reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.48 - Pharmacy Benefits Managers-Informational Filing of Contracts and Amendments › Section 31.10.48.03 - Submission Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Pursuant to the requirements of Insurance Article, §
									15-1628(b), Annotated Code of Maryland, a PBM shall submit to the Commissioner as an informational filing each participating pharmacy contract form and each amendment to a contract form at least 30 days before the contract form or amendment to the contract form is to become effective.
B. The Commissioner is not required to review the informational filing to evaluate whether a contract form or amendment to a contract form is in violation of Maryland law at the time the informational filing is made.
C. Unless it is disapproved by the Commissioner, a PBM may use a contract form or amendment to a contract form after it has been filed with the Commissioner and 30 days have passed since the filing was acknowledged by the Commissioner in writing as having been received
D. A PBM may not file a contract form or amendment form that has been previously disapproved by the Commissioner.
E. Nothing in this regulation shortens the time period for notice under Insurance Article, §
									15-1628(a), Annotated Code of Maryland, which requires a PBM to provide at least 30 working days' notice before any contract change.
F. The filing shall include a cover letter which includes the following:
(1) A list of the contract forms and amendment forms included in the submission; and
(2) A brief description of the purpose of each contract form and amendment form included in the submission.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.48 - Pharmacy Benefits Managers-Informational Filing of Contracts and Amendments › Section 31.10.48.04 - Noncompliant Contract Terms

Current through Register Vol. 51, No. 14, July 12, 2024
A. A PBM may have a contract form or amendment to a contract form disapproved at any time after the contract form or amendment to a contract form has been submitted as part of an informational filing if the contract form or amendment form contains or uses any language that:
(1) Violates Insurance Article, Title 15, Subtitle 16, Annotated Code of Maryland, or any applicable statutory provisions, including but not limited to Insurance Article, §§
										15-112,  15-112.2(a)  -(e), 15-123(d), 15-1004, 15-1005, 15-1008(c), 15-1009, 15-1628-15-1628.3, 15-1629, 15-1631, and 15-1633-15-1639, and Health-General Article, §§ 19-710(s) and (t) and 19-712.2, Annotated Code of Maryland;
(2) Does not disclose the components of the compensation program through which a reimbursement rate is set;
(3) Includes a definition of "multisource generic drug " that is inconsistent with COMAR 31.10.46, or "generic" or "brand name drug" that is inconsistent with Health Occupations Article, §
										12-504, Annotated Code of Maryland;
(4) Allows the PBM to reimburse a covered drug in an amount that differs, including zero, based on the identity of the wholesale distributor used by a contracting pharmacy for acquisition of the covered drug;
(5) Except for instances of error or fraud, allows the PBM to reclassify, recategorize, or recharacterize an adjudicated claim;
(6) In any way prohibits or restricts a pharmacist or pharmacy from filing a complaint with the Commissioner; or
(7) Fails to include the internal appeal provisions in the contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.48 - Pharmacy Benefits Managers-Informational Filing of Contracts and Amendments › Section 31.10.48.05 - Use of Noncompliant Contract or Amendment

Current through Register Vol. 51, No. 14, July 12, 2024
A. If a PBM uses a contract form or amendment form which becomes effective and the contract form or amendment form is subsequently found by the Commissioner to be noncompliant, the Commissioner may:
(1) Issue an order that:
(a) Gives notice of the disapproval;
(b) States a reason for the disapproval; and
(c) States the effective date of the disapproval in the notice; and
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.49 - Pharmacy Services Administrative Organizations › Section 31.10.49.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all contractual agreements between a pharmacy services administrative organization and an independent pharmacy in which a pharmacy services administrative organization negotiates on behalf of an independent pharmacy with purchasers or pharmacy benefit managers for prescription drug coverage or benefits, medical devices, or biologics provided to a beneficiary of a purchaser.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.49 - Pharmacy Services Administrative Organizations › Section 31.10.49.02 - 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) "Appeal decision" means a written or electronic notice in response to an appeal under this chapter provided to a contracted pharmacy that includes a reason for the appeal denial.
(2) "Contracted pharmacy" means an independent pharmacy in a pharmacy services administrative contract.
(3) "Delivered by electronic means" includes:
(a) Delivery to an electronic mail address at which an independent pharmacy or contracted pharmacy has consented to receive notice; and
(b) Posting on an electronic network, together with separate notice to an independent pharmacy or contracted pharmacy directed to the electronic mail address at which the independent pharmacy or contracted pharmacy has consented to receive notice of the posting.
(4) "Independent pharmacy" has the meaning stated in Insurance Article, §
										15-2001(b), Annotated Code of Maryland.
(5) "Material change" means a change in control or business operations of a pharmacy services administrative organization after a purchase, merger, or acquisition of a parent company, subsidiary, or other organization.
(6) Medical Device.
(a) "Medical device" means a device used in the diagnosis, treatment, or prevention of disease.
(b) "Medical device" does not include:
(i) Any surgical or dental instrument;
(ii) Physical therapy equipment;
(ii) Any x-ray apparatus; or
(iii) Any component or accessory of any of these items.
(7) "Pharmacy benefits manager (PBM)" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
(8) "Pharmacy services administrative contract" has the meaning stated in Insurance Article, §
										15-2001(d), Annotated Code of Maryland.
(9) "Pharmacy services administrative organization" or "PSAO" has the meaning stated in Insurance Article, §
										15-2001(e), Annotated Code of Maryland.
(10) "Purchaser" has the meaning stated in Insurance Article, §
										15-2001(f), Annotated Code of Maryland.
(11) "Working days" means any day that the Maryland Insurance Administration is open for business.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.49 - Pharmacy Services Administrative Organizations › Section 31.10.49.03 - Disclosures to an Independent Pharmacy

Current through Register Vol. 51, No. 14, July 12, 2024
A. A PSAO shall provide to a contracted pharmacy an electronic or paper copy of any contracts, amendments, payment schedules, or reimbursement rates within 5 working days after the execution of a contract, or an amendment to a contract, signed on behalf of the contracted pharmacy by the PSAO.
B. A PSAO shall provide written notice to an independent pharmacy of any ownership interest or control by a parent company, subsidiary, or other organization before entering into a pharmacy services administrative contract with the independent pharmacy.
C. A PSAO shall disclose to a contracted pharmacy in writing within 5 working days of any material change of ownership or control or a parent company, subsidiary, or other organization.
D. The written disclosures required in §§B and C of this regulation shall identify the extent of any ownership interest or control, to include the percent of shares owned, by a parent company, subsidiary, or other organization that:
(1) Provides pharmacy services, prescription drug, or device services; or
(2) Manufactures, sells, or distributes prescription drugs, biologics, or medical devices.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.49 - Pharmacy Services Administrative Organizations › Section 31.10.49.04 - Internal Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each PSAO subject to this chapter shall establish written procedures to investigate and resolve disputes filed against the PSAO by a contracted pharmacy.
B. The internal appeal procedures shall:
(1) Be in writing; and
(2) Contain administrative processes and safeguards designed to ensure and verify that a PSAO remits payment to a contracted pharmacy in accordance with the pharmacy services administrative contract and Maryland law, and that the contract provisions have not been applied in an arbitrary or capricious manner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.49 - Pharmacy Services Administrative Organizations › Section 31.10.49.05 - Complaint Process

Current through Register Vol. 51, No. 14, July 12, 2024
A. Prior to filing a complaint with the Commissioner, a contracted pharmacy or its designee shall exhaust the internal appeal process established by the PSAO.
B. A complaint is properly completed and may be filed if a contracted pharmacy or designee for the pharmacy:
(1) Completes all applicable portions of the Commissioner's complaint form; and
(2) Provides a copy of the relevant contract or the provisions that are related to the internal dispute, including but not limited to any applicable remittance and copy of any appeal decision.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.50 - Filing of PSAO Contracts and Amendments › Section 31.10.50.01 - Applicability and Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to the submission of a pharmacy services administrative contract or an amendment to a pharmacy services administrative contract required to be filed under Insurance Article, Title 15, Subtitle 20, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.50 - Filing of PSAO Contracts and Amendments › Section 31.10.50.02 - 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) "Commissioner" means the Maryland Insurance Commissioner.
(2) "Contracted pharmacy" means an independent pharmacy in a contract with a pharmacy services administrative organization.
(3) "Independent pharmacy" has the meaning stated in Insurance Article, §
										15-2001(b), Annotated Code of Maryland.
(4) "Noncompliant" means a contract or amendment that is not in compliance with Maryland statutes and regulations.
(5) "Pharmacy benefits manager (PBM)" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
(6) "Pharmacy services administrative contract" has the meaning stated in Insurance Article, §
										15-2001(d), Annotated Code of Maryland.
(7) "Pharmacy services administrative organization" or "PSAO" has the meaning stated in Insurance Article, §
										15-2001(e), Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.50 - Filing of PSAO Contracts and Amendments › Section 31.10.50.03 - Submission Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Pursuant to the requirements of Insurance Article, §
									15-2010, Annotated Code of Maryland, and except as provided in §E of this regulation, a PSAO shall submit to the Commissioner all pharmacy services administrative contract forms and amendments to pharmacy services administrative contract forms.
B. Unless it is disapproved by the Commissioner, and except as provided in §E of this regulation, a PSAO may not use a contract form or amendment to a contract form unless it has been filed with the Commissioner and:
(1) 60 days have passed since the filing was acknowledged by the Commissioner in writing as having been received; or
(2) Subject to the filing corrections under §C of this regulation, a PSAO receives written notice from the Commissioner that the contract form or amendment to a contract form may be used in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.50 - Filing of PSAO Contracts and Amendments › Section 31.10.50.04 - Noncompliant Contract Terms

Current through Register Vol. 51, No. 14, July 12, 2024
A. A PSAO may have a contract form or amendment to a contract form disapproved if the contract or amendment contains or uses any language that:
(1) Violates Title 15, Subtitle 16 or Subtitle 20 of the Insurance Article, Annotated Code of Maryland or any applicable statutory provisions, including but not limited to Insurance Article, §§
										15-1611,  15-1628,  15-1628.1,  15-1628.2,  15-1628.3,  15-1629,  15-1631,  15-1633, 15-1634-151639,  15-2011,  15-2013(c),  15-2015, and  15-2016, Annotated Code of Maryland;
(2) Includes a definition of "multisource generic drug" that is inconsistent with COMAR 31.46, or "generic" or "brand name drug" that is inconsistent with Health Occupations Article, §
										12-504, Annotated Code of Maryland;
(3) Allows the PBM to reimburse a covered drug in an amount that differs, including zero, based on the identity of the wholesale distributor used by a contracting pharmacy for acquisition of the covered drug;
(4) Except for instances of error or fraud, allows a PBM or PSAO to re-classify, re-categorize, or re-characterize an adjudicated claim;
(5) In any way prohibits or restricts a pharmacist or pharmacy from filing a complaint with the Commissioner; and
(6) Fails to include the internal appeal provisions in the contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.50 - Filing of PSAO Contracts and Amendments › Section 31.10.50.05 - Use of Noncompliant Contract or Amendment

Current through Register Vol. 51, No. 14, July 12, 2024
A. If a PSAO uses a contract or amendment that becomes effective and the contract or amendment is subsequently found by the Commissioner to be noncompliant, the Commissioner may:
(1) Issue an order that:
(a) Gives notice of the disapproval;
(b) States a reason for the disapproval; and
(c) States the effective date of the disapproval in the notice; and
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.51 - Mental Health Benefits and Substance Use Disorder Benefits - Reports on Nonquantitative Treatment Limitations and Data › Section 31.10.51.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to adopt regulations to implement Insurance Article, §
									15-144, Annotated Code of Maryland, to ensure uniform definitions and methodology for the reporting requirements established under this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.51 - Mental Health Benefits and Substance Use Disorder Benefits - Reports on Nonquantitative Treatment Limitations and Data › Section 31.10.51.02 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to carriers that deliver or issue for delivery a health benefit plan in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.51 - Mental Health Benefits and Substance Use Disorder Benefits - Reports on Nonquantitative Treatment Limitations and Data › Section 31.10.51.05 - Filing of Data Report

Current through Register Vol. 51, No. 14, July 12, 2024
A. For the five health benefit plans with the highest enrollment for each product offered by the carrier in the individual, small, and large group markets, a carrier that delivers or issues for delivery a health benefit plan in the State shall submit a data report for the immediately preceding calendar year for mental health benefits, substance use disorder benefits, and medical/surgical benefits by Parity Act classification.
B. The data report shall be filed with the Commissioner using only the standardized form posted on the Administration's website.
C. Carriers shall follow the instructions posted on the Administration's website to complete the data report.
D. A complete data report shall include responses to each applicable section of the standardized form and follow the instructions posted to the Administration's website.
E. Each data report shall contain a statement, signed by a corporate officer, attesting to the accuracy of the information contained in the data report.
F. Failure to file a complete data report shall result in penalties under Insurance Article, §
									15-144(j), Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.51 - Mental Health Benefits and Substance Use Disorder Benefits - Reports on Nonquantitative Treatment Limitations and Data › Section 31.10.51.06 - Summary Form

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier subject to Insurance Article, §
									15-144, Annotated Code of Maryland, shall prepare a summary form using only the template form posted on the Administration's website.
B. The summary form shall be made available to plan members and accessible to the public on the carrier's website no later than April 1, 2022 and April 1, 2024. The carrier shall make the summary form available to plan members in response to a written request within 30 days of the request.
C. Carriers shall follow the instructions for completing the summary form using the instructions posted on the Administration's website.
D. A complete summary form shall include responses to each applicable section of the standardized form, as described in the instructions posted on the Administration's website.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.51 - Mental Health Benefits and Substance Use Disorder Benefits - Reports on Nonquantitative Treatment Limitations and Data › Section 31.10.51.07 - Compliance Plan

Current through Register Vol. 51, No. 14, July 12, 2024
A. If, as a result of the review of the reports desalbed in Regulations .02 and .03 of this chapter, the Commissioner finds that a carrier subject to Insurance Article, §
									15-144, Annotated Code of Maiyland, failed to comply with provisions of the Parity Act, the Commissioner shall notify the carrier and require the carrier to submit a compliance plan pursuant to Insurance Article, §
									15-144(i). Annotated Code of Maiyland, to correct the noncompliance. The notice shall be in writing, but may be transmitted electronically.
B. The carrier shall have 90 days to file a compliance plan following the date a notice of noncompliance is issued by the Commissioner.
C. The compliance plan shall include:
(1) An acknowledgement of the Commissioner's finding of noncompliance;
(2) A summary of action or actions taken by the carrier to correct the noncompliance prior to the notice from the Commissioner;
(3) A summary of future action or actions to correct the noncompliance and the time frame when the actions will be taken; and
(4) A summary of amounts owed to members or providers due to violations of the Parity Act, including:
(a) Any amounts owed to members and the payment date or dates;
(b) Draft correspondence to members;
(c) Any amounts owed to providers and the payment date or dates;
(d) Draft correspondence to providers; and
(e) Confirmation of amounts paid to members and providers.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.51 - Mental Health Benefits and Substance Use Disorder Benefits - Reports on Nonquantitative Treatment Limitations and Data › Section 31.10.51.08 - Effective Date

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter is applicable to all reports filed after January 1, 2022.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to provide appropriate standards and requirements for implementing the conversion privilege and notification requirements under group health insurance policies.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.02 - 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) An insurer as defined in Insurance Article, §
											1-101, Annotated Code of Maryland; or
(b) A nonprofit health service plan that is licensed to operate in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.03 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter is applicable to group health insurance policies issued or renewed in Maryland on or after October 1, 1983 and prior to January 1, 2014, except as provided in §§B-C of this regulation.
B. This chapter is not applicable to:
(1) Group policies providing coverage only for:
(a) Specified diseases;
(b) Accidental injuries;
(c) Accidental death;
(d) Dental benefits;
(e) Vision care or any other supplemental benefit; or
(f) Any combination of the benefits described in §B(1)(a)-(e) of this regulation; or
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.04 - Conversion Privilege

Current through Register Vol. 51, No. 14, July 12, 2024
A. All group policies, as defined in this chapter, shall contain a provision stating that an insured person who has been continuously covered under the group policy and under any group policy providing similar benefits which it replaces for at least 3 months and whose coverage is terminated for any reason other than the reasons described in §D of this regulation, shall have issued to him without evidence of insurability a converted policy providing benefits not less than the minimum benefits required by this chapter.
B. A carrier shall include a notice of the right of conversion in each certificate of coverage provided to individuals covered under group policies.
C. Termination.
(1) Termination of coverage shall include, but not be limited to, termination by reason of discontinuance of the group policy in its entirety or with respect to an insured class, or termination by reason of the individual's no longer meeting the definition of a dependent contained in the group policy, or by reason of no longer meeting the definition in the policy of an employee or member, or by reason of the individual's retirement.
(2) The following are intended as illustrations of terminations by reason of no longer meeting the definition of dependent:
(a) A surviving spouse, whose coverage under the group policy terminates at the death of the employee or member;
(b) A spouse whose coverage under the group policy terminates by reason of divorce or legal separation;
(c) A child whose coverage under the group policy terminates at the death of an employee or member;
(d) A child whose coverage under the group policy terminates by reason of his reaching a limiting age specified in the group policy.
(3) If a group policy provides that a retired employee may continue to be covered under the group policy, the employee shall be given the option of electing the same conversion rights that would apply if the employee's insurance under the group policy had terminated at retirement.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.05 - Insurer's Option

Current through Register Vol. 51, No. 14, July 12, 2024
A. Instead of issuing an individual converted policy, the carrier may elect to provide the coverage required by this chapter by means of a group policy issued to a trustee and covering persons eligible for the conversion rights of these regulations.
B. The policy issued under §A of this regulation may provide that the entire premium be payable by the insured persons.
C. The group policy issued under §A of this regulation shall provide benefits not less than those stated in Regulations .06 and .10 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.06 - Standards for Converted Policies

Current through Register Vol. 51, No. 14, July 12, 2024
A. The converted policy shall become effective on the day following the date of termination of insurance coverage under the group policy.
B. The converted policy shall cover the employee or member or dependents of the employee or member, or both, who are covered by the group policy on the date of termination of insurance. At the option of the insurer, a separate converted policy may be issued to cover any dependent.
C. If a converted policy issued to an employee or member also covers a dependent child whose coverage under the group policy would have terminated at a specified date, the converted policy may provide for termination on or after that date, subject, however, to the requirements of Insurance Article, §
									15-402, Annotated Code of Maryland, whichever is applicable.
D. With respect to a person who was covered by the group policy, the period specified in the Time Limit on Certain Defenses provision of the converted policy shall begin with the date that person's insurance became effective under the group policy.
E. Preexisting Conditions.
(1) The converted policy may not contain exclusions for preexisting conditions, except to the extent that a condition was excluded from the group policy from which conversion was made.
(2) Benefits for pregnancy and childbirth may not be excluded from the converted policy if benefits for these conditions were provided under the group policy.
(3) The converted policy may provide that:
(a) Any hospital, surgical, or medical benefits payable under the converted policy may be reduced by the amount of any hospital, surgical, or medical benefits payable under the group policy after the termination of the individual's group coverage; and
(b) During the first policy year, the benefits payable under the converted policy, together with the benefits payable under the group policy, will not exceed the benefits that would have been payable had the individual's coverage under the group policy remained in force and effect.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.07 - Evidence of Insurability

Current through Register Vol. 51, No. 14, July 12, 2024
A. The converted policy shall be issued without evidence of insurability.
B. If the insured person was individually rated less favorably than standard under the group policy, or if all persons in the group policy were rated less favorably than standard, the converted policy may be issued with a corresponding rating.
C. If, by reason of a specific waiver or endorsement in the group policy, the insured person was specifically excluded from coverage for a specific named condition or conditions, a corresponding waiver or endorsement may be attached to the converted policy.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.08 - Application for Converted Policy

Current through Register Vol. 51, No. 14, July 12, 2024
A. The conversion provision in the group policy may require that the insured person, or a person acting on behalf of the insured person, make written application for the converted policy and may not require that the first premium due to the carrier be paid sooner than 31 days following the termination of the insured person's coverage under the group policy, or sooner than any extended time provided in these regulations.
B. The application for the converted policy may not contain questions relating to the health, occupation, avocation, or lifestyle of the insured person, or other questions relating to insurability, except information required to determine eligibility for the converted policy.
C. The carrier may refuse to issue a converted policy or may issue a converted policy for a reduced amount if the application shows the insured person is covered under a group policy providing benefits substantially similar to the maximum benefits which the insured person could elect under the converted policy, or if the insured person has other health benefits available at least equal to the level of benefits which would permit the carrier to refuse to renew a converted policy in accordance with the standards of Regulation .06G and H of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.09 - Premiums for Converted Policies

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as provided in §C of this regulation, the initial premium for the converted policy for the first 12 months and subsequent renewal premium shall be determined in accordance with the carrier's premium rates applicable to:
(1) Individually underwritten standard risks;
(2) The age and class of risk of each individual to be covered under the converted policy; and
(3) The type and amount of coverage provided.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.10 - Minimum Benefits under Converted Policies

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as provided in §B of this regulation, if the group policy from which conversion is made provided coverage for basic hospital, medical, or surgical expense insurance, the insured person at the insured person's option shall be entitled to obtain a converted policy under any one of Plans A, B, or C, which are described in §C of this regulation.
B. If the group policy provided hospital benefits based on the full cost of a semiprivate room, the carrier, at its option, may offer the insured person only Plan A, and if the group policy provided hospital benefits on a basis other than the full cost of a semiprivate room, the carrier, at its option, may offer the insured person only Plans B and C.
C. Plans A-C provide the following minimum benefits:
(1) A Plan A policy shall provide as minimum the following benefits or similar benefits which are substantially actuarially equivalent:
(a) All semiprivate room and board and miscellaneous hospital charges for a 70-day maximum duration, and
(b) Surgical-medical expense benefits according to a schedule consistent with those customarily offered by the carrier under group insurance policies and providing a maximum benefit of $7,000;
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.11 - Benefit Levels

Current through Register Vol. 51, No. 14, July 12, 2024
If the coverage under the group policy from which conversion is being made provided benefits less than those which would be required in Regulation .10 of this chapter, the carrier, at its option, may provide a converted policy with benefits which are substantially similar to those provided under the group policy instead of offering the plans required in Regulation .10 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.12 - Out-of-State Conversions

Current through Register Vol. 51, No. 14, July 12, 2024
A. A converted policy which is delivered outside of Maryland as a conversion from a group policy issued in Maryland shall be on a form which is permitted to be delivered in the other jurisdiction.
B. If the carrier is prohibited by the law of the other jurisdiction from issuing a converted policy by reason of not being licensed in that jurisdiction, the carrier shall provide coverage in accordance with the requirements of these regulations under a group policy issued in Maryland or in another jurisdiction in which the carrier is licensed.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.13 - Modified Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
Upon request of a carrier, the Commissioner may grant approval for modification of any of the minimum specifications or other requirements of these regulations upon a showing by the carrier that modification is equitably warranted.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.14 - Notification

Current through Register Vol. 51, No. 14, July 12, 2024
A. The insured person whose coverage under a group policy terminates and who is entitled to make application for a converted policy shall be notified of this right, on or before the date of termination of coverage, but not more than 61 days before.
B. An insured person who receives the timely notice of the conversion privilege, as described in §A of this regulation, shall be given the right to apply for the converted policy until at least 45 days after the date the individual's coverage under the group policy terminates.
C. If the insured person is not provided the notification described in §A of this regulation, then the insured person shall have the right to apply for a converted policy within the time stated in the notice which shall be at least 31 days after the date of the notice, except that the late notice may not extend the period for making application beyond 90 days after the termination of coverage in the group policy.
D. Except as provided in §E of this regulation, written notice presented to the insured person or mailed by the group policyholder to the last known address of the insured person or mailed by the carrier to the last known address of the insured person as furnished by the policyholder shall constitute notice for the purpose of this regulation.
E. Notice given by the policyholder or the carrier by mail which is returned undelivered does not constitute notice for the purpose of this regulation.
F. Unless the written notice is to be provided by the carrier, the group policy shall contain a provision to the effect that notice of the conversion privilege shall be given by the group policyholder to the affected certificate holder upon termination of coverage of the insured person.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.01 - Conversion of Group Health Insurance › Section 31.11.01.15 - Amendment of Group Policy

Current through Register Vol. 51, No. 14, July 12, 2024
Any group policy issued in Maryland before the effective date of these regulations and not in conformity with these regulations, shall be amended on the annual renewal date of the group policy to conform to the regulations in this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.02 - Group Health Insurance - Continuation of Coverage of Divorced Spouses › Section 31.11.02.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to provide standards for implementing requirements of the Insurance Article and of Health-General Article, Annotated Code of Maryland, with respect to providing or continuing coverage for certain divorced spouses and dependent children.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.02 - Group Health Insurance - Continuation of Coverage of Divorced Spouses › Section 31.11.02.03 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
A. These regulations shall be applicable to all group health insurance policies or contracts issued or delivered in this State to the employer of the insured which provide hospital, surgical, medical, or major medical benefits on an expense-incurred basis whether issued by a nonprofit health service plan or by any other insurer and to all group policies or contracts issued or delivered in this State to an employer of an insured by a health maintenance organization certified under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.
B. These regulations shall be applicable to any policy or contract issued on or after the effective date of these regulations, beginning with the date of issue of the policy or contract.
C. These regulations shall be applicable to any policy or contract issued before the effective date of these regulations, beginning on the first annual renewal date or the first anniversary of the date of issue of the policy or contract occurring on or next following the effective date of these regulations.
Agency Note: Federal statutes and regulations may provide broader or additional benefits for persons to whom these regulations are applicable.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.02 - Group Health Insurance - Continuation of Coverage of Divorced Spouses › Section 31.11.02.04 - Eligibility

Current through Register Vol. 51, No. 14, July 12, 2024
A. Beginning with an applicable change in status and until the occurrence of an event described in Regulation .07 of this chapter, the qualified secondary beneficiary shall be entitled to the benefits provided under the group contract.
B. Section A of this regulation may not be applicable to any period during which the insured is not covered by a group contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.02 - Group Health Insurance - Continuation of Coverage of Divorced Spouses › Section 31.11.02.05 - Coverage Provided

Current through Register Vol. 51, No. 14, July 12, 2024
A. The coverage provided to a qualified secondary beneficiary shall be identical to the coverage which would have been provided under the group contract for the benefit of the qualified secondary beneficiary if the individual had remained an eligible dependent of the insured employee and there had been no applicable change in status.
B. If modifications are made in the employer's group contract, the coverage provided to the qualified secondary beneficiary shall be correspondingly modified.
C. If the employer transfers from one group contract to another, the coverage provided the qualified secondary beneficiary shall be transferred to that provided under the new group contract.
D. If the employer provides various hospital, surgical, medical, or major medical coverages under one or more group contracts, a qualified secondary beneficiary may not choose less than all of the benefits provided unless the insured employee would have had the option of making such a choice for an eligible dependent if there had been no applicable change in status.
E. The benefits to be provided under the group contract shall be in no respect less favorable than those required by these regulations.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.02 - Group Health Insurance - Continuation of Coverage of Divorced Spouses › Section 31.11.02.06 - Conditions of Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. In order to receive the benefits provided under the group contract, an insured employee, or the divorced spouse of the insured employee, shall notify the employer of the applicable change in status not later than:
(1) 60 days after the applicable change in status if on the date of the applicable change in status the employee is covered under the employer's group contract or under another group contract issued to the same employer replacing that contract. The coverage shall be retroactive to the applicable change in status.
(2) 30 days after the date the insured employee becomes eligible for coverage under a group contract issued to another employer, if the insured employee becomes covered under the new employer's group contract after the applicable change in status. The coverage shall be retroactive to the date of eligibility.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.02 - Group Health Insurance - Continuation of Coverage of Divorced Spouses › Section 31.11.02.07 - Termination

Current through Register Vol. 51, No. 14, July 12, 2024
A. Coverage for a qualified secondary beneficiary will terminate when the coverage under the group contract terminates with respect to the insured employee.
B. Even though the insured employee continues to be covered under the group contract, coverage with respect to any individual qualified secondary beneficiary shall terminate on the date of occurrence of any of the following:
(1) The date on which the qualified secondary beneficiary becomes eligible for hospital, surgical, medical, or major medical benefits under any insured group contract or any health maintenance organization group contract or any self-insured group health benefit program or plan provided the:
(a) Group contract or the self-insured program or plan is on an expense-incurred basis, and
(b) Eligibility does not result from the provisions of these regulations;
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.02 - Group Health Insurance - Continuation of Coverage of Divorced Spouses › Section 31.11.02.09 - Notification Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each group contract to which these regulations are applicable shall include a statement as provided in §B of this regulation.
B. The statement shall disclose the availability of the benefits provided under these regulations and shall provide a summary of the eligibility requirements, the duration and general description of the benefits.
C. Each group contract issued before the effective date of these regulations, to which these regulations are applicable, shall be amended in accordance with these regulations not later than the date of applicability stated in Regulation .03B of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.02 - Group Health Insurance - Continuation of Coverage of Divorced Spouses › Section 31.11.02.10 - Termination Statement

Current through Register Vol. 51, No. 14, July 12, 2024
A. The termination statement shall be in language substantially as indicated in this regulation.
B. If the termination statement is signed by the insured and a qualified secondary beneficiary:
To ____________________________________________________ (name of employer)
This is to advise that ___________________________ (name or names of qualified secondary beneficiaries) is/are no longer to be covered under our group health insurance contract effective ____________________________(date)
The reason for this termination is __________________________________________ (reason)
Date:_________________________________________________
_______________________________________________________ (signature of insured)
_______________________________________________________ (signature of qualified secondary beneficiary)
C. If the termination statement is to be signed only by the insured:
To ____________________________________________________ (name of employer)
This is to advise that ___________________________ (name or names of qualified secondary beneficiaries) is/are no longer to be covered under our group health insurance contract effective ____________________________(date)
The reason for this termination is __________________________________________ (reason)
I affirm under penalties of perjury that the reason given in this statement is factually correct.
Date:_________________________________________________
_______________________________________________________ (signature of insured)
On this ___________________ (date) personally appeared before me ___________________________________________________ (name of insured) who affirmed under oath that the above is true to the best of his/her knowledge and belief.
_______________________________ (signature of notary public)
My appointment expires _______________________________(Notary Seal)
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses › Section 31.11.03.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to provide standards for implementing requirements of the Insurance Article and of Health-General Article, Annotated Code of Maryland, with respect to providing or continuing coverage for certain surviving spouses and dependent children.