Code of Maryland Regulations
Title 31 - MARYLAND INSURANCE ADMINISTRATION
Subtitle 12 - HEALTH MAINTENANCE ORGANIZATIONS; ENTITIES THAT ACT AS HEALTH INSURERS
Chapter 31.12.02 - Health Maintenance Organizations - Contract Forms and Premium Rates
Section 31.12.02.10 - Termination of Services

Universal Citation: MD Code Reg 31.12.02.10

Current through Register Vol. 51, No. 19, September 20, 2024

A. Termination of a Particular Service.

(1) If an HMO desires to cease offering a service under the health care contract in force, the services may not be terminated without prior approval of the Commissioner.

(2) If an HMO ceases offering a service under an in-force health care contract, arrangements equitable to the members regarding a cost adjustment or substitution of an equivalent service satisfactory to the Commissioner shall be made.

B. A member of an HMO may have the membership cancelled or nonrenewed by the HMO only for the following reasons:

(1) Termination of the conditions, other than a change in the health of the member, under which the member became eligible to be enrolled under a group contract;

(2) Inability of the medical staff and the member to establish a reasonable physician-patient relationship;

(3) The member no longer resides, lives, or works in the service area;

(4) Failure of the member to pay any deductible or copayment charges permitted under any contracts approved by the Commissioner;

(5) Fraudulent use of the HMO's identification card by the member;

(6) The alteration or sale of prescriptions by the member;

(7) An attempt by the subscriber to enroll noneligible persons as dependents;

(8) The member has performed an act or practice that constitutes fraud;

(9) The member has made an intentional misrepresentation of material fact under the application for the HMO coverage; or

(10) Failure of the subscriber to pay any premium charge when due.

C. Failure to Follow Prescribed Course of Treatment.

(1) An HMO may not cancel or nonrenew a member's HMO membership due to the member's refusal to follow a prescribed course of treatment.

(2) The HMO contract may provide that the HMO is not required to furnish any further benefits or services for a particular condition if the member refuses to follow a prescribed course of treatment for that condition.

(3) If the member disagrees with a prescribed course of treatment from an HMO physician, the HMO shall permit the member to receive a second opinion from another HMO physician.

(4) If the member receives a second opinion as described in §C(3) of this regulation, and if the second physician disagrees with the prescribed course of treatment, the HMO may not refuse to provide services or benefits for that particular condition, subject to the HMO's coverage documents and its utilization review protocols and policies.

D. Required Notice of Termination.

(1) Except as provided in §D(3) of this regulation, if a member's coverage in an HMO is terminated or nonrenewed for a reason set forth in §B(2)-(9) of this regulation, the HMO shall provide notice of the termination or nonrenewal not less than 30 days before the date of cancellation or nonrenewal.

(2) The notice required by §D(1) of this regulation shall be delivered to the member in person or by first class mail addressed to the member's address last known to the HMO.

(3) An HMO is not required to provide the notice described in §D(1) of this regulation if the cause of termination is nonpayment of premium.

E. If the member is entitled to have issued a health care contract, the notice required by §D(1) of this regulation shall be accompanied by information as to how the member may apply for a contract.

F. If termination or nonrenewal is for nonpayment of copayments or deductibles, the notice required by §D(1) of this regulation shall state:

(1) The amount of charges due; and

(2) That if the member pays the amount of charges due, plus any administrative cost incurred in preparing and delivering the notice before the date of cancellation, membership will remain in full force and effect.

Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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