Md. Code Regs. 31.11.06.07

Current through Register Vol. 51, No. 10, May 17, 2024

Section 31.11.06.07 - 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 provisions of Insurance Article, § 15-1205, Annotated Code of Maryland, the benefits are community rated; and

(6) The benefits do not duplicate any of the benefits in the plan.

B. An additional benefit that a carrier offers shall meet at least one of the following requirements:

(1) The benefit increases access to care choices available under the plan;

(2) The benefit increases the number of services available to covered persons under the plan;

(3) The benefit increases the frequency that covered persons can obtain specified services under the plan; or

(4) The benefit lowers the uniform cost-sharing arrangements described in Regulations .04 and .05 of this chapter.

C. A health maintenance organization may offer, or may contract with another carrier to offer, a point-of-service option as an additional benefit to the health maintenance organization delivery system or the HMO-HSA delivery system subject to the following requirements:

(1) The point-of-service benefit allows a covered person to obtain services outside the network;

(2) For out-of-network services, the health maintenance organization's coinsurance percentage shall be no less than the percentage of allowable charges specified in Regulations .04F and .05B of this chapter; and

(3) The health maintenance organization may limit the benefits a covered person may obtain outside the network.

D. An insurer or nonprofit health service plan offering an exclusive provider delivery system or an EPO-HSA delivery system specified under this chapter may offer a limited out-of-network additional benefit as defined under Regulation .02 of this chapter as an additional benefit subject to the following requirements:

(1) The limited out-of-network additional benefit allows a covered person to obtain services outside the network;

(2) Except as specified in §D(4) of this regulation, for out-of-network services, the insurer's or nonprofit health service plan's coinsurance may not be less than 60 percent of allowable charges;

(3) The insurer or nonprofit health service plan may limit the benefits a covered person may obtain outside the network; and

(4) For outpatient services for mental health and substance abuse, rehabilitation, and chiropractic services received out-of-network, the insurer's or nonprofit health service plans' coinsurance may not be less than 50 percent of allowable charges.

E. A carrier may offer a rider to cover the services of Christian Science practitioners and Christian Science facilities.

Md. Code Regs. 31.11.06.07

Regulations .07 amended effective May 3, 1999 (26:9 Md. R. 731)
Regulation .07 amended effective March 24, 2008 (35:6 Md. R. 702)
Regulation .07A amended effective February 7, 2000 (27:2 Md. R. 148)
Regulation .07C amended effective April 10, 2006 (33:7 Md. R. 676)