Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 135 - EMPLOYEE BENEFIT EXCESS INSURANCE
Section 031-135-5 - Employee Benefit Excess Insurance Standards

Universal Citation: 02 ME Code Rules ยง 031-135-5

Current through 2024-38, September 18, 2024

1. An employee benefit excess insurance policy may not:

A. Have an annual attachment point that is less than $28,700 for health benefit claims incurred per individual;

B. Have an annual aggregate attachment point for health benefits that is less than 120 percent of expected claims, determined net of any specific excess coverage that might be provided by the policy, and verified by the insurer using reasonable and accepted actuarial principles; or

C.Provide direct coverage to individual plan participants or beneficiaries.

2. An insurer may not offeror renew an employee benefit excess insurance policy to a group with ten or fewer employees enrolled in the group health plan, with the exception of a policy that was in force on the effective date of this rule, covering a group with ten or fewer enrolled employees.

3. If the applicant or policyholder is a small employer, the insurer may not offer or renew an employee benefit excess insurance policy that excludes or restricts coverage for claims made by any individual who is covered by the underlying benefit plan, or for claims arising out of any medical condition that is covered by the underlying benefit plan.

4. If an insurer offers or renews an employee benefit excess insurance policy that has an annual limit on coverage, or an exclusion applying to claims that are covered by the employer's benefit plan, the insurer must provide the employer with a disclosure notice explaining that the employer has unlimited responsibility for paying any claims that are above the annual limit of the excess insurance policy or are excluded from reimbursement by the excess policy.

5. Pursuant to 24-A M.R.S. §2452(1), an employee benefit excess insurance policy may not discriminate unfairly among or against beneficiaries of the underlying benefit plan, or treat conditions related to the Human Immunodeficiency Virus, or HIV, more restrictively than other sicknesses or disabling conditions.

6. Pursuant to 24-A M.R.S. §2849-B(7), an insurer may only offer or renew an employee benefit excess insurance policy when the underlying benefit plan meets the requirements of continuity of coverage in Title 24-A, Chapter 36.

7. At the time an employee benefit excess insurance policy is issued or renewed, an insurer must make tail coverage available with a run-out period of at least six months. An insurer may issue or renew an employee benefit excess insurance policy that does not include this tail coverage only if:

A. The employer requests that the policy does not include this tail coverage;

B. The insurer provides the employer with a disclosure notice, approved by the Superintendent, advising the employer that the policy does not include this tail coverage and explaining any risk associated with declining the coverage; and

C. The insurer obtains written acknowledgment from the employer that the employer declines this tail coverage.

8. An insurer must pay the claims for which it is liable under an employee benefit excess insurance policy even if the employer is insolvent or otherwise fails to pay valid claims within the self-insured retention.

A. Notwithstanding paragraph 1(C) of this section, claims paid under this section shall be paid for the benefit of plan participants as directed by a bankruptcy trustee or court of competent jurisdiction or as agreed between the insurer and the plan's administrator or fiduciary.

B. This subsection does not require an insurer to drop down and pay claims within the self-insured retention.

C. This subsection does not prohibit the insurer from cancelling the policy for nonpayment of premiums or other good cause as permitted by law with timely advance notice, but cancellation does not extinguish the insurer's liability with respect to health care services provided before the effective date of the cancellation.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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