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<regulation prefix="Regulation" num=".12" citation="COMAR 31.12.02.12" title_num="31" subtitle_num="12" chapter_num="02" heading="General Operation of Health Maintenance Organizations.">
  <paragraph num="A.">
    <text>The HMO shall provide, without limitations as to frequency or cost, except as established in the health care contract and provided for in these regulations, basic and supplemental health services to its members in the following manner:</text>
    <paragraph num="(1)">
      <text>Reasonable deductibles and copayments may be required for the provision of specific services within the basic health services, unless the payments or the manner of payment unduly serves as a barrier to the delivery of basic health services;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>All services of health care providers provided for in the health care contract shall be provided through health care providers that are under contract to, or have agreements with, the HMO, except that this subsection does not apply to:</text>
      <paragraph num="(a)">
        <text>Health care providers' services which the HMO and the Commissioner determine are unusual or infrequently used;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Emergency services;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Services performed outside of the HMO's service area for urgent care services;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Services received from health care providers that do not contract with the HMO, if the member has a benefit under the HMO contract for services received from non-HMO health care providers; or</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Services received from a health care provider that does not contract with the HMO, if the member was referred to the health care provider by the HMO or by a provider under contract with the HMO;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>All services provided for in the health care contract shall, within the area serviced by the HMO, be available and accessible to each of its members:</text>
      <paragraph num="(a)">
        <text>Promptly as appropriate;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>In a manner which assures continuity; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>When medically necessary, 24 hours a day and 7 days a week; and</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Emergency services as follows:</text>
      <paragraph num="(a)">
        <text>The HMO shall be liable for emergency expenses incurred by the member in securing any service customarily provided in the contract for emergency services incurred by the member which cannot reasonably be provided through the facilities of the HMO and which are considered medically necessary and justified; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The method used to establish the necessity of these services and the method the HMO shall use in fulfilling its financial responsibility for its health care services shall be set forth in the health care contract.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Health Care Contracts.</text>
    <paragraph num="(1)">
      <text>The HMO shall bind itself to provide to the members basic health services and other supplemental services as specified in the health care contract.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A copy of coverages and costs shall be given to each member or member family unit.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>All services included in the benefits, as well as any limitations or exclusions, shall be clearly stated in written form.</text>
    </paragraph>
  </paragraph>
</regulation>