Chapter 05. Group Health Insurance Options for Alzheimer's Disease and for Diseases of the Elderly
Regulation .01 Scope.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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 annotations
Authority: Insurance Article, §§2-109, 14-124(b), and 15-801, Annotated Code of Maryland
History: Effective date: December 28, 1987 (14:26 Md. R. 2745)
History: Chapter recodified from COMAR 09.30.80 to COMAR 31.11.05 effective September 7, 1998 (25:18 Md. R. 1439)