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, pursuant to Title
24-A M.R.S.A.,
Section2809-A, shall be entitled to obtain a
converted policy, or at the insurer's option, a group certificate providing, at
the individual's option, coverage on an expense incurred basis under any one of
the 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,
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 benefits, 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 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 duration 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
(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 six hundred dollars.
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 duration of seventy days per
hospital confinement,
(b)
miscellaneous hospital benefits in the amount of ten times the hospital 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 four hundred dollars.
The dollar amount in Plan A, Subsection a, as of the
effective date of this Rule is $200. This amount 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 Plans 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 90 days.
If recurrent hospital confinements do not result from the same cause or are
separated by a period of 90 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, pursuant to Title
24-A M.R.S.A.,
Section2809-A 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:
AA The maximum benefit provided under the group policy;
or
BB 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:
AA The maximum benefit provided under the group policy;
or
BB 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 $1000, after which benefits will be paid at the rate of 100
percent during the remainder of such benefit period. If the group policy
provided benefits for the outpatient treatment of mental illness, the converted
policy shall provide a similar level of benefits for such treatment but need
not exceed a level of 50 percent of covered expenses. If the group policy
contained a maximum limitation on total mental health benefits, the converted
policy may contain that same limitation.
(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. The term "benefits deductible," as used herein,
means the value of any benefits provided on an expense incurred basis which are
provided with respect to covered medical expenses by: other hospital, surgical,
or medical insurance policy; hospital or medical service subscriber contract;
medical practice or other prepayment plan; or any other plan or program whether
on an insured or uninsured basis; or in accordance with the requirements of any
state or federal law; and, if pursuant to Subsection (f) of this Section 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 each 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 such amount 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 $1200 maximum benefit.
(f) If the group insurance policy insures the
employee or member for basic hospital and/or surgical expense insurance as well
as major medical expense insurance, then, at the option of the insurer, the
benefits outlined in subsections
1 and
2 above may be provided under one
policy or certificate.
(3) Comprehensive Medical Expense Benefits.
(a) The insurer may also, in lieu of the
plans of benefits set forth in subsections
1 and
2 above, provide a policy of
Comprehensive Medical Expense Benefits without first dollar coverage. Said
policy shall conform to the requirements of subsection
2 above, provided however, that an
insurer electing to provide such a policy shall make available a low deductible
option, not to exceed $100, a high deductible option between $500 and $1000,
and a third deductible option midway between the high and low deductible
option.
