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§ 15-1204. Carrier health benefit plan requirements and restrictions

West's Annotated Code of MarylandInsuranceEffective: January 1, 2014

West's Annotated Code of Maryland
Insurance (Refs & Annos)
Title 15. Health Insurance
Subtitle 12. Maryland Health Insurance Reform Act (Refs & Annos)
Effective: January 1, 2014
MD Code, Insurance, § 15-1204
§ 15-1204. Carrier health benefit plan requirements and restrictions
Application of section
(a) This section applies to a carrier with respect to any health benefit plan that is a grandfathered health plan, as defined in § 1251 of the Affordable Care Act.
Capacity to administer health benefit plan, satisfactory grievance procedure, and access to providers of health care
(b) In addition to any other requirement under this article, a carrier shall:
(1) have demonstrated the capacity to administer the health benefit plan, including adequate numbers and types of administrative personnel;
(2) have a satisfactory grievance procedure and ability to respond to enrollees' calls, questions, and complaints;
(3) provide, in the case of individuals covered under more than one health benefit plan, for coordination of coverage under all of those health benefit plans in an equitable manner; and
(4) design policies to help ensure adequate access to providers of health care.
Standard Plan required for person to offer health benefit plan
(c) A person may not offer a health benefit plan in the State unless the person offers at least the Standard Plan.
Restrictions relating to benefits of health benefit plan
(d) A carrier may not offer a health benefit plan that has fewer benefits than those in the Standard Plan.
Benefits in addition to those in Standard Plan
(e) A carrier may offer benefits in addition to those in the Standard Plan if:
(1) the additional benefits:
(i) are offered and priced separately from benefits specified in accordance with § 15-1207 of this subtitle; and
(ii) do not have the effect of duplicating any of those benefits; and
(2) the carrier:
(i) clearly distinguishes the Standard Plan from other offerings of the carrier;
(ii) indicates the Standard Plan is the only plan required by State law; and
(iii) specifies that all enhancements to the Standard Plan are not required by State law.
Point of service delivery system as additional benefit
(f) Notwithstanding subsection (c) of this section, a health maintenance organization may provide a point of service delivery system as an additional benefit through another carrier regardless of whether the other carrier also offers the Standard Plan.
Dental care and services as additional benefit
(g) A carrier may offer coverage for dental care and services as an additional benefit.
Wellness benefits offered by prominent carriers
(h)(1) In this subsection, “prominent carrier” means a carrier that insures at least 10% of the total lives insured in the small group market.
(2)(i) A prominent carrier shall offer a wellness benefit for a health benefit plan offered under this subtitle.
(ii) A carrier that is not a prominent carrier may offer a wellness benefit for a health benefit plan offered under this subtitle.
(3) A carrier may not condition the sale of a wellness benefit to a small employer on participation of the eligible employees of the small employer in wellness programs or activities.


Added by Acts 1997, c. 35, § 2, eff. Oct. 1, 1997; Amended by Acts 2003, c. 93, § 1, eff. July 1, 2003; Acts 2004, c. 287, § 2, eff. July 1, 2004; Acts 2007, 1st Sp. Sess., c. 7, § 2, eff. Nov. 19, 2007; Acts 2012, c. 152, § 2, eff. Jan. 1, 2014.
Formerly Art. 48A, § 699.
MD Code, Insurance, § 15-1204, MD INSURANCE § 15-1204
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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