Chapter 12. Limited Benefit Plan
Regulation .01 Scope.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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.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:
(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.LinkCopy Citation
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.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) 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.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 .10 Preexisting Conditions.LinkCopy Citation
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.LinkCopy Citation
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.LinkCopy Citation
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 annotations
Authority: Health-General Article, §§19-103(c)(6) and 19-108; Insurance Article, §§2-108, 2-109, and 15-1207; Annotated Code of Maryland
History: Effective date: April 11, 2005 (32:7 Md. R. 686)
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)
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)