Chapter 10. Summary Explanation of Benefits
Regulation .01 Applicability and Scope.LinkCopy Citation
This chapter applies to all health insurers, including nonprofit health service plans, authorized to do business in Maryland, which provide benefits for inpatient hospitalization or outpatient surgical care on an expense-incurred basis in group or individual contracts, both for insured business and business for which the insurer is an administrator.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Claimant” means an insured individual resident in Maryland making a claim against the insurer for benefits, who is a:
(a)
Policyholder covered by an individual policy; or
(b)
Certificate holder covered under a group policy or under an administration contract.
(2)
“Service” means any service for which a charge is made which is covered under the policy or contract, including charges for, but not limited to:
(a)
Fees of surgeons, anesthetists, and other physicians;
(b)
Room and board charges;
(c)
Operating room charges;
(d)
Recovery room charges; and
(e)
Nursing care charges.
Regulation .03 Summary Form.LinkCopy Citation
A.
An insurer which provides benefits for inpatient hospitalization or outpatient surgical care on an expense-incurred basis shall provide claimants annually a consolidated summary explanation regarding benefits claimed for those services during each calendar year.
B.
The summary shall identify the provider by name and shall state the:
(1)
Date of the service;
(2)
Amount claimed;
(3)
Amount which was paid or is payable by the insurer on claims processed during the year; and
(4)
Balance to be paid by the covered individual, if the balance is determinable from the claim forms submitted.
C.
The summary referred to in §B of this regulation shall be provided by insurers to claimants between January 1 and February 15 for claims made during the preceding calendar year.
D.
At the insurer's option, the summary may include information pertaining to benefits other than those specified in §A of this regulation.
Regulation .04 Group Coverage.LinkCopy Citation
Instead of the procedure outlined in Regulation .03 of this chapter, an insurer may make the annual summary to claimants who are covered under group policies, or who are covered under employer-employee groups administered by the insurer, within 36 days after the annual anniversary of the group policy, or of the administration contract, for the 12-month period ending with that anniversary.
Regulation .05 Group Coverage — Election of Alternate Procedure.LinkCopy Citation
A.
An insurer desiring to use the alternate procedure specified in Regulation .04 of this chapter may elect the procedure for:
(1)
All groups; or
(2)
Groups in excess of a certain size.
B.
An insurer shall notify the Insurance Commissioner of its election under this regulation and Regulation .04 of this chapter within 90 days of the effective date of this chapter.
C.
An insurer that follows the procedures set forth in Regulation .03 of this chapter, or that elects to comply with the procedures set forth in this regulation and Regulation .04 of this chapter, may change its procedures only after approval by the Commissioner.
Chapter annotations
Authority: Insurance Article, §§2-109 and 15-1007, Annotated Code of Maryland
History: Effective date: December 1, 1993 (20:20 Md. R. 1570)
History: Chapter recodified from COMAR 09.30.95 to COMAR 31.10.10 effective September 7, 1998 (25:18 Md. R. 1439)