Free Maine Accident & Health practice questions

Answer: C. Suspending the license and levying a civil penalty in the same action

For any listed cause, including intentionally misrepresenting the terms of an actual or proposed insurance contract, the superintendent may place a producer's license on probation, suspend it, revoke it, refuse to issue or renew it, or levy a civil penalty, and may use any combination of those actions. Suspension together with a civil penalty in one action is therefore permitted. The statute does not bar pairing revocation with a penalty, does not require probation to be tried first, and does not make probation depend on the producer's consent.

Answer: D. It must cover them without prior authorization, using in-network cost sharing

Under Maine's emergency services provision, a carrier whose health plan covers any services in an emergency facility or setting must cover emergency services without prior authorization. The deductible, copayment and coinsurance for out-of-network emergency services must be the same as would apply in network, and what the enrollee pays counts toward the in-network cost-sharing limit. Once the enrollee has paid the in-network share, the carrier must hold the enrollee harmless from any additional amount the out-of-network provider is owed. The statute does not make in-network cost sharing depend on whether a network facility was reachable, so that condition, a denial for lack of authorization and out-of-network cost sharing are all inconsistent with it.

Answer: B. It covers practices the act defines as unfair and practices determined under the act to be unfair

The general prohibition bars any person from engaging, in Maine, in a trade practice that the act defines as unfair competition or an unfair or deceptive insurance practice, or that is found under the act to be one. Because it reaches practices determined under the act as well as those it defines, it is wrong to say only listed practices are covered. It applies to any person, not only insurers. Nothing in the prohibition requires a prior court finding or a financial loss to a policyholder.

Answer: B. If it is neither paid nor disputed within 30 days after that date

Under Maine's overdue-payment statute, a claim is payable within 30 days after the insurer receives proof of loss and the loss is ascertained, and a claim that is neither disputed nor paid within those 30 days is overdue. The 60-day period applies to a standard fire policy and the fire portion of certain combination policies, and the 2-month period applies to individual life insurance; neither describes a medical expense claim. A 15-calendar-day deadline is not the payment period this statute sets.

Answer: B. No, because an individual's license authority does not pass to other employees of the entity

Under Maine's business entity licensing rule, an entity cannot act on its own without an individual licensee, and a license authority held by one individual employed by the entity does not transfer to other employees within it. Alex therefore cannot borrow Sam's authority. The entity license does not cover unlicensed staff, supervision and countersignature do not substitute for a license, and naming Sam as the responsible person changes nothing about whose authority Alex holds.

Answer: C. Refusing renewal does not prejudice the claim, which arose while in force

Sec. 2729 applies to health policies, other than accident-only policies, in which the insurer reserves a right to refuse renewal on an individual basis. It requires the policy to state that any refusal of renewal is without prejudice to a claim originating while the policy was in force. The illness began in March, while the policy was in force, so refusing renewal leaves that claim intact. Ending benefits at the renewal date, recovering benefits already paid, or conditioning the claim on the insurer's written consent would each prejudice a claim that the required provision protects. The same section also limits timing: subject to termination for nonpayment, the refusal cannot take effect before the renewal date on or after and nearest each policy anniversary.

Answer: A. As routine technical rules in every case

The Affordable Care Act compliance section lets the superintendent enforce and administer it with all powers under Titles 24 and 24-A, adopt and amend rules, set standards and enforce federal statutes and regulations to carry out the purposes of the federal law. It classifies rules and amendments adopted under that authority as routine technical rules, and it says so expressly even for amendments to major substantive rules. Calling them major substantive rules, emergency rules or nonbinding guidance contradicts that classification.

Answer: D. They must be the same as those given married certificate holders with maternity coverage

Maine requires every group or blanket health policy, contract and certificate to give unmarried women certificate holders the same maternity benefits that married certificate holders with maternity coverage receive. The same requirement reaches the minor dependents of certificate holders who have dependent or family coverage, and that dependent or family coverage condition attaches to those dependents, not to the unmarried certificate holder herself. Because the section calls for the same benefits, a separate rider, or a 12-month limit imposed on her but not on married certificate holders, would depart from it.

Answer: B. Within 31 days after the date of birth

Maine's newborn coverage rule for group and blanket expense-incurred policies makes benefits payable from the moment of birth. Where a specific premium is charged for a child, the policy may make coverage beyond the first 31 days depend on the insurer receiving notice of the birth and the premium within 31 days after the birth, and it may require that payment to run back to the date of birth. The 15-day and 60-day periods are not the period the section sets, and the section measures the period from the date of birth rather than from a hospital discharge.

Answer: A. 3 months from the premium due date

Maine bars an individual health policy from lapsing for an unpaid premium until 3 months have passed from the due date, unless the insurer mailed the insured a notice of the amount and due date at least 10 and at most 45 days before that date. No notice was sent here, so the insured may pay the overdue premium at any point in that 3-month period. The provision's exceptions, a policy renewable only with the insurer's consent and a policy with monthly or more frequent premiums, do not describe a guaranteed renewable policy billed quarterly. Forty-five days is the outer edge of the window for mailing the notice, not a payment period. Two years is the deadline for starting a lawsuit on a policy that has lapsed for nonpayment. Six months is not a period this provision uses.