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31.11.06.00.htm 31.11.06.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 11 HEALTH INSURANCE ― GROUP Chapter 06 Comprehensive Standard Health Benefit Plan 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
31.11.06.01.htm 31.11.06.01. 01 Scope.. 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 a
31.11.06.02.htm 31.11.06.02. 02 Definitions.. 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.
31.11.06.03.htm 31.11.06.03. 03 Covered Services.. 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 lice
31.11.06.03-1.htm 31.11.06.03-1. 03-1 Covered Services ― Preventive Care Services.. 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:
31.11.06.04.htm 31.11.06.04. 04 Uniform Cost-Sharing Arrangements ― In General.. 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)
31.11.06.05.htm 31.11.06.05. 05 Uniform Cost-Sharing Arrangements ― Specific Services.. 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 regula
31.11.06.06.htm 31.11.06.06. 06 Limitations and Exclusions.. 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
31.11.06.07.htm 31.11.06.07. 07 Additional Benefits.. 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 provisi
31.11.06.08.htm 31.11.06.08. 08 Mandatory Point-of-Service Option or Out-of-Network Option.. 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;.
31.11.06.09.htm 31.11.06.09. 09 Mandated Benefits.. 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 ma
31.11.06.10.htm 31.11.06.10. 10 Rates.. 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.
31.11.06.11.htm 31.11.06.11. 11 Pre-existing Conditions.. 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
31.11.06.12.htm 31.11.06.12. 12 Review.. 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.
31.11.06.9999.htm 31.11.06.9999. Administrative History Effective date: April 25, 1994 (21:8 Md. R. 672). 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) ―Chapter revised effective February 12, 1996 (23:3 Md. R. 167). Regulation .01 amended effective May 18, 1998 (25:10 Md. R. 746). Regulation .02B amended as an emergency provision effective February 2, 1996 (23:4 Md. R. 270) emerg
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