reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.04 - Dental Plans - General Provisions › Section 31.12.04.05 - Grace Period Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Individual Dental Benefit Contracts.
(1) If the individual dental benefit contract is guaranteed renewable for the life of the individual dental benefit contract, the dental benefit contract shall contain in substance the following provision: "Grace Period: A grace period of 31 days will be granted for the payment of each premium falling due after the first premium, during which grace period this contract shall continue in force."
(2) If the individual dental benefit contract gives the dental plan organization the right to refuse renewal, the individual dental benefit contract shall contain in substance the following provision: "Grace Period: Unless at least 30 days before the premium due date the dental plan organization has delivered to the subscriber, or has mailed to the subscriber's last address as shown by the records of the dental plan organization, written notice of its intention not to renew this contract beyond the period for which the premium has been accepted, a grace period of 31 days will be granted for the payment of each premium falling due after the first premium, during which grace period this contract shall continue in force."
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.04 - Dental Plans - General Provisions › Section 31.12.04.06 - Evidence of Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except for Regulation .04A-C of this chapter, the evidence of coverage under any group contract shall contain all of the provisions required in Regulation .04 of this chapter.
B. The name of the group shall be specified in the evidence of coverage.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.04 - Dental Plans - General Provisions › Section 31.12.04.08 - Provider Contracts

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each provider contract shall contain the provisions in §§B-G of this regulation.
B. A provision shall be included to require the provider to make an initial commitment to the plan of at least 12 months. The provider may not terminate the contract during this 12-month period unless the provider becomes unavailable during that initial time for reasons beyond the control of the dental plan organization or the provider.
C. Hold-Harmless Clause. A hold-harmless clause, which shall read substantially as follows is required: "The provider agrees that under no circumstances, including nonpayment by the dental plan organization, insolvency of the dental plan organization, or breach of this contract, shall provider seek payment from an enrollee for services rendered under this contract for other than a copayment listed in the dental benefit contract. Provider further agrees that this provision shall survive the termination of this provider contract regardless of the cause of the termination."
D. A provision specifying when the contract becomes effective is required.
E. A provision specifying the date the contract terminates is required.
F. A renewal provision is required.
G. A provision specifying the benefits the provider shall supply the enrollees is required, specifying that:
(1) The provider shall supply services to enrollees in exchange for the copayments specified in the dental benefit contract while the provider's provider contract is in force; and
(2) After the provider contract terminates, the provider shall continue to provide services to enrollees in accordance with Insurance Article, §
										15-112, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.04 - Dental Plans - General Provisions › Section 31.12.04.09 - Contract Forms

Current through Register Vol. 51, No. 14, July 12, 2024
A. The dental plan organization:
(1) Shall provide a written dental benefit contract to each group contract holder;
(2) Shall provide a written evidence of coverage to each individual covered under a group dental benefit contract;
(3) Shall provide a written dental benefit contract to each individual who applies for individual dental coverage;
(4) Shall execute a written provider contract with each of the dental plan organization's plan dentists;
(5) May not deliver or issue for delivery in this State any of the following forms unless the form has been filed with and approved by the Insurance Commissioner:
(a) Dental benefit contract,
(b) Evidence of coverage,
(c) Provider contract,
(d) Application form, and
(e) Riders or endorsement forms.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.04 - Dental Plans - General Provisions › Section 31.12.04.10 - Filing Requirements for Premium Rates and Subscription Fees

Current through Register Vol. 51, No. 14, July 12, 2024
A. The filing of any dental plan contract or rider or endorsement by a dental plan organization in accordance with Regulation .09A(5) of this chapter shall be accompanied by the filing of premium rates or subscription fees.
B. A subsequent change in premium rates or subscription fees shall be filed with supporting data at least 30 days before the change is proposed to become effective.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.05 - Dental Benefit Plan Coverage - Mandatory Point-of-Service Option › Section 31.12.05.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to health maintenance organizations and dental plan organizations operating in this State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.05 - Dental Benefit Plan Coverage - Mandatory Point-of-Service Option › Section 31.12.05.02 - Required Notice

Current through Register Vol. 51, No. 14, July 12, 2024
A. When a health maintenance organization or dental plan organization dental provider panel is the sole dental provider panel offered to group members by a group policyholder, the dental plan organization or the health maintenance organization:
(1) Shall offer the group policyholder a dental point-of-service option for the individual group member to accept or reject;
(2) May not impose a minimum participation level on the mandatory dental point-of-service option; and
(3) As part of the application, shall provide to each group policyholder the disclosure statement described in §B of this regulation, for each dental point-of-service option offered.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.05 - Dental Benefit Plan Coverage - Mandatory Point-of-Service Option › Section 31.12.05.03 - Record Retention

Current through Register Vol. 51, No. 14, July 12, 2024
Each health maintenance organization or dental plan organization shall maintain copies of the notice and the group policyholder response for a period of 3 years or until its next market conduct examination, whichever occurs first.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.06 - Managed Care Organizations - Financial Compliance Requirements › Section 31.12.06.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. All terms defined in Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, which are used in this chapter have the same meaning as in that statute unless the terms are defined differently in this chapter. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Administration" means the Maryland Insurance Administration.
(2) "Applicant" means an organization applying to become a managed care organization.
(3) "Commissioner" means the Maryland Insurance Commissioner.
(4) "Contract" means the contractual agreement for the provision of health care services on a prepaid, capitated basis entered into between a managed care organization and the Department of Health and Mental Hygiene to provide health care benefits only to medical assistance program recipients.
(5) "Department" means the Department of Health and Mental Hygiene.
(6) "Leasehold estate improvements" means capital improvements made to properties leased for 20 or more years and depreciated over the remaining life of the lease.
(7) "Managed care organization (MCO)" means a managed care organization as defined in Health-General Article, §15-101(e)(2), Annotated Code of Maryland.
(8) "NAIC" means the National Association of Insurance Commissioners.
(9) "Secretary" means the Secretary of Health and Mental Hygiene.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.06 - Managed Care Organizations - Financial Compliance Requirements › Section 31.12.06.02 - Financial Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. An applicant or MCO may not engage in business as an MCO unless determined by the Insurance Commissioner to be in compliance with the financial requirements of Health-General Article, §15-102.4, Annotated Code of Maryland.
B. Upon request, the MCO shall submit to the Administration the following documents:
(1) A copy of the articles of incorporation of the applicant or MCO and any amendments to it, certified by the Maryland Department of Assessments and Taxation;
(2) A copy of the applicant's or MCO's current bylaws, if any, certified by the appropriate officer of the applicant or MCO;
(3) A list of the names, addresses, and official capacity with the applicant or MCO of the individuals who are to be responsible for the conduct of the applicant's or MCO's affairs, including the members of the governing body, the officers, and directors;
(4) A resume of the qualifications of the administrator, the medical director, officers, and other individuals associated with the applicant or MCO as requested by the Commissioner and the Department;
(5) A statement generally describing the:
(a) Applicant or MCO and its corporate structure;
(b) Applicant's or MCO's operations;
(c) Location of the facilities at which health care services will be regularly available to enrollees;
(d) Number of physicians and personnel engaged or contracted with to provide health care services;
(6) A statement describing with reasonable certainty the geographic area or areas to be served by the applicant or MCO;
(7) A financial statement audited by an independent certified public accountant of the financial condition of the applicant or MCO, including:
(a) Assets, liabilities, and minimum tangible net equity;
(b) A prospective budget and expected cash flow analysis of the applicant or MCO for the first 24 months of its anticipated operation demonstrating its financial viability based on reasonable assumptions; and
(c) Other financial information the Commissioner requires for adequate financial evaluation;
(8) A power of attorney duly executed by the applicant or MCO appointing the Commissioner and the Commissioner's authorized deputies as the true and lawful attorney of the MCO in and for the State upon whom may be served all lawful process in any action, proceeding, or cause of action arising in this State against the MCO regarding the solvency and financial condition of the MCO; and
(9) A certificate of compliance evidencing employee coverage under Labor and Employment Article, §
										9-105, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.06 - Managed Care Organizations - Financial Compliance Requirements › Section 31.12.06.02-1 - Risk-Based Capital Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Health Insurer. In this regulation, the term "health insurer" has the meaning stated in Insurance Article, §
									4-301(g), Annotated Code of Maryland.
B. Requirements Applicable to MCOs. Unless exempted by the Insurance Commissioner, beginning with the Annual Statement filed for the year ending December 31, 2001, an MCO shall comply with the risk-based capital requirements of Insurance Article, Title 4, Subtitle 3, Annotated Code of Maryland, in the same manner as a health insurer.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.06 - Managed Care Organizations - Financial Compliance Requirements › Section 31.12.06.03 - Application of Maryland Insurance Acquisitions Disclosure and Control Act

Current through Register Vol. 51, No. 14, July 12, 2024
A. Exemption. If the Commissioner determines that this regulation or a part of this regulation is not intended to apply to a managed care organization or affiliate, the Commissioner may exempt the managed care organization or affiliate from this regulation or the part of this regulation.
B. In this regulation, the following terms have the meanings indicated:
(1) "Holding company" means a person that directly or indirectly controls a managed care organization, or controls a person that controls a managed care organization.
(2) "Holding company system" means two or more affiliates, at least one of which is a managed care organization.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.06 - Managed Care Organizations - Financial Compliance Requirements › Section 31.12.06.04 - Annual and Interim Financial Reports

Current through Register Vol. 51, No. 14, July 12, 2024
A. On or before March 1 of each year, each MCO operating under a contract with the Department shall file, in duplicate, a report that includes a consolidated financial statement.
B. The Commissioner may require interim statements of the MCOs, on such points as the Commissioner deems necessary and proper at any time during the period between the filing of annual statements.
C. The report shall:
(1) Cover the MCO and all of its affiliates and subsidiaries;
(2) Consist of the financial statements of the MCO, and all of its affiliates and subsidiaries, prepared in accordance with statutory accounting principles on a form approved by the Commissioner and certified by an independent certified public accountant as to the financial condition, transactions, and affairs of the MCO and its affiliates and subsidiaries for the immediately preceding calendar year;
(3) Provide a list of the total compensation from the MCO, including all cash and deferred compensation stock, and stock options in addition to salary, of each member of the board of directors of the MCO, and each senior officer of the MCO, or any subsidiary of the MCO, as designated by the Commissioner;
(4) Contain loss ratios for medical assistance business as required under Insurance Article, §
										15-605, Annotated Code of Maryland;
(5) Be on the form adopted by the Commissioner;
(6) Be supplemented with a description of any changes in the information submitted with the last previous annual report or with the MCO's original application for financial compliance; and
(7) Provide any other information or documents necessary to assure compliance with Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.06 - Managed Care Organizations - Financial Compliance Requirements › Section 31.12.06.05 - Financial Examination

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Commissioner may make an examination of the operation of a managed care organization as often as the Commissioner deems necessary for the protection of the interest of the people of Maryland, but the examinations may not be less frequent than once every 5 years.
B. The expense of examinations shall be assessed against the MCO being examined in accordance with Health-General Article, §19-718, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.06 - Managed Care Organizations - Financial Compliance Requirements › Section 31.12.06.06 - Rehabilitation or Liquidation of an MCO

Current through Register Vol. 51, No. 14, July 12, 2024
Any rehabilitation or liquidation of an MCO shall be:
A. Deemed to be the rehabilitation or liquidation of a health maintenance organization; and
B. Subject to the requirements of Health-General Article, §19-706.1, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.07 - Required Standard Provisions › Section 31.12.07.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all health maintenance organizations operating in this State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.07 - Required Standard Provisions › Section 31.12.07.02 - 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 contract or group contract provides protection, in exchange for the payment of a particular premium.
(1-1) Group Contract.
(a) "Group contract" means a contractual agreement entered into between an HMO and an employer, union, trustee, association, or other organization for the provision of health care services on a prepaid basis to:
(i) Subscribers of the group contract holder; or
(ii) Subscribers of the group contract holder and the subscriber's dependents.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.07 - Required Standard Provisions › Section 31.12.07.03 - Required Standard Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. A group contract may not be delivered in Maryland unless it contains in substance the provisions:
(1) Listed in Regulation .04 of this chapter; or
(2) Which in the opinion of the Commissioner, as compared to the provisions in Regulation .04 of this chapter, are:
(a) More favorable to the members, or
(b) At least as favorable to the members and more favorable to the group contract holder.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.07 - Required Standard Provisions › Section 31.12.07.04 - Group Contract Standard Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Entire Contract; Changes. Each group contract shall contain a provision that specifies:
(1) Which documents constitute the entire contract; and
(2) That a change in the contract may not be valid:
(a) Until approved by an executive officer of the HMO, and
(b) Unless the approval is endorsed on the contract or attached to the contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.07 - Required Standard Provisions › Section 31.12.07.05 - Individual Contract Standard Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each individual contract shall contain in substance the provisions set forth in Regulation .04C, E, F, G, H, and L of this chapter.
B. Entire Contract; Changes. Each individual contract shall contain in substance the following provision: "Entire contract; changes: This agreement, including the endorsements and the attached papers, if any, constitutes the entire contract. No change in this agreement shall be valid until approved by an executive officer of the HMO and unless such approval is endorsed on the agreement or attached to the agreement. No agent has authority to change this agreement or to waive any of its provisions."
C. Contestability of the Contract.
(1) Each individual contract shall contain in substance a provision that:
(a) The contract may not be contested, except for nonpayment of premiums, after it has been in force for 2 years from its date of issue;
(b) Absent fraud, each statement made by an applicant or member is considered to be a representation and not a warranty; and
(c) A statement made to effectuate coverage may not be used to avoid the coverage or reduce benefits under the contract unless:
(i) The statement is contained in a written instrument signed by the subscriber or member, and
(ii) a copy of the statement is given to the subscriber or member.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.07 - Required Standard Provisions › Section 31.12.07.06 - Limitations and Exclusions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Crime.
(1) An individual or group contract may not include a limitation or exclusion for loss to which a contributing cause was the member's commission of or attempt to commit a crime.
(2) An individual or group 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 member.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.07 - Required Standard Provisions › Section 31.12.07.07 - Group Contract Optional Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. An HMO may include in group contracts any of the optional provisions described in §§C and D of this regulation.
B. An HMO may not include in a group contract an optional provision dealing with the same subjects set forth in §§C and D of this regulation if the provision is drafted in a manner that is less favorable to the group contract holder, subscriber, or member than the corresponding optional provision set forth in §§C and D of this regulation.
C. Physical Examination.
(1) An HMO may include a provision in a group contract giving the HMO the right to examine the person of the member when and as often as it may reasonably require during the pendency of a claim under the contract.
(2) If the HMO includes the provision described in §C(1) of this regulation, the provision shall indicate that any physical examination required by the HMO will be performed at the expense of the HMO.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.07 - Required Standard Provisions › Section 31.12.07.08 - Individual Contract Optional Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. An HMO may include in an individual contract any of the optional provisions described in Regulation .07C and D of this chapter and §C of this regulation.
B. An HMO may not include in an individual contract an optional provision dealing with the same subjects set forth in Regulation .07C and D of this chapter and §C of this regulation if the provision is drafted in a manner that is less favorable to the subscriber or member than the corresponding optional provision set forth in Regulation .07C and D of this chapter and §C of this regulation.
C. Unpaid Premiums. An individual contract may contain the following provision: "Unpaid premiums: Upon the payment of a claim under this contract, any premium then due and unpaid or covered by any note or written order may be deducted from the claim payment."
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.08 - Payments to Nonparticipating Providers › Section 31.12.08.01 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to covered services paid by health maintenance organizations to nonparticipating providers for services provided on or after January 1, 2010.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.08 - Payments to Nonparticipating Providers › Section 31.12.08.02 - 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) "Berenson-Eggers Type of Service Code" has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.
(2) "CPT code" means the Current Procedural Terminology Code maintained and distributed by the American Medical Association, including its codes and modifiers, and codes for anesthesia services.
(3) "Enrollee" has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.
(4) "Evaluation and management services" has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.
(5) "Geographic area" means each geographic area as published by the Centers for Medicare and Medicaid Services.
(6) "HCPCS" means the Healthcare Common Procedure Coding System, a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology and other services such as ambulance services, prosthetic devices, other supplies, and non-physician services that are not covered by CPT codes but are recognized and maintained by the Centers for Medicare and Medicaid Services.
(7) "Health maintenance organization" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.
(8) "Medicare Economic Index" has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.
(9) "Nonparticipating provider" means a provider other than a hospital or trauma physician who is not included on the provider panel of a health maintenance organization.
(10) "Participating provider" means a provider other than a hospital or trauma physician who is included on the provider panel of a health maintenance organization.
(11) "Provider" means a health care practitioner licensed, certified, or otherwise authorized by law to provide health care services.
(12) "Provider panel" has the meaning stated in Insurance Article, §
										15-112, Annotated Code of Maryland.
(13) "Reference year" means, for services provided in a particular calendar year, the period beginning with July 1 of the second previous calendar year through June 30 of the previous calendar year.
(14) "Similarly licensed provider" has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.
(15) "Trauma physician" has the meaning stated in Health-General Article, §19-710.1, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.08 - Payments to Nonparticipating Providers › Section 31.12.08.03 - Payment to Nonparticipating Providers

Current through Register Vol. 51, No. 14, July 12, 2024
A. A health maintenance organization shall calculate the amount owed to a nonparticipating provider for covered evaluation and management services provided to an enrollee in accordance with Regulation .05 of this chapter.
B. A health maintenance organization shall calculate the amount owed to a nonparticipating provider for covered services other than evaluation and management services provided to an enrollee in accordance with Regulation .06 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.08 - Payments to Nonparticipating Providers › Section 31.12.08.04 - Annual Rate Schedule

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each year, beginning with January 1, 2010, each health maintenance organization shall develop an annual rate schedule for each geographic area.
B. The annual rate schedule required by §A of this regulation shall include a rate for each occurrence of a CPT code or HCPCS code that describes covered services for each type of similarly licensed provider in the same geographic area derived in accordance with the formula specified in §C of this regulation.
C. The rate in the annual rate schedule for each CPT code or HCPCS code shall be developed as follows:
(1) For each type of similarly licensed provider, the rate paid for the CPT code or HCPCS code shall be equal to the total amount allowed for the occurrences of the CPT code or HCPCS code to participating providers who are similarly licensed providers in the same geographic area during the reference year divided by the total number of occurrences paid for the same CPT code or HCPCS code to participating providers who are similarly licensed providers in the same geographic area during the reference year.
(2) For any new CPT code or HCPCS code, the rate paid for the CPT code or HCPCS code shall be equal to 125 percent of the rate paid to a similarly licensed provider in the same geographic area.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.08 - Payments to Nonparticipating Providers › Section 31.12.08.05 - Evaluation and Management Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. If a nonparticipating provider submits a claim to a health maintenance organization for a covered evaluation and management service, the health maintenance organization shall pay the nonparticipating provider, less any applicable copayment, coinsurance or deductible amount, an amount not less than the greater of:
(1) 125 percent of the fee for the covered evaluation and management service in the annual fee schedule applicable to similarly licensed providers in the same geographic area; or
(2) 140 percent of the fee for the covered evaluation and management service paid by Medicare as published by the Centers for Medicare and Medicaid Services as of August 1, 2008, inflated by the four quarter moving average percent change in the Medicare Economic Index from 2008 to the current year.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.08 - Payments to Nonparticipating Providers › Section 31.12.08.06 - Other Covered Services

Current through Register Vol. 51, No. 14, July 12, 2024
If a nonparticipating provider submits a claim to a health maintenance organization for a covered service other than a covered evaluation and management service, the health maintenance organization shall pay the nonparticipating provider, less any applicable copayment, coinsurance or deductible amount, an amount not less than 125 percent of the rate for the covered service in the annual rate schedule applicable to similarly licensed providers in the same geographic area.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to:
A. Establish standards for premium rates for credit life and credit health insurance which are neither excessive nor inadequate in relation to benefits, giving due consideration to past and expected loss experience within and outside of this State, to underwriting practice and judgement, to past and prospective expense factors, to a reasonable margin for profit and contingencies, and to other relevant factors; and
B. Regulate certain other aspects of the credit life and credit health insurance business in order to assure that the credit life and credit health insurance operations of an insurer do not endanger the solvency of the insurer so as to render its transaction of business hazardous to its policyholders or the public, and do not adversely affect other classes of business of the insurer.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.02 - Regulation of Commissions

Current through Register Vol. 51, No. 14, July 12, 2024
To assure that credit life and credit health insurance operations of insurers do not result in rates which are excessive in relation to benefits, do not endanger the solvency of insurers rendering their transaction of business hazardous to policyholders or the public, and do not adversely affect other classes of business of insurers, the Commissioner has found it necessary to establish maximum rates of commission which may be paid to agents or brokers and maximum benefits payable to creditor group policyholders in the form of dividends, retrospective rate credits, or in any other form.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.03 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all authorized life insurers and all authorized health insurers delivering or issuing for delivery or proposing to deliver or issue for delivery credit life insurance or credit health insurance in Maryland under individual policies, group policies, or group certificates which are required to be filed in accordance with the provisions of Insurance Article, §
									13-110, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.05 - Loss Ratio

Current through Register Vol. 51, No. 14, July 12, 2024
Benefits for policies issued under these regulations shall be deemed reasonable in relation to premiums if claims incurred under the policies result in, or may reasonably be expected to result in, a loss ratio of not less than 55 percent when premiums do not exceed prima facie premium rates. When the prima facie loss ratio exceeds 55 percent, the premiums shall be determined in accordance with the methods of Regulation .18 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.06 - Statistics and Reporting Forms

Current through Register Vol. 51, No. 14, July 12, 2024
A. Filing with Commissioner.
(1) To permit the Commissioner to review the basis of prima facie premium rates and the basis of premium rates being charged on the case method, each insurer writing credit life or credit health insurance shall:
(a) Maintain statistics relating to the insurer's Maryland business; and
(b) File the statistics with the Commissioner in the form required by the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.07 - Rate Changes and Creditor-Paid Insurance

Current through Register Vol. 51, No. 14, July 12, 2024
A. Premium rates under a group policy of credit life or credit health insurance may not be increased more than once during the first policy year, and a subsequent increased rate may not be charged within 12 months of any prior change in rates.
B. In a policy of outstanding balance insurance, a change in rates may not be made effective until 31 days after all existing debtors in the group have been notified of any increased charge that they will be required to pay as a result of the change in rates. If the insurer is unable to identify the existing debtors, notice required by this section shall be deemed to be satisfied if the insurer notifies the creditor and provides necessary forms to be mailed by the creditor to the debtors advising them of the increased charge.
C. An insurer may file for approval of policy forms and premium rates for creditor-paid insurance on a basis other than that established by these regulations upon a showing satisfactory to the Commissioner that the forms and rates meet the requirements of Insurance Article, Title 13, Subtitle 1, Annotated Code of Maryland, and that the rates are actuarially consistent with rates prescribed by these regulations for other forms of credit life and credit health insurance.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.08 - Premium Rates by Case Method

Current through Register Vol. 51, No. 14, July 12, 2024
A. -
B. Repealed.
C. Case Comprised of Two or More Accounts.
(1) If an insurer has combined two or more accounts to establish a case, it may not add additional accounts or remove accounts from that case except with the permission of the Commissioner and under conditions which the Commissioner may specify.
(2) When submitting an experience report for a case comprised of two or more accounts, the insurer shall include a list of the names of each account included in the case.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.09 - General Premium Rate Standards and Increased Rates

Current through Register Vol. 51, No. 14, July 12, 2024
A. With respect to all premium rates not eligible for filing in accordance with the case method, the Commissioner will accept as meeting the standards of Insurance Article, §
									13-110(b)(1)  and (2), Annotated Code of Maryland, those premium rate filings which do not exceed prima facie premium rates stated in Regulations .10 - .11 and .14 - .15 of this chapter for the several categories of insurance described in those regulations. The prima facie premium rates in those regulations are based on the assumption that a policy fee, policy issue fee, certificate fee, or other additional charge will not be made.
B. Premium rates for use with forms which have more restrictive provisions than those described in Regulation .13 or .17 of this chapter, whichever is applicable, shall reflect those restrictions in a reduction in rates commensurate with the differences in claim costs which can reasonably be anticipated by reason of the restrictions. Filings in connection with a policy containing those restrictions shall be accompanied by credible statistics applicable to the policy form and shall require an application for specific approval as in the case of a filing made for increased rates.
C. Unless specific reference is made in these regulations to joint life insurance, all prima facie premium rates and standards and formulas for increased rates refer to individual policies and group certificates insuring single lives.
D. With respect to premium rates not eligible for filing in accordance with the case method, an insurer may file with the Commissioner an application for approval of rates higher than the prima facie premium rates for a single creditor or for one or more classes of business. The application shall specify the basis for the increased rate requested and shall be accompanied by credible statistics applicable to the business under consideration and by a demonstration that the requested rates are in conformity with, or less than, rates which would meet the guidelines for increased rates set forth in Regulation .18 of this chapter.
E. The Commissioner may grant approval of an increased rate for a stated period, or for an indefinite period until revoked by him on 90 days' notice. If a period is not specified in the Commissioner's notice of approval, an approval by the Commissioner of an increased rate shall be effective for a period of 1 year.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.10 - Prima Facie Premium Rates for Credit Life Insurance

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as specified in Regulation .11 of this chapter, the premiums charged for credit life insurance policies having all policy provisions not less favorable to the insured debtor than those permitted by Regulation .13 of this chapter, may not exceed the following:
(1) For single premium decreasing term policies insuring one life, issued on the total-of-payments method, $0.43 per annum per $100 of initial amount of insured indebtedness;
(2) For outstanding balance term policies insuring one life, $0.66 per month per $1,000 of the amount of insured outstanding indebtedness; or
(3) For single premium level term policies insuring one life, $0.71 per annum per $100 of the amount of insured indebtedness.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.11 - Prima Facie Premium Rates-Credit Life Insurance-Net Payoff Balance Method

Current through Register Vol. 51, No. 14, July 12, 2024
A. The premium charged for credit life insurance policies issued under the net payoff balance method and having all policy provisions not less favorable to the insured debtor than those permitted by Regulation .13 of this chapter, may not exceed the following:
(1) For single premium decreasing term policies insuring one life, a premium based on $0.66 per $1,000 of the sum of the scheduled insured outstanding principal indebtedness each month over the term of insurance coverage; or
(2) For joint life policies, the premium determined in accordance with Regulation .10D of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.13 - Underwriting Requirements for Credit Life Prima Facie Premium Rates

Current through Register Vol. 51, No. 14, July 12, 2024
A. The prima facie premium rates used in Regulations 10 - .11 of this chapter assume that contracts providing credit life insurance do not require evidence of individual insurability from any eligible debtor electing to purchase coverage within 30 days of the date the debtor becomes eligible.
B. If an insurer requires evidence of insurability from debtors electing to purchase coverage within 30 days of the date they become eligible and the initial amount of credit life insurance or the insurable maximum revolving credit account limit of an insured debtor does not exceed $15,000, the insurer shall reduce the premium rates stated in Regulations .10 - .11 of this chapter by 10 percent on all:
(1) Individual policies of credit life insurance issued through the same creditor, regardless of whether the initial amount of credit life insurance or the insurable maximum revolving credit account limit exceeds $15,000; or
(2) Certificates of credit life insurance issued under the group policy through the same credit or creditor, regardless of whether the initial amount of credit life insurance or the insurable maximum revolving credit account limit exceeds $15,000.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.14 - Disability Benefit Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. If a credit life insurance policy, otherwise meeting the requirements of Regulation .13 of this chapter provides for payment of the policy proceeds in the event of the loss of two limbs or in the event of the complete loss of eyesight, the insurer may charge a rate not to exceed 1 percent more than the rates in Regulation .10 or .11 of this chapter, whichever is applicable. If the policy provides for payment of the policy proceeds in event of loss of a single limb or in event of the loss of the sight of one eye, the insurer may charge a rate not to exceed 3 percent more than the rates in Regulation .10 or .11 of this chapter, whichever is applicable.
B. If a credit life insurance policy otherwise meeting the requirements of Regulation .13 of this chapter provides for payment of the policy proceeds in event of total and permanent disability, other than the benefit described in §A of this regulation, the Commissioner shall determine an appropriate increase in the premium rates on application of the insurer.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 13 - CREDIT LIFE AND CREDIT HEALTH INSURANCE › Chapter 31.13.01 - Standards for Credit Life and Credit Health Insurance › Section 31.13.01.17 - Underwriting Requirements for Credit Health Prima Facie Premium Rates

Current through Register Vol. 51, No. 14, July 12, 2024
A. The prima facie premium rates in Regulation .15 of this chapter assume that contracts providing credit health insurance do not require evidence of individual insurability from any eligible debtor electing to purchase coverage within 30 days of the date the debtor becomes eligible.
B. If an insurer requires evidence of insurability from debtors electing to purchase coverage within 30 days of the date they become eligible and the total amount of insured periodic indemnity payable in event of disability of the debtor or the insurable maximum revolving credit account limit of an insured debtor does not exceed $15,000, the insurer shall reduce the premium rates stated in Regulation .15 of this chapter by 10 percent on all:
(1) Individual policies of credit health insurance issued through the same creditor; or
(2) Certificates of credit health insurance issued under the group policy through the same creditor.