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31.12.07.00.htm 31.12.07.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 12 HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS Chapter 07 Required Standard Provisions Authority: Health-General Article, §19-713(f) Insurance Article, §12-203(g) Annotated Code of Maryland
31.12.07.01.htm 31.12.07.01. 01 Scope.. This chapter applies to all health maintenance organizations operating in this State..
31.12.07.02.htm 31.12.07.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) “Coverage period” means the interval of time the individual contract or group contract provides protection, in exchange for the payment of a particular premium.1-1) Group Contract.. a) "Group contract" means a contractual agreement entered into between an HMO and an employer, union, trustee, association, or other organization for the provision of health c
31.12.07.03.htm 31.12.07.03. 03 Required Standard Provisions.. A. A group contract may not be delivered in Maryland unless it contains in substance the provisions:. 1) Listed in Regulation .04 of this chapter; or. 2) Which in the opinion of the Commissioner, as compared to the provisions in Regulation .04 of this chapter, are:a) More favorable to the members, or. b) At least as favorable to the members and more favorable to the group contract holder.. B. An individual contract may not be delivered in
31.12.07.04.htm 31.12.07.04. 04 Group Contract Standard Provisions.. A. Entire Contract; Changes. Each group contract shall contain a provision that specifies:. 1) Which documents constitute the entire contract; and. 2) That a change in the contract may not be valid:. a) Until approved by an executive officer of the HMO, and. b) Unless the approval is endorsed on the contract or attached to the contract.. B. Contestability of the Contract.. 1) Each group contract shall contain a provision that:.
31.12.07.05.htm 31.12.07.05. 05 Individual Contract Standard Provisions.. A. Each individual contract shall contain in substance the provisions set forth in Regulation .04C, E, F, G, H, and L of this chapter.B. Entire Contract; Changes. Each individual contract shall contain in substance the following provision: "Entire contract; changes: This agreement, including the endorsements and the attached papers, if any, constitutes the entire contract. No change in this agreement shall be valid until approved
31.12.07.06.htm 31.12.07.06. 06 Limitations and Exclusions.. A. Crime.. 1) An individual or group contract may not include a limitation or exclusion for loss to which a contributing cause was the member's commission of or attempt to commit a crime.2) An individual or group contract may not include a limitation or exclusion for loss for which a contributing cause was the commission of or the attempt to commit a crime by an individual other than the member.B. Illegal Occupation. An individual or group cont
31.12.07.07.htm 31.12.07.07. 07 Group Contract Optional Provisions.. A. An HMO may include in group contracts any of the optional provisions described in §C and D of this regulation.B. An HMO may not include in a group contract an optional provision dealing with the same subjects set forth in §C and D of this regulation if the provision is drafted in a manner that is less favorable to the group contract holder, subscriber, or member than the corresponding optional provision set forth in §C and D of thi
31.12.07.08.htm 31.12.07.08. 08 Individual Contract Optional Provisions.. A. An HMO may include in an individual contract any of the optional provisions described in Regulation .07C and D of this chapter and §C of this regulation.B. An HMO may not include in an individual contract an optional provision dealing with the same subjects set forth in Regulation .07C and D of this chapter and §C of this regulation if the provision is drafted in a manner that is less favorable to the subscriber or member th
31.12.07.9999.htm 31.12.07.9999. Administrative History Effective date: October 30, 2000 (27:21 Md. R. 1979). Regulation .02B amended effective October 18, 2010 (37:21 Md. R. 1439). Regulation .04 amended effective August 3, 2015 (42:15 Md. R. 1019). Regulation .04N adopted effective October 18, 2010 (37:21 Md. R. 1439). Regulation .05D amended effective November 7, 2005 (32:22 Md. R. 1760). Regulation .05E amended effective August 3, 2015 (42:15 Md. R. 1019).
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