Contract Filings - Small Group HMOs

BULLETIN DATE: March 17, 1999 TO: Small Group Health Maintenance Organizations RE: Contract Filings Bulletin No.: Life and Health 99-4 We would like to bring to your attention revisions that will be required of the small group contracts issued or renewed on or after July 1, 1999. These revisions were published in the Maryland Register on February 12, 1999. We recommend that these changes be made through an amendment rider which will be attached to the group policy and certificate. Please specify the form number and date of approval of the policy to which the amendment rider will be attached. To ensure approval by July 1, 1999, the filings must be received by this Administration by May 1, 1999. Revisions Required By COMAR 31.11.06 • Mental Health and Substance Abuse Services * Inpatient benefit--Increased benefit from 25 days per covered person per year to 60 days per covered person per year. See COMAR 31.11.06.03A(4). * Outpatient Services--Substituted a fixed benefit for outpatient visits instead of a sliding scale. The new benefit is 70% of allowable charges. See COMAR 31.11.06.05A(1). • Family Planning Services * Revised benefit to include contraceptive devices, the insertion and removal of contraceptive devices and medical examinations associated with the use of contraceptive drugs or devices. See COMAR 31.11.06.03A(22). * The exclusion for IUDs and other contraceptive devices is deleted. See COMAR 31.11.06.06B(52). • New Benefit for Breast Prosthesis--See COMAR 31.11.06.03A(30) and COMAR 31.11.06.03I. March 17, 1999 Page 2 • New Benefit for Audiology Screening for Newborns--See COMAR 31.11.06.03A(31). • New Benefit for General Anesthesia and Associated Hospital or Ambulatory Facility Charges for Certain Children Who Require Dental Care--See COMAR 31.11.06.03A(32) and COMAR 31.11.06.03J. • Prescription Drug Benefit * Maintenance Drugs--An exemption is provided for the 90 day supply of maintenance drugs for the first prescription of a maintenance drug or a change in a prescription of a maintenance drug. See COMAR 31.11.06.03E(5). * New prohibition against a carrier from reimbursing a health care practitioner in an amount that is less than the cost to the practitioner for oncology drugs used in treating a patient in the practitioner’s office. See COMAR 31.11.06.03E(3). • Child Wellness--Clarified benefit with regard to the copayment, which applies when the child is exactly 2 years old. See COMAR 31.11.06.05I. • Mandatory POS Option * Clarified that under the mandatory POS option, the carrier may not limit the benefits a covered person can receive out-of-network. See COMAR 31.11.06.08A(3). * Specified that the carrier’s coinsurance percentage for out-of-network services must be at least 60%. See COMAR 31.11.06.04F(4)(d). We are enclosing copies of the February 12, 1999, changes to the small group regulations. Please note that the above summary does not include all changes to the regulations; it details only the changes which are required by July 1, 1999. Please contact Ellen Woodall, Supervisor, Managed Care Unit at (410) 468-2226 if you have any questions regarding these filings. _____________________________ Donna B. Imhoff Associate Commissioner