Md. Code Regs. 31.12.02.12

Current through Register Vol. 52, No. 1, January 10, 2025

Section 31.12.02.12 - General Operation of Health Maintenance Organizations

A. The HMO shall provide, without limitations as to frequency or cost, except as established in the health care contract and provided for in these regulations, basic and supplemental health services to its members in the following manner:

(1) Reasonable deductibles and copayments may be required for the provision of specific services within the basic health services, unless the payments or the manner of payment unduly serves as a barrier to the delivery of basic health services;

(2) All services of health care providers provided for in the health care contract shall be provided through health care providers that are under contract to, or have agreements with, the HMO, except that this subsection does not apply to:

(a) Health care providers' services which the HMO and the Commissioner determine are unusual or infrequently used;

(b) Emergency services;

(c) Services performed outside of the HMO's service area for urgent care services;

(d) Services received from health care providers that do not contract with the HMO, if the member has a benefit under the HMO contract for services received from non-HMO health care providers; or

(e) Services received from a health care provider that does not contract with the HMO, if the member was referred to the health care provider by the HMO or by a provider under contract with the HMO;

(3) All services provided for in the health care contract shall, within the area serviced by the HMO, be available and accessible to each of its members:

(a) Promptly as appropriate;

(b) In a manner which assures continuity; and

(c) When medically necessary, 24 hours a day and 7 days a week; and

(4) Emergency services as follows:

(a) The HMO shall be liable for emergency expenses incurred by the member in securing any service customarily provided in the contract for emergency services incurred by the member which cannot reasonably be provided through the facilities of the HMO and which are considered medically necessary and justified; and

(b) The method used to establish the necessity of these services and the method the HMO shall use in fulfilling its financial responsibility for its health care services shall be set forth in the health care contract.

B. Health Care Contracts.

(1) The HMO shall bind itself to provide to the members basic health services and other supplemental services as specified in the health care contract.

(2) A copy of coverages and costs shall be given to each member or member family unit.

(3) All services included in the benefits, as well as any limitations or exclusions, shall be clearly stated in written form.

Md. Code Regs. 31.12.02.12