Maine Revised Statutes Title 24-A Sec. 4207 – Evidence of coverage and charges for health care services
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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.
[PL 1975, c. 503 (NEW).]
Terms Used In Maine Revised Statutes Title 24-A Sec. 4207
- Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
- Contract: A legal written agreement that becomes binding when signed.
- Copayment: means an amount an enrollee must pay in order to receive a specific service that is not fully prepaid. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Deductible: means the amount an enrollee is responsible to pay out of pocket before a health maintenance organization begins to pay the costs associated with treatment. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Enrollee: means an individual who is enrolled in a health maintenance organization. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Evidence of coverage: means any certificate, agreement or contract issued to a group contract holder or an enrollee setting out the coverage to which an enrollee is entitled. See Maine Revised Statutes Title 24-A Sec. 4202-A
- Health care services: means any services included in the furnishing of medical care, dental care or hospitalization to an individual, or any services incident to the furnishing of that care or hospitalization, as well as the furnishing of any other services to an individual to prevent, alleviate, cure or heal human illness or injury. See Maine Revised Statutes Title 24-A Sec. 4202-A
- health insurance: means insurance of human beings against bodily injury, disablement or death by accident or accidental means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining thereto, including provision for the mental and emotional welfare of human beings by defraying the costs of legal services only to the extent provided for in chapter 38. See Maine Revised Statutes Title 24-A Sec. 704
- Health maintenance organization: means a public or private organization that is organized under the laws of the Federal Government, this State, another state or the District of Columbia or a component of such an organization, and that:
A. See Maine Revised Statutes Title 24-A Sec. 4202-Ain writing: include printing and other modes of making legible words. See Maine Revised Statutes Title 1 Sec. 72 Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases. Nonprofit hospital or medical service organization: means any organization defined in and authorized to act under Title 24, chapter 19. See Maine Revised Statutes Title 24-A Sec. 4202-A Person: means an individual, firm, partnership, corporation, association, syndicate, organization, society, business trust, attorney-in-fact or any legal entity. See Maine Revised Statutes Title 24-A Sec. 4202-A Superintendent: means the Superintendent of Insurance. See Maine Revised Statutes Title 24-A Sec. 4202-A
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.
[PL 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 [PL 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. [PL 1975, c. 503 (NEW).]
[PL 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.
[PL 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.
[PL 2003, c. 469, Pt. E, §19 (AMD).]
6. Such charges may be established in accordance with actuarial principles for various categories of enrollees, as long as charges applicable to an enrollee are not individually determined based on the status of the enrollee’s health. However, the charges may not be excessive, inadequate or unfairly discriminatory. A certification, by a qualified actuary, to the appropriateness of the charges, based on reasonable assumptions, must accompany the filing along with adequate supporting information.
[RR 2021, c. 1, Pt. B, §343 (COR).]
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 is unlawful to issue such form or to use such schedule of charges until approved. If the superintendent disapproves such filing, the superintendent shall notify the filer. In the notice, the superintendent shall specify the reasons for the superintendent’s 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 must be deemed approved.
[RR 2021, c. 1, Pt. B, §344 (COR).]
8. The superintendent may require the submission of whatever relevant information the superintendent considers necessary in determining whether to approve or disapprove a filing made pursuant to this section.
[RR 2021, c. 1, Pt. B, §345 (COR).]
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.
[PL 1989, c. 27, §2 (NEW).]
SECTION HISTORY
PL 1975, c. 503 (NEW). PL 1989, c. 27, §2 (AMD). PL 1993, c. 645, §A6 (AMD). PL 1995, c. 332, §O3 (AMD). PL 2003, c. 469, §E19 (AMD). PL 2009, c. 14, §6 (AMD). RR 2021, c. 1, Pt. B, §§343-345 (COR).