Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 745 - INDIVIDUAL HEALTH INSURANCE PILOT PROJECTS FOR PERSONS UNDER 30 YEARS OF AGE
Section 031-745-4 - DEFINITIONS

Universal Citation: 02 ME Code Rules ยง 031-745-4

Current through 2024-38, September 18, 2024

For purposes of this Rule, the following terms have the following meaning:

1. "Deductible" means the dollar amount the insured must pay directly to the provider for covered services in a plan year before any benefits subject to the deductible are payable by the plan.

2. "Coinsurance" means the percentage of eligible charges that the insured must pay directly to the provider, after any deductible applicable to the service has been satisfied.

3. "Copayment" means a flat dollar charge that must be paid by the insured directly to the provider for each service or prescription.

4. "Out-of-Pocket Expense" means an eligible charge paid by the insured directly to a provider for covered services, including deductibles, coinsurance and copayments.

5. "Eligible Charge" means:

A. An amount the provider is required to accept as payment in full for a given service under the terms of its contract with an HMO, non-profit service organization, preferred provider organization, or plan sponsor.

B. If a service is not rendered pursuant to a contract with an insurance carrier, HMO, non-profit service organization, preferred provider organization or plan sponsor, the eligible charge is the lesser of:
(1) The actual amount charged; or

(2) The Usual and Customary Charge for the services provided, taking into consideration the geographic area in which the services are provided and significant regional variations in the cost of services. A relative value scale or other reasonable methodology may be used in calculating the usual and customary charge.

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