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.

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.