reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.11 - Additional Information

Current through Register Vol. 51, No. 14, July 12, 2024
A. The following are permissible categories of disputed claims for which third-party payors may request additional information pursuant to Insurance Article, §§
									15-1004(c)  and  15-1005(c), Annotated Code of Maryland:
(1) Except in cases of services rendered in accordance with Health-General Article, §§19-701(d) and 19-712.5, Annotated Code of Maryland, the legitimacy, medical necessity, or appropriateness of the health care service, if:
(a) There is no authorization; or
(b) There was preauthorization and the third-party payor disputes the claim:
(i) Consistent with the bases for a carrier's denial as set forth in Insurance Article, §
												15-1009(b), Annotated Code of Maryland, or
(ii) Because the claim is for services provided outside of the time or scope of the authorization and the applicable attachment required in Regulation .10 of this chapter was not submitted with the claim;
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.12 - Receipt of a Claim

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each third-party payor shall:
(1) Date-stamp the claim with the date received, for a written claim; or
(2) Assign to the document a batch number that includes the date received for an electronic claim.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.13 - Disclosure

Current through Register Vol. 51, No. 14, July 12, 2024
A. Third-party payors shall follow the disclosure requirements set forth in Insurance Article, §
									15-1004(d), Annotated Code of Maryland.
B. If a third-party payor uses auto codes to determine whether health care services provided in a hospital emergency facility are "emergency services" as defined in Health-General Article, §19-701(e), Annotated Code of Maryland, the third-party payor shall provide to all contracting health care practitioners or hospitals rendering emergency services, or to all health care practitioners or hospitals rendering emergency services that request them:
(1) Auto codes used by the third-party payor to determine emergency services; and
(2) Updated auto codes for emergency services at least 30 days before an update of the auto codes will be used, stating the date on which the updated auto codes for emergency services will be used.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.11 - Uniform Claims Forms › Section 31.10.11.14 - Claims Data Filing

Current through Register Vol. 51, No. 14, July 12, 2024
A. Required.
(1) Except as provided in §B(2) of this regulation, twice each calendar year a third-party payor shall submit to the Commissioner a claims data filing that documents the payment and denial practices for claims from health care practitioners, hospitals, and other persons entitled to reimbursement of:
(a) The third-party payor; and
(b) Each entity to which the third-party payor has delegated claims processing.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.12 - Uniform Consultation Referral › Section 31.10.12.01 - Applicability and Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter is applicable to all:
A. Carriers as defined in Regulation .02B(1) of this chapter;
B. Consultant/facility providers as defined in Regulation .02B(2) of this chapter; and
C. Primary or requesting providers as defined in Regulation .02B(4) of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.12 - Uniform Consultation Referral › Section 31.10.12.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Carrier" means:
(a) An insurer;
(b) A nonprofit health service plan;
(c) A health maintenance organization; or
(d) A dental plan organization.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.12 - Uniform Consultation Referral › Section 31.10.12.03 - Uniform Consultation Referral Form - Carrier Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. If a carrier requires a covered person to have a written referral in order to receive services, the carrier shall use the uniform consultation referral form as defined in Regulation .02B(6) of this chapter.
B. The carrier may not impose as a condition of coverage a requirement to:
(1) Modify the uniform consultation referral form, except as provided in E of this regulation; or
(2) Submit additional consultation referral forms.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.12 - Uniform Consultation Referral › Section 31.10.12.04 - Uniform Consultation Referral Form - Primary or Requesting Provider

Current through Register Vol. 51, No. 14, July 12, 2024
A. The primary or requesting provider shall use the uniform consultation referral form as defined in Regulation .02B(6) of this chapter and instructions as provided in Regulation .03C of this chapter.
B. The uniform consultation referral form shall be properly completed by the primary or requesting provider.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.12 - Uniform Consultation Referral › Section 31.10.12.05 - Uniform Consultation Referral Form - Consultant/Facility Provider

Current through Register Vol. 51, No. 14, July 12, 2024
The consultant/facility provider shall accept a properly completed uniform consultation referral form.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.12 - Uniform Consultation Referral › Section 31.10.12.06 - General Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. The requirements under these regulations do not apply to an entity that would be using a consultation form solely for internal purposes.
B. The Maryland Uniform Consultation Referral Form shall read as follows:
Click here to
				  view Image
C. The electronic equivalent of the uniform consultation referral form is as follows:
Electronic Equivalent of the Uniform Consultation Referral Form
Field
Length
Start
Stop
1 - Patient last name
18
1
18
2 - Patient first name
12
19
30
3 - Patient MI
1
31
31
4 - Patient DOB
8
32
39
5 - Patient phone number
10
40
49
6 - Patient member number
16
50
65
7 - Patient site number
10
66
75
8 - Carrier name
24
76
99
9 - Carrier address 1
24
100
123
10 -Carrier address 2
24
124
147
11 - Carrier city
24
148
171
12 - Carrier state
2
172
173
13 - Carrier zip code
9
174
182
14 - Carrier phone number
10
183
192
15 - Carrier fax number
10
193
202
16 - Primary/requesting provider last name
18
203
220
17 - Primary/requesting provider first name
12
221
232
18 - Primary/requesting provider MI
1
233
233
19 - Primary/requesting provider specialty
25
234
258
20 - Primary/requesting provider institution/group name
80
259
338
21 - Primary/requesting provider NPI #
10
339
348
22 - Primary/requesting provider address 1
24
349
372
23 - Primary/requesting provider address 2
24
373
396
24 - Primary/requesting provider city
24
397
420
25 - Primary/requesting provider state
2
421
422
26 - Primary/requesting provider zip
9
423
431
27 - Primary/requesting provider phone
10
432
441
28 - Primary/requesting provider fax
10
442
451
29 - Consultant/facility provider last name
18
452
469
30 - Consultant/facility provider first name
12
470
481
31 - Consultant/facility provider MI
1
482
482
32 - Consultant/facility provider specialty
25
483
507
33 - Consultant/facility provider institution/group name
80
508
587
34 - Consultant/facility provider NPI #
10
588
597
35 - Consultant/facility provider address 1
24
598
621
36 - Consultant/facility provider address 2
24
622
645
37 - Consultant/facility provider city
24
646
669
38 - Consultant/facility provider state
2
670
671
39 - Consultant/facility provider zip
9
672
680
40 - Consultant/facility provider phone
10
681
690
41 - Consultant/facility provider fax
10
691
700
42 - Reasons for referral
80
701
780
43 - Brief history, dx, results or attachment
120
781
900
44 - Service desired - code
2
901
902
45 - Place of service - code
2
903
904
46 - Number of visits
2
905
906
47 - Authorization number
10
907
916
48 - Referral validity date
8
917
924
49 - Signature/electronic person completing the form
30
925
954
50 - Authorized signature/electronic
30
955
984
Referral certification is not a guarantee of payment. Payment of benefits is subject to a member's eligibility on the date that the service is rendered and to any other contractual provision of the plan/carrier.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.12 - Uniform Consultation Referral › Section 31.10.12.07 - Electronic Transfer of the Uniform Consultation Referral Form

Current through Register Vol. 51, No. 14, July 12, 2024
A. A transmission by facsimile is not considered an electronic transfer for the purposes of this chapter.
B. A carrier shall accept the electronic transfer of the uniform consultation referral form.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.12 - Uniform Consultation Referral › Section 31.10.12.08 - Uniform Consultation Referral Form - Required Forms

Current through Register Vol. 51, No. 14, July 12, 2024
A. The Maryland Uniform Dental Consultation Referral Form shall read as follows:
Click here to
				  view Image
B. The electronic equivalent of the uniform consultation referral form is as follows:
Uniform Dental Consultation Referral
Field
Length
Start
Stop
1 - Patient last name
18
1
18
2 - Patient first name
12
19
30
3 - Patient MI
1
31
31
4 - Patient DOB
8
32
39
5 - Patient phone number
10
40
49
6 - Patient member number
16
50
65
7 - Patient site number
10
66
75
8 - Carrier name
24
76
99
9 - Carrier address 1
24
100
123
10 -Carrier address 2
24
124
147
11 - Carrier city
24
148
171
12 - Carrier state
2
172
173
13 - Carrier zip code
9
174
182
14 - Carrier phone number
10
183
192
15 - Carrier fax number
10
193
202
16 - Primary/requesting dentist last name
18
203
220
17 - Primary/requesting dentist first name
12
221
232
18 - Primary/requesting dentist MI
1
233
233
19 - Primary/requesting dentist specialty
25
234
258
20 - Primary/requesting dentist institution/group name
80
259
338
21 - Primary/requesting dentist NPI #
10
339
348
22 - Primary/requesting dentist address 1
24
349
372
23 - Primary/requesting dentist address 2
24
373
396
24 - Primary/requesting dentist city
24
397
420
25 - Primary/requesting dentist state
2
421
422
26 - Primary/requesting dentist zip
9
423
431
27 - Primary/requesting dentist phone
10
432
441
28 - Primary/requesting dentist fax
10
442
451
29 - Specialist dentist last name
18
452
469
30 - Specialist dentist first name
12
470
481
31 - Specialist dentist MI
1
482
482
32 - Specialist dentist specialty
25
483
507
33 - Specialist dentist institution/group name
80
508
587
34 - Specialist dentist NPI #
10
588
597
35 - Specialist dentist address 1
24
598
621
36 - Specialist dentist address 2
24
622
645
37 - Specialist dentist city
24
646
669
38 - Specialist dentist state
2
670
671
39 - Specialist dentist zip
9
672
680
40 - Specialist dentist phone
10
681
690
41 - Specialist dentist fax
10
691
700
42 - Reasons for referral
80
701
780
43 - Brief history, dx, results or attachment
120
781
900
44 - Service desired - code
2
901
902
45 - Place of service - code
2
903
904
46 - Teeth diagram - attachment
2
905
906
47 - Authorization number
10
907
916
48 - Referral validity date
8
917
924
49 - Signature/electronic person completing the form
30
925
954
50 - Authorized signature/electronic
30
955
984
Referral certification is not a guarantee of payment. Payment of benefits is subject to a member's eligibility on the date that the service is rendered and to any other contractual provision of the plan/carrier.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.01 - Preface

Current through Register Vol. 51, No. 14, July 12, 2024
The issuance or delivery of health insurance policies in Maryland in any manner not in compliance with this chapter shall be deemed to constitute the transaction of insurance business hazardous to policyholders and the public and contrary to the public interest and otherwise contrary to requirements of the Insurance Article. Insurance Article, §
									2-109, Annotated Code of Maryland, authorizes the Commissioner to make reasonable regulations necessary for or as an aid to implementing any provision of the Insurance Article. Insurance Article, §
									12-203, Annotated Code of Maryland, provides, in part, that no health insurance policy form shall be delivered or issued for delivery in this State unless the form has been filed with and approved by the Commissioner. Insurance Article, §
									12-205, Annotated Code of Maryland, authorizes the Commissioner to disapprove any policy form if it contains an inequitable provision or a provision without substantial benefit to the policyholder or if the policy benefits are unreasonable in relation to the premium charged or if the policy benefits are not of real economic value to the insured.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.02 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to individual policies of health insurance and its application varies with the types of benefit provided by a policy. For this purpose, the benefits which have been found to appear in individual policies of health insurance are classified as follows:
A. Type 1: A benefit payable if an event involving a morbidity risk occurs or commences during the premium paying period of the policy. Most accident and health insurance benefits fall into this category.
B. Type 2: A deferred benefit in the form of a payment at the expiration date of the policy or at a date specified instead of an expiration date. This payment may be defined as an amount equal to all or a stated portion of the accumulated premiums for the policy, with or without interest, or the amount may be defined without regard to the premiums.
C. Type 3: A deferred periodic benefit providing for specified amounts payable at one or more specified times or intervals during the premium paying period. The specified amounts may be defined as equal to all or a stated portion of the premiums paid during a specified period, with or without interest, or the amounts of the payments may be defined without regard to the premiums.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.03 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to serve the interests of continuing policyholders and to afford reasonable protection to the interests of those policyholders who are forced to discontinue their policies prematurely by regulating the design of the policies in a manner which is equitable to the policyholder and which provides benefits reasonable in relation to the premium charged and which provides benefits of economic value to the insured.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.04 - Construction

Current through Register Vol. 51, No. 14, July 12, 2024
The classification in Regulation .02 of this chapter applies to the benefit rather than to the policy. A policy may contain benefits of more than one type. Benefits of Type 2 and Type 3 are deemed supplementary to Type 1 benefits. Premiums for Type 2 benefits and Type 3 benefits are normally payable at the same time as premiums for other benefits of the policy, but payments of Type 2 and and Type 3 benefits will normally be made only after the passage of a considerable period of time.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.05 - 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) "Guaranteed renewable" when used in connection with an individual health insurance policy means that the insured has the right to continue the policy in force by the timely payment of premiums:
(a) Until at least age 50; or
(b) In the case of a policy issued after age 44, for at least 5 years from its date of issue, during which period the insurer has no right to make unilaterally any change in any policy provision except the right to change premiums in accordance with the terms of the policy.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.06 - Type 1 Benefit

Current through Register Vol. 51, No. 14, July 12, 2024
Provision for a withdrawal benefit in connection with a nondeferred benefit, Type 1, is not required. However, provision for a withdrawal benefit in connection with a Type 1 benefit may be used at the insurer's option, if any payment under it is not greater than an amount corresponding to a reserve which might properly be held at the time of withdrawal with respect to the Type 1 benefit to which it is related.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.08 - Combining Withdrawal Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
If a policy provides for withdrawal benefits in connection with more than one benefit or more than one type of benefit, provision for these withdrawal benefits may be combined in a single part of the policy.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.09 - Death of an Insured

Current through Register Vol. 51, No. 14, July 12, 2024
Any cash withdrawal benefit provided by a policy shall be payable on death of an insured.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.10 - Policies Insuring More Than One Life

Current through Register Vol. 51, No. 14, July 12, 2024
If a policy covers more than one life, any provision of the regulation defining a minimum withdrawal benefit shall be construed, when appropriate, to be applicable separately to each covered life. The benefit provision shall be specific in regard to the determination of the amount of benefits under these cases.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.11 - Dividends

Current through Register Vol. 51, No. 14, July 12, 2024
For purposes of this chapter, dividends to policyholders may not be regarded as claims paid, but may be regarded as reductions of premiums paid.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.12 - Premium Waiver

Current through Register Vol. 51, No. 14, July 12, 2024
For purposes of this chapter, a waived premium shall be regarded both as a premium paid and a claim paid.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.13 - Premium Notices

Current through Register Vol. 51, No. 14, July 12, 2024
The insurer shall send the policyholder timely advance notice of each premium as it comes due, unless the premium installments are payable on a payroll savings or salary deduction plan, or by a series of preauthorized checks or bank drafts, or a similar plan.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.13 - Return of Premium, Cash Surrender, or Other Nonforfeiture Benefits in Health Insurance Policies › Section 31.10.13.14 - Advertising

Current through Register Vol. 51, No. 14, July 12, 2024
A sales presentation or advertising concerning any Type 2 or Type 3 benefit may not state, or in any manner indicate or imply, or tend to cause the policyholder to believe, that any withdrawal benefit is provided free or without additional cost or charge to the policyholder.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.14 - Minimum Loss Ratio with Respect to Specified Disease Policies › Section 31.10.14.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to establish minimum loss ratios with respect to specified disease policies in order to assure that the benefits provided in those policies are reasonable in relation to the premium charged and may be approved under the requirements of Insurance Article, 12-203-----12-205, and 15-109, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.14 - Minimum Loss Ratio with Respect to Specified Disease Policies › Section 31.10.14.02 - 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) "Claim reserve" means the sum of the present value of amounts not yet due on claims plus the reserve for future contingent benefits included in Exhibit 9, Part B of the Annual Statement. All numerical references to the Annual Statement in this regulation are to the National Association of Insurance Commissioners form for Life and Accident and Health insurers, current edition.
(2) "Claims liability" means the amount included in Line 4a of Exhibit 11, Part 1 of the Annual Statement.
(3) "Loss ratio" means the ratio of losses incurred to premiums earned on specified disease policies.
(4) "Policy reserves" means the sum of the additional reserves plus the reserve for future contingent benefits included in Lines 2 and 3 of Exhibit 9, Part A of the Annual Statement.
(5) "Premium reserve" means unearned premiums plus advance premiums plus reserve for dividends, refunds, and retrospective rate credits.
(6) "Premiums written" means premiums due during the current year and is equal to premiums collected during the current year plus premiums uncollected at the end of the current year less premiums uncollected at the end of the previous year.
(7) Specified Disease Policy.
(a) "Specified disease policy" means a health insurance policy that provides:
(i) Benefits only for a disease or diseases specified in the policy or for treatment unique to a specified disease or diseases; or
(ii) Additional benefits for a disease or diseases specified in the policy or for treatment unique to a specified disease or diseases, provided the actuarial net premium for the additional benefits exceeds 33 percent of the actuarial net premium for all of the health insurance benefits provided in the policy.
(b) If an insurer issues a health insurance policy to which a rider providing coverage for a specified disease or diseases may be added at the option of the policy owner and if the actuarial net premium for the benefits provided by the rider exceeds 33 percent of the actuarial net premium for all of the health insurance benefits provided by the policy including the rider, then either the policy to which the rider is attached, or the rider separately, shall be considered to be a "specified disease policy", whichever the insurer elects.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.14 - Minimum Loss Ratio with Respect to Specified Disease Policies › Section 31.10.14.03 - Minimum Loss Ratio

Current through Register Vol. 51, No. 14, July 12, 2024
A. In order to assure that benefits under specified disease policies are reasonable in relation to the premium charged, the insurer shall establish premiums for specified disease policies in accordance with generally accepted actuarial principles and practices so as to return to policyholders in the form of aggregate benefits provided under the policy during the period for which rates are computed at least 75 percent of the aggregate premiums earned in the case of group and blanket policies, and at least 60 percent of the aggregate premiums earned in the case of individual policies.
B. Policies issued as a result of solicitation of individuals through the mail or mass media advertising, including both print and broadcast advertising, shall be considered individual policies for purposes of this regulation.
C. The benefits provided in a specified disease policy shall be considered unreasonable in relation to the premium charged if the actual or anticipated loss ratio is less than 75 percent in the case of group and blanket policies, or less than 60 percent in the case of individual policies.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.14 - Minimum Loss Ratio with Respect to Specified Disease Policies › Section 31.10.14.04 - Rate Filings

Current through Register Vol. 51, No. 14, July 12, 2024
In filing a specified disease policy for approval, the insurer shall also file the premium rates proposed to be charged for the policy and shall include an actuarial memorandum based on credible data to show that the anticipated loss ratio under the policy will be not less than the ratios required by Regulation .03 of this chapter. The actuarial memorandum shall describe how the rates were determined and how the anticipated loss ratio was calculated and shall include a general description and the source of each assumption used in the memorandum. This filing as well as those required under Regulations .05 and .06 of this chapter shall assume a reasonable rate of interest to be earned on claim and policy reserves.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.14 - Minimum Loss Ratio with Respect to Specified Disease Policies › Section 31.10.14.05 - Reports to the Commissioner

Current through Register Vol. 51, No. 14, July 12, 2024
A. On or before June 30 of each calendar year, each insurer issuing specified disease policies in Maryland shall file with the Commissioner a report regarding the loss ratio being experienced under each specified disease policy form being issued by the insurer in this State. Experience with regard to substantially similar policy forms may be combined as if they were the same form.
B. The report as to each policy form or combination of similar policy forms shall show for each of the 5 preceding calendar years, or for the preceding years since the policy form was first issued, the following information regarding experience on direct business (before reinsurance ceded or assumed) issued, delivered, or renewed in Maryland:
(1) Premiums written;
(2) Dividends, refunds, and retrospective rate credits paid or allowed;
(3) Premiums written net of §B(2) of this regulation;
(4) Premium reserve at end of previous year;
(5) Premium reserve at end of current year;
(6) Premiums earned (§B(3) + (4) - (5));
(7) Claims paid;
(8) Claims liability at end of current year;
(9) Claim reserve at end of current year;
(10) Policy reserves at end of current year;
(11) Claims liability at end of previous year;
(12) Claim reserve at end of previous year;
(13) Policy reserves at end of previous year;
(14) Losses incurred (§B(7) + (8) + (9) + (10) - (11) - (12) - (13));
(15) Loss ratio (§B(14) divided by (6)).
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.14 - Minimum Loss Ratio with Respect to Specified Disease Policies › Section 31.10.14.06 - Procedure for Rate Reduction

Current through Register Vol. 51, No. 14, July 12, 2024
If the report referred to in Regulation .05 of this chapter with respect to a policy form or combination of similar policy forms indicates that the form or forms are not meeting the loss ratio requirements of Regulation .03 of this chapter, the insurer, within 30 days after the due date of the report, shall file for an appropriate reduction in premium to be effective not later than 90 days after the due date of the report. The filing shall include an actuarial memorandum as described in Regulation .04 of this chapter. If the insurer does not propose a reduced premium which in the opinion of the Commissioner meets the requirements of these regulations, the Commissioner shall afford the insurer a hearing upon due notice. If, as a result of the hearing, the Commissioner finds that the premium proposed to be charged by the insurer would not be likely to result in a loss ratio meeting the requirements of these regulations, he may withdraw approval of the affected policy form or forms in accordance with Insurance Article, §
									12-203(c)(5), Annotated Code of Maryland.
B. If a reduced premium is required, the insurer may offer the policy owner the option of obtaining increased benefits instead of the reduction in premium. The proposed benefit increase should be filed in accordance with Regulation .04 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.14 - Minimum Loss Ratio with Respect to Specified Disease Policies › Section 31.10.14.07 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
These regulations apply to all insurers to whom Insurance Article, §
									15-109, Annotated Code of Maryland, is applicable.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.16 - Carrier Provider Panels - Application Process › Section 31.10.16.01 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all insurers, nonprofit health service plans, health maintenance organizations, dental plans, and to any other person or organization which utilizes a provider panel and which provides health benefit plans subject to regulation in this State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.16 - Carrier Provider Panels - Application Process › Section 31.10.16.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) Carrier.
(a) "Carrier" means:
(i) An insurer;
(ii) A nonprofit health service plan;
(iii) A health maintenance organization;
(iv) A dental plan organization; and
(v) Any other person or organization that provides health benefit plans subject to State regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.16 - Carrier Provider Panels - Application Process › Section 31.10.16.03 - Requirements for Application Process

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier that utilizes a provider panel shall establish written procedures for reviewing applications for participation in the provider panel.
B. A carrier that utilizes a provider panel shall, upon request, make its applications publicly available.
C. The form of application:
(1) Shall include instructions for completion of the application;
(2) Shall provide a specifically designated space for dating the receipt of the application by the carrier; and
(3) Shall comply with federal and State laws concerning the Americans with Disability Act.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.16 - Carrier Provider Panels - Application Process › Section 31.10.16.04 - Application Fees

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier may charge a reasonable fee for any application that a provider submits to the carrier.
B. The fee shall be nonrefundable and uniform for all applicants within a practice specialty.
C. The fee may not exceed $75 for each provider application.
D. A carrier may not charge additional fees for processing an application which was returned because of insufficient information.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.16 - Carrier Provider Panels - Application Process › Section 31.10.16.05 - Document Retention

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier shall maintain its provider application log for a minimum of 3 years or until its next market conduct examination, whichever occurs last.
B. A carrier shall:
(1) Date stamp each application received from a provider upon initial receipt; and
(2) Maintain a legible copy of each application, and any correspondence regarding that application, for a minimum of 3 years or until its next market conduct examination, whichever occurs last.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.17 - Health Care Consumer Information and Education Act › Section 31.10.17.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all carriers that provide health care services to enrollees or otherwise make health care services available to enrollees through contracts with providers.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.17 - Health Care Consumer Information and Education Act › Section 31.10.17.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Carrier" means:
(a) An insurer;
(b) A nonprofit health service plan;
(c) A health maintenance organization;
(d) A dental plan organization;
(e) Any person or entity acting as a third-party administrator; or
(f) Except for a managed care organization as defined in Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, any other person that provides health benefit plans subject to regulation by the State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.17 - Health Care Consumer Information and Education Act › Section 31.10.17.03 - Information to be Disclosed

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each carrier that provides health care services to enrollees, or otherwise makes health care services available to enrollees through contracts with providers, shall disclose in its enrollment sales material the:
(1) Methodology or methodologies that the carrier uses to compensate the physicians for health care services rendered to enrollees; and
(2) Distribution of each $100 it receives in premium dollars from enrollees for the preceding calendar year.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.17 - Health Care Consumer Information and Education Act › Section 31.10.17.04 - Disclosure of Compensation Methodologies

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each carrier shall include the following in its enrollment sales materials:
(1) The following disclosure statement typeset in bold italic type:
"Our compensation to physicians who offer health care services to our insured members or enrollees may be based on a variety of payment mechanisms such as fee-for-service payments, salary, or capitation. Bonuses may be used with these various types of payment methods.
If you desire additional information about our methods of paying physicians, or if you want to know which method(s) apply to your physician, please call us (name) at (phone number) or write (address).";
(2) The table, specified in §C of this regulation, defining methods of paying physicians and giving an example of each method; and
(3) A statement of:
(a) The payment method or methods used to compensate physicians during the preceding year, and
(b) An estimated percentage of physicians under contract with the carrier compensated by each payment method.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.17 - Health Care Consumer Information and Education Act › Section 31.10.17.05 - Disclosure of Distribution of Premium Dollars

Current through Register Vol. 51, No. 14, July 12, 2024
A. The disclosure required under this regulation shall:
(1) Be in the form of a pie chart or bar graph; and
(2) Identify, in layman's terms, the proportion of every $100 in premium dollars that the carrier uses to pay:
(a) Providers for the provision of health care services to enrollees, including what proportion is for direct medical care expenses, and
(b) For plan administration.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.17 - Health Care Consumer Information and Education Act › Section 31.10.17.06 - Manner of Disclosure

Current through Register Vol. 51, No. 14, July 12, 2024
The disclosures required by this chapter may be on a separate form, which shall be provided to employers at the time of plan selection and to enrollees at the time of enrollment.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.17 - Health Care Consumer Information and Education Act › Section 31.10.17.07 - Other Permitted Disclosures

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier may disclose on the pie chart or bar graph that the administrative expenses do not include taxes.
B. A carrier may disclose on the pie chart or bar graph whether the carrier includes dental benefits as part of the underlying benefit plan.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity › Section 31.10.18.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to carriers and to private review agents to whom the internal grievance process has been delegated by a carrier.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity › Section 31.10.18.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) Adverse Decision.
(a) "Adverse decision" means a utilization review determination by a private review agent, a carrier, or a health care provider acting on behalf of a carrier that:
(i) A proposed or delivered health care service which would otherwise be covered under the member's contract is not or was not medically necessary, appropriate, or efficient; and
(ii) May result in noncoverage of the health care service.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity › Section 31.10.18.04 - Health Advocacy Unit Information in Notice of Adverse Decision

Current through Register Vol. 51, No. 14, July 12, 2024
A carrier shall include in each notice of adverse decision the following disclosure in at least 12-point typeface, with the first sentence in bold capital typeface:
"THERE IS HELP AVAILABLE TO YOU IF YOU WISH TO DISPUTE THE DECISION OF THE PLAN ABOUT PAYMENT FOR HEALTH CARE SERVICES. You may contact the Health Advocacy Unit of Maryland's Consumer Protection Division at (phone number, address, fax, e-mail).
The Health Advocacy Unit can help you, your representative, and your health care provider prepare a grievance to file under the carrier's internal grievance procedure. That unit can also attempt to mediate a resolution to your dispute. The Health Advocacy Unit is not available to represent or accompany you during any proceeding of the internal grievance process.
Additionally, you, your representative, or your health care provider may file a complaint with the Maryland Insurance Administration, without having to first file a grievance with the plan, if:
(1) The plan has denied authorization for a health care service not yet provided to you; and
(2) You, your representative, or your provider can show a compelling reason to file a complaint, including that a delay in receiving the health care service could result in loss of life, serious impairment to a bodily function, or serious dysfunction of a bodily organ or part, or the member remaining seriously mentally ill with symptoms that cause the member to be in danger to self or others. INFORMATION DESCRIBED IN THIS NOTICE MAY ALSO BE FOUND IN (cite policy, plan, certificate, enrollment materials, or other evidence of coverage)."
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity › Section 31.10.18.05 - Procedures for Emergency Cases

Current through Register Vol. 51, No. 14, July 12, 2024
A. An expedited review of an adverse decision in accordance with this regulation is required if the:
(1) Adverse decision is rendered for health care services that are proposed but have not been delivered; and
(2) Services are necessary to treat a condition or illness that, without immediate medical attention, would:
(a) Seriously jeopardize the life or health of the member of the member's ability to regain maximum functions;
(b) Cause the member to be in danger to self or others; or
(c) Cause the member to continue using intoxicating substances in an imminently dangerous manner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity › Section 31.10.18.06 - Establishment, Filing, and Reporting of Internal Grievance Process

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each carrier shall establish an internal grievance process.
B. Each carrier shall:
(1) File with the Commissioner its internal grievance process not more than 30 days after the effective date of this chapter;
(2) File with the Commissioner each amendment to its internal process at least 30 days before its intended use;
(3) Include with the filing the circumstances, if any, under which the internal grievance process will be delegated to a private review agent;
(4) Include with the filing a copy of the applicable part of the policy, plan, certificate, enrollment materials, or other evidence of coverage that shows the information required under Insurance Article, § 15-10 A-02(k), Annotated Code of Maryland; and
(5) Submit to the Health Advocacy Unit the document describing the details of its internal grievance process and procedures that the carrier will send to a member, member's representative, or health care provider when the member, member's representative, or provider contacts the carrier about an adverse decision.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity › Section 31.10.18.07 - Requirements for Internal Grievance Process

Current through Register Vol. 51, No. 14, July 12, 2024
An internal grievance process shall:
A. Meet the requirements established under this chapter; and
B. Include an expedited procedure for use in an emergency case for purposes of rendering a grievance decision within 24 hours after filing the grievance pursuant to the carrier's internal grievance process, that includes an explanation about:
(1) Who will make the determination whether an emergency case exists when a grievance asserts an emergency case,
(2) How the determination will be made about the existence of an emergency case,
(3) How the disclosure to the member, the member's representative, or health care provider required by Insurance Article, § 15-10 A-02(g), Annotated Code of Maryland, will be provided when the grievance asserts that an emergency case exists; and
(4) How the notice to the member and, if applicable, the member's representative and health care provider required by Insurance Article, § 15-10 A-02(i), Annotated Code of Maryland, will be provided when the grievance asserts that an emergency case exists.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.18 - Denials of Coverage Based on Medical Necessity › Section 31.10.18.08 - Time for Rendering Final Decisions Resulting from Internal Grievance Process

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as otherwise provided in this regulation, a carrier shall render a final decision on a grievance that involves a:
(1) Prospective denial in a nonemergency case within 30 working days after the filing date; and
(2) Retrospective denial within 45 working days after the filing date.