02-031-281 Me. Code R. § 3

Current through 2024-46, November 13, 2024

Section 031-281-3 - Similar benefits

Conversion policies providing benefits set forth in this section will be deemed to be providing benefits similar to those provided by the group policy from which conversion is being made, in accordance with the requirements of 24-A M.R.S.A. Section 2809-A and 24 M.R.S.A. Section 24M.R.S.A. Section 2330.

A. Insurers other than non-profit hospital, medical, and health care service organizations.

(1) Hospital Surgical Expense Benefits. If the group insurance policy from which conversion is made insures the employee or member, with or without dependent coverage, for basic hospital and/or surgical expense insurance; the covered individuals shall be entitled to obtain a converted policy, or at the insurer's option a group certificate, providing coverage on an expense incurred basis under plans meeting the following requirements:

PLAN A

(a) hospital room and board daily expense benefits in a dollar amount approximating or equal to the average semi-private rate charged in metropolitan areas of this State, as determined by the Superintendent, for a period of seventy days per hospital confinement,

(b) miscellaneous hospital expense benefits, in the amount of ten times the room and board daily expense benefit, per hospital confinement, and

(c) surgical expense benefits according to a surgical schedule consistent with those customarily offered by the insurer under group or individual health insurance policies and providing a maximum benefit of eight hundred dollars; or

PLAN B

(a) hospital room and board daily expense benefits in a dollar amount equal to 75 percent of the dollar amount determined in Plan A, for a period of seventy days per hospital confinement,

(b) miscellaneous hospital expense benefits, in the amount of ten times the hospital room and board daily expense benefits, per hospital confinement, and

PLAN C

(a) hospital room and board daily expense benefits in a dollar amount equal to 50 percent of the dollar amount determined for Plan A, for a period of seventy days per hospital confinement.

(b) miscellaneous hospital expense benefits, in the amount of ten times the hospital room and board daily expense benefit, per hospital confinement, and

The insurer must offer all three of these plans. The individual may choose any one of the three. The average semi-private rate referred to in Plan A, Subparagraph a, originally determined to be $200 in Bureau Rules Chapter 280 effective October 18, 1982, shall continue to be $200 until July 1, 1988.

Effective July 1, 1988, this amount will increase to $240. Any insurer needing to file new forms or rates in order to comply with this change, must submit the filing on or before April 1, 1988. Any insurer intending to use previously approved forms and rates to comply with this change, must file a statement, specifying the forms and rates to be used, by April 1, 1988.

The average semi-private rate referred to in Plan A, Subparagraph a, may be redetermined by the Superintendent from time to time, as to converted policies issued subsequent to such redetermination, but not more often than once in three years. The dollar amounts in Plan A, B, and C shall be rounded upward to the nearest multiple of ten dollars ($10).

For the purpose of determining the hospital room and board daily expense benefits and the miscellaneous hospital expense benefits under Plans A, B, and C, the policy or certificate may define recurrent hospital confinements resulting from the same cause to be one continuous period of confinement if the confinements are separated by a period of less than 180 days. If recurrent hospital confinements do not result from the same cause or are separated by a period of 180 days or more, the subsequent confinement shall be considered to be a separate confinement for the purpose of determining the benefits payable under the policy or certificate.

(2) Major Medical Benefits. If the group insurance policy from which conversion is made insures the employee or member, with or without dependent coverage, for major medical expense insurance; the covered individuals shall be entitled to obtain a converted policy, or at the insurer's option a group certificate, providing major medical coverage under a plan meeting the following requirements:

(a) A Maximum benefit at least equal to either, at the option of the insurer, (i) or (ii) below:

(i) The smaller of the following amounts:

(A) The maximum benefit provided under the group policy; or

(B) A maximum payment of $250,000 per covered person for all covered medical expenses incurred during the covered person's lifetime.

(ii) The smaller of the following amounts:

(A) The maximum benefit provided under the group policy; or

(B) A maximum payment of $250,000 for each unrelated injury or sickness.

(b) Payment of benefits at the rate of 80 percent of covered medical expenses which are in excess of the deductible, until 20 percent of such expenses in a benefit period reaches $1,000, after which benefits will be paid at the rate of 100 percent during the remainder of such benefit period. If the group policy from which conversion is made provided benefits for the outpatient treatment of mental illness at a level exceeding 50 percent of covered expenses, the converted policy need not provide benefits in excess of 50 percent of covered expenses.

(c) A deductible for each benefit period which, at the option of the insurer, shall be (i) the sum of the benefits deductible and $100, or (ii) the corresponding deductible in the group policy from which conversion is made. The term "benefits deductible," as used herein, means the value of any benefits provided on an expense incurred basis with respect to covered medical expenses by: any other hospital, surgical, or medical insurance policy; any hospital or medical service subscriber contract; any medical practice or other prepayment plan; any other plan or program whether on an insured or uninsured basis; or any requirements of state or federal law; and, if pursuant to Subparagraph (f) below the converted policy provides both basic hospital or surgical coverage and major medical coverage, the value of such basic benefits. If the maximum benefit is determined by (a) (ii) above, the insurer may require that the deductible be satisfied during a period of not less than three months, if the deductible is $100 or less; and not less than six months if the deductible exceeds $100.

(d) The benefit period shall be a calendar year when the maximum benefit is determined by (a) (i) above or twenty-four months when the maximum benefit is determined by (a) (ii) above.

(e) The term "covered medical expenses" as used above shall include at least, in the case of hospital room and board charges, the lesser of the dollar amount in Plan A or the average semi-private room and board rate for the hospital in which the individual is confined and twice these amounts for charges in an intensive care unit. Any surgical schedule shall be consistent with those customarily offered by the insurer under group or individual health insurance policies and must provide at least a $1,200 maximum benefit.

(f) If the group insurance policy from which conversion is made provides the employee or member with basic hospital and/or surgical expense insurance as well as major medical expense insurance, then the benefits outlined in paragraphs 1 and 2 above may be offered under one policy or certificate. However, the three basic plans outlined in Section 3(A) (1) above must also be offered as alternatives.

(g) The policy or certificate shall contain no exclusions other than those contained in the group policy from which conversion is made. However, if the group policy covered dental and/or vision services, these services need not be covered by the conversion policy or certificate.

02-031 C.M.R. ch. 281, § 3