200 St. Paul Place, Suite 2700, Baltimore, Maryland 21202
Direct Dial: 410-468-2000 Fax: 410-468-2020
1-800-492-6116 TTY: 1-800-735-2258
www.insurance.maryland.gov
MARYLAND’S MANDATED BENEFITS FOR
LARGE GROUP PLANS AND GRANDFATHERED PLANS
1
As of February 5, 2024
Who should use this chart?
This handout describes the Mandatory Benefits that may be contained in your contract if
you have coverage through a large group (groups of more than 50 employees
2
) health
benefit plan or are in a grandfathered plan. (Your plan is a grandfathered plan if you were
in a plan on or prior to March 23, 2010 and the plan has not substantially changed
3
.)For
discussion purposes, the terms “carrier” or “health carrier” will be used to refer to all of
the different types of health insurer providers, including insurers, HMOs and nonprofit
health service plans. This handout also describes Mandatory Offerings.
If you have a small group plan or a non-grandfathered individual plan, this chart does not
apply to you. Please refer to the Essential Health Benefits Chart that may be found at
www.insurance.maryland.gov or by contacting us at (800) 492-6116.
Background
Maryland law requires certain health carriers to include specific benefits in their large
group and grandfathered health benefit plan contracts. These are called “Mandated
Benefits” because the law mandates insurance carriers provide them. Maryland law also
requires that health carriers offer certain benefits, though it is up to the policyholder
whether to purchase such benefits. These are called “Mandatory Offerings.” The
requirements of the law with respect to Mandatory Benefits and Mandatory Offerings
depend on what type of plan you have. For example, HMOs are not required to provide
1
This advisory does not include grandfathered small group plans.
2
The number of employees is determined by adding the full-time employees (those working 30 hours per
week) plus the number of full time equivalent employees. The number of full-time equivalent employees
for a particular month is calculated by dividing the aggregate number of hours worked in that month by all
employees who are not full-time employees and dividing the sum by 120.
3
Substantive changes can include, for example, certain increases in copayments, coinsurance or
deductibles. To determine whether your plan is a grandfathered plan, contact your insurance company or
review your insurance documents (plans are required to inform you whether your plan is a grandfathered
plan).
all of the Mandatory Benefits that insurance companies are required to provide. Your
contract may also include exclusions that are not described here or may include benefits
that are not required by law. If a health carrier fails to provide Mandatory Benefits, or does
not offer benefits which it is required by law to offer, the carrier may be subject to fines or
sanctions, including the payment of restitution, if appropriate. If you believe a carrier has
violated the insurance law, you may file a complaint with the Maryland Insurance
Administration (MIA).
Below, please find a list of benefits that must be offered by certain carriers under certain
circumstances (“Mandatory Offerings”), followed by a discussion regarding Mandatory
Benefits. Attached is a chart containing a list of Mandated Benefits and the types of plans
that must provide coverage for these Mandated Benefits along with a description of when
a carrier may impose a deductible or copayment.
Mandatory Offerings
The following coverages must be offered by certain carriers in certain situations:
Alzheimer’s Disease Treatment – This optional benefit covers expenses arising from the
care of individuals with Alzheimer’s Disease and includes nursing home care and
intermediate or custodial nursing care. Only group insurers and nonprofit health service
group plans must offer this coverage. (Insurance Article §15-801)
Disability Benefits for Disabilities Caused by Pregnancy or Childbirth – Insurers offering
group policies that provide benefits for temporary disability must offer the policyholder the
option to purchase coverage for temporary disability caused or contributed by pregnancy
or childbirth. (Insurance Article §15-813)
Hospice Services – Inpatient and Outpatient – This optional benefit covers the services
of hospice, a coordinated care program for people who are dying and their family
members. By law, all health carriers are required to offer this benefit. (Health General
Article § 19-703(c) for HMOs; Insurance Article § 15-809 for all other carriers)
Are All Health Benefit Plans Required By Law To Include Mandatory Benefits?
The law exempts certain carriers and health benefit plans from the requirement to provide
Mandatory Benefits and the requirement to make Mandatory Offerings. These include:
Group policies issued to the group’s home office which is not located in Maryland.
If you work for an employer whose home office is located in another state, your
health insurance policy may have been issued in that other state. The MIA
regulates only those policies issued or delivered in Maryland. This also applies
if you are an individual insured under a group policy issued to an association that
is not located in Maryland.
The federal government’s health benefit plans. States do not regulate federal
government health benefit plans.
Self-funded plans/self-insured plans. A self-funded/self-insured plan is a type of
health insurance in which a company determines what health benefits will be
offered to its employees and directly pays for the costs of the health care for its
employees. There is no health insurance policy issued, so laws governing what
must be covered in health insurance policies do not apply. Check with your
employer to find out whether you are in a self-insured/self-funded plan.
Medicare or Medicaid (Maryland Medical Assistance Program and Maryland’s
Children’s Health Insurance Program). These federally-regulated programs and
policies are not subject to state insurance law relating to benefits.
What Can You Do If Your Carrier Has Not Provided Or Offered These Benefits?
You should look at your policy or contract, or call the carrier’s customer service
department to determine which benefits are covered under the terms of your policy. Your
carrier is required to provide you with a Summary of Benefits and Coverage. If the service
is covered by your plan but the health plan is denying your coverage, you may file an
appeal with the health plan.
If you believe that the carrier has improperly denied your claim for health care services or
is not in compliance with Maryland’s mandatory benefits and offerings laws, you may file
a complaint with the MIA. The MIA regulates only those policies that are issued or
delivered in Maryland. You can obtain complaint forms and authorizations to release
medical records from the MIA’s website, www.insurance.maryland.gov. These completed
forms, along with copies of any related documents, such as the policy, should be mailed
to the MIA. For further assistance, you may call the MIA at (800) 492- 6116.
Maryland’s Mandated Benefits Chart
This chart includes a list and a brief description of all of the benefits mandated under Maryland law. As indicated in the introduction to
this brochure, the requirements of the law depend on what type of plan you have. Therefore, you will need to look at your plan to see if
your plan is required to include the Mandated Benefit. The citation for the statute that provides the benefit is listed. If the box is blank,
that indicates that the benefit is not mandated by law for your plan. Generally, a carrier may require an insured to pay a deductible or
copayment for Mandatory Benefits; however, the law may prohibit these fees for certain benefits. The chart also indicates when such fees
are prohibited.
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Amino Acid–
Based Elemental
Formula (also see
Medical Foods)
Coverage for amino acid-based elemental formula, regardless of delivery
method, for the diagnosis and treatment of:
(I)
Immunoglobulin E and non-immunoglobulin E mediated allergies to
multiple food proteins;
(II)
Severe food protein induced Enterocolitis Syndrome;
(III)
Eosinophilic disorders, as evidenced by the results of a biopsy; and
(IV)
Impaired absorption of nutrients caused by disorders affecting the
absorptive surface, functional length, and motility of the gastrointestinal
tract.
Provided that the ordering physician issues a written order that states the
amino acid-based elemental formula is medically necessary for treatment of
one of the above listed diseases or disorders.
Insurance Article
§15-843
Insurance Article §15-
843
Anesthesia for
Dental Care
Limited coverage for individuals age 7 or younger or individuals with
developmental disabilities for general anesthesia and associated hospital or
ambulatory charges in conjunction with dental care when a successful result
cannot be expected without anesthesia.
Insurance Article
§15-828
Insurance Article §15-
828
Biomarker Testing
Requires coverage for biomarker testing for the purpose of diagnosis,
treatment, appropriate management, or ongoing monitoring of a disease or
condition that is supported by medical and scientific evidence, including
testing:(1) cleared or approved by the U.S. Food and Drug Administration;(2)
required or recommended for a drug approved by the U.S. Food and Drug
Administration to ensure an insured or enrollee is a good candidate for the
drug treatment;(3) required or recommended through a warning or
precaution for a drug approved by the U.S. Food and Drug Administration to
identify whether an insured or enrollee will have an adverse reaction to the
drug treatment or dosage;(4) covered under a Centers for Medicare and
Medicaid Services National Coverage Determination or Medicare
Administrative Contractor Local Coverage Determination; or (5) supported
by nationally recognized clinical practice guidelines.
Insurance Article
§15-859
Insurance Article §15-
859
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Blood Products
Payment for blood products, other than whole blood or concentrated red
blood cells, may not be excluded.
Insurance Article
§15-803
Insurance Article §15-
803
Breast Cancer
Screening
(including
mammograms)
Coverage for breast cancer screening in accordance with the latest screening
guidelines issued by the American Cancer Society. Coverage shall include
digital tomosynthesis that, under accepted standards in the practice of
medicine, the treating physician determines is medically appropriate and
necessary for an enrollee or insured. This may include screening
mammograms. A copayment or coinsurance requirement for digital
tomosynthesis may not be greater than a copayment or coinsurance
requirement for other breast cancer screenings for which coverage is
required.
Insurance Article
§15-814
Insurance Article §15-
814
Breast Prosthesis
Coverage for a prosthesis prescribed by a physician where the member has
had a mastectomy but has not had reconstructive surgery.
Insurance Article
§15-834
Insurance Article §15-
834
Child Wellness
Requires coverage of certain preventative services, including well child visits,
immunizations and screening tests for hearing, vision, tuberculosis, anemia
and lead toxicity. For newborns, coverage of hereditary and metabolic
screening also included.
Health – General
Article §19-701
(g)(2) and §19-
705.1(c)(4)
Insurance Article §15-
817
Chlamydia
Screening
Coverage for annual screening Chlamydia for sexually active women under
the age of 20, and for men and women 20 years and older who have multiple
risk factors.
Insurance Article
§15-829
Insurance Article §15-
829
Cleft Lip/Cleft
Palate
Coverage for inpatient or outpatient expenses arising from orthodontics, oral
surgery, and otologic, audiological, and speech/language treatment involved
in the management of cleft lip and/or cleft palate.
Insurance Article
§15-818
Insurance Article §15-
818
Clinical Trials
Coverage for patient cost for participation in a clinical trial approved by
specified institutions including National Institutes of Health, U.S. Food and
Drug Administration or the U.S. Department of Veteran’s Affairs, for treatment
provided for a life-threatening condition, or prevention, early detection and
treatment studies on cancer.
Insurance Article
§15-827
Insurance Article §15-
827
Colorectal Cancer
Screening
Coverage for colorectal screening.
Insurance Article
§15-837
Insurance Article §15-
837
Contraceptive
Drugs or Devices
This mandate only applies to individuals that have prescription coverage.
Coverage of FDA-approved drugs or devices that are prescribed for use as a
contraceptive. Coverage for the insertion or removal of contraceptive devices
as well as any medically necessary examination associated with the use of a
contraceptive drug or device. Health coverage provided through a religious
organization may exclude this mandated health benefit if it conflicts with the
organizations bona fide religious beliefs and practices.
Insurance Article
§15-826
Insurance Article §15-
826
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Diabetic
Equipment and
Supplies
Coverage for all medically appropriate and necessary diabetes equipment,
diabetic supplies, and diabetes outpatient self-management training and
educational services, including medical nutrition therapy necessary for the
treatment of insulin-using diabetes; noninsulin-using diabetes; elevated or
impaired blood glucose levels induced by pregnancy; or consistent with the
American Diabetes Association’s standards, elevated or impaired blood
glucose levels induced by prediabetes. A deductible, copayment, or
coinsurance requirement on diabetes test strips may not be imposed;
however, if an insured or enrollee is covered under a high-deductible health
plan, may subject diabetes test strips to the deductible requirement of the
high-deductible health plan.
Insurance Article
§15-822
Insurance Article §15-
822
Emergency Room
Services
This benefit covers the cost of emergency room visits. Requires that an HMO
have a system for providing a member with 24-hour access to a physician in
cases where there is an immediate need for medical services. Requires
HMO to provide coverage for emergency services rendered by a physician
other than one preauthorized by the plan when the 24-hour telephone system
is not operational or the member’s primary care provider or specialist cannot
be accessed within a reasonable time as determined by the treating
emergency physician.
Health – General
Article §19-
701(g); §19-
705.1(b); §19-
705.6
Extension of
Benefits
Unless coverage is terminated due to non-payment or fraud or
misrepresentation, requires carriers that provide benefits on an expense
incurred basis to extend certain benefits according to the terms of the policy.
Charging of premiums is prohibited when benefits are extended.
Insurance Article
§15-833
Insurance Article §15-
833
Fertility
Awareness-Based
Methods
Coverage for instruction by a licensed health care provider on fertility
awareness-based methods which can be used to identify times of fertility and
infertility by an individual to avoid pregnancy.
Insurance Article
§15-826.3
Insurance Article §15-
826.3
Fertility
Preservation
Procedures
Coverage for “standard fertility preservation procedures” that are medically
necessary to preserve fertility due to a need for medical treatment that may
directly or indirectly cause iatrogenic infertility. Standard fertility preservation
procedures are those that are consistent with established medical practices
and professional guidelines published by the American Society for
Reproductive Medicine, the American College of Gynecologists, or the
American Society of Clinical Oncology. Coverage includes sperm/oocyte
cryopreservation and associated laboratory assessments, medications, and
treatments, but does not include the storage of sperm or oocytes. Health
coverage provided through a religious organization may exclude this
mandated health benefit if it conflicts with the organizations bona fide
religious beliefs and practices.
Insurance Article
§15-810.1
Insurance Article §15-
810.1
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Gynecological
Care
Requires that an obstetrician/gynecologist may be classified as a primary
care provider or that a woman may receive services from an in-network
obstetrician/gynecologist without first requiring a visit to a primary care
provider for routine care. In the instances where the patient belongs to a
health plan that requires the member to receive a referral prior to receiving
treatment from a specialist, the law provides that women must have direct
access to gynecological care from an in-network obstetrician/gynecologist or
other non-physician, including a certified nurse midwife, who is not her
primary care physician; requires an obstetrician/gynecologist to confer with a
primary care physician.
Insurance Article
§15-816
Insurance Article §15-
816
Habilitative
Services
Coverage for services and devices, including occupational therapy, physical
therapy, and speech therapy, that help a child keep, learn, or improve skills
and functioning for daily living. Coverage must be kept in effect until the end
of the month in which the child turns 19 years old. Coverage is not required
for services delivered through early intervention or school services.
Insurance Article
§15-835
Insurance Article §15-
835
Hair Prosthesis
(Wigs)
Coverage for a hair prosthesis where the hair loss results from chemotherapy
or radiation treatment for cancer and when prescribed by the treating
oncologist. The coverage is for one prosthesis and the benefit may be limited
to $350.
Insurance Article
§15-836
Insurance Article §15-
836
Hearing Aids for
Minor Children
Coverage for hearing aids for a child under the age of 19 years that are
prescribed, fitted and dispensed by a licensed audiologist. The benefit may
be limited to $1,400 per hearing aid for each impaired ear every 36 months;
an insured or enrollee can choose a more expensive unit and pay the
difference between the actual cost and benefit maximum if she or he so
elects.
Insurance Article
§15-838
Insurance Article §15-
838
Home Health Care
Health insurance policies that provide coverage for inpatient hospital care on
an expense-incurred basis must provide coverage for home health care if
institutionalization has been required without the use of home health care.
The carrier may limit visits to 40 visits in any calendar year; up to 4 hours of
home health care services is considered one home health care visit. The
service provider must be licensed under the Health Occupations Article.
Insurance Article §15-
808
Human
Papillomavirus
Screening Test
Coverage for annual screening for Human Papillomavirus for sexually active
women under the age of 20, and for men and women 20 years and older who
have multiple risk factors.
Insurance Article
§15-829
Insurance Article §15-
829
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Infertility Benefits
(For Iatrogenic
Infertility, see also
“Fertility
Preservation
Procedures”)
In Vitro Fertilization – Carriers that provide pregnancy-related benefits may not
exclude benefits for all outpatient expenses arising from IVF procedures.
For insurers and nonprofit health service plans, benefits provided must be the
same as for other pregnancy-related procedures.
For HMOs, the benefits provided must be the same as provided for other
infertility services.
For all insurers, nonprofit health service plans and HMOs that provide infertility
benefits, the coverage must be provided:
(a)
for a patient whose spouse is of the opposite sex, the patient’s oocytes
are fertilized with the patient’s spouse’s sperm; unless:
▪
the patient’s spouse is unable to produce and deliver functional
sperm; and
▪
the inability to produce and deliver functional sperm does not
result from:
-
a vasectomy; or
-
another method of voluntary sterilization;
(b)
the patient and the patient’s spouse have a history of involuntary
infertility, which may be demonstrated by a history of:
▪
If the patient and the patient’s spouse are of opposite sexes,
intercourse of at least 2 years’ duration failing to result in
pregnancy; or
▪
If the patient and the patient’s spouse are of the same sex, six
attempts of artificial insemination over the course of 2 years failing
to result in pregnancy.
(c)
the infertility is associated with any of the following medical conditions:
▪
Endometriosis;
▪
Exposure in utero to diethylstilbestrol, commonly known as DES;
▪
Blockage of, or surgical removal of, one or both fallopian tubes
(lateral or bilateral salpingectomy); or
▪
Abnormal male factors, including oligospermia, contributing to the
infertility.
(d)
the patient has been unable to attain a successful pregnancy through a
less costly infertility treatment for which coverage is available under
the policy or contract; and
(e)
the procedure must be performed at medical facilities that meet the
minimum guidelines for in vitro fertilization established by the
American College of Obstetricians and Gynecologists or the American
Society for Reproductive Medicine.
Carriers may limit the benefit to $100,000 per lifetime and three attempts per
live birth.
Carriers are not responsible for any cost incurred by the patient or the patient’s
spouse in obtaining donor sperm.
Insurance Article
§15-810
Insurance Article §15-
810
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Inpatient Hospital
Services
This benefit covers the cost of a hospital stay.
For hospitalization due to childbirth or maternal care, see “Pregnancy and
Maternity Benefits.”
Health – General
Article §19-
701(g)(2)
Laboratory
Services
This benefit covers tests, ordered by a doctor or other health care provider,
that are conducted at a lab.
Health – General
Article §19-
701(g)(2)
Lung Cancer
Screening
Requires coverage for recommended follow-up diagnostic Imaging to assist
in the diagnosis of lung cancer for individuals when the screening is
recommended by the U.S Preventive Services Task Force,
including diagnostic, ultrasound, magnetic resonance imaging; computed
tomography; and image-guided biopsy. The copayment; co insurance and
deductible shall not be greater than the copayment; co insurance and
deductible for breast cancer screening and diagnosis.
Insurance Article
§15-860
Insurance Article §15-860
Lymphedema
Diagnosis,
Evaluation and
Treatment
Coverage for the medically necessary diagnosis, evaluation, and treatment of
lymphedema, including equipment, supplies, complex decongestive therapy,
gradient compression garments, and self-management training and
education.
The annual deductible, copayment or coinsurance requirements imposed may
not be more than those imposed for similar coverages.
Insurance Article
§15-853
Insurance Article §15-
853
Male Sterilization
Coverage for male sterilization. No deductible, copayment, or coinsurance
requirement may be imposed unless it is a grandfathered plan. If it is a high-
deductible health plan, the benefit may be subject to the deductible
requirement of the high-deductible health plan. Health coverage provided
through a religious organization may exclude this mandated health benefit if it
conflicts with the organizations bona fide religious beliefs and practices.
Insurance Article
§15-826.2
Insurance Article §15-
826.2
Mastectomies
Coverage for a minimum 48-hour inpatient hospital stay following a
mastectomy. The patient may request a shorter length of stay. A carrier
must provide a patient that receives less than a 48 hour stay, or who
undergoes a mastectomy on an outpatient basis, one home visit scheduled to
occur within 24 hours after discharge and an additional home visit if
prescribed.
Insurance Article
§15-832.1
Insurance Article §15-
832.1
Medical Foods
(Also see Amino
Acid-Based
Elemental
Formula)
Coverage for medical foods and low protein-modified food products for the
treatment of inherited metabolic diseases if the medical foods or low protein
modified food products are:
(1)
Prescribed as medically necessary for therapeutic treatment of inherited
metabolic diseases; and
(2)
Administered under the direction of a physician.
Health – General
Article §19-705.5
Insurance Article §15-
807
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Mental Health/
Substance Misuse
Treatment
Coverage – Coverage shall be provided for at least the following benefits for
the diagnosis and treatment of a mental illness, emotional disorder, drug use
disorder or alcohol use disorder:
(1)
Inpatient benefits for services provided in a licensed or certified facility,
including hospital inpatient and residential treatment center benefits;
(2)
Partial hospitalization benefits; and
(3)
Outpatient and intensive outpatient benefits, including all office visits,
diagnostic evaluation, opioid treatment services, medication evaluation and
management, and psychological and neuropsychological testing for
diagnostic purposes.
Although federal law does not require a plan to provide coverage for mental
health benefits, when such coverage is provided, the Mental Health Parity Act
generally requires that the mental health benefits not be more restrictive than
medical and surgical benefits provided under the plan.
Insurance Article
§15-802
Insurance Article §15-
802
Methadone Maintenance Treatment – As of January 1, 2020, an insurer,
nonprofit health service plan, or health maintenance organization shall use
the ASAM criteria for all medical necessity and utilization management
determinations for substance use disorder benefits.
Insurance Article
§15-802(d)(5)
Insurance Article §15-
802(d)(5)
Residential Crisis Services – Coverage for medically necessary residential
crisis services, defined as intensive mental health and support services:
(1)
Provided to a child or an adult with a mental illness who is experiencing
or is at risk of a psychiatric crisis;
(2)
Designed to prevent or provide an alternative to a psychiatric inpatient
admission, or shorten the length of inpatient stay;
(3)
Provided out of the individual’s residence in a community-based
residential setting; and
(4)
Provided by DHMH-licensed entities.
Insurance Article
§15-840
Insurance Article §15-
840
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Morbid Obesity
Coverage for surgical treatment that is:
(1)
Recognized by the National Institutes of Health as effective for the long-
term reversal of morbid obesity; and
(2)
Consistent with guidelines approved by the National Institutes of Health.
Coverage must be to the same extent as for other medically necessary
surgical procedures under the policy.
Insurance Article
§15-839
Insurance Article §15-
839
Osteoporosis
Prevention and
Treatment
Coverage for qualified individuals for reimbursement for bone mass
measurement for the prevention, diagnosis, and treatment of osteoporosis
when the bone mass measurement is requested by a health care provider for
the qualified individual.
Insurance Article
§15-823
Insurance Article §15-
823
Ostomy
Equipment and
Supplies
Coverage for all medically appropriate and necessary equipment and supplies
used for the treatment of ostomies, including flanges, collection bags, clamps,
irrigation devices, sanitizing products, ostomy rings, ostomy belts, and
catheters used for drainage of urostomies. The annual deductibles or
coinsurance requirements may not be greater than the annual deductibles or
coinsurance requirements for similar coverages.
Insurance Article
§15-848
Insurance Article §15-
848
Physician
Services
This benefit covers the services of a physician.
Health – General
Article §19-
701(g)(2)
Pregnancy and
Maternity Benefits
Hospitalization Benefits for Child Birth – Every insurance policy that provides
hospitalization benefits for normal pregnancy must provide hospitalization
benefits to the same extent as that for any covered illness. In addition,
whenever a mother is required to remain hospitalized after childbirth for
medical reasons and the mother requests that the newborn remain in the
hospital, the insurer or nonprofit health service plan must pay the cost of
additional hospitalization for the newborn for up to 4 days.
Health – General
Article §19-703(f)
Insurance Article §15-
811
Inpatient Hospital Coverage for Mothers and Newborns – Requires carriers
that provide inpatient hospitalization coverage on an expense-incurred basis
to provide inpatient hospitalization coverage for a mother and newborn child
for a minimum of 48 hours after an uncomplicated vaginal delivery and 96
hours after an uncomplicated caesarean section; if the mother requests a
shorter hospital stay, the carrier must provide coverage for one home visit by
a registered nurse within 24 hours after discharge from the hospital, and if
prescribed by the attending provider, an additional home visit.
Insurance Article
§15-812
Insurance Article §15-
812
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Prescription Benefits
{Note: Carriers are
not required to
include prescription
drug benefits. When
benefits are
provided under a
policy or contract,
these laws apply.}
Off-Label Use of Drugs – A policy or contract that provides coverage for drugs may not
exclude coverage of a drug for an off-label use of the drug if the drug is recognized for
treatment in any of the standard reference compendia or in the medical literature.
Coverage of a drug required by this subsection also includes medically necessary
services associated with the administration of the drug.
Insurance Article
§15-804
Insurance Article §15-
804
Reimbursement for Pharmaceutical Products – If a policy provides reimbursement for
a pharmaceutical product (i.e. a drug or medicine prescribed by an authorized
prescriber), it cannot establish varied reimbursement based on the type of prescriber
and cannot request different copayments, deductibles, or any other condition when a
community pharmacy is utilized rather than a mail order program.
A policy issued to an employer under a collective bargaining agreement is not required
to include this benefit.
Insurance Article §15-
805
Choice of Pharmacy. A nonprofit health service plan is required to allow the member
to fill prescriptions at the pharmacy of choice.
Insurance Article §15-
806
Maintenance Drug Coverage – Carrier shall allow the insured to receive up to a 90-
day supply of a prescribed maintenance drug in a single dispensing, except for new
prescriptions or changes in prescriptions. An insured or enrollee who is a resident of a
nursing home is not entitled to this mandatory benefit.
Insurance Article
§15-824
Insurance Article §15-
824
Copayment/Coinsurance – Carriers may not impose a copayment or coinsurance that
exceeds the retail price.
Insurance Article
§15-842
Insurance Article
§15-842
Use of Formulary – Each entity limiting its coverage of Rx drugs or devices to those in
a formulary shall establish & implement a procedure by which a member can receive a
Rx drug or device that is not in the entity’s formulary or have been removed from the
formulary or continue the same cost sharing requirements if the prescription drug or
device has been moved to a higher deductible, copayment, or coinsurance tier.
Insurance Article
§15-831
Insurance Article §15-
831
Coverage or Abuse-Deterrent Opioid Analgesic Drug Products – A policy or contract
that provides coverage for prescription drugs shall provide coverage for:
At least two brand name abuse-deterrent opioid analgesic drug products, each
containing different analgesic ingredients, on the lowest cost tier for brand
name prescription drugs on the entity’s formulary for prescription drug
coverage; and
If available, at least two generic abuse-deterrent opioid analgesic drug
products, each containing different analgesic ingredients, on the lowest cost
tier for generic drugs on the entity’s formulary for prescription drug coverage.
Carriers may not require an insured or an enrollee to first use an opioid analgesic drug
product without abuse-deterrent labeling before providing coverage for an abuse-
deterrent opioid analgesic drug product covered on the entity’s formulary for
prescription drug coverage.
Carriers may undertake utilization review, including preauthorization, for an abuse-
deterrent opioid analgesic drug product covered by the carrier, if the same utilization
review requirements are applied to non-abuse-deterrent opioid analgesic drug
products covered by the carrier in the same formulary tier as the abuse-deterrent
opioid analgesic product.
Insurance Article
§15-849
Insurance Article §15-
849
MANDATE
DESCRIPTION OF BENEFIT
HMO
NONPROFIT HEALTH
SERVICE PLAN
Preventative
Services
This benefit covers all preventative services that are meant to help prevent
disease and injury.
For preventative services related to the care of a minor child, see “Child
Wellness.”
Health – General
Article §19-
701(g)(2)
See Specific Service
Prosthetic Devices
Coverage for prosthetic devices, components of prosthetic devices and
repairs to prosthetic devices. Copayment and coinsurance requirements for
these devices may not be higher than those required for any primary care
benefit. No annual or lifetime dollar maximum on coverage for the device can
be applied that is separate from the aggregate maximum applicable total
benefit.
Insurance Article
§15-844
Insurance Article §15-
820 and §15-844
Prostate Cancer
Screening
Coverage for the expenses incurred in conducting a medically-recognized
diagnostic examination including a digital rectal exam and prostate-specific
antigen (PSA) test for:
(1)
Men between 40 and 75;
(2)
When used for the purpose of guiding patient management in monitoring
the response to prostate cancer treatment;
(3)
When used for staging in determining the need for a bone scan in
patients with prostate cancer; or
(4)
When used for male patients who are at high risk for prostate cancer.
Insurance Article
§15-825
Insurance Article §15-
825
Reconstructive
Breast Surgery
Coverage for reconstructive breast surgery resulting from a mastectomy to
reestablish symmetry between the two breasts. Coverage includes surgery on
the nondiseased breast to establish symmetry when reconstructive breast
surgery is performed on the diseased breast. Coverage of physical
complications of all stages of mastectomy, including lymphedemas, is also
mandatory.
Insurance Article
§15-815
Insurance Article §15-
815
Referrals to
Specialist
Requires carriers that do not allow direct access to specialists to establish
and implement a procedure by which a member may receive, under certain
circumstances, a standing referral to a participating specialist and under
certain circumstances to a non-participating specialist (including a physician
or nonphysician specialist); provides pregnant members with a standing
referral to an obstetrician.
Insurance Article
§15-830
Insurance Article §15-
830
Second Opinions
and Coverage of
Outpatient
Services
If the policy provides coverage for an inpatient service in an acute general
hospital, and coverage for an inpatient admission is denied, the carrier must
cover the expenses of:
(1)
Corresponding outpatient service that is provided to the insured instead
of the inpatient service; and
(2)
An objective second opinion, given to the insured when requested by a
utilization review program under § 19-319 of the Health-General Article.
Insurance Article §15-
819
MANDATE
DESCRIPTION OF BENEFIT
INSURER
HMO
NONPROFIT HEALTH
SERVICE PLAN
Smoking
Cessation
Plans that provide prescription coverage must provide coverage for any drug
that is not an over-the-counter product which is approved by the FDA as an
aid for the cessation of the use of tobacco products; and is obtained under a
prescription written by an authorized prescriber. The plan must also provide
coverage for two 90-day courses of nicotine replacement therapy during
each policy year.
Copayments or coinsurance amounts for drugs provided must be the same
as that for comparable prescriptions.
Insurance Article
§15-841
Insurance Article
§15-841
Insurance Article §15-
841
Surgical Removal
of Testicles
Coverage for at least 1 home health visit within 24 hours after discharge for a
patient who had less than 48 hours of inpatient hospitalization after surgical
removal of a testicle, or who undergoes the procedure on an outpatient basis
and an additional visit must be covered if ordered by the treating physician.
Insurance Article
§15-832
Insurance Article
§15-832
Insurance Article §15-
832
Temporo-
Mandibular Joint
Syndrome (TMJ)
Treatment
Health insurers that provide coverage for a diagnostic or surgical procedure
involving a bone or joint of the skeletal structure may not exclude or deny
coverage for the same diagnostic or surgical procedure involving a bone or
joint of the face, neck, or head if the procedure is medically necessary to
treat a condition caused by a congenital deformity, disease, or injury.
Coverage for intraoral prosthetic devices is not mandatory.
Insurance Article
§15-821
Insurance Article §15-
821
X-Ray
This benefit covers x-rays ordered by a doctor or other health professional.
Health – General
Article §19-
701(g)(2)
DISCLAIMER: The information in this chart is provided for informational purposes only and is not intended as legal advice or
legal analysis. If you have a question as to whether a specific service or healthcare product is required to be covered, you
should seek the advice of independent legal counsel.