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§ 15-1207. Comprehensive Standard Health Benefit Plan

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, § 15-1207
§ 15-1207. Comprehensive Standard Health Benefit Plan
Regulations relating to Comprehensive Standard Health Benefit Plan
(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.
Exclusion or limitation of benefits or adjustments to cost-sharing arrangements
(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.
Judgment of preventive services, medical treatments, procedures, and related health services
(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.
Other permissible exclusions
(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.
Mental health and substance abuse benefits
(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.
Deductibles and cost-sharing associated with benefits
(f) The Commission shall specify the deductibles and cost-sharing associated with the benefits in the Standard Plan.
Cost-sharing established as part of 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.
Application of section to grandfathered health plans
(h) Beginning January 1, 2014, this section applies only to grandfathered health plans as defined in § 1251 of the Affordable Care Act.

Credits

Added by Acts 1997, c. 35, § 2, eff. Oct. 1, 1997. Amended by Acts 1997, c. 698, § 1, eff. Oct. 1, 1997; Acts 2000, c. 400, § 1, eff. June 1, 2000; Acts 2003, c. 93, § 1, eff. July 1, 2003; Acts 2004, c. 287, § 2, eff. July 1, 2004; Acts 2004, c. 386, § 1, eff. July 1, 2004; Acts 2007, 1st Sp. Sess., c. 7, § 4, eff. July 1, 2008; Acts 2009, c. 577, § 2, eff. Oct. 1, 2009; Acts 2009, c. 578, § 2, eff. Oct. 1, 2009; Acts 2011, c. 3, § 1, eff. July 1, 2011; Acts 2011, c. 4, § 1, eff. July 1, 2011; Acts 2013, c. 368, § 2, eff. Jan. 1, 2014.
Formerly Art. 48A, §§ 698, 700.
MD Code, Insurance, § 15-1207, MD INSURANCE § 15-1207
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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