Plain Text Law

Regulation .07 Additional Benefits.

Regulation .07 Additional Benefits.Copy Citation

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.