Md. Code Regs. 31.12.02.06

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.12.02.06 - Contract Forms

A. Form Numbers.

(1) Each form shall be identified by a form number that is unique to that form.

(2) The form number shall be printed in the lower left corner of the first page, and no other number may appear near the form number.

B. The text of each form shall be printed in a style of type which is easily legible, the size of which shall be uniform and not less than 10 point with a lower case unspaced alphabet length not less than 120 point. The text shall include all printed matter except the name and address of the HMO, name or title of the policy, the brief description, if any, and captions and subcaptions.

C. Each form shall be clearly worded with all limitations, exclusions, and exceptions printed in the same size of type used to describe the benefits and grouped together under appropriate captions in boldfaced type.

D. Name of HMO.

(1) Each complete form, except riders or endorsements, shall bear on the face the corporate name and either:

(a) The address (city and state) of the HMO; or

(b) The address of the company office that will administer the form.

(2) The name of the HMO shall appear more prominently on a form than the name of:

(a) An affiliate;

(b) A producer;

(c) An underwriter;

(d) A holding company; or

(e) A third party administrator.

(3) The name of the HMO shall be printed in a size of type larger than the title of the policy.

E. Time shall be determined by any of the following which the HMO specifies in the contract:

(1) Time at the place the enrollee resides;

(2) Time at the place the contract is delivered;

(3) Time at the place the treatment is delivered; or

(4) Time at the location of the administrative office of the HMO.

F. Each form shall contain the signature of a responsible officer of the HMO.

G. A contract, certificate, rider, or endorsement may not contain any advertising material.

H. HMO Coverage as Secondary Coverage.

(1) Each individual contract, group contract, and group certificate shall state whether or not benefits provided are to be secondary to the benefits which the member is entitled to receive under:

(a) Workers' compensation insurance;

(b) Medicare; and

(c) Any programs for which the member is not required to pay.

(2) An HMO contract may not:

(a) Provide benefits that are secondary to benefits payable under an automobile policy; or

(b) Include an exclusion for losses covered by an automobile policy.

I. Each individual contract and group contract shall provide that notice of any increase in charges shall be given to the contract holder by the HMO at least 45 days before the change in rate is proposed to become effective.

J. Each individual contract provided to subscribers shall describe the health services to be provided under the contract and shall contain the entire agreement between the HMO and the subscriber, including but not limited to:

(1) Date and time of inception and termination of contract;

(2) Initial rate to be charged and when the initial rate may be modified;

(3) Mode of payment, with provision for change of mode, if available;

(4) Late payment and reinstatement privileges;

(5) Cost sharing provisions, including copayments, coinsurance, and deductibles;

(6) Renewal conditions and applicable termination provisions;

(7) Provisions for adding new family members;

(8) Services to be provided under the contract;

(9) Provision for out-of-area coverage;

(10) Limits on length of stay, if any;

(11) Other limitations, exclusions, and exceptions; and

(12) The formal procedure to be followed in filing complaints or grievances.

K. Each individual contract which covers the spouse of the subscriber shall provide that, in the event of the death of the subscriber, the spouse will become the successor subscriber.

L. Each individual contract shall provide that the subscriber may, if the contract is not satisfactory for any reason, return it within 10 days of its receipt and receive a full refund of the charges paid. This right may not be exercised, however, if any member under the contract utilizes the services of the HMO within the 10-day period.

M. Each group contract and each group certificate furnished to subscribers of a group shall comply with all applicable provisions required by §§A-J of this regulation, inclusive, except that the certificate may omit those items which pertain only to the group contract holder.

N. Each individual contract, group contract, and group certificate shall include an incapacitated child provision that complies with the requirements found in Insurance Article, § 15-402, Annotated Code of Maryland.

O. Newborn Child, Adopted Child, Child Under Guardianship Provision. Each individual contract, group contract, and group certificate shall contain a provision for covering newborn children, adopted children, and children under guardianship in accordance with Insurance Article, § 15-401, Annotated Code of Maryland.

P. Each individual contract, group contract, and group certificate shall provide that, if the HMO for any reason beyond its control is unable to provide the health services promised in the contract, the HMO shall be liable for reimbursement of the expenses necessarily incurred by any member in procuring the services through other providers, to the extent prescribed by the Insurance Commissioner of Maryland.

Md. Code Regs. 31.12.02.06