Section 15-1A-09 – Acceptance of All Employers and Individuals — Exceptions
(a) Except as provided in subsections (b) through (d) of this section, a carrier shall accept every employer and individual in the State that applies for a health benefit plan, subject to the following provisions of this article: (1) Subtitle 4 of this title; (2) §§ 15–1206(c), 15–1208.1, 15–1208.2, 15–1209, and 15–1210 of this title; (3) §§ 15–1316 and […]
Section 15-1A-10 – Coverages Required and Additional Charges Prohibited — Out-of-Network Charges — Services Recommended or Not by Task Force
(a) Except as provided in subsections (b) and (c) of this section, a carrier shall provide coverage for and may not impose any cost–sharing requirements, including copayments, coinsurance, or deductibles for: (1) evidence–based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task […]
Section 15-1A-11 – Lifetime or Annual Limits on Benefits
(a) Except as provided in subsections (b) and (c) of this section, a carrier that offers a health benefit plan, including a grandfathered plan, may not establish lifetime limits or annual limits on the dollar value of benefits for any insured individual. (b) To the extent that limits are otherwise authorized under federal or State law, a […]
Section 15-1A-12 – Limit on Waiting Period for Otherwise Eligible Individual
A carrier offering a group plan, including a grandfathered plan, may not apply a waiting period of more than 90 days that must pass before coverage becomes effective for an individual who is otherwise eligible for the group plan.
Section 15-1A-13 – Identification of Participating Primary Care Provider — Children — Obstetrical or Gynecological Care
(a) If a carrier requires or provides for the designation of a participating primary care provider for an insured individual, the carrier shall allow each insured individual to designate any participating primary care provider if the provider is available to accept the insured individual. (b) (1) (i) This subsection applies only to an individual who has a child who […]
Section 15-1A-01 – Definitions
(a) In this subtitle the following words have the meanings indicated. (b) “Carrier” means: (1) an insurer that holds a certificate of authority in the State and provides health insurance in the State; (2) a health maintenance organization that is licensed to operate in the State; (3) a nonprofit health service plan that is licensed to operate in the State; […]
Section 15-1A-02 – Enforcement of Provisions by Commissioner
(a) The Commissioner may enforce: (1) the provisions of this subtitle; and (2) notwithstanding any other provisions of law, the following provisions of Title 1, Subtitles A, C, and D of the Affordable Care Act as they apply to individual health insurance coverage and health insurance coverage offered in the small group and large group markets as those […]
Section 15-1A-03 – Adoption of Regulations — Application to Health Benefit Plan — Grandfathered Plans
(a) For purposes of this subtitle, to the extent necessary, the Commissioner shall adopt regulations that: (1) establish criteria that a health benefit plan must meet to be considered a grandfathered plan; and (2) are consistent with 45 C.F.R. § 147.140 and any corresponding federal rules and guidance as those provisions were in effect December 1, 2019. (b) Except […]
Section 15-1A-04 – Criteria for Health Benefit Plans — Consistent With Federal Law
For purposes of this subtitle, to the extent necessary, the Commissioner shall adopt regulations that: (1) establish criteria that a health benefit plan must meet to be considered a health benefit plan that covers essential health benefits; and (2) are consistent with 45 C.F.R. Part 156 Subpart B and any corresponding federal rules and guidance as those […]
Section 15-1A-05 – Application to Grandfathered Plans — Prohibition on Certain Exclusions or Denials
(a) This section applies to all grandfathered plans except grandfathered plans that are individual plans and to every health benefit plan that is not a grandfathered plan. (b) A carrier may not: (1) exclude or limit benefits because a health condition was present before the effective date of coverage; or (2) deny coverage because a health condition was present […]