Md. Code Regs. 31.11.06.08

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

Section 31.11.06.08 - Mandatory Point-of-Service Option or Out-of-Network Option

A. When a health maintenance organization is the sole delivery system offered to employees by an eligible employer, the health maintenance organization:

(1) Shall offer the employer a mandatory point-of-service option for the individual employee to accept or reject;

(2) May not impose a minimum participation level on the mandatory point-of-service option;

(3) May not limit the benefits a covered person can receive out of network;

(4) As part of the application, shall provide to each eligible employer the following disclosure statement for each point-of-service option offered:

"Under Maryland law, your employees may purchase a point-of-service option as an additional benefit. A point-of-service option allows your employees to obtain health care services from physicians and other providers outside the HMO network under certain circumstances that are described in attachment A.

You have the choice to pay this point-of-service option, pay a percentage of the cost of this option, or require your employees to pay for the entire cost of this option. The cost of the point-of-service option described in attachment A is identified in your proposal. Please indicate below the employees who have chosen this point-of-service option.

I have read and understand this disclosure statement and the attachments and have provided notice of the availability of this additional benefit to my eligible employees."

B. By July 1, 1996, when a carrier's provider panel is the sole delivery system offered to employees by an eligible employer for dental services, the carrier:

(1) Shall offer the employer a mandatory dental point-of-service option for the individual employee to accept or reject;

(2) May not impose a minimum participation level on the mandatory dental point-of-service option;

(3) As part of the application, shall provide to each eligible employer the following disclosure statement for each dental point-of-service option offered:

"Under Maryland law, your employees may purchase a dental point-of-service option as an additional benefit. A dental point-of-service option allows your employees to obtain services from dentists and other providers outside the provider panel under certain circumstances that are described in attachment A.

You have the choice to pay this dental point-of-service option, pay a percentage of the cost of this option, or require your employees to pay for the entire cost of this option. The cost of the dental point-of-service option described in attachment A is identified in your proposal. Please indicate below the employees who have chosen this dental point-of-service option.

I have read and understand this disclosure statement and the attachments and have provided notice of the availability of this additional benefit to my eligible employees."

C. When an exclusive provider delivery system is the sole delivery system offered to employees by an eligible employer, the insurer or nonprofit health service plan:

(1) Shall offer the employer a mandatory out-of-network option for the individual employee to accept or reject;

(2) May not impose a minimum participation level on the mandatory out-of-network option;

(3) May not limit the benefits a covered person can receive from non-preferred providers;

(4) As part of the application, shall provide to each eligible employer the following disclosure statement for each out-of-network option offered:

"Under Maryland law, your employees may purchase an out-of-network option as an additional benefit. An out-of-network option allows your employees to obtain health care services from non-preferred providers under certain circumstances that are described in Attachment A.

You have the choice to pay the cost of this out-of-network option, pay a percentage of the cost of this option, or require your employees to pay for the entire cost of this option. The cost of the out-of-network option described in Attachment A is identified in your proposal. Please indicate below the employees who have chosen this out-of-network option.

I have read and understand this disclosure statement and the attachments and have provided notice of the availability of this additional benefit to my eligible employees."

D. This regulation does not apply to self-employed individuals.

Md. Code Regs. 31.11.06.08

Regulation .08 amended as an emergency provision effective September 30, 1996 (23:21 Md. R. 1464); amended permanently effective March 10, 1997 (24:5 Md. R. 407)
Regulation .08A amended as an emergency provision effective April 25, 1996 (23:10 Md. R. 729); emergency status extended at 23:18 Md. R. 1314; emergency status expired January 16, 1997
Regulations .08 amended effective May 3, 1999 (26:9 Md. R. 731)
Regulation .08 amended effective March 24, 2008 (35:6 Md. R. 702)