Md. Code Regs. 31.10.32.03

Current through Register Vol. 51, No. 18, September 6, 2024

Section 31.10.32.03 - Material Modification

For purposes of Insurance Article, § 14-115(d)(11)(i), Annotated Code of Maryland, a modification is material if it modifies:

A. The options available in a health benefit plan marketed in the State in a manner that results in a change of 20 percent or more in the actuarial benefit value of the health benefit plan;

B. A provider network in a manner that results in a change of:

(1) 10 percent or more in the number of health care providers in the provider network:

(a) For the entire State: or

(b) In the Baltimore metro region or DC metro region;

(2) 7 percent or more in the number of health care providers in the provider network in the Southern Maryland region;

(3) 5 percent or more in the number of health care providers in the provider network in the Eastern Shore region or Western Maryland region;

(4) 10 percent or more in the number of health care providers in a key specialty in the provider network:

(a) For the entire State; or

(b) In the Baltimore metro region, DC metro region, Eastern Shore region, Southern Maryland region, or Western Maryland region;

(5) 10 percent or more in the amount of reimbursement paid to health care providers in the provider network:

(a) For the entire State; or

(b) In the Baltimore metro region or DC metro region;

(6) 7 percent or more in the amount of reimbursement paid to health care providers in the provider network in the Southern Maryland region; or

(7) 5 percent or more in the amount of reimbursement paid to health care providers in the provider network in the Eastern Shore region or the Western Maryland region;

C. Underwriting guidelines for a product of a nonprofit health insurance plan in a manner that results in:

(1) A refusal to provide the least expensive rate for the product of a nonprofit health service plan to 20 percent or more of applicants for the product; or

(2) A relative increase of 50 percent or more in the current level of refusals to provide the least expensive rate for the product of a nonprofit health service plan to applicants; or

D. Rates or rating plans that are required to be approved by the Commissioner in a manner that results in:

(1) A rate increase of 15 percent or more in 1 year for any product sold by a nonprofit health service plan in a particular market; or

(2) A rate increase of 25 percent or more in 1 year for coverage variations within a product sold by a nonprofit health service plan in a particular market.

Md. Code Regs. 31.10.32.03