Maine Revised Statutes

§4207. Evidence of coverage and charges for health care services

1.    Every person who has enrolled as a legal resident of this State in a health maintenance organization is entitled to evidence of coverage. If the enrollee obtains coverage under a health maintenance organization through an insurance policy or contract whether by option or otherwise, the insurer, nonprofit hospital and medical service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage.
[ 1975, c. 503, (NEW) .]
2.    No evidence of coverage, or amendment thereto, or underlying contract may be issued or delivered to any person in this State until a copy of the form of the evidence of coverage, amendment thereto and any underlying contract, has been filed with and approved by the superintendent. A filing required under this section must be made electronically in a format required by the superintendent unless exempted by rule adopted by the superintendent. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A.
[ 2009, c. 14, §6 (AMD) .]
3.    An evidence of coverage shall contain:
A. No provisions or statements which are unjust, unfair, inequitable, misleading, deceptive, which encourage misrepresentation, or which are untrue, misleading or deceptive as defined in section 4212; and [1975, c. 503, (NEW).]
B. A clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of:
(1) The health care services and the insurance or other benefits, if any, to which the enrollee is entitled;
(2) Any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or copayment feature;
(3) Where and in what manner information is available as to how services may be obtained;
(4) The total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts or an indication whether the plan is contributory or noncontributory with respect to group certificates; and
(5) A clear and understandable description of the health maintenance organization's method of resolving enrollee complaints.
Any subsequent change shall be evidenced in a separate document issued to the enrollee prior to the change. [1975, c. 503, (NEW).]
[ 1975, c. 503, (NEW) .]
4.    A copy of the form of the evidence of coverage to be used in this State, and any amendment thereto shall be subject to the filing and approval requirements of this section unless it is subject to the jurisdiction of the superintendent under the laws governing health insurance, or nonprofit hospital or medical service organization, in which event the filing and approval provisions of such laws shall apply.
[ 1975, c. 503, (NEW) .]
5.    A schedule or an amendment to a schedule of charge for enrollee health coverage for health care services may not be used by any health maintenance organization unless it complies with section 2736, 2808-B or 2839, whichever is applicable.
[ 2003, c. 469, Pt. E, §19 (AMD) .]
6.    Such charges may be established in accordance with actuarial principles for various categories of enrollees, provided that charges applicable to an enrollee shall not be individually determined based on the status of his health. However, the charges shall not be excessive, inadequate or unfairly discriminatory. A certification, by a qualified actuary, to the appropriateness of the charges, based on reasonable assumptions, shall accompany the filing along with adequate supporting information.
[ 1975, c. 503, (NEW) .]
7.    The superintendent shall, within a reasonable period, approve any form and any schedule of charges if the requirements of this section are met. It shall be unlawful to issue such form or to use such schedule of charges until approved. If the superintendent disapproves such filing, he shall notify the filer. In the notice, the superintendent shall specify the reasons for his disapproval. A hearing will be granted within 10 days after a request in writing by the person filing. If the superintendent does not disapprove any form or schedule of charges within 30 days of the filing of such form or charges, they shall be deemed approved.
[ 1975, c. 503, (NEW) .]
8.    The superintendent may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to this section.
[ 1975, c. 503, (NEW) .]
9.    A health maintenance organization may issue a Medicare supplement policy. Chapter 67 and any rules adopted pursuant to that chapter shall apply to health maintenance organizations issuing Medicare supplement policies, except when that application is inconsistent with that chapter.
[ 1989, c. 27, §2 (NEW) .]
1975, c. 503, (NEW). 1989, c. 27, §2 (AMD). 1993, c. 645, §A6 (AMD). 1995, c. 332, §O3 (AMD). 2003, c. 469, §E19 (AMD). 2009, c. 14, §6 (AMD).