2013 Maryland Code
INSURANCE
§ 15-1207 - Comprehensive Standard Health Benefit Plan and modified plans qualifying under Health Insurance Portability and Accountability Act [Effective until January 1, 2014]


MD Ins Code § 15-1207 (2013) What's This?

§15-1207.

(a) In accordance with Title 19, Subtitle 1 of the Health - General Article, the Commission shall adopt regulations that specify:

(1) the Comprehensive Standard Health Benefit Plan to apply under this subtitle; and

(2) the requirements for a wellness benefit offered by a carrier to apply under this subtitle.

(b) (1) Subject to paragraph (2) of this subsection, the Commission shall exclude or limit benefits or adjust cost-sharing arrangements in the Standard Plan if the average rate for the Standard Plan exceeds 10% of the average annual wage in the State.

(2) The Commission annually shall determine the average rate for the Standard Plan by using the average rate submitted by each carrier that offers the Standard Plan.

(c) In establishing benefits, the Commission shall judge preventive services, medical treatments, procedures, and related health services based on:

(1) their effectiveness in improving the health status of individuals;

(2) their impact on maintaining and improving health and on reducing the unnecessary consumption of health care services; and

(3) their impact on the affordability of health care coverage.

(d) The Commission may exclude:

(1) a health care service, benefit, coverage, or reimbursement for covered health care services that is required under this article or the Health - General Article to be provided or offered in a health benefit plan that is issued or delivered in the State by a carrier; or

(2) reimbursement required by statute, by a health benefit plan for a service when that service is performed by a health care provider who is licensed under the Health Occupations Article and whose scope of practice includes that service.

(e) The Commission shall include mental health and substance abuse benefits required under § 15-802 of this title and § 19-703.1 of the Health - General Article for employers that meet the large employer definition under § 15-802 of this title and § 19-703.1 of the Health - General Article.

(f) The Commission shall specify the deductibles and cost-sharing associated with the benefits in the Standard Plan.

(g) In establishing cost-sharing as part of the Standard Plan, the Commission shall:

(1) include cost-sharing and other incentives to help prevent consumers from seeking unnecessary services;

(2) balance the effect of cost-sharing in reducing premiums and in affecting utilization of appropriate services; and

(3) limit the total cost-sharing that may be incurred by an individual in a year.

§ 15-1207 - Comprehensive Standard Health Benefit Plan and modified plans qualifying under Health Insurance Portability and Accountability Act [Effective January 1, 2014]

(a) In general. -- In accordance with Title 19, Subtitle 1 of the Health -- General Article, the Commission shall adopt regulations that specify:

(1) the Comprehensive Standard Health Benefit Plan to apply under this subtitle; and

(2) the requirements for a wellness benefit offered by a carrier to apply under this subtitle.

(b) Exclusions, limitations, or adjustments. --

(1) Subject to paragraph (2) of this subsection, the Commission shall exclude or limit benefits or adjust cost-sharing arrangements in the Standard Plan if the average rate for the Standard Plan exceeds 10% of the average annual wage in the State.

(2) The Commission annually shall determine the average rate for the Standard Plan by using the average rate submitted by each carrier that offers the Standard Plan.

(c) Criteria for establishing benefits. -- In establishing benefits, the Commission shall judge preventive services, medical treatments, procedures, and related health services based on:

(1) their effectiveness in improving the health status of individuals;

(2) their impact on maintaining and improving health and on reducing the unnecessary consumption of health care services; and

(3) their impact on the affordability of health care coverage.

(d) Exclusion of mandated benefits allowed. -- The Commission may exclude:

(1) a health care service, benefit, coverage, or reimbursement for covered health care services that is required under this article or the Health - General Article to be provided or offered in a health benefit plan that is issued or delivered in the State by a carrier; or

(2) reimbursement required by statute, by a health benefit plan for a service when that service is performed by a health care provider who is licensed under the Health Occupations Article and whose scope of practice includes that service.

(e) Mental health and substance abuse benefits included for large employers. -- The Commission shall include mental health and substance abuse benefits required under § 15-802 of this title and § 19-703.1 of the Health - General Article for employers that meet the large employer definition under § 15-802 of this title and § 19-703.1 of the Health - General Article.

(f) Deductibles and cost-sharing. -- The Commission shall specify the deductibles and cost-sharing associated with the benefits in the Standard Plan.

(g) Considerations for cost-sharing. -- In establishing cost-sharing as part of the Standard Plan, the Commission shall:

(1) include cost-sharing and other incentives to help prevent consumers from seeking unnecessary services;

(2) balance the effect of cost-sharing in reducing premiums and in affecting utilization of appropriate services; and

(3) limit the total cost-sharing that may be incurred by an individual in a year.

(h) Scope of section. -- Beginning January 1, 2014, this section applies only to grandfathered health plans as defined in § 1251 of the Affordable Care Act.

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