Skip to Main Content
<< Back | Return to Main COMAR Search Page

14 records match your request.

FileAbstract
31.11.12.00.htm 31.11.12.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 11 HEALTH INSURANCE ― GENERAL Chapter 12 Limited Benefit Plan Authority: Health-General Article, §19-103(c)6) and 19-108; Insurance Article, §2-108, 2-109, and 15-1207; Annotated Code of Maryland
31.11.12.01.htm 31.11.12.01. 01 Scope.. 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.
31.11.12.02.htm 31.11.12.02. 02 Definitions.. 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
31.11.12.03.htm 31.11.12.03. 03 Covered Services.. 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.
31.11.12.04.htm 31.11.12.04. 04 Uniform Cost-Sharing Arrangements In General.. 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
31.11.12.05.htm 31.11.12.05. 05 Uniform Cost-Sharing Arrangements Specific Services.. 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 chap
31.11.12.06.htm 31.11.12.06. 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
31.11.12.07.htm 31.11.12.07. 07 Additional Benefits.. 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. Subject to the provisi
31.11.12.08.htm 31.11.12.08. 08 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) 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 re
31.11.12.09.htm 31.11.12.09. 09 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.
31.11.12.10.htm 31.11.12.10. 10 Preexisting Conditions.. 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.
31.11.12.11.htm 31.11.12.11. 11 Exemption for Certain Prominent Carriers.. 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 con
31.11.12.12.htm 31.11.12.12. 12 Review.. 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.
31.11.12.9999.htm 31.11.12.9999. Administrative History Effective date: April 11, 2005 (32:7 Md. R. 686). 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)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)
<< Back | Return to Main COMAR Search Page