COMAR 31.10.09 · Chapter 09 Hospice Care Benefits

Administrative History Effective date: April 7, 1997 (24:7 Md. R. 553) —————— Chapter recodified from COMAR 09.31.15 to COMAR 31.10.09 effective September 7, 1998 (25:18 Md. R. 1439) Authority Insurance Article, §§ 2-109 , 12-204 , 12-205 , and 15-809 ; Health-General Article, §§19-703(c) and 19-901; Annotated Code of Maryland

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.01 Scope. A. This chapter is applicable to each: (1) Group, blanket, or individual health insurance contract written on an expense-incurred basis which is issued or renewed in the State on or after April 1, 1997; (2) Individual or group nonprofit health service plan contract which is issued or renewed on or after April 1, 1997; and (3) Individual or group contract issued or renewed by a health maintenance organization on or after April 1, 1997. B. This chapter does not apply to a comprehensive health benefit plan issued to a small employer in accordance with Insurance Article, Title 15, Subtitle 12, Annotated Code of Maryland .

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.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) "Bereavement counseling" means counseling provided to the immediate family or family caregiver of the insured after the insured's death to help the immediate family or family caregiver cope with the death of the insured. (2) "Carrier" means an insurer, a nonprofit health service plan, or a health maintenance organization. (3) Expense Incurred. (a) "Expense incurred" means the benefits payable under the contract are based on the medical expenses the insured incurs. (b) For the purpose of this chapter, a contract which includes both expense-incurred benefits and indemnity benefits shall be considered to be written on an "expense-incurred" basis. (4) "Family caregiver" means a relative by blood, marriage, or adoption who lives with or is the primary caregiver of the terminally ill insured. (5) "Family counseling" means counseling given to the immediate family or family caregiver of the terminally ill insured for the purpose of learning to care for the insured and to adjust to the death of the insured. (6) "Hospice care program" means a coordinated, interdisciplinary program of hospice care services for meeting the special physical, psychological, spiritual, and social needs of terminally ill individuals and their families, by providing palliative and supportive medical, nursing, and other health services through home or inpatient care during the illness and bereavement to: (a) Individuals who have no reasonable prospect of cure as estimated by a physician; and (b) The immediate families or family caregivers of those individuals described in §B(6)(a) of this regulation . (7) "Immediate family" means the spouse, parents, siblings, grandparents, and children of the terminally ill insured. (8) "Indemnity" means the benefits payable under the contract are flat amounts which are not related to the expenses the insured incurs, such as a hospital indemnity contract which pays a flat fee for each day the insured is confined in a hospital regardless of the actual expenses the insured incurs during the hospital confinement. (9) "Insured" means a person who is covered under a: (a) Group, blanket, or individual health insurance policy written on an expense-incurred basis; (b) Nonprofit health service plan contract; or (c) Health maintenance organization contract. (10) "Respite care" means temporary care provided to the terminally ill insured to relieve the family caregiver from the daily care of the insured. (11) "Terminally ill" means a medical prognosis given by a physician that the insured's life expectancy is 6 months or less.

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.03 Required Hospice Care Benefit Options. A. A carrier shall offer the policyholder the option of purchasing the minimum hospice care benefits required by this chapter when the policyholder applies for coverage. B. Contracts Issued Before April 1, 1997. (1) Except as provided in §B(2) of this regulation , if a policyholder purchases a contract with hospice care benefits before April 1, 1997, the carrier shall revise the contract to include at least the minimum benefits required by this chapter on the renewal date occurring on or after April 1, 1997. (2) Section B(1) of this regulation does not apply to guaranteed renewable or noncancellable contracts.

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.04 Minimum Hospice Care Benefits. A. Except as provided in §B of this regulation , the hospice care benefit offered shall include the following minimum benefits provided through a hospice care program: (1) 30 days of inpatient care per insured; (2) Part-time nursing care by or supervised by a registered graduate nurse; (3) Counseling, including dietary counseling, for the terminally ill insured; (4) Family counseling for the immediate family and the family caregiver before the death of the terminally ill insured; (5) Bereavement counseling for the immediate family or family caregiver of the insured for at least the 6-month period following the insured's death or 15 visits, whichever occurs first; (6) Respite care subject to the following: (a) The annual benefit shall be at least 14 days, and (b) The carrier may limit any one inpatient stay for respite care to 5 consecutive days; and (7) Medical supplies, equipment, and medication required to maintain the comfort and manage the pain of the terminally ill insured. B. If a contract does not include inpatient benefits, the carrier shall offer the benefits described in §A(2)—(7) of this regulation. C. If a contract contains hospital indemnity benefits but is defined as an expense incurred policy according to Regulation .02B(3) of this chapter , the hospice care benefit may limit the hospice daily inpatient benefit to the amount payable for hospital confinement under the contract.

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.05 Prohibited Exclusions and Limitations. A. The hospice care benefit may not be subject to a lifetime maximum which is separate from the lifetime maximum applicable to other benefits in the contract. B. The hospice care benefit may not be subject to an annual maximum benefit which is separate from the annual maximum applicable to other benefits in the contract. C. A carrier may not exclude immediate family members or family caregivers of the insured from the family counseling benefit or the bereavement counseling benefit because the immediate family member or family caregiver is not otherwise covered under the contract which provides coverage to the insured. D. A carrier may not exclude the siblings of a terminally ill child from the family counseling benefit or the bereavement counseling benefit, even if the siblings are not otherwise covered under the same contract as the terminally ill child. E. A hospice care benefit may not exclude inpatient benefits if the hospice care benefit appears in a contract which includes other inpatient benefits. F. The benefits provided as part of the hospice care benefit may not be subject to separate dollar maximum limits, except as provided in this chapter. G. The carrier may not condition the inpatient hospice care benefits on a prior hospital confinement.

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Previous Chapter 08 Limited Benefits Policies — Minimum Loss Ratio [Repealed]

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Next Chapter 10 Summary Explanation of Benefits

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