reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses › Section 31.11.03.03 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter is applicable to all group health insurance policies or contracts issued or delivered in this State to the employer of the insured which provide hospital, surgical, medical, or major medical benefits on an expense-incurred basis whether issued by a nonprofit health service plan or by any other insurer, and to all group policies or contracts issued or delivered in this State to an employer by a health maintenance organization certified under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.
B. This chapter is applicable to any policy or contract issued on or after the effective date of this chapter, beginning with the date of issue of the policy or contract.
C. This chapter is applicable to any policy or contract issued before the effective date of this chapter, beginning on the first annual renewal date or the first anniversary of the date of issue of the policy or contract occurring on or next following the effective date of this chapter.
Agency Note: Federal statutes and regulations may provide broader or additional benefits for persons to whom this chapter is applicable.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses › Section 31.11.03.04 - Eligibility

Current through Register Vol. 51, No. 14, July 12, 2024
Beginning with an applicable change in status and until the occurrence of an event described in Regulation .07 of this chapter, the qualified secondary beneficiary shall be entitled to the benefits provided under the group contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses › Section 31.11.03.05 - Coverage Provided

Current through Register Vol. 51, No. 14, July 12, 2024
A. The coverage provided to a qualified secondary beneficiary shall be identical to the coverage which would have been provided under the group contract for the benefit of the qualified secondary beneficiary if the qualified secondary beneficiary had remained an eligible dependent of the insured employee and there had been no applicable change in status.
B. If modifications are made in the employer's group contract, the coverage provided to the qualified secondary beneficiary shall be correspondingly modified.
C. If the employer transfers from one group contract to another, the coverage provided the qualified secondary beneficiary will be transferred to that provided under the new group contract.
D. If the employer provides various hospital, surgical, medical, or major medical coverages under one or more group contracts, a qualified secondary beneficiary may not elect to choose less than all of the benefits provided unless the insured employee would have had the option of making such a choice for an eligible dependent if there had been no applicable change in status.
E. The benefits to be provided under the group contract shall be in no respect less favorable than those required by this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses › Section 31.11.03.06 - Conditions of Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. In order to receive the benefits provided under the group contract, a surviving spouse of the insured employee shall elect coverage not later than 45 days after the applicable change in status if a request is made for coverage under the group contract under which the insured employee is covered on the date of the applicable change in status. The coverage shall be retroactive to the applicable change in status.
B. The request to the employer under §A of this regulation shall be in writing and signed by the qualified secondary beneficiary.
C. Costs to Secondary Beneficiary.
(1) The qualified secondary beneficiary shall pay to the employer the employer's entire cost for the coverage to be provided.
(2) The entire cost to the employer includes the employer's customary contribution as well as the contribution customarily required of an employee if there were no applicable change in status.
(3) The entire cost to the employer may include a reasonable administrative fee not to exceed 2 percent of the amount permitted under §C(2) of this regulation.
(4) If the insurer quotes rates to the employer separately for individual coverage and for dependent coverage, the payment to be made on behalf of the qualified secondary beneficiary shall be the rate quoted for dependents.
(5) If the insurer quotes a family rate which would normally include an employee and eligible dependents, the amount payable on behalf of the qualified secondary beneficiary shall be the difference between the family rate and the rate payable for an individual employee who is not covered for dependents.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses › Section 31.11.03.07 - Termination

Current through Register Vol. 51, No. 14, July 12, 2024
Coverage for a qualified secondary beneficiary will terminate on the earliest of any of the following:
A. 18 months after the date of the applicable change in status;
B. The date on which the qualified secondary beneficiary becomes eligible for hospital, surgical, medical, or major medical benefits under any insured group contract or any health maintenance organization group contract or any self-insured group health benefit program or plan provided:
(1) The group contract or the self-insured program or plan is on an expense-incurred basis; and
(2) The eligibility does not result from the provisions of these regulations;
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses › Section 31.11.03.09 - Notification Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each group contract to which these regulations are applicable shall include a statement as provided in §B of this regulation.
B. The statement shall disclose the availability of the benefits provided under these regulations and shall provide a summary of the eligibility requirements, the duration, and general description of the benefits.
C. Each group contract issued before the effective date of this chapter, to which this chapter is applicable, shall be amended in accordance with this chapter not later than the date of applicability stated in Regulation .03C of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses › Section 31.11.03.10 - Election Statement

Current through Register Vol. 51, No. 14, July 12, 2024
The form which a qualified secondary beneficiary shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation:
To ________________________________________ (name of employer)
The employee _______________________________ (name of employee)
whose Social Security number was _______________ (number)
died on ____________________________________ (date of death)
This is to advise that ___________________________
___________________________________________ (name or names of qualified secondary beneficiaries)
who were covered as qualified dependents of the employee under the employer's group health insurance contract elect(s) to continue to be covered under that contract beginning with the date of death.
Date of Application: ________________________________
Signature of Qualified Secondary Beneficiary: ______________________________
Mailing Address of Secondary Beneficiary: ______________________________
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.03 - Group Health Insurance - Continuation of Coverage of Surviving Spouses › Section 31.11.03.11 - Termination Statement

Current through Register Vol. 51, No. 14, July 12, 2024
The termination statement shall be in language substantially as indicated in this regulation:
To ________________________________________ (name of employer)
This is to advise that ___________________________
___________________________________________ (name or names of qualified secondary beneficiaries)
is/are no longer to be covered under our group health insurance contract effective __________________________________ (date)
The reason for this termination is ______________________ _______________________________________________ (reason)
Date: __________________________________________ _______________________________________________ Signature of qualified secondary beneficiary
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to provide standards for implementing requirements of the Insurance Article, Health-General Article, and Unemployment Insurance Law, Annotated Code of Maryland, with respect to continuation of coverage for certain terminated employees.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.02 - 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) Applicable Change in Status.
(a) "Applicable change in status" means the termination of the insured's employment other than for cause.
(b) "Applicable change in status" includes:
(i) Involuntary termination of the insured's employment other than for cause; and
(ii) Voluntary termination of the insured's employment by the insured.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.03 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
A. These regulations shall be applicable to all group health insurance policies or contracts issued or delivered in this State to the employer of the insured which provide hospital, surgical, medical, or major medical benefits on an expense-incurred basis whether issued by a nonprofit health service plan or by any other insurer and to all group policies or contracts issued or delivered in this State to an employer by a health maintenance organization certified under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.
B. These regulations shall be applicable to any policy or contract issued on or after the effective date of these regulations, beginning with the date of issue of the policy or contract.
C. These regulations shall be applicable to any policy or contract issued before the effective date of these regulations, beginning on the first annual renewal date or the first anniversary of the date of issue of the policy or contract occurring on or next following the effective date of this chapter.
Agency Note: Federal statutes and regulations may provide broader or additional benefits for persons to whom this chapter is applicable.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.04 - Eligibility

Current through Register Vol. 51, No. 14, July 12, 2024
Entitlement to continuation benefits shall begin with an applicable change in status and last until the occurrence of an event described in Regulation .06 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.05 - Coverage Provided

Current through Register Vol. 51, No. 14, July 12, 2024
A. The coverage provided shall be identical to the coverage offered under the group contract to similarly situated individuals for whom there has been no applicable change in status.
B. If the group policy provides benefits for spouses and dependent children, the coverage provided shall be available to the insured's:
(1) Spouse if the spouse was covered under the group policy before the applicable change in status; and
(2) Dependent children if the insured had coverage for dependent children before the applicable change in status.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.06 - Conditions of Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. In order to receive the benefits provided under the group contract, an insured shall elect coverage not later than 45 days after the applicable change in status.
B. The coverage shall be retroactive to the applicable change in status.
C. The request to the employer under §A of this regulation shall be in writing and signed by the insured.
D. Continuation coverage shall be provided without evidence of insurability or additional waiting periods.
E. Costs to Insured.
(1) The insured shall pay to the employer the employer's entire cost for the coverage to be provided.
(2) The entire cost to the employer includes the employer's customary contribution as well as the contribution customarily required of an employee if there were no applicable change in status.
(3) The entire cost to the employer may include a reasonable administrative fee not to exceed 2 percent of the amount permitted under §E(2) of this regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.07 - Termination

Current through Register Vol. 51, No. 14, July 12, 2024
Coverage for the insured shall terminate on the earliest of any of the following:
A. 18 months after the date of the applicable change in status;
B. The date on which the insured becomes eligible for hospital, surgical, medical, or major medical benefits under any insured group contract or any health maintenance organization group contract or any self-insured group health benefit program or plan provided:
(1) The group contract or the self-insured program or plan is on an expense-incurred basis; and
(2) The eligibility does not result from the provisions of this chapter;
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.09 - Notification Requirements

Current through Register Vol. 51, No. 14, July 12, 2024
A. Every group contract to which this chapter is applicable shall include a statement as provided in §B of this regulation.
B. The statement shall disclose the availability of the benefits provided under this chapter and shall provide a summary of the eligibility requirements, the duration, and general description of the benefits.
C. Every group contract issued before the effective date of this chapter, to which this chapter is applicable, shall be amended in accordance with this chapter not later than the date of applicability stated in Regulation .03C of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.10 - Election Statement

Current through Register Vol. 51, No. 14, July 12, 2024
The form which the insured shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation:
To ___________________________________________ ( name of employer)
I _____________________________ whose Social Security ( name of employee)
number is __________________________ have been ( number )
terminated as an employee on ______________________. (date of termination)
Before termination I was covered under the employer's group health insurance contract (check one)
____ for myself.
____ for myself and dependents.
I elect to have this coverage continue in force and I agree to pay the required premium.
Date of Application: __________________________________
Signature of Insured: _________________________________
Mailing Address: ______________________________________
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.04 - Group Health Insurance - Continuation of Coverage for Terminated Employees › Section 31.11.04.11 - Termination Statement

Current through Register Vol. 51, No. 14, July 12, 2024
The termination statement shall be in language substantially as indicated in this regulation.
To ___________________________________________ (name of employer)
This is to advise that ___________________________ and (name of insured)
covered dependants, if any, are no longer to be covered under our group health insurance contract effective _______________(date)
The reason for this termination is ________________________ ___________________________________________________ (reason)
Date: _____________________
Signature of Insured: _________________________________
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.05 - Group Health Insurance Options for Alzheimer's Disease and for Diseases of the Elderly › Section 31.11.05.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter is applicable to all group health insurance policies issued or renewed in Maryland on or after July 1, 1987, except as noted below.
B. Any group health insurance policy issued before the effective date of this chapter shall be subject to this chapter on the annual renewal date of the policy falling on or next following the effective date.
C. This chapter is not applicable to group health insurance policies which:
(1) Do not provide benefits for the cost of medical care on an expense-incurred basis; or
(2) Provide benefits for accidents only.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.05 - Group Health Insurance Options for Alzheimer's Disease and for Diseases of the Elderly › Section 31.11.05.02 - 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) "Alzheimer's disease" means a progressive brain disease diagnosed as Alzheimer's disease by the insured's licensed attending physician and confirmed by a second opinion of a licensed physician.
(2) "Diseases of the elderly" means any disease, illness, injury, or medical condition which has caused the elderly insured to become functionally impaired or disabled so as to require nursing home care or intermediate or custodial nursing care and which has been confirmed by a second opinion of a licensed physician.
(3) "Elderly" means an insured who is 65 years old or older.
(4) "Group health insurance policy" means an insurance policy issued in Maryland either:
(a) Providing benefits for hospital, surgical, medical, major medical, or all of the above, in accordance with Insurance Article, §
											15-302, Annotated Code of Maryland; or
(b) Providing benefits for health, surgical, medical, major medical, or all of the above to a group of persons by a nonprofit health service plan, pursuant to Insurance Article, Title 14, Subtitle 1, Annotated Code of Maryland.
(5) "Group of persons" means the types of groups as defined in Insurance Article, §
										15-302, Annotated Code of Maryland.
(6) "Insured" means a person covered under a group health insurance policy.
(7) "Intermediate or custodial nursing care" means any form of health or health-related service, whether provided in a custodial or noncustodial setting, which is designed to provide therapeutic, rehabilitative, supportive, or maintenance care to a person who has chronic or deteriorating medical conditions which impair the person's ability to function at his or her own optimum level, but not including treatment of the conditions during the initial, acute stage of the condition or conditions.
(8) "Nursing home" means a facility or institution or part of it that:
(a) Provides nursing care for chronically ill or convalescent patients; or
(b) Offers to provide 24-hour a day nursing care of patients in a home-type facility such as a:
(i) Convalescent home,
(ii) Nursing unit of a home for the aged,
(iii) Psychiatric nursing home,
(iv) Nursing facility for the handicapped,
(v) Home for alcoholics, or
(vi) Halfway house.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.05 - Group Health Insurance Options for Alzheimer's Disease and for Diseases of the Elderly › Section 31.11.05.03 - Required Health Insurance Options

Current through Register Vol. 51, No. 14, July 12, 2024
Each insurer shall offer the following options for its group health insurance policies:
A. One option to cover Alzheimer's disease; and
B. One option to cover Alzheimer's disease as well as diseases of the elderly.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.05 - Group Health Insurance Options for Alzheimer's Disease and for Diseases of the Elderly › Section 31.11.05.04 - Required Coverage

Current through Register Vol. 51, No. 14, July 12, 2024
A. The coverages provided by the required health insurance options shall include, but are not limited to:
(1) The institutional and professional care expenses for nursing home care alone, or in addition to intermediate or custodial nursing care, while confined in a nursing home or other custodial care facility or institution; and
(2) Expenses for the type of care described in §A(1) of this regulation for an insured who is not confined to a facility or institution.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
A. This chapter applies to all carriers that offer the comprehensive standard health benefit plan to the small employer market.
B. This chapter identifies the uniform benefits which must be offered in a comprehensive standard health benefit plan which a carrier offers to a Maryland small employer if the policy is issued or renewed after June 30, 1994. A carrier participating in the small employer market shall market this plan to all employers with as few as two eligible employees and as many as 50 eligible employees.
C. With the exception set forth in §D of this regulation, a carrier may offer the plan through one or more of the following delivery systems:
(1) Indemnity;
(2) Preferred provider;
(3) Point-of-service delivered in conjunction with an indemnity or preferred provider delivery system;
(4) A health maintenance organization;
(5) A high deductible health maintenance organization;
(6) A triple option point-of-service;
(7) An HSA-compatible delivery system; or
(8) An exclusive provider.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.03-1 - Covered Services - Preventive Care Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. This regulation applies to plans with plan years that begin on or after September 23, 2010.
B. The benefits required by Regulation .03A(9), (9-1), (9-2), (10), (31) and (33), Regulation .04F(5)(e) and (6)(e), and Regulation .05I of this chapter do not apply to plans with plan years that begin on or after September 23, 2010.
C. Plans that are subject to this regulation shall provide benefits for the following preventive care services:
(1) Except as provided in §D of this regulation, evidence"based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force;
(2) Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;
(3) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
(4) With respect to women, to the extent not described in §C(1) of this regulation, evidence-informed preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.04 - Uniform Cost-Sharing Arrangements - In General

Current through Register Vol. 51, No. 14, July 12, 2024
A. For each delivery system identified in §F of this regulation, a carrier shall apply the uniform cost-sharing arrangements specified.
B. Copayments.
(1) Except for copayments for emergency services, which a carrier shall apply to the deductible and the out-of-pocket limit, a carrier may not apply the copayments set forth in this chapter to reduce the amount of a deductible or out-of-pocket limit.
(2) Notwithstanding §B(1) of this regulation, a carrier shall apply all copayments set forth in this chapter to reduce the amount of a deductible or out-of-pocket limit for a HSA-compatible delivery system.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.05 - Uniform Cost-Sharing Arrangements - Specific Services

Current through Register Vol. 51, No. 14, July 12, 2024
A. General Cost-Sharing Arrangement for Outpatient Mental Health and Substance Abuse Services.
(1) Except as provided in §B of this regulation, for outpatient mental health and substance abuse, the carrier shall pay for each service 70 percent of allowable charges.
(2) A carrier may substitute a copayment for these services at an actuarially equivalent amount to the coinsurance percentages described in this regulation subject to the approval of the Insurance Commissioner and the Maryland Health Care Commission.
(3) For purposes of the cost-sharing arrangement set forth in §A(1) of this regulation, a carrier shall treat a visit made solely for medication management purposes for mental health or substance abuse treatment as a covered service under Regulation .03A(1) of this chapter and may not count the visit as a mental health or substance abuse service described in Regulation .03A(5) of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.07 - Additional Benefits

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier may offer benefits in addition to the plan only if:
(1) The benefits are offered separately from the plan;
(2) The benefits are priced separately from the plan;
(3) Subject to the provisions of Insurance Article, §
										15-1213, Annotated Code of Maryland, the benefits are guarantee issued;
(4) Subject to the provisions of Insurance Article, §
										15-1212, Annotated Code of Maryland, the benefits are guarantee renewed;
(5) Subject to the provisions of Insurance Article, §
										15-1205, Annotated Code of Maryland, the benefits are community rated; and
(6) The benefits do not duplicate any of the benefits in the plan.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.08 - Mandatory Point-of-Service Option or Out-of-Network Option

Current through Register Vol. 51, No. 14, July 12, 2024
A. When a health maintenance organization is the sole delivery system offered to employees by an eligible employer, the health maintenance organization:
(1) Shall offer the employer a mandatory point-of-service option for the individual employee to accept or reject;
(2) May not impose a minimum participation level on the mandatory point-of-service option;
(3) May not limit the benefits a covered person can receive out of network;
(4) As part of the application, shall provide to each eligible employer the following disclosure statement for each point-of-service option offered:
"Under Maryland law, your employees may purchase a point-of-service option as an additional benefit. A point-of-service option allows your employees 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 pay this point-of-service option, pay a percentage of the cost of this option, or require your employees 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. Please indicate below the employees who have chosen this point-of-service option.
I have read and understand this disclosure statement and the attachments and have provided notice of the availability of this additional benefit to my eligible employees."
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.09 - 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)  -(h), 15-414, 15-604, 15-701, 15-811, 15-812, 15-815, 15-816, 15-823, 15-839, and 15-10B-09, Annotated Code of Maryland, and Health-General Article, §§19-703(d) and (g), 19-706(h), 19-710.1(b)(1)(ii), and 19-712.5, Annotated Code of Maryland, to the extent those sections are considered mandated benefits.
B. Notwithstanding the mandated benefits included in Regulation .09A of this chapter, the requirements of Insurance Article, §
									15-812(g), Annotated Code of Maryland, relating to imposition of copayment, coinsurance, or deductibles, are inapplicable to a HSA-compatible delivery system.
C. These regulations do 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.
D. A health maintenance organization shall include the conversion benefit required under COMAR 31.12.02.11B.
E. 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;
(3) [Shall] For plan years beginning before September 23, 2010, shall provide direct access to obstetric and gynecological care as specified in Insurance Article, §
										15-816, Annotated Code of Maryland; and
(4) For plan years beginning on or after September 23, 2010, shall provide direct access to obstetric and gynecological care as specified in 45 CFR 147.138(a)(3).
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.10 - 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 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.11 - Pre-existing 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, or to individuals younger than 19 years old.
B. Except as provided in §A of this regulation, for contracts issued or renewed on or after October 1, 2009, an insurer or non-profit health service plan may impose a preexisting condition provision in accordance with Insurance Article, §
									15-508, Annotated Code of Maryland.
C. A carrier may impose a waiting period from the date of application, in accordance with Insurance Article, §
									15-1208, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.06 - Comprehensive Standard Health Benefit Plan › Section 31.11.06.12 - Review

Current through Register Vol. 51, No. 14, July 12, 2024
In addition to the requirement 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 31.11.08 - Small Group Market Health Insurance Geographic Areas › Section 31.11.08.01 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all carriers which offer health benefits plans to small employers in the State.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.08 - Small Group Market Health Insurance Geographic Areas › Section 31.11.08.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Baltimore Metropolitan Area" means Baltimore City, Baltimore County, Harford County, Howard County, and Anne Arundel County.
(2) "Eastern and Southern Maryland" means St. Mary's County, Charles County, Calvert County, Cecil County, Kent County, Queen Anne's County, Talbot County, Caroline County, Dorchester County, Wicomico County, Somerset County, and Worcester County.
(3) "Washington, D.C. Metropolitan area" means Montgomery County and Prince George's County.
(4) "Western Maryland" means Garrett County, Allegany County, Washington County, Carroll County, and Frederick County.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.08 - Small Group Market Health Insurance Geographic Areas › Section 31.11.08.03 - Geographic Areas

Current through Register Vol. 51, No. 14, July 12, 2024
If carriers subject to this chapter adjust their community rates based on geography, they may only use the geographic areas defined in Regulation .02 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.09 - Solicitation of Coverage under Group Health or Blanket Health Insurance Policy Issued in Another Jurisdiction › Section 31.11.09.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all insurers seeking to solicit coverage in this State under a group health or blanket health insurance policy issued in another jurisdiction.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.09 - Solicitation of Coverage under Group Health or Blanket Health Insurance Policy Issued in Another Jurisdiction › Section 31.11.09.02 - Standards for Approval to Solicit

Current through Register Vol. 51, No. 14, July 12, 2024
A. An insurer seeking the Commissioner's approval to solicit coverage in this State under a group health or blanket health insurance policy issued in another jurisdiction shall submit to the Commissioner documentation sufficient to enable the Commissioner to determine whether the type of group to be covered conforms substantially to one of the types of groups described in Insurance Article, §
									15-302 or  15-305, Annotated Code of Maryland. An insurer may not solicit this coverage in Maryland until the Commissioner has made that determination.
B. If the Commissioner determines that the type of group to be covered conforms substantially to one of the types of groups described in Insurance Article, §
									15-302 or  15-305, Annotated Code of Maryland, the insurer shall file with the Commissioner all forms and endorsements necessary to demonstrate that the insurer provides all of the applicable benefits which are required by Insurance Article, Annotated Code of Maryland, to be included in a group health or blanket health insurance policy issued in another jurisdiction.
C. If the Commissioner determines that the type of group to be covered does not conform substantially to one of the types of groups described in Insurance Article, §
									15-302 or  15-305, Annotated Code of Maryland, the insurer shall submit to the Commissioner each policy form, certificate form, application form, rider, and endorsement which it proposes to use in connection with insurance coverage provided to Maryland residents.
D. Each filing made pursuant to these regulations shall be made not less than 60 days in advance of the form's use. At the expiration of the 60-day period, unless extended by the Commissioner an additional 30 days, the right to solicit the filed coverage is considered approved unless the Commissioner has previously approved or disapproved the right to solicit the filed coverage.
E. The Commissioner may at any time withdraw approval previously given by sending to the insurer, not less than 30 days in advance of the effective date of the Commissioner's action, a notice of withdrawal setting forth the grounds for withdrawal in sufficient detail as to reasonably apprise the insurer of the basis for withdrawal.
F. Approval to solicit coverage in this State may not be given if any of the forms fail to contain those applicable benefits which are required by Insurance Article, Annotated Code of Maryland, to be included in a group or blanket health insurance policy issued in another jurisdiction.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.09 - Solicitation of Coverage under Group Health or Blanket Health Insurance Policy Issued in Another Jurisdiction › Section 31.11.09.03 - Notice to Insured Concerning Mandated Benefits

Current through Register Vol. 51, No. 14, July 12, 2024
An insurer who seeks to solicit coverage for Maryland residents under a group health or blanket health insurance policy issued in another jurisdiction shall include in the certificate form used in connection with the coverage, a notice on the first page in 12-point bold type that the policy may omit some of the benefits required for a policy issued and delivered in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.10 - Required Standard Provisions › Section 31.11.10.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to each group health insurance contract, each blanket health insurance contract, and each group nonprofit health service plan contract issued or delivered in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.10 - Required Standard Provisions › Section 31.11.10.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Blanket health insurance" has the meaning stated in Insurance Article, §
										15-305, Annotated Code of Maryland.
(2) "Carrier" means an insurer or nonprofit health service plan.
(2-1) "Coverage period" means the interval of time the blanket health insurance contract or group health insurance contract provides protection, in exchange for the payment of a particular premium.
(3) Group Health Insurance.
(a) "Group health insurance" has the meaning stated in Insurance Article, §
											15-302, Annotated Code of Maryland.
(b) "Group health insurance" includes:
(i) A small employer health benefit plan as defined in Insurance Article, §
												15-1201, Annotated Code of Maryland; and
(ii) A contract issued to a group policyholder by a nonprofit health service plan.
(4) "Group policyholder" means the entity to whom the group health insurance contract or blanket health insurance contract is issued.
(5) "Insured" means an individual covered under a group health insurance contract or blanket health insurance contract.
(6) "Preferred provider" means a provider that has entered into a provider service contract.
(7) "Preferred provider benefit" means a benefit that appears in a group health insurance contract or blanket health insurance contract under which health care services are to be provided to the insured by a preferred provider.
(8) "Provider service contract" means a contract between a provider and a carrier or other entity, under which the provider agrees to provide health care services on a preferential basis under contracts containing preferred provider benefits.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.10 - Required Standard Provisions › Section 31.11.10.03 - Required Standard Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. A group health insurance contract may not be delivered in Maryland unless it contains in substance the provisions:
(1) Listed in Regulation .04 of this chapter; or
(2) Which in the opinion of the Commissioner, as compared to the provisions in Regulation .04 of this chapter, are:
(a) More favorable to the individuals insured, or
(b) At least as favorable to the individuals insured and more favorable to the policyholder.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.10 - Required Standard Provisions › Section 31.11.10.04 - Group Health Insurance Standard Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Entire Contract; Changes. Each group health insurance contract shall contain a provision that specifies:
(1) Which documents constitute the entire contract of insurance; and
(2) That a change in the policy may not be valid:
(a) Until approved by an executive officer of the carrier, and
(b) Unless the approval is endorsed on the policy or attached to the policy.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.10 - Required Standard Provisions › Section 31.11.10.05 - Blanket Health Insurance Standard Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each blanket health insurance contract shall contain in substance the provisions set forth in Regulation .04A, C, D, G, H, I, and L of this chapter.
B. Statements in Applications. Each blanket health insurance contract shall contain a provision that:
(1) Absent fraud, each statement made by the group policyholder is considered to be a representation and not a warranty; and
(2) A statement made by the group policyholder may not be used in defense to a claim under the policy unless the statement is contained in a written application.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.10 - Required Standard Provisions › Section 31.11.10.06 - Limitations and Exclusions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Crime.
(1) Except as described in §A(3) of this regulation, a group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's commission of or attempt to commit a crime.
(2) A group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss for which a contributing cause was the commission of or the attempt to commit a crime by an individual other than the insured.
(3) A group disability benefit or a group accidental death and dismemberment benefit:
(a) May include an exclusion or limitation for loss to which a contributing cause was the insured's commission of or attempt to commit a felony; and
(b) May not contain an exclusion or limitation which is more restrictive to the insured than the exclusion or limitation set forth in §A(3)(a) of this regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 11 - HEALTH INSURANCE - GROUP › Chapter 31.11.10 - Required Standard Provisions › Section 31.11.10.07 - Optional Provisions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Physical Examination.
(1) A carrier may include a provision in a group health insurance contract or blanket health insurance contract giving the carrier the right to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim under the contract.
(2) If the carrier includes the provision described in §A(1) of this regulation, the provision shall indicate that any physical examination required by the carrier will be performed at the expense of the carrier.
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 31.11.11.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all carriers that offer the Comprehensive Standard Health Benefit Plan to the small employer market.