reglab/statecodes huggingface dataset:
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.37 - Delivery of Policy or Certificate › Section 31.10.37.02 - 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 insurance" has the meaning stated in Insurance Article, §
										15-305, Annotated Code of Maryland.
(2) "Carrier" means any of the following:
(a) An insurer;
(b) A nonprofit health service plan;
(c) A health maintenance organization; and
(d) A dental plan organization.
(3) "Certificate" or "summary plan description" means the benefit summary that sets forth the essential elements of a group contract and that is required to be provided by a carrier to individuals covered under a group contract.
(4) "Certificate holder" means an individual who is eligible to be covered under a group contract by reason of satisfying the eligibility requirements of the group contract, other than an individual who is covered under a group contract as the spouse, domestic partner, or dependent of the certificate holder.
(5) "Contract holder" means the entity to whom a contract is issued.
(6) "Group contract" means a health insurance contract, a nonprofit health service plan contract, a health maintenance organization contract, or a dental plan organization contract issued by a carrier to a group for the purpose of covering:
(a) Employees or members of the group;
(b) The dependents of employees or members of the group; or
(c) The employees, or members of the group, and the employee's, or member's dependents.
(7) "Health insurance" has the meaning stated in Insurance Article, §
										1-101, Annotated Code of Maryland.
(8) "Individual contract" means a health insurance contract, a nonprofit health service plan contract, a health maintenance organization contract, or a dental plan organization contract issued by a carrier to a contract holder covering:
(a) The contract holder;
(b) The contract holder's dependents; or
(c) The contract holder, and the contract holder's dependents.
(9) "Insurance producer" has the meaning stated in Insurance Article, §
										1-101, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.37 - Delivery of Policy or Certificate › Section 31.10.37.03 - Delivery Requirements for Contracts and Policies

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as described in §B of this regulation, a carrier shall deliver an individual health insurance contract, an individual nonprofit health service plan contract, an individual health maintenance organization contract, or an individual dental plan organization contract to the contract holder within 60 days of the effective date of the contract.
B. If a carrier back dates an individual health insurance contract so that the individual health insurance contract is written at a younger age, the carrier shall deliver the individual health insurance contract to the contract holder within 60 days of the later of the:
(1) Effective date of the individual health insurance contract; or
(2) Date the carrier approves the application for the individual health insurance contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.37 - Delivery of Policy or Certificate › Section 31.10.37.04 - Delivery Requirements for Certificates

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier shall deliver a certificate under a group health insurance contract, a group nonprofit health service plan contract, a group health maintenance organization contract, or a group dental plan organization contract to the:
(1) Certificate holder within 60 days of the effective date of the certificate holder's coverage; or
(2) Group contract holder within 60 days of the effective date of the certificate holder's effective date of coverage, for delivery to each certificate holder.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.37 - Delivery of Policy or Certificate › Section 31.10.37.05 - Compliance

Current through Register Vol. 51, No. 14, July 12, 2024
Failure of a carrier to deliver a contract or certificate as provided in Regulations .03 and .04 of this chapter shall constitute:
A. A violation of Insurance Article, §
									4-113, Annotated Code of Maryland, for a carrier, other than a health maintenance organization; or
B. A violation of Health-General Article, §19-729, Annotated Code of Maryland, for a health maintenance organization.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.38 - Wellness Program Incentives › Section 31.10.38.01 - Purpose

Current through Register Vol. 51, No. 14, July 12, 2024
The purpose of this chapter is to establish a limit on the value of incentives offered by carriers in wellness programs.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.38 - Wellness Program Incentives › Section 31.10.38.02 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies only to the wellness programs as defined in Regulation .03 of this chapter, and Insurance Article, §
									27-210(h)(1), Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.38 - Wellness Program Incentives › Section 31.10.38.03 - 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 31.10.38 - Wellness Program Incentives › Section 31.10.38.04 - Incentive Permitted

Current through Register Vol. 51, No. 14, July 12, 2024
A carrier may offer an incentive for participation in a wellness program if the incentive:
A. Is reasonably related to the wellness program; and
B. Does not have a value that exceeds any limit established by Regulation .05 of this chapter.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.38 - Wellness Program Incentives › Section 31.10.38.05 - Value of Incentive Offered

Current through Register Vol. 51, No. 14, July 12, 2024
An incentive offered for participation in a wellness program by a carrier may not have a value that exceeds $500 per year, per individual who is an insured, a subscriber, or a member.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.39 - Utilization Review of Treatment for Autism and Autism Spectrum Disorders › Section 31.10.39.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter establishes the manner in which carriers and private review agents acting on behalf of carriers may apply utilization review criteria and impose documentation requirements regarding the treatment of children diagnosed with autism or autism spectrum disorders, when covered under a habilitative services benefit under a health benefit plan.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.39 - Utilization Review of Treatment for Autism and Autism Spectrum Disorders › Section 31.10.39.02 - 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) "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.
(2) "Behavioral health treatment" means professional counseling and treatment programs, including applied behavior analysis, that are necessary to develop, maintain, or restore, to the maximum extent practicable, the functioning of an individual.
(3) "Carrier" means an insurer, a nonprofit health service plan, or a health maintenance organization.
(4) "Child" means an individual who is:
(a) Younger than 19 years of age; and
(b) Diagnosed with autism or autism spectrum disorder.
(5) "Commissioner" means the Maryland Insurance Commissioner.
(6) "Habilitative services" has the meaning stated in Insurance Article, §
										15-835, Annotated Code of Maryland.
(7) "Health benefit plan" has the meaning stated in Insurance Article, §
										15-1301, Annotated Code of Maryland.
(8) "Health maintenance organization" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.
(9) "Insurer" has the meaning stated in Insurance Article, §
										1-101, Annotated Code of Maryland.
(10) "Nonprofit health service plan" means a person who has received a certificate of authority from the Commissioner to act as a nonprofit health service plan in the State.
(11) "Private review agent" has the meaning stated in Insurance Article, § 15-10 B-01, Annotated Code of Maryland.
(12) Psychological Care.
(a) "Psychological care" means direct or consultative services provided by a psychologist licensed in the state in which the services are provided or by a social worker licensed in the state in which in which the services are provided.
(b) "Psychological care" includes psychotherapy.
(13) "Therapeutic care" means services provided by a speech-language pathologist, occupational therapist, or physical therapist licensed in the state in which the services are provided.
(14) "Utilization review" has the meaning stated in Insurance Article, § 15-10 B-01, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.39 - Utilization Review of Treatment for Autism and Autism Spectrum Disorders › Section 31.10.39.03 - Utilization Review Criteria for Treatment of Autism and Autism Spectrum Disorders

Current through Register Vol. 51, No. 14, July 12, 2024
A. The utilization review criteria of a carrier or private review agent acting on behalf of a carrier to determine medical necessity or appropriateness may not be more restrictive for habilitative services for the treatment of autism and autism spectrum disorders than the criteria listed in this regulation.
B. The carrier's criteria for habilitative services shall include criteria for behavioral health treatment, psychological care, and therapeutic care.
C. Utilization review criteria of a carrier or private review agent acting on behalf of a carrier may require:
(1) A comprehensive evaluation of a child by the child's primary care provider or specialty physician identifying the need for habilitative services for the treatment of autism or autism spectrum disorder;
(2) A prescription from a child's primary care provider or specialty physician that includes specific treatment goals; and
(3) An annual review by the prescribing primary care provider or specialty physician, in consultation with the habilitative services provider, that includes:
(a) Documentation of benefit to the child;
(b) Identification of new or continuing treatment goals; and
(c) Development of a new or continuing treatment plan.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.39 - Utilization Review of Treatment for Autism and Autism Spectrum Disorders › Section 31.10.39.04 - Coverage for Habilitative Services

Current through Register Vol. 51, No. 14, July 12, 2024
Coverage required under this chapter may be subject to limitations in a health benefit plan relating to coordination of benefits, participating provider requirements, restrictions on services provided by family or household members, case management provisions, and co-payments, co-insurance, and deductible amounts.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.41 - Assignment of Benefits to Nonpreferred Providers › Section 31.10.41.01 - Applicability

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to preferred provider insurance policies that are issued, renewed, or delivered by a carrier in the State on or after July 1, 2011.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.41 - Assignment of Benefits to Nonpreferred Providers › Section 31.10.41.02 - 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) "Allowed amount" has the meaning stated in Insurance Article, §
										14-201, Annotated Code of Maryland.
(2) "Assignment of benefits" has the meaning stated in Insurance Article, §
										14-201, Annotated Code of Maryland.
(3) "Carrier" means an insurer or nonprofit health service plan.
(4) "Covered service" has the meaning stated in Insurance Article, §
										14-201, Annotated Code of Maryland.
(5) "Explanation of benefits" means the document that is provided by a carrier to an insured that explains the claims paid, reduced, or denied by the carrier.
(6) "Hospital-based physician" has the meaning stated in Insurance Article, §
										14-201, Annotated Code of Maryland and does not include an on-call physician.
(7) "Insured" has the meaning stated in Insurance Article, §
										14-201, Annotated Code of Maryland.
(8) "Insurer" has the meaning stated in Insurance Article, §
										1-101, Annotated Code of Maryland.
(9) "Nonpreferred provider" has the meaning stated in Insurance Article, §
										14-201, Annotated Code of Maryland.
(10) "Nonprofit health service plan" means a person who has a certificate of authority to operate as a nonprofit health service plan in Maryland.
(11) "On-call physician" has the meaning stated in Insurance Article, §
										14-201, Annotated Code of Maryland.
(12) "Preferential basis" has the meaning stated in Insurance Article, §
										14-201, Annotated Code of Maryland.
(13) "Preferred provider insurance policy" means a policy or insurance contract issued or delivered in the State by a carrier under which health care services furnished by a preferred provider are paid on a preferential basis.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.41 - Assignment of Benefits to Nonpreferred Providers › Section 31.10.41.03 - Assignment of Benefits - On-Call Physicians

Current through Register Vol. 51, No. 14, July 12, 2024
A. A nonpreferred provider who is an on-call physician may accept an assignment of benefits under a preferred provider insurance policy.
B. A nonpreferred provider who is an on-call physician and accepts an assignment of benefits under a preferred provider insurance policy shall:
(1) Accept the carrier's allowed amount as payment in full for the covered services provided;
(2) Collect or attempt to collect from the insured only the monies for the items identified in Insurance Article, §
										14-205.2(b)(3), Annotated Code of Maryland;
(3) Submit to the carrier the uniform claims form required by COMAR 31.10.11.03B and indicate acceptance of the assignment of benefits in box 27 of the uniform claims form to satisfy the notice requirements under Insurance Article, §
										14-205.2(a)(3), Annotated Code of Maryland; and
(4) Designate CPT code 99026, or its successor, on the uniform claims form.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.41 - Assignment of Benefits to Nonpreferred Providers › Section 31.10.41.04 - Assignment of Benefits - Hospital-Based Physicians

Current through Register Vol. 51, No. 14, July 12, 2024
A. A nonpreferred provider who is a hospital-based physician may accept an assignment of benefits under a preferred provider insurance policy.
B. A nonpreferred provider who is a hospital-based physician and accepts an assignment of benefits under a preferred provider insurance policy shall:
(1) Accept the carrier's allowed amount as payment in full for the covered services provided;
(2) Collect or attempt to collect from the insured only the monies for the items identified in Insurance Article, §
										14-205.2(b)(3), Annotated Code of Maryland; and
(3) Submit to the carrier the uniform claims form required by COMAR 31.10.11.03B and indicate acceptance of the assignment of benefits in box 27 of the uniform claims form to satisfy the notice requirements of Insurance Article, §
										14-205.2(a)(3), Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.41 - Assignment of Benefits to Nonpreferred Providers › Section 31.10.41.05 - Assignment of Benefits - Nonpreferred Providers

Current through Register Vol. 51, No. 14, July 12, 2024
A. This regulation applies to carriers who receive claims for services provided by physicians who are nonpreferred providers but are not on-call physicians or hospital-based physicians.
B. A carrier shall permit a nonpreferred provider described in §A of this regulation to accept an assignment of benefits under a preferred provider insurance policy offered by the carrier.
C. Except as provided in Insurance Article, §
									14-205.3(g), Annotated Code of Maryland, a carrier that receives a claim for services provided by a nonpreferred provider described in §A of this regulation who accepts an assignment of benefits under a preferred provider insurance policy shall pay the nonpreferred provider directly if the nonpreferred provider:
(1) Provides a copy of the disclosure set forth in Regulation .06 of this chapter to an insured before performing a health care service for the insured; and
(2) Submits a copy of the signed disclosure set forth in Regulation .06 of this chapter to the carrier.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.41 - Assignment of Benefits to Nonpreferred Providers › Section 31.10.41.06 - Required Disclosure for Nonpreferred Providers Seeking Assignment of Benefits

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except for a nonpreferred provider who is an on-call physician or a hospital-based physician, a nonpreferred provider who is a physician shall provide a copy of the disclosure set forth in §B of this regulation to each insured before performing a health care service for the insured in order to qualify for an assignment of benefits under a preferred provider insurance policy.
B. The disclosure text required by §A of this regulation shall be printed in at least 12 point type and shall read as follows:
"* Your doctor's charge may be higher than the amount your health insurer will pay and, if so, you may be required to pay the difference; and
"* Your coinsurance, deductible and out-of-pocket maximum may be higher because your doctor is not in your health insurer's network.
"* An estimate of the cost of the services;
"* Any payment terms that apply; and
"* Whether your doctor will charge you interest on any unpaid balance, and the amount of the interest, if any.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.41 - Assignment of Benefits to Nonpreferred Providers › Section 31.10.41.07 - Notice to Insureds by Carriers

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier shall provide the information listed in §B of this regulation with the payment to the insured for health care services if:
(1) The carrier receives a claim for health care services provided by a physician who is a nonpreferred provider and who is not an on-call physician or a hospital-based physician; and
(2) The insured did not provide an assignment of benefits to the physician who provided the health care services.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.42 - Continuity of Health Care Notice › Section 31.10.42.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to each:
A. Receiving carrier that issues or delivers individual or group health benefit plans in Maryland; and
B. Receiving managed care organization that enrolls Program recipients in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.42 - Continuity of Health Care Notice › Section 31.10.42.02 - 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 authorized to sell health insurance;
(b) A nonprofit health service plan;
(c) A health maintenance organization;
(d) A dental plan organization; or
(e) Any other entity providing a plan of health insurance, health benefits, or health services authorized under the Insurance Article of the Annotated Code of Maryland or the Affordable Care Act.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.42 - Continuity of Health Care Notice › Section 31.10.42.03 - Requirement to Provide Continuity of Health Care Notice

Current through Register Vol. 51, No. 14, July 12, 2024
A. A receiving carrier shall send a transitioning enrollee the Continuity of Health Care Notice set forth in Regulation .04A of this chapter:
(1) Except as provided in §A(2) of this regulation, within 30 days of the enrollee's effective date of coverage; and
(2) If the enrollee's coverage is made effective retroactively, within 30 days of the date the receiving carrier is notified of the enrollment
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.42 - Continuity of Health Care Notice › Section 31.10.42.04 - Continuity of Health Care Notice

Current through Register Vol. 51, No. 14, July 12, 2024
A. The following form is to be used by receiving carriers as the Continuity of Health Care Notice required by Regulation .03A of this chapter:
Click
				  here
B. The following form is to be used by receiving managed care organizations as the Continuity of Health Care Notice required by Regulation .03B of this chapter:
Click
				  here
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.43 - Medical Stop-Loss Insurance Disclosure › Section 31.10.43.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to carriers that sell medical stop-loss insurance to small employers in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.43 - Medical Stop-Loss Insurance Disclosure › Section 31.10.43.02 - 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 an insurer or nonprofit health service plan that sells medical stop loss insurance in Maryland.
(2) "Medical stop-loss insurance" has the meaning stated in Insurance Article, §
										15-129, Annotated Code of Maryland.
(3) "Medical stop-loss insurance disclosure form" means the form shown in Regulation .04 of this chapter.
(4) "Small employer" has the meaning stated in Insurance Article, §
										31-101, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.43 - Medical Stop-Loss Insurance Disclosure › Section 31.10.43.03 - Rules for Providing the Medical Stop-Loss Insurance Disclosure Form

Current through Register Vol. 51, No. 14, July 12, 2024
A. Before entering into a policy or contract of medical stop-loss insurance with a small employer, a carrier shall provide the small employer a completed medical stop-loss insurance disclosure form.
B. When determining whether an employer satisfies the definition of a small employer, the carrier shall base the determination on the definition that applies on the proposed effective date of the medical stop-loss insurance policy or contract.
C. The medical stop-loss insurance disclosure form shall be printed in at least 12-point type.
D. The portion of the medical stop-loss insurance disclosure form that requires a listing of any limitations in the medical stop-loss insurance policy or contract is required to include any:
(1) Dollar limitations in the medical stop-loss insurance policy or contract, such as annual limitations;
(2) Day or visit limits on the services covered under the medical stop-loss insurance policy or contract;
(3) Limitations or exclusions that apply to benefits covered under the medical stop-loss insurance policy or contract, such as:
(a) Pre-existing condition exclusions;
(b) Exclusions or limitations for particular services, such as an exclusion or limitation for prescription drugs or mental health services;
(c) Exclusions or limitations for particular medical conditions, such as AIDS;
(d) Limitations or exclusions for non-medically necessary services; and
(e) Limitations or exclusions for experimental or investigational services; and
(4) Different attachment points for any particular service, such as organ transplants.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.43 - Medical Stop-Loss Insurance Disclosure › Section 31.10.43.04 - Medical Stop-Loss Insurance Disclosure Form

Current through Register Vol. 51, No. 14, July 12, 2024
The medical stop-loss insurance disclosure form shall read as follows:
NOTE: The form referenced in this regulation appears on the following two pages.
View
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Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.44 - Network Adequacy › Section 31.10.44.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to carriers that issue or renew health benefit plans in Maryland and use a provider panel for a health benefit plan offered in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.44 - Network Adequacy › Section 31.10.44.04 - Filing and Content of Access Plan

Current through Register Vol. 51, No. 14, July 12, 2024
A. Using the instructions on the Maryland Insurance Administration's website for submission method and to determine rural, suburban, and urban zip code areas, each carrier subject to this chapter shall file an annual access plan with the Commissioner on or before July 1 of each year for each provider panel used by the carrier, with the first access plan filing due on or before July 1, 2018.
B. If a carrier makes a material change to an access plan, the carrier shall:
(1) Notify the Commissioner of the change in writing within 15 business days after the material change to the access plan occurs; and
(2) Include in the notice required under §B(1) of this regulation a reasonable timeframe within which the carrier will file with the Commissioner an update to the existing access plan for review by the Commissioner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.44 - Network Adequacy › Section 31.10.44.07 - Provider-to-Enrollee Ratio Standards

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except for a Group Model HMO's health benefit plan, the provider panel for each carrier shall meet the provider-to-enrollee ratio standards listed in §B of this regulation.
B. The provider-to-enrollee ratios shall be equivalent to at least 1 full-time physician, or as appropriate, another full-time provider for:
(1) 1,200 enrollees for primary care;
(2) 2,000 enrollees for pediatric care;
(3) 2,000 enrollees for obstetrical/gynecological care;
(4) 2,000 enrollees for mental health care or services; and
(5) 2,000 enrollees for substance use disorder care or services.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.44 - Network Adequacy › Section 31.10.44.08 - Telehealth

Current through Register Vol. 51, No. 14, July 12, 2024
A. Telehealth Utilization Data Reporting.
(1) For annual access plans submitted on or after July 1, 2024, a carrier shall report the following data on telehealth utilization for the calendar year prior to submission of the annual access plan:
(a) The total number of in-network telehealth claims for each provider type and facility type listed in Regulation .05 of this chapter in each of the urban, rural, and suburban areas and in each Maryland county and Baltimore City; and
(b) The percentage of total in-network claims for each provider type and facility type listed in Regulation .05 of this chapter in each of the urban, rural, and suburban areas and in each Maryland county and Baltimore City that are in-network telehealth claims.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.44 - Network Adequacy › Section 31.10.44.09 - Network Adequacy Waiver Standards

Current through Register Vol. 51, No. 14, July 12, 2024
A. If a carrier's provider panel fails to meet one or more of the standards specified in Regulations .05-.07 of this chapter, the carrier shall provide the following information to the Commissioner as part of the annual access plan:
(1) A description of any network adequacy waiver previously granted by the Commissioner;
(2) An explanation of how many providers in each specialty or health care facility type that the carrier reasonably estimates it would need to contract with or otherwise include in its network to satisfy each unmet standard;
(3) A description of the methodology used to calculate the estimated number of providers in §A(2) of this regulation;
(4) A list of physicians, other providers, or health care facilities related to each unmet standard and within the relevant service area that the carrier attempted to contract with, identified by name and specialty, if any, or health care facility type;
(5) A description of how and when the carrier last contacted the physicians, other providers, or health care facilities;
(6) A description of any reason each physician, other provider, or health care facility gave for refusing to contract with the carrier;
(7) An analysis of any trends in the reasons given by physicians, providers, or health care facilities for refusing to contract with the carrier, and a description of the carrier's proposals or attempts to address those reasons and improve future contracting efforts;
(8) Identification of all incentives the carrier offers to providers to join the network;
(9) If applicable, a substantiated statement that there are insufficient numbers of physicians, other providers, or health care facilities available within the relevant service area for a covered service or services for which the carrier failed to meet a standard;
(10) A description of other efforts and initiatives undertaken by the carrier in the past year to enhance its network and address the deficiencies that contributed to each unmet standard;
(11) A description of steps the carrier will take to attempt to improve its network to avoid a future failure to meet a standard;
(12) An explanation of any other mitigating factors that the carrier requests the Commissioner to consider; and
(13) An attestation to the accuracy of the information provided in relation to each unmet standard.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.44 - Network Adequacy › Section 31.10.44.10 - Confidential Information in Access Plans

Current through Register Vol. 51, No. 14, July 12, 2024
A. Subject to Insurance Article, §
									15-802, Annotated Code of Maryland, the following information that is included in a carrier's access plan shall be considered confidential by the Commissioner:
(1) Proprietary methodology used to annually assess the carrier's performance in meeting the standards established under this chapter;
(2) Proprietary methodology used to annually measure timely access to health care services; and
(3) Factors used by the carrier to build its network.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.44 - Network Adequacy › Section 31.10.44.11 - Network Adequacy Access Plan Executive Summary Form

Current through Register Vol. 51, No. 14, July 12, 2024
A. For each provider panel used by a carrier for a health benefit plan, the carrier shall provide the following network sufficiency results for the health benefit plan service area in the standardized format described on the Maryland Insurance Administration's website:
(1) Travel Distance Standards.
(a) For each provider type and facility type listed in Regulation .05 of this chapter, list the percentage of enrollees for which the carrier met the travel distance standards, in the following format, with provider types listed first in alphabetical order, followed by facility types in alphabetical order:
Urban Area
Suburban Area
Rural Area
Provider Type
Facility Type
(b) All provider and facility types described in §§A(4) and B(4) of Regulation .05 of this chapter and included on the carrier's provider panel shall be listed individually in the chart described in §A(1)(a) of this regulation with the corresponding data for that specific type of provider or facility.
(c) If the telehealth mileage credit described Regulation .08B of this chapter was applied when calculating the percentage of enrollees for which the carrier met the travel distance standards, the carrier shall:
(i) Note the particular provider types and geographic areas to which the credit was applied by including an asterisk in the chart; and
(ii) Include a corresponding footnote stating "As permitted by Maryland regulations, a telehealth mileage credit was applied to up to 10 percent of enrollees for each provider type noted with an asterisk in each of the urban, rural, or suburban geographic areas. The mileage credit is 5 miles for urban areas, 10 miles for suburban areas, and 15 miles for rural areas."
(d) List the total number of certified registered nurse practitioners counted as a primary care provider.
(e) List the total percentage of primary care providers who are certified registered nurse practitioners.
(f) List the total number of essential community providers in the carrier's network in each of the urban, rural, and suburban areas providing:
(i) Medical services;
(ii) Mental health services; and
(iii) Substance use disorder services.
(g) List the total percentage of essential community providers available in the health benefit plan's service area that are participating providers for each of the nine categories described in §A(1)(f) of this regulation.
(h) List the total number and percentage of local health departments in the carrier's network providing:
(i) Medical services;
(ii) Mental health services; and
(iii) Substance use disorder services.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.45 - Dental Network Adequacy › Section 31.10.45.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to carriers that issue or renew dental plans in Maryland and use a provider panel for a dental plan offered in Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.45 - Dental Network Adequacy › Section 31.10.45.02 - 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 authorized to sell dental insurance;
(b) A nonprofit health service plan that provides coverage for dental services; or
(c) A dental plan organization as defined in Insurance Article, §
											14-401, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.45 - Dental Network Adequacy › Section 31.10.45.03 - Travel Distance Standards

Current through Register Vol. 51, No. 14, July 12, 2024
A. Sufficiency Standards.
(1) Using the zip code list on the Maryland Insurance Administration's website, each provider panel of a carrier shall have within the geographic area served by the carrier's network or networks, sufficient dentists, including specialty providers, and facilities to meet the maximum travel distance standards listed in the chart under §A(2) of this regulation for each type of geographic area measured from the enrollee's place of residence.
(2) Chart of Travel Distance Standards.
Urban Area Maximum Distance (miles)
Suburban Area Maximum Distance (miles)
Rural Area Maximum Distance (miles)
Provider type:
General dentist
15
30
60
Endodontic
30
45
75
Orthodontics and dentofacial orthopedics
30
45
75
Oral and maxillofacial pathology
30
45
75
Oral and maxillofacial radiology
30
45
75
Oral and maxillofacial surgery
30
45
75
Pediatric dentistry
30
45
75
Periodontic
30
45
75
Prosthodontics
30
45
75
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.45 - Dental Network Adequacy › Section 31.10.45.04 - Appointment Waking Time Standards

Current through Register Vol. 51, No. 14, July 12, 2024
A. Sufficiency Standards.
(1) Subject to §B of this regulation, each carrier's provider panel shall meet the waiting time standards listed in §C of this regulation for at least 95 percent of the enrollees covered under dental plans that use that provider panel.
(2) When it is clinically appropriate and an enrollee elects to utilize a telehealth appointment, a carrier may consider that utilization as a part of its meeting the standards listed in §C of this regulation.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.45 - Dental Network Adequacy › Section 31.10.45.05 - Waiver Request Standards

Current through Register Vol. 51, No. 14, July 12, 2024
A. A carrier may apply for a dental network adequacy waiver, for up to 1 year, of a dental network adequacy requirement listed in this chapter.
B. The Commissioner may find good cause to grant the dental network adequacy waiver request only if the carrier demonstrates that the providers necessary for an adequate network:
(1) Are not available to contract with the carrier;
(2) Are not available in sufficient numbers;
(3) Have refused to contract with the carrier; or
(4) Are unable to reach agreement with the carrier.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.45 - Dental Network Adequacy › Section 31.10.45.06 - Dental Network Adequacy Executive Summary Form

Current through Register Vol. 51, No. 14, July 12, 2024
A. For each provider panel used by a carrier for a dental plan, the carrier shall provide the network sufficiency results for the dental plan service area as follows:
(1) Travel Distance Standards.
(a) For each provider type listed in Regulation . 03 of this chapter, list the percentage of enrollees for which the carrier met the travel distance standards, in the following format:
Urban Area
Suburban Area
Rural Area
General dentist
Specialty provider
(b) List the total number of essential community providers in the carrier's network.
(c) List the total percentage of essential community providers available in the dental benefit plan 's service area that are participating providers.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.46 - Pharmacy Benefits Managers-Maximum Allowable Cost › Section 31.10.46.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all maximum allowable cost pricing claims made to a pharmacy benefits manager for a multisource generic prescription drug, medical product, or device, provided to a beneficiary of a purchaser.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.46 - Pharmacy Benefits Managers-Maximum Allowable Cost › Section 31.10.46.03 - Disclosures to a Contracted Pharmacy

Current through Register Vol. 51, No. 14, July 12, 2024
A. A PBM, whether its contract is directly with a pharmacy or indirectly with a pharmacy through a PSAO or group purchasing organization, shall disclose to a contracted pharmacy at the time of entering into a contract with a pharmacy and at least 30 working days before any contract change for a contracted pharmacy:
(1) The applicable terms, conditions, and reimbursement rates, including:
(a) The sources; and
(b) The terms of the compensation program;
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.46 - Pharmacy Benefits Managers-Maximum Allowable Cost › Section 31.10.46.04 - Internal Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each PBM subject to this chapter shall establish written procedures to investigate and resolve disputes filed by a contracted pharmacy.
B. The internal appeal procedures established by the PBM shall:
(1) Be in writing; and
(2) Contain administrative processes and safeguards designed to ensure and verify that the MAC pricing was determined in accordance with the participating pharmacy contract and Maryland law, and that the contract provisions have not been applied in an arbitrary or capricious manner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.46 - Pharmacy Benefits Managers-Maximum Allowable Cost › Section 31.10.46.05 - MAC Complaint Process

Current through Register Vol. 51, No. 14, July 12, 2024
A. Prior to filing a MAC complaint with the Commissioner, a contracted pharmacy or its designee shall exhaust the internal appeal process established in the participating pharmacy contract and used by the PBM to appeal, investigate, and resolve a dispute regarding the MAC claim amount.
B. A contracted pharmacy or its designee may file a MAC complaint with the Commissioner to dispute a PBM's appeal decision for the following reasons:
(1) The PBM's MAC pricing did not meet the requirements of Insurance Article, Title 15, Subtitle 16, Annotated Code of Maryland, related to MAC pricing; or
(2) The PBM's MAC pricing did not meet the applicable terms of the applicable participating pharmacy contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.47 - Cost Pricing and Reimbursement Other than MAC › Section 31.10.47.01 - Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to all cost pricing and reimbursement disputes or a request to review the failure to pay the contractual reimbursement amount of a submitted claim made to a pharmacy benefits manager by a pharmacist or pharmacy for a prescription drug, medical product, or device, provided to a beneficiary of a purchaser.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.47 - Cost Pricing and Reimbursement Other than MAC › Section 31.10.47.03 - Disclosures to a Contracted Pharmacy

Current through Register Vol. 51, No. 14, July 12, 2024
A. A PBM, whether its contract is directly with a pharmacy or indirectly with a pharmacy through a PSAO or group purchasing organization, shall disclose to a contracted pharmacy at the time of entering into a contract with a pharmacy and at least 30 working days before any contract change for a contracted pharmacy:
(1) The applicable terms, conditions, and reimbursement rates, including:
(a) The sources; and
(b) The terms of the compensation program;
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.47 - Cost Pricing and Reimbursement Other than MAC › Section 31.10.47.04 - Internal Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each PBM subject to this chapter shall establish written procedures to investigate and resolve disputes filed by a contracted pharmacy.
B. The internal appeal procedures established by the PBM shall:
(1) Be in writing; and
(2) Contain administrative processes and safeguards designed to ensure and verify that the pricing was determined in accordance with the participating pharmacy contract and Maryland law, and that the contract provisions have not been applied in an arbitrary or capricious manner.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.47 - Cost Pricing and Reimbursement Other than MAC › Section 31.10.47.05 - Complaint Process

Current through Register Vol. 51, No. 14, July 12, 2024
A. Prior to filing a complaint with the Commissioner, a contracted pharmacy or its designee shall exhaust the internal appeal process established in the participating pharmacy contract.
B. A contracted pharmacy or its designee may file a complaint with the Commissioner to dispute a PBM's appeal decision for the following reasons:
(1) The PBM's cost pricing did not comply with Insurance Article, Title 15, Subtitle 16, Annotated Code of Maryland; or
(2) The PBM's cost pricing or reimbursement amount determination did not meet the terms of the applicable participating pharmacy contract.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.48 - Pharmacy Benefits Managers-Informational Filing of Contracts and Amendments › Section 31.10.48.01 - Applicability and Scope

Current through Register Vol. 51, No. 14, July 12, 2024
This chapter applies to the submission of any participating pharmacy contract or amendment required to be filed under Insurance Article, Title 15, Subtitle 16, Annotated Code of Maryland.
Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.48 - Pharmacy Benefits Managers-Informational Filing of Contracts and Amendments › Section 31.10.48.02 - 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) 'Administration" means the Maryland Insurance Administration.
(2) "Commissioner" means the Maryland Insurance Commissioner.
(3) "Noncompliant" means a contract or amendment that is not in compliance with Maryland statutes and regulations.
(4) "Participating pharmacy contract" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
(5) "Working day" means any day that the Maryland Insurance Administration is open for business.