Evidences of coverage, including group contracts, individual contracts and certificates, must be delivered or issued for delivery to enrollees or group contract holders not more than fifteen (15) days from the later of the effective date of coverage or the date on which the HMO is notified of enrollment, and must, in addition to the requirements of 24-A M.R.S. §4207, include:
A.Essential Information1) The name, address and telephone number of the HMO.2) How to contact the HMO by telephone at no cost to the enrollee.3) A description of the HMO's service area, or reference to a separate document bearing this information.4) Detailed information on how to obtain services during regular office hours.5) Detailed information on how to obtain services after hours.6) Detailed information on how to obtain emergency, urgent and specialty services.7) Detailed information on how to obtain coverage for emergency and urgent care outside the service area.9) Detailed information about the availability of assistance regarding coverage, complaints, and appeals, including explanations of: a) How to file a complaint or appeal, and a statement of the enrollee's right to contact the Superintendent of Insurance for assistance at any time.The statement shall include the Superintendent's telephone number and address. b) How to obtain assistance from the Maine Consumer Assistance Program in order to understand the enrollee's coverage or appeal rights.The statement shall include the Program's telephone number and address.10) How to select and change providers within the HMO's provider network.11) The processes in place for coordination and continuity of care.12) A description of the medications and services covered and excluded under the contract, including a description of how a consumer may obtain a copy of the plan's certificate of coverage and a copy of the complete formulary or a URL or URLs at which the most current certificate of coverage and prescription formulary may be accessed.B.Eligibility Requirements Explanations of coverage must clearly outline the conditions that must be met by enrollees and their eligible dependents to obtain and maintain coverage.
C.Claims Procedures1) Any required notice to the HMO.2) If claim forms are required, how, when and where to obtain and submit them.3) Any requirements for filing proper proofs of loss.4) Any time limit for payment of claims.5) Notice of any provisions for resolving disputed claims, including appeals and external review.6) All policies 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 Section 9(C) does not affect or limit the payment of benefits otherwise payable under the policy.D.Coordination of Benefits Evidences of coverage may contain a provision for coordination of benefits, providedthat such provision shall not relieve an HMO of its duty to provide or arrange for a covered health care service to an enrollee solely because the enrollee is entitled to coverage under any other contract, policy or plan, including coverage provided under government programs.Coordination with Medicare is permitted underthe same conditions and manner applicable to non-HMO plans and described in 24-A M.R.S. §§ 2844 and 2723-A.
E.Term of CoverageEvidences of coverage shall describe the time and date or occurrence upon which coverage takes effect.
F.Cancellation or Termination The group or individual contract shall contain the conditions upon which cancellation, rescission or other termination may be affected by the HMO, the group contract holder or the enrollee.
G.Renewal Evidences of coverage shall contain the conditions for, and any restrictions upon, the enrollee's right to renew.
K.Grace Period1) The group or individual contract shall provide for a grace period of not less than thirty days for the payment of any premium except the first, during which time the coverage shall remain in effect if payment is made during the grace period.The evidence of coverage shall include notice that a grace period exists under the group contract and that coverage continues in force during the grace period.2) During the grace period: a) The HMO shall remain liable for providing the services and benefits contracted for;b) The contract holder shall remain liable for the payment of premium for coverage during the grace period; andc) The enrollee shall remain liable for any copayments and deductibles.3) If the premium is not paid during the grace period, and the HMO has given 10 days' notice to the designated third party if one has been designated pursuant to Bureau of Insurance Rule 580,coverage is automatically terminated at the end of the grace period, subject to any right of reinstatement pursuant to 24-A M.R.S. §§2707-A or 2847-C.For group contracts the HMO shall provide at least 10 days' notice to certificate holders prior to cancellation in a manner consistent with the requirements of 24-A M.R.S.§2809-A(1-A).Following the effective date of such termination, the HMO shall send the contract holder written notice advising that coverage has been terminated.L.Conformity with State LawEvidences of coverage delivered or issued for delivery in this State shall include a provision stating that any provision not in conformity with Chapter 56 of Title 24-A, this rule or any other applicable law or regulation in this State shall not be rendered invalid but shall be construed and applied as if it were in full compliance with the applicable laws and regulations of this State.
M.Covered Services. A plan must providebasic health care services that include coverage for all state and federally mandated benefits, including any essential health benefits required for individual and small group plans under the federal Affordable Care Act.Mental health and substance use disorder services must be covered in all group and individual contracts in a manner consistent with state and federal mental health parity requirements. [Drafting Note: When the 2017 amendments to this rule were adopted, the Affordable Care Actrequired coverage for the following essential health benefits:
1) Ambulatory patient services, 4) Maternity and newborn care, 5) Mental health and substance use disorder services, including behavioral health treatment,7) Rehabilitative and habilitative services and devices, 9) Preventive and wellness services and chronic disease management,10) Pediatric services, including oral and vision care.] In addition to other state and federal requirements, and to the extent medically necessary, a plan must cover the following, subject to any applicable minimum benefit provisions.
1) Inpatient Hospital Services.3) Routine Newborn Services must be made available under either the mother's policy or the father's policy, consistent with the requirements of 24-A M.R.S.§§4234-B and 4234-C. [Drafting note:When the 2017 amendments to this rule were adopted, routine newborn services included:
1) Routine inpatient hospital nursery care for the newborn,2) Routine inpatient hospital physician services for the newborn, 3) Vaccines and immunizations administered to the newborn prior to discharge, 4) Vitamins administered to the newborn prior to discharge,5) Routine eye care administered to the newborn prior to discharge,6) Metabolic screening administered to the newborn prior to discharge.]4) Annual physical examinations for children and adults, which must include: a) Gynecological examinations, when appropriate. b) For children ages three to seventeen, periodic evaluation of physical and emotional status, a history, a complete physical examination, a developmental assessment, anticipatory guidance, appropriate immunizations, and laboratory tests in keeping with prevailing medical standards.5) Prescription drugsmust be covered, except that the HMO is not required to include a prescription drug benefit for large group plans if the employer has offered a separate prescription drug benefit.6) If emergency care is required, ambulance transportation to the nearest contracted facility or to the nearest non-contracted facility capable of providing necessary care. 7) Home health care by an accredited agency under a written plan by a physician, or other licensed provider such as a Nurse Practitioner or Physician Assistant, working within the provider's scope of practice, for a minimum of 90 visits per calendar year.N.ExclusionsA plan may contain exclusions approved by the Superintendent that are not otherwise prohibited by state or federal law, rule, or regulation.Unless otherwise directed by the Superintendent, HMO plans may contain exclusions similar to exclusions permitted in non-HMO plans that provide Essential Healthcare Benefits in accordance with the Affordable Care Act.
O.Right to Examine Contract An individual contract shall contain a provision stating that the enrollee may return the contract within ten (10) days of receiving it and receive a refund of the premium paid if the person is not satisfied with the contract for any reason.If the contract is returned to the HMO or to the agent through whom it was purchased, it is considered void from the effective date.However, if services are rendered or claims are paid for such person by the HMO during the ten-day examination period and the person returns the contract to receive a refund of the premium paid, the person shall be required to pay for such services.Contracts may impose reasonable requirements on enrollees for establishing the 10 day time frame for returning a purchased contract.This provision does not apply to individuals covered under a group contract issued to an employee group as defined by 24-A M.R.S. §2804 or a labor union group as defined in §2805.
02-031 C.M.R. ch. 191, § 9