Regulation .03 Material Modification.
Regulation .03 Material Modification.LinkCopy Citation
For purposes of Insurance Article, §14-115(d)(11)(i), Annotated Code of Maryland, a modification is material if it modifies:
A.
The options available in a health benefit plan marketed in the State in a manner that results in a change of 20 percent or more in the actuarial benefit value of the health benefit plan;
B.
A provider network in a manner that results in a change of:
(1)
10 percent or more in the number of health care providers in the provider network:
(a)
For the entire State: or
(b)
In the Baltimore metro region or DC metro region;
(2)
7 percent or more in the number of health care providers in the provider network in the Southern Maryland region;
(3)
5 percent or more in the number of health care providers in the provider network in the Eastern Shore region or Western Maryland region;
(4)
10 percent or more in the number of health care providers in a key specialty in the provider network:
(a)
For the entire State; or
(b)
In the Baltimore metro region, DC metro region, Eastern Shore region, Southern Maryland region, or Western Maryland region;
(5)
10 percent or more in the amount of reimbursement paid to health care providers in the provider network:
(a)
For the entire State; or
(b)
In the Baltimore metro region or DC metro region;
(6)
7 percent or more in the amount of reimbursement paid to health care providers in the provider network in the Southern Maryland region; or
(7)
5 percent or more in the amount of reimbursement paid to health care providers in the provider network in the Eastern Shore region or the Western Maryland region;
C.
Underwriting guidelines for a product of a nonprofit health insurance plan in a manner that results in:
(1)
A refusal to provide the least expensive rate for the product of a nonprofit health service plan to 20 percent or more of applicants for the product; or
(2)
A relative increase of 50 percent or more in the current level of refusals to provide the least expensive rate for the product of a nonprofit health service plan to applicants; or
D.
Rates or rating plans that are required to be approved by the Commissioner in a manner that results in:
(1)
A rate increase of 15 percent or more in 1 year for any product sold by a nonprofit health service plan in a particular market; or
(2)
A rate increase of 25 percent or more in 1 year for coverage variations within a product sold by a nonprofit health service plan in a particular market.