reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.11 - Small Employer Group Health Insurance-Disclosure Statement › Section 31.11.11.02 - 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) "Additional benefits" means benefits offered in addition to the Comprehensive Standard Health Benefit Plan that:
(a) Are offered separately from the plan;
(b) Are priced separately from the plan;
(c) Are guarantee issued subject to the provisions of Insurance Article, §
											15-1213, Annotated Code of Maryland;
(d) Are guarantee renewed subject to the provisions of Insurance Article, §
											15-1212, Annotated Code of Maryland;
(e) Are community rated subject to the provisions of Insurance Article, §
											15-1205, Annotated Code of Maryland; and
(f) Do not duplicate any of the benefits in the Comprehensive Standard Health Benefit Plan.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.11 - Small Employer Group Health Insurance-Disclosure Statement › Section 31.11.11.03 - Required Notice - Initial Purchase of Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. At the time of the initial purchase of coverage, a carrier who offers benefits additional to the benefits offered in the Comprehensive Standard Health Benefit Plan shall obtain a signed disclosure statement certifying that:
(1) The small employer was offered the Standard Comprehensive Health Benefit Plan; and
(2) Additional benefits were offered and priced separately.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.11 - Small Employer Group Health Insurance-Disclosure Statement › Section 31.11.11.04 - Required Notice - Renewal of Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. At the time of renewal of coverage, a carrier who offers benefits additional to the benefits offered in the Comprehensive Standard Health Benefit Plan shall provide a disclosure statement that:
(1) Indicates that, except as described in §A(4) of this regulation, the Comprehensive Standard Health Benefit Plan is the only plan required by State law;
(2) Identifies any additional benefits offered by the carrier at renewal;
(3) Identifies the cost of any additional benefits offered by the carrier at renewal; and
(4) Specifies that all additional benefits to the Comprehensive Standard Health Benefit Plan are not required by State law, with the exception of the additional benefit for compliance with the federal Mental Health Parity and Addiction Equity Act of 2008 for small employers subject to the federal Mental Health Parity and Addiction Equity Act of 2008.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter applies to all carriers that offer the Limited Benefit Plan to the small employer market.
B. This chapter identifies the uniform benefits which shall be offered in a Limited Benefit Plan which a carrier offers to a Maryland small employer.
C. A carrier may offer the Limited Benefit Plan through one or both of the preferred provider delivery systems, as defined in Regulation .02B(46) of this chapter and as described in Regulation .04 of this chapter.
D. Except as provided in Regulation .11 of this chapter, a prominent carrier, as that term is defined in Regulation .02B(49) of this chapter, shall offer, and any other carrier that participates in the small group market may offer, the Limited Benefit Plan only to a small employer:
(1) That has not provided the Standard Plan during the 12-month period preceding the date of application or, if the small employer has existed for less than 12 months, from the date the small employer commenced its business; and
(2) For which the average annual wage of the employees of the small employer does not exceed 75 percent of the average annual wage in the State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.04 - Uniform Cost-Sharing Arrangements In General

Current through Register Vol. 51, No. 14, July 12, 2024
A. For each delivery system identified in §§B and C of this regulation, a carrier shall apply the uniform cost-sharing arrangements specified.
B. Preferred Provider-Credit Fund Delivery System.
(1) Covered services are divided into three categories, designated as Categories I, II, and III, based on the type of service to be provided, as follows:
(a) Category I includes the services listed in Regulation .03A(1), (9)-(12), (15)-(18), (20), (22), (23), (25), (26), (29), (31), and (33)-(35) of this chapter;
(b) Category II includes the services listed in Regulation .03A(2)-(8), (13), (14), (19), (21), (24), (28), (30), and (32) of this chapter; and
(c) Category III includes the services listed in Regulation .03A(27) of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.05 - Uniform Cost-Sharing Arrangements Specific Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. Preferred Provider-Credit Fund Delivery System.
(1) Coverage of Category I Services.
(a) Except for services listed in Regulation .03A(15), (17), (18), (22), (25), and (34) of this chapter, Category I services shall be covered as follows:
(i) Payment for covered services by the fund;
(ii) After exhaustion of the fund and after meeting the deductible requirement as described in Regulation .04B(3) of this chapter, coinsurance requirements as described in Regulation .04B(4) of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.07 - Additional Benefits

Current through Register Vol. 51, No. 14, July 12, 2024
A carrier may offer benefits in addition to the Limited Benefit Plan only if:
A. The benefits are offered separately from the plan;
B. The benefits are priced separately from the plan;
C. Subject to the provisions of Insurance Article, §
									15-1213, Annotated Code of Maryland, the benefits are guaranteed issue;
D. Subject to the provisions of Insurance Article, §
									15-1213, Annotated Code of Maryland, the benefits are guaranteed renewable;
E. Subject to the provisions of Insurance Article, §
									15-1205, Annotated Code of Maryland, the benefits are subject to adjusted community rating;
F. The benefits do not duplicate any of the benefits in the plan; and
G. The benefit lowers the cost-sharing arrangements in the Limited Benefit Plan described in Regulations .04 and .05 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.08 - Mandated Benefits

Current through Register Vol. 51, No. 14, July 12, 2024
A. The plan excludes mandated benefits, except for Insurance Article, §§
									15-123(d),  15-401,  15-407,  15-408,  15-409,  15-412(a)  and (h), 15-414, 15-604, 15-701, 15-811, 15-812, 15-815, 15-816, and 15-10B-09, Annotated Code of Maryland, and Health-General Article, §§19-703(d) and (g), and 19-706(h), Annotated Code of Maryland, to the extent those sections are considered mandated benefits.
B. This chapter does not exclude any requirement contained in statute or regulation that a carrier shall pay hospitals for hospital services rendered in accordance with rates approved by the Health Services Cost Review Commission.
C. Referrals to Specialists. Each carrier:
(1) That does not allow direct access to specialists shall provide for a standing referral to a specialist under the requirements of Insurance Article, §
										15-830, Annotated Code of Maryland;
(2) Shall provide for a referral to a specialist who is not part of the carrier's panel under the requirements of Insurance Article, §
										15-830, Annotated Code of Maryland; and
(3) Shall provide direct access to obstetric and gynecological care as specified in Insurance Article, §
										15-816, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.09 - Rates

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier shall market the Plan in the following compositions:
(1) Individual; and
(2) Individual, spouse, and dependents.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.10 - Preexisting Conditions

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier may not apply a preexisting condition provision to health care services for pregnancy or newborns.
B. A carrier may impose a preexisting condition provision of up to 12 months for a late enrollee.
C. A carrier may impose a waiting period from the date of application, in accordance with Insurance Article, §
									15-1208(b)(2), Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.11 - Exemption for Certain Prominent Carriers

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as provided in §B of this regulation, a prominent carrier that offers insurance in the small group market shall offer the Limited Benefit Plan to a small employer as required under Regulation .01D of this chapter.
B. A prominent carrier that is controlled by an insurance holding company is exempt from the requirement to offer the Limited Benefit Plan to a small employer if another prominent carrier which is controlled by the same insurance holding company as the carrier seeking exemption offers the Limited Benefit Plan to small employers in the State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.12 - Limited Benefit Plan › Section 31.11.12.12 - Review

Current through Register Vol. 51, No. 14, July 12, 2024
In addition to the requirements set forth in Insurance Article, §
									15-1207, Annotated Code of Maryland, the Maryland Health Care Commission shall review the Plan from time to time. Unless otherwise stated, all changes in the Plan made pursuant to this review are effective for contracts issued or renewed after July 1 of the calendar year in which the changes are promulgated.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.13 - Limited Benefit Plan-Disclosure Statement › Section 31.11.13.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all carriers that offer the Limited Benefit Plan to the small employer market.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.13 - Limited Benefit Plan-Disclosure Statement › Section 31.11.13.02 - 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" has the meaning stated in Insurance Article, §
										15-1201, Annotated Code of Maryland.
(2) "Comprehensive Standard Health Benefit Plan" means the health benefit plan adopted by the Maryland Health Care Commission in accordance with Insurance Article, §
										15-1207, and Health-General Article, Title 19, Subtitle 1, Annotated Code of Maryland.
(3) "Limited Benefit Plan" means the Limited Health Benefit Plan adopted by the Maryland Health Care Commission in accordance with Insurance Article, §
										15-1207, and Health-General Article, Title 19, Subtitle 1, Annotated Code of Maryland.
(4) "Small employer" has the meaning stated in Insurance Article, §
										15-1201, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.13 - Limited Benefit Plan-Disclosure Statement › Section 31.11.13.03 - Required Notice - Limited Benefit Plan

Current through Register Vol. 51, No. 14, July 12, 2024
A. When a carrier offers the Limited Benefit Plan to a small employer qualified under Insurance Article, §
									15-1209, Annotated Code of Maryland, and the small employer chooses the Limited Benefit Plan, the carrier shall obtain a signed disclosure statement certifying that:
(1) The small employer was offered the Limited Benefit Plan; and
(2) The small employer received notice that more comprehensive coverage is available under the Comprehensive Standard Health Benefit Plan.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.14 - Wellness Benefits under Small Employer Health Benefit Plans › Section 31.11.14.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter specifies the requirements for:
A. A wellness benefit offered by a carrier to a small employer under Insurance Article, Title 15, Subtitle 12, Annotated Code of Maryland;
B. Determining if a carrier is considered a prominent carrier; and
C. Carriers offering wellness benefits to small employers.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.14 - Wellness Benefits under Small Employer Health Benefit Plans › Section 31.11.14.02 - 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" has the meaning stated in Insurance Article, §
										15-1201, Annotated Code of Maryland.
(2) "Case management program" means a program that involves a collaborative process of assessment, planning, implementation, coordination, monitoring, and evaluation of the options and services required to meet an individual's health needs through communication and available resources to promote quality cost effective outcomes.
(3) "Disease management program" means a program of preventive, diagnostic, and therapeutic services for certain patients that are considered to be at risk.
(4) "Eligible employee" has the meaning stated in Insurance Article, §
										15-1201, Annotated Code of Maryland.
(5) "Health benefit plan" has the meaning stated in Insurance Article, §
										15-1201, Annotated Code of Maryland.
(6) "Health risk assessment" means a self-reported health questionnaire that:
(a) Asks a variety of personal questions about lifestyle and behavioral habits, such as physical activity level, eating habits, and stress; and
(b) Includes, but is not limited to, biometric measures and other health status information.
(7) "Preventive services" means the services required to be covered under the small employer standard plan, as described in COMAR 31.11.06.03A(9).
(8) "Prominent carrier" means a carrier that insures at least 10 percent of the total lives insured in the Maryland small group market.
(9) "Small employer" has the meaning stated in Insurance Article, §
										15-1201, Annotated Code of Maryland.
(10) "Standard plan" has the meaning stated in Insurance Article, §
										15-1201, Annotated Code of Maryland.
(11) "Wellness benefit":
(a) Has the meaning stated in Insurance Article, §
											15-1201, Annotated Code of Maryland; and
(b) Complies with the requirements set forth in Regulations .03 and .04 of this chapter.
(12) "Wellness program" has the meaning stated in Insurance Article, §
										15-1201, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.14 - Wellness Benefits under Small Employer Health Benefit Plans › Section 31.11.14.03 - Components of a Wellness Benefit

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each wellness benefit shall include:
(1) A health risk assessment that is:
(a) Available at no cost to all employees covered under the small employer's wellness benefit; and
(b) Completed by each employee on a voluntary basis;
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.14 - Wellness Benefits under Small Employer Health Benefit Plans › Section 31.11.14.04 - General Requirements for Wellness Benefits Offered to Small Employers

Current through Register Vol. 51, No. 14, July 12, 2024
A. A wellness benefit offered to a small employer:
(1) Shall satisfy the requirements of an additional benefit found in COMAR 31.11.06.07A; and
(2) May not violate any requirement regarding wellness programs as described in 45 CFR §
											146.121.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.14 - Wellness Benefits under Small Employer Health Benefit Plans › Section 31.11.14.05 - Requirement for Carriers to Offer a Wellness Benefit

Current through Register Vol. 51, No. 14, July 12, 2024
A. A prominent carrier shall offer a wellness benefit to a small employer for a health benefit plan offered in Maryland.
B. A carrier that is not a prominent carrier may offer a wellness benefit to a small employer for a health benefit plan offered in Maryland.
C. The determination of which carriers are prominent carriers shall be determined each calendar year, based on the market share that each carrier had of the Maryland small group market for the prior calendar year.
D. A carrier may not condition the sale of a wellness benefit to a small employer on participation of the eligible employees of the small employer in wellness programs or activities.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.01 - Authority and Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The Insurance Commissioner adopts and promulgates this chapter according to Health-General Article, §19-705, Annotated Code of Maryland, for the purpose of governing and regulating various phases of the operations of health maintenance organizations.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. All terms defined in the Health Maintenance Organization Act of 1975 which are used in this chapter have the same meaning as in the Act unless the terms are defined differently in this chapter.
B. Terms Defined.
(1) "HMO" means a health maintenance organization.
(2) "Individual contract" means a contractual agreement for the provision of health care services on a prepaid basis entered into between an HMO and a subscriber, provided the contract covers only the following persons:
(a) The subscriber;
(b) The subscriber and the subscriber's dependents; or
(c) The subscriber's dependents.
(3) "Leasehold estate improvements" means improvements made to property which is leased by the HMO and used by it to provide health care directly.
(4) "Member" means the subscriber and any of the subscriber's dependents who are enrolled in the HMO.
(5) "Subscriber" means, for:
(a) Group HMO contracts, the person who is eligible to be covered under the contract, other than as a dependent, due to satisfaction of the eligibility requirements of the group; and
(b) Individual HMO contracts, the person who completes the application for coverage with the HMO.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.03 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
The scope of this chapter is the scope of Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland, as it relates to the Insurance Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.05 - Change of Ownership

Current through Register Vol. 51, No. 14, July 12, 2024
The HMO shall notify the Commissioner within 10 days of any transfer of ownership or more than an aggregate of 10 percent of the stock or ownership interest in the HMO occurring during any 12-month period.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.06 - Change of Name

Current through Register Vol. 51, No. 14, July 12, 2024
No name other than that approved by the Commissioner may be used. The name of the HMO may not be changed without prior approval of the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.07 - Filings, Forms, and Rates

Current through Register Vol. 51, No. 14, July 12, 2024
HMOs shall be subject to the applicable procedures and requirements for filings, forms, and rates as outlined in COMAR 31.12.02.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.08 - Repealed

Current through Register Vol. 51, No. 14, July 12, 2024
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.09 - Marketing

Current through Register Vol. 51, No. 14, July 12, 2024
The manner of marketing health care contracts shall be fully set forth in writing by the HMO before licensing, and any substantive alterations in marketing procedures must be approved by the Commissioner before use.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.10 - Repealed

Current through Register Vol. 51, No. 14, July 12, 2024
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.11 - Annual Report

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each licensed health maintenance organization, unless the time is extended for good cause shown, shall file a report with the Commissioner, certified by an audit of a certified public accounting firm, showing its financial condition on the last day of the preceding calendar year. The report shall be on the form adopted by the Commissioner and shall annually be filed with the Commissioner on or before the first day of March. The report shall be supplemented with a description of any changes in the information submitted with the last previous annual report or with the HMO's original application for a certificate of authority.
B. If the fiscal year of the HMO does not coincide with the calendar year, at the request of the HMO the Commissioner may, in his discretion, accept a certified audit showing the HMO's financial condition at the end of its last completed fiscal year, the audit to be accomplished by an annual report for the corresponding fiscal year to be filed on or before the 60th day following the last day of the fiscal year. As a condition for granting this exception, the Commissioner will require the HMO to also file on or before the first day of the following March an unaudited calendar year report.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.12 - Fiscal Examination

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Commissioner may make an examination of the operation of any health maintenance organization as often as the Commissioner deems necessary for the protection of the interest of the people of Maryland, but the examinations may not be less frequent than once every 5 years.
B. The expense of each examination shall be assessed against the HMO being examined and the HMO shall remit the cost of the examination to the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.13 - Repealed

Current through Register Vol. 51, No. 14, July 12, 2024
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.01 - Health Maintenance Organizations - Certificate of Authority and Fiscal Requirements › Section 31.12.01.14 - Insurance - Catastrophic or Back-Up Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. Unless the Commissioner grants an exemption from the requirements of this section, the HMO shall secure insurance coverage to provide:
(1) Payments or services required to be made or furnished under the health care contract to those enrollees who are injured or become ill outside the geographic limits served by the HMO; and
(2) Reinsurance protection to the HMO in event of catastrophic or unusual losses which would be in excess of the levels of loss which the HMO assumes in the basis of its calculation of premium charges.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.01 - Authority and Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The Insurance Commissioner promulgates this chapter pursuant to Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland, for the purpose of governing and regulating various phases of the operations of health maintenance organizations.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.02 - 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) "Advertising" means:
(a) Printed and published material;
(b) Descriptive literature and sales aids;
(c) Sales talks;
(d) Sales materials, booklets, forms, pamphlets, brochures, illustrations, depictions, and form letters;
(e) Newspaper, radio, television, or direct mail advertising; and
(f) Any other material used for the promotion of enrollment.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.03 - Submittals

Current through Register Vol. 51, No. 14, July 12, 2024
A. Submittals of Forms to Commissioner.
(1) An HMO shall submit to the Commissioner for approval every form that it intends to use in Maryland.
(2) The Commissioner shall either approve or disapprove the form for use within 60 days of the receipt of the form in the Commissioner's office.
(3) An HMO may not use a form before the Commissioner's approval unless the Commissioner has not acted at the end of the 60-day period described in §A(2) of this regulation.
(4) The Commissioner may withdraw the Commissioner's prior approval or may disapprove a form previously permitted to be used if the Commissioner gives the HMO at least 30 days' notice before the effective date of the Commissioner's action disapproving the form.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.04 - Variable Information

Current through Register Vol. 51, No. 14, July 12, 2024
A. Individual Contracts.
(1) Except as specified in §A(2) of this regulation, an HMO may not include variable material in an individual contract, or in a form to be used with an individual contract.
(2) An HMO may include variable material, in an individual contract or in a form to be used with an individual contract in the following portions of the form:
(a) The specifications, data, or schedule page;
(b) The product marketing name;
(c) The address of the HMO;
(d) Signatures of officers of the HMO;
(e) Descriptions of copayment amounts, deductibles, coinsurance amounts, out-of-pocket limits, annual maximums, or lifetime maximums;
(f) Specific dates, such as effective dates and termination dates; and
(g) Descriptions of benefit amounts or benefit limits.
(3) If an individual contract or a form to be used with an individual contract contains variable material as permitted under §A(2) of this regulation, the HMO shall:
(a) Bracket the variable material or otherwise mark the variable material to denote variability; and
(b) Include a statement of variability, in duplicate, that discusses how each variable item may change.
(4) If an individual contract or a form to be used with an individual contract is approved with variable material, an HMO may not submit a new statement of variability to be used with the previously approved contract or form, except for the following:
(a) Copayment amounts;
(b) Coinsurance amounts;
(c) Deductible amounts;
(d) Out-of-pocket limits;
(e) Annual maximums;
(f) Lifetime maximums;
(g) Benefit amounts; or
(h) Benefit limits.
(5) An HMO shall include the following with a new statement of variability filing for a previously approved form:
(a) A cover letter identifying the HMO and the HMO's National Association of Insurance Commissioners company code number; and
(b) The form number and date of approval of the form for which new variable material is being submitted.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.05 - Failure to Respond to the Commissioner's Correspondence

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Commissioner shall deem a filing withdrawn by the HMO if the HMO fails to respond to correspondence from the Commissioner regarding the filing within 90 days of the date of the correspondence from the Commissioner.
B. If an HMO resubmits a form for approval after 90 days of the date of the Commissioner's correspondence regarding the filing in which the form was included, the HMO shall:
(1) Include a new filing fee for the form and associated premium rates included in the filing; and
(2) Include in the filing all the information required in Regulation .03 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.06 - Contract Forms

Current through Register Vol. 51, No. 14, July 12, 2024
A. Form Numbers.
(1) Each form shall be identified by a form number that is unique to that form.
(2) The form number shall be printed in the lower left corner of the first page, and no other number may appear near the form number.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.07 - Application

Current through Register Vol. 51, No. 14, July 12, 2024
A. An application form shall stipulate the plan and any optional benefits being applied for.
B. Permissible Look-Back Periods.
(1) Except as provided in §B(2) of this regulation, an application form may not ask any question relative to any previously existing injury, sickness, or condition which has not required medical care or advice during the:
(a) 7-year period immediately preceding the date of the application if the application is made for coverage under a group contract; or
(b) 5-year period immediately preceding the date of the application, if the application is made for coverage under an individual contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.08 - Charges

Current through Register Vol. 51, No. 14, July 12, 2024
A. The submittal of a form shall be accompanied by the submittal of the rates charged for it, together with detailed supporting actuarial data. Subsequent changes in charged rates shall be submitted with detailed supporting actuarial data at least 60 days before the date that any change in the rate is proposed to become effective.
B. The Commissioner shall approve or disapprove any rate submittal or change in the same manner as prescribed for approval or disapproval of forms.
C. An HMO may not make or permit any differential in charged rates for any reason based on the age or sex of an enrollee unless there is actuarial justification for the differential.
D. Charges may not be excessive, inadequate, or unfairly discriminatory.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.09 - Advertising

Current through Register Vol. 51, No. 14, July 12, 2024
A. Advertising shall be truthful and may not be misleading in fact or implication.
B. Advertising may not use words or phrases whose:
(1) Meaning is unclear or ambiguous; or
(2) Understanding depends upon familiarity with technical terminology.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.10 - Termination of Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. Termination of a Particular Service.
(1) If an HMO desires to cease offering a service under the health care contract in force, the services may not be terminated without prior approval of the Commissioner.
(2) If an HMO ceases offering a service under an in-force health care contract, arrangements equitable to the members regarding a cost adjustment or substitution of an equivalent service satisfactory to the Commissioner shall be made.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.11 - Conversion of Coverage - Repealed

Current through Register Vol. 51, No. 14, July 12, 2024
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates › Section 31.12.02.12 - General Operation of Health Maintenance Organizations

Current through Register Vol. 51, No. 14, July 12, 2024
A. The HMO shall provide, without limitations as to frequency or cost, except as established in the health care contract and provided for in these regulations, basic and supplemental health services to its members in the following manner:
(1) Reasonable deductibles and copayments may be required for the provision of specific services within the basic health services, unless the payments or the manner of payment unduly serves as a barrier to the delivery of basic health services;
(2) All services of health care providers provided for in the health care contract shall be provided through health care providers that are under contract to, or have agreements with, the HMO, except that this subsection does not apply to:
(a) Health care providers' services which the HMO and the Commissioner determine are unusual or infrequently used;
(b) Emergency services;
(c) Services performed outside of the HMO's service area for urgent care services;
(d) Services received from health care providers that do not contract with the HMO, if the member has a benefit under the HMO contract for services received from non-HMO health care providers; or
(e) Services received from a health care provider that does not contract with the HMO, if the member was referred to the health care provider by the HMO or by a provider under contract with the HMO;
(3) All services provided for in the health care contract shall, within the area serviced by the HMO, be available and accessible to each of its members:
(a) Promptly as appropriate;
(b) In a manner which assures continuity; and
(c) When medically necessary, 24 hours a day and 7 days a week; and
(4) Emergency services as follows:
(a) The HMO shall be liable for emergency expenses incurred by the member in securing any service customarily provided in the contract for emergency services incurred by the member which cannot reasonably be provided through the facilities of the HMO and which are considered medically necessary and justified; and
(b) The method used to establish the necessity of these services and the method the HMO shall use in fulfilling its financial responsibility for its health care services shall be set forth in the health care contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.03 - Health Maintenance Organizations - Mandatory Point-of-Service Option › Section 31.12.03.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all health maintenance organizations operating in this State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.03 - Health Maintenance Organizations - Mandatory Point-of-Service Option › Section 31.12.03.02 - Required Notice

Current through Register Vol. 51, No. 14, July 12, 2024
When a health maintenance organization is the sole carrier offered to group members by a group policyholder, the health maintenance organization:
A. Shall offer the group policyholder a point-of-service option for the individual group member to accept or reject;
B. May not impose a minimum participation level on the mandatory point-of-service option; and
C. As part of the application, shall provide to each group policyholder the following disclosure statement, for each point-of-service option offered:
"Under Maryland law, if you choose a point-of-service option for your group members, your group member may select a point-of-service option as an additional benefit. A point-of-service option allows your group members to obtain health care services from physicians and other providers outside the HMO network under certain circumstances that are described in attachment A. You have the choice to either pay for this point-of-service option, pay a percentage of the cost of this option, or require your group members to pay for the entire cost of this option. The cost of the point-of-service option described in attachment A is identified in your proposal.
I have read and understand this disclosure statement and the attachments and, if I have chosen the point-of-service option, I will provide notice of the availability of this additional benefit to my eligible group members. Group Policyholder Signature"
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.03 - Health Maintenance Organizations - Mandatory Point-of-Service Option › Section 31.12.03.03 - Record Retention

Current through Register Vol. 51, No. 14, July 12, 2024
Each health maintenance organization shall maintain copies of the notice and the group policyholder response for a period of 3 years or until its next market conduct examination, whichever occurs first.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.04 - Dental Plans - General Provisions › Section 31.12.04.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to provide appropriate standards and requirements for dental plan contracts.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.04 - Dental Plans - General Provisions › Section 31.12.04.02 - 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) "Closed panel dental benefit contract" means a dental benefit contract that does not provide benefits for services provided by a dentist who is not a plan dentist, with the exception of
(a) Emergency services; and
(b) Out-ofnetwork services required by Insurance Article, §
											15-830, Annotated Code of Maryland
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.04 - Dental Plans - General Provisions › Section 31.12.04.03 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to:
A. Dental plan organizations authorized under Insurance Article, Title 14, Subtitles 1 and 4, Annotated Code of Maryland; and
B. Contracts issued or renewed by the dental plan organizations listed in §A of this regulation on or after the effective date of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS › Chapter 31.12.04 - Dental Plans - General Provisions › Section 31.12.04.04 - Dental Benefit Contract

Current through Register Vol. 51, No. 14, July 12, 2024
Each dental benefit contract shall contain the following provisions:
A. The effective date of contract provision;
B. A provision describing the payment of required subscription fees or premiums;
C. A grace period provision, pursuant to Regulation .05 of this chapter;
D. For group dental benefit contracts, the eligibility requirements and effective date of coverage for members of the group and their dependents;
E. A provision describing the benefits available under the contract;
F. A provision describing the copayments for which the enrollee is responsible;
G. A provision describing the service area, if applicable;
H. If a dental plan organization generally provides benefits only within a stated service area, a provision providing for emergency dental services outside the service area, with the term "emergency" including care to alleviate acute pain;
I. For closed panel dental benefit contracts:
(1) A provision indicating that if a plan dentist refers the enrollee to a specialist who is not a plan dentist for dental services which are covered under the dental benefit contract, the dental plan organization shall be responsible for payment of the specialist's charges to the extent the charges exceed the copayment specified in the dental benefit contract; and
(2) A provision which reads substantially as follows: "If during the term of this contract none of the plan dentists can render necessary care and treatment to the enrollee due to circumstances not reasonably within the control of the dental plan organization, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes, or the disability of a significant number of the plan dentists, then the enrollee may seek treatment from an independent licensed dentist of the enrollee 's own choosing. The dental plan organization will pay the enrollee for the expenses incurred for the dental services with the following limitations: The dental plan organization will pay the enrollee for services which are listed in the patient charge schedule as No Charge, to the extent that such fees are reasonable and customary for dentists in the same geographic area; the dental plan organization will also pay the enrollee for those services listed in the contract for which there is a copayment, to the extent that the reasonable and customary fees for such services exceed the copayment for such services as set forth in the contract. The enrollee may be required to give written proof of loss. The dental plan organization agrees to be subject to the jurisdiction of the Maryland Insurance Commissioner in any determination of the impossibility of providing services by plan dentists.";