# COMAR Title 31 — Maryland Insurance Administration

## Subtitle 11 — Health Insurance — Group

### Chapter 01 — Conversion of Group Health Insurance

**Authority:** Insurance Article, §2-109, Annotated Code of Maryland

**Administrative History:** Effective date: November 1, 1983 (10:14 Md. R. 1261)

**Administrative History:** Regulation .02C adopted effective May 6, 1996 (23:9 Md. R. 670)

**Administrative History:** Regulation .07C amended effective May 6, 1996 (23:9 Md. R. 670)

**Administrative History:** Regulation .11 amended effective May 6, 1996 (23:9 Md. R. 670)

**Administrative History:** Chapter recodified from COMAR 09.30.61 to COMAR 31.11.01 effective September 7, 1998 (25:18 Md. R. 1439)

**Administrative History:** Chapter revised effective April 7, 2008 (35:7 Md. R. 752)

**Administrative History:** Regulation .03A amended effective June 22, 2015 (42:12 Md. R. 764)

#### Regulation .01 Purpose.

*COMAR 31.11.01.01*

The purpose of this chapter is to provide appropriate standards and requirements for implementing the conversion privilege and notification requirements under group health insurance policies.

#### Regulation .02 Definitions.

*COMAR 31.11.01.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Carrier” means:

    (a) An insurer as defined in Insurance Article, §1-101, Annotated Code of Maryland; or

    (b) A nonprofit health service plan that is licensed to operate in Maryland.

  (2) “Converted policy” means an individual policy or certificate issued to an individual in accordance with the requirements of this chapter upon termination of the individual's coverage under a group policy.

  (3) Expense Incurred.

    (a) “Expense incurred” means that the benefits payable under the contract are based on the medical expenses that the covered person incurs.

    (b) For the purposes of this chapter, a contract that includes both expense-incurred benefits and indemnity benefits shall be considered to be written on an “expense-incurred” basis.

  (4) “Group health insurance policy” or “group policy” means either:

    (a) An insurance contract issued by an insurer under Insurance Article, §15-302, Annotated Code of Maryland, that insures employees or members, with or without their dependents, for hospital, surgical, medical, or major medical insurance on an expense-incurred basis; or

    (b) A contract issued by a nonprofit health service plan to a group that insures employees or members, with or without their dependents, for hospital, medical, major medical, or surgical insurance on an expense-incurred basis.

  (5) “Indemnity” means that the benefits payable under the contract are set amounts that are not related to the expenses the covered person incurs, such as a hospital indemnity policy that pays a flat fee for each day the covered person is confined in a hospital, regardless of the actual expenses the covered person incurs during the hospital confinement.

  (6) “Insured person” means:

    (a) An employee, a member, or another certificate holder covered under the group policy; or

    (b) Any eligible dependent of the employee, member, or certificate holder covered under the group policy.

  (7) “Medicare” means Title XVIII of the United States Social Security Act as added by the Social Security Amendments of 1965 or as later amended or superseded.

#### Regulation .03 Applicability.

*COMAR 31.11.01.03*

A. This chapter is applicable to group health insurance policies issued or renewed in Maryland on or after October 1, 1983 and prior to January 1, 2014, except as provided in §§B—C of this regulation.

B. This chapter is not applicable to:

  (1) Group policies providing coverage only for:

    (a) Specified diseases;

    (b) Accidental injuries;

    (c) Accidental death;

    (d) Dental benefits;

    (e) Vision care or any other supplemental benefit; or

    (f) Any combination of the benefits described in §B(1)(a)—(e) of this regulation; or

  (2) The following types of group policies:

    (a) Hospital indemnity or other fixed indemnity coverage;

    (b) Credit insurance;

    (c) Disability income insurance;

    (d) Long term care insurance as defined in Insurance Article, §18-101, Annotated Code of Maryland;

    (e) Medicare supplement contracts;

    (f) Any coverage issued under Chapter 55 of Title 10, U.S. Code, and any coverage issued as supplemental to coverage issued under Chapter 55 of Title 10, U.S. Code;

    (g) Any coverage issued as supplemental to liability insurance, Workers' Compensation, or similar insurance;

    (h) Automobile medical-payment insurance, or any insurance under which benefits are payable with or without regard to fault, whether written on a group, blanket or individual basis; or

    (i) Any combination of the insurance benefits described in §B(2)(a)—(h) of this regulation.

C. The requirements of Regulations .09 and .10 of this chapter apply to all converted policies issued or renewed on or after April 7, 2008.

#### Regulation .04 Conversion Privilege.

*COMAR 31.11.01.04*

A. All group policies, as defined in this chapter, shall contain a provision stating that an insured person who has been continuously covered under the group policy and under any group policy providing similar benefits which it replaces for at least 3 months and whose coverage is terminated for any reason other than the reasons described in §D of this regulation, shall have issued to him without evidence of insurability a converted policy providing benefits not less than the minimum benefits required by this chapter.

B. A carrier shall include a notice of the right of conversion in each certificate of coverage provided to individuals covered under group policies.

C. Termination.

  (1) Termination of coverage shall include, but not be limited to, termination by reason of discontinuance of the group policy in its entirety or with respect to an insured class, or termination by reason of the individual's no longer meeting the definition of a dependent contained in the group policy, or by reason of no longer meeting the definition in the policy of an employee or member, or by reason of the individual's retirement.

  (2) The following are intended as illustrations of terminations by reason of no longer meeting the definition of dependent:

    (a) A surviving spouse, whose coverage under the group policy terminates at the death of the employee or member;

    (b) A spouse whose coverage under the group policy terminates by reason of divorce or legal separation;

    (c) A child whose coverage under the group policy terminates at the death of an employee or member;

    (d) A child whose coverage under the group policy terminates by reason of his reaching a limiting age specified in the group policy.

  (3) If a group policy provides that a retired employee may continue to be covered under the group policy, the employee shall be given the option of electing the same conversion rights that would apply if the employee's  insurance under the group policy had terminated at retirement.

D. Exceptions.

  (1) The carrier is not required to issue a converted policy if the insured person is enrolled in a health maintenance organization, or is covered or eligible for coverage under another group policy which provides benefits substantially equal to the minimum benefits required by these regulations, or if the provisions of Regulation .06H(1) of this chapter would be applicable.

  (2) The carrier is not required to issue a converted policy to a person eligible for Medicare.

  (3) The carrier is not required to issue a converted policy if termination under the group policy occurred because:

    (a) The employee, member, or dependent performed an act or practice that constitutes fraud in connection with the coverage;

    (b) The employee, member, or dependent made an intentional misrepresentation of a material fact under the terms of coverage; or

    (c) The terminated coverage under the group policy was replaced by similar coverage within 31 days after the date of termination of the group policy.

  (4) The carrier is not required to issue a converted policy if the individual's coverage under the group policy terminated due to the insured person's failure to pay a required premium.

#### Regulation .05 Insurer's Option.

*COMAR 31.11.01.05*

A. Instead of issuing an individual converted policy, the carrier may elect to provide the coverage required by this chapter by means of a group policy issued to a trustee and covering persons eligible for the conversion rights of these regulations.

B. The policy issued under §A of this regulation may provide that the entire premium be payable by the insured persons.

C. The group policy issued under §A of this regulation shall provide benefits not less than those stated in Regulations .06 and .10 of this chapter.

#### Regulation .06 Standards for Converted Policies.

*COMAR 31.11.01.06*

A. The converted policy shall become effective on the day following the date of termination of insurance coverage under the group policy.

B. The converted policy shall cover the employee or member or dependents of the employee or member, or both, who are covered by the group policy on the date of termination of insurance. At the option of the insurer, a separate converted policy may be issued to cover any dependent.

C. If a converted policy issued to an employee or member also covers a dependent child whose coverage under the group policy would have terminated at a specified date, the converted policy may provide for termination on or after that date, subject, however, to the requirements of Insurance Article, §15-402, Annotated Code of Maryland, whichever is applicable.

D. With respect to a person who was covered by the group policy, the period specified in the Time Limit on Certain Defenses provision of the converted policy shall begin with the date that person's insurance became effective under the group policy.

E. Preexisting Conditions.

  (1) The converted policy may not contain exclusions for preexisting conditions, except to the extent that a condition was excluded from the group policy from which conversion was made.

  (2) Benefits for pregnancy and childbirth may not be excluded from the converted policy if benefits for these conditions were provided under the group policy.

  (3) The converted policy may provide that:

    (a) Any hospital, surgical, or medical benefits payable under the converted policy may be reduced by the amount of any hospital, surgical, or medical benefits payable under the group policy after the termination of the individual's group coverage; and

    (b) During the first policy year, the benefits payable under the converted policy, together with the benefits payable under the group policy, will not exceed the benefits that would have been payable had the individual's coverage under the group policy remained in force and effect.

F. Any and all probationary and waiting periods set forth in the converted policy shall be considered as being met to the extent coverage was in force under the group policy.

G. A converted policy may include a provision under which the carrier may request the following information in advance of any premium due date of the policy of any person covered under the policy whether:

  (1) The person is covered for similar benefits by another hospital, surgical, medical or major medical expense insurance policy, or hospital or medical service subscriber contract, or medical practice, health maintenance organization, or other prepayment plan, or by any other plan or program;

  (2) The person is covered for similar benefits under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis, or whether the person is in the military service; or

  (3) Similar benefits are provided for or available to this person, pursuant to or in accordance with the requirements of any state or federal law.

H. The converted policy may provide that the carrier may refuse to renew the policy or the coverage of any person insured under the policy if:

  (1) Benefits provided or available to the person under the sources referred to in §G of this regulation together with the benefits provided by the converted policy would result in overinsurance according to the insurer's standards on file with the Commissioner;

  (2) The information requested in accordance with §G of this regulation is not provided in timely fashion;

  (3) The information provided in response to the requirement of §G of this regulation is fraudulent or contains material misstatements;

  (4) The individual failed to pay premiums or contributions in accordance with the terms of the converted policy, including timeliness requirements;

  (5) The individual performed an act or practice that constitutes fraud in connection with coverage; or

  (6) The individual made an intentional misrepresentation of a material fact under the terms of coverage.

I. Converted policies shall comply with the requirements of and contain the benefit provisions mandated under Insurance Article, Titles 14 and 15, Annotated Code of Maryland, to the extent applicable.

#### Regulation .07 Evidence of Insurability.

*COMAR 31.11.01.07*

A. The converted policy shall be issued without evidence of insurability.

B. If the insured person was individually rated less favorably than standard under the group policy, or if all persons in the group policy were rated less favorably than standard, the converted policy may be issued with a corresponding rating.

C. If, by reason of a specific waiver or endorsement in the group policy, the insured person was specifically excluded from coverage for a specific named condition or conditions, a corresponding waiver or endorsement may be attached to the converted policy.

#### Regulation .08 Application for Converted Policy.

*COMAR 31.11.01.08*

A. The conversion provision in the group policy may require that the insured person, or a person acting on behalf of the insured person, make written application for the converted policy and may not require that the first premium due to the carrier be paid sooner than 31 days following the termination of the insured person's coverage under the group policy, or sooner than any extended time provided in these regulations.

B. The application for the converted policy may not contain questions relating to the health, occupation, avocation, or lifestyle of the insured person, or other questions relating to insurability, except information required to determine eligibility for the converted policy.

C. The carrier may refuse to issue a converted policy or may issue a converted policy for a reduced amount if the application shows the insured person is covered under a group policy providing benefits substantially similar to the maximum benefits which the insured person could elect under the converted policy, or if the insured person has other health benefits available at least equal to the level of benefits which would permit the carrier to refuse to renew a converted policy in accordance with the standards of Regulation .06G and H of this chapter.

#### Regulation .09 Premiums for Converted Policies.

*COMAR 31.11.01.09*

A. Except as provided in §C of this regulation, the initial premium for the converted policy for the first 12 months and subsequent renewal premium shall be determined in accordance with the carrier's premium rates applicable to:

  (1) Individually underwritten standard risks;

  (2) The age and class of risk of each individual to be covered under the converted policy; and

  (3) The type and amount of coverage provided.

B. The experience under converted policies may not be an acceptable basis for establishing rates for converted policies.

C. A carrier may amend renewal premium rates for the subsequent year if:

  (1) The carrier experiences incurred losses for a period of 2 years, on converted policies that have been in force for at least 1 year, which exceed earned premiums by more than 20 percent; and

  (2) The amended premium rates are anticipated to produce a loss ratio of at least 120 percent.

D. Conditions pertaining to health status may not be an acceptable basis for classification for the purposes of this regulation.

E. The frequency of premium payment shall be the frequency customarily required by the carrier for the policy form and plan selected, provided that the carrier may not require premium payments less frequently than quarterly without the consent of the policyholder.

#### Regulation .10 Minimum Benefits under Converted Policies.

*COMAR 31.11.01.10*

A. Except as provided in §B of this regulation, if the group policy from which conversion is made provided coverage for basic hospital, medical, or surgical expense insurance, the insured person at the insured person's option shall be entitled to obtain a converted policy under any one of Plans A, B, or C, which are described in §C of this regulation.

B. If the group policy provided hospital benefits based on the full cost of a semiprivate room, the carrier, at its option, may offer the insured person only Plan A, and if the group policy provided hospital benefits on a basis other than the full cost of a semiprivate room, the carrier, at its option, may offer the insured person only Plans B and C.

C. Plans A—C provide the following minimum benefits:

  (1) A Plan A policy shall provide as minimum the following benefits or similar benefits which are substantially actuarially equivalent:

    (a) All semiprivate room and board and miscellaneous hospital charges for a 70-day maximum duration, and

    (b) Surgical-medical expense benefits according to a schedule consistent with those customarily offered by the carrier under group insurance policies and providing a maximum benefit of $7,000;

  (2) A Plan B policy shall provide as minimum the following benefits or similar benefits which are substantially actuarially equivalent:

    (a) Hospital room and board benefits in a maximum amount of $700 daily for a 70-day maximum duration;

    (b) Miscellaneous hospital expense benefits in a maximum amount of $7,000; and

    (c) Surgical-medical expense benefits according to a schedule consistent with those customarily offered by the carrier under group policies and providing a maximum benefit of $7,000;

  (3) A Plan C policy shall provide as minimum the following benefits or similar benefits which are substantially actuarially equivalent:

    (a) Hospital room and board benefits in a maximum amount of $350 daily for a 70-day maximum duration;

    (b) Miscellaneous hospital expense benefits in a maximum amount of $3,500; and

    (c) Surgical-medical expense benefits according to a schedule consistent with those customarily offered by the carrier under group policies and providing a maximum benefit of $3,500.

D. If the group policy from which conversion is made provided coverage for major medical or catastrophe expense benefits, the insured person shall be entitled to obtain a converted policy meeting the following minimum specifications subject to the deductible and the limitation of §§E and F of this regulation, or similar benefits which are substantially actuarially equivalent:

  (1) Hospital room and board benefits in an amount not less than 75 percent of the charges for semiprivate room accommodations;

  (2) Miscellaneous hospital expense benefits for the charges made by the hospital for services and supplies which are customarily furnished by the hospital and provided for use during a period of hospital confinement, in an amount not less than 75 percent of the charges incurred subject to a maximum of $7,000;

  (3) Surgical expense benefits not less than 75 percent of the scheduled benefits customarily offered by the carrier under its group policy with a maximum of $7,000;

  (4) Anesthesia services, consisting of administration of necessary general anesthesia and related procedures in connection with covered surgical services rendered by a physician other than the physician, or the physician's assistant, performing the surgical services, in an amount not less than 75 percent of the reasonable charges;

  (5) Medical expense benefits for the diagnosis and treatment of sickness or injury, in an amount not less than 75 percent of the reasonable charges; and

  (6) Seventy-five percent of reasonable charges for diagnostic X-ray, laboratory services, radiation therapy, prosthetic appliances, and rental of durable medical equipment required for therapeutic use.

E. Major medical or catastrophe coverage benefits may be subject to a deductible equal to the benefits provided under any basic hospital-medical-surgical policy or other plan of health benefits covering the insured person plus a cash deductible of $800.

F. A major medical or catastrophe converted policy may be subject to an aggregate maximum benefit limit per person of $350,000.

G. Benefit Periods and Benefit Limits.

  (1) The converted policy may use a definition of benefit period similar to that contained in the group policy from which conversion is made or may use a calendar year benefit period.

  (2) The converted policy may contain a benefit limit for each benefit period.

  (3) The benefit limit need not be greater than the limit for each benefit period which was available under the group policy, or $87,500, if less.

H. The benefits required under §§C and D of this regulation may be combined in a comprehensive policy which affords benefits at least as favorable as those required under §§C and D of this regulation, when both are applicable.

#### Regulation .11 Benefit Levels.

*COMAR 31.11.01.11*

If the coverage under the group policy from which conversion is being made provided benefits less than those which would be required in Regulation .10 of this chapter, the carrier, at its option, may provide a converted policy with benefits which are substantially similar to those provided under the group policy instead of offering the plans required in Regulation .10 of this chapter.

#### Regulation .12 Out-of-State Conversions.

*COMAR 31.11.01.12*

A. A converted policy which is delivered outside of Maryland as a conversion from a group policy issued in Maryland shall be on a form which is permitted to be delivered in the other jurisdiction.

B. If the carrier is prohibited by the law of the other jurisdiction from issuing a converted policy by reason of not being licensed in that jurisdiction, the carrier shall provide coverage in accordance with the requirements of these regulations under a group policy issued in Maryland or in another jurisdiction in which the carrier is licensed.

#### Regulation .13 Modified Requirements.

*COMAR 31.11.01.13*

Upon request of a carrier, the Commissioner may grant approval for modification of any of the minimum specifications or other requirements of these regulations upon a showing by the carrier that modification is equitably warranted.

#### Regulation .14 Notification.

*COMAR 31.11.01.14*

A. The insured person whose coverage under a group policy terminates and who is entitled to make application for a converted policy shall be notified of this right, on or before the date of termination of coverage, but not more than 61 days before.

B. An insured person who receives the timely notice of the conversion privilege, as described in §A of this regulation, shall be given the right to apply for the converted policy until at least 45 days after the date the individual's coverage under the group policy terminates.

C. If the insured person is not provided the notification described in §A of this regulation, then the insured person shall have the right to apply for a converted policy within the time stated in the notice which shall be at least 31 days after the date of the notice, except that the late notice may not extend the period for making application beyond 90 days after the termination of coverage in the group policy.

D. Except as provided in §E of this regulation, written notice presented to the insured person or mailed by the group policyholder to the last known address of the insured person or mailed by the carrier to the last known address of the insured person as furnished by the policyholder shall constitute notice for the purpose of this regulation.

E. Notice given by the policyholder or the carrier by mail which is returned undelivered does not constitute notice for the purpose of this regulation.

F. Unless the written notice is to be provided by the carrier, the group policy shall contain a provision to the effect that notice of the conversion privilege shall be given by the group policyholder to the affected certificate holder upon termination of coverage of the insured person.

#### Regulation .15 Amendment of Group Policy.

*COMAR 31.11.01.15*

Any group policy issued in Maryland before the effective date of these regulations and not in conformity with these regulations, shall be amended on the annual renewal date of the group policy to conform to the regulations in this chapter.

### Chapter 02 — Group Health Insurance — Continuation of Coverage of Divorced Spouses

**Authority:** Insurance Article, §§2-109, 15-407—15-409, and 15-412; Health-General Article, §19-703; Annotated Code of Maryland

**Administrative History:** Effective date: September 19, 1988 (15:19 Md. R. 2247)

**Administrative History:** Chapter recodified from COMAR 09.30.77 to COMAR 31.11.02 effective September 7, 1998 (25:18 Md. R. 1439)

**Administrative History:** Regulation .08 repealed effective June 22, 2015 (42:12 Md. R. 764)

#### Regulation .01 Purpose.

*COMAR 31.11.02.01*

The purpose of this chapter is to provide standards for implementing requirements of the Insurance Article and of Health-General Article, Annotated Code of Maryland, with respect to providing or continuing coverage for certain divorced spouses and dependent children.

#### Regulation .02 Definitions.

*COMAR 31.11.02.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Applicable change in status” means the divorce of the insured and the insured's spouse.

  (2) “Dependent child” means an individual who:

    (a) Is a child of the insured; and

    (b) Either was covered under the group contract as a qualified or eligible dependent of the insured immediately preceding the applicable change in status, or was born to a qualified secondary beneficiary after the applicable change in status.

  (3) “Employer” means an employer, an association of employers, or a trust sponsored by an employer or an association of employers to whom a group contract has been issued.

  (4) Expense-Incurred Basis.

    (a) “Expense-incurred Basis” means that the:

      (i) Payment of benefits is based in whole or in part on the charge made by the provider; or

      (ii) Services are directly provided without additional charge except for any deductible or copayment specified in the policy.

    (b) Policies or contracts issued on an expense-incurred basis include, but are not limited to:

      (i) Health maintenance organization coverage;

      (ii) A policy which provides for the cost of a semiprivate hospital room;

      (iii) A policy which provides coverage for a semiprivate hospital room subject to a daily deductible;

      (iv) A policy which provides coverage for a semiprivate hospital room but which is subject to a copayment;

      (v) A policy which provides a daily hospital benefit of more than $100;

      (vi) A policy which pays medical-surgical benefits on a usual and customary basis.

    (c) The following policies or contracts are not to be regarded as being on an expense-incurred basis:

      (i) A policy which provides a daily hospital benefit of a fixed dollar amount not in excess of $100 per day;

      (ii) A policy which provides only medical-surgical benefits in accordance with a fixed schedule of fees.

  (5) “Group policy” or “group contract” means an insurance contract issued or delivered in this State which provides hospital, surgical, medical, or major medical coverage issued to an employer for the benefit of its employees by:

    (a) An authorized insurer in accordance with Insurance Article, §15-302, Annotated Code of Maryland;

    (b) A nonprofit health service plan authorized under Insurance Article, §§14-108—14-111, Annotated Code of Maryland; or

    (c) A health maintenance organization authorized under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.

  (6) “Insured” means an employee who is a resident of this State and is covered under a group policy.

  (7) “Qualified secondary beneficiary” means, with respect to the insured, an individual other than the insured who is a:

    (a) Beneficiary under the group contract as the spouse of the insured for at least the 30-day period immediately preceding an applicable change in status; or

    (b) Dependent child.

  (8) “Self-insured group health benefit program or plan” means a program or plan furnished by an employer for the benefit if its employees providing hospital, medical, surgical, or major medical benefits on an expense-incurred basis similar to benefits which could be provided under a group health insurance policy.

  (9) “Termination statement” means a written notice of an event specified in Regulation .07 of this chapter provided to an employer on a form containing language prescribed by the Commissioner, or in substantially similar language, which is signed by the insured and:

    (a) A qualified secondary beneficiary; or

    (b) Accompanied by a signed and sworn affidavit of the insured verifying the factual content of the statement.

#### Regulation .03 Applicability.

*COMAR 31.11.02.03*

A. These regulations shall be applicable to all group health insurance policies or contracts issued or delivered in this State to the employer of the insured which provide hospital, surgical, medical, or major medical benefits on an expense-incurred basis whether issued by a nonprofit health service plan or by any other insurer and to all group policies or contracts issued or delivered in this State to an employer of an insured by a health maintenance organization certified under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.

B. These regulations shall be applicable to any policy or contract issued on or after the effective date of these regulations, beginning with the date of issue of the policy or contract.

C. These regulations shall be applicable to any policy or contract issued before the effective date of these regulations, beginning on the first annual renewal date or the first anniversary of the date of issue of the policy or contract occurring on or next following the effective date of these regulations.

#### Regulation .04 Eligibility.

*COMAR 31.11.02.04*

A. Beginning with an applicable change in status and until the occurrence of an event described in Regulation .07 of this chapter, the qualified secondary beneficiary shall be entitled to the benefits provided under the group contract.

B. Section A of this regulation may not be applicable to any period during which the insured is not covered by a group contract.

#### Regulation .05 Coverage Provided.

*COMAR 31.11.02.05*

A. The coverage provided to a qualified secondary beneficiary shall be identical to the coverage which would have been provided under the group contract for the benefit of the qualified secondary beneficiary if the individual had remained an eligible dependent of the insured employee and there had been no applicable change in status.

B. If modifications are made in the employer's group contract, the coverage provided to the qualified secondary beneficiary shall be correspondingly modified.

C. If the employer transfers from one group contract to another, the coverage provided the qualified secondary beneficiary shall be transferred to that provided under the new group contract.

D. If the employer provides various hospital, surgical, medical, or major medical coverages under one or more group contracts, a qualified secondary beneficiary may not choose less than all of the benefits provided unless the insured employee would have had the option of making such a choice for an eligible dependent if there had been no applicable change in status.

E. The benefits to be provided under the group contract shall be in no respect less favorable than those required by these regulations.

#### Regulation .06 Conditions of Coverage.

*COMAR 31.11.02.06*

A. In order to receive the benefits provided under the group contract, an insured employee, or the divorced spouse of the insured employee, shall notify the employer of the applicable change in status not later than:

  (1) 60 days after the applicable change in status if on the date of the applicable change in status the employee is covered under the employer's group contract or under another group contract issued to the same employer replacing that contract. The coverage shall be retroactive to the applicable change in status.

  (2) 30 days after the date the insured employee becomes eligible for coverage under a group contract issued to another employer, if the insured employee becomes covered under the new employer's group contract after the applicable change in status. The coverage shall be retroactive to the date of eligibility.

B. The request to the employer under §A of this regulation shall be in writing and signed by the insured.

C. Costs Paid to Employer.

  (1) The insured employee or the qualified secondary beneficiary shall pay to the employer the employer's entire cost for the coverage to be provided.

  (2) The entire cost to the employer includes the employer's customary contribution as well as the contribution customarily required of an employee if there were no applicable changes in status.

  (3) If the insurer quotes rates to the employer separately for individual coverage and for dependent coverage, the payment to be made on behalf of the qualified secondary beneficiary shall be the rate quoted for dependents.

  (4) If the insurer quotes a family rate which would normally include an employee and eligible dependents, the amount payable on behalf of the qualified secondary beneficiary shall be the difference between the family rate and the rate payable for an individual employee who is not covered for dependents.

  (5) If, in connection with a divorce, there is a court order or an agreement between the insured and the insured's spouse as to the allocation of the cost of the insurance coverage between the insured employee and the spouse, payment to the employer shall be made in accordance with the terms of the court order or the agreement.

D. Payment to the employer for the cost of the coverage is due and shall be paid on or before the first day of each month for which coverage is to be provided unless the employer agrees in writing to payment at a later date. The following apply:

  (1) If the employer customarily collects employee contributions under the group contract on a quarterly basis, the required payment is due and shall be paid on or before the first day of each quarter for which coverage is to be provided.

  (2) At the time of the notice referred to in §A of this regulation, payment will be due on the date notice is given. On that date the amount of payment due shall be the accumulated charges to cover the period beginning with the effective date of the coverage to be provided to the end of the month in which the notice is given.

#### Regulation .07 Termination.

*COMAR 31.11.02.07*

A. Coverage for a qualified secondary beneficiary will terminate when the coverage under the group contract terminates with respect to the insured employee.

B. Even though the insured employee continues to be covered under the group contract, coverage with respect to any individual qualified secondary beneficiary shall terminate on the date of occurrence of any of the following:

  (1) The date on which the qualified secondary beneficiary becomes eligible for hospital, surgical, medical, or major medical benefits under any insured group contract or any health maintenance organization group contract or any self-insured group health benefit program or plan provided the:

    (a) Group contract or the self-insured program or plan is on an expense-incurred basis, and

    (b) Eligibility does not result from the provisions of these regulations;

  (2) The date on which the insured becomes entitled to benefits under Title XVIII of the Social Security Act;

  (3) The date on which a qualified secondary beneficiary who is a dependent child would no longer have been covered under the group contract if there had been no applicable change in status;

  (4) The date of remarriage of an individual who is a qualified secondary beneficiary by reason of having been the divorced spouse of the insured employee;

  (5) The date on which the qualified secondary beneficiary becomes insured under a non-group policy or contract or under a non-group health maintenance organization contract which provides coverage for hospital, surgical, medical, or major medical benefits on an expense-incurred basis;

  (6) The effective date of an election by a qualified secondary beneficiary to no longer be covered under the group contract;

  (7) The date the employer receives a duly executed notice of termination, or the effective date of the notice if later;

  (8) The premium due date on which the premium payable to the employer by or on behalf of the qualified secondary beneficiary is not timely made.

#### Regulation .08 Conversion and Continuation — Repealed.

*COMAR 31.11.02.08*

#### Regulation .09 Notification Requirements.

*COMAR 31.11.02.09*

A. Each group contract to which these regulations are applicable shall include a statement as provided in §B of this regulation.

B. The statement shall disclose the availability of the benefits provided under these regulations and shall provide a summary of the eligibility requirements, the duration and general description of the benefits.

C. Each group contract issued before the effective date of these regulations, to which these regulations are applicable, shall be amended in accordance with these regulations not later than the date of applicability stated in Regulation .03B of this chapter.

#### Regulation .10 Termination Statement.

*COMAR 31.11.02.10*

A. The termination statement shall be in language substantially as indicated in this regulation.

B. If the termination statement is signed by the insured and a qualified secondary beneficiary:

C. If the termination statement is to be signed only by the insured:

### Chapter 03 — Group Health Insurance — Continuation of Coverage of Surviving Spouses

**Authority:** Insurance Article, §§2-109, 14-124(b), 15-407—15-409, and 15-412; Health-General Article, §19-703; Annotated Code of Maryland

**Administrative History:** Effective date: December 14, 1987 (14:25 Md. R. 2659)

**Administrative History:** Chapter recodified from COMAR 09.30.83 to COMAR 31.11.03 effective September 7, 1998 (25:18 Md. R. 1439)

**Administrative History:** Regulation .08 repealed effective June 22, 2015 (42:12 Md. R. 764)

#### Regulation .01 Purpose.

*COMAR 31.11.03.01*

The purpose of this chapter is to provide standards for implementing requirements of the Insurance Article and of Health-General Article, Annotated Code of Maryland, with respect to providing or continuing coverage for certain surviving spouses and dependent children.

#### Regulation .02 Definitions.

*COMAR 31.11.03.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Applicable change in status” means the death of the insured.

  (2) “Dependent child” means an individual who:

    (a) Is a child of the insured; and

    (b) Either was covered under the group contract as a qualified or eligible dependent of the insured immediately preceding the applicable change in status, or was born to a qualified secondary beneficiary after the applicable change in status.

  (3) “Employer” means an employer, an association of employers, or a trust sponsored by an employer or an association of employers to whom a group contract has been issued.

  (4) “Expense-incurred basis” means that the:

    (a) Payment of benefits is based in whole or in part on the charge made by the provider; or

    (b) Services are directly provided without additional charge except for any deductible or copayment specified in the policy;

    (c) Policies or contracts issued on an expense-incurred basis include but are not limited to:

      (i) Health maintenance organization coverage,

      (ii) A policy which provides for the cost of a semiprivate hospital room,

      (iii) A policy which provides coverage for a semiprivate hospital room subject to a daily deductible,

      (iv) A policy which provides coverage for a semiprivate hospital room but which is subject to a copayment,

      (v) A policy which provides a daily hospital benefit of more than $100,

      (vi) A policy which pays medical-surgical benefits on a usual and customary basis;

    (d) Following policies or contracts are not to be regarded as being on an expense-incurred basis:

      (i) A policy which provides a daily hospital benefit of a fixed dollar amount not in excess of $100 per day,

      (ii) A policy which provides only medical-surgical benefits in accordance with a fixed schedule of fees.

  (5) “Group policy” or “group contract” means an insurance contract issued or delivered in this State which provides hospital, surgical, medical, or major medical coverage issued to an employer for the benefit of its employees by:

    (a) An authorized insurer in accordance with Insurance Article, §15-302, Annotated Code of Maryland;

    (b) A nonprofit health service plan authorized under Insurance Article, §§14-108—14-111, Annotated Code of Maryland; or

    (c) A health maintenance organization authorized under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.

  (6) “Insured” means an employee who is a resident of this State and covered under a group policy for a period of not less than 3 months.

  (7) “Qualified secondary beneficiary” means, with respect to an insured, an individual other than the insured who is:

    (a) A beneficiary under the group contract as the spouse of the insured for at least the 30-day period immediately preceding an applicable change in status; or

    (b) A dependent child.

  (8) “Self-insured group health benefit program or plan” means a program or plan furnished by an employer for the benefit of its employees providing hospital, surgical, medical, or major medical benefits on an expense-incurred basis similar to benefits which could be provided under a group health insurance policy.

  (9) “Termination statement” means a written notice of an event specified in Regulation .07 of this chapter provided to an employer on a form containing language prescribed by the Commissioner, or in substantially similar language, which is signed by the insured.

#### Regulation .03 Applicability.

*COMAR 31.11.03.03*

A. This chapter is applicable to all group health insurance policies or contracts issued or delivered in this State to the employer of the insured which provide hospital, surgical, medical, or major medical benefits on an expense-incurred basis whether issued by a nonprofit health service plan or by any other insurer, and to all group policies or contracts issued or delivered in this State to an employer by a health maintenance organization certified under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.

B. This chapter is applicable to any policy or contract issued on or after the effective date of this chapter, beginning with the date of issue of the policy or contract.

C. This chapter is applicable to any policy or contract issued before the effective date of this chapter, beginning on the first annual renewal date or the first anniversary of the date of issue of the policy or contract occurring on or next following the effective date of this chapter.

#### Regulation .04 Eligibility.

*COMAR 31.11.03.04*

Beginning with an applicable change in status and until the occurrence of an event described in Regulation .07 of this chapter, the qualified secondary beneficiary shall be entitled to the benefits provided under the group contract.

#### Regulation .05 Coverage Provided.

*COMAR 31.11.03.05*

A. The coverage provided to a qualified secondary beneficiary shall be identical to the coverage which would have been provided under the group contract for the benefit of the qualified secondary beneficiary if the qualified secondary beneficiary had remained an eligible dependent of the insured employee and there had been no applicable change in status.

B. If modifications are made in the employer's group contract, the coverage provided to the qualified secondary beneficiary shall be correspondingly modified.

C. If the employer transfers from one group contract to another, the coverage provided the qualified secondary beneficiary will be transferred to that provided under the new group contract.

D. If the employer provides various hospital, surgical, medical, or major medical coverages under one or more group contracts, a qualified secondary beneficiary may not elect to choose less than all of the benefits provided unless the insured employee would have had the option of making such a choice for an eligible dependent if there had been no applicable change in status.

E. The benefits to be provided under the group contract shall be in no respect less favorable than those required by this chapter.

#### Regulation .06 Conditions of Coverage.

*COMAR 31.11.03.06*

A. In order to receive the benefits provided under the group contract, a surviving spouse of the insured employee shall elect coverage not later than 45 days after the applicable change in status if a request is made for coverage under the group contract under which the insured employee is covered on the date of the applicable change in status. The coverage shall be retroactive to the applicable change in status.

B. The request to the employer under §A of this regulation shall be in writing and signed by the qualified secondary beneficiary.

C. Costs to Secondary Beneficiary.

  (1) The qualified secondary beneficiary shall pay to the employer the employer's entire cost for the coverage to be provided.

  (2) The entire cost to the employer includes the employer's customary contribution as well as the contribution customarily required of an employee if there were no applicable change in status.

  (3) The entire cost to the employer may include a reasonable administrative fee not to exceed 2 percent of the amount permitted under §C(2) of this regulation.

  (4) If the insurer quotes rates to the employer separately for individual coverage and for dependent coverage, the payment to be made on behalf of the qualified secondary beneficiary shall be the rate quoted for dependents.

  (5) If the insurer quotes a family rate which would normally include an employee and eligible dependents, the amount payable on behalf of the qualified secondary beneficiary shall be the difference between the family rate and the rate payable for an individual employee who is not covered for dependents.

D. Due Date of Premium.

  (1) Payment to the employer for the cost of the coverage is due and shall be paid on or before the first day of each month for which coverage is to be provided unless the employer agrees in writing to payment at a later date.

  (2) At the time of the request referred to in §A of this regulation, payment will be due on the date of request. At the date of the request, the amount of payment due shall be the accumulated charges to cover the period beginning with the effective date of the coverage to be provided to the end of the month in which the request is made.

#### Regulation .07 Termination.

*COMAR 31.11.03.07*

Coverage for a qualified secondary beneficiary will terminate on the earliest of any of the following:

A. 18 months after the date of the applicable change in status;

B. The date on which the qualified secondary beneficiary becomes eligible for hospital, surgical, medical, or major medical benefits under any insured group contract or any health maintenance organization group contract or any self-insured group health benefit program or plan provided:

  (1) The group contract or the self-insured program or plan is on an expense-incurred basis; and

  (2) The eligibility does not result from the provisions of these regulations;

C. The date on which the qualified secondary beneficiary becomes entitled to benefits under Title XVIII of the Social Security Act;

D. The date on which a qualified secondary beneficiary who is a dependent child would no longer have been covered under the group contract if there had been no applicable change in status;

E. The date on which the qualified secondary beneficiary becomes insured under a non-group policy or contract or under a non-group health maintenance organization contract which provides coverage for hospital, surgical, medical, or major medical benefits on an expense-incurred basis;

F. The effective date of an election by a qualified secondary beneficiary to no longer be covered under the group contract; or

G. The premium due date on which the qualified secondary beneficiary fails to make timely payment of any amount required under Regulation .06C of this chapter.

#### Regulation .08 Conversion and Continuation — Repealed.

*COMAR 31.11.03.08*

#### Regulation .09 Notification Requirements.

*COMAR 31.11.03.09*

A. Each group contract to which these regulations are applicable shall include a statement as provided in §B of this regulation.

B. The statement shall disclose the availability of the benefits provided under these regulations and shall provide a summary of the eligibility requirements, the duration, and general description of the benefits.

C. Each group contract issued before the effective date of this chapter, to which this chapter is applicable, shall be amended in accordance with this chapter not later than the date of applicability stated in Regulation .03C of this chapter.

#### Regulation .10 Election Statement.

*COMAR 31.11.03.10*

The form which a qualified secondary beneficiary shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation:

To _____________________________________________________________________________________________

(name of employer)

The employee ____________________________________________________________________________________

(name of employee)

Whose Social Security number was ____________________________ died on ____________________________________

(date od death)

This is to advise that _______________________________________________________________________________

____________________________________________________________________________________________

(name or names of qualified secondary beneficiaries)

who were covered as qualified dependents of the employee under the employer's group health insurance contract elect(s) to continue to be covered under that contract beginning with the date of death.

Date of Application: ________________________________

Signature of Qualified

Secondary Beneficiary: _____________________________________________________________________________

Mailing Address of

Secondary Beneficiary: _______________________________________________________________________________

#### Regulation .11 Termination Statement.

*COMAR 31.11.03.11*

The termination statement shall be in language substantially as indicated in this regulation:

To _____________________________________________________________________________________________

(name of employer)

This is to advise that _______________________________________________________________________________

_______________________________________________________________________________________________

(name or names of qualified secondary beneficiaries)

is/are no longer to be covered under our group health insurance contract effective ________________________________

(date)

The reason for this termination is ______________________________________________________________________

_________________________________________________________________________________________________

(reason)

Date: ___________________________

____________________________________________________________________________________________

(signature of qualified secondary beneficiary)

### Chapter 04 — Group Health Insurance — Continuation of Coverage for Terminated Employees

**Authority:** Insurance Article, §§2-109, 14-124(b), and 15-409; Health-General Article, §19-703; Annotated Code of Maryland

**Administrative History:** Effective date: December 14, 1987 (14:25 Md. R. 2659)

**Administrative History:** Regulation .10 amended effective April 27, 1992 (19:8 Md. R. 804)

**Administrative History:** Chapter recodified from COMAR 09.30.84 to COMAR 31.11.04 effective September 7, 1998 (25:18 Md. R. 1439)

**Administrative History:** Regulation .01 amended effective September 27, 2004 (31:19 Md. R. 1434)

**Administrative History:** Regulation .02B amended effective September 27, 2004 (31:19 Md. R. 1434)

**Administrative History:** Regulation .08 repealed effective June 22, 2015 (42:12 Md. R. 764)

#### Regulation .01 Purpose.

*COMAR 31.11.04.01*

The purpose of this chapter is to provide standards for implementing requirements of the Insurance Article, Health-General Article, and Unemployment Insurance Law, Annotated Code of Maryland, with respect to continuation of coverage for certain terminated employees.

#### Regulation .02 Definitions.

*COMAR 31.11.04.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) Applicable Change in Status.

    (a) “Applicable change in status” means the termination of the insured's employment other than for cause.

    (b) “Applicable change in status” includes:

      (i) Involuntary termination of the insured's employment other than for cause; and

      (ii) Voluntary termination of the insured's employment by the insured.

  (2) “Employer” means an employer, an association of employers, or a trust sponsored by an employer or an association of employers to whom a group contract has been issued.

  (3) “Expense-incurred basis” means that the:

    (a) Payment of benefits is based in whole or in part on the charge made by the provider; or

    (b) Services are directly provided without additional charge except for any deductible or copayment specified in the policy;

    (c) Policies or contracts issued on an expense-incurred basis include but are not limited to:

      (i) Health maintenance organization coverage;

      (ii) A policy which provides for the cost of a semiprivate hospital room;

      (iii) A policy which provides coverage for a semiprivate hospital room subject to a daily deductible;

      (iv) A policy which provides coverage for a semiprivate hospital room but which is subject to a copayment;

      (v) A policy which provides a daily hospital benefit of more than $100;

      (vi) A policy which pays medical-surgical benefits on a usual and customary basis;

    (d) Following policies or contracts are not to be regarded as being on an expense-incurred basis:

      (i) A policy which provides a daily hospital benefit of a fixed dollar amount not in excess of $100 per day;

      (ii) A policy which provides medical-surgical benefits in accordance with a fixed schedule of fees.

  (4) “Group policy” or “group contract” means an insurance contract issued or delivered in this State which provides hospital, surgical, medical, or major medical coverage issued to an employer for the benefit of its employees by:

    (a) An authorized insurer in accordance with Insurance Article, §15-302, Annotated Code of Maryland;

    (b) A nonprofit health service plan authorized under Insurance Article, §§14-108—14-111, Annotated Code of Maryland; or

    (c) A health maintenance organization authorized under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.

  (5) “Insured” means an employee who is a resident of this State and covered under a group policy for a period of not less than 3 months.

  (6) “Self-insured group health benefit program or plan” means a program or plan furnished by an employer for the benefit of its employees providing hospital, surgical, medical, or major medical benefits on an expense-incurred basis similar to benefits which could be provided under a group health insurance policy.

  (7) “Termination statement” means a written notice of an event specified in Regulation .07 of this chapter provided to an employer on a form containing language prescribed by the Commissioner, or in substantially similar language, which is signed by the insured.

#### Regulation .03 Applicability.

*COMAR 31.11.04.03*

A. These regulations shall be applicable to all group health insurance policies or contracts issued or delivered in this State to the employer of the insured which provide hospital, surgical, medical, or major medical benefits on an expense-incurred basis whether issued by a nonprofit health service plan or by any other insurer and to all group policies or contracts issued or delivered in this State to an employer by a health maintenance organization certified under Health-General Article, Title 19, Subtitle 7, Annotated Code of Maryland.

B. These regulations shall be applicable to any policy or contract issued on or after the effective date of these regulations, beginning with the date of issue of the policy or contract.

C. These regulations shall be applicable to any policy or contract issued before the effective date of these regulations, beginning on the first annual renewal date or the first anniversary of the date of issue of the policy or contract occurring on or next following the effective date of this chapter.

#### Regulation .04 Eligibility.

*COMAR 31.11.04.04*

Entitlement to continuation benefits shall begin with an applicable change in status and last until the occurrence of an event described in Regulation .06 of this chapter.

#### Regulation .05 Coverage Provided.

*COMAR 31.11.04.05*

A. The coverage provided shall be identical to the coverage offered under the group contract to similarly situated individuals for whom there has been no applicable change in status.

B. If the group policy provides benefits for spouses and dependent children, the coverage provided shall be available to the insured's:

  (1) Spouse if the spouse was covered under the group policy before the applicable change in status; and

  (2) Dependent children if the insured had coverage for dependent children before the applicable change in status.

C. If the employer transfers from one group contract to another, the coverage provided the insured will be transferred to that coverage provided under the new group contract.

D. If the employer provides various hospital, surgical, medical, or major medical coverages under one or more group contracts, an insured may not elect to choose less than all of the benefits provided unless the insured would have had the option of making such a choice if there had been no applicable change in status.

E. The benefits to be provided under the group contract shall be in no respect less favorable than those required by these regulations.

#### Regulation .06 Conditions of Coverage.

*COMAR 31.11.04.06*

A. In order to receive the benefits provided under the group contract, an insured shall elect coverage not later than 45 days after the applicable change in status.

B. The coverage shall be retroactive to the applicable change in status.

C. The request to the employer under §A of this regulation shall be in writing and signed by the insured.

D. Continuation coverage shall be provided without evidence of insurability or additional waiting periods.

E. Costs to Insured.

  (1) The insured shall pay to the employer the employer's entire cost for the coverage to be provided.

  (2) The entire cost to the employer includes the employer's customary contribution as well as the contribution customarily required of an employee if there were no applicable change in status.

  (3) The entire cost to the employer may include a reasonable administrative fee not to exceed 2 percent of the amount permitted under §E(2) of this regulation.

F. The insured may elect to pay the employer the amount due for the cost of the coverage in monthly installments.

G. In addition to the allowable cost provided for under §E of this regulation, the first payment to the employer by the insured shall include the cost for the coverage provided after the change in status and until the end of the month in which the insured makes an election.

#### Regulation .07 Termination.

*COMAR 31.11.04.07*

Coverage for the insured shall terminate on the earliest of any of the following:

A. 18 months after the date of the applicable change in status;

B. The date on which the insured becomes eligible for hospital, surgical, medical, or major medical benefits under any insured group contract or any health maintenance organization group contract or any self-insured group health benefit program or plan provided:

  (1) The group contract or the self-insured program or plan is on an expense-incurred basis; and

  (2) The eligibility does not result from the provisions of this chapter;

C. The date on which the insured becomes entitled to benefits under Title XVIII of the Social Security Act;

D. The date on which the insured becomes covered under a non-group policy or under a non-group health maintenance organization contract which provides coverage for hospital, surgical, medical, or major medical benefits on an expense-incurred basis;

E. The premium due date on which the insured does not make timely payment in the amount required for the provided coverage;

F. The date on which the insured elects not to be covered under the group contract;

G. The date on which the employer ceases to provide hospital, surgical, medical, or major medical benefits to its employees under a group contract.

#### Regulation .08 Conversion and Continuation — Repealed.

*COMAR 31.11.04.08*

#### Regulation .09 Notification Requirements.

*COMAR 31.11.04.09*

A. Every group contract to which this chapter is applicable shall include a statement as provided in §B of this regulation.

B. The statement shall disclose the availability of the benefits provided under this chapter and shall provide a summary of the eligibility requirements, the duration, and general description of the benefits.

C. Every group contract issued before the effective date of this chapter, to which this chapter is applicable, shall be amended in accordance with this chapter not later than the date of applicability stated in Regulation .03C of this chapter.

#### Regulation .10 Election Statement.

*COMAR 31.11.04.10*

The form which the insured shall use to elect coverage under these regulations shall be in language substantially as indicated in this regulation:

To _____________________________________________________________________________________________

(name of employer)

I _____________________________________________________________________________ whose Social Security

(name of employee)

number is __________________________________have been terminated as an employee on _______________________.

(date of termination)

Before termination I was covered under the employer's group health insurance contract (check one)

____ for myself.

____ for myself and dependents.

I elect to have this coverage continue in force and I agree to pay the required premium.

Date of Application: __________________________________

Signature of Insured: _________________________________

Mailing Address: ___________________________________________________________________________________

#### Regulation .11 Termination Statement.

*COMAR 31.11.04.11*

The termination statement shall be in language substantially as indicated in this regulation.

To _____________________________________________________________________________________________

(name of employer)

This is to advise that ____________________________________________________________and covered dependents,

(name of insured)

if any, are no longer to be covered under our group health insurance contract effective ______________________________

(date)

The reason for this termination is ______________________________________________________________________

_________________________________________________________________________________________________

(reason)

Date: ___________________________

Signature of Insured: _______________________________________________________________________________

### Chapter 05 — Group Health Insurance Options for Alzheimer's Disease and for Diseases of the Elderly

**Authority:** Insurance Article, §§2-109, 14-124(b), and 15-801, Annotated Code of Maryland

**Administrative History:** Effective date: December 28, 1987 (14:26 Md. R. 2745)

**Administrative History:** Chapter recodified from COMAR 09.30.80 to COMAR 31.11.05 effective September 7, 1998 (25:18 Md. R. 1439)

#### Regulation .01 Scope.

*COMAR 31.11.05.01*

A. This chapter is applicable to all group health insurance policies issued or renewed in Maryland on or after July 1, 1987, except as noted below.

B. Any group health insurance policy issued before the effective date of this chapter shall be subject to this chapter on the annual renewal date of the policy falling on or next following the effective date.

C. This chapter is not applicable to group health insurance policies which:

  (1) Do not provide benefits for the cost of medical care on an expense-incurred basis; or

  (2) Provide benefits for accidents only.

#### Regulation .02 Definitions.

*COMAR 31.11.05.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Alzheimer's disease” means a progressive brain disease diagnosed as Alzheimer's disease by the insured's licensed attending physician and confirmed by a second opinion of a licensed physician.

  (2) “Diseases of the elderly” means any disease, illness, injury, or medical condition which has caused the elderly insured to become functionally impaired or disabled so as to require nursing home care or intermediate or custodial nursing care and which has been confirmed by a second opinion of a licensed physician.

  (3) “Elderly” means an insured who is 65 years old or older.

  (4) “Group health insurance policy” means an insurance policy issued in Maryland either:

    (a) Providing benefits for hospital, surgical, medical, major medical, or all of the above, in accordance with Insurance Article, §15-302, Annotated Code of Maryland; or

    (b) Providing benefits for health, surgical, medical, major medical, or all of the above to a group of persons by a nonprofit health service plan, pursuant to Insurance Article, Title 14, Subtitle 1, Annotated Code of Maryland.

  (5) “Group of persons” means the types of groups as defined in Insurance Article, §15-302, Annotated Code of Maryland.

  (6) “Insured” means a person covered under a group health insurance policy.

  (7) “Intermediate or custodial nursing care” means any form of health or health-related service, whether provided in a custodial or noncustodial setting, which is designed to provide therapeutic, rehabilitative, supportive, or maintenance care to a person who has chronic or deteriorating medical conditions which impair the person's ability to function at his or her own optimum level, but not including treatment of the conditions during the initial, acute stage of the condition or conditions.

  (8) “Nursing home” means a facility or institution or part of it that:

    (a) Provides nursing care for chronically ill or convalescent patients; or

    (b) Offers to provide 24-hour a day nursing care of patients in a home-type facility such as a:

      (i) Convalescent home,

      (ii) Nursing unit of a home for the aged,

      (iii) Psychiatric nursing home,

      (iv) Nursing facility for the handicapped,

      (v) Home for alcoholics, or

      (vi) Halfway house.

#### Regulation .03 Required Health Insurance Options.

*COMAR 31.11.05.03*

Each insurer shall offer the following options for its group health insurance policies:

A. One option to cover Alzheimer's disease; and

B. One option to cover Alzheimer's disease as well as diseases of the elderly.

#### Regulation .04 Required Coverage.

*COMAR 31.11.05.04*

A. The coverages provided by the required health insurance options shall include, but are not limited to:

  (1) The institutional and professional care expenses for nursing home care alone, or in addition to intermediate or custodial nursing care, while confined in a nursing home or other custodial care facility or institution; and

  (2) Expenses for the type of care described in §A(1) of this regulation  for an insured who is not confined to a facility or institution.

B. The insurer may establish reasonable limits on the benefits offered for the above coverages including, but not limited to, copayments, deductibles, and maximum annual and lifetime limits.

### Chapter 06 — Comprehensive Standard Health Benefit Plan

**Authority:** Health-General Article, §§19-103(c)(6), 19-108, and 19-1510; Insurance Article, §§2-108, 2-109, and 15-1207; Annotated Code of Maryland

**Administrative History:** Effective date: April 25, 1994 (21:8 Md. R. 672)

**Administrative History:** Regulation .02B amended as an emergency provision effective July 1, 1994 (21:13 Md. R. 1151); amended permanently effective November 7, 1994 (21:22 Md. R. 1876)

**Administrative History:** Chapter revised effective February 12, 1996 (23:3 Md. R. 167)

**Administrative History:** Regulation .01 amended effective May 18, 1998 (25:10 Md. R. 746)

**Administrative History:** Regulation .02B amended as an emergency provision effective February 2, 1996 (23:4 Md. R. 270); emergency status expired August 2, 1996; amended permanently effective October 21, 1996 (23:21 Md. R. 1467)

**Administrative History:** Regulation .02B amended as an emergency provision effective April 1, 1997 (24:9 Md. R. 653); emergency status extended at 24:21 Md. R. 1444; amended permanently effective September 22, 1997 (24:19 Md. R. 1340)

**Administrative History:** Regulation .02B amended effective May 18, 1998 (25:10 Md. R. 746)

**Administrative History:** Regulation .03A amended and H, I adopted as an emergency provision effective April 1, 1997 (24:9 Md. R. 653);  emergency status extended at 24:21 Md. R. 1444; amended permanently effective September 22, 1997 (24:19 Md. R. 1340)

**Administrative History:** Regulation .03A, D amended effective May 18, 1998 (25:10 Md. R. 746)

**Administrative History:** Regulation .04F amended effective May 18, 1998 (25:10 Md. R. 746)

**Administrative History:** Regulation .05 amended effective May 18, 1998 (25:10 Md. R. 746)

**Administrative History:** Regulation .05H amended as an emergency provision effective October 1, 1997 (24:21 Md. R. 1444); amended permanently effective January 12, 1998 (25:1 Md. R. 15)

**Administrative History:** Regulation .05I amended as an emergency provision effective June 1, 1996 (23:13 Md. R. 937); emergency status extended at 23:18 Md. R. 1313; emergency status expired January 16, 1997

**Administrative History:** Regulation .05I amended effective March 10, 1997 (24:5 Md. R. 407)

**Administrative History:** Regulation .08 amended as an emergency provision effective September 30, 1996 (23:21 Md. R. 1464); amended permanently effective March 10, 1997 (24:5 Md. R. 407)

**Administrative History:** Regulation .08A amended as an emergency provision effective April 25, 1996 (23:10 Md. R. 729); emergency status extended at 23:18 Md. R. 1314; emergency status expired January 16, 1997

**Administrative History:** Regulation .09A amended as an emergency provision effective June 1, 1996 (23:13 Md. R. 937); emergency status extended at 23:18 Md. R. 1313; emergency status expired January 16, 1997

**Administrative History:** Regulation .09A amended effective March 10, 1997 (24:5 Md. R. 407)

**Administrative History:** Regulation .09A amended as an emergency provision effective October 1, 1997 (24:21 Md. R. 1441); amended permanently effective January 12, 1998 (25:1 Md. R. 15)

**Administrative History:** Regulation .09A amended as an emergency provision effective December 31, 1997 (25:2 Md. R. 73); amended permanently effective April 6, 1998 (25:7 Md. R. 527)

**Administrative History:** Regulation .09A amended effective May 18, 1998 (25:10 Md. R. 746)

**Administrative History:** Regulation .12 amended effective May 18, 1998 (25:10 Md. R. 746)

**Administrative History:** Chapter recodified from COMAR 09.31.05 to COMAR 31.11.06 effective September 7, 1998 (25:18 Md. R. 1439)

**Administrative History:** Regulation .01 amended effective April 10, 2006 (33:7 Md. R. 675)

**Administrative History:** Regulation .01C amended effective April 9, 2007 (34:7 Md. R. 700); March 24, 2008 (35:6 Md. R. 702)

**Administrative History:** Regulation .02B amended effective February 7, 2000 (27:2 Md. R. 148); February 5, 2001 (28:2 Md. R. 106); March 18, 2002 (29:5 Md. R. 506); April 14, 2003 (30:7 Md. R. 489)

**Administrative History:** Regulation .02B amended as an emergency provision effective May 21, 2004 (31:12 Md. R. 909); amended permanently effective August 16, 2004 (31:16 Md. R. 1257)

**Administrative History:** Regulation .02B amended effective February 28, 2005 (32:4 Md. R. 412); April 10, 2006 (33:7 Md. R. 676); March 24, 2008 (35:6 Md. R. 702); April 20, 2009 (36:8 Md. R. 598)

**Administrative History:** Regulation .02B amended as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); amended permanently effective January 13, 2011 (38:1 Md. R. 13)

**Administrative History:** Regulations .03—.08 amended effective May 3, 1999 (26:9 Md. R. 731)

**Administrative History:** Regulation .03 amended effective April 10, 2006 (33:7 Md. R. 676)

**Administrative History:** Regulation .03A amended as an emergency provision effective October 1, 1999 (26:22 Md. R. 1689); emergency status expired February 1, 2000

**Administrative History:** Regulation .03A amended effective February 7, 2000 (27:2 Md. R. 148); February 5, 2001 (28:2 Md. R. 106); March 18, 2002 (29:5 Md. R. 506); April 14, 2003 (30:7 Md. R. 489); April 20, 2009 (36:8 Md. R. 598)

**Administrative History:** Regulation .03A-1 adopted effective April 20, 2009 (36:8 Md. R. 598)

**Administrative History:** Regulation .03E amended effective February 7, 2000 (27:2 Md. R. 148)

**Administrative History:** Regulation .03-1 adopted as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); adopted permanently effective January 13, 2011 (38:1 Md. R. 13)

**Administrative History:** Regulation .04 amended effective April 10, 2006 (33:7 Md. R. 676)

**Administrative History:** Regulation .04B, F amended as an emergency provision effective May 21, 2004 (31:12 Md. R. 909); amended permanently effective August 16, 2004 (31:16 Md. R. 1257)

**Administrative History:** Regulation .04F amended effective February 7, 2000 (27:2 Md. R. 148); February 5, 2001 (28:2 Md. R. 106); March 15, 2004 (31:5 Md. R. 452); April 9, 2007 (34:7 Md. R. 700); March 24, 2008 (35:6 Md. R. 702)

**Administrative History:** Regulation .04F amended as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); amended permanently effective January 13, 2011 (38:1 Md. R. 13)

**Administrative History:** Regulation .05 amended effective February 5, 2001 (28:2 Md. R. 106); March 15, 2004 (31:5 Md. R. 452); April 10, 2006 (33:7 Md. R. 676)

**Administrative History:** Regulation .05E, I amended effective March 24, 2008 (35:6 Md. R. 702)

**Administrative History:** Regulation .05H amended effective February 7, 2000 (27:2 Md. R. 148)

**Administrative History:** Regulation .05H amended as an emergency provision effective May 21, 2004 (31:12 Md. R. 909); amended permanently effective August 16, 2004 (31:16 Md. R. 1257)

**Administrative History:** Regulation .05H amended as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); amended permanently effective January 13, 2011 (38:1 Md. R. 13)

**Administrative History:** Regulation .05I amended effective May 3, 1999 (26:9 Md. R. 731)

**Administrative History:** Regulation .06B amended effective February 7, 2000 (27:2 Md. R. 148); February 5, 2001 (28:2 Md. R. 106); March 18, 2002 (29:5 Md. R. 506); April 14, 2003 (30:7 Md. R. 489); April 20, 2009 (36:8 Md. R. 598)

**Administrative History:** Regulation .06F adopted effective November 16, 2009 (36:23 Md. R. 1819)

**Administrative History:** Regulation .07 amended effective March 24, 2008 (35:6 Md. R. 702)

**Administrative History:** Regulation .07A amended effective February 7, 2000 (27:2 Md. R. 148)

**Administrative History:** Regulation .07C amended effective April 10, 2006 (33:7 Md. R. 676)

**Administrative History:** Regulation .08 amended effective March 24, 2008 (35:6 Md. R. 702)

**Administrative History:** Regulation .09 amended as an emergency provision effective May 21, 2004 (31:12 Md. R. 909); amended permanently effective August 16, 2004 (31:16 Md. R. 1257)

**Administrative History:** Regulation .09A amended effective March 18, 2002 (29:5 Md. R. 506); April 20, 2009 (36:8 Md. R. 598)

**Administrative History:** Regulation .09B amended effective April 10, 2006 (33:7 Md. R. 676)

**Administrative History:** Regulation .09D adopted as an emergency provision effective October 1, 1999 (26:22 Md. R. 1689); emergency status expired February 1, 2000

**Administrative History:** Regulation .09D adopted effective February 7, 2000 (27:2 Md. R. 148)

**Administrative History:** Regulation .09D amended effective February 5, 2001 (28:2 Md. R. 106); April 10, 2006 (33:7 Md. R. 676)

**Administrative History:** Regulation .09E amended as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); amended permanently effective January 13, 2011 (38:1 Md. R. 13)

**Administrative History:** Regulation .10D adopted as an emergency provision effective May 21, 2004 (31:12 Md. R. 909); adopted permanently effective August 16, 2004 (31:16 Md. R. 1257)

**Administrative History:** Regulation .10D repealed effective April 10, 2006 (33:7 Md. R. 676)

**Administrative History:** Regulation .11A, B amended as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); amended permanently effective January 13, 2011 (38:1 Md. R. 13)

**Administrative History:** Regulation .11B amended effective November 16, 2009 (36:23 Md. R. 1819)

**Administrative History:** Regulation .11C amended effective February 28, 2005 (32:4 Md. R. 412); November 16, 2009 (36:23 Md. R. 1819)

#### Regulation .01 Scope.

*COMAR 31.11.06.01*

A. This chapter applies to all carriers that offer the comprehensive standard health benefit plan to the small employer market.

B. This chapter identifies the uniform benefits which must be offered in a comprehensive standard health benefit plan which a carrier offers to a Maryland small employer if the policy is issued or renewed after June 30, 1994. A carrier participating in the small employer market shall market this plan to all employers with as few as two eligible employees and as many as 50 eligible employees.

C. With the exception set forth in §D of this regulation, a carrier may offer the plan through one or more of the following delivery systems:

  (1) Indemnity;

  (2) Preferred provider;

  (3) Point-of-service delivered in conjunction with an indemnity or preferred provider delivery system;

  (4) A health maintenance organization;

  (5) A high deductible health maintenance organization;

  (6) A triple option point-of-service;

  (7) An HSA-compatible delivery system; or

  (8) An exclusive provider.

D. This chapter also specifies the uniform cost-sharing arrangements of the plan applicable to each delivery system. This chapter permits carriers to offer additional benefits or lower cost-sharing arrangements by marketing one or more riders to the plan at an additional cost.

E. A carrier that offers the comprehensive standard health benefit plan to an eligible employer shall offer the plan to all eligible employees. An eligible employer may, at the employer's election, direct the carrier to offer the comprehensive standard health benefit plan to the employer's part-time employees and those employees covered by other public or private health benefit plans or health benefit arrangements, and to all dependents.

F. This chapter includes case management for medically complex and costly services to assure adequate cost containment and appropriate utilization to maximize the affordability of the comprehensive standard health benefit plan to the small employer market.

#### Regulation .02 Definitions.

*COMAR 31.11.06.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Anniversary date” means the date that is the same date, excluding year, as the effective date of the health benefit plan.

  (2) “Carrier” has the meaning stated in Insurance Article, §15-1201(c), Annotated Code of Maryland.

  (3) “Case management” means a form of utilization review used with high cost cases to monitor and manage treatment and suggest appropriate medical services.

  (4) “Chlamydia screening test” has the meaning stated in Insurance Article, §15-829, Annotated Code of Maryland.

  (5) “Coinsurance percentage” or “coinsure” means the percentage of allowable charges allocated to the carrier and to the covered person.

  (6) “Congenital or genetic birth defect” means a defect existing at or from birth, including a hereditary defect, which includes, but is not limited to, autism or an autism spectrum disorder and cerebral palsy.

  (7) “Controlled clinical trial” means a treatment that is:

    (a) Approved by an institutional review board;

    (b) Conducted for the primary purpose of determining whether or not a particular treatment is safe and efficacious; and

    (c) Approved by:

      (i) An institute or center of the National Institutes of Health,

      (ii) The Food and Drug Administration,

      (iii) The Department of Veterans' Affairs, or

      (iv) The Department of Defense.

  (8) “Covered person” means an employee or a dependent of an employee covered by a carrier under the comprehensive standard health benefit plan.

  (9) “Copayment” means a specified charge that a covered person must pay each time services of a particular type or in a designated setting are received.

  (10) “Deductible” means the amount of allowable charges that must be incurred by an individual or a family per year before a carrier begins payment.

  (11) “Delivery system” means the method that a carrier uses to provide the comprehensive standard health benefit plan to covered persons.

  (12) “Dependent” means a covered person's lawful spouse or dependent child.

  (13) Dependent Child.

    (a) For plan years beginning before September 23, 2010, “dependent child” means an individual who is unmarried, younger than 25 years old, a dependent of the covered employee as that term is used in 26 U.S.C §§104, 105, and 106, and any regulations adopted under those sections, and is a:

      (i) Biological child, stepchild, grandchild, or foster child of the covered employee;

      (ii) Lawfully adopted child of the covered employee, or, from the date of placement, a child in the process of being adopted by the covered employee;

      (iii) Child for whom the covered employee has been granted legal custody, including custody as a result of a guardianship, other than a temporary guardianship of less than 12 months duration, by a court or testamentary appointment; or

      (iv) Child for whom the covered person has the legal obligation to provide coverage pursuant to court order, court-approved agreement, or testamentary appointment.

    (b) For plan years beginning on or after September 23, 2010, “dependent child” means an individual who is younger than 26 years old and is a:

      (i) Biological child, stepchild, grandchild, or foster child of the covered employee;

      (ii) Lawfully adopted child of the covered employee or, from the date of placement, a child in the process of being adopted by the covered employee;

      (iii) Child for whom the covered employee has been granted legal custody, including custody as a result of a guardianship, other than a temporary guardianship of less than 12 months duration, by a court or testamentary appointment; or

      (iv) Child for whom the covered person has the legal obligation to provide coverage pursuant to a court-ordered, court-approved agreement, or testamentary appointment.

    (c) Notwithstanding the age limitation stated in §B(13)(a) and (b) of this regulation, “dependent child” includes an unmarried child who is dependent upon the covered employee for more than 50 percent of the child’s support and who, at the time of reaching the age limitation set forth in §B(13)(a) or (b) of this regulation, is incapable of self-support because of mental or physical incapacity that began before the dependent child’s attaining the limiting age.

  (14) “Domiciliary care” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

  (15) “Durable medical equipment” means equipment furnished by a supplier or a home health agency that:

    (a) Can withstand repeated use;

    (b) Is primarily and customarily used to serve a medical purpose;

    (c) Generally is not useful to an individual in the absence of a disability, illness, or injury; and

    (d) Is appropriate for use in the home.

  (16) “Eligible employee” has the meaning stated in Insurance Article, §15-1201(e), Annotated Code of Maryland.

  (17) “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

    (a) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

    (b) Serious impairment to bodily functions; or

    (c) Serious dysfunction of any bodily organ or part.

  (18) “Emergency services” means, with respect to an emergency medical condition:

    (a) A medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate the emergency medical condition; and

    (b) Such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under section 1867 of the Social Security Act (42 U.S.C. 1395dd(e)(3)).

  (19) “Exclusive provider” means a delivery system offered by an insurer or nonprofit health service plan that provides services to a covered person through preferred providers in accordance with Insurance Article, §14-205.1, Annotated Code of Maryland.

  (20) Experimental Services.

    (a) “Experimental services” means services that are not recognized as efficacious as that term is defined in the edition of the Institute of Medicine Report on Assessing Medical Technologies that is current when the care is rendered.

    (b) “Experimental services” do not include controlled clinical trials as defined in §B(7) of this regulation.

  (21) “Family” means:

    (a) An individual and spouse;

    (b) An individual and dependent minor or minors; or

    (c) An individual, spouse, and dependent minor or minors.

  (22) “Family planning services” means counseling, implanting or fitting birth control devices, and follow-up visits after a covered person selects a birth control method.

  (23) “Federally qualified health maintenance organization” means a health maintenance organization which meets the requirements of Title XIII of the Public Health Service Act, 42 U.S.C. §3000e et seq.

  (24) “Habilitative services” means services, including occupational therapy, physical therapy, and speech therapy, for the treatment of children with congenital and genetic birth defects to enhance the child's ability to function.

  (25) “Health benefit plan” has the meaning stated in Insurance Article, §15-1201(f), Annotated Code of Maryland.

  (26) “Health maintenance organization” has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.

  (27) “Health care facility” has the meaning stated in Health-General Article, §19-114, Annotated Code of Maryland.

  (28) “Home health care” means the continued care and treatment of a covered person in the home if:

    (a) The institutionalization of the covered person in a hospital or related institution or skilled nursing facility would otherwise have been required if home health care were not provided; and

    (b) The plan of treatment covering the home health care service is established and approved in writing by the health care practitioner.

  (29) “Hospice care” has the meaning stated in 42 U.S.C. §1395x(dd).

  (30) “Health care practitioner” has the meaning stated in Health-General Article, §19-132, Annotated Code of Maryland.

  (31) “Health savings account” means a health savings account as defined in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Title 12, §1201(a) as codified at Part VII, subchapter B, chapter 1, §223(d) of the Internal Revenue Code of 1986.

  (32) “Health savings account compatible delivery system” or “HSA-compatible delivery system” means a health benefit plan which:

    (a) To be used with a health savings account, meets the requirements of a high deductible health plan as defined in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, codified at §223(c)(2) of the Internal Revenue Code of 1986; and

    (b) May be:

      (i) A preferred provider organization delivery system to be used with a health savings account (PPO-HSA);

      (ii) A health maintenance organization delivery system to be used with a health savings account (HMO-HSA); or

      (iii) An exclusive provider delivery system to be used with a health savings account (EPO-HSA).

  (33) “Indemnity” means a delivery system in which:

    (a) Payment is made on an expense-incurred basis; and

    (b) The covered person's choice of health care practitioner is not limited to a network of providers.

  (34) “Insulin-using beneficiary” means a beneficiary who uses insulin as part of a treatment plan prescribed by the beneficiary's medical care provider.

  (35) “Insurer” has the meaning stated in Insurance Article, §1-101(v), Annotated Code of Maryland.

  (36) “Late enrollee” has the meaning stated in Insurance Article, §15-1201(h), Annotated Code of Maryland.

  (37) “Lifetime maximum” means the maximum amount the carrier is obligated to pay for all services in the lifetime of a covered person.

  (38) “Limited out-of-network additional benefit” means an additional benefit offered by an insurer or nonprofit health service plan that:

    (a) Permits a covered person enrolled in an exclusive provider delivery system to receive certain health care services out-of-network that would be covered in network; and

    (b) Conditions the payment of benefits as required under Insurance Article, §14-205.1, Annotated Code of Maryland.

  (39) “Maintenance drug” has the meaning set forth in Insurance Article, §15-824(a)(3), Annotated Code of Maryland.

  (40) “Managed care system” means a method that a carrier uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality, and claims.

  (41) “Mandated benefit” means:

    (a) A health care service, benefit, coverage, or reimbursement for covered health care services that is required under the Insurance Article or the Health-General Article, Annotated Code of Maryland, to be provided or offered in a health benefit plan that is issued or delivered in the State by a carrier; or

    (b) Reimbursement, required by statute, by a health benefit plan for a service when that service is performed by a care provider who is licensed under the Health Occupations Article and whose scope of practice includes that service.

  (42) “Multiple risk factors” has the meaning stated in Insurance Article, §15-829, Annotated Code of Maryland.

  (43) “Network” means providers who have entered into a provider service contract with a carrier to provide services on a preferential basis.

  (44) “Out-of-network option” means an additional benefit offered by an insurer or nonprofit health service plan that:

    (a) Permits a covered person enrolled in an exclusive provider delivery system to receive any healthcare service that would be covered from network providers also to be covered when received from non-network providers; and

    (b) Conditions the payment of benefits as required under Insurance Article, §14-205.1, Annotated Code of Maryland.

  (45) “Out-of-pocket limit” means the maximum amount of copayments, deductibles, and coinsurance that an individual or family is obligated to pay for covered services per contract year.

  (46) “Outpatient rehabilitative services” means occupational therapy, speech therapy, and physical therapy, provided to covered persons not admitted to a hospital or related institution.

  (47) “Partial hospitalization” means the provision of medically directed intensive or intermediate short-term psychiatric treatment for a period of less than 24 hours but more than 4 hours in a day for an individual patient in a hospital, psychiatric day-care treatment center, or community mental health facility.

  (48) “Personal care” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

  (49) “Plan” means the comprehensive standard health benefit plan described in this chapter.

  (50) “Plan year” means a 12-month period that begins:

    (a) For the first year of the plan, on the effective date of the plan; and

    (b) For plans that have been in effect for 1 year or longer, on the anniversary date of the plan.

  (51) “Point-of-service (POS)” means a delivery system that permits a covered person to receive services outside the network in accordance with the recommendations of the primary care physician within a managed care system.

  (52) “Point-of-service option” means an additional benefit offered by a health maintenance organization that permits a covered person enrolled in a health maintenance organization to receive any health care service outside the provider panel of the health maintenance organization that is covered under the covered person's contract with the health maintenance organization.

  (53) “Preferred provider organization” means a delivery system offered by an insurer or nonprofit health service plan that provides services to a covered person through a network and permits the covered person to select services outside the network.

  (54) “Preexisting condition” has the meaning stated in Insurance Article, §15-1201(k), Annotated Code of Maryland.

  (55) “Primary care” means services rendered by a health care practitioner in the following disciplines:

    (a) General internal medicine;

    (b) Family practice medicine;

    (c) Pediatrics; or

    (d) Obstetrics/gynecology.

  (56) “Provider” means a health care practitioner or a health care facility licensed or otherwise authorized by law to provide health care services.

  (57) “Related institution” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

  (58) “Religious organization” means an entity that is organized and operated exclusively for religious purposes and has obtained a tax exemption under §501(c)(3) of the U.S. Internal Revenue Code.

  (59) “Residential crisis services” means intensive mental health and support services that are:

    (a) Provided to a child or an adult with a mental illness who is experiencing or is at risk of a psychiatric crisis that would impair the individual's ability to function in the community;

    (b) Designed to prevent a psychiatric inpatient admission, provide an alternative to psychiatric inpatient admission, or shorten the length of inpatient stay;

    (c) Provided out of the individual's residence on a short-term basis in a community-based residential setting; and

    (d) Provided by entities that are licensed by the Maryland Department of Health to provide residential crisis services.

  (60) “Service” means a health care diagnosis, procedure, treatment, or item.

  (61) “Skilled nursing facility” means an institution, or a distinct part of an institution, licensed by the Maryland Department of Health, which is:

    (a) Primarily engaged in providing:

      (i) Skilled nursing care, and related services, for residents who require medical or nursing care, or

      (ii) Rehabilitation services for the rehabilitation of injured, disabled, or sick persons; and

    (b) Certified by the Medicare Program as a skilled nursing facility.

  (62) “Small employer” has the meaning stated in Insurance Article, §15-1201(o), Annotated Code of Maryland.

  (63) “Specialty services” means care provided by a health care practitioner who is not providing primary care services.

  (64) “Triple option point-of-service (triple option POS)” means a delivery system that permits a covered person to select an indemnity, preferred provider, or health maintenance organization delivery system at the time of medical need.

#### Regulation .03 Covered Services.

*COMAR 31.11.06.03*

A. The comprehensive standard health benefit plan includes the following:

  (1) Care in medical offices for treatment of illness or injury;

  (2) Inpatient hospital services;

  (3) Outpatient hospital services;

  (4) Inpatient mental health and substance abuse services provided through a carrier's managed care system, including residential crisis services, up to a maximum of 60 days per covered person per year in a hospital, related institution, or entity licensed by the Maryland Department of Health to provide residential crisis services;

  (5) Outpatient mental health and substance abuse services provided through a carrier's managed care system;

  (6) Emergency services;

  (7) Detoxification in a hospital or related institution;

  (8) Ambulance services to or from the nearest hospital where needed medical services can appropriately be provided;

  (9) Except for prostate cancer screening for men between 40 and 75 years old, and colorectal screening for men and women 50 years old or older, preventive services recommended in the report of the United States Preventive Services Task Force, Guide to Clinical Preventive Services, which is current when the services are rendered, and any other preventive service required to be offered by a federally qualified health maintenance organization;

  (9-1) Prostate cancer screening shall be covered as set forth in the current recommendations of the American Cancer Society, which recommends an annual:

    (a) Digital rectal examination for both prostate and colorectal cancer, beginning at age 40;

    (b) PSA screening for African-American men and all men 40 years old and older with a family history of prostate cancer; and

    (c) PSA screening for all other men 50 years old and older;

  (9-2) Colorectal screening shall be covered for men and women 50 years old or older as follows:

    (a) A yearly fecal occult blood test, accompanied by digital rectal examination, plus flexible sigmoidoscopy every 5 years;

    (b) A colonoscopy, accompanied by digital rectal examination, every 10 years; or

    (c) A double contrast barium enema, accompanied by digital rectal examination, every 5 years;

  (10) Mammography services for persons ages 40 to 49 once every other calendar year, and for ages 50 and above once per calendar year;

  (11) Home health care services:

    (a) As an alternative to otherwise covered services in a hospital or related institution; and

    (b) For contracts issued or renewed on or after November 1, 1999, for covered persons who receive less than 48 hours of inpatient hospitalization following a mastectomy or removal of a testicle or who undergo a mastectomy or removal of a testicle on an outpatient basis:

      (i) One home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility; and

      (ii) An additional home visit if prescribed by the covered person's attending physician;

  (12) Hospice care services;

  (13) Durable medical equipment, including nebulizers, peak flow meters, prosthetic devices such as leg, arm, back, or neck braces, artificial legs, arms, or eyes, and the training necessary to use these prostheses;

  (14) Outpatient laboratory and diagnostic services;

  (15) Outpatient rehabilitative services provided through a carrier's managed care system for a maximum of:

    (a) 30 physical therapy visits per condition per year;

    (b) 30 speech therapy visits per condition per year;

    (c) 30 occupational therapy visits per condition per year; or

    (d) When provided by a federally qualified health maintenance organization, the outpatient rehabilitation service coverage specified in 42 CFR §417.101(a)(2)(iii).

  (16) Chiropractic services up to 20 visits per condition per year;

  (17) Skilled nursing facility services as an alternative to medically necessary inpatient hospital services up to a maximum of 100 days per year;

  (18) Infertility services, except for those services excluded in this chapter;

  (19) Nutritional services for the treatment of cardiovascular disease, diabetes, malnutrition, cancer, cerebral vascular disease, or kidney disease up to a maximum of six visits per year per condition;

  (20) Autologous and nonautologous bone marrow, cornea, kidney, liver, heart, lung, heart/lung, pancreas, and pancreas/kidney transplants;

  (21) Medical food for persons with metabolic disorders when ordered by a health care practitioner qualified to provide diagnosis and treatment in the field of metabolic disorders;

  (22) Family planning services, including:

    (a) Prescription contraceptive drugs or devices;

    (b) Coverage for the insertion or removal of contraceptive devices;

    (c) Medically necessary examination associated with the use of contraceptive drugs or devices; and

    (d) Voluntary sterilization;

  (23) Except for habilitative services provided in early intervention and school services, habilitative services for children 0—19 years old for the treatment of congenital or genetic birth defects;

  (24) All cost recovery expenses for blood, blood products, derivatives, components, biologics, and serums to include autologous services, whole blood, red blood cells, platelets, plasma, immunoglobulin, and albumin;

  (25) Pregnancy and maternity services, including abortion;

  (26) Prescription drugs;

  (27) Controlled clinical trials;

  (28) Any other service approved by a carrier's case management program;

  (29) Diabetes treatment, equipment, and supplies; and

  (30) Breast reconstructive surgery as specified in Insurance Article, §15-815, Annotated Code of Maryland, and breast prosthesis;

  (31) Audiology screening for newborns, limited to one screen and one confirming screen; and

  (32) General anesthesia and associated hospital or ambulatory facility charges in conjunction with dental care provided to the following:

    (a) Individuals who are 7 years old or younger or developmentally disabled and for whom a:

      (i) Successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual, or other medically compromising condition of the enrollee or insured; and

      (ii) Superior result can be expected from dental care provided under general anesthesia;

    (b) Individuals 17 years old or younger who:

      (i) Are extremely uncooperative, fearful, or uncommunicative;

      (ii) Have dental needs of such magnitude that treatment should not be delayed or deferred; and

      (iii) Are individuals for whom lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral or dental morbidity;

  (33) An annual chlamydia screening test for:

    (a) Women who are:

      (i) Younger than 20 years old who are sexually active; or

      (ii) At least 20 years old who have multiple risk factors; and

    (b) Men who have multiple risk factors;

  (34) The cost to beneficiaries of hearing aids for persons 0 to 18 years of age, up to $1,400 per hearing aid for each hearing-impaired ear every 36 months; and

  (35) The surgical treatment of morbid obesity as specified in Insurance Article, §15-839, Annotated Code of Maryland.

A-1. Morbid Obesity.

  (1) When establishing utilization review criteria for the surgical treatment of morbid obesity, a carrier or a private review agent acting on behalf of a carrier shall adhere to the requirements of COMAR 31.10.33.03.

  (2) Surgical treatment of morbid obesity shall occur in a facility that is:

    (a) Designated by the American Society for Metabolic and Bariatric Surgery as a Bariatric Surgery Center of Excellence; and

    (b) Designated by the carrier.

  (3) If a carrier does not make a designation under §A-1(2) of this regulation, the carrier shall provide benefits under the health benefit plan for the surgical treatment of morbid obesity at any facility that is designated by the American Society for Metabolic and Bariatric Surgery as a Bariatric Surgery Center of Excellence.

B. The services described in §A(23) of this regulation shall be delivered through a carrier's managed care system and shall include services for cleft lip and cleft palate, orthodontics, oral surgery, otologic, audiological, and speech therapy, physical therapy, and occupational therapy for children 0—19 years old for treatment of congenital or genetic birth defects.

C. All mental health and substance abuse services described in §A(4) and (5) of this regulation shall be delivered through a carrier's managed care system.

D. Rehabilitative services and habilitative services required to be offered in the plan shall be provided through the carrier's managed care system.

E. Prescription Drugs.

  (1) Carriers shall cover prescription drugs and may, for brand name drugs, use a formulary which complies with the requirements of Insurance Article, §15-831, Annotated Code of Maryland.

  (2) Carriers shall cover insulin and birth control drugs.

  (3) Except as provided in §E(4) of this regulation, coverage under §A(26) of this regulation of prescription drugs includes up to a 90-day supply of maintenance drugs dispensed in a single dispensing of a prescription.

  (4) Coverage of up to a 90-day supply of maintenance drugs in a single dispensing is not required for the first prescription of a maintenance drug or a change in a prescription of a maintenance drug.

F. The carrier shall provide benefits for the covered services in accordance with the terms of the contract, if:

  (1) The service is rendered by a health care practitioner who is licensed under the laws of the state in which the practitioner is practicing; and

  (2) The health care practitioner is practicing within the scope of the license.

G. Under §A(4) of this regulation, two partial hospitalization days may be substituted for one inpatient day in a hospital or related institution.

H. Under §A(29) of this regulation, diabetes equipment includes glucose monitoring equipment under the durable medical equipment coverage for insulin-using beneficiaries. Insulin pumps are not included. Diabetes supplies include coverage for insulin syringes and needles and testing strips for glucose monitoring equipment under the prescription coverage for insulin-using beneficiaries.

I. Under §A(30) of this regulation, breast prosthesis and breast reconstruction on the nondiseased breast to achieve symmetry is covered regardless of the patient's insurance status at the time of the mastectomy or the time lag between the mastectomy and reconstruction.

J. Under §A(32) of this regulation:

  (1) Carriers may require prior authorization for covered services and associated charges in the same manner that prior authorization is required for these benefits in connection with other covered medical care;

  (2) Carriers may restrict coverage to dental care that is provided by a:

    (a) Fully accredited specialist in pediatric dentistry;

    (b) Fully accredited specialist in oral and maxillofacial surgery; and

    (c) Dentist to whom hospital privileges have been granted; and

  (3) Dental care for which general anesthesia is required is not covered.

#### Regulation .03-1 Covered Services — Preventive Care Services.

*COMAR 31.11.06.03-1*

A. This regulation applies to plans with plan years that begin on or after September 23, 2010.

B. The benefits required by Regulation .03A(9), (9-1), (9-2), (10), (31) and (33), Regulation .04F(5)(e) and (6)(e), and Regulation .05I of this chapter do not apply to plans with plan years that begin on or after September 23, 2010.

C. Plans that are subject to this regulation shall provide benefits for the following preventive care services:

  (1) Except as provided in §D of this regulation, evidence–based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force;

  (2) Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;

  (3) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and

  (4) With respect to women, to the extent not described in §C(1) of this regulation, evidence-informed preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

D. For the purposes of §C(1) of this regulation, recommendations of the United States Preventive Services Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 are not considered to be current.

E. For the purposes of §C(2) of this regulation, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered to be:

  (1) In effect after it has been adopted by the director of the Centers for Disease Control and Prevention; and

  (2) For routine use if it is listed on the immunization schedules of the Centers for Disease Control and Prevention.

F. Cost Sharing Requirements.

  (1) Except as described §F(2) and (3) of this regulation, a carrier may not impose any cost sharing requirements, such as copayment amounts, coinsurance amounts, or deductible amounts, on the preventive care services required under §C of this regulation.

  (2) If a carrier’s plan permits individuals covered under the plan to receive services from nonparticipating providers, the carrier may impose a carrier’s coinsurance percentage of 60 percent of allowable charges.

  (3) If a new recommendation or guideline described in §C of this regulation is issued after the effective date of the plan, the new recommendation or guideline shall apply the first plan year that begins on the date that is 1 year after the date the recommendation or guideline is issued.

#### Regulation .04 Uniform Cost-Sharing Arrangements — In General.

*COMAR 31.11.06.04*

A. For each delivery system identified in §F of this regulation, a carrier shall apply the uniform cost-sharing arrangements specified.

B. Copayments.

  (1) Except for copayments for emergency services, which a carrier shall apply to the deductible and the out-of-pocket limit, a carrier may not apply the copayments set forth in this chapter to reduce the amount of a deductible or out-of-pocket limit.

  (2) Notwithstanding §B(1) of this regulation, a carrier shall apply all copayments set forth in this chapter to reduce the amount of a deductible or out-of-pocket limit for a HSA-compatible delivery system.

C. A carrier shall apply the covered person's coinsurance amount and emergency services copayments to the deductible and out-of-pocket limit.

D. A carrier shall apply the deductible to the out-of-pocket limit.

E. A carrier may increase deductibles, copayments, coinsurance, or out-of-pocket limits up to 1.5 times the amounts specified in §F of this regulation in accordance with Insurance Article, §15-1208, Annotated Code of Maryland.

F. For each of the delivery systems identified, the following general cost-sharing requirements apply:

  (1) Indemnity:

    (a) For an employee enrolled under individual coverage, a deductible of $2,500 per year; for an employee enrolled under other than individual coverage, a deductible of $5,000 in aggregate per year;

    (b) For an employee enrolled under individual coverage, out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, out-of-pocket limit of $9,800 in aggregate per year;

    (c) Lifetime maximum of:

      (i) For plan years beginning before September 23, 2010, $2 million per covered person; and

      (ii) For plan years beginning on or after September 23, 2010, unlimited;

    (d) Carrier's coinsurance percentage of 80 percent of allowable charges;

  (2) Preferred provider organizations:

    (a) Non-health savings account-compatible preferred provider organizations (PPO):

      (i) For an employee enrolled under individual coverage, combined in-network and out-of-network deductible of $2,500 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network deductible of $5,000 in aggregate per year;

      (ii) For an employee enrolled under individual coverage, combined in-network and out-of-network out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network out-of-pocket limit of $9,800 in aggregate per year;

    (b) PPO-HSA:

      (i) For an employee enrolled under individual coverage, combined in-network, out-of-network, and prescription drug deductible of $2,700 per year; for an employee enrolled under other than individual coverage, combined in-network, out-of-network, and prescription drug deductible of $5,450 in aggregate per year;

      (ii) For an employee enrolled under individual coverage, combined in-network and out-of-network out-of-pocket limit of $5,250 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network out-of-pocket limit of $10,500 in aggregate per year;

      (iii) For the health savings account-compatible preferred provider, carriers may not offer additional benefits to reduce deductibles below the minimum deductibles required by federal law or raise out-of-pocket limits above the maximum out-of-pocket limits required by federal law;

    (c) A carrier may offer either a PPO-HSA or a non PPO-HSA, or both;

    (d) Lifetime maximum of:

      (i) For plan years beginning before September 23, 2010, $2 million per covered person; and

      (ii) For plan years beginning on or after September 23, 2010, unlimited;

    (e) Carrier's coinsurance percentage of 80 percent of allowable charges for in-network services;

    (f) Carrier's coinsurance percentage of 60 percent of allowable charges for out-of-network services;

  (3) Point-of-service when delivered in conjunction with preferred provider:

    (a) For an employee enrolled under individual coverage, a deductible of $2,500 per year; for an employee enrolled under other than individual coverage, a deductible of $5,000 in aggregate per year;

    (b) For an employee enrolled under individual coverage, combined in-network and out-of-network out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network out-of-pocket limit of $9,800 in aggregate per year;

    (c) Lifetime maximum of:

      (i) For plan years beginning before September 23, 2010, $2 million per covered person; and

      (ii) For plan years beginning on or after September 23, 2010, unlimited;

    (d) Carrier's coinsurance percentage of 80 percent of allowable charges for in-network services;

    (e) Carrier's coinsurance percentage of 60 percent of allowable charges for out-of-network services;

  (4) Health maintenance organization-non-health savings account compatible delivery system:

    (a) A covered person shall be responsible for copayments for the following services at the payment level indicated:

      (i) Primary care services—$30;

      (ii) Specialty care services—$40;

      (iii) Physician inpatient hospital visits—$30;

      (iv) Outpatient laboratory services—$40 or 50 percent of the cost of the service, whichever is less;

      (v) Outpatient diagnostic services—$40 or 50 percent of the cost of the service, whichever is less; and

      (vi) Inpatient hospital copayment—$1,000 per admission;

    (b) For an employee enrolled under individual coverage, the out-of-pocket limit is 200 percent of the total annual premium as specified by a fixed dollar amount in the employee's certificate;

    (c) For an employee enrolled under other than individual coverage, the out-of-pocket limit is 200 percent of the total annual premium in aggregate as specified by a fixed dollar amount in the employee's certificate;

    (d) Under the mandatory POS option, carrier's coinsurance percentage of at least 60 percent of allowable charges for out-of-network services;

  (5) High deductible health maintenance organization—non-health savings account compatible delivery system:

    (a) Except as described in §F(5)(e) of this regulation, for an employee enrolled under individual coverage, combined in-network and out-of-network deductible of $2,500 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network deductible of $5,000 in aggregate per year;

    (b) For an employee enrolled under individual coverage, combined in-network and out-of-network out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, combined in-network and out-of-network out-of-pocket limit of $9,800 in aggregate per year;

    (c) After the deductible described in §F(5)(a) of this regulation is satisfied, the covered person shall be responsible for copayments for the following services at the payment level indicated:

      (i) Primary care services—$30;

      (ii) Specialty care services—$40;

      (iii) Physician inpatient hospital visits—$30;

      (iv) Outpatient laboratory services—$40 or 50 percent of the cost of the service, whichever is less;

      (v) Outpatient diagnostic services—$40 or 50 percent of the cost of the service, whichever is less; and

      (vi) Inpatient hospital copayment—$1,000 per admission;

    (d) Under the mandatory POS option, the carrier's coinsurance percentage shall be at least 60 percent of allowable charges for out-of-network services; and

    (e) Well-child care and immunization benefits provided in conjunction with the high deductible health maintenance organization—non-health savings account compatible delivery system shall be subject to a $10 copayment and not subject to the overall deductible;

  (6) HMO-HSA:

    (a) Except as described in §F(6)(e) of this regulation, combined annual deductible for all covered services, including prescription drugs, of $2,700 for an employee enrolled in individual coverage and $5,450 in aggregate for an employee enrolled in other than individual coverage;

    (b) The out-of-pocket limit for all covered services, including prescription drugs, child wellness, and immunization services, shall be subject to the annual out-of-pocket maximum for HSA-compatible delivery systems of $5,250 for employees enrolled as individuals and $10,500 in aggregate for employees enrolled as other than individuals;

    (c) After the deductible described in §F(6)(a) of this regulation is satisfied, the covered person shall be responsible for copayments at the payment level indicated:

      (i) Primary care services—$30;

      (ii) Specialty care services—$40;

      (iii) Physician inpatient hospital visits—$30;

      (iv) Outpatient laboratory services—$40 or 50 percent of the cost of the service, whichever is less;

      (v) Outpatient diagnostic services—$40 or 50 percent of the cost of the service, whichever is less; and

      (vi) Inpatient hospital copayment—$1,000 per admission;

    (d) Under the mandatory POS option, the carrier's coinsurance percentage shall be at least 60 percent of allowable charges for out-of-network services;

    (e) Well-child care and immunization benefits provided in conjunction with the HMO-HSA shall be subject to a $10 copayment and not subject to the overall deductible;

  (7) Triple option point-of-service:

    (a) For the indemnity portion of the triple option, the general cost-sharing requirements set forth in §F(1) of this regulation shall apply;

    (b) For the preferred provider portion of the triple option, the general cost-sharing requirements set forth in §F(2)(a), (e)—(g) of this regulation shall apply;

    (c) For the health maintenance organization portion of the triple option, the general cost-sharing requirements set forth in §F(4) of this regulation shall apply;

    (d) For plan years beginning before September 23, 2010, a $2 million lifetime maximum per covered person is applicable to the indemnity and preferred provider portions of the triple option;

    (e) For plan years beginning on or after September 23, 2010, a lifetime maximum may not apply to the indemnity and preferred portions of the triple option;

    (f) A lifetime maximum may not apply to the health maintenance organization portion of the triple option;

  (8) Exclusive provider:

    (a) Non-health savings account-compatible exclusive provider organization (EPO):

      (i) For an employee enrolled under individual coverage, a deductible of $2,500 per year; for an employee enrolled under other than individual coverage, a deductible of $5,000 in aggregate per year;

      (ii) For an employee enrolled under individual coverage, an out-of-pocket limit of $4,900 per year; for an employee enrolled under other than individual coverage, an out-of-pocket limit of $9,800 in aggregate per year;

    (b) EPO-HSA:

      (i) For an employee enrolled under individual coverage, a deductible of $2,700 per year; for an employee enrolled under other than individual coverage, a deductible of $5,450 in aggregate per year;

      (ii) For an employee enrolled under individual coverage, an out-of-pocket limit of $5,250 per year; for an employee enrolled under other than individual coverage, an out-of-pocket limit of $10,500 in aggregate per year;

      (iii) For the health savings account-compatible exclusive provider organization, carriers may not offer additional benefits to reduce deductibles below the minimum deductibles required by federal law or raise out-of-pocket limits above the maximum out-of-pocket limits required by federal law;

    (c) A carrier may offer an EPO or an EPO-HSA, or both;

    (d) There shall be a lifetime maximum of:

      (i) For plan years beginning before September 23, 2010, $2 million per covered person; and

      (ii) For plan years beginning on or after September 23, 2010, unlimited;

    (e) There shall be a carrier's coinsurance percentage of 80 percent of allowable charges for covered services;

    (f) Under the mandatory out-of-network option described in Regulation .08 of this chapter, there shall be a carrier's coinsurance percentage of at least 60 percent of allowable charges for out-of-network services.

#### Regulation .05 Uniform Cost-Sharing Arrangements — Specific Services.

*COMAR 31.11.06.05*

A. General Cost-Sharing Arrangement for Outpatient Mental Health and Substance Abuse Services.

  (1) Except as provided in §B of this regulation, for outpatient mental health and substance abuse, the carrier shall pay for each service 70 percent of allowable charges.

  (2) A carrier may substitute a copayment for these services at an actuarially equivalent amount to the coinsurance percentages described in this regulation subject to the approval of the Insurance Commissioner and the Maryland Health Care Commission.

  (3) For purposes of the cost-sharing arrangement set forth in §A(1) of this regulation, a carrier shall treat a visit made solely for medication management purposes for mental health or substance abuse treatment as a covered service under Regulation .03A(1) of this chapter and may not count the visit as a mental health or substance abuse service described in Regulation .03A(5) of this chapter.

B. Out-of-Network Cost-Sharing Arrangements for Outpatient Mental Health and Substance Abuse Services.

  (1) For outpatient services for mental health and substance abuse received out-of-network in a preferred provider organization delivery system or point-of-service delivery system, triple option delivery system, or HSA-compatible delivery system, the carrier shall pay for each service 50 percent of allowable charges.

  (2) A carrier may substitute a copayment for these services at an actuarially equivalent amount to the coinsurance percentages described in this regulation subject to the approval of the Insurance Commissioner and the Maryland Health Care Commission.

  (3) For purposes of the uniform cost-sharing arrangements set forth in §B(1) of this regulation, a carrier shall treat a visit made solely for medication management purposes for mental health or substance abuse treatment as a covered service under Regulation .03A(1) and may not count the visit as a mental health or substance abuse service described in Regulation .03A(5) of this chapter.

C. For outpatient services or surgery, the covered person shall pay a $40 copayment or the coinsurance percentage applicable under Regulation .04F of this chapter, whichever is greater, but not greater than the charges.

D. Except for health maintenance organizations, for outpatient laboratory or diagnostic services, the covered person shall pay a $40 copayment or the coinsurance percentage applicable under Regulation .04F of this chapter, whichever is greater, but not greater than the charges.

E. For emergency services, the covered person shall pay:

  (1) A $100 copayment, which the carrier shall waive if the covered person is admitted to the hospital; and

  (2) For coinsurance the:

    (a) Amount applicable for indemnity or exclusive provider under Regulation .04F of this chapter; or

    (b) In-network amount for preferred provider, point-of-service and triple option point-of-service under Regulation .04F of this chapter.

F. For infertility services obtained after the diagnosis of infertility has been confirmed, a carrier shall coinsure 50 percent of allowable charges.

G. For skilled nursing facility services, a covered person shall pay a $40 per day copayment or the coinsurance percentage applicable under Regulation .04F of this chapter, whichever is greater.

H. For prescription drugs:

  (1) Persons in a non-HSA-compatible delivery system with individual coverage shall pay a $2,500 deductible, and persons with non-individual coverage a $5,000 in aggregate deductible separate from the deductibles set forth in Regulation .04F of this chapter;

  (2) Persons enrolled under a HSA-compatible delivery system shall satisfy the deductible set forth in Regulation .04F(2)(b) or (6) of this chapter as a prerequisite to receiving prescription drug benefits;

  (3) After paying the applicable deductible, each covered person shall pay a 75% coinsurance percentage.

I. Well-Child Visits Cost-Sharing.

  (1) For well-child visits, a covered person shall pay:

    (a) Only a $10 copayment for all visits for children 0—24 months of age in a health maintenance organization or indemnity delivery system and for in-network services in a preferred provider delivery system, point-of-service delivery system, triple-option delivery system, HSA-compatible delivery system, or an exclusive provider delivery system;

    (b) Only a $10 copayment for visits that include immunization for children older than 24 months through 13 years of age in a health maintenance organization or indemnity delivery system and for in-network services in a preferred provider delivery system, point-of-service delivery system, triple-option point-of-service delivery system, HSA-compatible delivery system, or an exclusive provider delivery system;

    (c) For out-of-network services in a preferred provider delivery system, point-of-service delivery system, triple-option point-of-service delivery system, or HSA-compatible delivery system, in accordance with the uniform cost-sharing arrangements described in Regulation .04F(2), (3), and (7) of this chapter; and

    (d) For all other visits in accordance with uniform cost-sharing arrangements described in Regulation .04 of this chapter for each delivery system.

  (2) A carrier may substitute a copayment that is the actuarial equivalent to the amount specified in §I(1)(b) of this regulation for all well-child visits for children 2—13 years old.

J. General Cost-Sharing Arrangements for Outpatient Rehabilitation and Chiropractic Services. Except as provided in §K of this regulation, for outpatient rehabilitation services and chiropractic services, the carrier shall pay 70 percent of the allowable charges, or may substitute a $40 copayment for these services.

K. Out-of-Network Cost-Sharing Arrangements for Outpatient Rehabilitation Services and Chiropractic Services. For outpatient rehabilitation services and chiropractic services received out-of-network in a preferred provider delivery system, point-of-service delivery system, triple option delivery system, or PPO-HSA, the carrier shall pay 50 percent of allowable charges.

#### Regulation .06 Limitations and Exclusions.

*COMAR 31.11.06.06*

A. A carrier shall apply the limitations and exclusions specified in §B of this regulation to the covered services specified in Regulation .03 of this chapter.

B. The following are exclusions and limitations to the covered services:

  (1) Services that are not medically necessary;

  (2) Services performed or prescribed under the direction of a person who is not a health care practitioner;

  (3) Services that are beyond the scope of practice of the health care practitioner performing the service;

  (4) Services to the extent they are covered by any government unit, except for veterans in Veterans' Administration or armed forces facilities for services received for which the recipient is liable;

  (5) Services for which a covered person is not legally, or as a customary practice, required to pay in the absence of a health benefit plan;

  (6) The purchase, examination, or fitting of eyeglasses or contact lenses, except for aphakic patients and soft or rigid gas permeable lenses or sclera shells intended for use in the treatment of a disease or injury;

  (7) Personal care services and domiciliary care services;

  (8) Services rendered by a health care practitioner who is a covered person's spouse, mother, father, daughter, son, brother, or sister;

  (9) Experimental services;

  (10) Practitioner, hospital, or clinical services related to radial keratotomy, myopic keratomileusis, and surgery which involves corneal tissue for the purpose of altering, modifying, or correcting myopia, hyperopia, or stigmatic error;

  (11) In vitro fertilization, ovum transplants and gamete intrafallopian tube transfer, zygote intrafallopian transfer, or cryogenic or other preservation techniques used in these or similar procedures;

  (12) Services to reverse a voluntary sterilization procedure;

  (13) Services for sterilization or reverse sterilization for a dependent minor;

  (14) Medical or surgical treatment or regimen for reducing or controlling weight, unless otherwise specified in the covered services;

  (15) Services incurred before the effective date of coverage for a covered person;

  (16) Services incurred after a covered person's termination of coverage, including any extension of benefits;

  (17) Surgery or related services for cosmetic purposes to improve appearance, but not to restore bodily function or correct deformity resulting from disease, trauma, or congenital or developmental anomalies;

  (18) Services for injuries or diseases related to a covered person's job to the extent the covered person is required to be covered by a workers' compensation law;

  (19) Services rendered from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar persons or groups;

  (20) Personal hygiene and convenience items, including, but not limited to, air conditioners, humidifiers, or physical fitness equipment;

  (21) Charges for telephone consultations, failure to keep a scheduled visit, or completion of any form;

  (22) Inpatient admissions primarily for diagnostic studies, unless authorized by the carrier;

  (23) The purchase, examination, or fitting of hearing aids and supplies, and tinnitus maskers, except as provided in Regulation .03A(34) of this chapter;

  (24) Except for covered ambulance services, travel, whether or not recommended by a health care practitioner;

  (25) Except for emergency services, services received while the covered person is outside the United States;

  (26) Immunizations related to foreign travel;

  (27) Unless otherwise specified in covered services, dental work or treatment which includes hospital or professional care in connection with:

    (a) The operation or treatment for the fitting or wearing of dentures,

    (b) Orthodontic care or malocclusion,

    (c) Operations on or for treatment of or to the teeth or supporting tissues of the teeth, except for removal of tumors and cysts or treatment of injury to natural teeth due to an accident if the treatment is received within 6 months of the accident; and

    (d) Dental implants;

  (28) Accidents occurring while and as a result of chewing;

  (29) Routine foot care, including the paring or removing of corns and calluses, or trimming of nails, unless these services are determined to be medically necessary;

  (30) Arch support, orthotic devices, in-shoe supports, orthopedic shoes, elastic supports, or exams for their prescription or fitting, unless these services are determined to be medically necessary;

  (31) Inpatient admissions primarily for physical therapy, unless authorized by the carrier;

  (32) Treatment leading to or in connection with transsexualism, or sex changes or modifications, including but not limited to surgery;

  (33) Treatment of sexual dysfunction not related to organic disease;

  (34) Services that duplicate benefits provided under federal, State, or local laws, regulations, or programs;

  (35) Organ transplants except those included under Regulation .03 of this chapter;

  (36) Nonhuman organs and their implantation;

  (37) Nonreplacement fees for blood and blood products;

  (38) Lifestyle improvements, including nutrition counseling, or physical fitness programs, unless included as a covered service;

  (39) Wigs or cranial prosthesis;

  (40) Weekend admission charges, except for emergencies and maternity, unless authorized by the carrier;

  (41) Out-patient orthomolecular therapy, including nutrients, vitamins, and food supplements;

  (42) Temporomandibular joint syndrome (TMJ) treatment and treatment for craniomandibular pain syndrome (CPS), except for surgical services for TMJ and CPS, if medically necessary and if there is a clearly demonstrable radiographic evidence of joint abnormality due to disease or injury;

  (43) Services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable under a medical expense payment provision of an automobile insurance policy;

  (44) Services for conditions that State or local laws, regulations, ordinances, or similar provisions require to be provided in a public institution;

  (45) Services for, or related to, the removal of an organ from a covered person for purposes of transplantation into another person, unless the:

    (a) Transplant recipient is covered under the plan and is undergoing a covered transplant, and

    (b) Services are not payable by another carrier;

  (46) Physical examinations required for obtaining or continuing employment, insurance, or government licensing;

  (47) Nonmedical ancillary services such as vocational rehabilitation, employment counseling, or educational therapy;

  (48) Private hospital room, unless authorized by the carrier;

  (49) Private duty nursing, unless authorized by the carrier;

  (50) Treatment for mental health or substance abuse not authorized by the carrier through its managed care system, or a mental health or substance abuse condition determined by the carrier through its managed care system to be untreatable; and

  (51) Services related to smoking cessation.

C. A religious organization may request and a carrier shall grant the request for an exclusion from coverage for a service mandated under the plan if the service is in conflict with the religious organization's bona fide religious beliefs and practices.

D. A religious organization that obtains an exclusion from coverage for a service mandated under the plan shall provide its employees reasonable and timely notice of this exclusion.

E. The carrier's premium rate for the plan may not be affected by the religious organization's exclusions from coverage for a service mandated under the plan.

F. An insurer or non-profit health service plan may impose a preexisting condition exclusion as specified in Regulation .11 of this chapter.

#### Regulation .07 Additional Benefits.

*COMAR 31.11.06.07*

A. A carrier may offer benefits in addition to the plan only if:

  (1) The benefits are offered separately from the plan;

  (2) The benefits are priced separately from the plan;

  (3) Subject to the provisions of Insurance Article, §15-1213, Annotated Code of Maryland, the benefits are guarantee issued;

  (4) Subject to the provisions of Insurance Article, §15-1212, Annotated Code of Maryland, the benefits are guarantee renewed;

  (5) Subject to the provisions of Insurance Article, §15-1205, Annotated Code of Maryland, the benefits are community rated; and

  (6) The benefits do not duplicate any of the benefits in the plan.

B. An additional benefit that a carrier offers shall meet at least one of the following requirements:

  (1) The benefit increases access to care choices available under the plan;

  (2) The benefit increases the number of services available to covered persons under the plan;

  (3) The benefit increases the frequency that covered persons can obtain specified services under the plan; or

  (4) The benefit lowers the uniform cost-sharing arrangements described in Regulations .04 and .05 of this chapter.

C. A health maintenance organization may offer, or may contract with another carrier to offer, a point-of-service option as an additional benefit to the health maintenance organization delivery system or the HMO-HSA delivery system subject to the following requirements:

  (1) The point-of-service benefit allows a covered person to obtain services outside the network;

  (2) For out-of-network services, the health maintenance organization's coinsurance percentage shall be no less than the percentage of allowable charges specified in Regulations .04F and .05B of this chapter; and

  (3) The health maintenance organization may limit the benefits a covered person may obtain outside the network.

D. An insurer or nonprofit health service plan offering an exclusive provider delivery system or an EPO-HSA delivery system specified under this chapter may offer a limited out-of-network additional benefit as defined under Regulation .02 of this chapter as an additional benefit subject to the following requirements:

  (1) The limited out-of-network additional benefit allows a covered person to obtain services outside the network;

  (2) Except as specified in §D(4) of this regulation, for out-of-network services, the insurer's or nonprofit health service plan's coinsurance may not be less than 60 percent of allowable charges;

  (3) The insurer or nonprofit health service plan may limit the benefits a covered person may obtain outside the network; and

  (4) For outpatient services for mental health and substance abuse, rehabilitation, and chiropractic services received out-of-network, the insurer's or nonprofit health service plans' coinsurance may not be less than 50 percent of allowable charges.

E. A carrier may offer a rider to cover the services of Christian Science practitioners and Christian Science facilities.

#### Regulation .08 Mandatory Point-of-Service Option or Out-of-Network Option.

*COMAR 31.11.06.08*

A. When a health maintenance organization is the sole delivery system offered to employees by an eligible employer, the health maintenance organization:

  (1) Shall offer the employer a mandatory point-of-service option for the individual employee to accept or reject;

  (2) May not impose a minimum participation level on the mandatory point-of-service option;

  (3) May not limit the benefits a covered person can receive out of network;

  (4) As part of the application, shall provide to each eligible employer the following disclosure statement for each point-of-service option offered:

B. By July 1, 1996, when a carrier's provider panel is the sole delivery system offered to employees by an eligible employer for dental services, the carrier:

  (1) Shall offer the employer a mandatory dental point-of-service option for the individual employee to accept or reject;

  (2) May not impose a minimum participation level on the mandatory dental point-of-service option;

  (3) As part of the application, shall provide to each eligible employer the following disclosure statement for each dental point-of-service option offered:

C. When an exclusive provider delivery system is the sole delivery system offered to employees by an eligible employer, the insurer or nonprofit health service plan:

  (1) Shall offer the employer a mandatory out-of-network option for the individual employee to accept or reject;

  (2) May not impose a minimum participation level on the mandatory out-of-network option;

  (3) May not limit the benefits a covered person can receive from non-preferred providers;

  (4) As part of the application, shall provide to each eligible employer the following disclosure statement for each out-of-network option offered:

"Under Maryland law, your employees may purchase an out-of-network option as an additional benefit. An out-of-network option allows your employees to obtain health care services from non-preferred providers under certain circumstances that are described in Attachment A.

D. This regulation does not apply to self-employed individuals.

#### Regulation .09 Mandated Benefits.

*COMAR 31.11.06.09*

A. The plan excludes mandated benefits, except for Insurance Article, §§15-123(d), 15-401, 15-407, 15-408, 15-409, 15-412(a)—(h), 15-414, 15-604, 15-701, 15-811, 15-812, 15-815, 15-816, 15-823, 15-839, and 15-10B-09, Annotated Code of Maryland, and Health-General Article, §§19-703(d) and (g), 19-706(h), 19-710.1(b)(1)(ii), and 19-712.5, Annotated Code of Maryland, to the extent those sections are considered mandated benefits.

B. Notwithstanding the mandated benefits included in Regulation .09A of this chapter, the requirements of Insurance Article, §15-812(g), Annotated Code of Maryland, relating to imposition of copayment, coinsurance, or deductibles, are inapplicable to a HSA-compatible delivery system.

C. These regulations do not exclude any requirement contained in statute or regulation that a carrier shall pay hospitals for hospital services rendered in accordance with rates approved by the Health Services Cost Review Commission.

D. A health maintenance organization shall include the conversion benefit required under COMAR 31.12.02.11.

E. Referrals to Specialists. Each carrier:

  (1) That does not allow direct access to specialists shall provide for a standing referral to a specialist under the requirements of Insurance Article, §15-830, Annotated Code of Maryland;

  (2) Shall provide for a referral to a specialist who is not part of the carrier's panel under the requirements of Insurance Article, §15-830, Annotated Code of Maryland;

  (3) [Shall] For plan years beginning before September 23, 2010, shall provide direct access to obstetric and gynecological care as specified in Insurance Article, §15-816, Annotated Code of Maryland; and

  (4) For plan years beginning on or after September 23, 2010, shall provide direct access to obstetric and gynecological care as specified in 45 CFR 147.138(a)(3).

#### Regulation .10 Rates.

*COMAR 31.11.06.10*

A. A carrier shall market the plan in the following compositions:

  (1) Individual; and

  (2) Individual, spouse, and dependents.

B. In addition to §A of this regulation, a carrier may market the plan in one or more of the following compositions:

  (1) Individual and spouse; or

  (2) Individual and dependent.

C. For each composition in §§A and B of this regulation, the carrier shall calculate a separate community rate.

#### Regulation .11 Pre-existing Conditions.

*COMAR 31.11.06.11*

A. A carrier may not apply a preexisting condition provision to health care services for pregnancy or newborns, or to individuals younger than 19 years old.

B. Except as provided in §A of this regulation, for contracts issued or renewed on or after October 1, 2009, an insurer or non-profit health service plan may impose a preexisting condition provision in accordance with Insurance Article, §15-508, Annotated Code of Maryland.

C. A carrier may impose a waiting period from the date of application, in accordance with Insurance Article, §15-1208, Annotated Code of Maryland.

#### Regulation .12 Review.

*COMAR 31.11.06.12*

In addition to the requirement set forth in Insurance Article, §15-1207, Annotated Code of Maryland, the Maryland Health Care Commission shall review the plan from time to time. Unless otherwise stated, all changes in the plan made pursuant to this review are effective for contracts issued or renewed after July 1 of the calendar year in which the changes are promulgated.

### Chapter 07 — Small Employer Group Health Insurance — Self-Employed Individuals

*Repealed*

**Administrative History:** Effective date:

**Administrative History:** Regulations .01—.05 adopted as an emergency provision effective April 1, 1996 (23:8 Md. R. 602); adopted permanently effective June 17, 1996 (23:12 Md. R. 870)

**Administrative History:** Regulation .02B amended as an emergency provision effective June 6, 1997 (24:13 Md. R. 928); amended permanently effective September 8, 1997 (24:18 Md. R. 1295)

**Administrative History:** Regulation .03 amended as an emergency provision effective October 1, 1996 (23:21 Md. R. 1464); amended permanently effective December 30, 1996 (23:26 Md. R. 1859)

**Administrative History:** Regulation .04 amended as an emergency provision effective October 1, 1996 (23:21 Md. R. 1464); amended permanently effective December 30, 1996 (23:26 Md. R. 1859)

**Administrative History:** Regulation .06 adopted as an emergency provision effective October 1, 1996 (23:21 Md. R. 1464); adopted permanently effective December 30, 1996 (23:26 Md. R. 1859)

**Administrative History:** Chapter recodified from COMAR 09.31.12 to COMAR 31.11.07 effective September 7, 1998 (25:18 Md. R. 1439)

**Administrative History:** Regulation .02B amended effective November 11, 2002 (29:22 Md. R. 1725)

**Administrative History:** Regulation .03 amended effective November 11, 2002 (29:22 Md. R. 1725)

**Administrative History:** Regulations .01—.06 repealed effective June 23, 2014 (41:12 Md. R. 669)

### Chapter 08 — Small Group Market Health Insurance Geographic Areas

**Authority:** Insurance Article, §§2-109 and 15-1205, Annotated Code of Maryland

**Administrative History:** Effective date: May 23, 1994 (21:10 Md. R. 843)

**Administrative History:** Regulation .02B amended effective October 1, 1995 (22:16 Md. R. 1221)

**Administrative History:** Chapter recodified from COMAR 09.31.04 to COMAR 31.11.08 effective September 7, 1998 (25:18 Md. R. 1439)

#### Regulation .01 Applicability.

*COMAR 31.11.08.01*

This chapter applies to all carriers which offer health benefits plans to small employers in the State.

#### Regulation .02 Definitions.

*COMAR 31.11.08.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Baltimore Metropolitan Area” means Baltimore City, Baltimore County, Harford County, Howard County, and Anne Arundel County.

  (2) “Eastern and Southern Maryland” means St. Mary's County, Charles County, Calvert County, Cecil County, Kent County, Queen Anne's County, Talbot County, Caroline County, Dorchester County, Wicomico County, Somerset County, and Worcester County.

  (3) “Washington, D.C. Metropolitan area” means Montgomery County and Prince George's County.

  (4) “Western Maryland” means Garrett County, Allegany County, Washington County, Carroll County, and Frederick County.

#### Regulation .03 Geographic Areas.

*COMAR 31.11.08.03*

If carriers subject to this chapter adjust their community rates based on geography, they may only use the geographic areas defined in Regulation .02 of this chapter.

### Chapter 09 — Solicitation of Coverage under Group Health or Blanket Health Insurance Policy Issued in Another Jurisdiction

**Authority:** Insurance Article, §§2-109, 4-205, and 15-310, Annotated Code of Maryland

**Administrative History:** Effective date: September 1, 1966

**Administrative History:** Amended effective May 1, 1968

**Administrative History:** Chapter, Excess of Loss and Catastrophe Coverage—Suspension of General Filing Requirements, repealed effective March 6, 1989 (16:4 Md. R. 497)

**Administrative History:** Regulations .01—.03, Solicitation of Coverage Under Group Health or Blanket Health Insurance Policy Issued in Another Jurisdiction, adopted effective April 27, 1992 (19:8 Md. R. 804)

**Administrative History:** Regulations .01—.03 amended effective November 9, 1992 (19:22 Md. R. 1988)

**Administrative History:** Chapter recodified from COMAR 09.30.35 to COMAR 31.11.09 effective September 7, 1998 (25:18 Md. R. 1439)

#### Regulation .01 Scope.

*COMAR 31.11.09.01*

This chapter applies to all insurers seeking to solicit coverage in this State under a group health or blanket health insurance policy issued in another jurisdiction.

#### Regulation .02 Standards for Approval to Solicit.

*COMAR 31.11.09.02*

A. An insurer seeking the Commissioner's approval to solicit coverage in this State under a group health or blanket health insurance policy issued in another jurisdiction shall submit to the Commissioner documentation sufficient to enable the Commissioner to determine whether the type of group to be covered conforms substantially to one of the types of groups described in Insurance Article, §15-302 or 15-305, Annotated Code of Maryland. An insurer may not solicit this coverage in Maryland until the Commissioner has made that determination.

B. If the Commissioner determines that the type of group to be covered conforms substantially to one of the types of groups described in Insurance Article, §15-302 or 15-305, Annotated Code of Maryland, the insurer shall file with the Commissioner all forms and endorsements necessary to demonstrate that the insurer provides all of the applicable benefits which are required by Insurance Article, Annotated Code of Maryland, to be included in a group health or blanket health insurance policy issued in another jurisdiction.

C. If the Commissioner determines that the type of group to be covered does not conform substantially to one of the types of groups described in Insurance Article, §15-302 or 15-305, Annotated Code of Maryland, the insurer shall submit to the Commissioner each policy form, certificate form, application form, rider, and endorsement which it proposes to use in connection with insurance coverage provided to Maryland residents.

D. Each filing made pursuant to these regulations shall be made not less than 60 days in advance of the form's use. At the expiration of the 60-day period, unless extended by the Commissioner an additional 30 days, the right to solicit the filed coverage is considered approved unless the Commissioner has previously approved or disapproved the right to solicit the filed coverage.

E. The Commissioner may at any time withdraw approval previously given by sending to the insurer, not less than 30 days in advance of the effective date of the Commissioner's action, a notice of withdrawal setting forth the grounds for withdrawal in sufficient detail as to reasonably apprise the insurer of the basis for withdrawal.

F. Approval to solicit coverage in this State may not be given if any of the forms fail to contain those applicable benefits which are required by Insurance Article, Annotated Code of Maryland, to be included in a group or blanket health insurance policy issued in another jurisdiction.

#### Regulation .03 Notice to Insured Concerning Mandated Benefits.

*COMAR 31.11.09.03*

An insurer who seeks to solicit coverage for Maryland residents under a group health or blanket health insurance policy issued in another jurisdiction shall include in the certificate form used in connection with the coverage, a notice on the first page in 12-point bold type that the policy may omit some of the benefits required for a policy issued and delivered in Maryland.

### Chapter 10 — Required Standard Provisions

**Authority:** Insurance Article, §12-203(g), Annotated Code of Maryland

**Administrative History:** Effective date: October 30, 2000 (27:21 Md. R. 1978)

**Administrative History:** Regulation .02B amended effective October 18, 2010 (37:21 Md. R. 1438)

**Administrative History:** Regulation .04N adopted effective October 18, 2010 (37:21 Md. R. 1438)

**Administrative History:** Regulation .06A amended as an emergency provision effective May 9, 2003 (30:11 Md. R. 733); amended permanently effective October 27, 2003 (30:21 Md. R. 1531)

#### Regulation .01 Scope.

*COMAR 31.11.10.01*

This chapter applies to each group health insurance contract, each blanket health insurance contract, and each group nonprofit health service plan contract issued or delivered in Maryland.

#### Regulation .02 Definitions.

*COMAR 31.11.10.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Blanket health insurance” has the meaning stated in Insurance Article, §15-305, Annotated Code of Maryland.

  (2) “Carrier” means an insurer or nonprofit health service plan.

  (2-1) “Coverage period” means the interval of time the blanket health insurance contract or group health insurance contract provides protection, in exchange for the payment of a particular premium.

  (3) Group Health Insurance.

    (a) “Group health insurance” has the meaning stated in Insurance Article, §15-302, Annotated Code of Maryland.

    (b) “Group health insurance” includes:

      (i) A small employer health benefit plan as defined in Insurance Article, §15-1201, Annotated Code of Maryland; and

      (ii) A contract issued to a group policyholder by a nonprofit health service plan.

  (4) “Group policyholder” means the entity to whom the group health insurance contract or blanket health insurance contract is issued.

  (5) “Insured” means an individual covered under a group health insurance contract or blanket health insurance contract.

  (6) “Preferred provider” means a provider that has entered into a provider service contract.

  (7) “Preferred provider benefit” means a benefit that appears in a group health insurance contract or blanket health insurance contract under which health care services are to be provided to the insured by a preferred provider.

  (8) “Provider service contract” means a contract between a provider and a carrier or other entity, under which the provider agrees to provide health care services on a preferential basis under contracts containing preferred provider benefits.

#### Regulation .03 Required Standard Provisions.

*COMAR 31.11.10.03*

A. A group health insurance contract may not be delivered in Maryland unless it contains in substance the provisions:

  (1) Listed in Regulation .04 of this chapter; or

  (2) Which in the opinion of the Commissioner, as compared to the provisions in Regulation .04 of this chapter, are:

    (a) More favorable to the individuals insured, or

    (b) At least as favorable to the individuals insured and more favorable to the policyholder.

B. A blanket health insurance contract may not be delivered in Maryland unless it contains in substance the provisions:

  (1) Listed in Regulation .05 of this chapter; or

  (2) Which in the opinion of the Commissioner, as compared to the provisions in Regulation .05 of this chapter, are:

    (a) More favorable to the individuals insured, or

    (b) At least as favorable to the individuals insured and more favorable to the policyholder.

C. Inapplicable and Inconsistent Provisions. If a provision required by Regulation .04 or .05 of this chapter is wholly or partly inapplicable to or inconsistent with the coverage provided by a particular contract, the carrier shall:

  (1) Omit from the contract the inapplicable provision or part of the provision; or

  (2) Modify the inconsistent provision or part of the provision to make it consistent with the coverage provided by the contract.

#### Regulation .04 Group Health Insurance Standard Provisions.

*COMAR 31.11.10.04*

A. Entire Contract; Changes. Each group health insurance contract shall contain a provision that specifies:

  (1) Which documents constitute the entire contract of insurance; and

  (2) That a change in the policy may not be valid:

    (a) Until approved by an executive officer of the carrier, and

    (b) Unless the approval is endorsed on the policy or attached to the policy.

B. Contestability of Coverage.

  (1) Each group health insurance contract shall contain a provision that:

    (a) The contract may not be contested, except for nonpayment of premiums, after it has been in force for 2 years from its date of issue;

    (b) A statement made by any person covered under the policy relating to insurability may not be used in contesting the validity of the insurance with respect to which the statement was made after the insurance has been in force before the contest for a period of 2 years during the person's lifetime;

    (c) Absent fraud, each statement made by an applicant, group policyholder, or insured is considered to be a representation and not a warranty; and

    (d) A statement made to effectuate insurance may not be used to avoid the insurance or reduce benefits under the policy unless:

      (i) The statement is contained in a written instrument signed by the group policyholder or insured, and

      (ii) A copy of the statement is given to the group policyholder, insured, or beneficiary of the insured.

  (2) The provision required by §B(1) of this regulation does not preclude the assertion at any time of defenses based upon the person's ineligibility for coverage under the contract or upon other provisions in the contract.

C. Notice of Claim.

  (1) Each group contract shall contain a provision describing how and when a claim form can be requested from a carrier.

  (2) If the carrier requires written notice of claim for the carrier to send a claim form to the claimant, the provision shall indicate that:

    (a) The written notice of claim is not required before 20 days after the occurrence or commencement of the loss covered by the policy; and

    (b) The carrier may not invalidate or reduce a claim if it is shown that:

      (i) It was not reasonably possible to give notice within 20 days, and

      (ii) Notice was given as soon as was reasonably possible.

D. Claim Forms. Each group health insurance contract shall contain a provision that:

  (1) The carrier shall provide claim forms for filing proof of loss to each claimant or to the group policyholder for delivery to the claimant; and

  (2) If the carrier does not provide the claim forms within 15 days after notice of claim is received, the claimant is considered to have complied with the requirements of the policy as to proof of loss if the claimant submits, within the time fixed in the policy for filing proof of loss, written proof of the occurrence, character, and extent of the loss for which the claim is made.

E. Proofs of Loss. Each group health insurance contract shall contain a provision that:

  (1) Written proof of loss shall be furnished to the carrier:

    (a) In case of claim for loss of time because of disability, within 90 days after the commencement of the period for which the carrier is liable, and that subsequent written proofs that the disability continues shall be furnished to the carrier at the intervals that the carrier reasonably requires; or

    (b) In case of claim for any loss other than loss of time because of disability, within 90 days after the date of the loss; and

  (2) Failure to furnish the proof of loss within the time required does not invalidate or reduce a claim if it was not reasonably possible to submit the proof within the required time, if the proof is furnished as soon as reasonably possible and, except in the absence of legal capacity of the claimant, not later than 1 year from the time proof is otherwise required.

F. Time of Payment of Claims.

  (1) Each group health insurance contract shall contain a provision that:

    (a) Benefits payable under the policy for any loss other than benefits for the loss of time will be paid not more than 30 days after receipt of written proof of loss; and

    (b) Subject to written proof of loss, all accrued indemnities for loss of time will be paid not less frequently than monthly during the continuance of the period for which the carrier is liable, and any balance remaining unpaid at the termination of the period will be paid as soon as reasonably possible after receipt of proof.

  (2) A policy is considered to provide for periodic payment for loss under §F(1)(b) of this regulation only if the policy contains a specific statement to that effect.

G. Payment of Claims.

  (1) Each group health insurance contract shall contain a provision that all benefits, other than those described in §G(2) and (3) of this regulation, will be payable to the insured.

  (2) Loss of Life Benefits.

    (a) Benefits for loss of life of the insured shall be payable to the beneficiary designated by the insured.

    (b) If the contract contains conditions pertaining to family status, the beneficiary may be the family member specified by the policy terms.

    (c) The payment of the loss of life benefits are subject to the provisions of the policy if no designated or specified beneficiary is living at the time of death of the insured.

  (3) If a group health insurance policy contains a preferred provider benefit, the policy may indicate that benefits for services rendered by a preferred provider will be paid directly to the preferred provider rendering the services.

  (4) At the option of the carrier, the contract may provide that if any benefit of the contract is payable to the estate of an individual, or to an individual who is a minor or otherwise not competent to give a valid release, the carrier may pay the benefit, up to an amount not exceeding $5,000, to any relative by blood or connection by marriage of the individual who is considered by the carrier to be equitably entitled to the benefit.

H. Legal Action. Each group health insurance contract shall contain a provision that an action at law or in equity may not be brought:

  (1) To recover on the policy before the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the policy; and

  (2) After the expiration of 3 years after the written proof of loss is required to be furnished.

I. Grace Period.

  (1) Each group health insurance contract shall contain in substance the following provision: “Grace Period: A grace period of 30 days will be granted for payment of each premium due after the first premium, unless the carrier does not intend to renew the policy beyond the period for which premium has been accepted and notice of the intention not to renew is delivered to the group policyholder at least 45 days before the premium is due. During the grace period the policy shall continue in force.”

  (2) Any additional provisions related to the grace period shall be expressly stated in the policy subject to the following limitations:

    (a) Unless a carrier receives a notice of the group policyholder's intention to terminate the policy before the end of the grace period, the carrier may collect premium for the 30-day grace period;

    (b) If a carrier receives a notice of intention to terminate the policy during the grace period, the carrier may collect premium for the period beginning on the first day of the grace period until the date on which notice is received or the date of termination stated in the notice, whichever is later; and

    (c) If premium for the 30-day grace period is paid after the grace period ends, a carrier may charge interest for the premium, but:

      (i) Interest may not begin to accrue during the 30-day grace period, and

      (ii) The interest rate charged may not exceed an effective rate of 6 percent per year.

J. Certificates. Each group health insurance contract shall contain a provision that:

  (1) Unless the carrier makes delivery directly to the employee or member, the carrier will provide to the group policyholder, for delivery to each employee or member of the insured group, a statement that summarizes the essential features of the insurance coverage of the employee or member and that indicates to whom benefits under the policy are payable; and

  (2) If dependents are included in the coverage, only one statement need be issued for each family unit.

K. Addition of Employees/Members. Each group health insurance contract shall contain a provision that eligible new employees, members, or dependents may be added periodically to the group originally insured in accordance with the terms of the policy.

L. Misstatement of Age. If the premiums or benefits vary by age, each group health insurance contract shall contain:

  (1) A provision specifying an equitable adjustment of premiums or of benefits, or both, to be made in the event the age of an insured has been misstated; and

  (2) A clear statement of the method of adjustment to be used.

M. Group Policyholder Liable for Premium Until Notice of Termination is Received. Each group health insurance contract shall contain a provision that requires the employer, labor union, association, or other entity to which a contract of group health insurance has been issued to continue to pay the premium for an employee, member, or dependent under the policy until notice of termination of coverage has been received by the carrier.

N. Premium Due Date.

  (1) Each group health insurance contract shall specify the premium due date.

  (2) The premium due date shall be the date the coverage period begins.

  (3) A carrier may offer each group policyholder the option to pay the premium through an electronic payment.

  (4) If the group policyholder elects an electronic payment, the carrier may not debit or charge the amount of the premium due prior to the premium due date, except as authorized by the group policyholder.

#### Regulation .05 Blanket Health Insurance Standard Provisions.

*COMAR 31.11.10.05*

A. Each blanket health insurance contract shall contain in substance the provisions set forth in Regulation .04A, C, D, G, H, I, and L of this chapter.

B. Statements in Applications. Each blanket health insurance contract shall contain a provision that:

  (1) Absent fraud, each statement made by the group policyholder is considered to be a representation and not a warranty; and

  (2) A statement made by the group policyholder may not be used in defense to a claim under the policy unless the statement is contained in a written application.

C. Proofs of Loss. Each blanket health insurance contract shall contain a provision that:

  (1) If a claim is for loss of time because of disability, written proof of loss shall be submitted to the insurer within 30 days after the beginning of the period for which the insurer is liable, and subsequent written proofs that the disability continues shall be submitted to the insurer at the intervals that the insurer reasonably requires;

  (2) If a claim is for a loss other than loss of time because of disability, written proof of loss shall be submitted to the insurer within 90 days after the date of the loss; and

  (3) Failure to submit proof of loss within the time required does not invalidate or reduce a claim if it is shown that it was not reasonably possible to submit the proof of loss within the time required, and that proof of loss was submitted as soon as was reasonably possible.

D. Time of Payment of Claims. Each blanket health insurance contract shall contain a provision that:

  (1) Benefits payable under the policy, other than benefits for loss of time, are payable immediately on the insurer's receipt of written proof of loss; and

  (2) Subject to proof of loss:

    (a) Accrued benefits payable under the policy for loss of time are payable not later than at the end of each period of 30 days during the period for which the insurer is liable, and

    (b) Any balance remaining unpaid at the end of the period set forth in §D(2)(a) of this regulation is payable immediately on the insurer's receipt of proof of loss.

#### Regulation .06 Limitations and Exclusions.

*COMAR 31.11.10.06*

A. Crime.

  (1) Except as described in §A(3) of this regulation, a group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's commission of or attempt to commit a crime.

  (2) A group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss for which a contributing cause was the commission of or the attempt to commit a crime by an individual other than the insured.

  (3) A group disability benefit or a group accidental death and dismemberment benefit:

    (a) May include an exclusion or limitation for loss to which a contributing cause was the insured's commission of or attempt to commit a felony; and

    (b) May not contain an exclusion or limitation which is more restrictive to the insured than the exclusion or limitation set forth in §A(3)(a) of this regulation.

B. Illegal Occupation.

  (1) Except as described in §B(2) of this regulation, a group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss to which a contributing cause was the insured's being engaged in an illegal occupation.

  (2) A group disability benefit or a group accidental death and dismemberment benefit:

    (a) May include an exclusion or limitation for loss to which a contributing cause was the insured being engaged in an illegal occupation; and

    (b) May not contain an exclusion or limitation which is more restrictive to the insured than the exclusion or limitation set forth in §B(2)(a) of this regulation.

C. Intoxicants and Narcotics.

  (1) Except as described in §C(2) of this regulation, a group health insurance contract or blanket health insurance contract may not include a limitation or exclusion for loss:

    (a) Sustained or contracted in consequence of the insured being intoxicated or under the influence of any drug;

    (b) Due to the use of alcohol;

    (c) Due to the use of drugs or narcotics; or

    (d) Due to alcoholism or drug addiction.

  (2) A group disability benefit or a group accidental death and dismemberment benefit:

    (a) May include an exclusion or limitation for loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of any narcotic; and

    (b) May not contain an exclusion or limitation regarding the use of alcohol or drugs which is more restrictive to the insured than the exclusion or limitation set forth in §C(2)(a) of this regulation.

D. Preexisting Conditions.

  (1) Each group health insurance contract or blanket health insurance contract shall contain a provision specifying the additional exclusions or limitations, if any, applicable under the contract with respect to a disease or physical condition of an individual, not otherwise excluded from the individual's coverage by name or specific description effective on the date of the individual's loss, that existed before the effective date of the individual's coverage under the contract.

  (2) The exclusion described in §D(1) of this regulation may apply only to a disease or physical condition for which medical advice or treatment was received by the individual during the 12 months before the effective date of the individual's coverage.

  (3) The exclusion described in §D(1) of this regulation does not apply to loss incurred or disability beginning after the earlier of:

    (a) The end of a continuous period of 12 months beginning on or after the effective date of the individual's coverage during all of which the individual has received no medical advice or treatment in connection with the disease or physical condition;

    (b) The end of the 1-year period beginning on the effective date of the individual's coverage, if the individual's application or enrollment form does not include health questions; and

    (c) The end of the 2-year period beginning on the effective date of the individual's coverage, if the individual's application or enrollment form includes health questions.

  (4) If a group health insurance contract or blanket health insurance contract contains a preexisting condition limitation or exclusion, the limitation or exclusion may not apply to a condition that the applicant revealed in the application for the contract, unless the condition is excluded by means of a signed waiver rider attached to the contract.

#### Regulation .07 Optional Provisions.

*COMAR 31.11.10.07*

A. Physical Examination.

  (1) A carrier may include a provision in a group health insurance contract or blanket health insurance contract giving the carrier the right to examine the person of the insured when and as often as it may reasonably require during the pendency of a claim under the contract.

  (2) If the carrier includes the provision described in §A(1) of this regulation, the provision shall indicate that any physical examination required by the carrier will be performed at the expense of the carrier.

B. Autopsy.

  (1) A carrier may include a provision in a group health insurance contract or blanket health insurance contract giving the carrier the right to make an autopsy in case of death when an autopsy is not forbidden by law.

  (2) A carrier may include a provision in a group health insurance contract or blanket health insurance contract that any autopsy required by the carrier will be performed at the expense of the carrier.

C. Arbitration.

  (1) A carrier may include a provision in a group health insurance contract or blanket health insurance contract giving the insured or the group policyholder the option of entering binding arbitration to settle a dispute with the carrier.

  (2) If the carrier includes the provision described in §C(1) of this regulation, the provision may not require the insured or the group policyholder to enter binding arbitration.

### Chapter 11 — Small Employer Group Health Insurance — Disclosure Statement

**Authority:** Insurance Article, §§2-109 and 15-1204, Annotated Code of Maryland

**Administrative History:** Effective date: May 10, 2004 (31:9 Md. R. 713)

**Administrative History:** Regulation .03B amended effective March 21, 2011 (38:6 Md. R. 397)

**Administrative History:** Regulation .04A amended effective March 21, 2011 (38:6 Md. R. 397)

#### Regulation .01 Scope.

*COMAR 31.11.11.01*

This chapter applies to all carriers that offer the Comprehensive Standard Health Benefit Plan to the small employer market.

#### Regulation .02 Definitions.

*COMAR 31.11.11.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Additional benefits” means benefits offered in addition to the Comprehensive Standard Health Benefit Plan that:

    (a) Are offered separately from the plan;

    (b) Are priced separately from the plan;

    (c) Are guarantee issued subject to the provisions of Insurance Article, §15-1213, Annotated Code of Maryland;

    (d) Are guarantee renewed subject to the provisions of Insurance Article, §15-1212, Annotated Code of Maryland;

    (e) Are community rated subject to the provisions of Insurance Article, §15-1205, Annotated Code of Maryland; and

    (f) Do not duplicate any of the benefits in the Comprehensive Standard Health Benefit Plan.

  (2) “Carrier” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

  (3) “Comprehensive Standard Health Benefit Plan” means the health benefit plan adopted by the Maryland Health Care Commission in accordance with Insurance Article, §15-1207, and Health-General Article, Title 19, Subtitle 1, Annotated Code of Maryland.

  (4) “Small employer” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

#### Regulation .03 Required Notice — Initial Purchase of Coverage.

*COMAR 31.11.11.03*

A. At the time of the initial purchase of coverage, a carrier who offers benefits additional to the benefits offered in the Comprehensive Standard Health Benefit Plan shall obtain a signed disclosure statement certifying that:

  (1) The small employer was offered the Standard Comprehensive Health Benefit Plan; and

  (2) Additional benefits were offered and priced separately.

B. The disclosure statement required in §A of this regulation shall be in at least 12-point type and shall read as follows:

C. The disclosure statement required by §A of this regulation may be included on the carrier's sales proposal sheet.

D. The carrier or insurance producer shall maintain the signed disclosure statement for not less than 5 years.

#### Regulation .04 Required Notice — Renewal of Coverage.

*COMAR 31.11.11.04*

A. At the time of renewal of coverage, a carrier who offers benefits additional to the benefits offered in the Comprehensive Standard Health Benefit Plan shall provide a disclosure statement that:

  (1) Indicates that, except as described in §A(4) of this regulation, the Comprehensive Standard Health Benefit Plan is the only plan required by State law;

  (2) Identifies any additional benefits offered by the carrier at renewal;

  (3) Identifies the cost of any additional benefits offered by the carrier at renewal; and

  (4) Specifies that all additional benefits to the Comprehensive Standard Health Benefit Plan are not required by State law, with the exception of the additional benefit for compliance with the federal Mental Health Parity and Addiction Equity Act of 2008 for small employers subject to the federal Mental Health Parity and Addiction Equity Act of 2008.

B. The disclosure statement required by §A of this regulation may be included on the renewal notice or another document.

### Chapter 12 — Limited Benefit Plan

**Authority:** Health-General Article, §§19-103(c)(6) and 19-108; Insurance Article, §§2-108, 2-109, and 15-1207; Annotated Code of Maryland

**Administrative History:** Effective date: April 11, 2005 (32:7 Md. R. 686)

**Administrative History:** Regulation .03A amended as an emergency provision effective June 17, 2005 (32:14 Md. R. 1274); amended permanently effective October 10, 2005 (32:20 Md. R. 1657)

**Administrative History:** Regulation .04C amended as an emergency provision effective June 17, 2005 (32:14 Md. R. 1274); amended permanently effective October 10, 2005 (32:20 Md. R. 1657)

#### Regulation .01 Scope.

*COMAR 31.11.12.01*

A. This chapter applies to all carriers that offer the Limited Benefit Plan to the small employer market.

B. This chapter identifies the uniform benefits which shall be offered in a Limited Benefit Plan which a carrier offers to a Maryland small employer.

C. A carrier may offer the Limited Benefit Plan through one or both of the preferred provider delivery systems, as defined in Regulation .02B(46) of this chapter and as described in Regulation .04 of this chapter.

D. Except as provided in Regulation .11 of this chapter, a prominent carrier, as that term is defined in Regulation .02B(49) of this chapter, shall offer, and any other carrier that participates in the small group market may offer, the Limited Benefit Plan only to a small employer:

  (1) That has not provided the Standard Plan during the 12-month period preceding the date of application or, if the small employer has existed for less than 12 months, from the date the small employer commenced its business; and

  (2) For which the average annual wage of the employees of the small employer does not exceed 75 percent of the average annual wage in the State.

E. A small employer that qualifies for and chooses the Limited Benefit Plan:

  (1) May renew the Limited Benefit Plan even if the average annual wage of the employees of the small employer exceeds 75 percent of the average annual wage in the State at the time of renewal;

  (2) Shall offer coverage for all eligible employees and dependents under the Limited Benefit Plan;

  (3) May not offer the Standard Plan for any employee of the small employer;

  (4) Need not contribute to the premium payments for an eligible employee or a dependent of an eligible employee.

F. This chapter also specifies the uniform cost-sharing arrangements of the Limited Benefit Plan applicable to each delivery system. This chapter permits carriers to offer additional benefits to those of the Limited Benefit Plan only if the additional benefits lower the cost-sharing arrangements in the Plan. The additional benefits may be offered by marketing one or more riders to the Limited Benefit Plan at an additional cost.

G. A carrier that offers the Limited Benefit Plan to an eligible employer shall offer the Plan to all eligible employees. An eligible employer may, at the employer's election, direct the carrier to offer the Limited Benefit Plan to the employer's part-time employees, as that term is defined in Regulation .02B(42) of this chapter, and those employees covered by other public or private health benefit plans or health benefit arrangements.

H. This chapter includes case management for medically complex and costly services to assure adequate cost containment and appropriate utilization to maximize the affordability of the Limited Benefit Plan to the small employer market.

#### Regulation .02 Definitions.

*COMAR 31.11.12.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Annual maximum” means the maximum amount the carrier is obligated to pay for all services of a covered person during the contract year.

  (2) “Carrier” has the meaning stated in Insurance Article, §15-1201(c), Annotated Code of Maryland.

  (3) “Case management” means a form of utilization review used with high cost cases to monitor and manage treatment and suggest appropriate medical services.

  (4) “Chlamydia screening test” has the meaning stated in Insurance Article, §15-829, Annotated Code of Maryland.

  (5) “Coinsurance percentage” or “coinsure” means the percentage of allowable charges allocated to the carrier and to the covered person.

  (6) “Congenital or genetic birth defect” means a defect existing at or from birth, including a hereditary defect, which includes, but is not limited to, autism or an autism spectrum disorder and cerebral palsy.

  (7) “Controlled clinical trial” means a treatment that is:

    (a) Approved by an institutional review board;

    (b) Conducted for the primary purpose of determining whether or not a particular treatment is safe and efficacious; and

    (c) Approved by:

      (i) An institute or center of the National Institutes of Health;

      (ii) The Food and Drug Administration;

      (iii) The Department of Veterans' Affairs; or

      (iv) The Department of Defense.

  (8) “Covered person” means an employee or a dependent of an employee covered by a carrier under the Limited Benefit Plan.

  (9) “Copayment” means a specified charge that a covered person shall pay each time services of a particular type or in a designated setting are received.

  (10) “Deductible” means the amount of allowable charges that must be incurred by an individual or a family per contract year before a carrier begins payment.

  (11) “Delivery system” means the method that a carrier uses to provide the Limited Benefit Plan to covered persons.

  (12) “Dependent” means a covered person's lawful spouse or dependent child.

  (13) Dependent Child.

    (a) “Dependent child” means an individual who is younger than 19 years old, or a full-time student younger than 23 years old, and is a:

      (i) Biological child;

      (ii) Stepchild;

      (iii) Foster child;

      (iv) Lawfully adopted child, or child in the process of being adopted from the date of placement;

      (v) Child for whom the covered employee has been granted legal custody, including custody as a result of a guardianship, other than a temporary guardianship of less than 12 months duration, granted by a court or testamentary appointment; or

      (vi) Child for whom the covered employee has the legal obligation to provide coverage pursuant to court order, court-approved agreement, or testamentary appointment.

    (b) Notwithstanding the age limitation stated in §B(13)(a) of this regulation, “dependent child” includes an unmarried child who:

      (i) Is chiefly dependent for support upon the covered employee; and

      (ii) At the time of reaching the age limitation set forth in §B(13)(a) of this regulation, is incapable of self-support because of mental or physical incapacity that began before the dependent child's attaining the limiting age.

  (14) “Domiciliary care” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

  (15) “Durable medical equipment” means equipment furnished by a supplier or a home health agency that:

    (a) Can withstand repeated use;

    (b) Is primarily and customarily used to serve a medical purpose;

    (c) Generally is not useful to an individual in the absence of a disability, illness, or injury; and

    (d) Is appropriate for use in the home.

  (16) “Emergency services” has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.

  (17) “Eligible employee” has the meaning stated in Insurance Article, §15-1201(e), Annotated Code of Maryland.

  (18) Experimental Services.

    (a) “Experimental services” means services that are not recognized as efficacious as that term is defined in the edition of the Institute of Medicine Report on Assessing Medical Technologies that is current when the care is rendered.

    (b) “Experimental services” does not include controlled clinical trials as defined in §B(7) of this regulation.

  (19) “Family” means:

    (a) An individual and spouse;

    (b) An individual and dependent minor or minors; or

    (c) An individual, spouse, and dependent minor or minors.

  (20) “Family planning services” means counseling, implanting or fitting birth control devices, and follow-up visits after a covered person selects a birth control method.

  (21) “Federally qualified health maintenance organization” means a health maintenance organization which meets the requirements of Title XIII of the Public Health Service Act, 42 U.S.C. §3000e et seq.

  (22) “Habilitative services” means services, including occupational therapy, physical therapy, and speech therapy, for the treatment of children with congenital and genetic birth defects to enhance the child's ability to function.

  (23) “Health benefit plan” has the meaning stated in Insurance Article, §15-1201(f), Annotated Code of Maryland.

  (24) “Health care facility” has the meaning stated in Health-General Article, §19-114, Annotated Code of Maryland.

  (25) “Health care practitioner” has the meaning stated in Health-General Article, §19-132, Annotated Code of Maryland.

  (26) “Health maintenance organization” has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.

  (27) “Home health care” means the continued care and treatment of a covered person in the home if:

    (a) The institutionalization of the covered person in a hospital or related institution or skilled nursing facility would otherwise have been required if home health care were not provided; and

    (b) The plan of treatment covering the home health care service is established and approved in writing by the health care practitioner.

  (28) “Hospice care” has the meaning stated in 42 U.S.C. §1395x(dd).

  (29) “Insulin-using beneficiary” means a beneficiary who uses insulin as part of a treatment plan prescribed by the beneficiary's medical care provider.

  (30) “Late enrollee” has the meaning stated in Insurance Article, §15-1201(h), Annotated Code of Maryland.

  (31) “Limited Benefit Plan” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

  (32) “Maintenance drug” has the meaning set forth in Insurance Article, §15-824(a)(3), Annotated Code of Maryland.

  (33) “Managed care system” means a method that a carrier uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality, and claims.

  (34) “Mandated benefit” means:

    (a) A health care service, benefit, coverage, or reimbursement for covered health care services that is required under the Insurance Article or the Health-General Article, Annotated Code of Maryland, to be provided or offered in a health benefit plan that is issued or delivered in the State by a carrier; or

    (b) Reimbursement, required by statute, by a health benefit plan for a service if that service is performed by a care provider who is licensed under the Health Occupations Article and whose scope of practice includes that service.

  (35) “Multiple risk factors” has the meaning stated in Insurance Article, §15-829, Annotated Code of Maryland.

  (36) “Network” means providers who have entered into a provider service contract with a carrier to provide services on a preferential basis.

  (37) “Nonpreferred brand name drug” means a drug that a carrier has not designated as a preferred drug.

  (38) “Open formulary” means that prescription drugs to treat a covered service (brand and generic) are available to the insured or enrollee at specified levels of copayment.

  (39) “Other nonfacility services” means services provided by non-physician health care practitioners and includes diagnostic and laboratory services.

  (40) “Out-of-pocket limit” means the maximum amount of copayments, deductibles, and coinsurance that an individual or family is obligated to pay for covered services per contract year.

  (41) “Outpatient rehabilitative services” means occupational therapy, speech therapy, and physical therapy, provided to covered persons not admitted to a hospital or related institution.

  (42) “Part-time employee” has the meaning stated in Insurance Article, §15-1210, Annotated Code of Maryland.

  (43) “Partial hospitalization” means the provision of medically directed intensive or intermediate short-term psychiatric treatment for a period of less than 24 hours but more than 4 hours in a day for an individual patient in a hospital, psychiatric day-care treatment center, or community mental health facility.

  (44) “Personal care” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

  (45) “Preferred brand name drug” means a drug that a carrier has designated on its preferred drug list.

  (46) “Preferred provider delivery system” means a delivery system that:

    (a) Provides services to a covered person through a network; and

    (b) Permits the covered person to select services outside the network.

  (47) “Preexisting condition” has the meaning stated in Insurance Article, §15-1201(l), Annotated Code of Maryland.

  (48) “Primary care” means services rendered by a health care practitioner in the following disciplines:

    (a) General internal medicine;

    (b) Family practice medicine;

    (c) Pediatrics; or

    (d) Obstetrics/gynecology.

  (49) “Prominent carrier” has the meaning stated in Insurance Article, §15-1209, Annotated Code of Maryland.

  (50) “Provider” means a health care practitioner or a health care facility licensed or otherwise authorized by law to provide health care services.

  (51) “Related institution” has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

  (52) “Religious organization” means an entity that:

    (a) Is organized and operated exclusively for religious purposes; and

    (b) Has obtained a tax exemption under 26 U.S.C. §501(c)(3) of the U.S. Internal Revenue Code.

  (53) “Residential crisis services” means intensive mental health and support services that are:

    (a) Provided to a child or an adult with a mental illness who is experiencing or is at risk of a psychiatric crisis that would impair the individual's ability to function in the community;

    (b) Designed to prevent a psychiatric inpatient admission, provide an alternative to psychiatric inpatient admission, or shorten the length of inpatient stay;

    (c) Provided out of the individual's residence on a short-term basis in a community-based residential setting; and

    (d) Provided by entities that are licensed by the Maryland Department of Health to provide residential crisis services.

  (54) “Service” means a health care diagnosis, procedure, treatment, or item.

  (55) “Skilled nursing facility” means an institution, or a distinct part of an institution, licensed by the Maryland Department of Health, which is:

    (a) Primarily engaged in providing:

      (i) Skilled nursing care, and related services, for residents who require medical or nursing care; or

      (ii) Rehabilitation services for injured, disabled, or sick persons; and

    (b) Certified by the Medicare Program as a skilled nursing facility.

  (56) “Small employer” has the meaning stated in Insurance Article, §15-1201(o), Annotated Code of Maryland.

  (57) “Standard Plan” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

#### Regulation .03 Covered Services.

*COMAR 31.11.12.03*

A. The Limited Benefit Plan includes the following:

  (1) Care in medical offices for treatment of illness or injury;

  (2) Inpatient hospital services as follows:

    (a) Inpatient hospital physician and other nonfacility services; and

    (b) Inpatient hospital facility services;

  (3) Outpatient services as follows:

    (a) Outpatient hospital physician and other health care practitioner services;

    (b) Outpatient facility surgical services; and

    (c) Outpatient facility nonsurgical services;

  (4) Inpatient mental health and substance abuse services provided through a carrier's managed care system, including residential crisis services, in a hospital, related institution, or entity licensed by the Maryland Department of Health to provide residential crisis services, including:

    (a) Physician and other nonfacility services;

    (b) Facility services;

  (5) Outpatient mental health and substance abuse services provided through a carrier's managed care system, including:

    (a) Physician and other health care practitioner services; and

    (b) Facility services;

  (6) Emergency services;

  (7) Detoxification in a hospital or related institution, including:

    (a) Physician and other nonfacility services; and

    (b) Facility services;

  (8) Ambulance services to or from the nearest hospital where needed medical services can appropriately be provided;

  (9) Except for prostate cancer screening for men 40 years old through 75 years old, and colorectal screening for men and women 50 years old or older:

    (a) Preventive services recommended in the report of the United States Preventive Services Task Force, Guide to Clinical Preventive Services, which is current when the services are rendered; and

    (b) Any other preventive service required to be offered by a federally qualified health maintenance organization;

  (10) Prostate cancer screening as set forth in the current recommendations of the American Cancer Society, which recommends an annual:

    (a) Digital rectal examination for both prostate and colorectal cancer, at 40 years old or older; and

    (b) Prostate-Specific Antigen (PSA) screening for:

      (i) African-American men 40 years old or older;

      (ii) All men 40 years old or older with a family history of prostate cancer; and

      (iii) All other men 50 years old or older;

  (11) Colorectal screening for men and women 50 years old or older as follows:

    (a) A yearly fecal occult blood test, accompanied by digital rectal examination, plus flexible sigmoidoscopy every 5 years;

    (b) A colonoscopy, accompanied by digital rectal examination, every 10 years; or

    (c) A double contrast barium enema, accompanied by digital rectal examination, every 5 years;

  (12) Mammography services for women:

    (a) 40 years old through 49 years old once every other calendar year; and

    (b) 50 years old or older once per calendar year;

  (13) Home health care services provided:

    (a) As an alternative to otherwise covered services in a hospital or related institution; and

    (b) For covered persons:

      (i) Who receive less than 48 hours of inpatient hospitalization following a mastectomy or removal of a testicle; or

      (ii) Who undergo a mastectomy or removal of a testicle on an outpatient basis, one home visit scheduled to occur within 24 hours after discharge from the hospital or outpatient health care facility, and an additional home visit if prescribed by the covered person's attending physician;

  (14) Hospice care services, including:

    (a) Physician and other health care practitioner services; and

    (b) Facility services;

  (15) Durable medical equipment, including:

    (a) Nebulizers;

    (b) Peak flow meters;

    (c) Prosthetic devices such as:

      (i) Leg, arm, back, or neck braces; and

      (ii) Artificial legs, arms, or eyes; and

    (d) The training necessary to use these prostheses;

  (16) Outpatient laboratory and diagnostic services;

  (17) Outpatient rehabilitative services provided through a carrier's managed care system including physical therapy, occupational therapy, and speech therapy services;

  (18) Chiropractic services;

  (19) Skilled nursing facility services as an alternative to medically necessary inpatient hospital services, including:

    (a) Physician and other nonfacility services;

    (b) Facility services;

  (20) Nutritional services up to a maximum of six visits per contract year per condition, for the treatment of:

    (a) Cardiovascular disease;

    (b) Diabetes;

    (c) Malnutrition;

    (d) Cancer;

    (e) Cerebral vascular disease; or

    (f) Kidney disease;

  (21) Autologous and nonautologous bone marrow, cornea, kidney, liver, heart, lung, heart/lung, pancreas, and pancreas/kidney transplants, including:

    (a) Physician and other nonfacility services; and

    (b) Facility services;

  (22) Medical food for persons with metabolic disorders if ordered by a health care practitioner qualified to provide diagnosis and treatment in the field of metabolic disorders;

  (23) Family planning services, including:

    (a) Coverage for the insertion or removal of contraceptive devices;

    (b) Medically necessary examination associated with the use of contraceptive drugs or devices; and

    (c) Voluntary sterilization;

  (24) Except for habilitative services provided in early intervention and school services, habilitative services for children 19 years old or younger for the treatment of congenital or genetic birth defects;

  (25) All cost recovery expenses for blood, blood products, derivatives, components, biologics, and serums to include autologous services, whole blood, red blood cells, platelets, plasma, immunoglobulin, and albumin;

  (26) Pregnancy and maternity services, including abortion, including:

    (a) Physician and other nonfacility services; and

    (b) Facility services;

  (27) Prescription drugs;

  (28) Controlled clinical trials, including:

    (a) Physician and other nonfacility services; and

    (b) Facility services;

  (29) Diabetes treatment, equipment, and supplies;

  (30) Breast reconstructive surgery as specified in Insurance Article, §15-815, Annotated Code of Maryland, and breast prosthesis, including:

    (a) Physician and other nonfacility services; and

    (b) Facility services;

  (31) Audiology screening for newborns, limited to one screening and one confirming screening;

  (32) General anesthesia and associated hospital or ambulatory facility charges in conjunction with dental care provided to the following:

    (a) Individuals who are 7 years old or younger or developmentally disabled and for whom a:

      (i) Successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual, or other medically compromising condition of the enrollee or insured; and

      (ii) Superior result can be expected from dental care provided under general anesthesia; and

    (b) Individuals 17 years old or younger who:

      (i) Are extremely uncooperative, fearful, or uncommunicative;

      (ii) Have dental needs of such magnitude that treatment should not be delayed or deferred; and

      (iii) Are individuals for whom lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral or dental morbidity;

  (33) An annual chlamydia screening test for:

    (a) Women who are:

      (i) Younger than 20 years old who are sexually active; or

      (ii) 20 years old or older who have multiple risk factors; and

    (b) Men who have multiple risk factors;

  (34) The cost to beneficiaries of hearing aids for persons ages 18 years old or younger, every 36 months; and

  (35) Osteoporosis screening as specified in Insurance Article, §15-823, Annotated Code of Maryland.

B. The services described in §A(24) of this regulation shall be delivered through a carrier's managed care system and shall include services for cleft lip and cleft palate, orthodontics, oral surgery, otologic, audiological, and speech therapy, physical therapy, and occupational therapy for children 19 years old or younger for treatment of congenital or genetic birth defects.

C. All mental health and substance abuse services described in §A(4) and (5) of this regulation shall be delivered through a carrier's managed care system.

D. Rehabilitative services and habilitative services required to be offered in the Plan shall be provided through the carrier's managed care system.

E. Prescription Drugs.

  (1) Prescription drugs are covered only as provided in the specific services in Regulation .05 of this chapter.

  (2) Birth control pills, Norplant, Depo Provera, and insulin, or their generic equivalents, are also covered only as provided in the specific services in Regulation .05 of this chapter.

  (3) Except as provided in §E(4) of this regulation, coverage under §A(27) of this regulation includes up to a 90-day supply of maintenance drugs dispensed in a single dispensing of a prescription.

  (4) Coverage of up to a 90-day supply of maintenance drugs in a single dispensing is not required for:

    (a) The first prescription of a maintenance drug; or

    (b) A change in a prescription of a maintenance drug.

F. The carrier shall provide benefits for the covered services in accordance with the terms of the contract, if:

  (1) The service is rendered by a health care practitioner who is licensed under the laws of the state in which the practitioner is practicing; and

  (2) The health care practitioner is practicing within the scope of the license.

G. Under §A(4) of this regulation, 2 partial hospitalization days may be substituted for 1 inpatient day in a hospital or related institution.

H. Diabetes Equipment and Supplies.

  (1) Under §A(29) of this regulation, diabetes equipment includes glucose monitoring equipment under the durable medical equipment coverage for insulin-using beneficiaries.

  (2) Insulin pumps are not included.

  (3) Under the prescription coverage for insulin-using beneficiaries, diabetes supplies include coverage for:

    (a) Insulin syringes and needles; and

    (b) Testing strips for glucose monitoring equipment

I. Under §A(30) of this regulation, breast prosthesis and breast reconstruction on the nondiseased breast to achieve symmetry are covered regardless of:

  (1) The patient's insurance status at the time of the mastectomy; or

  (2) The time lag between the mastectomy and reconstruction.

J. Under §A(32) of this regulation:

  (1) Carriers may require prior authorization for covered services and associated charges in the same manner that prior authorization is required for these benefits in connection with other covered medical care;

  (2) Carriers may restrict coverage to dental care that is provided by a:

    (a) Fully accredited specialist in pediatric dentistry;

    (b) Fully accredited specialist in oral and maxillofacial surgery; and

    (c) Dentist to whom hospital privileges have been granted; and

  (3) Dental care for which general anesthesia is required is not covered.

#### Regulation .04 Uniform Cost-Sharing Arrangements In General.

*COMAR 31.11.12.04*

A. For each delivery system identified in §§B and C of this regulation, a carrier shall apply the uniform cost-sharing arrangements specified.

B. Preferred Provider—Credit Fund Delivery System.

  (1) Covered services are divided into three categories, designated as Categories I, II, and III, based on the type of service to be provided, as follows:

    (a) Category I includes the services listed in Regulation .03A(1), (9)—(12), (15)—(18), (20), (22), (23), (25), (26), (29), (31), and (33)—(35) of this chapter;

    (b) Category II includes the services listed in Regulation .03A(2)—(8), (13), (14), (19), (21), (24), (28), (30), and (32) of this chapter; and

    (c) Category III includes the services listed in Regulation .03A(27) of this chapter.

  (2) Credit Fund.

    (a) The carrier shall provide a fund which shall cover:

      (i) For a person enrolled under individual coverage, $250 of Category I services; and

      (ii) For a person enrolled under other than individual coverage, $500 of Category I services.

    (b) The fund in §B(2)(a) of this regulation shall be renewed each contract year.

  (3) Required Deductibles.

    (a) Except as provided in §B(3)(b) of this regulation, services covered under Categories I and II shall be subject to a contract year deductible of:

      (i) $1,000 for a person enrolled under individual coverage; and

      (ii) $2,000 for a person enrolled under other than individual coverage.

    (b) A carrier may not apply the deductible for Category I services until the fund in §B(2)(a) of this regulation has been exhausted.

  (4) Services covered under Categories I and II for which coinsurance is applicable shall require coinsurance by the covered person of 30 percent for in-network services and 50 percent for out-of-network services.

  (5) All Categories I and II covered services combined are subject to an annual maximum of $10,000 per covered person without regard to whether the person is enrolled under individual coverage or other than individual coverage.

C. Preferred Provider—Capped Benefit Delivery System.

  (1) Covered services shall be divided into six groups, designated as Groups A, B, C, D, E, and F, based on the type of services to be provided, as follows:

    (a) Group A includes the services listed in Regulation .03A(1), (2)(a), (3)(a), (4)(a), (5)(a), (7)(a), (9)—(12), (13), (14)(a), (15), (17), (18), (19)(a), (20), (21)(a), (22), (23)—(25), (26)(a), (28)(a), (29), (30)(a), (31), and (33)—(35) of this chapter;

    (b) Group B includes the services listed in Regulation .03A(6), (8), and (16) of this chapter;

    (c) Group C includes the services listed in Regulation .03A(2)(b), (4)(b), (7)(b), (14)(b), (19)(b), (21)(b), (26)(b), (28)(b), (30)(b), and (32) of this chapter;

    (d) Group D includes the services listed in Regulation .03A(3)(b) of this chapter;

    (e) Group E includes the services listed in Regulation .03A(3)(c) and (5)(b)of this chapter; and

    (f) Group F includes the services listed in Regulation .03A(27) of this chapter.

  (2) Services covered under Group A shall require coinsurance by the covered person of 0 percent for in-network services and 50 percent for out-of-network services up to the specific annual maximum set out in Regulation .05 of this chapter for the specific type of Group A service.

  (3) Services covered under Group B shall require 0 percent coinsurance by the covered person up to the specific annual maximum set out in Regulation .05 of this chapter for the specific type of Group B service.

  (4) Services covered under Group C shall require payment by the covered person of all charges less up to $1,000 per day for an in-network provider and less $700 per day for an out-of-network provider for a period of up to 30 days per covered person per contract year.

  (5) Services covered under Group D shall require coinsurance by the covered person of 30 percent for in-network services and 50 percent for out-of-network services up to a maximum of $10,000 per covered person per contract year.

  (6) Services covered under Group E shall require the covered person to pay, for in-network services, 100 percent of the rate negotiated between the carrier and the provider. Out-of-network services are not covered.

  (7) Services covered under Group F shall be covered as set out in Regulation .05 of this chapter.

#### Regulation .05 Uniform Cost-Sharing Arrangements Specific Services.

*COMAR 31.11.12.05*

A. Preferred Provider—Credit Fund Delivery System.

  (1) Coverage of Category I Services.

    (a) Except for services listed in Regulation .03A(15), (17), (18), (22), (25), and (34) of this chapter, Category I services shall be covered as follows:

      (i) Payment for covered services by the fund;

      (ii) After exhaustion of the fund and after meeting the deductible requirement as described in Regulation .04B(3) of this chapter, coinsurance requirements as described in Regulation .04B(4) of this chapter.

    (b) In addition to the deductible and coinsurance requirements specified in §A(1)(a)(ii) of this regulation, services listed in Regulation .03A(17) and (18) of this chapter are subject to a combined benefit maximum of $1,000 per person per contract year.

    (c) In addition to the deductible and coinsurance requirements specified in §A(1)(a)(ii) of this regulation, services listed in Regulation .03A(15), (22), (25), and (34) of this chapter are subject to a benefit maximum of $1,000 per person per contract year.

  (2) Coverage of Category II Services.

    (a) Except for emergency services, Category II services shall be covered by meeting the deductible requirement as described in Regulation .04B(3) of this chapter and coinsurance requirements as described in Regulation .04B(4) of this chapter.

    (b) After meeting the deductible requirement as described in Regulation .04B(3) of this chapter, emergency services shall be subject to a $100 copay in addition to the coinsurance requirements as described in Regulation .04B(4) of this chapter.

  (3) Coverage of Category III Services.

    (a) Except as required in §A(3)(d) of this regulation, each covered person shall pay the lesser of the cost of the prescription or a copayment of $15.

    (b) Coverage for brand name drugs covered through a pharmacy discount card shall require coinsurance by the covered person of 100 percent of the discounted rate.

    (c) Category III services for generic drugs shall be subject to a $500 benefit maximum per contract year for each covered person.

    (d) Each covered person shall pay the lesser of the cost of the prescription or a $30 copayment for a 90-day supply of generic maintenance drugs dispensed in a single dispensing of a prescription.

    (e) Coverage of up to a 90-day supply of maintenance drugs in a single dispensing is not required for the first prescription of a maintenance drug or a change in a prescription of a maintenance drug.

B. Preferred Provider—Capped Benefit Delivery System.

  (1) Group A services are divided into the following services categories:

    (a) Physician and other health care practitioner office visits (non-preventive services);

    (b) Physician and other health care practitioner office visits (preventive services);

    (c) Equipment and supplies;

    (d) Inpatient physician and other non-facility services; and

    (e) Outpatient physician and other health care practitioner services.

  (2) The following benefit maximums apply to the Group A service category indicated:

    (a) $200 per covered person per contract year for physician and other health care practitioner office visits (nonpreventive services), as listed in Regulation .03A(1), (17), (18), (20), (23), (24), and (29) of this chapter;

    (b) $150 per covered person per contract year for physician and other health care practitioner office visits (preventive services), as listed in Regulation .03A(9)—(12), (31), (33), and (35) of this chapter;

    (c) $250 per covered person per contract year for equipment and supplies, as listed in Regulation .03A(15), (22), (25), and (34) of this chapter;

    (d) $700 per covered person per contract year for inpatient physician and other nonfacility services, as listed in Regulation .03A(2)(a), (4)(a), (7)(a), (13), (14)(a), (19)(a), (21)(a), (26)(a), (28)(a), and (30)(a) of this chapter; and

    (e) $500 per covered person per contract year for outpatient physician and other health care practitioner services, as listed in Regulation .03A(3)(a) and (5)(a) of this chapter.

  (3) The following benefit maximums apply to the Group B service category indicated:

    (a) $200 per covered person per contract year for emergency and ambulance services, as listed in Regulations .03A(6) and (8) of this chapter; and

    (b) $150 per covered person per contract year for outpatient laboratory and diagnostic services, as listed in Regulation .03A(16) of this chapter.

  (4) Services covered under Group F shall be covered as follows:

    (a) Except as required in §B(4)(b) of this regulation, each covered person shall pay the lesser of the cost of the prescription or a copayment of:

      (i) $10 for generic drugs;

      (ii) $30 for preferred brand-name drugs; or

      (iii) $50 for nonpreferred brand-name drugs;

    (b) Each covered person shall pay the lesser of the cost of the prescription or a copayment for a 90-day supply of maintenance drugs dispensed in a single dispensing of a prescription as follows:

      (i) For generic maintenance drugs, one $20 copayment;

      (ii) For preferred brand-name maintenance drugs, one $60 copayment; or

      (iii) For nonpreferred brand-name maintenance drugs, one $100 copayment;

    (c) Coverage of up to a 90-day supply of maintenance drugs in a single dispensing is not required for the first prescription of a maintenance drug or a change in a prescription of a maintenance drug; and

    (d) Services covered in Group F shall be subject to a maximum benefit per contract year of:

      (i) $250 for a person enrolled under individual coverage; and

      (ii) $750 for a person enrolled under other than individual coverage.

#### Regulation .06 Limitations and Exclusions.

*COMAR 31.11.12.06*

A. A carrier shall apply the limitations and exclusions specified in §B of this regulation to the covered services specified in Regulation .03 of this chapter.

B. The following are exclusions and limitations to the covered services:

  (1) Services that are not medically necessary;

  (2) Services performed or prescribed under the direction of a person who is not a health care practitioner;

  (3) Services that are beyond the scope of practice of the health care practitioner performing the service;

  (4) Services to the extent they are covered by any government unit, except for veterans in Veterans' Administration or armed forces facilities for services received for which the recipient is liable;

  (5) Services for which a covered person is not legally, or as a customary practice, required to pay in the absence of a health benefit plan;

  (6) The purchase, examination, or fitting of eyeglasses or contact lenses, except for:

    (a) Aphakic patients and soft or rigid gas permeable lenses; or

    (b) Sclera shells intended for use in the treatment of a disease or injury;

  (7) Personal care services and domiciliary care services;

  (8) Services rendered by a health care practitioner who is a covered person's spouse, mother, father, daughter, son, brother, or sister;

  (9) Experimental services;

  (10) Practitioner, hospital, or clinical services related to radial keratotomy, myopic keratomileusis, and surgery which involves corneal tissue for the purpose of altering, modifying, or correcting myopia, hyperopia, or stigmatic error;

  (11) Infertility services, including:

    (a) Testing;

    (b) In vitro fertilization;

    (c) Ovum transplants and gamete intrafallopian tube transfer;

    (d) Zygote intrafallopian transfer; or

    (e) Cryogenic or other preservation techniques used in these or similar procedures.

  (12) Services to reverse a voluntary sterilization procedure;

  (13) Services for sterilization or reverse sterilization for a dependent minor;

  (14) Medical or surgical treatment for obesity, unless otherwise specified in the covered services;

  (15) Medical or surgical treatment or regimen for reducing or controlling weight, unless otherwise specified in the covered services;

  (16) Services incurred before the effective date of coverage for a covered person;

  (17) Services incurred after a covered person's termination of coverage, including any extension of benefits;

  (18) Surgery or related services for cosmetic purposes to improve appearance, but not to restore bodily function or correct deformity resulting from disease, trauma, or congenital or developmental anomalies;

  (19) Services for injuries or diseases related to a covered person's job to the extent the covered person is required to be covered by a workers' compensation law;

  (20) Services rendered from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar persons or groups;

  (21) Personal hygiene and convenience items, including, but not limited to, air conditioners, humidifiers, or physical fitness equipment;

  (22) Charges for telephone consultations, failure to keep a scheduled visit, or completion of any form;

  (23) Inpatient admissions primarily for diagnostic studies, unless authorized by the carrier;

  (24) Except as provided in Regulation .03A(34) of this chapter, the purchase, of examination for, or fitting of:

    (a) Hearing aids and supplies; and

    (b) Tinnitus maskers;

  (25) Travel, whether or not recommended by a health care practitioner;

  (26) Except for emergency services, services received while the covered person is outside the United States;

  (27) Immunizations related to foreign travel;

  (28) Unless otherwise specified in covered services, dental work or treatment which includes hospital or professional care in connection with:

    (a) The operation or treatment for the fitting or wearing of dentures;

    (b) Orthodontic care or malocclusion;

    (c) Operations on or for treatment of or to the teeth or supporting tissues of the teeth, except for:

      (i) Removal of tumors and cysts; or

      (ii) Treatment of injury to natural teeth due to an accident, if the treatment is received within 6 months of the accident; and

    (d) Dental implants;

  (29) Accidents occurring while and as a result of chewing;

  (30) Routine foot care, including the paring or removing of corns and calluses, or trimming of nails, unless these services are determined to be medically necessary;

  (31) Arch support, orthotic devices, in-shoe supports, orthopedic shoes, elastic supports, or exams for their prescription or fitting, unless these services are determined to be medically necessary;

  (32) Inpatient admissions primarily for physical therapy, unless authorized by the carrier;

  (33) Treatment leading to or in connection with transsexualism, or sex changes or modifications, including but not limited to surgery;

  (34) Treatment of sexual dysfunction not related to organic disease;

  (35) Services that duplicate benefits provided under federal, State, or local laws, regulations, or programs;

  (36) Organ transplants except those included under Regulation .03 of this chapter;

  (37) Nonhuman organs and their implantation;

  (38) Nonreplacement fees for blood and blood products;

  (39) Lifestyle improvements, including nutrition counseling, or physical fitness programs, unless included as a covered service;

  (40) Wigs or cranial prosthesis;

  (41) Weekend admission charges, except for emergencies and maternity, unless authorized by the carrier;

  (42) Outpatient orthomolecular therapy, including nutrients, vitamins, and food supplements;

  (43) Temporomandibular joint syndrome (TMJ) treatment and treatment for craniomandibular pain syndrome (CPS), except for surgical services for TMJ and CPS, if medically necessary and if there is a clearly demonstrable radiographic evidence of joint abnormality due to disease or injury;

  (44) Services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable under a medical expense payment provision of an automobile insurance policy;

  (45) Services for conditions that State or local laws, regulations, ordinances, or similar provisions require to be provided in a public institution;

  (46) Services for, or related to, the removal of an organ from a covered person for purposes of transplantation into another person, unless the:

    (a) Transplant recipient is covered under the plan and is undergoing a covered transplant; and

    (b) Services are not payable by another carrier;

  (47) Physical examinations required for obtaining or continuing employment, insurance, or government licensing;

  (48) Nonmedical ancillary services such as vocational rehabilitation, employment counseling, or educational therapy;

  (49) Private hospital room, unless authorized by the carrier;

  (50) Private duty nursing, unless authorized by the carrier;

  (51) Treatment for:

    (a) Mental health or substance abuse not authorized by the carrier through its managed care system; or

    (b) A mental health or substance abuse condition determined by the carrier through its managed care system to be untreatable; and

  (52) Services related to smoking cessation.

C. A religious organization may request and a carrier shall grant the request for an exclusion from coverage for a service mandated under the Plan if the service is in conflict with the religious organization's bona fide religious beliefs and practices.

D. A religious organization that obtains an exclusion from coverage for a service mandated under the Plan shall provide its employees reasonable and timely notice of this exclusion.

E. The carrier's premium rate for the Plan may not be affected by the religious organization's exclusions from coverage for a service mandated under the plan.

#### Regulation .07 Additional Benefits.

*COMAR 31.11.12.07*

A carrier may offer benefits in addition to the Limited Benefit Plan only if:

A. The benefits are offered separately from the plan;

B. The benefits are priced separately from the plan;

C. Subject to the provisions of Insurance Article, §15-1213, Annotated Code of Maryland, the benefits are guaranteed issue;

D. Subject to the provisions of Insurance Article, §15-1213, Annotated Code of Maryland, the benefits are guaranteed renewable;

E. Subject to the provisions of Insurance Article, §15-1205, Annotated Code of Maryland, the benefits are subject to adjusted community rating;

F. The benefits do not duplicate any of the benefits in the plan; and

G. The benefit lowers the cost-sharing arrangements in the Limited Benefit Plan described in Regulations .04 and .05 of this chapter.

#### Regulation .08 Mandated Benefits.

*COMAR 31.11.12.08*

A. The plan excludes mandated benefits, except for Insurance Article, §§15-123(d), 15-401, 15-407, 15-408, 15-409, 15-412(a) and (h), 15-414, 15-604, 15-701, 15-811, 15-812, 15-815, 15-816, and 15-10B-09, Annotated Code of Maryland, and Health-General Article, §§19-703(d) and (g), and 19-706(h), Annotated Code of Maryland, to the extent those sections are considered mandated benefits.

B. This chapter does not exclude any requirement contained in statute or regulation that a carrier shall pay hospitals for hospital services rendered in accordance with rates approved by the Health Services Cost Review Commission.

C. Referrals to Specialists. Each carrier:

  (1) That does not allow direct access to specialists shall provide for a standing referral to a specialist under the requirements of Insurance Article, §15-830, Annotated Code of Maryland;

  (2) Shall provide for a referral to a specialist who is not part of the carrier's panel under the requirements of Insurance Article, §15-830, Annotated Code of Maryland; and

  (3) Shall provide direct access to obstetric and gynecological care as specified in Insurance Article, §15-816, Annotated Code of Maryland.

#### Regulation .09 Rates.

*COMAR 31.11.12.09*

A. A carrier shall market the Plan in the following compositions:

  (1) Individual; and

  (2) Individual, spouse, and dependents.

B. In addition to §A of this regulation, a carrier may market the Plan in one or more of the following compositions:

  (1) Individual and spouse; or

  (2) Individual and dependent.

C. For each composition in §§A and B of this regulation, the carrier shall calculate a separate community rate.

#### Regulation .10 Preexisting Conditions.

*COMAR 31.11.12.10*

A. A carrier may not apply a preexisting condition provision to health care services for pregnancy or newborns.

B. A carrier may impose a preexisting condition provision of up to 12 months for a late enrollee.

C. A carrier may impose a waiting period from the date of application, in accordance with Insurance Article, §15-1208(b)(2), Annotated Code of Maryland.

#### Regulation .11 Exemption for Certain Prominent Carriers.

*COMAR 31.11.12.11*

A. Except as provided in §B of this regulation, a prominent carrier that offers insurance in the small group market shall offer the Limited Benefit Plan to a small employer as required under Regulation .01D of this chapter.

B. A prominent carrier that is controlled by an insurance holding company is exempt from the requirement to offer the Limited Benefit Plan to a small employer if another prominent carrier which is controlled by the same insurance holding company as the carrier seeking exemption offers the Limited Benefit Plan to small employers in the State.

#### Regulation .12 Review.

*COMAR 31.11.12.12*

In addition to the requirements set forth in Insurance Article, §15-1207, Annotated Code of Maryland, the Maryland Health Care Commission shall review the Plan from time to time. Unless otherwise stated, all changes in the Plan made pursuant to this review are effective for contracts issued or renewed after July 1 of the calendar year in which the changes are promulgated.

### Chapter 13 — Limited Benefit Plan — Disclosure Statement

**Authority:** Insurance Article, §§2-109 and 15-207, Annotated Code of Maryland; Ch. 287, Acts of 2004

**Administrative History:** Effective date:

**Administrative History:** Regulations .01—.03 adopted as an emergency provision effective July 1, 2005 (32:15 Md. R. 1315); emergency status extended at 33:4 Md. R. 350; adopted permanently effective January 16, 2006 (33:1 Md. R. 40)

#### Regulation .01 Scope.

*COMAR 31.11.13.01*

This chapter applies to all carriers that offer the Limited Benefit Plan to the small employer market.

#### Regulation .02 Definitions.

*COMAR 31.11.13.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Carrier” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

  (2) “Comprehensive Standard Health Benefit Plan” means the health benefit plan adopted by the Maryland Health Care Commission in accordance with Insurance Article, §15-1207, and Health-General Article, Title 19, Subtitle 1, Annotated Code of Maryland.

  (3) “Limited Benefit Plan” means the Limited Health Benefit Plan adopted by the Maryland Health Care Commission in accordance with Insurance Article, §15-1207, and Health-General Article, Title 19, Subtitle 1, Annotated Code of Maryland.

  (4) “Small employer” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

#### Regulation .03 Required Notice — Limited Benefit Plan.

*COMAR 31.11.13.03*

A. When a carrier offers the Limited Benefit Plan to a small employer qualified under Insurance Article, §15-1209, Annotated Code of Maryland, and the small employer chooses the Limited Benefit Plan, the carrier shall obtain a signed disclosure statement certifying that:

  (1) The small employer was offered the Limited Benefit Plan; and

  (2) The small employer received notice that more comprehensive coverage is available under the Comprehensive Standard Health Benefit Plan.

B. The disclosure statement required in §A of this regulation shall be in at least 12-point type and shall read as follows:

C. The carrier shall maintain the signed disclosure statement for not less than 5 years.

### Chapter 14 — Wellness Benefits Under Small Employer Health Benefit Plans

**Authority:** Health General Article, §19-108; Insurance Article, §§2-109, 15-1201, 15-1204(g), and 15-1207(a); Annotated Code of Maryland

**Administrative History:** Effective date:

**Administrative History:** Regulations .01—.05 adopted as an emergency provision effective April 1, 2008 (35:9 Md. R. 896); adopted permanently effective July 17, 2008 (35:14 Md. R. 1248)

**Administrative History:** Regulation .02B amended effective October 19, 2009 (36:21 Md. R. 1594)

**Administrative History:** Regulation .05A amended effective October 19, 2009 (36:21 Md. R. 1594)

#### Regulation .01 Purpose.

*COMAR 31.11.14.01*

This chapter specifies the requirements for:

A. A wellness benefit offered by a carrier to a small employer under Insurance Article, Title 15, Subtitle 12, Annotated Code of Maryland;

B. Determining if a carrier is considered a prominent carrier; and

C. Carriers offering wellness benefits to small employers.

#### Regulation .02 Definitions.

*COMAR 31.11.14.02*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Carrier” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

  (2) “Case management program” means a program that involves a collaborative process of assessment, planning, implementation, coordination, monitoring, and evaluation of the options and services required to meet an individual's health needs through communication and available resources to promote quality cost effective outcomes.

  (3) “Disease management program” means a program of preventive, diagnostic, and therapeutic services for certain patients that are considered to be at risk.

  (4) “Eligible employee” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

  (5) “Health benefit plan” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

  (6) “Health risk assessment” means a self-reported health questionnaire that:

    (a) Asks a variety of personal questions about lifestyle and behavioral habits, such as physical activity level, eating habits, and stress; and

    (b) Includes, but is not limited to, biometric measures and other health status information.

  (7) “Preventive services” means the services required to be covered under the small employer standard plan, as described in COMAR 31.11.06.03A(9).

  (8) “Prominent carrier” means a carrier that insures at least 10 percent of the total lives insured in the Maryland small group market.

  (9) “Small employer” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

  (10) “Standard plan” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

  (11) “Wellness benefit”:

    (a) Has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland; and

    (b) Complies with the requirements set forth in Regulations .03 and .04 of this chapter.

  (12) “Wellness program” has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

#### Regulation .03 Components of a Wellness Benefit.

*COMAR 31.11.14.03*

A. Each wellness benefit shall include:

  (1) A health risk assessment that is:

    (a) Available at no cost to all employees covered under the small employer's wellness benefit; and

    (b) Completed by each employee on a voluntary basis;

  (2) Written feedback to each employee who completes the health risk assessment, with recommendations for lowering risks identified in the completed health risk assessment; and

  (3) A financial incentive to promote:

    (a) Preventive care;

    (b) Healthy behavior and lifestyle choices; or

    (c) Participation in a disease management program or case management program.

B. The financial incentive described in §A(3) of this regulation may be in the form of:

  (1) A direct reward of financial value given to the employee, such as a monetary reward or a gift card; or

  (2) A reduction in the employee's copayments, coinsurance, or deductible that would otherwise be payable under the small employer's health benefit plan.

C. A carrier shall be considered to have satisfied the requirement of §A(3) of this regulation, if the wellness benefit offered by the carrier eliminates the deductible for preventive services only.

#### Regulation .04 General Requirements for Wellness Benefits Offered to Small Employers.

*COMAR 31.11.14.04*

A. A wellness benefit offered to a small employer:

  (1) Shall satisfy the requirements of an additional benefit found in COMAR 31.11.06.07; and

  (2) May not violate any requirement regarding wellness programs as described in 45 CFR §146.121.

B. A wellness benefit may appear in an additional benefit rider as the only benefit in the rider, or it may be bundled with other benefits in an additional benefit rider.

#### Regulation .05 Requirement for Carriers to Offer a Wellness Benefit.

*COMAR 31.11.14.05*

A. A prominent carrier shall offer a wellness benefit to a small employer for a health benefit plan offered in Maryland.

B. A carrier that is not a prominent carrier may offer a wellness benefit to a small employer for a health benefit plan offered in Maryland.

C. The determination of which carriers are prominent carriers shall be determined each calendar year, based on the market share that each carrier had of the Maryland small group market for the prior calendar year.

D. A carrier may not condition the sale of a wellness benefit to a small employer on participation of the eligible employees of the small employer in wellness programs or activities.