensable under Title 39-A.
[1991, c. 885, Pt. E, §30 (amd); §47 (aff).]
H. At the expiration of any continued group coverage obtained under this subsection, the member or employee has the same conversion
privileges as otherwise granted under this section.
[1985, c. 684, §2 (new).]
I. This subsection may not be construed to:
(1) Prevent members or employees from negotiating for or receiving greater continued coverage of group insurance than is
provided in this subsection;
(2) Require coverage beyond the time limit set in paragraph F; or
(3) Permit an employee to increase the level of benefits or coverage that the employee received immediately before the termination
of the employee's coverage.
[1991, c. 885, Pt. E, §30 (amd); §47 (aff).]
J. This subsection does not apply to any group policy subject to the United States Consolidated Omnibus Budget Reconciliation
Act, Public Law 99-272, Title X, Private Health Insurance Coverage, Sections 10001 to 10003.
[1987, c. 25, §4 (new).]
[1991, c. 885, Pt. E, §30 (amd); §47 (aff).]
12. This section applies to all policies issued in other states to the extent they cover employees whose primary workplace is
in this State.
[1991, c. 668, §3 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2809. Coverage of family, dependents; continuation of coverage
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2809. Coverage of family, dependents; continuation of coverage
1. Any policy of group health insurance issued pursuant to sections 2804 (employee groups), 2805 (labor union groups), 2805-A
(association groups), 2806 (trustee groups), 2807-A (credit union groups) or 2808 (other groups) may include coverage for
members of the family or dependents of individuals otherwise insured in such groups.
[1981, c. 147, § 9 (amd).]
1-A. Any such policy of group health insurance that provides coverage for family members or dependents of individuals in the
insured group may not define the terms "family" or "dependent" to exclude from coverage those minor children of any covered
individual who do not reside with that individual. Insurers must comply with 42 United States Code, Section 1396g-1.
[1995, c. 418, Pt. C, §3 (amd).]
2. Any group health insurance policy which contains provisions for the payment by the insurer of benefits for expenses incurred
on account of hospital, nursing, medical or surgical services for members of the family or dependents of an individual in
the insured group may provide for the continuation of such benefit provisions, or any part or parts thereof, after the death
of such individual.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2810. Group health insurance payments; beneficiaries
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2810. Group health insurance payments; beneficiaries
The benefits payable under any policy or contract of group health insurance shall be payable to the employee or other insured
member of the group or to some beneficiary or beneficiaries designated by him, other than the employer or the association
or any officer thereof as such; but if there is no designated beneficiary as to all or any part of the insurance at the death
of the employee or member, then the amount of insurance payable for which there is no designated beneficiary shall be payable
to the estate of the employee or member, except that the insurer may in such case, at its option, pay such insurance to any
one or more of the following surviving relatives of the employee or member: Wife, husband, mother, father, child or children,
brothers or sisters; and except that payment of benefits for expenses incurred on account of hospitalization or medical or
surgical aid, as provided in section 2811, may be made by the insurer to the hospital or other person or persons furnishing
such aid. Payment so made shall discharge the insurer's obligation with respect to the amount of insurance so paid.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2811. Payment of expenses
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2811. Payment of expenses
Any policy or contract of group health insurance may include provisions for the payment by the insurer of benefits for expenses
incurred, by the employee or other member of the insured group, on account of hospitalization or medical or surgical aid for
himself, his spouse, his child or children, or other persons chiefly dependent upon him for support and maintenance.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2812-A. Dividends and experience refunds
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2812-A. Dividends and experience refunds
The following requirements apply to all group health insurance with the exception of insurance in which the policyholder is
subject to the fiduciary standards of the federal Employee Retirement Income Security Act of 1974, ERISA, 29 United States
Code, Section 1001-1381 (1975).
[1991, c. 200, Pt. D, §4 (new).]
1. Refunds. The amount by which any dividend, experience refund or rate reduction exceeds the amount of premium contributed by the group
policyholder for the same period must be refunded to the employees, members or debtors in proportion to their premium contributions
for that period, except as provided in subsection 2.
[1991, c. 200, Pt. D, §4 (new).]
2. Refund amounts less than $25 per employee, member or debtor. If the refunds required by subsection 1 would average less than $25 per employee, member or debtor, then the group policyholder
may request approval from the superintendent to apply those amounts in a different manner. The superintendent shall approve
the request if, in the superintendent's opinion, the manner of application proposed would be for the sole benefit of insured
employees, members or debtors.
[1991, c. 200, Pt. D, §4 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2812. Readjustment of premium rate (REPEALED)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2812. Readjustment of premium rate (REPEALED)
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2813. "Blanket health insurance" defined
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2813. "Blanket health insurance" defined
Blanket health insurance is hereby declared to be that form of health insurance covering groups of persons as enumerated in
one of the following paragraphs:
[1969, c. 132, § 1 (new).]
1. Under a policy or contract issued to any common carrier or to any operator, owner or lessee of a means of transportation,
who or which shall be deemed the policyholder, covering a group of persons who may become passengers defined by reference
to their travel status on such common carrier or such means of transportation.
[1969, c. 132, § 1 (new).]
2. Under a policy or contract issued to an employer, who shall be deemed the policyholder, covering any group of employees,
dependents or guests, defined by reference to specified hazards incident to an activity or activities or operations of the
policyholder.
[1969, c. 132, § 1 (new).]
3. Under a policy or contract issued to a college, school or other institution of learning, a school district or districts,
or school jurisdictional unit, or to the head, principal or governing board of any such educational unit, who or which shall
be deemed the policyholder, covering students, teachers, or employees.
[1969, c. 132, § 1 (new).]
4. Under a policy or contract issued to any religious, charitable, recreational, educational, or civic organization, or branch
thereof, which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified
hazards incident to an activity or activities or operations sponsored or supervised by such policyholder.
[1969, c. 132, § 1 (new).]
5. Under a policy or contract issued to a sports team, camp or sponsor thereof, which shall be deemed the policyholder, covering
members, campers, employees, officials or supervisors.
[1969, c. 132, § 1 (new).]
6. Under a policy or contract issued to any volunteer fire department, first aid, civil defense, or other such volunteer organization,
which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified hazards
incident to an activity or activities or operations sponsored or supervised by such policyholder.
[1969, c. 132, § 1 (new).]
7. Under a policy or contract issued to a newspaper or other publisher, which shall be deemed the policyholder, covering its
carriers.
[1969, c. 132, § 1 (new).]
8. Under a policy or contract issued to an association, including a labor union, which has a constitution and bylaws and which
has been organized and is maintained in good faith for purposes other than that of obtaining insurance, which shall be deemed
the policyholder, covering any group of members or participants defined by reference to specified hazards incident to an activity
or activities or operations sponsored or supervised by such policyholder.
[1969, c. 132, § 1 (new).]
9. Under a policy or contract issued to cover any other risk or class of risks which, in the discretion of the superintendent,
may be properly eligible for blanket health insurance. The discretion of the superintendent may be exercised on an individual
risk basis or class of risks, or both.
[1973, c. 585, § 12 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2814. Blanket health insurance -- payments; beneficiaries
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2814. Blanket health insurance -- payments; beneficiaries
All benefits under any blanket health insurance policy shall be payable to the person insured, or to his designated beneficiary
or beneficiaries, or to his estate, as shall be specified in the policy, except that if the person insured be a minor, such
benefits may be made payable to his parent, guardian or other person actually supporting him, or to a person or persons chiefly
dependent upon him for support and maintenance.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2815. Legal liability of policyholders
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2815. Legal liability of policyholders
Nothing contained in this chapter shall be deemed to affect the legal liability of policyholders for the death of or injury
to any member of any such group.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2816. Requirements
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2816. Requirements
No policy of group or blanket health insurance shall, except as provided in section 2829, be delivered or issued for delivery
in this State, unless the policy contains in substance each and all of the provisions set forth in sections 2817 to 2828,
or provisions which in the opinion of the superintendent are more favorable to the holders of such certificates or not less
favorable to the holders of such certificates and more favorable to policyholders. Insurers offering policies under this chapter
shall offer to certificate holders the right of review and arbitration set forth in section 2747, subsection 1, with respect
to denials of medical expense reimbursement benefits based upon the grounds set forth in section 2747, subsection 2, except
that the requirement of section 2747, subsection 1 shall not apply to certificate holders in groups subject to the United
States Employee Retirement Income Security Act of 1974, Public Law 93-406, as amended, or to any policy or certificate holder
to whom the insurer voluntarily extends a review similar to that which it provides to persons insured under group policies
subject to that Act.
[1981, c. 698, § 110 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2817. Applicant's statements; waivers, amendments
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2817. Applicant's statements; waivers, amendments
There shall be a provision that no statement made by the applicant for insurance shall avoid the insurance or reduce benefits
thereunder unless contained in the written application signed by the applicant; and a provision that no agent has authority
to change the policy or to waive any of its provisions; and that no change in the policy shall be valid unless approved by
an officer of the insurer and evidenced by indorsement on the policy, or by amendment to the policy signed by the policyholder
and the insurer.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2818. Statements in application
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2818. Statements in application
There shall be a provision that all statements contained in any such application for insurance shall be deemed representations
and not warranties.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2819. New employees, members
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2819. New employees, members
There shall be a provision that all new employees or new members, as the case may be, in the groups or classes eligible for
such insurance must be added to such groups or classes for which they are respectively eligible.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2820. Renewal of policy
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2820. Renewal of policy
There shall be a provision stating the conditions under which the insurer may decline to renew the policy.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2821. Individual certificates
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2821. Individual certificates
Except in the case of blanket health insurance, a provision that the insurer shall issue to the policyholder, for delivery
to each member of the insured group, an individual certificate or printed information setting forth in summary form a statement
of the essential features of the insurance coverage of such employee or such member and in substance the provisions of sections
2821 to 2828. The insurer shall also provide for distribution by the policyholder to each member of the insured group a statement,
where applicable, setting forth to whom the benefits under such policy are payable. If dependents are included in the coverage,
only one certificate or printed summary need be issued for each family unit.
[1975, c. 183, § 2 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2822. Age limits
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2822. Age limits
There shall be a provision specifying the ages, if any there be, to which the insurance provided therein shall be limited;
and the ages, if any there be, for which additional restrictions are placed on benefits and the additional restrictions placed
on the benefits at such ages.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2823-A. Explanation and notice to parent of minor
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2823-A. Explanation and notice to parent of minor
If the insured is a minor under 18 years of age, and if the insurer is so requested by either of the minor's parents, the
insurer shall provide that parent with:
[1989, c. 556, Pt. D, §3 (new).]
1. Payment or denial of claim. An explanation of the payment or denial of any claim filed on behalf of the insured minor;
[1989, c. 556, Pt. D, §3 (new).]
2. Change in terms and conditions. An explanation of any proposed change in the terms and conditions of the policy; or
[1989, c. 556, Pt. D, §3 (new).]
3. Notice of lapse. Reasonable notice that the policy may lapse, but only if the parent has provided the insurer with the address at which the
parent may be notified.
[1989, c. 556, Pt. D, §3 (new).]
div>
In addition, any parent who is able to provide the information necessary for the insurer to process a claim shall be permitted
to authorize the filing of any claims under the policy.
[1989, c. 556, Pt. D, §3 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2823-B. Standardized claim forms
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2823-B. Standardized claim forms
All insurers providing group medical expense insurance on an expense-incurred basis providing payment or reimbursement for
diagnosis or treatment of a condition or a complaint by a licensed health care practitioner must accept the current standardized
claim form for professional services approved by the Federal Government and submitted electronically. All insurers providing
group medical expense insurance on an expense-incurred basis providing payment or reimbursement for diagnosis or treatment
of a condition or a complaint by a licensed hospital must accept the current standardized claim form for professional or facility
services, as applicable, approved by the Federal Government and submitted electronically. An insurer may not be required
to accept a claim submitted on a form other than the applicable form specified in this section and may not be required to
accept a claim that is not submitted electronically, except from a health care practitioner who is exempt pursuant to Title
24, section 2985. All services provided by a health care practitioner in an office setting must be submitted on the standardized
federal form used by noninstitutional providers and suppliers. Services in a nonoffice setting may be billed as negotiated
between the insurer and health care practitioner. For purposes of this section, "office setting" means a location where the
health care practitioner routinely provides health examinations, diagnosis and treatment of illness or injury on an ambulatory
basis whether or not the office is physically located within a facility.
[2005, c. 97, §3 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2823. Notice of claim
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2823. Notice of claim
There shall be a provision that written notice of sickness or of injury must be given to the insurer within 30 days after
the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any
claim, if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as
was reasonably possible.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2824. Proof of loss
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2824. Proof of loss
There shall be a provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished
to the insurer within 30 days after the commencement of the period for which the insurer is liable, and that subsequent written
proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably
require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within
90 days after the date of such loss. Failure to furnish such proof within such time shall not invalidate nor reduce any claim,
if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon
as was reasonably possible.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2825. Forms for proof of loss
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2825. Forms for proof of loss
There shall be a provision that the insurer will furnish to the policyholder such forms as are usually furnished by it for
filing proof of loss. If such forms are not furnished before the expiration of 15 days after the insurer received notice of
any claim under the policy, the person making such claim shall be deemed to have complied with the requirements of the policy
as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the
occurrence, character and extent of the loss for which claim is made.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2826. Examination, autopsy
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2826. Examination, autopsy
There shall be a provision that the insurer shall have the right and opportunity to examine the person of the insured when
and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity
to make an autopsy in case of death where it is not prohibited by law.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2827-A. Assignment of benefits
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2827-A. Assignment of benefits
All policies and certificates providing benefits for medical or dental care on an expense-incurred basis must contain a provision
permitting the insured to assign benefits for such care to the provider of the care. An assignment of benefits under this
section does not affect or limit the payment of benefits otherwise payable under the policy or certificate.
[1999, c. 21, §3 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2827. Time for payment of benefits
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2827. Time for payment of benefits
There shall be a provision that all benefits payable under the policy, other than benefits for loss of time, will be payable
not more than 60 days after receipt of proof, and that, subject to due proof of loss, all accrued benefits payable under the
policy for loss of time will be paid not later than at the expiration of each period of 30 days during the continuance of
the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period will be
paid immediately upon receipt of such proof.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2828. Time for suits
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2828. Time for suits
There shall be a provision that no action at law or in equity shall be brought to recover on the policy prior to the expiration
of 60 days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall
be brought at all, unless brought within 2 years from the expiration of the time within which proof of loss is required by
the policy.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2829-A. Disability benefit offsets
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2829-A. Disability benefit offsets
1. Disclosure to persons eligible for coverage. For any policy or contract subject to this chapter that provides disability income benefits, if the benefits under that policy
or contract are subject to reduction due to other sources of income, then the insurer shall include in any written enrollment
material and certificate of coverage developed by the insurer that is intended to be distributed to persons eligible for coverage
under the policy or contract a clear and conspicuous notice that accurately explains all types of other sources of income
that may result in a reduction of the benefits payable under the policy or contract. The notice requirement under this section
does not apply to an advertisement intended for the general public.
[2005, c. 42, §2 (new).]
2. Recovery of disability benefit overpayments. For claims filed after January 1, 2006, an insurer that is entitled to reduce disability income benefit payments when the
insured receives income from other sources and that is entitled to recover overpayments through offsets against current payments
to the insured may not recover such overpayments at a rate greater than 20% of the net benefit per benefit payment period
unless:
A. For policies applied for after September 13, 2003, the insurer has complied with the requirements of subsection 1;
[2005, c. 42, §2 (new).]
B. The insurer effects the offset of benefits within 60 days of notice to the insurer, or such later date as the insurer begins
paying benefits to the insured, that the insured is receiving or is entitled to receive income that may result in a reduction
of benefits payable under the policy;
[2005, c. 42, §2 (new).]
C. The overpayment did not result from the insurer's miscalculation of benefit reductions or the insurer's miscalculation of
benefits payable under the policy; and
[2005, c. 42, §2 (new).]
D. The insurer provided the insured with clear and conspicuous written notice that accurately explains to the insured all types
of other sources of income that may result in a reduction of the benefits payable under the policy within 30 days of the date
a claim for disability benefits was filed.
[2005, c. 42, §2 (new).]
[2005, c. 42, §2 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2829. Exceptions
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2829. Exceptions
1. Any portion of any such policy, delivered or issued for delivery in this State, which purports, by reason of the circumstances
under which a loss is incurred, to reduce any benefits promised thereunder to an amount less than that provided for the same
loss occurring under ordinary circumstances, shall be printed in such policy and in each certificate issued thereunder, in
bold face type and with greater prominence than any other portion of the rest of such policy or certificate, respectively;
and all other exceptions of the policy shall be printed in the policy and certificate with the same prominence as the benefits
to which they apply.
[1969, c. 132, § 1 (new).]
2. If any such policy contains any provision which affects the liability of the insurer because of any violation of law by
the insured during the term of the policy, it shall be in the following form: The insurer shall not be liable for death, injury
incurred or disease contracted, to which a contributing cause was the insured's commission of or attempt to commit a felony,
or which occurs while the insured is engaged in an illegal occupation.
[1969, c. 132, § 1 (new).]
3. If any such policy contains any provision which affects the liability of the insurer because of the insured's use of intoxicating
liquor or narcotics or hallucinogenic drugs during the term of the policy, it shall be in the following form: The insurer
shall not be liable for death, injury incurred or disease contracted while the insured is intoxicated or under the influence
of narcotics or hallucinogenic drugs unless administered on the advice of a physician.
[1969, c. 132, § 1 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2830. Omissions, modifications: superintendent may approve
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2830. Omissions, modifications: superintendent may approve
The superintendent may approve any form of group or blanket health insurance policy, or any form of certificate or printed
information to be issued under such policy, which omits or modifies any of the provisions hereinbefore required, if he deems
such omission or modification suitable for the character of such insurance and not unjust to the persons insured thereunder.
[1973, c. 585, § 12 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2831. Hospital, medical benefits -- direct payment
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2831. Hospital, medical benefits -- direct payment
Any such group or blanket policy may include benefits payable on account of hospital or medical or surgical aid for an employee
or other member of the group insured by such policy, his or her spouse, child or children or other dependents, and may provide
that, at the insured's option, any such benefits be paid by the insurer directly to the hospital, physician, surgeon doctor,
nurse or other person furnishing services covered by such provisions of the policy.
[1987, c. 219 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2832-A. Mandated offer of domestic partner benefits
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2832-A. Mandated offer of domestic partner benefits
1. Definition. As used in this section, unless the context otherwise indicates, "domestic partner" means the partner of a certificate holder
who:
A. Is a mentally competent adult as is the certificate holder;
[2001, c. 347, §3 (new); §5 (aff).]
B. Has been legally domiciled with the certificate holder for at least 12 months;
[2001, c. 347, §3 (new); §5 (aff).]
C. Is not legally married to or legally separated from another individual;
[2001, c. 347, §3 (new); §5 (aff).]
D. Is the sole partner of the certificate holder and expects to remain so; and
[2001, c. 347, §3 (new); §5 (aff).]
E. Is jointly responsible with the certificate holder for each other's common welfare as evidenced by joint living arrangements,
joint financial arrangements or joint ownership of real or personal property.
[2001, c. 347, §3 (new); §5 (aff).]
[2001, c. 347, §3 (new); §5 (aff).]
2. Mandated offer of domestic partner benefits. All group or blanket health insurance policies or contracts issued by any insurer operating pursuant to this chapter must
make available to group policyholders the option for additional benefits for the domestic partner of a certificate holder,
at appropriate rates and under the same terms and conditions as those benefits or options for benefits are provided to spouses
of married certificate holders covered under a group policy.
[2001, c. 347, §3 (new); §5 (aff).]
3. Financial dependency. Financial dependency of a domestic partner on the certificate holder may not be required as a condition for eligibility
for coverage.
[2001, c. 347, §3 (new); §5 (aff).]
4. Evidence of domestic partnership. As a condition of eligibility for coverage, an insurer or group policyholder may require a certificate holder and the certificate
holder's domestic partner to sign an affidavit attesting that the certificate holder and the certificate holder's domestic
partner meet the definition in subsection 1 and to show documentation of joint ownership or occupancy of real property, such
as a joint deed, joint mortgage or a joint lease, or the existence of a joint credit card, joint bank account or powers of
attorney in which each domestic partner is authorized to act for the other.
[2001, c. 347, §3 (new); §5 (aff).]
5. Preexisting conditions. A domestic partner is subject to the same provisions on coverage of preexisting conditions as any spouse or dependent of
a certificate holder.
[2001, c. 347, §3 (new); §5 (aff).]
6. Termination of domestic partner benefits. An insurer may terminate coverage in accordance with other applicable provisions of this Title for the domestic partner
of a certificate holder upon notification by the certificate holder that the domestic partner relationship has terminated.
A certificate holder may not enroll another individual as a domestic partner under a group contract until 12 months after
the termination of coverage for a prior domestic partner.
[2001, c. 347, §3 (new); §5 (aff).]
7. Construction. This section does not prohibit an insurer from negotiating a policy providing domestic partner benefits to a policyholder
that does not comply with the requirements of this section.
[2001, c. 347, §3 (new); §5 (aff).]
8. Exemption. This section does not apply to accidental injury, specified disease, hospital indemnity, Medicare supplement, disability
income, long-term care and other limited benefit health insurance policies.
[2001, c. 347, §3 (new); §5 (aff).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2832. Maternity benefits for unmarried women certificate holders and the minor dependents of certificate holders with dependent
or family coverage required
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2832. Maternity benefits for unmarried women certificate holders and the minor dependents of certificate holders with dependent
or family coverage required
All group or blanket health insurance policies, contracts and certificates shall provide the same maternity benefits for unmarried
women certificate holders, and the minor dependents of certificate holders with dependent or family coverage, as is provided
married certificate holders with maternity coverage and the wives of certificate holders with maternity coverage. This requirement
applies to all group or blanket insurance written or renewed after the effective date of this Act, and includes, but is not
limited to, all types and forms of group insurance issued by individual companies or corporations.
[2003, c. 517, Pt. B, §11 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2833. Child coverage
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2833. Child coverage
1. Definitions. For the purposes of this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Dependent children" means children who are under 19 years of age and are children, stepchildren or adopted children of,
or children placed for adoption with, the certificate holder, member or spouse of the certificate holder or member.
[1993, c. 666, Pt. A, §5 (new).]
B. "Placed for adoption" means the assumption and retention of a legal obligation by a person for the total or partial support
of a child in anticipation of adoption of the child. If the legal obligation ceases to exist, the child is no longer considered
placed for adoption.
[1993, c. 666, Pt. A, §5 (new).]
[1993, c. 666, Pt. A, §5 (rpr).]
2. Coverage. All group or blanket health insurance plans issued in accordance with the requirements of section 2832 must provide unmarried
women certificate holders with the option of coverage of their children from the date of birth. A certificate holder who,
pursuant to the laws of this State or any other state, has been adjudicated or has acknowledged himself to be the father of
an illegitimate child must be given the option of coverage for that child from the date of his adjudication or acknowledgement
of paternity. This optional coverage must be the same as that provided the children of a married certificate holder with
family or dependent coverage.
[1991, c. 200, Pt. B, §4 (new).]
3. Financial dependency. Financial dependency of dependent children on the certificate holder or the spouse of the certificate holder may not be
required as a condition for eligibility for coverage.
[1991, c. 200, Pt. B, §4 (new).]
4. Adopted children. All group or blanket health insurance policies and certificates issued in accordance with the requirements of this section
must provide the same benefits to dependent children placed for adoption with the certificate holder or spouse of the certificate
holder under the same terms and conditions as apply to natural dependent children or stepchildren of the certificate holder,
irrespective of whether the adoption has become final.
[1993, c. 666, Pt. A, §6 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2834-A. Maternity and routine newborn care
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2834-A. Maternity and routine newborn care
An insurer that issues group contracts and certificates providing maternity benefits, including benefits for childbirth, shall
provide coverage for services related to maternity and routine newborn care, including coverage for hospital stay, in accordance
with the attending physician's or attending certified nurse midwife's determination in conjunction with the mother that the
mother and newborn meet the criteria outlined in the "Guidelines for Perinatal Care," published by the American Academy of
Pediatrics and the American College of Obstetrics and Gynecology. For the purposes of this section, "routine newborn care"
does not include any services provided after the mother has been discharged from the hospital. For the purposes of this section,
"attending physician" includes the obstetrician, pediatrician or other physician attending the mother and newborn. Benefits
for routine newborn care required by this section are part of the mother's benefit. The mother and the newborn are treated
as one person in calculating the deductible, coinsurance and copayments for coverage required by this section.
[2003, c. 517, Pt. B, §12 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2834-B. Dependent special enrollment period
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2834-B. Dependent special enrollment period
1. Application. This section applies to all group and blanket medical insurance policies issued by nonprofit hospital or medical service
organizations, insurers or health maintenance organizations except hospital indemnity, specified accident, specified disease
and long-term care policies.
[1997, c. 445, §19 (new); §32 (aff).]
2. Definition. For purposes of this section, an "eligible individual" is a person who is a certificate holder under the policy or who has
met any waiting period applicable to becoming a certificate holder and is eligible to be enrolled under the policy but for
a failure to enroll during a previous enrollment period.
[1997, c. 445, §19 (new); §32 (aff).]
3. Requirement. If a policy makes coverage available with respect to dependents of certificate holders, the policy must provide for a dependent
special enrollment period when a person becomes a dependent of an eligible individual through marriage, birth or adoption
or placement for adoption or if a court order is issued changing custody of a child. During this period, the dependent may
be enrolled under the plan as a dependent of the eligible individual and, in the case of the birth or adoption of a child,
the spouse of the eligible individual may be enrolled as a dependent if otherwise eligible for coverage. If the eligible
individual is not already enrolled, the individual may enroll during this period.
[1999, c. 256, Pt. B, §1 (amd).]
4. Length of period. A dependent special enrollment period under this section must be a period of not less than 30 days and must begin on the
later of:
A. The date dependent coverage is made available; or
[1997, c. 445, §19 (new); §32 (aff).]
B. The date of the marriage, birth or adoption or placement for adoption or the date of the court order.
[1999, c. 256, Pt. B, §2 (amd).]
[1999, c. 256, Pt. B, §2 (amd).]
5. No waiting period. If an individual seeks to enroll a dependent during the first 30 days of a dependent special enrollment period, the coverage
of the dependent becomes effective:
A. In the case of marriage, no later than the first day of the first month beginning after the date the completed request for
enrollment is received;
[1997, c. 445, §19 (new); §32 (aff).]
B. In the case of a dependent's birth, as of the date of the birth;
[1999, c. 256, Pt. B, §3 (amd).]
C. In the case of a dependent's adoption or placement for adoption, as of the date of the adoption or placement for adoption;
or
[1999, c. 256, Pt. B, §3 (amd).]
D. In the case of a court order changing custody of a child, as of the date of the order.
[1999, c. 256, Pt. B, §4 (new).]
[1999, c. 256, Pt. B, §§3, 4 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2834. Newborn children coverage
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2834. Newborn children coverage
All group and blanket health insurance policies and certificates providing coverage on an expense-incurred basis must provide
that health insurance benefits are payable for a newly born child of the insured or subscriber from the moment of birth. An
adopted child is deemed to be newly born to the adoptive parents from the date of the signed placement agreement. Preexisting
conditions of an adopted child may not be excluded from coverage.
[2003, c. 517, Pt. A, §5 (amd); §13 (aff).]
div>
The coverage for newly born children must consist of coverage of injury or sickness or other benefits provided by the policy,
including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.
[1997, c. 604, Pt. C, §3 (amd).]
div>
If payment of a specific premium or subscription fee is required to provide coverage for a child, the policy or contract may
require that notification of birth of a newly born child and payment of the required premium or fees must be furnished to
the insurer or nonprofit service or indemnity corporation within 31 days after the date of birth in order to have the coverage
continue beyond that 31-day period. The payment may be required to be retroactive to the date of birth. Benefits required
by section 2834-A must be paid regardless of whether coverage under this section is elected.
[1997, c. 604, Pt. C, §3 (amd).]
div>
The requirements of this section apply to all policies and certificates delivered or issued for delivery in this State.
[2003, c. 517, Pt. A, §6 (amd); §13 (aff).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2835. Mental health services (CONFLICT)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2835. Mental health services (CONFLICT)
1. (CONFLICT: Text as amended by PL 2005, c. 121, Pt. I, §3) Notwithstanding any provision of a health insurance policy or
certificate issued under a group policy subject to this chapter, whenever the policy provides for payment or reimbursement
for services that are within the lawful scope of practice of a professional listed in subsection 2-A, any person covered by
the policy is entitled to reimbursement for these services if the services are performed by a physician or a professional
listed in subsection 2-A. Payment or reimbursement for services rendered by a professional listed in subsection 2-A, paragraph
B, C or D may not be conditioned upon prior diagnosis or referral by a physician or other health care professional, except
in cases where diagnosis of the condition for which the services are rendered is beyond the scope of their licensure.
[2005, c. 121, Pt. I, §3 (amd).]
1. (CONFLICT: Text as amended by PL 2005, c. 213, §2) Notwithstanding any provision of a health insurance policy or certificate
issued under a group policy subject to this chapter, whenever the policy provides for payment or reimbursement for services
that are within the lawful scope of practice of a psychologist licensed to practice in this State, a certified social worker
licensed for the independent practice of social work in this State, a licensed clinical professional counselor licensed for
the independent practice of counseling in this State, a marriage and family therapist licensed as a marriage and family therapist
in this State or a licensed nurse who is certified by the American Nurses' Association as a clinical specialist in adult psychiatric
and mental health nursing or as a clinical specialist in child and adolescent psychiatric and mental health nursing, any person
covered by the policy is entitled to reimbursement for these services if the services are performed by a physician, a psychologist
licensed to practice in this State, a certified social worker licensed for independent practice in this State, a licensed
clinical professional counselor licensed for the independent practice of counseling in this State, a marriage and family therapist
licensed as a marriage and family therapist in this State or a licensed nurse certified by the American Nurses' Association
as a clinical specialist in adult or child and adolescent psychiatric and mental health nursing. Payment or reimbursement
for services rendered by clinical social workers licensed in this State, licensed clinical professional counselors licensed
in this State, licensed marriage and family therapists licensed in this State or licensed nurses certified by the American
Nurses' Association as clinical specialists in adult or child and adolescent psychiatric and mental health nursing may not
be conditioned upon prior diagnosis or referral by a physician or other health care professional, except in cases where diagnosis
of the condition for which the services are rendered is beyond the scope of their licensure.
[2005, c. 213, §2 (amd); §3 (aff).]
1. (CONFLICT: Text as amended by PL 2005, c. 214, §2) Notwithstanding any provision of a health insurance policy or certificate
issued under a group policy subject to this chapter, whenever the policy provides for payment or reimbursement for services
that are within the lawful scope of practice of a psychologist licensed to practice in this State; a certified social worker
licensed for the independent practice of social work in this State; a licensed clinical professional counselor licensed for
the independent practice of counseling in this State; a licensed pastoral counselor licensed as a pastoral counselor in this
State; or a licensed nurse who is certified by the American Nurses' Association as a clinical specialist in adult psychiatric
and mental health nursing or as a clinical specialist in child and adolescent psychiatric and mental health nursing, any person
covered by the policy is entitled to reimbursement for these services if the services are performed by a physician; a psychologist
licensed to practice in this State; a certified social worker licensed for independent practice in this State; a licensed
clinical professional counselor licensed for the independent practice of counseling in this State; a licensed pastoral counselor
licensed as a pastoral counselor in this State; or a licensed nurse certified by the American Nurses' Association as a clinical
specialist in adult or child and adolescent psychiatric and mental health nursing. Payment or reimbursement for services
rendered by clinical social workers licensed in this State, licensed clinical professional counselors licensed in this State,
licensed pastoral counselors licensed in this State or licensed nurses certified by the American Nurses' Association as clinical
specialists in adult or child and adolescent psychiatric and mental health nursing may not be conditioned upon prior diagnosis
or referral by a physician or other health care professional, except in cases where diagnosis of the condition for which the
services are rendered is beyond the scope of their licensure.
[2005, c. 214, §2 (amd); §3 (aff).]
2. (CONFLICT: Text as amended by PL 2005, c. 121, Pt. I, §4) Nothing in subsection 1 may be construed to require a health
insurance policy subject to this chapter to provide for reimbursement of services that are within the lawful scope of practice
of a professional listed in subsection 2-A.
[2005, c. 121, Pt. I, §4 (amd).]
2. (CONFLICT: Text as amended by PL 2005, c. 213, §2) Nothing in subsection 1 may be construed to require a health insurance
policy subject to this chapter to provide for reimbursement of services that are within the lawful scope of practice of a
psychologist licensed to practice in this State, a clinical social worker licensed in this State, a clinical professional
counselor licensed in this State, a licensed marriage and family therapist licensed in this State, a certified social worker
licensed to practice in this State or a nurse certified and licensed to practice in this State.
[2005, c. 213, §2 (amd); §3 (aff).]
2. (CONFLICT: Text as amended by PL 2005, c. 214, §2) Nothing in subsection 1 may be construed to require a health insurance
policy subject to this chapter to provide for reimbursement of services that are within the lawful scope of practice of a
psychologist licensed to practice in this State, a clinical social worker licensed in this State, a clinical professional
counselor licensed in this State, a licensed pastoral counselor licensed in this State, a certified social worker licensed
to practice in this State, or a nurse certified and licensed to practice in this State.
[2005, c. 214, §2 (amd); §3 (aff).]
2-A. Subsections 1 and 2 apply with respect to the following types of professionals:
A. A psychologist licensed to practice in this State;
[2005, c. 121, Pt. I, §5 (new).]
B. A certified social worker licensed for the independent practice of social work in this State who has at least a master's
degree in social work from an accredited educational institution, who has been employed in social work for at least 2 years
and who, after January 1, 1985, is licensed as a clinical social worker in this State;
[2005, c. 121, Pt. I, §5 (new).]
C. A licensed clinical professional counselor licensed for the independent practice of counseling who has at least a master's
degree in counseling from an accredited educational institution, who has been employed in counseling for at least 2 years
and who, after January 1, 2002, is licensed as a clinical professional counselor in this State; and
[2005, c. 121, Pt. I, §5 (new).]
D. A licensed nurse who is certified by the American Nurses' Association as a clinical specialist in adult psychiatric and
mental health nursing or as a clinical specialist in child and adolescent psychiatric and mental health nursing.
[2005, c. 121, Pt. I, §5 (new).]
[2005, c. 121, Pt. I, §5 (new).]
3. (CONFLICT: Text as amended by PL 2005, c. 213, §2) Mental health services provided by counseling professionals. Except as provided in subsection 1 with regard to reimbursement of clinical professional counselors and marriage and family
therapists licensed in this State, an insurer that issues group health care contracts providing coverage for mental health
services shall make available coverage for those services when performed by a counseling professional who is licensed by the
State pursuant to Title 32, chapter 119 to assess and treat interpersonal and intrapersonal problems, has at least a masters
degree in counseling or a related field from an accredited educational institution and has been employed as a counselor for
at least 2 years. Any contract providing coverage for the services of counseling professionals pursuant to this section may
be subject to any reasonable limitations, maximum benefits, coinsurance, deductibles or exclusion provisions applicable to
overall benefits under the contract. This subsection applies to all policies, contracts and certificates executed, delivered,
issued for delivery, continued or renewed in this State. For purposes of this subsection, all contracts are deemed renewed
no later than the next yearly anniversary of the contract date.
[2005, c. 213, §2 (amd); §3 (aff).]
3. (CONFLICT: Text as amended by PL 2005, c. 214, §2) Mental health services provided by counseling professionals. Except as provided in subsection 1 with regard to reimbursement of clinical professional counselors and pastoral counselors
licensed in this State, an insurer that issues group health care contracts providing coverage for mental health services shall
make available coverage for those services when performed by a counseling professional who is licensed by the State pursuant
to Title 32, chapter 119 to assess and treat interpersonal and intrapersonal problems, has at least a masters degree in counseling
or a related field from an accredited educational institution and has been employed as a counselor for at least 2 years.
Any contract providing coverage for the services of counseling professionals pursuant to this section may be subject to any
reasonable limitations, maximum benefits, coinsurance, deductibles or exclusion provisions applicable to overall benefits
under the contract. This subsection applies to all policies, contracts and certificates executed, delivered, issued for delivery,
continued or renewed in this State. For purposes of this subsection, all contracts are deemed renewed no later than the next
yearly anniversary of the contract date.
[2005, c. 214, §2 (amd); §3 (aff).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2836. Limits on priority liens
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2836. Limits on priority liens
No group or blanket policy shall provide for priority over the insured member of payment for any hospital, nursing, medical
or surgical services, or of any expenses paid or reimbursed under the policy, in the event the insured member is entitled
to receive payment reimbursement from any other person as a result of legal action or claim, except as provided in this section.
[1975, c. 770, § 108 (new).]
div>
A policy may contain a provision that allows such payments, if that provision is approved by the superintendent, and if that
provision requires the prior written approval of the insured member and allows such payments only on a just and equitable
basis, and not on the basis of a priority lien. A just and equitable basis shall mean that any factors that diminish the potential
value of the insured member's claim shall likewise reduce the share in the claim for those claiming payment for services or
reimbursement. Such factors shall include, but are not limited to:
[1975, c. 770, § 108 (new).]
1. Legal defenses. Questions of liability and comparative negligence or other legal defenses;
[1975, c. 770, § 108 (new).]
2. Exigencies of trial. Exigencies of trial that reduce a settlement or award in order to resolve the claim; and
[1975, c. 770, § 108 (new).]
3. Limits of coverage. Limits on the amount of applicable insurance coverage that reduce the claim to an amount recoverable by the insured member.
[1975, c. 770, § 108 (new).]
div>
In the event of a dispute as to the application of any such provision or the amount available for payment to those claiming
payment for services or reimbursement, the dispute shall be determined if the action is pending, before the court in which
it is pending; or if no action is pending, by filing an action in any court for determination of the dispute.
[1975, c. 770, § 108 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2837-A. Screening mammograms
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2837-A. Screening mammograms
1. Definition. For purposes of this section, "screening mammogram" means a radiologic procedure that is provided to an asymptomatic woman
for the purpose of early detection of breast cancer and that consists of 2 radiographic views per breast.
[1989, c. 875, Pt. I, §6 (new).]
2. Required coverage. All group insurance policies that cover radiologic procedures, except those policies that cover only dental procedures,
accidental injury or specific diseases, must provide coverage for screening mammograms performed by providers that meet the
standards established by the Department of Health and Human Services rules relating to radiation protection. The policies
must reimburse for screening mammograms performed at least once a year for women 40 years of age and over.
A.
[1997, c. 408, §5 (rp); §8 (aff).]
B.
[1997, c. 408, §5 (rp); §8 (aff).]
[1997, c. 408, §5 (rpr); §8 (aff); 2003, c. 689, Pt. B, §6 (rev).]
3. Application. This section applies to all policies, contracts and certificates that cover radiologic procedures, except those policies
that cover only dental procedures, accidental injury or specific diseases, executed, delivered, issued for delivery, continued
or renewed in this State on or after March 1, 1991. For purposes of this section, all policies and contracts are deemed to
be renewed no later than the next yearly anniversary of the policy or contract date.
[1991, c. 156, §2 (amd).]
4. Reports. Each insurer that issues policies subject to this section shall report to the superintendent its experience for each calendar
year beginning with 1991 not later than April 30th of the following calendar year. The report must include the information
required and be presented in the form prescribed by the superintendent. The report must include the amount of claims paid
in this State for services required by this section. The superintendent shall compile this data in an annual report and submit
the report to the joint standing committee of the Legislature having jurisdiction over banking and insurance matters.
[1991, c. 701, §9 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2837-B. Acupuncture services
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2837-B. Acupuncture services
All group insurance policies and certificates providing coverage for acupuncture must provide coverage for those services
when performed by an acupuncturist licensed pursuant to Title 32, chapter 113-B, subchapter 2, under the same conditions that
apply to the services of a licensed physician.
[2003, c. 517, Pt. B, §14 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2837-C. Coverage for breast cancer treatment
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2837-C. Coverage for breast cancer treatment
1. Inpatient care. All group health policies providing coverage for medical and surgical benefits, except accidental injury, specified disease,
hospital indemnity, Medicare supplement, long-term care and other limited benefit health insurance policies and contracts,
must ensure that inpatient coverage with respect to the treatment of breast cancer is provided for a period of time determined
by the attending physician, in consultation with the patient, to be medically appropriate following a mastectomy, a lumpectomy
or a lymph node dissection for the treatment of breast cancer.
Nothing in this subsection may be construed to require the provision of inpatient coverage if the attending physician and
patient determine that a shorter period of hospital stay is appropriate.
In implementing the requirements of this subsection, a group health policy may not modify the terms and conditions of coverage
based on the determination by any enrollee to request less than the minimum coverage required under this subsection.
All group health policies must provide written notice to each enrollee under the contract regarding the coverage required
by this subsection. The notice must be prominently positioned in any literature or correspondence made available or distributed
by the plan and must be transmitted in the next mailing made by the plan to the enrollee or as part of any yearly information
packet sent to the enrollee, whichever is earlier.
[1997, c. 408, §6 (new); §8 (aff).]
2. Reconstruction. All group health policies providing coverage for mastectomy surgery must provide coverage for reconstruction of the breast
on which surgery has been performed and surgery and reconstruction of the other breast to produce a symmetrical appearance
if the patient elects reconstruction and in the manner chosen by the patient and the physician.
[1997, c. 408, §6 (new); §8 (aff).]
3. Application. The requirements of this section apply to all group policies, contracts and certificates executed, delivered, issued for
delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later
than the next yearly anniversary of the contract date.
[2003, c. 517, Pt. B, §15 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2837-D. Medical food coverage for inborn error of metabolism
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2837-D. Medical food coverage for inborn error of metabolism
1. Inborn error of metabolism; special modified low-protein food product. As used in this section, "inborn error of metabolism" means a genetically determined biochemical disorder in which a specific
enzyme defect produces a metabolic block that may have pathogenic consequences at birth or later in life. As used in this
section, "special modified low-protein food product" means food formulated to reduce the protein content to less than one
gram of protein per serving and does not include foods naturally low in protein.
[1995, c. 369, §3 (new).]
2. Required coverage. All group insurance policies and contracts, except accidental injury, specified disease, hospital indemnity, Medicare supplement,
long-term care and other limited benefit health insurance policies and contracts, must provide coverage for metabolic formula
and special modified low-protein food products that have been prescribed by a licensed physician for a person with an inborn
error of metabolism. The policies and contracts must reimburse:
A. For metabolic formula; and
[1995, c. 369, §3 (new).]
B. Up to $3,000 per year for special modified low-protein food products.
[1995, c. 369, §3 (new).]
[1995, c. 369, §3 (new).]
3. Application. The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery,
continued or renewed in this State on or after January 1, 1996. For purposes of this section, all contracts are deemed to
be renewed no later than the next yearly anniversary of the contract date.
[1995, c. 369, §3 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2837-E. Coverage for Pap tests
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2837-E. Coverage for Pap tests
All group health insurance policies, contracts and certificates must provide coverage for screening Pap tests recommended
by a physician.
[2003, c. 517, Pt. A, §7 (amd); §13 (aff).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2837-F. Off-label use of prescription drugs for cancer
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2837-F. Off-label use of prescription drugs for cancer
1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Medically accepted indication" includes any use of a drug that has been approved by the federal Food and Drug Administration
and includes another use of the drug if that use is supported by one or more citations in the standard reference compendia
or if the insurer involved, based upon guidance provided by the federal Department of Health and Human Services Medicare program
pursuant to 42 United States Code, Section 1395x(t), determines that that use is medically accepted based on supportive clinical
evidence in peer-reviewed medical literature.
[1997, c. 701, §3 (new).]
B. "Off-label use" means the prescription and use of drugs for medically accepted indications other than those stated in the
labeling approved by the federal Food and Drug Administration.
[1997, c. 701, §3 (new).]
C. "Peer-reviewed medical literature" means scientific studies published in at least 2 articles from major peer-reviewed medical
journals that present data that supports the proposed off-label use as generally safe and effective.
[1997, c. 701, §3 (new).]
D. "Standard reference compendia" means:
(1) The United States Pharmacopeia Drug Information or information published by its successor organization; or
(2) The American Hospital Formulary Service Drug Information or information published by its successor organization.
[1997, c. 701, §3 (new).]
[1997, c. 701, §3 (new).]
2. Required coverage for off-label use. All group insurance policies and contracts that provide coverage for prescription drugs must provide coverage for off-label
use in accordance with the following.
A. Group insurance policies and contracts that provide coverage for prescription drugs may not exclude coverage of any such
drug used for the treatment of cancer for a medically accepted indication on the grounds that the drug has not been approved
by the federal Food and Drug Administration for that indication, as long as that use of that drug is a medically accepted
indication for the treatment of cancer.
[1997, c. 701, §3 (new).]
B. Coverage of a drug required by this subsection also includes medically necessary services associated with the administration
of the drug.
[1997, c. 701, §3 (new).]
C. This subsection may not be construed to require coverage for a drug when the federal Food and Drug Administration has determined
its use to be contraindicated for treatment of the current indication.
[1997, c. 701, §3 (new).]
D. A drug use that is covered pursuant to paragraph A may not be denied coverage based on a "medical necessity" requirement
except for a reason that is unrelated to the legal status of the drug use.
[1997, c. 701, §3 (new).]
E. A contract that provides coverage of a drug as required by this subsection may contain provisions for maximum benefits and
coinsurance and reasonable limitations, deductibles and exclusions to the same extent that these provisions are applicable
to coverage of all prescription drugs and are not inconsistent with the requirements of this subsection.
[1997, c. 701, §3 (new).]
[1997, c. 701, §3 (new).]
3. Application. The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery,
continued or renewed in this State on or after January 1, 1999. For purposes of this section, all contracts are deemed to
be renewed no later than the next yearly anniversary of the contract date.
[1997, c. 701, §3 (new).]
24-A §02837-F
Coverage for prostate cancer screening
(As enacted by PL 1997, c. 754, §3 is REALLOCATED TO TITLE 24-A, SECTION 2837-H)
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2837-G. Off-label use of prescription drugs for HIV or AIDS
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2837-G. Off-label use of prescription drugs for HIV or AIDS
1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Off-label use" means the prescription and use of drugs for indications other than those stated in the labeling approved
by the federal Food and Drug Administration.
[1997, c. 701, §3 (new).]
B. "Peer-reviewed medical literature" means scientific studies published in at least 2 articles from major peer-reviewed medical
journals that present data that supports the proposed off-label use as generally safe and effective.
[1997, c. 701, §3 (new).]
C. "Standard reference compendia" means:
(1) The United States Pharmacopeia Drug Information or information published by its successor organization; or
(2) The American Hospital Formulary Service Drug Information or information published by its successor organization.
[1997, c. 701, §3 (new).]
[1997, c. 701, §3 (new).]
2. Required coverage for off-label use. All group insurance policies and contracts that provide coverage for prescription drugs must provide coverage for off-label
use in accordance with the following.
A. Group insurance policies and contracts that provide coverage for prescription drugs may not exclude coverage of any such
drug used for the treatment of HIV or AIDS on the grounds that the drug has not been approved by the federal Food and Drug
Administration for that indication, as long as that drug is recognized for the treatment of that indication in one of the
standard reference compendia or in peer-reviewed medical literature.
[1997, c. 701, §3 (new).]
B. Coverage of a drug required by this subsection also includes medically necessary services associated with the administration
of the drug.
[1997, c. 701, §3 (new).]
C. This subsection may not be construed to require coverage for a drug when the federal Food and Drug Administration has determined
its use to be contraindicated for treatment of the current indication.
[1997, c. 701, §3 (new).]
D. A drug use that is covered pursuant to paragraph A may not be denied coverage based on a "medical necessity" requirement
except for a reason that is unrelated to the legal status of the drug use.
[1997, c. 701, §3 (new).]
E. A contract that provides coverage of a drug as required by this subsection may contain provisions for maximum benefits and
coinsurance and reasonable limitations, deductibles and exclusions to the same extent that these provisions are applicable
to coverage of all prescription drugs and are not inconsistent with the requirements of this subsection.
[1997, c. 701, §3 (new).]
[1997, c. 701, §3 (new).]
3. Application. The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery,
continued or renewed in this State on or after January 1, 1999. For purposes of this section, all contracts are deemed to
be renewed no later than the next yearly anniversary of the contract date.
[1997, c. 701, §3 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2837-H. Coverage for prostate cancer screening (REALLOCATED FROM TITLE 24-A, SECTION 2837-F)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2837-H. Coverage for prostate cancer screening (REALLOCATED FROM TITLE 24-A, SECTION 2837-F)
1. Definition. As used in this section, "services for the early detection of prostate cancer" means the following procedures provided to
a man for the purpose of early detection of prostate cancer:
A. A digital rectal examination; and
[RR 1997, c. 2, §52 (ral).]
B. A prostate-specific antigen test.
[RR 1997, c. 2, §52 (ral).]
[RR 1997, c. 2, §52 (ral).]
2. Required coverage for prostate cancer screening. All group insurance policies and contracts except accidental injury, specified disease, hospital indemnity, Medicare supplement,
long-term care and other limited benefit health insurance policies and contracts must provide coverage for services for the
early detection of prostate cancer. The contracts must reimburse for services for the early detection of prostate cancer,
if recommended by a physician, at least once a year for men 50 years of age or older until a man reaches the age of 72.
[RR 1997, c. 2, §52 (ral).]
3. Application. The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery,
continued or renewed in this State on or after September 1, 1998. For purposes of this section, all contracts are deemed
to be renewed no later than the next yearly anniversary of the contract date.
[RR 1997, c. 2, §52 (ral).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2837. Home health care coverage
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2837. Home health care coverage
Every insurer which issues or issues for delivery in this State group or blanket health insurance policies or plans, which
provide coverage on an expense incurred basis for inpatient hospital care, shall make available that coverage for home health
care services by a home health care provider.
[1977, c. 696, § 202 (rpr).]
div>
The policy providing coverage for home health care services may contain reasonable limitation on the number of home care visits
and other services provided, but the number of such visits shall not be less than 90 in any continuous period of 12 months
for each person covered under the policy. Each visit by an individual member of a home health care provider shall be considered
as one home care visit.
[1977, c. 470, § 3 (new).]
1. Home health care services. "Home health care services" means those health care services rendered in his place of residence on a part-time basis to a
covered person only if:
A. Hospitalization or confinement in a skilled nursing facility as defined in Title XVIII of the Social Security Act, 42 U.S.C.
§ 1395, et seq., would otherwise have been required if home health care was not provided; and
[1977, c. 470, § 3 (new).]
B. The plan covering the home health services is established as prescribed in writing by a physician.
[1977, c. 470, § 3 (new).]
There shall be no requirement that hospitalization be an antecedent to coverage under the policy.
[1977, c. 470, § 3 (new).]
2. Home health care included. "Home health care services" shall include:
A. Visits by a registered nurse or licensed practical nurse to carry out treatments prescribed, or supportive nursing care
and observation as indicated;
[1977, c. 470, § 3 (new).]
B. A physician's home or office visits or both;
[1977, c. 470, § 3 (new).]
C. Visits by a registered physical, speech, occupational, inhalation or dietary therapist for services or for evaluation of,
consultation with and instruction of nurses in carrying out such therapy prescribed by the attending physician, or both;
[1977, c. 470, § 3 (new).]
D. Any prescribed laboratory tests and x-ray examination using hospital or community facilities, drugs, dressings, oxygen or
medical appliances and equipment as prescribed by a physician, but only to the extent that such charges would have been covered
under the contract if the covered person had remained in the hospital; and
[1977, c. 470, § 3 (new).]
E. Visits by persons who have completed a home health aide training course under the supervision of a registered nurse for
the purpose of giving personal care to the patient and performing light household tasks as required by the plan of care, but
not including services.
[1977, c. 470, § 3 (new).]
[1977, c. 470, § 3 (new).]
3. Home health care provider. "Home health care provider" means a home health care agency which is certified under Title XVIII of the Social Security Act
of 1965, as amended, which:
A. Is primarily engaged in and licensed or certified to provide skilled nursing and other therapeutic services;
[1977, c. 470, § 3 (new).]
B. Has standards, policies and rules established by a professional group, associated with the agency or organization, which
professional group must include at least one physician and one registered nurse;
[1977, c. 470, § 3 (new).]
C. Is available to provide the care needed in the home 7 days a week and has telephone answering service available 24 hours
per day;
[1977, c. 470, § 3 (new).]
D. Has the ability to and does provide, either directly or through contract, the services of a coordinator responsible for
case discovery and planning and assuring that the covered person receives the services ordered by the physician;
[1977, c. 470, § 3 (new).]
E. Has under contract the services of a physician-advisor licensed by the State or a physician;
[1977, c. 470, § 3 (new).]
F. Conducts periodic case conferences for the purpose of individualized patient care planning and utilization review; and
[1977, c. 470, § 3 (new).]
G. Maintains a complete medical record on each patient.
[1977, c. 470, § 3 (new).]
[1977, c. 470, § 3 (new).]
4. Exclusions.
A. No policy shall require home health care coverage to persons eligible for medicare; and
[1977, c. 470, § 3 (new).]
B. No payment shall be made for services provided by a person who resides in the covered person's residence or who is a member
of the covered person's family.
[1977, c. 470, § 3 (new).]
[1977, c. 470, § 3 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2838. Community health service coverage (REPEALED)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2838. Community health service coverage (REPEALED)
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2839-A. Notice of rate increase (CONTAINS TEXT WITH VARYING EFFECTIVE DATES)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2839-A. Notice of rate increase (CONTAINS TEXT WITH VARYING EFFECTIVE DATES)
1. Notice of rate increase on existing policies. An insurer offering group health insurance, except for accidental injury, specified disease, hospital indemnity, disability
income, Medicare supplement, long-term care or other limited benefit group health insurance, must provide written notice by
first class mail of a rate increase to all affected policyholders or others who are directly billed for group coverage at
least 60 days before the effective date of any increase in premium rates. An increase in premium rates may not be implemented
until 60 days after the notice is provided. For small group health plan rates subject to section 2808-B, subsection 2-B,
if the increase is pending approval at the time of notice, the disclosure must state that the increase is subject to regulatory
approval.
[2005, c. 121, Pt. F, §1 (amd).]
1-A. (TEXT EFFECTIVE UNTIL 1107) Notice of rate increase on existing policies renewed in calendar year 2006. Notwithstanding subsection 1, for existing policies renewed in calendar year 2006, an insurer offering group health insurance
for 2006 plan years, except for accidental injury, specified disease, hospital indemnity, disability income, Medicare supplement,
long-term care or other limited benefit group health insurance, must provide written notice by first class mail of a rate
increase to all affected policyholders or others who are directly billed for group coverage at least 30 days before the effective
date of any increase in premium rates. An increase in premium rates may not be implemented until 30 days after the notice
is provided.
This subsection is repealed January 1, 2007.
[2005, c. 400, Pt. A, §2 (new).]
1-A. (TEXT REPEALED 1107) Notice of rate increase on existing policies renewed in calendar year 2006.
[2005, c. 400, Pt. A, §2 (new); T. 24-A, §2839-A, sub-§1-A (rp).]
2. Notice of rate increase on new business. When an insurer offering group health insurance, except for accidental injury, specified disease, hospital indemnity, disability
income, Medicare supplement, long-term care or other limited benefit group health insurance, quotes a rate for new business,
it must disclose any rate increase that the insurer anticipates implementing within the following 90 days. If the quote is
in writing, the disclosure must also be in writing. If such disclosure is not provided, an increase may not be implemented
until at least 90 days after the date the quote is provided. For small group health plan rates subject to section 2808-B,
subsection 2-B, if the increase is pending approval at the time of notice, the disclosure must state that the increase is
subject to regulatory approval.
[2005, c. 121, Pt. F, §1 (amd).]
3. (TEXT EFFECTIVE UNTIL 1107) Notice of rate increase on new business for calendar year 2006. Notwithstanding subsection 2, for new business quoted in calendar year 2006 by an insurer offering group health insurance,
except for accidental injury, specified disease, hospital indemnity, disability income, Medicare supplement, long-term care
or other limited benefit group health insurance, quotes a rate for new business, the insurer must disclose any rate increase
that the insurer anticipates implementing within the following 30 days. If the quote is in writing, the disclosure must also
be in writing. If such disclosure is not provided, an increase may not be implemented until at least 30 days after the date
the quote is provided.
This subsection is repealed January 1, 2007.
[2005, c. 400, Pt. A, §2 (new).]
3. (TEXT REPEALED 1107) Notice of rate increase on new business for calendar year 2006.
[2005, c. 400, Pt. A, §2 (new); T. 24-A, §2839-A, sub-§3 (rp).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2839-B. Large group rates
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2839-B. Large group rates
1. Application. This section applies to group health insurance offered in the large group market as defined in section 2850-B, except insurance
covering only accidental injury, specified disease, hospital indemnity, dental, vision, disability income, long-term care,
Medicare supplement or other limited benefit health insurance.
[2003, c. 469, Pt. E, §17 (new).]
2. Annual filing. Every carrier offering group health insurance specified in subsection 1 shall annually file with the superintendent on or
before April 30th a certification signed by a member in good standing of the American Academy of Actuaries or a successor
organization that the carrier's rating methods and practices are in accordance with generally accepted actuarial principles
and with the applicable actuarial standards of practice as promulgated by an actuarial standards board. The filing must also
certify that the carrier has included in its experience any savings offset payments or recovery of those savings offset payments
consistent with section 6913. The filing also must state the number of policyholders, certificate holders and dependents,
as of the close of the preceding calendar year, enrolled in large group health insurance plans offered by the carrier. A filing
and supporting information are public records except as provided by Title 1, section 402, subsection 3.
[2003, c. 469, Pt. E, §17 (new).]
3. Documentation. Every carrier shall maintain at its principal place of business a complete and detailed description of its rating practices,
including information and documentation that demonstrates that its rating methods and practices are in accordance with generally
accepted actuarial principles and with the applicable actuarial standards of practice as promulgated by an actuarial standards
board.
[2003, c. 469, Pt. E, §17 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2839. Rates filed
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2839. Rates filed
A policy of group health insurance may not be delivered in this State until a copy of the group rates to be used in calculating
the premium for these policies has been filed for informational purposes with the superintendent. The filing must include
the base rates and a description of any procedures to be used to adjust the base rates to reflect factors including but not
limited to age, gender, health status, claims experience, group size and coverage of dependents. Notwithstanding this section,
rates for group Medicare supplement, nursing home care or long-term care insurance contracts and for certain association groups
and other groups specified in section 2701, subsection 2, paragraph C must be filed in accordance with section 2736. Rates
for small group health insurance subject to section 2808-B are subject to the additional filing requirements specified in
that section.
[2003, c. 428, Pt. E, §2 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2840-A. Coverage for chiropractic services
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2840-A. Coverage for chiropractic services
1. Therapeutic, adjustive and manipulative services. Notwithstanding any other provisions of this chapter, every insurer which issues group or blanket health care contracts
providing coverage for the services of a "physician" or "doctor" to residents of this State shall provide coverage to any
subscriber or other person covered under those contracts for those services when performed by a chiropractor, to the extent
that the services are within the lawful scope of practice of a chiropractor licensed to practice in this State. Therapeutic,
adjustive and manipulative services shall be covered whether performed by an allopathic, osteopathic or chiropractic doctor.
[1985, c. 516, § 5 (new).]
2. Limits; coinsurance; deductibles. Any contract which provides coverage for the services required by this section may contain provisions for maximum benefits
and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent
with the requirements of this section.
[1985, c. 516, § 5 (new).]
3. Reports to the Superintendent of Insurance. Every insurer subject to this section shall report its experience for each calendar year to the Superintendent of Insurance
not later than April 30th of the following year. The report shall be in a form prescribed by the superintendent and shall
include the amount of claims paid in this State for the services required by this section and the total amount of claims paid
in this State for health care contracts. The superintendent shall compile this data for all insurers in an annual report.
[1989, c. 141, §5 (amd).]
4. Application; expiration.
[1989, c. 141, §6 (rp).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2840. Optional coverage for chiropractic services (REPEALED)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2840. Optional coverage for chiropractic services (REPEALED)
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2841. Optional coverage for optometric services
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2841. Optional coverage for optometric services
1. Coverage required to be made available. Every insurer which issues for delivery in this State group health policies which provide coverage on an expense-incurred
basis for the services of a "physician" or "doctor" to residents of this State shall make available to all groups coverage
for such services when performed by an optometrist, to the extent the services are within the scope of the practice of an
optometrist licensed to practice in this State.
[1981, c. 254, § 2 (new).]
2. Policy. The group or blanket policy making available coverage for the services referred to in this section shall contain provisions
for maximum benefits and coinsurance, and reasonable limitations, deductibles and exclusions.
[1981, c. 254, § 2 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2842. Equitable health care for alcoholism and drug dependency treatment
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2842. Equitable health care for alcoholism and drug dependency treatment
1. Purpose. The Legislature recognizes that alcoholism and drug dependency constitute major health problems in the State and in the Nation.
The Legislature further recognizes that alcoholism is a disease and that alcoholism and drug dependency can be effectively
treated. As such, alcoholism and drug dependency warrant the same attention from the health care industry as other serious
diseases and illnesses. The Legislature further recognizes that health insurance contracts, at times, fail to provide adequate
benefits for the treatment of alcoholism and drug dependency, which results in more costly health care for treatment of complications
caused by the lack of early intervention and other treatment services for persons suffering from these illnesses. This situation
causes a higher health care, social, law enforcement and economic cost to the citizens of this State than is necessary, including
the need for the State to provide treatment to some insureds at public expense. To assist the many citizens of this State
who suffer from these illnesses in a more cost effective way, the Legislature declares that certain health insurance coverage
providing benefits for the treatment of the illness of alcoholism and drug dependency shall be included in all group health
insurance contracts.
[1983, c. 527, § 2 (rpr).]
2. Definitions. As used in this section, unless the context indicates otherwise, the following terms have the following meanings.
A. "Outpatient care" means care rendered by a state-licensed, approved or certified detoxification, residential treatment or
outpatient program, or partial hospitalization program on a periodic basis, including, but not limited to, patient diagnosis,
assessment and treatment, individual, family and group counseling and educational and support services.
[1983, c. 527, § 2 (new).]
B. "Residential treatment" means services at a facility that provides care 24 hours daily to one or more patients, including,
but not limited to, the following services: Room and board; medical, nursing and dietary services; patient diagnosis, assessment
and treatment; individual, family and group counseling; and educational and support services, including a designated unit
of a licensed health care facility providing any and all other services specified in this paragraph to patients with the illnesses
of alcoholism and drug dependency.
[1983, c. 527, § 2 (new).]
C. "Treatment plan" means a written plan initiated at the time of admission, approved by a Doctor of Medicine, Doctor of Osteopathy
or a Registered Substance Abuse Counselor employed by a certified or licensed substance abuse program, including, but not
limited to, the patient's medical, drug and alcoholism history; record of physical examination; diagnosis; assessment of physical
capabilities; mental capacity; orders for medication, diet and special needs for the patient's health or safety and treatment,
including medical, psychiatric, psychological, social services, individual, family and group counseling; and educational,
support and referral services.
[1983, c. 527, § 2 (new).]
[1983, c. 527, § 2 (rpr).]
3. Requirement. Every insurer which issues group health care contracts providing coverage for hospital care to residents of this State shall
provide benefits as required in this section to any subscriber or other person covered under those contracts for the treatment
of alcoholism and other drug dependency pursuant to a treatment plan.
[1983, c. 527, § 2 (new).]
4. Services; providers. Each grop contract shall provide, at a minimum, for the following coverage, pursuant to a treatment plan:
A. Residential treatment at a hospital or free-standing residential treatment center which is licensed, certified or approved
by the State; and
[1983, c. 527, § 2 (new).]
B. Outpatient care rendered by state licensed, certified or approved providers.
[1983, c. 527, § 2 (new).]
Treatment or confinement at any facility shall not preclude further or additional treatment at any other eligible facility,
provided that the benefit days used do not exceed the total number of benefit days provided for under the contract.
[1983, c. 527, § 2 (new).]
5. Exceptions. This section shall not apply to employee group insurance policies issued to employers with 20 or fewer employees insured
under the group policy or to group policies designed primarily to supplement the Civilian Health and Medical Program of the
Uniformed Services, as described in Title 10 of the United States Code, Title 10, Section 1072, subsection 4.
[1989, c. 490, §3 (amd).]
6. Limits; coinsurance; deductibles. Any policy or contract which provides coverage for the services required by this section may contain provisions for maximum
benefits and coinsurance, and reasonable limitations, deductibles and exclusions to the extent that these provisions are not
inconsistent with the requirements of this section.
[1983, c. 527, § 2 (new).]
7. Notice. At the time of delivery or renewal, the group health insurer shall provide written notification to all individuals eligible
for benefits under group policies or contracts of these alcoholism and drug dependency benefits.
[1983, c. 527, § 2 (new).]
8. Confidentiality. The confidentiality of all alcoholism and drug treatment patient records shall be protected.
[1983, c. 527, § 2 (new).]
9. Reports to the Superintendent of Insurance. Every insurer subject to this section shall report its experience for each calendar year beginning with 1984 to the superintendent
not later than April 30th of the following year. The report shall be in a form prescribed by the superintendent and shall
include the amount of claims paid in this State for the services required by this section and the total amount of claims paid
in this State for group health care contracts, both separated between those paid for inpatient and outpatient services. The
superintendent shall compile this data for all insurers in an annual report.
[1983, c. 527, § 2 (new).]
10. Application; expiration. The requirements of this section shall apply to all policies and any certificates or contracts executed, delivered, issued
for delivery, continued or renewed in this State on or after January 1, 1984. For purposes of this section, all contracts
shall be deemed to be renewed no later than the next yearly anniversary of the contract date.
[1987, c. 480, § 5 (rpr).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2843. Mental health services coverage
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2843. Mental health services coverage
1. Findings. The Legislature finds that:
A. Mental illness affects nearly 170,000 Maine people each year, resulting in anguish, grief, desperation, fear, isolation
and a sense of hopelessness of significant levels among victims and families;
[1983, c. 515, §6 (new).]
B. Consequences of mental illness include the expenditure of millions of dollars of public funds for treatment and losses of
millions of dollars by Maine businesses in accidents, absenteeism, nonproductivity and turnover. Excessive stress and anxiety
and other forms of mental illness clearly contribute to general health problems and costs;
[1983, c. 515, §6 (new).]
C. Typical health coverage in this State discriminates against mental illness, the victims and affected families with nonexistent
or limited benefits compared to provisions for other illnesses; and
[1983, c. 515, §6 (new).]
D. Experience in this State and several other states demonstrates that the risk of mental illness can be insured at reasonable
cost and with adequate controls on quality and utilization of treatment.
[1983, c. 515, §6 (new).]
[1983, c. 515, §6 (new).]
2. Policy and purpose. The Legislature declares that it is the policy of this State to:
A. Promote equitable and nondiscriminatory health coverage benefits for all forms of illness, including mental and emotional
disorders, which are of significant consequence to the health of Maine people and which can be treated in a cost effective
manner;
[1983, c. 515, §6 (new).]
B. Assure that victims of mental and other illnesses have access to and choice of appropriate treatment at the earliest point
of illness in least restrictive settings;
[1983, c. 515, §6 (new).]
C. Assure that costs of treatment of mental illness are supported through an equitable combination of public and private responsibilities;
and
[1983, c. 515, §6 (new).]
D. Assure that the Legislature reasonably exercises its legal responsibility for insurance policy in this State by prescribing
types of illnesses and treatment for which benefits shall be provided.
[1983, c. 515, §6 (new).]
[1983, c. 515, §6 (new).]
3. Definitions. For purposes of this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Day treatment services" includes psychoeducational, physiological, psychological and psychosocial concepts, techniques
and processes to maintain or develop functional skills of clients, provided to individuals and groups for periods of more
than 2 hours but less than 24 hours per day.
[1983, c. 515, §6 (new).]
A-1. "Diagnostic and statistical manual" means the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, published
by the American Psychiatric Association.
[2003, c. 20, Pt. VV, §10 (new); §25 (aff).]
A-2. "Home health care services" means those services rendered by a licensed provider of mental health services to provide medically
necessary health care to a person suffering from a mental illness in the person's place of residence if:
(1) Hospitalization or confinement in a residential treatment facility would otherwise have been required if home health
care services were not provided;
(2) Hospitalization or confinement in a residential treatment facility is not required as an antecedent to the provision
of home health care services; and
(3) The services are prescribed in writing by a licensed allopathic or osteopathic physician or a licensed psychologist who
is trained and has received a doctorate in psychology specializing in the evaluation and treatment of mental illness.
[2003, c. 20, Pt. VV, §10 (new); §25 (aff).]
B. "Inpatient services" includes a range of physiological, psychological and other intervention concepts, techniques and processes
in a community mental health psychiatric inpatient unit, general hospital psychiatric unit or psychiatric hospital licensed
by the Department of Health and Human Services or accredited public hospital to restore psychosocial functioning sufficient
to allow maintenance and support of the client in a less restrictive setting.
[1983, c. 515, §6 (new); 2003, c. 689, Pt. B, §6 (rev).]
B-1. "Medically necessary health care" has the same meaning as in section 4301-A, subsection 10-A.
[2003, c. 20, Pt. VV, §11 (new); §25 (aff).]
C. "Outpatient services" includes screening, evaluation, consultations, diagnosis and treatment involving use of psychoeducational,
physiological, psychological and psychosocial evaluative and interventive concepts, techniques and processes provided to individuals
and groups.
[1983, c. 515, §6 (new).]
D. "Person suffering from a mental illness" means a person whose psychobiological processes are impaired severely enough to
manifest problems in the areas of social, psychological or biological functioning. Such a person has a disorder of thought,
mood, perception, orientation or memory that impairs judgment, behavior, capacity to recognize or ability to cope with the
ordinary demands of life. The person manifests an impaired capacity to maintain acceptable levels of functioning in the areas
of intellect, emotion or physical well-being.
[2003, c. 20, Pt. VV, §12 (amd); §25 (aff).]
E. "Provider" means individuals included in section 2835, and a licensed physician with 3 years approved residency in psychiatry,
an accredited public hospital or psychiatric hospital or a community agency licensed at the comprehensive service level by
the Department of Health and Human Services. All agency or institutional providers named in this paragraph shall assure that
services are supervised by a psychiatrist or licensed psychologist.
[1995, c. 560, Pt. K, §82 (amd); §83 (aff); 2001, c. 354, §3 (amd); 2003, c. 689, Pt. B, §6 (rev).]
[2003, c. 20, Pt. VV, §§10-12 (amd); §25 (aff); c. 689, Pt. B, §6 (rev).]
4. Requirement. Every insurer that issues group health care contracts providing coverage to residents of this State shall provide benefits
as required in this section to any subscriber or other person covered under those contracts for conditions arising from mental
illness.
[2003, c. 20, Pt. VV, §13 (amd); §25 (aff).]
5. Services. Each group contract must provide for medically necessary health care for a person suffering from mental illness. Medically
necessary health care includes, but is not limited to, the following services for a person suffering from a mental illness:
A. Inpatient care;
[1983, c. 515, §6 (new).]
B. Day treatment services;
[2003, c. 20, Pt. VV, §13 (amd); §25 (aff).]
C. Outpatient services; and
[2003, c. 20, Pt. VV, §13 (amd); §25 (aff).]
D. Home health care services.
[2003, c. 20, Pt. VV, §13 (new); §25 (aff).]
[2003, c. 20, Pt. VV, §13 (amd); §25 (aff).]
5-A. Exceptions. This section shall not apply to employee group insurance policies issued to employers with 20 or fewer employees insured
under the group policy or to group policies designed primarily to supplement the Civilian Health and Medical Program of the
Uniformed Services, as described in the United States Code, Title 10, Section 1072, subsection 4.
[1989, c. 490, §4 (amd).]
5-B. Coverage for certain mental illness treatment.
[1991, c. 881, §3 (new); §7 (aff); §8 (rp).]
5-C. Coverage for treatment for certain mental illness. Coverage for medical treatment for mental illnesses listed in paragraph A-1 is subject to this subsection.
A.
[2003, c. 20, Pt. VV, §14 (rp); §25 (aff).]
A-1. All group contracts must provide, at a minimum, benefits according to paragraph B, subparagraph (1) for a person receiving
medical treatment for any of the following categories of mental illness as defined in the Diagnostic and Statistical Manual,
except for those that are designated as "V" codes by the Diagnostic and Statistical Manual:
(1) Psychotic disorders, including schizophrenia;
(2) Dissociative disorders;
(3) Mood disorders;
(4) Anxiety disorders;
(5) Personality disorders;
(6) Paraphilias;
(7) Attention deficit and disruptive behavior disorders;
(8) Pervasive developmental disorders;
(9) Tic disorders;
(10) Eating disorders, including bulimia and anorexia; and
(11) Substance abuse-related disorders.
For the purposes of this paragraph, the mental illness must be diagnosed by a licensed allopathic or osteopathic physician
or a licensed psychologist who is trained and has received a doctorate in psychology specializing in the evaluation and treatment
of mental illness.
[2003, c. 20, Pt. VV, §14 (new); §25 (aff).]
B. All policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State must
provide benefits that meet the requirements of this paragraph.
(1) The contracts must provide benefits for the treatment and diagnosis of mental illnesses under terms and conditions that
are no less extensive than the benefits provided for medical treatment for physical illnesses.
(2) At the request of a reimbursing insurer, a provider of medical treatment for mental illness shall furnish data substantiating
that initial or continued treatment is medically necessary health care. When making the determination of whether treatment
is medically necessary health care, the provider shall use the same criteria for medical treatment for mental illness as for
medical treatment for physical illness under the group contract.
(3) If benefits and coverage provided for treatment of physical illness are provided on an expense-incurred basis, the benefits
and coverage required under this subsection may be delivered separately under a managed care system.
(4) A policy or contract may not have separate maximums for physical illness and mental illness, separate deductibles and
coinsurance amounts for physical illness and mental illness, separate out-of-pocket limits in a benefit period of not more
than 12 months for physical illness and mental illness or separate office visit limits for physical illness and mental illness.
(5) A health benefit plan may not impose a limitation on coverage or benefits for mental illness unless that same limitation
is also imposed on the coverage and benefits for physical illness covered under the policy or contract.
(6) Copayments required under a policy or contract for benefits and coverage for mental illness must be actuarially equivalent
to any coinsurance requirements or, if there are no coinsurance requirements, may not be greater than any copayment or coinsurance
required under the policy or contract for a benefit or coverage for a physical illness.
(7) For the purposes of this section, a medication management visit associated with a mental illness must be covered in
the same manner as a medication management visit for the treatment of a physical illness and may not be counted in the calculation
of any maximum outpatient treatment visit limits.
[2003, c. 20, Pt. VV, §14 (amd); §25 (aff).]
This subsection does not apply to policies, contracts and certificates covering employees of employers with 20 or fewer employees,
whether the group policy is issued to the employer, to an association, to a multiple-employer trust or to another entity.
[2003, c. 20, Pt. VV, §14 (amd); §25 (aff).]
5-D. Mandated offer of coverage for certain mental illnesses. Except as otherwise provided in subsection 5-C, coverage for medical treatment for mental illnesses listed in paragraph
A by all group contracts is subject to this subsection.
A. All group contracts must make available coverage providing, at a minimum, benefits according to paragraph B, subparagraph
(1) for a person receiving medical treatment for any of the following mental illnesses diagnosed by a licensed allopathic
or osteopathic physician or a licensed psychologist who is trained and has received a doctorate in psychology specializing
in the evaluation and treatment of mental illness:
(1) Schizophrenia;
(2) Bipolar disorder;
(3) Pervasive developmental disorder, or autism;
(4) Paranoia;
(5) Panic disorder;
(6) Obsessive-compulsive disorder; or
(7) Major depressive disorder.
[2003, c. 20, Pt. VV, §15 (amd); §25 (aff).]
B. All group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State
must make available coverage providing benefits that meet the requirements of this paragraph.
(1) The offer of coverage must provide benefits for the treatment and diagnosis of mental illnesses under terms and conditions
that are no less extensive than the benefits provided for medical treatment for physical illnesses.
(2) At the request of a reimbursing insurer, a provider of medical treatment for mental illness shall furnish data substantiating
that initial or continued treatment is medically necessary health care. When making the determination of whether treatment
is medically necessary health care, the provider shall use the same criteria for medical treatment for mental illness as for
medical treatment for physical illness under the group contract.
[2003, c. 20, Pt. VV, §15 (amd); §25 (aff).]
[2003, c. 20, Pt. VV, §15 (amd); §25 (aff).]
6. Limits; coinsurance; deductibles. Any policy or contract which provides coverage for the services required by this section may contain provisions for maximum
benefits and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not
inconsistent with the requirements of this section.
[1983, c. 515, §6 (new).]
7. Reports to the Superintendent of Insurance. Every insurer subject to this section shall report its experience for each calendar year to the superintendent not later
than April 30th of the following year. The report must be in a form prescribed by the superintendent and include the amount
of claims paid in this State for the services required by this section and the total amount of claims paid in this State for
group health care contracts, both separated between those paid for inpatient, day treatment and outpatient services. The
superintendent shall compile this data for all insurers in an annual report.
[1995, c. 407, §8 (amd).]
8. Application. This section does not apply to accidental injury, specified disease, hospital indemnity, Medicare supplement, long-term
care or other limited benefit health insurance policies. Except as otherwise provided in this section, the requirements of
this section apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed
in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary
of the contract date.
[2003, c. 517, Pt. B, §16 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2844. Coordination of benefits
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2844. Coordination of benefits
1. Authorization. Provisions contained in group and blanket health insurance contracts relating to coordination of benefits payable under
the contract and under other plans of insurance or of health care coverage under which a certificate holder or the certificate
holder's dependents may be covered must conform to rules adopted by the superintendent. These rules may establish uniformity
in the permissive use of coordination of benefits provisions in order to avoid claim delays and misunderstandings that otherwise
result from the use of inconsistent or incompatible provisions among the several insurers and nonprofit hospital, medical
service and health care plans.
[1995, c. 332, Pt. H, §1 (amd).]
1-A. Coordination with Medicare. Coordination of benefits is governed by the following provisions.
A. The contract may not coordinate benefits with Medicare Part A unless:
(1) The insured is enrolled in Medicare Part A;
(2) The insured was previously enrolled in Medicare Part A and voluntarily disenrolled;
(3) The insured stated on an application or other document that the insured was enrolled in Medicare Part A; or
(4) The insured is eligible for Medicare Part A without paying a premium and the certificate states that it will not pay
benefits that would be payable under Medicare even if the insured fails to exercise the insured's right to premium-free Medicare
Part A coverage.
[1997, c. 604, Pt. G, §2 (new).]
B. The contract may not coordinate benefits with Medicare Part B unless:
(1) The insured is enrolled in Medicare Part B;
(2) The insured was previously enrolled in Medicare Part B and voluntarily disenrolled;
(3) The insured stated on an application or other document that the insured was enrolled in Medicare Part B; or
(4) The insured is eligible for Medicare Part A without paying a premium and the insurer provided prominent notification
to the insured both when the certificate was issued and, if applicable, when the insured becomes eligible for Medicare due
to age. The notification must state that the contract will not pay benefits that would be payable under Medicare even if
the insured fails to enroll in Medicare Part B.
[1997, c. 604, Pt. G, §2 (new).]
C. Coordination is not permitted with Medicare coverage for which the insured is eligible but not enrolled except as provided
in paragraphs A and B.
[1997, c. 604, Pt. G, §2 (new).]
[1997, c. 604, Pt. G, §2 (new).]
2. Medicaid and Cub Care programs. Insurers may not consider the availability or eligibility for medical assistance under 42 United States Code, Section 13969,
referred to as "Medicaid," or Title 22, section 3174-R, referred to as the "Cub Care program," when considering coverage eligibility
or benefit calculations for insureds and covered family members.
A. To the extent that payment for coverage expenses has been made under the Medicaid program or the Cub Care program for health
care items or services furnished to an individual, the State is considered to have acquired the rights of the insured or family
member to payment by the insurer for those health care items or services. Upon presentation of proof that the Medicaid program
or the Cub Care program has paid for covered items or services, the insurer shall make payment to the Medicaid program or
the Cub Care program according to the coverage provided in the contract or certificate.
[1997, c. 777, Pt. B, §3 (amd).]
B. An insurer may not impose requirements on a state agency that has been assigned the rights of an individual eligible for
Medicaid or Cub Care coverage and covered by a subscriber contract that are different from requirements applicable to an agent
or assignee of any other covered individual.
[1997, c. 777, Pt. B, §3 (amd).]
[1997, c. 777, Pt. B, §3 (amd).]
3. Credit toward deductible. When an insured is covered under more than one expense-incurred health plan, payments made by the primary plan, payments
made by the insured and payments made from a health savings account or similar fund for benefits covered under the secondary
plan must be credited toward the deductible of the secondary plan. This subsection does not apply if the secondary plan is
designed to supplement the primary plan.
[2005, c. 121, Pt. D, §3 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2845. Cardiac rehabilitation coverage
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2845. Cardiac rehabilitation coverage
1. Requirement. Every insurer which issues group health care contracts providing coverage for hospital care to residents of this State shall
make available to groups of 20 or more persons, at the option of the policyholder, benefits as required by this section to
any certificate holder or other person covered under those contracts for the expense of cardiac rehabilitation.
[1987, c. 293, § 2 (new).]
2. Cardiac rehabilitation. "Cardiac rehabilitation" means multidisciplinary, medically necessary treatment of persons with documented cardiovascular
disease, which shall be provided in either a hospital or other setting. That treatment shall include outpatient treatment
which is initiated within 26 weeks after the diagnosis of that disease and physician-recommended continuance of Phase II rehabilitation
services for up to 36 sessions in a hospital or community-based setting and up to 36 Phase III sessions in a community-based
setting.
[1987, c. 293, § 2 (new).]
3. Limitations. Benefits required to be made available pursuant to this section may be made subject to any reasonable limitation, maximum
benefit, coinsurance, deductible or exclusion provisions applicable to overall benefits under the policy or certificate.
[1987, c. 293, § 2 (new).]
4. Application. The requirements of this section shall apply to all policies and certificates executed, delivered, issued for delivery,
continued or renewed in this State on or after January 1, 1988. For purposes of this section only, all group policies shall
be deemed to be renewed no later than the next yearly anniversary of the contract date.
[1987, c. 293, §2 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2846. Acquired Immune Deficiency Syndrome
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2846. Acquired Immune Deficiency Syndrome
A group health insurance policy or certificate delivered or issued for delivery in this State may not provide more restrictive
benefits for sickness or disablement or the related expenses resulting from Acquired Immune Deficiency Syndrome (AIDS), AIDS
Related Complex (ARC) or HIV related diseases than for any other sickness or disabling condition or exclude benefits for AIDS,
ARC or HIV related diseases except through an exclusion under which all sicknesses and diseases are treated the same. This
section does not apply to a policy providing benefits for specific diseases or accidental injury only.
[2003, c. 517, Pt. B, §17 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-A. Penalty for failure to notify of hospitalization
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-A. Penalty for failure to notify of hospitalization
An insurance policy may not include a provision permitting the insurer to impose a penalty for the failure of any person to
notify the insurer of an insured person's hospitalization for emergency treatment. For purposes of this section, "emergency
treatment" has the same meaning as defined in Title 22, section 1829.
[1991, c. 695, §5 (new); c. 824, Pt. A, §51 (new).]
div>
This section applies to policies and certificates executed, delivered, issued for delivery, continued or renewed in this State
after the effective date of this section. For purposes of this section, all policies are deemed to be renewed no later than
the next yearly anniversary of the contract date.
[1991, c. 695, §5 (new); c. 824, Pt. A, §51 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-B. Jury service
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-B. Jury service
1. Prohibition. An insurer that issues group or blanket health care contracts providing coverage for medical care to residents of this State
may not terminate coverage for any person covered under those contracts because the person has been summonsed for or is engaged
in jury service under Title 14, chapter 305, subchapter I-A.
[1991, c. 695, §5 (new); c. 824, Pt. A, §51 (new).]
2. Application. This section applies to all policies and any certificate executed, delivered, issued for delivery, continued or renewed
in this State on or after January 1, 1991. For purposes of this section, all contracts are deemed to be renewed no later
than the next yearly anniversary of the contract date.
[1991, c. 695, §5 (new); c. 824, Pt. A, §51 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-C. Notification prior to cancellation
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-C. Notification prior to cancellation
The superintendent shall, by January 1, 1991, adopt rules to provide for notification of the insured person and another person,
if designated by the insured, prior to cancellation of a health insurance certificate for nonpayment of premiums, and to provide
restrictions on cancellation when an insured person suffers from organic brain disease.
[1991, c. 695, §5 (new); c. 824, Pt. A, §51 (new).]
div>
The rules may include, but are not limited to, definitions, minimum disclosure requirements, notice provisions and cancellation
restrictions.
[1991, c. 695, §5 (new); c. 824, Pt. A, §51 (new).]
div>
The requirements of this section apply to all policies and certificates executed, delivered, issued for delivery, continued
or renewed in this State.
[1991, c. 695, §5 (new); c. 824, Pt. A, §51 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-D. Penalty for noncompliance with utilization review programs
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-D. Penalty for noncompliance with utilization review programs
A policy or certificate issued or renewed after April 8, 1994 may not contain a provision that permits, upon retroactive review
and confirmation of medical necessity, the imposition of a penalty of more than $500 for failure to provide notification under
a utilization review program. This section does not limit the right of insurers to deny a claim when appropriate prospective
or retroactive review concludes that services or treatment rendered were not medically necessary.
[1995, c. 332, Pt. M, §9 (amd).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-E. Coverage for diabetes supplies
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-E. Coverage for diabetes supplies
All group insurance policies, contracts and certificates must provide coverage for the medically appropriate and necessary
equipment, limited to insulin, oral hypoglycemic agents, monitors, test strips, syringes and lancets, and the out-patient
self-management training and educational services used to treat diabetes, if:
[2003, c. 517, Pt. A, §8 (amd); §13 (aff).]
1. Certification of medical necessity. The insured's treating physician or a physician who specializes in the treatment of diabetes certifies that the equipment
and services are necessary; and
[1995, c. 592, §3 (new).]
2. Provision of medical services. The diabetes out-patient self-management training and educational services are provided through ambulatory diabetes education
facilities authorized by the State's Diabetes Control Project within the Bureau of Health.
[1995, c. 592, §3 (new).]
div>
The requirements of this section apply to all group policies, contracts and certificates executed, delivered, issued for delivery,
continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the
next yearly anniversary of the contract date.
[2003, c. 517, Pt. A, §8 (new); §13 (aff).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-F. Gynecological and obstetrical services (REALLOCATED FROM TITLE 24-A, SECTION 2850-A)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-F. Gynecological and obstetrical services (REALLOCATED FROM TITLE 24-A, SECTION 2850-A)
1. Coverage in managed care plans. With respect to managed care plans that require group members to select primary care physicians, an insurer that issues
group health insurance policies, contracts and certificates must meet the following requirements.
A. The insurer must permit a physician who specializes in obstetrics and gynecology to serve as a primary care physician if
the physician qualifies under the insurer's credentialling policy.
[1997, c. 370, Pt. H, §1 (ral).]
B. All group plan contracts must provide coverage for an annual gynecological examination, including routine pelvic and clinical
breast examinations, performed by a physician, certified nurse practitioner or certified nurse midwife participating in the
plan, without requiring the prior approval of the primary care physician.
[1997, c. 370, Pt. H, §1 (ral).]
C. If the examination specified in paragraph B reveals a gynecological condition for which another visit to the physician participating
in the plan is medically required and appropriate, or for any gynecological care beyond the annual examination, the carrier
may require the patient or the examining physician, certified nurse practitioner or certified nurse midwife to secure from
the patient's primary care physician a referral to the participating physician, certified nurse practitioner or certified
nurse midwife from whom such care may be obtained.
[1997, c. 370, Pt. H, §1 (ral).]
[2003, c. 517, Pt. A, §9 (amd); §13 (aff).]
2. Application. This section applies to all policies, contracts and certificates executed, delivered, issued for delivery, continued or
renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly
anniversary of the contract date.
[2003, c. 517, Pt. A, §9 (amd); §13 (aff).]
div>
This section does not prohibit a carrier from requiring a physician, certified nurse practitioner or certified nurse midwife
participating in the plan to inform a woman's primary care physician prior to each treatment pursuant to this section.
[1997, c. 370, Pt. H, §1 (ral).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-G. Coverage for contraceptives
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-G. Coverage for contraceptives
1. Coverage requirements. All group insurance policies and contracts, except accidental injury, specified disease, hospital indemnity, Medicare supplement,
disability income, long-term care and other limited benefit health insurance policies and contracts that provide coverage
for prescription drugs or outpatient medical services must provide coverage for all prescription contraceptives approved by
the federal Food and Drug Administration or for outpatient contraceptive services, respectively, to the same extent that coverage
is provided for other prescription drugs or outpatient medical services. For purposes of this section, the term "outpatient
contraceptive services" means consultations, examinations, procedures and medical services provided on an outpatient basis
and related to the use of contraceptive methods to prevent an unintended pregnancy. This section may not be construed to
apply to prescription drugs or devices that are designed to terminate a pregnancy.
[1999, c. 341, §3 (new); §5 (aff).]
2. Exclusion for religious employer. A religious employer may request and an insurer shall grant an exclusion under the policy or contract for the coverage
required by this section if the required coverage conflicts with the religious employer's bona fide religious beliefs and
practices. A religious employer that obtains an exclusion under this subsection shall provide prospective insureds and those
individuals insured under its policy written notice of the exclusion. This section may not be construed as authorizing an
insurer to exclude coverage for prescription drugs prescribed for reasons other than contraceptive purposes or for prescription
contraception that is necessary to preserve the life or health of a covered person. For the purposes of this section, "religious
employer" means an employer that is a church, convention or association of churches or an elementary or secondary school that
is controlled, operated or principally supported by a church or by a convention or association of churches as defined in 26
United States Code, Section 3121 (w) (3) (A) and that qualifies as a tax-exempt organization under 26 United States Code,
Section 501(c) (3).
[1999, c. 341, §3 (new); §5 (aff).]
3. Application. The requirements of this section apply to all policies, contracts and certificates executed, delivered, issued for delivery,
continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the
next yearly anniversary of the contract date.
[2003, c. 517, Pt. B, §18 (new).]
24-A §02847-G
Coverage for services of certified nurse practitioners; certified nurse midwives
(As enacted by PL 1999, c. 396, §3 and affected by §7 is REALLOCATED TO TITLE 24-A, SECTION 2847-H)
24-A §02847-G
Coverage for services provided by registered
nurse first assistants
(As enacted by PL 1999, c. 412, §3 is REALLOCATED TO TITLE 24-A, SECTION 2847-I)
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-H. Coverage for services of certified nurse practitioners; certified nurse midwives (REALLOCATED FROM TITLE 24-A, SECTION 2847-G)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-H. Coverage for services of certified nurse practitioners; certified nurse midwives (REALLOCATED FROM TITLE 24-A, SECTION 2847-G)
1. Required coverage for services upon referral of primary care provider. An insurer that issues group health insurance policies and contracts shall provide coverage under those contracts for services
performed by a certified nurse practitioner or certified nurse midwife to a patient who is referred to the certified nurse
practitioner or certified nurse midwife by a primary care provider when those services are within the lawful scope of practice
of the certified nurse practitioner or certified nurse midwife.
[RR 1999, c. 1, §34 (ral).]
2. Required coverage for self-referred services. With respect to group health insurance policies and contracts that do not require the selection of a primary care provider,
an insurer shall provide coverage under those contracts for services performed by a certified nurse practitioner or certified
nurse midwife when those services are covered services and when they are within the lawful scope of practice of the certified
nurse practitioner or certified nurse midwife.
[RR 1999, c. 1, §34 (ral).]
3. Limits; coinsurance; deductibles. Any contract that provides coverage for services under this section may contain provisions for maximum benefits and coinsurance
and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements
of this section.
[RR 1999, c. 1, §34 (ral).]
4. Application. The requirements of this section apply to all group policies, contracts and certificates executed, delivered, issued for
delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later
than the next yearly anniversary of the contract date.
[2003, c. 517, Pt. B, §19 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-I. Coverage for services provided by registered nurse first assistants (REALLOCATED FROM TITLE 24-A, SECTION 2847-G)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-I. Coverage for services provided by registered nurse first assistants (REALLOCATED FROM TITLE 24-A, SECTION 2847-G)
1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Perioperative nursing" means a practice of nursing in which the nurse provides preoperative, intraoperative and postoperative
nursing care to surgical patients.
[RR 1999, c. 1, §35 (ral).]
B. "Recognized program" means a program that addresses all content of the core curriculum for registered nurse first assistants
as established by the Association of Operating Room Nurses or its successor organization.
[RR 1999, c. 1, §35 (ral).]
C. "Registered nurse first assistant," or "RNFA," means a person who:
(1) Is licensed as a registered nurse under Title 32, chapter 31;
(2) Is experienced in perioperative nursing; and
(3) Has successfully completed a recognized program.
[RR 1999, c. 1, §35 (ral).]
[RR 1999, c. 1, §35 (ral).]
2. Institutional powers. Each health care institution, as defined in Title 22, chapter 405, may establish specific procedures for the appointment
and reappointment of registered nurse first assistants and for granting, renewing and revising their clinical privileges.
[RR 1999, c. 1, §35 (ral).]
3. Required coverage for services. Notwithstanding any other provisions of this chapter, an insurer that issues group health insurance policies and contracts
that provide coverage for surgical first assisting benefits or services shall provide coverage and payment under those contracts
to a registered nurse first assistant who performs services that are within the scope of a registered nurse first assistant's
qualifications. The provisions of this subsection apply only if reimbursement for an assisting physician would be covered
and a registered nurse first assistant who performed those services is used as a substitute. This section does not apply
to policies or contracts that cover only specified diseases.
[RR 1999, c. 1, §35 (ral).]
4. Limits; coinsurance; deductibles. Any contract that provides coverage for the services required by this section may contain provisions for maximum benefits
and coinsurance and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent
with the requirements of this section.
[RR 1999, c. 1, §35 (ral).]
5. Application. The requirements of this section apply to all group policies, contracts and certificates executed, delivered, issued for
delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later
than the next yearly anniversary of the contract date.
[2003, c. 517, Pt. B, §20 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-J. Coverage for hospice care services
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-J. Coverage for hospice care services
1. Definitions. As used in this section, unless the context otherwise indicates, the following terms have the following meanings.
A. "Hospice care services" means services provided on a 24-hours-a-day, 7-days-a-week basis to a person who is terminally ill
and that person's family. "Hospice care services" includes, but is not limited to, physician services; nursing care; respite
care; medical and social work services; counseling services; nutritional counseling; pain and symptom management; medical
supplies and durable medical equipment; occupational, physical or speech therapies; volunteer services; home health care services;
and bereavement services.
[2001, c. 358, Pt. LL, §3 (new); §5 (aff).]
B. "Person who is terminally ill" means a person that has a medical prognosis that the person's life expectancy is 12 months
or less if the illness runs its normal course.
[2001, c. 358, Pt. LL, §3 (new); §5 (aff).]
[2001, c. 358, Pt. LL, §3 (new); §5 (aff).]
2. Coverage for hospice care services. All group insurance policies and contracts must provide coverage for hospice care services to a person who is terminally
ill. Hospice care services must be provided according to a written care delivery plan developed by a hospice care provider
and the recipient of hospice care services. Coverage for hospice care services must be provided whether the services are provided
in a home setting or an inpatient setting.
[2001, c. 358, Pt. LL, §3 (new); §5 (aff).]
3. Application. The requirements of this section apply to all group policies, contracts and certificates executed, delivered, issued for
delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later
than the next yearly anniversary of the contract date.
[2003, c. 517, Pt. B, §21 (new).]
24-A §02847-J
Coverage for general anesthesia for dentistry
(REPEALED)
(REALLOCATED TO TITLE 24-A, SECTION 2847-K)
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-K. Coverage for general anesthesia for dentistry (REALLOCATED FROM TITLE 24-A, SECTION 2847-J)
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-K. Coverage for general anesthesia for dentistry (REALLOCATED FROM TITLE 24-A, SECTION 2847-J)
1. Enrollee defined. For the purposes of this section, unless the context otherwise indicates, "enrollee" means a person who is covered under
a group health insurance contract provided by an insurer.
[RR 2001, c. 1, §33 (ral).]
2. General anesthesia and associated facility charges. An insurer that issues group health insurance contracts shall provide coverage for general anesthesia and associated facility
charges for dental procedures rendered in a hospital when the clinical status or underlying medical condition of an enrollee
requires dental procedures that ordinarily would not require general anesthesia to be rendered in a hospital. The insurer
may require prior authorization of general anesthesia and associated charges required for dental care procedures in the same
manner that prior authorization is required for other covered diseases or conditions.
[RR 2001, c. 1, §33 (ral).]
3. Limitations on coverage. This section applies only to general anesthesia and associated facility charges for only the following enrollees if the
enrollees meet the criteria in subsection 2:
A. Enrollees, including infants, exhibiting physical, intellectual or medically compromising conditions for which dental treatment
under local anesthesia, with or without additional adjunctive techniques and modalities, can not be expected to provide a
successful result and for which dental treatment under general anesthesia can be expected to produce a superior result;
[RR 2001, c. 1, §33 (ral).]
B. Enrollees demonstrating dental treatment needs for which local anesthesia is ineffective because of acute infection, anatomic
variation or allergy;
[RR 2001, c. 1, §33 (ral).]
C. Extremely uncooperative, fearful, anxious or uncommunicative children or adolescents with dental needs of such magnitude
that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral
pain or infection, loss of teeth or other increased oral or dental morbidity; and
[RR 2001, c. 1, §33 (ral).]
D. Enrollees who have sustained extensive oral-facial or dental trauma for which treatment under local anesthesia would be
ineffective or compromised.
[RR 2001, c. 1, §33 (ral).]
[RR 2001, c. 1, §33 (ral).]
4. Dental procedures and dentist's fee not covered. This section does not require an insurer that issues group contracts to cover any charges for the dental procedure itself,
including, but not limited to, the professional fee of the dentist. Coverage for anesthesia and associated facility charges
pursuant to this section is subject to all other terms and conditions of the group contract that apply generally to other
benefits.
[RR 2001, c. 1, §33 (ral).]
5. Coordination of benefits with dental insurance. If an enrollee eligible for coverage under this section is also eligible for coverage for general anesthesia and associated
facility charges under a dental insurance policy or contract, the nonprofit health care service organization or insurer providing
dental insurance is the primary payer responsible for those charges and the insurer providing group health insurance is the
secondary payer.
[RR 2001, c. 1, §33 (ral).]
6. Application. The requirements of this section apply to all group policies, contracts and certificates executed, delivered, issued for
delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later
than the next yearly anniversary of the contract date.
[2003, c. 517, Pt. B, §22 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847-L. Offer of coverage for breast reduction surgery and symptomatic varicose vein surgery
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847-L. Offer of coverage for breast reduction surgery and symptomatic varicose vein surgery
All group health insurance policies, contracts and certificates must make available coverage for breast reduction surgery
and symptomatic varicose vein surgery determined to be medically necessary health care as defined in section 4301-A, subsection
10-A.
[2005, c. 128, §3 (new); §5 (aff).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
Title 24-A - §2847. Utilization review data
Title 24-A: MAINE INSURANCE CODE
Chapter 35: GROUP AND BLANKET HEALTH INSURANCE
§2847. Utilization review data
1. Report required. On or before April 1st of each year, any insurer or 3rd-party administrator which issues or administers a program or contract
in this State providing coverage for hospital care that contains a provision whereby in nonemergency cases the insured is
required to be prospectively evaluated through a prehospital admission certification, preinpatient service eligibility program
or any similar preutilization review or screening eligibility program or any similar preutilization review or screening procedure
prior to the delivery of contemplated hospitalization, inpatient or outpatient health care or medical services which are prescribed
or ordered by a duly licensed physician shall file a report on the results of that evaluation for the preceding year with
the superintendent which shall contain the following:
A. The number and type of evaluations performed. For the purposes of this section, the term "type of evaluations" means the
following preutilization review categories: presurgical inpatient days; setting of medical service, such as inpatient or
outpatient services; and the number of days of service;
[1989, c. 556, Pt. C, §3 (new).]
B. The result of the evaluation, such as whether the medical necessity of the level of service contemplated by the patient's
physician was agreed to or whether benefits paid for the service were reduced by the insurer;
[1989, c. 556, Pt. C, §3 (new).]
C. The number and result of any appeals by the patients or their physicians as a result of initial review decisions to reduce
benefits for services as determined through prospective evaluations; and
[1989, c. 556, Pt. C, §3 (new).]
D. Any complaints filed in a court of competent jurisdiction and served upon an insurer filing under this section stating a
cause of action against that insurer on the basis of damages to patients alleged to have been approximately caused by a delay,
reduction or denial of medical benefits by the insurer, as determined through prospective evaluations, and the determination
of liability or other disposition of the complaint.
[1989, c. 556, Pt. C, §3 (new).]
[1989, c. 556, Pt. C, §3 (new).]
2. Residents. This section is applicable to evaluations, appeals and complaints relating to residents of this State only.
[1989, c. 556, Pt. C, §3 (new).]
3. Confidentiality. Any information provided pursuant to this section shall not identify the patients.
[1989, c. 556, Pt. C, §3 (new).]
The Revisor's Office cannot provide legal advice or
interpretation of Maine law to the public. If you need legal
advice, please consult
a qualified attorney.
Office of the Revisor of Statutes
7 State House Station
State House Room 108
Augusta, Maine 04333-0007
This page created on: 2005-10-01
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