Chapter 17. Health Care Consumer Information and Education Act
Regulation .01 Scope.LinkCopy Citation
This chapter applies to all carriers that provide health care services to enrollees or otherwise make health care services available to enrollees through contracts with providers.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Carrier” means:
(a)
An insurer;
(b)
A nonprofit health service plan;
(c)
A health maintenance organization;
(d)
A dental plan organization;
(e)
Any person or entity acting as a third-party administrator; or
(f)
Except for a managed care organization as defined in Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, any other person that provides health benefit plans subject to regulation by the State.
(2)
“Enrollment sales materials” means any materials provided by a carrier to:
(a)
An employer at the time of plan selection; or
(b)
Enrollees at the time of enrollment.
Regulation .03 Information to be Disclosed.LinkCopy Citation
A.
Each carrier that provides health care services to enrollees, or otherwise makes health care services available to enrollees through contracts with providers, shall disclose in its enrollment sales material the:
(1)
Methodology or methodologies that the carrier uses to compensate the physicians for health care services rendered to enrollees; and
(2)
Distribution of each $100 it receives in premium dollars from enrollees for the preceding calendar year.
B.
The information required to be disclosed under §A of this regulation shall be based on Maryland-specific information.
Regulation .04 Disclosure of Compensation Methodologies.LinkCopy Citation
A.
Each carrier shall include the following in its enrollment sales materials:
(1)
The following disclosure statement typeset in bold italic type:
(2)
The table, specified in §C of this regulation, defining methods of paying physicians and giving an example of each method; and
(3)
A statement of:
(a)
The payment method or methods used to compensate physicians during the preceding year, and
(b)
An estimated percentage of physicians under contract with the carrier compensated by each payment method.
B.
Requests Pursuant to Disclosure.
(1)
Each carrier shall provide information in response to requests made pursuant to the disclosure requirement set forth in §A(1) of this regulation with respect to provider compensation by disclosing the method by which a specific physician is compensated.
(2)
A carrier is not required to state the dollar amount of compensation or otherwise provide more specific information about the compensation arrangement it has with a specific physician.
C.
Methods of Paying Physicians.
Regulation .05 Disclosure of Distribution of Premium Dollars.LinkCopy Citation
A.
The disclosure required under this regulation shall:
(1)
Be in the form of a pie chart or bar graph; and
(2)
Identify, in layman's terms, the proportion of every $100 in premium dollars that the carrier uses to pay:
(a)
Providers for the provision of health care services to enrollees, including what proportion is for direct medical care expenses, and
(b)
For plan administration.
B.
The computation used in the pie chart or bar graph shall be in accordance with the National Association of Insurance Commissioners' instructions and formulas used in deriving the 5-year historical data page of the carrier's annual statement.
C.
The pie chart or bar graph to be included in enrollment sales material shall be based on the annual statement of the:
(1)
Immediate prior year for enrollment sales material used on or after July 1 of each year; and
(2)
Year before the immediate prior year for enrollment sales material used before July 1 of each year.
D.
The computation used under §B of this regulation shall be limited to benefits under policies which make health care services available through contracts with providers.
Regulation .06 Manner of Disclosure.LinkCopy Citation
The disclosures required by this chapter may be on a separate form, which shall be provided to employers at the time of plan selection and to enrollees at the time of enrollment.
Regulation .07 Other Permitted Disclosures.LinkCopy Citation
A.
A carrier may disclose on the pie chart or bar graph that the administrative expenses do not include taxes.
B.
A carrier may disclose on the pie chart or bar graph whether the carrier includes dental benefits as part of the underlying benefit plan.
Chapter annotations
Authority: Insurance Article, §§2-109 and 15-121; Health-General Article, §19-706; Annotated Code of Maryland
History: Effective date: July 12, 1998 (25:14 Md. R. 1132)
History: Chapter recodified from COMAR 09.31.26 to COMAR 31.10.17 effective September 7, 1998 (25:18 Md. R. 1439)