reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.24 - Discount Medical Plan Organizations and Discount Drug Plan Organizations › Section 31.10.24.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Discount drug plan" has the meaning stated in Insurance Article, §
										14-601(b), Annotated Code of Maryland.
(2) "Discount drug plan organization" has the meaning stated in Insurance Article, §
										14-601(c), Annotated Code of Maryland.
(3) "Discount medical plan" has the meaning stated in Insurance Article, §
										14-601(d), Annotated Code of Maryland.
(4) "Discount medical plan organization" has the meaning stated in Insurance Article, §
										14-601(e), Annotated Code of Maryland.
(5) "Medical services" has the meaning stated in Insurance Article, §
										14-601(g), Annotated Code of Maryland.
(6) "Nominal fee" means the fee that may be retained by a discount drug plan organization or a discount medical plan organization if a plan member's membership in a discount drug plan or discount medical plan is canceled within the first 30 calendar days after the effective date of enrollment.
(7) "Plan member" has the meaning stated in Insurance Article, §
										14-601(i), Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.24 - Discount Medical Plan Organizations and Discount Drug Plan Organizations › Section 31.10.24.03 - Cancellations

Current through Register Vol. 51, No. 14, July 12, 2024
A. A discount drug plan organization or discount medical plan organization shall reimburse all monies collected from a plan member if the plan member cancels membership in the discount drug plan or the discount medical plan within the first 30 calendar days after the effective date of enrollment.
B. If electronic fund transfer is employed as a method of payment for discount drug plan or discount medical plan membership and membership is canceled within the first 30 calendar days after the effective date of enrollment, the discount drug plan organization or discount medical plan organization has 30 days from the date of cancellation in which to reverse the electronic fund transfer less the applicable nominal fee for this period.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.24 - Discount Medical Plan Organizations and Discount Drug Plan Organizations › Section 31.10.24.04 - Nominal Fee

Current through Register Vol. 51, No. 14, July 12, 2024
A. Notwithstanding the provisions of Regulation .03 of this chapter, a discount drug plan organization or a discount medical plan organization may retain a nominal fee if a plan member cancels membership in the discount drug plan or discount medical plan within the first 30 calendar days after the effective date of enrollment, if:
(1) The discount drug plan organization or the discount medical plan organization has filed the applicable nominal fee with the Insurance Commissioner prior to use; and
(2) The nominal fee does not exceed the lesser of $5, or the actual expenses incurred for issuing a plan member's discount drug plan card or discount medical plan card.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.25 - Required Standard Provisions for Individual Nonprofit Health Service Plan Contracts › Section 31.10.25.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to each individual nonprofit health service plan contract issued or delivered in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.25 - Required Standard Provisions for Individual Nonprofit Health Service Plan Contracts › Section 31.10.25.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Carrier" means a nonprofit health service plan.
(2) "Covered individual" means an individual covered under an individual contract.
(2-1) "Coverage period" means the interval of time the individual contract provides protection to the insured, in exchange for the payment of a particular premium.
(2-2) "Health benefit plan" has the meaning stated in Insurance Article, §
										15-1301, Annotated Code of Maryland.
(3) "Individual contract" means a contract issued by a nonprofit health service plan to a subscriber covering:
(a) The subscriber;
(b) The subscriber's dependents; or
(c) The subscriber and the subscriber's dependents.
(4) "Preferred provider" means a provider that has entered into a provider service contract.
(5) "Preferred provider benefit" means a benefit that appears in an individual contract under which health care services are to be provided to the covered individual by a preferred provider.
(6) "Provider service contract" means a contract between a provider and a carrier or other entity, under which the provider agrees to provide health care services on a preferential basis under contracts containing preferred provider benefits.
(7) "Subscriber" means the individual to whom the nonprofit health service plan contract is issued.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.25 - Required Standard Provisions for Individual Nonprofit Health Service Plan Contracts › Section 31.10.25.03 - Required Standard Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. An individual contract may not be delivered in Maryland unless it contains in substance the provisions listed in Regulation .04 of this chapter, or provisions which in the opinion of the Commissioner are not less favorable in any respect to the subscriber and covered individuals.
B. Inapplicable and Inconsistent Provisions. If a provision required by Regulation .04 of this chapter is wholly or partly inapplicable to or inconsistent with the coverage provided by a particular contract, the carrier shall:
(1) Omit from the contract the inapplicable provision or part of the provision; or
(2) Modify the inconsistent provision or part of the provision to make it consistent with the coverage provided by the contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.25 - Required Standard Provisions for Individual Nonprofit Health Service Plan Contracts › Section 31.10.25.04 - Standard Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Entire Contract; Changes. Each individual contract shall contain in substance the following provision: "Entire contract; changes: This certificate, including the endorsements and the attached papers, if any, constitutes the entire contract of insurance. No change in this certificate shall be valid until approved by an executive officer of the carrier and unless such approval is endorsed on the certificate or attached to the certificate. No agent has authority to change this certificate or to waive any of its provisions."
B. Time Limit on Certain Defenses.
(1) Except as provided in §B(2) of this regulation, each individual contract shall contain in substance the following provision: "Time limit on certain defenses:
(1) After two years from the date of issue of this contract no misstatements, except fraudulent misstatements, made by the applicant in the application for the contract shall be used to void the contract or to deny a claim for loss incurred after two years from the date of issue of the contract.
(2) No claim for loss incurred after two years from the date of issue of this contract shall be reduced or denied on the ground that a disease or physical condition not excluded from coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this contract."
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.25 - Required Standard Provisions for Individual Nonprofit Health Service Plan Contracts › Section 31.10.25.05 - Limitations and Exclusions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Crime.
(1) An individual contract may not include a limitation or exclusion for loss to which a contributing cause was the covered individual's commission of or attempt to commit a crime.
(2) An individual contract may not include a limitation or exclusion for loss for which a contributing cause was the commission of or the attempt to commit a crime by an individual other than the covered individual.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.25 - Required Standard Provisions for Individual Nonprofit Health Service Plan Contracts › Section 31.10.25.06 - Optional Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier may include any of the optional provisions described in §§C-G of this regulation.
B. A carrier may not include an optional provision dealing with the same subjects set forth in §§C-G of this regulation if the provision is drafted in a manner that is less favorable to the subscriber or any covered individual than the corresponding optional provision set forth in §§C-G of this regulation.
C. Physical Examination.
(1) A carrier may include a provision in an individual contract giving the carrier the right to examine the covered individual when and as often as it may reasonably require during the pendency of a claim under the contract.
(2) If the carrier includes the provision described in §C(1) of this regulation, the provision shall indicate that any physical examination required by the carrier will be performed at the expense of the carrier.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.26 - Uniform Credentialing Form › Section 31.10.26.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all:
A. Carriers as defined in Regulation .02B(1) of this chapter; and
B. Credentialing intermediaries as defined in Regulation .02B(2) of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.26 - Uniform Credentialing Form › Section 31.10.26.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) Carrier.
(a) "Carrier" means:
(i) An insurer;
(ii) A nonprofit health service plan;
(iii) A health maintenance organization;
(iv) A dental plan organization; or
(v) Any other person that provides health benefit plans subject to regulation by the State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.26 - Uniform Credentialing Form › Section 31.10.26.03 - Uniform Credentialing Form - Carrier and Credentialing Intermediary Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier or its credentialing intermediary shall:
(1) Accept the uniform credentialing form as the sole application for a health care provider to become credentialed or recredentialed for a provider panel of the carrier; and
(2) Make the uniform credentialing form available to any health care provider that is to be credentialed or recredentialed by the carrier or credentialing intermediary.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.26 - Uniform Credentialing Form › Section 31.10.26.04 - Electronic Filing

Current through Register Vol. 51, No. 14, July 12, 2024
A. The uniform credentialing form may be obtained in an electronic format.
B. The uniform credentialing form may be transmitted by facsimile.
C. A transmission by facsimile is not considered an electronic transfer for the purposes of this chapter.
D. Capability of Electronic Filing.
(1) The uniform credentialing form developed under this chapter shall be capable of electronic filing.
(2) The uniform credentialing form may be filed electronically in any format that contains the data required to be contained in the uniform credentialing form.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.26 - Uniform Credentialing Form › Section 31.10.26.05 - Effective Date

Current through Register Vol. 51, No. 14, July 12, 2024
The regulations in this chapter are applicable for all credentialing and recredentialing forms used on or after January 1, 2008.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.28 - Individual Health Insurance Contracts - Standard Provisions and Exclusions › Section 31.10.28.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter is applicable to each individual health insurance contract issued or delivered in Maryland on or after the effective date of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.28 - Individual Health Insurance Contracts - Standard Provisions and Exclusions › Section 31.10.28.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Coverage period" means the interval of time the individual health insurance contract provides protection to the insured, in exchange for the payment of a particular premium.
(2) "Individual health insurance contract" means a health insurance contract issued by an insurer to a policyholder that provides health insurance coverage for permissible individuals as described in Insurance Article, §
										15-201(c), Annotated Code of Maryland.
(3) "Insured" means a person covered under an individual health insurance contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.28 - Individual Health Insurance Contracts - Standard Provisions and Exclusions › Section 31.10.28.03 - Limitations and Exclusions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Crime.
(1) Except as provided in §A(3) of this regulation, an individual health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's commission of or attempt to commit a crime.
(2) An individual health insurance contract may not include a limitation or exclusion for loss for which a contributing cause was the commission of or the attempt to commit a crime by an individual other than the insured.
(3) A disability benefit or an accidental death and dismemberment benefit in an individual health insurance contract:
(a) May be subject to exclusion or limitation for loss to which a contributing cause was the insured's commission of or attempt to commit a felony; and
(b) May not be subject to an exclusion or limitation regarding the commission of or attempt to commit a crime that is more restrictive to the insured than the exclusion or limitation set forth in §A(3)(a) of this regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.28 - Individual Health Insurance Contracts - Standard Provisions and Exclusions › Section 31.10.28.04 - Arbitration

Current through Register Vol. 51, No. 14, July 12, 2024
If an insurer includes an arbitration provision in an individual health insurance contract, the arbitration provision may not require the insured to use arbitration to settle disputes with the insurer.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.28 - Individual Health Insurance Contracts - Standard Provisions and Exclusions › Section 31.10.28.05 - Premium Due Date

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each individual health insurance contract shall specify the premium due date.
B. The premium due date shall be no earlier than the date the coverage period begins.
C. An insurer may offer each individual policyholder the option to pay the premium through an electronic payment.
D. If the individual policyholder elects an electronic payment, the insurer may not debit or charge the amount of the premium due prior to the premium due date, except as authorized by the individual policyholder.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.29 - Complaint Process for Coverage Decisions › Section 31.10.29.03 - Exhaustion of Internal Appeal Process

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as provided in §B of this regulation, the carrier's internal appeal process shall be exhausted before filing a complaint with the Commissioner under this chapter.
B. In a case involving a prospective denial, a member, a member's representative, or a health care provider filing a complaint on behalf of a member may file a complaint with the Commissioner without first filing an appeal with a carrier and receiving a final decision on the appeal if the member, the member's representative, or the health care provider gives sufficient information and supporting documentation in the complaint that demonstrates an urgent medical condition exists as defined under this chapter.
C. In a case involving a retrospective denial, an urgent medical condition is not deemed to exist to allow a member, a member's representative, or a health care provider on behalf of a member to file to a complaint without first exhausting the internal appeal process of a carrier.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.30 - Disability Benefit Claims Procedures › Section 31.10.30.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to insurers that issue or deliver individual or group health insurance policies in Maryland that include a disability benefit.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.30 - Disability Benefit Claims Procedures › Section 31.10.30.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Adverse appeal determination" means a decision made by an insurer on an appeal of an adverse benefit determination to uphold:
(a) A denial, reduction, or termination of a disability benefit;
(b) A failure to provide or make payment, in whole or in part, for a disability benefit; or
(c) Any denial, reduction, termination, or failure to provide or make payment that is based on a determination of a covered individual's eligibility for coverage of a disability benefit.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.30 - Disability Benefit Claims Procedures › Section 31.10.30.04 - Timing and Content of Notice of Adverse Benefit Determination

Current through Register Vol. 51, No. 14, July 12, 2024
A. An insurer shall give written or electronic notice that complies with the standards imposed by 29 CFR §
										2520.104b-1(c)(1)(i), (iii), and (iv), of an adverse benefit determination to a covered individual within a reasonable period of time, but not later than 45 days after receipt of a claim for disability benefits, unless the 45-day period is extended in accordance with this regulation.
B. Subject to §F(2) of this regulation, the period of time within which a benefit determination shall be made begins at the time a claim is received, without regard to whether all the information necessary to make a benefit claim determination accompanies the filing.
C. The 45-day time period under §A of this regulation may be extended for up to 30 days if the insurer:
(1) Determines that the extension is necessary due to matters beyond the control of the insurer; and
(2) Provides the notice required under §E of this regulation to the covered individual before the expiration of the initial 45-day period.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.30 - Disability Benefit Claims Procedures › Section 31.10.30.05 - Timing and Notice of an Appeal Determination

Current through Register Vol. 51, No. 14, July 12, 2024
A. An insurer shall give written or electronic notice that complies with the standards imposed by 29 CFR §
										2520.104b-1(c)(1)(i), (iii), and (iv), of an appeal determination to a covered individual within a reasonable period of time, but not later than 45 days after receipt of an appeal of an adverse benefit determination, unless the 45-day period is extended in accordance with this regulation.
B. Subject to §E of this regulation, the period of time within which an appeal determination shall be made begins at the time an appeal is received, without regard to whether all the information necessary to make an appeal determination accompanies the filing.
C. The initial 45-day time period under §A of this regulation may be extended for a period not to exceed 45 days if the insurer:
(1) Determines that the extension is necessary due to special circumstances; and
(2) Provides the notice required under §D of this regulation to the covered individual prior to the expiration of the initial 45-day period.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.31 - Behavioral Health Care Expense Form › Section 31.10.31.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter applies to each carrier that provides behavioral health care services through:
(1) A company owned wholly or partly by the carrier; or
(2) A contract with a managed behavioral health care organization.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.31 - Behavioral Health Care Expense Form › Section 31.10.31.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) Behavioral Health Care Administrative Expenses.
(a) "Behavioral health care administrative expenses" means any expenses that are for administrative functions including:
(i) Billing and collection expenses;
(ii) Accounting and financial reporting expenses;
(iii) Quality assurance and utilization management program or activity expenses;
(iv) Promotion and marketing expenses;
(v) Taxes, fees, and assessments;
(vi) Legal expenses;
(vii) Salary expenses for employees that are not related to the delivery of behavioral health care services to patients;
(viii) Computer expenses;
(ix) Provider credentialing;
(x) Collection and administrative review of treatment plans;
(xi) Auditing the financial report submitted to the Commissioner under Insurance Article, §
												15-127, Annotated Code of Maryland;
(xii) Debt payment and debt service; and
(xiii) Other general and administrative expenses.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.31 - Behavioral Health Care Expense Form › Section 31.10.31.03 - Behavioral Health Care Expense Form

Current through Register Vol. 51, No. 14, July 12, 2024
Within 90 days after the end of each calendar year, each carrier shall complete the form developed by the Commissioner by obtaining, as necessary, and entering on the form the following information:
A. The name of each managed behavioral health care organization with which the carrier has a contract;
B. The calendar year for which the data is reported;
C. Total direct payments made by the carrier to each managed behavioral health care organization during the calendar year;
D. Direct behavioral health care expenses during the calendar year;
E. Amounts included in direct behavioral health care expenses for quality assurance or utilization management activities or treatment plan reviews;
F. Behavioral health care administrative expenses during the calendar year; and
G. The name, title, telephone number, and signature of the individual completing the form and the date that the form was completed.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.31 - Behavioral Health Care Expense Form › Section 31.10.31.04 - Maintenance of Form

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier shall maintain each form that the carrier is required to complete under Regulation .03 of this chapter for at least 5 years after the date that the form is required to be completed.
B. A carrier may maintain a form in paper, photographic, microprocessed, magnetic, mechanical, electronic, digital, or any other media provided that the form is maintained in a manner that:
(1) Is clear and legible;
(2) Reproduces accurately the original form in its entirety, including any attachments to the form;
(3) Is capable of producing a clear and legible hard copy of the original form; and
(4) Preserves evidence of the signature contained on the original form.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.32 - Nonprofit Health Service Plans-Material Modification › Section 31.10.32.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to each nonprofit health service plan that is subject to Insurance Article, §
									14-115(d), Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.32 - Nonprofit Health Service Plans-Material Modification › Section 31.10.32.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Baltimore metro region" means Anne Arundel County, Baltimore City, Baltimore County, Carroll County, Harford County, and Howard County.
(2) "Cost-sharing arrangement" includes:
(a) A deductible;
(b) A co-insurance amount;
(c) A co-payment amount;
(d) An annual limit;
(e) A lifetime limit; and
(f) An out-of-pocket maximum.
(3) "DC metro region" means Montgomery County and Prince George's County.
(4) "Eastern Shore region" means Caroline County, Cecil County, Dorchester County, Kent County, Queen Anne's County, Somerset County, Talbot County, Wicomico County, and Worcester County.
(5) Health Benefit Plan.
(a) "Health benefit plan" means a hospital or medical policy, contract, or certificate issued by a nonprofit health service plan.
(b) "Health benefit plan" includes:
(i) A Medicare supplement policy, contract, or certificate;
(ii) A long-term care policy, contract, or certificate; or
(iii) A stop loss contract.
(6) "Health care provider" has the meaning stated in Insurance Article, §
										14-101(b), Annotated Code of Maryland.
(7) "Key specialty" means:
(a) Cardiology;
(b) Dermatology;
(c) Family practice;
(d) Gastroenterology;
(e) Geriatrics;
(f) Internal medicine;
(g) Obstetrics/Gynecology (Ob/Gyn);
(h) Ophthalmology;
(i) Orthopedic surgery; or
(j) Pediatrics.
(8) "Market" means:
(a) The individual Medigap market;
(b) The individual non-Medigap market;
(c) The small-employer market governed by Insurance Article, Title 15, Subtitle 12, Annotated Code of Maryland; or
(d) The group market other than the small-employer market governed by Insurance Article, Title 15, Subtitle 12, Annotated Code of Maryland.
(9) "Nonprofit health service plan" means a corporation that:
(a) Holds a certificate of authority from the Commissioner to act as a nonprofit health service plan; and
(b) Has been assigned a National Association of Insurance Commissioners (NAIC) company code number.
(10) "Option" means a benefit or cost-sharing arrangement that:
(a) Is available in a health benefit plan; and
(b) If chosen, would alter the cost of the health benefit plan.
(11) "Product" means a category of one or more health benefits plans sold by a nonprofit health service plan in a particular market.
(12) "Southern Maryland region" means Calvert County, Charles County, and St. Mary's County.
(13) "Western Maryland region" means Allegany County, Frederick County, Garrett County, and Washington County.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.32 - Nonprofit Health Service Plans-Material Modification › Section 31.10.32.03 - Material Modification

Current through Register Vol. 51, No. 14, July 12, 2024
For purposes of Insurance Article, §
									14-115(d)(11)(i), Annotated Code of Maryland, a modification is material if it modifies:
A. The options available in a health benefit plan marketed in the State in a manner that results in a change of 20 percent or more in the actuarial benefit value of the health benefit plan;
B. A provider network in a manner that results in a change of:
(1) 10 percent or more in the number of health care providers in the provider network:
(a) For the entire State: or
(b) In the Baltimore metro region or DC metro region;
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.32 - Nonprofit Health Service Plans-Material Modification › Section 31.10.32.04 - Marketing Plan

Current through Register Vol. 51, No. 14, July 12, 2024
A. Development and Submission of Marketing Plan. Each year, a nonprofit health service plan shall:
(1) Develop a marketing plan; and
(2) Submit the marketing plan and any changes to the marketing plan to the board of directors of the nonprofit health service plan for approval.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.32 - Nonprofit Health Service Plans-Material Modification › Section 31.10.32.05 - Evaluation Report

Current through Register Vol. 51, No. 14, July 12, 2024
One year after the effective date of this chapter, the board of directors of a nonprofit health service plan shall submit to the Commissioner an evaluation report that contains:
A. The number of items that were required to be submitted to the board during the preceding year under each category contained in Regulation .03 of this chapter; and
B. An evaluation of whether Regulation .03 of this chapter is effective in ensuring that the board of a nonprofit health service plan reviews items that are appropriate for review by the board without being unduly burdened by review of items that are not appropriate for review by the board.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.32 - Nonprofit Health Service Plans-Material Modification › Section 31.10.32.06 - Fiduciary Duty

Current through Register Vol. 51, No. 14, July 12, 2024
Compliance with Insurance Article, §
									14-115(d)(11)(i), Annotated Code of Maryland, and this chapter does not relieve the board of directors of a nonprofit health service plan or the individual members of the board from taking or refraining from taking any action otherwise required to comply with their fiduciary duties.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.33 - Utilization Review of Surgical Treatment of Morbid Obesity › Section 31.10.33.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter establishes the manner in which carriers and private review agents acting on behalf of carriers may apply utilization review criteria and impose documentation requirements to the surgical treatment of the morbid obesity benefit mandated by Insurance Article, §
									15-839, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.33 - Utilization Review of Surgical Treatment of Morbid Obesity › Section 31.10.33.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Body mass index" has the meaning stated in Insurance Article, §
										15-839, Annotated Code of Maryland.
(2) "Carrier" means an insurer, a nonprofit health service plan, or a health maintenance organization.
(3) "Commissioner" means the Maryland Insurance Commissioner.
(4) "Health maintenance organization" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.
(5) "Insurer" has the meaning stated in Insurance Article, §
										1-101, Annotated Code of Maryland.
(6) "Member" means an individual who is covered by a contract that:
(a) Is issued or delivered by a carrier in the State; and
(b) Includes a benefit for the surgical treatment of morbid obesity.
(7) "Morbid obesity" has the meaning stated in Insurance Article, §
										15-839, Annotated Code of Maryland.
(8) "Nonprofit health service plan" means a person who has received a certificate of authority from the Commissioner to act as a nonprofit health service plan in the State.
(9) "Private review agent" has the meaning stated in Insurance Article, § 15-10 B-01, Annotated Code of Maryland.
(10) "Utilization review" has the meaning stated in Insurance Article, § 15-10 B-01, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.33 - Utilization Review of Surgical Treatment of Morbid Obesity › Section 31.10.33.03 - Utilization Review Criteria for Surgical Treatment of Morbid Obesity

Current through Register Vol. 51, No. 14, July 12, 2024
A. When establishing utilization review criteria for the surgical treatment of morbid obesity as a covered benefit under Insurance Article, §
									15-839, Annotated Code of Maryland, a carrier or a private review agent acting on behalf of a carrier:
(1) Shall limit the criteria to the permissible criteria listed in §B of this regulation; and
(2) May not use any criteria that is more restrictive to the member than the criteria listed in §B of this regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.33 - Utilization Review of Surgical Treatment of Morbid Obesity › Section 31.10.33.04 - Documentation Requirements for Structured Diet Programs

Current through Register Vol. 51, No. 14, July 12, 2024
A. The carrier or private review agent acting on behalf of the carrier shall accept any one of the items listed in §B of this regulation as acceptable documentation that the member has completed the structured diet program required by Regulation .03B(4) of this chapter.
B. Acceptable documentation of completion of a structured diet program includes:
(1) Physician notes;
(2) Notes of health care providers, other than physicians;
(3) Receipts of payment for a structured diet program; or
(4) Diet or weight loss logs from a structured diet program.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.34 - Carrier Provider Panels › Section 31.10.34.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to:
A. Establish standards for the creation and maintenance of provider panels by insurers, nonprofit health service plans, and dental plan organizations; and
B. Assure the availability of health care providers to meet the health care needs of enrollees.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.34 - Carrier Provider Panels › Section 31.10.34.02 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to insurers, nonprofit health service plans, and dental plan organizations that use provider panels.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.34 - Carrier Provider Panels › Section 31.10.34.03 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Accredited hospital" means a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations.
(2) "Carrier" means an insurer, a nonprofit health service plan, or a dental plan organization.
(3) "Enrollee" means an individual entitled to health care benefits from a carrier.
(4) "Hospital-based physician" means an anesthesiologist, pathologist, radiologist, neonatologist, hospitalist, intensivist, or emergency medicine physician that practices exclusively within an accredited hospital and provides care to enrollees only as a result of the enrollees being directed to the hospital.
(5) "Prominent carrier" means a carrier reporting at least $90,000,000 in written premium for medical benefits in Maryland in the most recent annual statement.
(6) "Provider" means a health care practitioner or group of health care practitioners licensed, certified, or otherwise authorized by law to provide health care services.
(7) "Provider panel" means the providers that contract either directly or through a subcontracting entity with a carrier to provide health care services to the carrier's enrollees under the carrier's health benefit plan.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.34 - Carrier Provider Panels › Section 31.10.34.04 - Provider Panel Sufficiency

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier shall maintain a provider panel that is sufficient in numbers and types of available providers to meet the health care needs of enrollees.
B. Standards to meet the health care needs of enrollees shall be determined in accordance with the requirements of this chapter, and may be established by reference to any reasonable criteria used by the carrier, including but not limited to:
(1) Provider-enrollee ratios by specialty;
(2) Primary care provider-enrollee ratios;
(3) Geographic accessibility;
(4) Waiting times for appointments with providers;
(5) Hours of operation; and
(6) The volume of technological and specialty services available to serve the needs of enrollees requiring technologically advanced or specialty care.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.34 - Carrier Provider Panels › Section 31.10.34.05 - Availability Plan

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier shall implement an availability plan describing:
(1) If the carrier is an insurer or nonprofit health service plan, the quantifiable and measurable standards for the number and geographic distribution of:
(a) General and internal medicine providers;
(b) Family practitioners;
(c) Pediatricians;
(d) Obstetricians and gynecologists;
(e) High-volume specialty behavioral health care providers, including psychiatrists, psychologists, clinical social workers, and any other behavioral health care providers identified by the carrier; and
(f) High-volume specialty health care providers, identified by the carrier; or
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.34 - Carrier Provider Panels › Section 31.10.34.06 - Enforcement

Current through Register Vol. 51, No. 14, July 12, 2024
A. In addition to any other enforcement powers available to the Commissioner, if a carrier violates this chapter, the Commissioner may order a carrier to take reasonably appropriate corrective action.
B. The reasonably appropriate corrective action required by the Commissioner in §A of this regulation may include, but not be limited to, ordering the carrier to:
(1) Meet the standards specified in the carrier's availability plan by increasing the number of providers by specialty or geographic area in the carrier's provider panel; and
(2) Make restitution to an enrollee who received services during the time the carrier failed to meet the standards specified in the carrier's availability plan, from a provider that was not on the carrier's provider panel, if the carrier fails to take a corrective action ordered by the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.35 - Domestic Partner Coverage › Section 31.10.35.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to establish:
A. The use of the term domestic partner in a contract; and
B. The proof that a carrier may use to determine if an individual is a domestic partner of another individual.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.35 - Domestic Partner Coverage › Section 31.10.35.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Carrier" means an insurer, a nonprofit health service plan, or a health maintenance organization.
(2) "Commissioner" means the Maryland Insurance Commissioner.
(3) "Contract" means either of the following:
(a) A health insurance contract that is issued or delivered in Maryland by an insurer or a nonprofit health service plan that provides inpatient hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis; or
(b) A contract issued or delivered in Maryland by a health maintenance organization to individuals or groups.
(4) "Health maintenance organization" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.
(5) "Insurer" has the meaning defined in Insurance Article, §
										1-101, Annotated Code of Maryland.
(6) "Nonprofit health service plan" means a person who has received a certificate of authority from the Commissioner to act as a nonprofit health service plan in the State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.35 - Domestic Partner Coverage › Section 31.10.35.03 - Domestic Partner Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. The term "domestic partner" in a contract or rider to a contract shall include individuals of the same and the opposite sex.
B. If an individual makes an application to include a domestic partner or a child dependent of a domestic partner as a dependent under a contract, the carrier may require the individual to submit not more than the following as proof of the domestic partner relationship:
(1) The affidavit described in §C of this regulation;
(2) Proof that the individual meets one criteria from §D of this regulation; and
(3) Proof that the individual meets one criteria from §E of this regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.36 - Pharmacy Benefit Managers-Approval of an Accrediting Organization › Section 31.10.36.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to establish the factors the Commissioner shall consider when approving an accrediting organization for the purposes of Insurance Article, §
									15-1618, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.36 - Pharmacy Benefit Managers-Approval of an Accrediting Organization › Section 31.10.36.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Accrediting organization" means an entity that accredits a pharmacy benefits manager.
(2) "Applicant" means a pharmacy benefits manager that is applying for a registration from the Commissioner to act as a pharmacy benefits manager in Maryland.
(3) "Commissioner" means the Maryland Insurance Commissioner.
(4) "Pharmacy and therapeutics committee" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
(5) "Pharmacy benefits manager" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.36 - Pharmacy Benefit Managers-Approval of an Accrediting Organization › Section 31.10.36.03 - Determination of Approved Accrediting Organization

Current through Register Vol. 51, No. 14, July 12, 2024
A. An accrediting organization is not an approved accrediting organization for the purposes of Insurance Article, §
									15-601, Annotated Code of Maryland, until the Commissioner issues a letter of approval to the accrediting organization.
B. For the purpose of determining which entities are approved accrediting organizations, the Commissioner shall consider whether:
(1) The accreditation standards required to be met for accreditation by the accrediting organization meet or exceed the requirements of Insurance Article, §§
										15-1614 and  15-1617, Annotated Code of Maryland;
(2) The accrediting organization measures an applicant's pharmacy and therapeutics committee's ability to meet each standard; and
(3) The accrediting organization agrees to notify the Commissioner at least 30 days in advance if it revises its accreditation standards that pertain to a pharmacy and therapeutics committee or changes the method in which it reviews a pharmacy and therapeutics committee of an applicant.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.37 - Delivery of Policy or Certificate › Section 31.10.37.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to establish time frames in which carriers are required to provide:
A. Health insurance contracts, nonprofit health service plan contracts, health maintenance organization contracts, and dental plan organization contracts to individual contract holders and group contract holders; and
B. Health insurance certificates, nonprofit health service plan certificates, health maintenance organization certificates, and dental plan organization certificates to certificate holders.