reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.05 - Minimum Standards for Medicare Supplement Policies › Section 31.10.05.11 - Required Disclosure Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. General.
(1) Medicare supplement policies shall contain a clearly worded provision regarding the right of the policyholder to renew or continue the policy. This provision shall be appropriately captioned and shall be printed on the first page of the policy.
(2) Except for riders or endorsements by which the insurer effectuates a request made in writing by the insured or exercises a specifically reserved right under a Medicare supplement policy, or is required to reduce or eliminate benefits to avoid duplication of Medicare benefits, all riders or endorsements added to a Medicare supplement policy after date of issue or at reinstatement or renewal which reduce or eliminate benefits or coverage in the policy shall require a signed acceptance by the insured unless otherwise authorized by the Commissioner. After the date of policy issue, any rider or endorsement which increases benefits or coverage with a concomitant increase in premium during the policy term must be agreed to in writing, signed by the insured unless the benefits or coverage are required by the minimum standards for Medicare supplement insurance policies or are required by law. When a separate additional premium is charged for benefits provided in connection with riders or endorsements, the additional premium charge shall be stated in the policy.
(3) A Medicare supplement policy which provides for the payment of benefits based on standards described as "usual and customary", "reasonable and customary", or words of similar import shall include a definition of these terms and an explanation of the terms in its accompanying outline of coverage.
(4) If a Medicare supplement policy contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy and may be labeled as "preexisting condition limitations" or a title of similar import.
(5) Medicare supplement policies or certificates shall have a notice prominently printed on the first page of the policy or certificate stating that the policyholder or certificate holder shall have the right to return the policy or certificate within 30 days of its delivery and to have the premium refunded.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.01 - Applicability and Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as otherwise provided in Regulations .10, .11, and .17 of this chapter, this chapter applies to all:
(1) Medicare supplement policies delivered or issued for delivery in this State; and
(2) Certificates issued under group Medicare supplement policies if the certificates are delivered or issued for delivery in this State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.03 - Policy Definitions and Terms

Current through Register Vol. 51, No. 14, July 12, 2024
A. A policy or certificate may not be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy or certificate unless the policy or certificate contains definitions or terms which conform to the requirements of these regulations.
B. Policy Terms Defined.
(1) Accident.
(a) "Accident", "accidental injury", or "accidental means" shall be defined to employ "result" language.
(b) "Accident", "accidental injury", or "accidental means" does not include words which establish an accidental means test or use words such as "external, violent, visible wounds" or similar words of description or characterization.
(c) The definition may not be more restrictive than the following: "Injury or injuries for which benefits are provided means accidental bodily injury sustained by the insured person which is the direct result of an accident, independent of disease or bodily infirmity or any other cause, and occurs while insurance coverage is in force."
(d) The definition may provide that injuries not include injuries for which benefits are provided or available under any workers' compensation, employer's liability or similar law, or motor vehicle no-fault plan, unless prohibited by law.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.04 - Filing and Approval of Policies and Certificates and Premium Rates

Current through Register Vol. 51, No. 14, July 12, 2024
A. An issuer may not deliver or issue for delivery a Medicare supplement policy or certificate to a resident of this State unless the policy form or certificate form has been filed with and approved by the Commissioner in accordance with filing requirements and procedures prescribed by applicable provisions of Insurance Article, §§
									12-203,  12-205, and  14-126, Annotated Code of Maryland, and other applicable provisions of Insurance Article and Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland, and applicable regulations and procedures for filing for approval of forms.
B. An issuer shall file any riders or amendments to policy or certificate forms to delete outpatient prescription drug benefits as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 only with the commissioner in the state in which the policy or certificate was issued.
C. Premium Rates.
(1) An insurer may not use or change premium rates for a Medicare supplement policy or certificate unless the rates, rating schedule, methodology, and supporting documentations have been filed with and approved by the Commissioner in accordance with the filing requirements and procedures prescribed by the Commissioner.
(2) An issuer may not increase the premium rates for a Medicare Supplement policy for an insured person until:
(a) For an individual policy, at least 1 year after the date on which the individual policy became effective; and
(b) For a group policy, at least 1 year after the date on which the certificate became effective.
(3) Starting 1 year after the date on which an individual policy or certificate became effective, an issuer may not increase the premium rates for a Medicare Supplement policy for an insured person more than once each year.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.05 - Filing Requirements for Advertising

Current through Register Vol. 51, No. 14, July 12, 2024
An issuer shall provide a copy of any Medicare supplement advertisement intended for use in this State whether through written, radio, or television medium or otherwise, to the Commissioner for review by the Commissioner at least 5 business days before using the advertisement.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.06 - Open Enrollment

Current through Register Vol. 51, No. 14, July 12, 2024
A. Period of Open Enrollment.
(1) An issuer may not deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this State, nor discriminate in the pricing of the policy or certificate because of the health status, claims experience, receipt of health care, or medical condition of an applicant when:
(a) An application for the policy or certificate is submitted during the 6-month period beginning with the first day of the first month in which an individual is both 65 years old or older and is enrolled for benefits under Medicare Part B; or
(b) An application for the policy or certificate is submitted on or up to 30 days after the birthday of an individual enrolled in a Medicare supplement policy or certificate.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.07 - Policy Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except for permitted preexisting condition clauses as described in Regulations .08B and .27B(2) of this chapter, a policy or certificate may not be advertised, solicited, or issued for delivery in this State as a Medicare supplement policy if the policy or certificate contains limitations or exclusions on coverage that are more restrictive than those of Medicare.
B. A Medicare supplement policy or certificate may not use waivers to exclude, limit, or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions.
C. A Medicare supplement policy or certificate in force in this State may not contain benefits which duplicate benefits provided by Medicare.
D. Polices With Benefits for Outpatient Prescription Drugs.
(1) Subject to COMAR 31.10.05.07B(4) and (6)-(9), and Regulation .08B(5)-(10) of this chapter, a Medicare supplement policy with benefits for outpatient prescription drugs in existence before January 1, 2006, shall be renewed for current policyholders who do not enroll in Part D at the option of the policyholder.
(2) A Medicare supplement policy with benefits for outpatient prescription drugs may not be issued after December 31, 2005.
(3) After December 31, 2005, a Medicare supplement policy with benefits for outpatient prescription drugs may not be renewed after the policyholder enrolls in Medicare Part D unless:
(a) The policy is modified to eliminate outpatient prescription coverage for expenses of outpatient prescription drugs incurred after the effective date of the individual's coverage under a Part D plan; and
(b) Premiums are adjusted to reflect the elimination of outpatient prescription drug coverage at the time of Medicare Part D enrollment, accounting for any claims paid, if applicable.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.08 - Benefit Standards for 1990 Standardized Medicare Supplement Benefit Plans

Current through Register Vol. 51, No. 14, July 12, 2024
A. General Standards.
(1) The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State on or after July 14, 1992, and with an effective date for coverage before June 1, 2010.
(2) A policy or certificate may not be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate unless it complies with these benefit standards.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.09 - Standard Medicare Supplement Benefit Plans for 1990 Plans

Current through Register Vol. 51, No. 14, July 12, 2024
A. Definitions.
(1) In this regulation, the following term has the meaning indicated.
(2) Term Defined. "Structure, language, and format" means style, arrangement, and overall content of a benefit.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.09-1 - Guaranteed Issue for Eligible Individuals

Current through Register Vol. 51, No. 14, July 12, 2024
A. Guaranteed Issue.
(1) Eligible individuals are those individuals described in §B of this regulation who:
(a) Seek to enroll under the policy during the period specified in §C of this regulation; and
(b) Submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with the application for a Medicare supplement policy.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.10 - Standards for Claims Payment

Current through Register Vol. 51, No. 14, July 12, 2024
A. An issuer shall comply with § 1882(c)(3) of the Social Security Act, as enacted by § 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Public Law No. 100-203, by:
(1) Accepting a notice from a Medicare carrier on dually assigned claims submitted by participating physicians and suppliers as a claim for benefits in place of any other claim form otherwise required and making a payment determination on the basis of the information contained in that notice;
(2) Notifying the participating physician or supplier and the beneficiary of the payment determination;
(3) Paying the participating physician or supplier directly;
(4) Furnishing, at the time of enrollment, each enrollee with a card listing the policy name, number, and a central mailing address to which notices from a Medicare carrier may be sent;
(5) Paying user fees for claim notices that are transmitted electronically or otherwise; and
(6) Providing to the federal Secretary of Health and Human Services, at least annually, a central mailing address to which all claims may be sent by Medicare carriers.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.11 - Loss Ratio Standards and Refund or Credit of Premium

Current through Register Vol. 51, No. 14, July 12, 2024
A. Loss Ratio Standards.
(1) An issuer may not deliver or issue for delivery a Medicare supplement policy form or certificate in this State unless the policy form or certificate can be expected, as estimated for the entire period for which rates are computed to provide coverage, to return to policyholders and certificate holders in the form of aggregate benefits, not including anticipated refunds or credits, provided under the policy form or certificate form:
(a) At least 75 percent of the aggregate amount of premiums earned in the case of group policies; or
(b) At least 65 percent of the aggregate amount of premiums earned in the case of individual policies.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.12 - Permitted Compensation Arrangements

Current through Register Vol. 51, No. 14, July 12, 2024
A. An issuer or other entity may provide commission or other compensation to an agent or other representative for the sale of a Medicare supplement policy or certificate only if the first year commission or other first year compensation is not more than 200 percent of the commission or other compensation paid for selling or servicing the policy or certificate in the second year or period.
B. The commission or other compensation provided in subsequent renewal years shall be the same as that provided in the second year or period and shall be provided for not fewer than 5 renewal years.
C. If an existing Medicare supplement policy or certificate is replaced, an issuer or other entity may not provide compensation to its agents or other producers and an agent or producer may not receive compensation greater than the renewal compensation payable by the replacing issuer on renewal policies or certificates.
D. For purposes of this regulation, "compensation" includes pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the policy or certificate including bonuses, gifts, prizes, awards, and finders fees.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.13 - Required Disclosure Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Definitions.
(1) In this regulation, the following terms have the meanings indicated.
(2) Terms Defined.
(a) "Form" means the language, format, type size, type proportional spacing, bold character, and line spacing.
(b) "Guide" means the Guide to Health Insurance for People with Medicare.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.15 - Standards for Marketing

Current through Register Vol. 51, No. 14, July 12, 2024
A. An issuer, directly or through its producers, shall:
(1) Establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate;
(2) Establish marketing procedures to assure that excessive insurance is not sold or issued;
(3) Display prominently by type, stamp, or other appropriate means on the first page of the policy the following: "Notice to buyer: This policy may not cover all of your medical expenses.";
(4) Inquire and otherwise make every reasonable effort to identify whether a prospective applicant or enrollee for Medicare supplement insurance already has health insurance and the types and amounts of any insurance;
(5) Establish auditable procedures for verifying compliance with this section.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.16 - Appropriateness of Recommended Purchase and Excessive Insurance

Current through Register Vol. 51, No. 14, July 12, 2024
A. In recommending the purchase or replacement of any Medicare supplement policy or certificate an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement.
B. Any sale of a Medicare supplement policy or certificate that will provide an individual more than one Medicare supplement policy or certificate is prohibited.
C. An issuer may not issue a Medicare supplement policy or certificate to an individual enrolled in Medicare Part C unless the effective date of the coverage is after the termination date of the individual's Part C coverage.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.17 - Report of Multiple Policies

Current through Register Vol. 51, No. 14, July 12, 2024
A. On or before March 1 of each year, an issuer shall report the following information for every individual resident of this State for which the issuer has in force more than one Medicare supplement policy or certificate:
(1) Policy or certificate number; and
(2) Date of issuance.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.18 - Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods, and Probationary Periods in Replacement Policies or Certificates

Current through Register Vol. 51, No. 14, July 12, 2024
A. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, and probationary periods in the new Medicare supplement policy or certificate to the extent time was spent under the original policy.
B. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate which has been in effect for at least 6 months, the replacing policy may not provide any time period applicable to preexisting conditions, waiting periods, elimination periods, and probationary periods.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.20 - Form for Reporting Multiple Policies

Current through Register Vol. 51, No. 14, July 12, 2024
The following form is to be used in making reports of multiple policies in accordance with the requirements of Regulation .17 of this chapter:
FORM FOR REPORTINGMEDICARE SUPPLEMENT POLICIES
Company name:
________________________________________
Address:
________________________________________
________________________________________
Phone Number:
________________________________________
Due: March 1, annually
The purpose of this form is to report the following information on each resident of this state who has in force more than one Medicare supplement policy or certificate. The information is to be grouped by individual policyholder.
Policy and
Certificate #
Date of
Issuance
__________________________
Signature
__________________________
Name and Title (please type)
__________________________
Date
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.21 - Severability

Current through Register Vol. 51, No. 14, July 12, 2024
If any regulations of this chapter or the application of these regulations to any person or circumstance is for any reason held to be invalid, the remainder of the chapter and the application of the regulations to other persons or circumstances may not be affected.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.22 - Disclosure Statements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Instructions.
Instructions for Use of the Disclosure Statements for Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate Medicare
(1) Section 1882(d) of the federal Social Security Act (42 U.S.C. 1395 ss) prohibits the sale of a health insurance policy (the term policy includes certificate) to Medicare beneficiaries that duplicates Medicare benefits unless it will pay benefits without regard to a beneficiary's other health coverage and it includes the prescribed disclosure statement on or together with the application for the policy.
(2) All types of health insurance policies that duplicate Medicare shall include one of the attached disclosure statements, according to the particular policy type involved, on the application or together with the application. The disclosure statement may not vary from the attached statements in terms of language or format (type size, type proportional spacing, bold character, line spacing, and usage of boxes around text).
(3) State and federal law prohibits insurers from selling a Medicare supplement policy to a person that already has a Medicare supplement policy except as a replacement.
(4) Property/casualty and life insurance policies are not considered health insurance.
(5) Disability income policies are not considered to provide benefits that duplicate Medicare.
(6) Long-term care insurance policies that coordinate with Medicare and other health insurance are not considered to provide benefits that duplicate Medicare.
(7) The federal law does not preempt state laws that are more stringent than the federal requirements.
(8) The federal law does not preempt existing state form filing requirements.
(9) Section 1882 of the federal Social Security Act was amended in subsection (d)(3)(A) to allow for alternative disclosure statements. The disclosure statements already in §B of this regulation remain. Carriers may use either disclosure statement with the requisite insurance product. However, carriers shall use either the original disclosure statements or the alternative disclosure statements and not use both simultaneously.
(10) Insurers shall use the disclosure statements found in §§B and C of this regulation if the disclosure statement was printed before January 1, 2006.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.23 - Disclosure Statements Printed After December 31, 2005

Current through Register Vol. 51, No. 14, July 12, 2024
A. Instructions.
(1) The instructions found in Regulation .22A(1)"(8) of this chapter also apply to the disclosure statements printed after December 31, 2005.
(2) Use of Original or Alternative Disclosure Statements.
(a) Section 1882 of the federal Social Security Act was amended in Subsection (d)(3)(A) to allow for alternative disclosure statements.
(b) Carriers may use either disclosure statement with the requisite insurance product.
(c) Carriers shall use either the original disclosure statements or the alternative disclosure statement, but not both simultaneously.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.24 - Medicare Select Policies and Certificates-General Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Applicability.
(1) This regulation applies to Medicare Select policies and certificates, as defined in Regulation .02 of this chapter.
(2) A policy or certificate may not be advertised as a Medicare Select policy or certificate unless it meets the requirements of this regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.25 - Medicare Select-Consumer Protection

Current through Register Vol. 51, No. 14, July 12, 2024
A. Applicability.
(1) This regulation shall apply to Medicare Select policies and certificates, as defined in Regulation .02 of this chapter.
(2) A policy or certificate may not be advertised as a Medicare Select policy or certificate unless it meets the requirements of this regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.27 - Benefit Standards for 2010 Standardized Medicare Supplement Benefit Plans

Current through Register Vol. 51, No. 14, July 12, 2024
A. General Standards.
(1) The standards found in §§B-D of this regulation are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this State with an effective date for coverage on or after June 1, 2010.
(2) A policy or certificate may not be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate on or after June 1, 2010, unless it complies with the benefit standards found in this regulation.
(3) An issuer may not offer a 1990 standardized Medicare supplement benefit plan for sale on or after June 1, 2010. Benefit standards applicable to Medicare supplement policies and certificates issued with an effective date for coverage before June 1, 2010, remain subject to the requirements of Regulation .08 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.28 - Standard Medicare Supplement Benefit Plans for 2010 Plans

Current through Register Vol. 51, No. 14, July 12, 2024
A. Definitions.
(1) In this regulation, the following term has the meaning indicated.
(2) Term Defined. "Structure, language, and format" means style, arrangement, and overall content of a benefit.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.30 - Outlines of Coverage for Standardized Medicare Supplement Benefit Plans

Current through Register Vol. 51, No. 14, July 12, 2024
A. Forms.
(1) The issuer shall include in the outline of coverage for:
(a) Policies or certificates sold with an effective date for coverage on or after June 1, 2010 and before January 1, 2020, the forms that appear in §§B(1), C-G, H(1), and I-L of this regulation, in the order that the forms appear in this regulation; and
(b) Policies and certificates with an effective date for coverage on or after January 1, 2020, the forms that appear in §§B(2), C-G, H(2), and I-L of this regulation, in the order that the forms appear in this regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.06 - Standards for Medicare Supplement Policies › Section 31.10.06.31 - Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or After January 1, 2020

Current through Register Vol. 51, No. 14, July 12, 2024
A. General Standards
(1) A policy or certificate that provides coverage of the Medicare Part B deductible may not be advertised, solicited, delivered, or issued for delivery in this State as a Medicare supplement policy or certificate to individuals newly eligible for Medicare on or after January 1, 2020.
(2) Medicare supplement policies and certificates delivered or issued for delivery to individuals eligible for Medicare before January 1, 2020 remain subject to the requirements of Regulation .28 of the chapter.
(3) Medicare supplement policies or certificates delivered or issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020 are subject to the requirements of Regulation .28 of this chapter, except as stated in §§B and C of this regulation.
(4) Standardized Medicare supplement benefit Plans C, F, and F with High Deductible may not be offered to individuals newly eligible for Medicare on or after January 1, 2020.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.09 - Hospice Care Benefits › Section 31.10.09.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter is applicable to each:
(1) Group, blanket, or individual health insurance contract written on an expense-incurred basis which is issued or renewed in the State on or after April 1, 1997;
(2) Individual or group nonprofit health service plan contract which is issued or renewed on or after April 1, 1997; and
(3) Individual or group contract issued or renewed by a health maintenance organization on or after April 1, 1997.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.09 - Hospice Care Benefits › Section 31.10.09.02 - 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) "Bereavement counseling" means counseling provided to the immediate family or family caregiver of the insured after the insured's death to help the immediate family or family caregiver cope with the death of the insured.
(2) "Carrier" means an insurer, a nonprofit health service plan, or a health maintenance organization.
(3) Expense Incurred.
(a) "Expense incurred" means the benefits payable under the contract are based on the medical expenses the insured incurs.
(b) For the purpose of this chapter, a contract which includes both expense-incurred benefits and indemnity benefits shall be considered to be written on an "expense-incurred" basis.
(4) "Family caregiver" means a relative by blood, marriage, or adoption who lives with or is the primary caregiver of the terminally ill insured.
(5) "Family counseling" means counseling given to the immediate family or family caregiver of the terminally ill insured for the purpose of learning to care for the insured and to adjust to the death of the insured.
(6) "Hospice care program" means a coordinated, interdisciplinary program of hospice care services for meeting the special physical, psychological, spiritual, and social needs of terminally ill individuals and their families, by providing palliative and supportive medical, nursing, and other health services through home or inpatient care during the illness and bereavement to:
(a) Individuals who have no reasonable prospect of cure as estimated by a physician; and
(b) The immediate families or family caregivers of those individuals described in §B(6)(a) of this regulation.
(7) "Immediate family" means the spouse, parents, siblings, grandparents, and children of the terminally ill insured.
(8) "Indemnity" means the benefits payable under the contract are flat amounts which are not related to the expenses the insured incurs, such as a hospital indemnity contract which pays a flat fee for each day the insured is confined in a hospital regardless of the actual expenses the insured incurs during the hospital confinement.
(9) "Insured" means a person who is covered under a:
(a) Group, blanket, or individual health insurance policy written on an expense-incurred basis;
(b) Nonprofit health service plan contract; or
(c) Health maintenance organization contract.
(10) "Respite care" means temporary care provided to the terminally ill insured to relieve the family caregiver from the daily care of the insured.
(11) "Terminally ill" means a medical prognosis given by a physician that the insured's life expectancy is 6 months or less.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.09 - Hospice Care Benefits › Section 31.10.09.03 - Required Hospice Care Benefit Options

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier shall offer the policyholder the option of purchasing the minimum hospice care benefits required by this chapter when the policyholder applies for coverage.
B. Contracts Issued Before April 1, 1997.
(1) Except as provided in §B(2) of this regulation, if a policyholder purchases a contract with hospice care benefits before April 1, 1997, the carrier shall revise the contract to include at least the minimum benefits required by this chapter on the renewal date occurring on or after April 1, 1997.
(2) Section B(1) of this regulation does not apply to guaranteed renewable or noncancellable contracts.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.09 - Hospice Care Benefits › Section 31.10.09.04 - Minimum Hospice Care Benefits

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as provided in §B of this regulation, the hospice care benefit offered shall include the following minimum benefits provided through a hospice care program:
(1) 30 days of inpatient care per insured;
(2) Part-time nursing care by or supervised by a registered graduate nurse;
(3) Counseling, including dietary counseling, for the terminally ill insured;
(4) Family counseling for the immediate family and the family caregiver before the death of the terminally ill insured;
(5) Bereavement counseling for the immediate family or family caregiver of the insured for at least the 6-month period following the insured's death or 15 visits, whichever occurs first;
(6) Respite care subject to the following:
(a) The annual benefit shall be at least 14 days, and
(b) The carrier may limit any one inpatient stay for respite care to 5 consecutive days; and
(7) Medical supplies, equipment, and medication required to maintain the comfort and manage the pain of the terminally ill insured.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.09 - Hospice Care Benefits › Section 31.10.09.05 - Prohibited Exclusions and Limitations

Current through Register Vol. 51, No. 14, July 12, 2024
A. The hospice care benefit may not be subject to a lifetime maximum which is separate from the lifetime maximum applicable to other benefits in the contract.
B. The hospice care benefit may not be subject to an annual maximum benefit which is separate from the annual maximum applicable to other benefits in the contract.
C. A carrier may not exclude immediate family members or family caregivers of the insured from the family counseling benefit or the bereavement counseling benefit because the immediate family member or family caregiver is not otherwise covered under the contract which provides coverage to the insured.
D. A carrier may not exclude the siblings of a terminally ill child from the family counseling benefit or the bereavement counseling benefit, even if the siblings are not otherwise covered under the same contract as the terminally ill child.
E. A hospice care benefit may not exclude inpatient benefits if the hospice care benefit appears in a contract which includes other inpatient benefits.
F. The benefits provided as part of the hospice care benefit may not be subject to separate dollar maximum limits, except as provided in this chapter.
G. The carrier may not condition the inpatient hospice care benefits on a prior hospital confinement.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.10 - Summary Explanation of Benefits › Section 31.10.10.01 - Applicability and Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all health insurers, including nonprofit health service plans, authorized to do business in Maryland, which provide benefits for inpatient hospitalization or outpatient surgical care on an expense-incurred basis in group or individual contracts, both for insured business and business for which the insurer is an administrator.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.10 - Summary Explanation of Benefits › Section 31.10.10.02 - 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) "Claimant" means an insured individual resident in Maryland making a claim against the insurer for benefits, who is a:
(a) Policyholder covered by an individual policy; or
(b) Certificate holder covered under a group policy or under an administration contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.10 - Summary Explanation of Benefits › Section 31.10.10.03 - Summary Form

Current through Register Vol. 51, No. 14, July 12, 2024
A. An insurer which provides benefits for inpatient hospitalization or outpatient surgical care on an expense-incurred basis shall provide claimants annually a consolidated summary explanation regarding benefits claimed for those services during each calendar year.
B. The summary shall identify the provider by name and shall state the:
(1) Date of the service;
(2) Amount claimed;
(3) Amount which was paid or is payable by the insurer on claims processed during the year; and
(4) Balance to be paid by the covered individual, if the balance is determinable from the claim forms submitted.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.10 - Summary Explanation of Benefits › Section 31.10.10.04 - Group Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
Instead of the procedure outlined in Regulation .03 of this chapter, an insurer may make the annual summary to claimants who are covered under group policies, or who are covered under employer-employee groups administered by the insurer, within 36 days after the annual anniversary of the group policy, or of the administration contract, for the 12-month period ending with that anniversary.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.10 - Summary Explanation of Benefits › Section 31.10.10.05 - Group Coverage - Election of Alternate Procedure

Current through Register Vol. 51, No. 14, July 12, 2024
A. An insurer desiring to use the alternate procedure specified in Regulation .04 of this chapter may elect the procedure for:
(1) All groups; or
(2) Groups in excess of a certain size.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.01 - Applicability and Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter is applicable to all:
(1) Claims submitted to third-party payors as defined in Regulation .02B(22) of this chapter;
(2) Claims submitted by health care practitioners as defined in Regulation .02B(12) of this chapter;
(3) Claims submitted by hospitals as defined in Health-General Article, §19-301(g), Annotated Code of Maryland; and
(4) Claims submitted by other persons entitled to reimbursement from a third-party payor who submit claims to third-party payors on the HCFA Form 1500 or HCFA Form UB-92.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.02 - 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) "Applicable standard code set" means the most recent versions, as of the date of service, of the following:
(a) For services rendered by health care practitioners, the Current Procedural Terminology (CPT) maintained and distributed by the American Medical Association, including its codes and modifiers, and codes for anesthesia services;
(b) For dental services, the Current Dental Terminology (CDT) maintained and distributed by the American Dental Association;
(c) For all professional and hospital services, the International Classification of Diseases, Clinical Modification (ICD-9 CM);
(d) For other health-related services, including prescribed drugs covered under a medical benefit of a contract issued by a third-party payor, the Centers for Medicare and Medicaid Services Common Procedure Coding System (HCPCS) levels I and II and modifiers maintained and distributed by the U.S. Department of Health and Human Services;
(e) For prescribed drugs covered under a pharmacy benefit of a contract issued by a third-party payor, the National Drug Codes (NDC) maintained and distributed by the U.S. Department of Health and Human Services;
(f) For anesthesia services, the codes maintained and distributed by the American Society of Anesthesiologists;
(g) For psychiatric services, the DSM-IV codes distributed by the American Psychiatric Association;
(h) For hospital and other applicable health-care services, including home health services, the State UB-92, Uniform Billing Data Elements Specification Manual;
(i) For hospital services pursuant to a Maryland contract or insurance policy, a revenue code:
(i) Approved by the Health Services Cost Review Commission for a hospital located in the State, or
(ii) Of the National or State Uniform Billing Data Elements Specifications for a hospital not located in the State; and
(j) For services rendered pursuant to Health-General Article, §15-103(b)(2), Annotated Code of Maryland, a code established by the Medicaid Program.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.03 - Requirements for Use of HCFA Form 1500

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as provided in Regulation .10 of this chapter, third-party payors shall accept the HCFA Form 1500 and instructions provided by CMS for use of the HCFA 1500 as the sole instrument for filing claims with third-party payors for professional services.
B. The requirement set forth in §A of this regulation does not apply to:
(1) Dental services which are billed by dentists using the J512 Form, or its equivalent, and CDT-1 Codes; or
(2) Pharmacists or pharmacies which are filing claims for prescription drugs.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.04 - Requirements for Use of J512 Form

Current through Register Vol. 51, No. 14, July 12, 2024
A. Third-party payors shall accept the J512 Form, or its equivalent, and most recent version of the instructions provided by the American Dental Association CDT-1 for use of the J512 Form, or its equivalent, as the sole instrument for filing claims with third-party payors for dental services.
B. A third-party payor may not require a dentist to use any code other than the CDT-1 codes for the initial filing of claims for dental care services.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.05 - Requirements for Use of HCFA Form UB-92

Current through Register Vol. 51, No. 14, July 12, 2024
A. Third-party payors shall accept HCFA Form UB-92, and its successors, and the instructions provided by CMS for use of the HCFA Form UB-92, as the sole instrument for filing claims with third-party payors for hospital and other health-care services.
B. Except for parties to a global contract, a third-party payor may not use, and may not require a hospital, or person entitled to reimbursement, to use any code or modifier for the filing of claims for hospital or other health-care services that is different from or in addition to, what is required under the applicable standard code set for the hospital or other health-care services provided.
C. Except as provided in Regulation .10 of this chapter, a third-party payor may not use and may not require a hospital or person entitled to reimbursement to furnish additional information with the initial submission of the UB-92 that is different from, or in addition to, the applicable standard code set or for the hospital or other health-care services provided.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.06 - Requirements for Use of Universal Prescription Drug Claim Form

Current through Register Vol. 51, No. 14, July 12, 2024
Third-party payors shall accept the Universal Prescription Drug Claim Form, or its electronic equivalent, as the sole instrument for filing claims with third-party payors for prescription drugs.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.07 - General Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. A third-party payor shall accept a clean claim which is submitted in compliance with these regulations for the processing of the third-party payor's claims.
B. A third-party payor is subject to the provisions of Insurance Article, §
									15-1005, Annotated Code of Maryland.
C. If a third party payor delegates its claims processing to another entity, the third-party payor is responsible for a violation by the entity of any regulation under this chapter.
D. A third-party payor shall accept current coding changes by the effective date of the changes set forth by the developers of the codes.
E. If a referral is required under Regulation .10 of this chapter, a third party payor may not deny a claim on the basis that a referral was not received unless the third party payor could not identify the member using the member's name and the following information specified on the referral form:
(1) Date of birth;
(2) Subscriber's plan identification number; or
(3) Other personally identifying information.