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§ 15-1A-15. Summary of benefits and coverage explanation

West's Annotated Code of MarylandInsuranceEffective: May 8, 2020

West's Annotated Code of Maryland
Insurance (Refs & Annos)
Title 15. Health Insurance
Subtitle 1a--Consumer Protections (Refs & Annos)
Effective: May 8, 2020
MD Code, Insurance, § 15-1A-15
§ 15-1A-15. Summary of benefits and coverage explanation
Application of section
(a) This section applies to all grandfathered plans and to every health benefit plan that is not a grandfathered plan.
In general
(b)(1) A carrier shall compile and provide to consumers a summary of benefits and coverage explanation that:
(i) accurately describes the benefits and coverage under the applicable health benefit plan; and
(ii) except as provided in paragraph (2) of this subsection, complies with the standards under 45 C.F.R. § 147.200.
(2) If the Commissioner adopts regulations as described in subsection (c) of this section, a summary of benefits and coverage explanation shall comply with the standards in the adopted regulations.
(c) To the extent necessary, the Commissioner, in consultation with the Maryland Health Benefit Exchange, shall adopt regulations that:
(1) establish standards for the summary of benefits and coverage; and
(2) are consistent with 45 C.F.R. § 147.200 and any corresponding federal rules and guidance in effect December 1, 2019.
(d) The summary of benefits and coverage shall be presented:
(1) in a uniform format that does not exceed four pages in length and does not include print smaller than 12 point type; and
(2) in a culturally and linguistically appropriate manner that uses terminology understandable by the average insured individual.
(e) The standards developed under subsection (c) of this section shall include:
(1) uniform definitions of standard insurance-related terms and medical terms so consumers may compare health benefit plans and understand the terms of and exceptions to coverage, including:
(i) premium;
(ii) deductible;
(iii) coinsurance;
(iv) copayment;
(v) out-of-pocket limit;
(vi) preferred provider;
(vii) nonpreferred provider;
(viii) out-of-network copayments;
(ix) usual, customary, and reasonable fees;
(x) excluded services;
(xi) grievance and appeals;
(xii) hospitalization;
(xiii) hospital outpatient care;
(xiv) emergency room care;
(xv) physician services;
(xvi) prescription drug coverage;
(xvii) durable medical equipment;
(xviii) home health care;
(xix) skilled nursing care;
(xx) rehabilitation services;
(xxi) hospice services;
(xxii) emergency medical transportation; and
(xxiii) any other terms the Commissioner determines are important to define so a consumer may compare the medical benefits offered by health benefit plans and understand the extent of and exceptions to those medical benefits;
(2) a description of the coverage of a health benefit plan, including cost-sharing for:
(i) each of the categories of the essential health benefits in the State benchmark plan selected in accordance with § 31-116 of this article; and
(ii) other benefits, as identified by the Commissioner;
(3) the exceptions, reductions, and limitations on coverage;
(4) the renewability and continuation of coverage provisions;
(5) a coverage facts label that includes examples to illustrate common benefits scenarios based on recognized clinical practice guidelines, including pregnancy and serious or chronic medical conditions and related cost-sharing requirements;
(6) a statement of whether the health benefit plan ensures that the plan or coverage share of the total allowed costs of benefits provided under the plan or coverage is not less than 60% of the costs;
(7) a statement that:
(i) the summary of benefits is an outline of the health benefit plan; and
(ii) the language of the health benefit plan should be consulted to determine the governing contractual provisions; and
(8) a contact number for the consumer to call with additional questions and a website where a copy of the actual health benefit plan can be reviewed and obtained.
(f) As appropriate, the Commissioner, in consultation with the Maryland Health Benefit Exchange, shall periodically review and update the standards developed under subsection (c) of this section.
(g)(1) Each carrier shall provide a summary of benefits and coverage explanation that complies with the standards developed under subsection (c) of this section by the Commissioner to:
(i) an applicant at the time of application; and
(ii) an insured individual before the time of enrollment or reenrollment, as applicable.
(2) A carrier may provide a summary of benefits and coverage explanation as required under paragraph (1) of this subsection in paper or electronic form.
Material modifications
(h) Except as otherwise provided in this article, if a carrier makes any material modification in any of the terms of the plan or coverage involved that is not reflected in the most recently provided summary of benefits and coverage explanation, the carrier shall provide notice of the modification to insured individuals not later than 60 days before the effective date of the modification.
(i)(1) The Maryland Insurance Administration shall levy a fine of not more than $1,000 against a carrier that willfully fails to provide the information required under this section.
(2) A failure with respect to each insured individual shall constitute a separate offense for purposes of this subsection.


Added by Acts 2020, c. 620, § 1, eff. May 8, 2020; Acts 2020, c. 621, § 1, eff. May 8, 2020.
MD Code, Insurance, § 15-1A-15, MD INSURANCE § 15-1A-15
Current through all legislation from the 2022 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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