Sec. 31.01.02.06. Life and Health

A. The bulletin issued by the Commissioner under Regulation .05 of this chapter may require health carriers to:

(1) Suspend health benefit cancellations and nonrenewals;

(2) Allow a provider in the geographic area to which the regulation applies to submit a claim for service provided 30 calendar days prior to the effective date of the regulation, up to 240 calendar days after the date the service was rendered;

(3) Waive any time restrictions on prescription medication refills and authorize payment to pharmacies for at least a 30-day supply of any prescription medication, regardless of the date upon which the prescription medication had most recently been filled by a pharmacist;

(4) Waive any restrictions on the time frame for the replacement of durable medical equipment or supplies, eyeglasses, and dentures;

(5) Except as provided in §§J and K of this regulation, waive any cost-sharing, including copayments, coinsurance, and deductibles, for any visit to diagnose or test for a specified illness, regardless of the setting of the testing (for example, an emergency room, urgent care center, or primary physician’s office);

(6) Except as provided in §§J and K of this regulation, waive any cost-sharing, including copayments, coinsurance, and deductibles, for laboratory fees to diagnose or test for a specified illness;

(7) Except as provided in §§J and K of this regulation, waive any cost-sharing, including copayments, coinsurance, and deductibles, for vaccination for a specified illness; and

(8) Except as provided in §§J and K of this regulation, waive any cost-sharing, including copayments, coinsurance, and deductibles, for treatment for a specified illness.

B. A health carrier may cancel or refuse to renew any health benefits if all premiums due are not paid within 60 calendar days following the date the bulletin issued pursuant to Regulation .05D of this chapter expires.

C. The effective date of cancellation or refusal to renew pursuant to §B of this regulation is the date the health carrier was originally permitted to take such action after the expiration of any applicable grace period.

D. The Commissioner may extend any time frames required for processing claims for a health carrier if the health carrier requests an extension in writing and demonstrates the legitimate reason for the business disruption to the Commissioner.

E. The Commissioner may suspend the requirement to pay interest on claims as required by Insurance Article, §15-1005, Annotated Code of Maryland, if the health carrier requests such suspension in writing and demonstrates to the Commissioner a legitimate reason for the suspension of the requirement to pay interest.

F. The Commissioner may require a health carrier to make a claims payment for treatment for a specified illness that the health carrier has denied as experimental.

G. A health carrier shall evaluate a request to use an out-of-network provider to perform diagnostic testing of a specified illness solely on the basis of whether the use of the out-of-network provider is medically necessary or appropriate.

H. Subject to §M of this regulation, the only prior authorization requirements a health carrier may utilize relating to testing for a specified illness shall relate to the medical necessity of that testing.

I. An adverse decision on a request for coverage of diagnostic services for a specified illness shall be considered an emergency case for which an expedited grievance procedure is required under Insurance Article, §15-10A-02, Annotated Code of Maryland.

J. The requirements of §A(5)-(8) of this regulation do not apply to a Medicare supplement policy as defined by Insurance Article, §15-901(k), Annotated Code of Maryland.

K. A carrier is not required to waive the deductible for an insured covered under a high deductible health plan, as defined in 26 U.S.C. §223, if the waiver of the deductible would disqualify the plan from being considered a high deductible health plan under federal law.

L. The Commissioner may require pharmacy benefits managers and health carriers to suspend random audits, including but not limited to in-person or “desk” audits, of pharmacies unless there is a reasonable suspicion of fraud.

M. The Commissioner may require health carriers to suspend, waive, or modify requirements related to prior authorizations, concurrent review, retrospective review, and notification of inpatient acute care, post-discharge care, and facility transfers.

N. With respect to an eligible individual, a carrier may not:

(1) Deny or place a condition on the issuance or effectiveness of a Medicare supplement policy that is offered and is available for issuance to new enrollees by the issuer;

(2) Discriminate in the pricing of a Medicare supplement policy because of health status, claims experience, receipt of health care, or medical condition; or

(3) Impose an exclusion of benefits based on a preexisting condition under a Medicare supplement policy.