Md. Code Regs. 31.11.06.05

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.11.06.05 - Uniform Cost-Sharing Arrangements - Specific Services

A. General Cost-Sharing Arrangement for Outpatient Mental Health and Substance Abuse Services.

(1) Except as provided in §B of this regulation, for outpatient mental health and substance abuse, the carrier shall pay for each service 70 percent of allowable charges.

(2) A carrier may substitute a copayment for these services at an actuarially equivalent amount to the coinsurance percentages described in this regulation subject to the approval of the Insurance Commissioner and the Maryland Health Care Commission.

(3) For purposes of the cost-sharing arrangement set forth in §A(1) of this regulation, a carrier shall treat a visit made solely for medication management purposes for mental health or substance abuse treatment as a covered service under Regulation .03A(1) of this chapter and may not count the visit as a mental health or substance abuse service described in Regulation .03A(5) of this chapter.

B. Out-of-Network Cost-Sharing Arrangements for Outpatient Mental Health and Substance Abuse Services.

(1) For outpatient services for mental health and substance abuse received out-of-network in a preferred provider organization delivery system or point-of-service delivery system, triple option delivery system, or HSA-compatible delivery system, the carrier shall pay for each service 50 percent of allowable charges.

(2) A carrier may substitute a copayment for these services at an actuarially equivalent amount to the coinsurance percentages described in this regulation subject to the approval of the Insurance Commissioner and the Maryland Health Care Commission.

(3) For purposes of the uniform cost-sharing arrangements set forth in §B(1) of this regulation, a carrier shall treat a visit made solely for medication management purposes for mental health or substance abuse treatment as a covered service under Regulation .03A(1) and may not count the visit as a mental health or substance abuse service described in Regulation .03A(5) of this chapter.

C. For outpatient services or surgery, the covered person shall pay a $40 copayment or the coinsurance percentage applicable under Regulation .04F of this chapter, whichever is greater, but not greater than the charges.

D. Except for health maintenance organizations, for outpatient laboratory or diagnostic services, the covered person shall pay a $40 copayment or the coinsurance percentage applicable under Regulation .04F of this chapter, whichever is greater, but not greater than the charges.

E. For emergency services, the covered person shall pay:

(1) A $100 copayment, which the carrier shall waive if the covered person is admitted to the hospital; and

(2) For coinsurance the:

(a) Amount applicable for indemnity or exclusive provider under Regulation .04F of this chapter; or

(b) In-network amount for preferred provider, point-of-service and triple option point-of-service under Regulation .04F of this chapter.

F. For infertility services obtained after the diagnosis of infertility has been confirmed, a carrier shall coinsure 50 percent of allowable charges.

G. For skilled nursing facility services, a covered person shall pay a $40 per day copayment or the coinsurance percentage applicable under Regulation .04F of this chapter, whichever is greater.

H. For prescription drugs:

(1) Persons in a non-HSA-compatible delivery system with individual coverage shall pay a $2,500 deductible, and persons with non-individual coverage a $5,000 in aggregate deductible separate from the deductibles set forth in Regulation .04F of this chapter;

(2) Persons enrolled under a HSA-compatible delivery system shall satisfy the deductible set forth in Regulation .04F(2)(b) or (6) of this chapter as a prerequisite to receiving prescription drug benefits;

(3) After paying the applicable deductible, each covered person shall pay a 75% coinsurance percentage.

I. Well-Child Visits Cost-Sharing.

(1) For well-child visits, a covered person shall pay:

(a) Only a $10 copayment for all visits for children 0-24 months of age in a health maintenance organization or indemnity delivery system and for in-network services in a preferred provider delivery system, point-of-service delivery system, triple-option delivery system, HSA-compatible delivery system, or an exclusive provider delivery system;

(b) Only a $10 copayment for visits that include immunization for children older than 24 months through 13 years of age in a health maintenance organization or indemnity delivery system and for in-network services in a preferred provider delivery system, point-of-service delivery system, triple-option point-of-service delivery system, HSA-compatible delivery system, or an exclusive provider delivery system;

(c) For out-of-network services in a preferred provider delivery system, point-of-service delivery system, triple-option point-of-service delivery system, or HSA-compatible delivery system, in accordance with the uniform cost-sharing arrangements described in Regulation .04F(2), (3), and (7) of this chapter; and

(d) For all other visits in accordance with uniform cost-sharing arrangements described in Regulation .04 of this chapter for each delivery system.

(2) A carrier may substitute a copayment that is the actuarial equivalent to the amount specified in §I(1)(b) of this regulation for all well-child visits for children 2-13 years old.

J. General Cost-Sharing Arrangements for Outpatient Rehabilitation and Chiropractic Services. Except as provided in §K of this regulation, for outpatient rehabilitation services and chiropractic services, the carrier shall pay 70 percent of the allowable charges, or may substitute a $40 copayment for these services.

K. Out-of-Network Cost-Sharing Arrangements for Outpatient Rehabilitation Services and Chiropractic Services. For outpatient rehabilitation services and chiropractic services received out-of-network in a preferred provider delivery system, point-of-service delivery system, triple option delivery system, or PPO-HSA, the carrier shall pay 50 percent of allowable charges.

Md. Code Regs. 31.11.06.05

Regulation .05 amended effective May 18, 1998 (25:10 Md. R. 746)
Regulation .05H amended as an emergency provision effective October 1, 1997 (24:21 Md. R. 1444); amended permanently effective January 12, 1998 (25:1 Md. R. 15)
Regulation .05I amended as an emergency provision effective June 1, 1996 (23:13 Md. R. 937); emergency status extended at 23:18 Md. R. 1313; emergency status expired January 16, 1997
Regulation .05I amended effective March 10, 1997 (24:5 Md. R. 407)
Regulations .05 amended effective May 3, 1999 (26:9 Md. R. 731)
Regulation .05 amended effective February 5, 2001 (28:2 Md. R. 106); March 15, 2004 (31:5 Md. R. 452); April 10, 2006 (33:7 Md. R. 676)
Regulation .05E, I amended effective March 24, 2008 (35:6 Md. R. 702)
Regulation .05H amended effective February 7, 2000 (27:2 Md. R. 148)
Regulation .05H amended as an emergency provision effective May 21, 2004 (31:12 Md. R. 909); amended permanently effective August 16, 2004 (31:16 Md. R. 1257)
Regulation .05H amended as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); amended permanently effective January 13, 2011 (38:1 Md. R. 13)
Regulation .05I amended effective May 3, 1999 (26:9 Md. R. 731)