Chapter 06. Comprehensive Standard Health Benefit Plan
Regulation .01 Scope.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy 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.
Regulation .08 Mandatory Point-of-Service Option or Out-of-Network Option.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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 annotations
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
History: Effective date: April 25, 1994 (21:8 Md. R. 672)
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)
History: Chapter revised effective February 12, 1996 (23:3 Md. R. 167)
History: Regulation .01 amended effective May 18, 1998 (25:10 Md. R. 746)
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)
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)
History: Regulation .02B amended effective May 18, 1998 (25:10 Md. R. 746)
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)
History: Regulation .03A, D amended effective May 18, 1998 (25:10 Md. R. 746)
History: Regulation .04F amended effective May 18, 1998 (25:10 Md. R. 746)
History: Regulation .05 amended effective May 18, 1998 (25:10 Md. R. 746)
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)
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
History: Regulation .05I amended effective March 10, 1997 (24:5 Md. R. 407)
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)
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
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
History: Regulation .09A amended effective March 10, 1997 (24:5 Md. R. 407)
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)
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)
History: Regulation .09A amended effective May 18, 1998 (25:10 Md. R. 746)
History: Regulation .12 amended effective May 18, 1998 (25:10 Md. R. 746)
History: Chapter recodified from COMAR 09.31.05 to COMAR 31.11.06 effective September 7, 1998 (25:18 Md. R. 1439)
History: Regulation .01 amended effective April 10, 2006 (33:7 Md. R. 675)
History: Regulation .01C amended effective April 9, 2007 (34:7 Md. R. 700); March 24, 2008 (35:6 Md. R. 702)
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)
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)
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)
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)
History: Regulations .03—.08 amended effective May 3, 1999 (26:9 Md. R. 731)
History: Regulation .03 amended effective April 10, 2006 (33:7 Md. R. 676)
History: Regulation .03A amended as an emergency provision effective October 1, 1999 (26:22 Md. R. 1689); emergency status expired February 1, 2000
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)
History: Regulation .03A-1 adopted effective April 20, 2009 (36:8 Md. R. 598)
History: Regulation .03E amended effective February 7, 2000 (27:2 Md. R. 148)
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)
History: Regulation .04 amended effective April 10, 2006 (33:7 Md. R. 676)
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)
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)
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)
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)
History: Regulation .05E, I amended effective March 24, 2008 (35:6 Md. R. 702)
History: Regulation .05H amended effective February 7, 2000 (27:2 Md. R. 148)
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)
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)
History: Regulation .05I amended effective May 3, 1999 (26:9 Md. R. 731)
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)
History: Regulation .06F adopted effective November 16, 2009 (36:23 Md. R. 1819)
History: Regulation .07 amended effective March 24, 2008 (35:6 Md. R. 702)
History: Regulation .07A amended effective February 7, 2000 (27:2 Md. R. 148)
History: Regulation .07C amended effective April 10, 2006 (33:7 Md. R. 676)
History: Regulation .08 amended effective March 24, 2008 (35:6 Md. R. 702)
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)
History: Regulation .09A amended effective March 18, 2002 (29:5 Md. R. 506); April 20, 2009 (36:8 Md. R. 598)
History: Regulation .09B amended effective April 10, 2006 (33:7 Md. R. 676)
History: Regulation .09D adopted as an emergency provision effective October 1, 1999 (26:22 Md. R. 1689); emergency status expired February 1, 2000
History: Regulation .09D adopted effective February 7, 2000 (27:2 Md. R. 148)
History: Regulation .09D amended effective February 5, 2001 (28:2 Md. R. 106); April 10, 2006 (33:7 Md. R. 676)
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)
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)
History: Regulation .10D repealed effective April 10, 2006 (33:7 Md. R. 676)
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)
History: Regulation .11B amended effective November 16, 2009 (36:23 Md. R. 1819)
History: Regulation .11C amended effective February 28, 2005 (32:4 Md. R. 412); November 16, 2009 (36:23 Md. R. 1819)