2014 Maryland Code
Insurance
Title 15 - Health Insurance
Subtitle 8 - Required Health Insurance Benefits
§ 15-835. Required coverage for habilitative services.

(a) "Habilitative services" and "managed care system" defined. --

(1) In this section the following words have the meanings indicated.

(2) (i) "Congenital or genetic birth defect" means a defect existing at or from birth, including a hereditary defect.

(ii) "Congenital or genetic birth defect" includes, but is not limited to:

1. autism or an autism spectrum disorder;

2. cerebral palsy;

3. intellectual disability;

4. Down syndrome;

5. spina bifida;

6. hydroencephalocele; and

7. congenital or genetic developmental disabilities.

(3) "Habilitative services" means services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child's ability to function.

(4) "Managed care system" means a method that an insurer, a nonprofit health service plan, or a health maintenance organization uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality, and claims.

(b) Applicability. -- This section applies to:

(1) insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State; and

(2) health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.

(c) Children under 19 years of age. --

(1) An entity subject to this section shall provide coverage of habilitative services for children under the age of 19 years and may do so through a managed care system.

(2) An entity subject to this section is not required to provide reimbursement for habilitative services delivered through early intervention or school services.

(d) Notice. -- An entity subject to this section shall provide notice annually to its insureds and enrollees about the coverage required under this section:

(1) in print; and

(2) on its Web site.

(e) Adverse decision. -- A determination by an entity subject to this section denying a request for habilitative services or denying payment for habilitative services on the grounds that a condition or disease is not a congenital or genetic birth defect is considered an "adverse decision" under § 15-10A-01 of this title.

(f) Treatment of autism. -- Beginning November 1, 2013, a determination by an entity subject to this section of whether habilitative services covered under this section are medically necessary and appropriate to treat autism and autism spectrum disorders shall be made in accordance with regulations adopted by the Commissioner.