Individual Insurance Market Rules in Maine
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- Can insurance companies deny me coverage?
Insurance companies cannot deny you coverage in Maine. All individual health insurance policies must be offered to all residents on a guaranteed issue basis year-round. This means that insurance companies are required to sell coverage to everyone who applies.
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- Can insurance companies charge me more than other people for the same policy?
In Maine insurance companies are limited in how they can adjust rates for different people. Maine uses an "adjusted community rating," which means that premiums can be adjusted for age or other factors but there are limits.
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- Can insurance companies exclude coverage of my pre-existing condition?
Insurance companies cannot permanently exclude coverage of your pre-existing condition in Maine. Insurance companies cannot permanently exclude from coverage any health problems you disclose, or they find in your medical records, at the time of application by an amendment to the individual health insurance contract (called an “elimination rider”).
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- Can insurance companies make up their own definition of a pre-existing condition?
Insurance companies cannot make up their own definition of a pre-existing condition in Maine. Insurance companies can consider something a pre-existing condition if the person received medical advice, diagnosis, care or treatment for that condition prior to enrollment in the plan. They can also consider a condition pre-existing if it was never diagnosed but you had symptoms for which an ordinary prudent person would have sought medical advice, care or treatment. This is called a "prudent person standard."
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- Can insurance companies accept my application for coverage and later search my medical records for an excuse to deny me coverage for needed care?
Insurance companies can accept your application for coverage and later search your medical records for an excuse to deny you coverage for needed care in Maine. If you make a claim for health care services during the first 12 months (one year) of coverage, the insurance company can search your medical history dating back 12 months (one year) prior to the purchase of your policy looking for evidence that your current health problem was pre-existing. If the insurance company finds any such evidence, it can deny you coverage for that condition.
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- Can insurance companies pay their doctors incentives to provide me with less care?
Insurance companies cannot pay their doctors incentives to provide you with less care in Maine. An insurance company cannot pay health care providers incentives to withhold covered care.
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- Can I appeal an insurance company’s denial of care to an outside entity?
You can appeal an insurance company's denial of care to an outside entity in Maine. You can file an appeal for any denial of service to the Bureau of Insurance. The process is free. You must file an appeal within 12 months of final notice of denial by a health plan.
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- Can I sue my insurance company if it denies medically necessary care that causes me or a loved-one harm?
You can sue your insurance company if it denies medically necessary care that causes you or a loved-one harm in Maine. You can sue an insurance company for harm that may have resulted from its denial of coverage or benefits.
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SOURCE: Kaiser Family Foundation State Health Facts, 2007
To learn about all your rights and protections in the individual insurance market, contact the Maine Bureau of Insurance.
