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<section article="gin" article_name="Insurance" number="15-1A-15" title_number="15" title_name="Health Insurance" subtitle_number="1A" subtitle_name="Consumer Protections">
  <level label="a">
    <text>This section applies to all grandfathered plans and to every health benefit plan that is not a grandfathered plan.</text>
  </level>
  <level label="b">
    <level label="1">
      <text>A carrier shall compile and provide to consumers a summary of benefits and coverage explanation that:</text>
      <level label="i">
        <text>accurately describes the benefits and coverage under the applicable health benefit plan; and</text>
      </level>
      <level label="ii">
        <text>except as provided in paragraph (2) of this subsection, complies with the standards under 45 C.F.R. § 147.200.</text>
      </level>
    </level>
    <level label="2">
      <text>If the Commissioner adopts regulations as described in subsection (c) of this section, a summary of benefits and coverage explanation shall comply with the standards in the adopted regulations.</text>
    </level>
  </level>
  <level label="c">
    <text>To the extent necessary, the Commissioner, in consultation with the Maryland Health Benefit Exchange, shall adopt regulations that:</text>
    <level label="1">
      <text>establish standards for the summary of benefits and coverage; and</text>
    </level>
    <level label="2">
      <text>are consistent with 45 C.F.R. § 147.200 and any corresponding federal rules and guidance in effect December 31, 2024.</text>
    </level>
  </level>
  <level label="d">
    <text>The summary of benefits and coverage shall be presented:</text>
    <level label="1">
      <text>in a uniform format that does not exceed four pages in length and does not include print smaller than 12 point type; and</text>
    </level>
    <level label="2">
      <text>in a culturally and linguistically appropriate manner that uses terminology understandable by the average insured individual.</text>
    </level>
  </level>
  <level label="e">
    <text>The standards developed under subsection (c) of this section shall include:</text>
    <level label="1">
      <text>uniform definitions of standard insurance–related terms and medical terms so consumers may compare health benefit plans and understand the terms of and exceptions to coverage, including:</text>
      <level label="i">
        <text>premium;</text>
      </level>
      <level label="ii">
        <text>deductible;</text>
      </level>
      <level label="iii">
        <text>coinsurance;</text>
      </level>
      <level label="iv">
        <text>copayment;</text>
      </level>
      <level label="v">
        <text>out–of–pocket limit;</text>
      </level>
      <level label="vi">
        <text>preferred provider;</text>
      </level>
      <level label="vii">
        <text>nonpreferred provider;</text>
      </level>
      <level label="viii">
        <text>out–of–network copayments;</text>
      </level>
      <level label="ix">
        <text>usual, customary, and reasonable fees;</text>
      </level>
      <level label="x">
        <text>excluded services;</text>
      </level>
      <level label="xi">
        <text>grievance and appeals;</text>
      </level>
      <level label="xii">
        <text>hospitalization;</text>
      </level>
      <level label="xiii">
        <text>hospital outpatient care;</text>
      </level>
      <level label="xiv">
        <text>emergency room care;</text>
      </level>
      <level label="xv">
        <text>physician services;</text>
      </level>
      <level label="xvi">
        <text>prescription drug coverage;</text>
      </level>
      <level label="xvii">
        <text>durable medical equipment;</text>
      </level>
      <level label="xviii">
        <text>home health care;</text>
      </level>
      <level label="xix">
        <text>skilled nursing care;</text>
      </level>
      <level label="xx">
        <text>rehabilitation services;</text>
      </level>
      <level label="xxi">
        <text>hospice services;</text>
      </level>
      <level label="xxii">
        <text>emergency medical transportation; and</text>
      </level>
      <level label="xxiii">
        <text>any other terms the Commissioner determines are important to define so a consumer may compare the medical benefits offered by health benefit plans and understand the extent of and exceptions to those medical benefits;</text>
      </level>
    </level>
    <level label="2">
      <text>a description of the coverage of a health benefit plan, including cost–sharing for:</text>
      <level label="i">
        <text>each of the categories of the essential health benefits in the State benchmark plan selected in accordance with § 31–116 of this article; and</text>
      </level>
      <level label="ii">
        <text>other benefits, as identified by the Commissioner;</text>
      </level>
    </level>
    <level label="3">
      <text>the exceptions, reductions, and limitations on coverage;</text>
    </level>
    <level label="4">
      <text>the renewability and continuation of coverage provisions;</text>
    </level>
    <level label="5">
      <text>a coverage facts label that includes examples to illustrate common benefits scenarios based on recognized clinical practice guidelines, including pregnancy and serious or chronic medical conditions and related cost–sharing requirements;</text>
    </level>
    <level label="6">
      <text>a statement of whether the health benefit plan ensures that the plan or coverage share of the total allowed costs of benefits provided under the plan or coverage is not less than 60% of the costs;</text>
    </level>
    <level label="7">
      <text>a statement that:</text>
      <level label="i">
        <text>the summary of benefits is an outline of the health benefit plan; and</text>
      </level>
      <level label="ii">
        <text>the language of the health benefit plan should be consulted to determine the governing contractual provisions; and</text>
      </level>
    </level>
    <level label="8">
      <text>a contact number for the consumer to call with additional questions and a website where a copy of the actual health benefit plan can be reviewed and obtained.</text>
    </level>
  </level>
  <level label="f">
    <text>As appropriate, the Commissioner, in consultation with the Maryland Health Benefit Exchange, shall periodically review and update the standards developed under subsection (c) of this section.</text>
  </level>
  <level label="g">
    <level label="1">
      <text>Each carrier shall provide a summary of benefits and coverage explanation that complies with the standards developed under subsection (c) of this section by the Commissioner to:</text>
      <level label="i">
        <text>an applicant at the time of application; and</text>
      </level>
      <level label="ii">
        <text>an insured individual before the time of enrollment or reenrollment, as applicable.</text>
      </level>
    </level>
    <level label="2">
      <text>A carrier may provide a summary of benefits and coverage explanation as required under paragraph (1) of this subsection in paper or electronic form.</text>
    </level>
  </level>
  <level label="h">
    <text>Except as otherwise provided in this article, if a carrier makes any material modification in any of the terms of the plan or coverage involved that is not reflected in the most recently provided summary of benefits and coverage explanation, the carrier shall provide notice of the modification to insured individuals not later than 60 days before the effective date of the modification.</text>
  </level>
  <level label="i">
    <level label="1">
      <text>The Maryland Insurance Administration shall levy a fine of not more than $1,000 against a carrier that willfully fails to provide the information required under this section.</text>
    </level>
    <level label="2">
      <text>A failure with respect to each insured individual shall constitute a separate offense for purposes of this subsection.</text>
    </level>
  </level>
</section>
