Title 15. Assistance Programs — Subtitle 1. Medical and Pharmacy Assistance Programs
Statutes in effect as of October 1, 2026.
Md. Code Ann., Health-Gen. § 15-101 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–101LinkCopy Citation
(a)
In this title the following words have the meanings indicated.
(a–1)
“Dental managed care organization” means a pre–paid dental plan that receives fees to manage dental services.
(a–2)
“Dental services” means diagnostic, emergency, preventive, and therapeutic services for oral diseases.
(b)
“Enrollee” means a program recipient who is enrolled in a managed care organization.
(b–1)
“Expedited eligibility” means a streamlined eligibility process, conducted by the local health departments, for medical assistance for children and pregnant women under which an eligibility determination is made promptly, but not later than 10 working days after the date of application.
(c)
“Facility” means a hospital or nursing facility including an intermediate care facility, skilled nursing facility, comprehensive care facility, or extended care facility.
(d)
“Former foster care adolescent” means an individual:
(1)
Who is under 26 years of age; and
(2)
Who, on the individual’s 18th birthday, was in foster care under the responsibility of the State, any other state, or the District of Columbia.
(d–1)
(1)
“Historic provider” means a health care provider, as defined in § 19–132 of this article, or a residential service agency licensed under Title 19, Subtitle 4A of this article, that, on or before June 30, 1995, had a demonstrated history of providing services to program recipients, as defined by the Department in regulations.
(2)
“Historic provider”, to the extent the provider meets the requirements in paragraph (1) of this subsection, shall include:
(i)
A federal or State qualified community health center;
(ii)
A provider with a program for the training of health care professionals, including an academic medical center;
(iii)
A hospital outpatient program, physician, or advanced practice nurse that is a Maryland Access to Care (MAC) provider;
(iv)
A local health department;
(v)
A hospice, as defined in Title 19, Subtitle 9 of this article;
(vi)
A pharmacy; and
(vii)
Any other historic provider designated in accordance with regulations adopted by the Department.
(e)
“Managed care organization” means:
(1)
A certified health maintenance organization that is authorized to receive medical assistance prepaid capitation payments; or
(2)
A corporation that:
(i)
Is a managed care system that is authorized to receive medical assistance prepaid capitation payments;
(ii)
Enrolls only program recipients or individuals or families served under the Maryland Children’s Health Program; and
(iii)
Is subject to the requirements of § 15–102.4 of this subtitle.
(f)
“Ombudsman program” means a program that assists enrollees in resolving disputes with managed care organizations in a timely manner and that is responsible, at a minimum, for the following functions:
(1)
Investigating disputes between enrollees and managed care organizations referred by the enrollee hotline;
(2)
Reporting to the Department:
(i)
The resolution of all disputes;
(ii)
A managed care organization’s failure to meet the Department’s requirements; and
(iii)
Any other information specified by the Department;
(3)
Educating enrollees about:
(i)
The services provided by the enrollee’s managed care organization; and
(ii)
The enrollee’s rights and responsibilities in receiving services from the managed care organization; and
(4)
Advocating on behalf of the enrollee before the managed care organization, including assisting the enrollee in using the managed care organization’s grievance process.
(g)
“Primary mental health services” means the clinical evaluation and assessment of services needed by an individual and the provision of services or referral for additional services as deemed medically appropriate by a primary care provider.
(h)
“Program” means the Maryland Medical Assistance Program.
(i)
“Program recipient” means an individual who receives benefits under the Program.
(j)
“Self–measured blood pressure monitoring” means the regular measurement of blood pressure by the patient outside the clinical setting, either at home or elsewhere, requiring the use of a home blood pressure measurement device by the patient.
(k)
“Special pediatric hospital” means a facility in the State that provides nonacute medical, rehabilitation, therapy, and palliative services to individuals:
(1)
Under the age of 22 years; or
(2)
Who are at least 2 years old and under the age of 23 years and have co–occurring physical and behavioral health conditions.
(l)
“Specialty mental health services” means any mental health services other than primary mental health services.
(m)
“Validated home blood pressure monitor” means a blood pressure measurement device that has been validated for accuracy and is listed in the U.S. Blood Pressure Validated Device Listing.
Md. Code Ann., Health-Gen. § 15-101.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–101.1LinkCopy Citation
(a)
Except as otherwise provided in this subtitle, a managed care organization is not subject to the insurance laws of the State or to the provisions of Title 19 of this article.
(b)
A managed care organization may not be required to offer a qualified plan, as defined in § 31–101 of the Insurance Article, in the Maryland Health Benefit Exchange.
Md. Code Ann., Health-Gen. § 15-102 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–102LinkCopy Citation
(a)
Subject to the limitations of the State budget, the Department shall provide preventive and home care services for indigent and medically indigent individuals.
(b)
(1)
The Program shall promote educational opportunities for recipients on:
(i)
Preventive health care;
(ii)
Good health habits; and
(iii)
The value of developing ongoing relationships with primary care and lower cost providers.
(2)
In educating Program recipients in accordance with the provisions of paragraph (1) of this subsection, the Program shall work with appropriate groups to assist in the education of Program recipients.
Md. Code Ann., Health-Gen. § 15-102.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–102.1LinkCopy Citation
(a)
The General Assembly finds that it is a goal of this State to promote the development of a health care system that provides adequate and appropriate health care services to indigent and medically indigent individuals.
(b)
The Department shall, to the extent permitted, subject to the limitations of the State budget:
(1)
Provide a comprehensive system of quality health care services with an emphasis on prevention, education, individualized care, and appropriate case management;
(2)
Develop a prenatal care program for Program recipients and encourage its utilization;
(3)
Allocate State resources for the Program to provide a balanced system of health care services to the population served by the Program;
(4)
Seek to coordinate the Program activities with other State programs and initiatives that are necessary to address the health care needs of the population served by the Program;
(5)
Promote Program policies that facilitate access to and continuity of care by encouraging:
(i)
Provider availability throughout the State;
(ii)
Consumer education;
(iii)
The development of ongoing relationships between Program recipients and primary health care providers; and
(iv)
The regular review of the Program’s regulations to determine whether the administrative requirements of those regulations are unnecessarily burdensome on Program providers;
(6)
Ensure access to and the continuity of services provided by family planning providers that were family planning providers in the Program as of December 31, 2024, and were discontinued as recipients of federal funding under federal law or regulation because of the scope of services offered by the provider or the scope of services for which the provider offered referrals, by:
(i)
Reimbursing for the Program services provided; and
(ii)
Establishing Program requirements for the family planning providers that:
(1)
Are similar to the requirements for other providers of the same services;
(2)
Do not prohibit a provider from offering a service if the service is within the scope of practice of the provider as established under the Health Occupations Article; and
(3)
Do not limit the scope of services for which a provider may offer referrals;
(7)
Strongly urge health care providers to participate in the Program and thereby address the needs of Program recipients;
(8)
Require health care providers who participate in the Program to provide access to Program recipients on a nondiscriminatory basis in accordance with State and federal law;
(9)
Seek to provide appropriate levels of reimbursement for providers to encourage greater participation by providers in the Program;
(10)
Promote individual responsibility for maintaining good health habits;
(11)
Encourage the Program and Maryland’s health care regulatory system to work to cooperatively promote the development of an appropriate mix of health care providers, limit cost increases for the delivery of health care to Program recipients, and ensure the delivery of quality health care to Program recipients;
(12)
Encourage the development and utilization of cost–effective and preventive alternatives to the delivery of health care services to appropriate Program recipients in inpatient institutional settings;
(13)
Encourage the appropriate executive agencies to coordinate the eligibility determination, policy, operations, and compliance components of the Program;
(14)
Work with representatives of inpatient institutions, third party payors, and the appropriate State agencies to contain Program costs;
(15)
Identify and seek to develop an optimal mix of State, federal, and privately financed health care services for Program recipients, within available resources through cooperative interagency efforts;
(16)
Develop joint Legislative and Executive Branch strategies to persuade the federal government to reconsider those policies that discourage the delivery of cost–effective health care services to Program recipients;
(17)
Evaluate departmental recommendations as to those persons whose financial need or health care needs are most acute;
(18)
Establish mechanisms for aggressively pursuing recoveries against third parties permitted under current law and exploring additional methods for seeking to recover other money expended by the Program;
(19)
Take appropriate measures to assure the quality of health care services provided by managed care organizations; and
(20)
Develop a process for providing information about the availability of the State’s earned income tax credit established under § 10–704 of the Tax – General Article to each Program enrollee or potential Program enrollee when providing information about the Program.
(c)
(1)
The Department shall collaborate with the Office of the Comptroller or the Office of the State Treasurer to:
(i)
Form a one–sentence statement advising that individuals who cannot afford health insurance may be eligible to enroll in a medical assistance program; and
(ii)
Print the statement formed under item (i) of this paragraph:
(1)
On each State–issued tax refund check stub;
(2)
Once each pay quarter, on each State–issued employee paycheck stub; and
(3)
On each State–issued child support payment check stub.
(2)
The statement shall include a telephone number or other contact information that an individual may use to receive more information on eligibility for medical assistance programs.
(3)
The statement may be altered by the Department in collaboration with the Office of the Comptroller or the Office of the State Treasurer to:
(i)
Provide the most current information;
(ii)
Fit within the space constraints of the different types of checks listed in paragraph (1)(ii) of this subsection; or
(iii)
Combine it with the statement required under § 15–304(c) of this title, if appropriate.
Md. Code Ann., Health-Gen. § 15-102.2 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–102.2LinkCopy Citation
(a)
Except as otherwise provided in this section, the provisions of § 19-706.1 of this article (Rehabilitation and liquidation) shall apply to managed care organizations in the same manner they apply to health maintenance organizations.
(b)
(1)
A health care provider may not assert a claim of subrogation against an enrollee of a managed care organization or the State.
(2)
Notwithstanding paragraph (1) of this subsection, a health care provider may assert any claim it may have against the receiver of the insolvent managed care organization.
Md. Code Ann., Health-Gen. § 15-102.3 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–102.3LinkCopy Citation
(a)
The provisions of § 15–112(b)(1)(ii) and (2), (f) through (m), (r), (s), and (u) through (w) of the Insurance Article (Provider panels) shall apply to managed care organizations in the same manner they apply to carriers.
(b)
The provisions of § 15–1005 of the Insurance Article shall apply to managed care organizations in the same manner they apply to health maintenance organizations.
(c)
The provisions of §§ 4–311, 15–604, and 15–605 of the Insurance Article shall apply to managed care organizations in the same manner they apply to carriers.
(d)
(1)
The provisions of §§ 19–712(b), (c), and (d), 19–713.2, and 19–713.3 of this article apply to managed care organizations in the same manner they apply to health maintenance organizations.
(2)
The Insurance Commissioner shall consult with the Secretary before taking any action against a managed care organization under this subsection.
(e)
The provisions of § 15–112.1 of the Insurance Article apply to managed care organizations in the same manner they apply to carriers.
(f)
The Insurance Commissioner or an agent of the Commissioner shall examine the financial affairs and status of each managed care organization at least once every 5 years.
(g)
The provisions of § 15–1628.3 of the Insurance Article apply to pharmacy benefits managers that contract with managed care organizations in the same manner as they apply to pharmacy benefits managers that contract with carriers.
(h)
(1)
The provisions of § 6–102.1 of the Insurance Article apply to managed care organizations.
(2)
For each calendar year that the Insurance Commissioner assesses a health insurance provider fee under § 6–102.1 of the Insurance Article, a managed care organization shall pay the fee on a quarterly basis in accordance with a schedule adopted by the Insurance Commissioner.
(i)
The provisions of §§ 15–130 and 15–130.1 of the Insurance Article apply to managed care organizations and pharmacy benefits managers that contract with managed care organizations.
(j)
The provisions of § 33–105(f) of the Insurance Article apply to managed care organizations.
(k)
(1)
To the extent authorized under federal law and subject to paragraph (2) of this subsection, the provisions of § 15–1008(a), (b), (c)(1) and (2)(i), (d), (e), and (f) of the Insurance Article shall apply to managed care organizations in the same manner they apply to carriers.
(2)
If a retroactive denial of reimbursement is the result of coordination of benefits, a written statement provided by a managed care organization to a health care provider in accordance with § 15–1008(c)(2)(i) of the Insurance Article shall include the name and address of the entity identified by the managed care organization as responsible for payment of the claim.
(l)
Beginning July 1, 2025, the provisions of § 15–859 of the Insurance Article apply to managed care organizations in the same manner they apply to carriers.
(m)
Beginning January 1, 2026, the provisions of § 15–862 of the Insurance Article apply to managed care organizations in the same manner that they apply to carriers.
(n)
The provisions of § 15–863 of the Insurance Article apply to managed care organizations in the same manner they apply to carriers.
Md. Code Ann., Health-Gen. § 15-102.4 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–102.4LinkCopy Citation
(a)
(1)
Each managed care organization shall be actuarially sound.
(2)
(i)
Except as otherwise provided in this section, the surplus that a managed care organization is required to have shall be paid in full.
(ii)
A managed care organization shall have an initial surplus that exceeds the liabilities of the managed care organization by at least $1,500,000.
(b)
(1)
In consultation with the Secretary, the Insurance Commissioner may adjust the initial surplus requirement for a managed care organization that is not licensed as a health maintenance organization. In determining whether to make an adjustment under this paragraph, the Commissioner shall consider:
(i)
The proposed capitation level that would be received by the managed care organization under a contract with the Department under this subtitle;
(ii)
The proposed range of benefits to be provided under a contract with the Department under this subtitle;
(iii)
The existence of any commitment by the Secretary to designate funds over and above the proposed capitation where the designated funds:
(1)
Are equivalent to the difference between the requirements of § 19–710 of this article and any lower requirements determined by the Commissioner under this subparagraph; and
(2)
Would be available in case of the impairment or insolvency of the managed care organization; and
(iv)
The availability of the money held in trust by the Secretary to pay claims in case of impairment or insolvency of the managed care organization.
(2)
Notwithstanding subsection (a)(2)(ii) of this section, a managed care organization shall have an initial surplus that exceeds liabilities by at least $1,250,000. If a managed care organization has an initial surplus that is at least $1,250,000 but less than $1,500,000, prior to approval, the Department shall designate funds under paragraph (1)(iii) of this subsection sufficient to provide an initial surplus of at least $1,500,000.
(c)
(1)
(i)
Each managed care organization shall maintain a surplus that exceeds the liabilities of the managed care organization in the amount that is at least equal to the greater of $750,000 or 5 percent of the subscription charges earned during the prior calendar year as recorded in the annual report filed by the managed care organization with the Commissioner.
(ii)
No managed care organization shall be required to maintain a surplus in excess of a value of $3,000,000.
(2)
(i)
For the protection of the managed care organization’s enrollees and creditors, the applicant shall deposit and maintain in trust with the State Treasurer $100,000 in cash or government securities of the type described in § 5–701(b) of the Insurance Article.
(ii)
(1)
The deposits shall be accepted and held in trust by the State Treasurer in accordance with the provisions of Title 5, Subtitle 7 of the Insurance Article.
(2)
For the purpose of applying this subparagraph, a managed care organization shall be treated as an insurer.
(d)
Each managed care organization shall comply with risk based capital standards in accordance with regulations adopted by the Insurance Commissioner under § 4–311 of the Insurance Article.
Md. Code Ann., Health-Gen. § 15-102.5 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–102.5LinkCopy Citation
(a)
Subject to § 15–103.1(dd) of this subtitle, a health maintenance organization that requires its panel providers to participate in a managed care organization shall establish a mechanism, subject to review by the Secretary, which provides for equitable distribution of enrollees and which ensures that a provider will not be assigned a disproportionate number of enrollees.
(b)
Nothing in this section may be interpreted as prohibiting a provider from voluntarily accepting additional enrollees.
Md. Code Ann., Health-Gen. § 15-102.6 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–102.6LinkCopy Citation
(a)
(1)
Subject to paragraph (2) of this subsection, the provisions of Title 7 of the Insurance Article apply to managed care organizations.
(2)
Before approving a transaction under § 7–306 of the Insurance Article, the Insurance Commissioner shall consult with the Secretary.
(3)
The Insurance Commissioner:
(i)
Shall adopt regulations establishing a reporting materiality threshold; and
(ii)
May adopt regulations necessary to implement the provisions of this subsection.
(4)
The provisions of this subsection may not apply to any transaction preempted by federal law.
(b)
The provisions of Title 4, Subtitle 5 of the Insurance Article apply to managed care organizations.
Md. Code Ann., Health-Gen. § 15-102.7 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–102.7LinkCopy Citation
The premium tax imposed under § 6-102 of the Insurance Article applies to managed care organizations.
Md. Code Ann., Health-Gen. § 15-102.8 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–102.8LinkCopy Citation
(a)
The Department may impose a claims processing charge on all Medicaid claims processed, approved, and paid by the Department to hospitals located in the District of Columbia for the provision of inpatient and outpatient hospital services.
(b)
The amount to be paid under subsection (a) of this section may not exceed 6% of the amount of claims paid.
(c)
The Department shall adopt regulations to implement this section.
Md. Code Ann., Health-Gen. § 15-103 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103LinkCopy Citation
(a)
The Secretary shall administer the Maryland Medical Assistance Program.
(b)
The Program:
(1)
Subject to the limitations of the State budget, shall provide medical and other health care services for indigent individuals or medically indigent individuals or both;
(2)
Shall provide, subject to the limitations of the State budget and as permitted by federal law, comprehensive medical, dental, and other health care services, including services provided in accordance with § 15–141.5 of this subtitle, for all eligible pregnant women whose family income is at or below 250% of the poverty level for the duration of the pregnancy and for 1 year immediately following the end of the woman’s pregnancy;
(3)
Shall provide, subject to the limitations of the State budget and as permitted by federal law, comprehensive medical and other health care services for all eligible children currently under the age of 1 year whose family income falls below 185% of the poverty level;
(4)
Beginning on January 1, 2012, shall provide, subject to the limitations of the State budget and as permitted by federal law, family planning services to all women whose family income is at or below 200% of the poverty level;
(5)
Shall provide, subject to the limitations of the State budget and as permitted by federal law, comprehensive medical and other health care services for all children who are at least 1 year old and under the age of 5 years whose family income falls below 133% of the poverty level;
(6)
Beginning on January 1, 2014, shall provide, subject to the limitations of the State budget and as permitted by federal law, comprehensive medical care and other health care services for all children who are at least 6 years old and under the age of 19 years whose family income falls below 133% of the poverty level;
(7)
Shall provide, subject to the limitations of the State budget and as permitted by federal law, comprehensive medical care and other health care services for all legal immigrants who meet Program eligibility standards and who arrived in the United States before August 22, 1996, the effective date of the federal Personal Responsibility and Work Opportunity Reconciliation Act;
(8)
Shall provide, subject to the limitations of the State budget and any other requirements imposed by the State, comprehensive medical care and other health care services for all legal immigrant children under the age of 18 years and pregnant women who meet Program eligibility standards and who arrived in the United States on or after August 22, 1996, the effective date of the federal Personal Responsibility and Work Opportunity Reconciliation Act;
(9)
Beginning on January 1, 2014, shall provide, subject to the limitations of the State budget, and as permitted by federal law, medical care and other health care services for adults whose annual household income is at or below 133% of the poverty level;
(10)
Subject to the limitations of the State budget, and as permitted by federal law:
(i)
Shall provide comprehensive medical care, dental care, and other health care services for former foster care adolescents who, on their 18th birthday, were in foster care under the responsibility of the State and are not otherwise eligible for Program benefits; and
(ii)
May provide comprehensive medical care, dental care, and other health care services for former foster care adolescents who, on their 18th birthday, were in foster care under the responsibility of any other state or the District of Columbia;
(11)
May include bedside nursing care for eligible Program recipients;
(12)
Shall provide services in accordance with funding restrictions included in the annual State budget bill;
(13)
Beginning on January 1, 2023, shall provide, subject to the limitations of the State budget, and as permitted by federal law, dental services for adults, including diagnostic, preventive, restorative, and periodontal services, whose annual household income is at or below 133 percent of the federal poverty level;
(14)
Shall provide, subject to the limitations of the State budget, medically appropriate drugs that are approved by the United States Food and Drug Administration for the treatment of hepatitis C, regardless of the fibrosis score, and that are determined to be medically necessary;
(15)
Shall provide, subject to the limitations of the State budget, health care services appropriately delivered through telehealth to a patient in accordance with § 15–141.2 of this subtitle;
(16)
Beginning on January 1, 2021, shall provide, subject to the limitations of the State budget and § 15–855(b)(2) of the Insurance Article, and as permitted by federal law, services for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome, including the use of intravenous immunoglobulin therapy, for eligible Program recipients, if pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome are coded for billing and diagnosis purposes in accordance with § 15–855(d) of the Insurance Article;
(17)
Beginning on January 1, 2022, may not include, subject to federal approval and limitations of the State budget, a frequency limitation on covered dental prophylaxis care or oral health exams that requires the dental prophylaxis care or oral health exams to be provided at an interval greater than 120 days within a plan year;
(18)
Shall provide, subject to the limitations of the State budget, comprehensive medical care and other health care services to noncitizen pregnant women who would be eligible for the Program but for their immigration status and to their children up to the age of 1 year;
(19)
Shall provide coverage of abortion care services to Program recipients in the manner described in § 15–857(b)(1)(ii) and (2) of the Insurance Article;
(20)
Beginning on July 1, 2023, shall provide, subject to federal approval and limitations of the State budget, community violence prevention services in accordance with § 15–141.3 of this subtitle;
(21)
Beginning on January 1, 2023, shall provide, subject to the limitations of the State budget, and as permitted by federal law, coverage for self–measured blood pressure monitoring for all Program recipients diagnosed with uncontrolled high blood pressure, including:
(i)
The provision of validated home blood pressure monitors; and
(ii)
Reimbursement of health care provider and other staff time used for patient training, transmission of blood pressure data, interpretation of blood pressure readings and reporting, and the delivery of co–interventions, including educational materials or classes, behavioral change management, and medication management;
(22)
Beginning on January 1, 2024, shall provide gender–affirming treatment in accordance with § 15–151 of this subtitle;
(23)
Beginning on July 1, 2025, shall provide, subject to the limitations of the State budget, and as permitted by federal law, coverage for biomarker testing in accordance with § 15–859 of the Insurance Article;
(24)
Beginning on January 1, 2025, shall provide coverage for prostheses in accordance with § 15–844 of the Insurance Article;
(25)
Beginning on January 1, 2026, shall provide, subject to the limitations of the State budget, and as permitted by federal law, coverage for self–measured blood pressure monitoring for eligible Program recipients in accordance with § 15–141.6 of this subtitle;
(26)
Beginning on January 1, 2026, shall provide coverage for a transfer to a special pediatric hospital in accordance with § 15–158 of the Insurance Article;
(27)
Beginning on January 1, 2026, if providing coverage for the delivery of anesthesia, shall provide coverage for the delivery of anesthesia in accordance with § 15–862 of the Insurance Article;
(28)
Beginning on January 1, 2026, shall provide calcium score testing in accordance with § 15–863 of the Insurance Article; and
(29)
Beginning on January 1, 2027, may provide comprehensive coverage for the treatment of obesity under § 15–160 of this subtitle.
(c)
Subject to restrictions in federal law or waivers, the Department may:
(1)
Impose cost–sharing on Program recipients; and
(2)
For adults who do not meet requirements for a federal category of eligibility for Medicaid:
(i)
Cap enrollment; and
(ii)
Limit the benefit package.
(d)
Subject to the limitations of the State budget, the Department shall implement the provisions of Title II of the federal Patient Protection and Affordable Care Act, as amended by the federal Health Care and Education Reconciliation Act of 2010, to include:
(1)
Parents and caretaker relatives who have a dependent child living in the parents’ or caretaker relatives’ home; and
(2)
Adults who do not meet requirements, such as age, disability, or parent or caretaker relative of a dependent child, for a federal category of eligibility for Medicaid and who are not enrolled in the federal Medicare program, as enacted by Title XVII of the Social Security Act.
(e)
(1)
On or before January 1, 2025, subject to the limitations of the State budget, and as permitted by federal law, the Department:
(i)
Shall establish an Express Lane Eligibility Program to enroll individuals in the Program and Maryland Children’s Health Program based on eligibility findings by the Supplemental Nutrition Assistance Program;
(ii)
May not consider any other income or eligibility requirements;
(iii)
To the extent that a waiver is needed to maximize the number of State residents who may qualify for the Express Lane Eligibility Program, shall apply to the Centers for Medicare and Medicaid Services for one or more waivers under § 1115 of the federal Social Security Act to implement the Express Lane Eligibility Program; and
(iv)
Subject to paragraph (2) of this subsection, shall make all reasonable efforts to expedite enrollment of eligible individuals in the Express Lane Eligibility Program.
(2)
The Department may propose or implement the use of Express Lane Eligibility for renewals before proposing or implementing the use of Express Lane Eligibility for initial enrollment.
(f)
(1)
The Department shall ensure that payments for services provided by a hospital located in a contiguous state or in the District of Columbia to an enrollee under the Program shall be reduced by 20% if the hospital fails to submit discharge data on all Maryland patients receiving care in the hospital to the Health Services Cost Review Commission in a form and manner the Commission specifies.
(2)
Paragraph (1) of this subsection does not apply to a hospital that presently provides discharge data to the public in a form the Health Services Cost Review Commission determines is satisfactory.
(g)
(1)
(i)
In this subsection the following words have the meanings indicated.
(ii)
“Certified nurse practitioner” means a registered nurse who is licensed in this State, has completed a nurse practitioner program approved by the State Board of Nursing, and has passed an examination approved by that Board.
(iii)
“Nurse anesthetist” means a registered nurse who is:
(1)
Certified under the Health Occupations Article to practice nurse anesthesia; and
(2)
Certified by the Council on Certification or the Council on Recertification of Nurse Anesthetists.
(iv)
“Nurse midwife” means a registered nurse who is licensed in this State and has been certified by the American College of Nurse–Midwives as a nurse midwife.
(v)
“Optometrist” has the meaning stated in § 11–101 of the Health Occupations Article.
(2)
The Secretary may contract for the provision of care under the Program to eligible Program recipients.
(3)
The Secretary may contract with insurance companies or nonprofit health service plans or with individuals, associations, partnerships, incorporated or unincorporated groups of physicians, chiropractors, dentists, podiatrists, optometrists, pharmacists, hospitals, nursing homes, nurses, including nurse anesthetists, nurse midwives and certified nurse practitioners, opticians, and other health practitioners who are licensed or certified in this State and perform services on the prescription or referral of a physician.
(4)
For the purposes of this section, the nurse midwife need not be under the supervision of a physician.
(5)
Except as otherwise provided by law, a contract that the Secretary makes under this subsection shall continue unless terminated under the terms of the contract by the Program or by the provider.
(h)
As permitted by federal law or waiver, the Secretary may administer the Medicare Option Prescription Drug Program, established under § 15–124.3 of this subtitle, as part of the Maryland Medical Assistance Program.
(i)
By regulation, the Department shall adopt a methodology to ensure that federally qualified health centers are paid reasonable cost–based reimbursement that is consistent with federal law.
Md. Code Ann., Health-Gen. § 15-103.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.1LinkCopy Citation
(a)
As permitted by federal law or waiver, the Secretary may establish a program under which Program recipients are required to enroll in managed care organizations.
(b)
(1)
The benefits required by the program developed under subsection (a) of this section shall be:
(i)
Adopted by regulation; and
(ii)
At least equivalent to the benefit level required by the Program on January 1, 1996.
(2)
Subject to the limitations of the State budget and as permitted by federal law or waiver, the Department shall provide reimbursement for medically necessary and appropriate inpatient, intermediate care, and halfway house substance use disorder treatment services for enrollees at least 21 years old with substance use disorders who are recipients of temporary cash assistance under the Family Investment Program.
(3)
Each managed care organization participating in the program developed under subsection (a) of this section shall provide or arrange for the provision of the benefits described in paragraph (2) of this subsection.
(4)
This subsection may not be construed to prohibit a managed care organization from offering additional benefits if the managed care organization is not receiving capitation payments based on the provision of the additional benefits.
(5)
Notwithstanding paragraph (1) of this subsection, the benefits required by the program developed under subsection (a) of this section shall include dental services for pregnant women.
(c)
Subject to the limitations of the State budget and as permitted by federal law or waiver, the program developed under subsection (a) of this section may provide guaranteed eligibility for each enrollee for up to 6 months unless an enrollee obtains health insurance through another source.
(d)
(1)
The Secretary may exclude specific populations or services from the program developed under subsection (a) of this section.
(2)
For any populations or services excluded under this subsection, the Secretary may authorize a managed care organization to provide the services or provide for the population, including authorization of a separate dental managed care organization or a managed care organization to provide services to Program recipients with special needs.
(e)
(1)
Except for a service excluded by the Secretary under subsection (d) of this section, each managed care organization shall provide all the benefits required by regulations adopted under subsection (b) of this section.
(2)
For a population or service excluded by the Secretary under subsection (d) of this section, the Secretary may authorize a managed care organization to provide only for that population or provide only that service.
(3)
A managed care organization may subcontract specified required services to a health care provider that is licensed or authorized to provide those services.
(f)
Except for the Program of All–Inclusive Care for the Elderly (“PACE”) Program, the Secretary may not include the long–term care population or long–term care services in the program developed under subsection (a) of this section.
(g)
The program developed under subsection (a) of this section shall ensure that enrollees have access to a pharmacy that:
(1)
Is licensed in the State; and
(2)
Is within a reasonable distance from the enrollee’s residence.
(h)
For cause, the Department may disenroll enrollees from a managed care organization and enroll them in another managed care organization.
(i)
(1)
Each managed care organization shall:
(i)
Have a quality assurance program in effect that is subject to the approval of the Department and that, at a minimum:
(1)
Complies with any health care quality improvement system developed by the Centers for Medicare and Medicaid Services;
(2)
Complies with the quality requirements of applicable State licensure laws and regulations;
(3)
Complies with practice guidelines and protocols specified by the Department;
(4)
Provides for an enrollee grievance system, including an enrollee hotline;
(5)
Provides for a provider grievance system;
(6)
Provides for enrollee and provider satisfaction surveys, to be taken at least annually;
(7)
Provides for a consumer advisory board to receive regular input from enrollees;
(8)
Provides for an annual consumer advisory board report to be submitted to the Secretary; and
(9)
Complies with specific quality, access, data, and performance measurements adopted by the Department for treating enrollees with special needs;
(ii)
Submit to the Department:
(1)
Service–specific data by service type in a format established by the Department;
(2)
Utilization and outcome reports, such as the Health Plan Employer Data and Information Set (HEDIS), as directed by the Department; and
(3)
At least semiannually, aggregate data that includes:
(A)
The number of enrollees provided with substance use disorder treatment services; and
(B)
The amount of money spent on substance use disorder treatment;
(iii)
Promote timely access to and continuity of health care services for enrollees;
(iv)
Demonstrate organizational capacity to provide special programs, including outreach, case management, and home visiting, tailored to meet the individual needs of all enrollees;
(v)
Provide assistance to enrollees in securing necessary health care services;
(vi)
Provide or ensure substance use disorder treatment for pregnant women with substance use disorders and all other enrollees of the managed care organization who require these services;
(vii)
Educate enrollees on health care prevention and good health habits;
(viii)
Ensure necessary provider capacity in all geographic areas under contract;
(ix)
Be accountable and hold its subcontractors accountable for standards established by the Department and, on failure to meet those standards, be subject to one or more of the following penalties:
(1)
Fines;
(2)
Suspension of further enrollments;
(3)
Withholding of all or part of the capitation payment;
(4)
Termination of the contract;
(5)
Disqualification from future participation in the Program; and
(6)
Any other penalties that may be imposed by the Department;
(x)
Subject to applicable federal and State law, include incentives for enrollees to comply with provisions of the managed care organization;
(xi)
Provide or arrange to provide primary mental health services;
(xii)
Provide or arrange to provide all Medicaid–covered services required to comply with State statutes and regulations mandating health and mental health services for children in State–supervised care:
(1)
According to standards set by the Department; and
(2)
Locally, to the extent the services are available locally;
(xiii)
Submit to the Department aggregate information from the quality assurance program, including complaints and resolutions from the enrollee and provider grievance systems, the enrollee hotline, and enrollee satisfaction surveys;
(xiv)
Maintain as part of the enrollee’s medical record the following information:
(1)
The basic health risk assessment conducted on enrollment;
(2)
Any information the managed care organization receives that results from an assessment of the enrollee conducted for the purpose of any early intervention, evaluation, planning, or case management program;
(3)
Information from the local department of social services regarding any other service or benefit the enrollee receives, including assistance or benefits from a program administered by the Department of Human Services under the Human Services Article; and
(4)
Any information the managed care organization receives from a school–based clinic, a core services agency, a local health department, or any other person that has provided health services to the enrollee;
(xv)
On provision of information specified by the Department under subsection (r)(3) of this section, pay school–based clinics for services provided to the managed care organization’s enrollees;
(xvi)
In coordination with participating dentists, enrollees, and families of enrollees, develop a process to arrange to provide dental therapeutic treatment to individuals under the age of 21 years that requires:
(1)
A participating dentist to notify a managed care organization when an enrollee is in need of therapeutic treatment and the dentist is unable to provide the treatment;
(2)
The managed care organization to provide the enrollee or the family of the enrollee with a list of participating providers who offer therapeutic dental services; and
(3)
The managed care organization to notify the enrollee or the family of the enrollee that the managed care organization will provide further assistance if the enrollee has difficulty obtaining an appointment with a provider of therapeutic dental services;
(xvii)
Provide the advance directive information sheet developed under § 5–615 of this article:
(1)
To all enrollees at the time of initial enrollment and in the managed care organization’s enrollee publications;
(2)
If the managed care organization maintains a website, on the managed care organization’s website; and
(3)
At the request of an enrollee; and
(xviii)
If the managed care organization maintains a website, provide a link to the webpage that is accessed through the tab on the State–designated health information exchange website required under § 19–145.1(b)(2)(iv) of this article.
(2)
Paragraph (1)(xvii) of this subsection may not be construed to require a managed care organization to:
(i)
Assist an enrollee in drafting an electronic advance care planning document;
(ii)
Store electronic advance care planning documents; or
(iii)
Access advance care planning documents.
(3)
(i)
Each managed care organization shall notify each enrollee when the enrollee should obtain an immunization, examination, or other wellness service.
(ii)
Each managed care organization shall:
(1)
Maintain evidence of compliance with paragraph (1) of this subsection; and
(2)
On initial application to provide health care services to enrollees and on an annual basis thereafter, provide to the Department evidence of compliance with paragraph (1) of this subsection including submission of a written plan.
(iii)
A managed care organization that does not comply with paragraph (1) of this subsection for at least 90% of its new enrollees:
(1)
Within 90 days of their enrollment may not receive more than 80% of its capitation payments;
(2)
Within 180 days of their enrollment may not receive more than 70% of its capitation payments; and
(3)
Within 270 days of their enrollment may not receive more than 50% of its capitation payments.
(iv)
If a managed care organization does not comply with the requirements of paragraph (1) of this subsection, the Department may contract with any community–based health organization that the Department determines is willing and able to perform comprehensive outreach services to enrollees.
(v)
In addition to the provisions of subparagraph (iv) of this paragraph, if a managed care organization does not comply with the requirements of paragraph (1) of this subsection or fails to provide evidence of compliance to the Department under subparagraph (ii) of this paragraph, the Department may:
(1)
Impose a fine on the managed care organization;
(2)
Suspend further enrollment into the managed care organization;
(3)
Withhold all or part of the capitation rate from the managed care organization;
(4)
Terminate the provider agreement; or
(5)
Disqualify the managed care organization from future participation in the program established under subsection (a) of this section.
(vi)
The Department shall deposit fines imposed under subparagraph (v)1 of this paragraph in the HealthChoice Performance Incentive Fund established under § 15–103.5 of this subtitle.
(j)
The Department shall adopt regulations that ensure that managed care organizations employ appropriate personnel to:
(1)
Ensure that individuals with special needs obtain needed services; and
(2)
Coordinate those services.
(k)
(1)
A managed care organization shall reimburse a hospital emergency facility and provider for:
(i)
Health care services that meet the definition of emergency services in § 19–701 of this article;
(ii)
Medical screening services rendered to meet the requirements of the federal Emergency Medical Treatment and Active Labor Act;
(iii)
Medically necessary services if the managed care organization authorized, referred, or otherwise allowed the enrollee to use the emergency facility and the medically necessary services are related to the condition for which the enrollee was allowed to use the emergency facility; and
(iv)
Medically necessary services that relate to the condition presented and that are provided by the provider in the emergency facility to the enrollee if the managed care organization fails to provide 24–hour access to a physician as required by the Department.
(2)
A provider may not be required to obtain prior authorization or approval for payment from a managed care organization in order to obtain reimbursement under this subsection.
(l)
The Department shall:
(1)
Establish and maintain an ombudsman program and a locally accessible enrollee hotline;
(2)
Perform focused medical reviews of managed care organizations that include reviews of how the managed care organizations are providing health care services to special populations;
(3)
Provide timely feedback to each managed care organization on its compliance with the Department’s quality and access system;
(4)
Establish and maintain within the Department a process for handling provider complaints about managed care organizations; and
(5)
Adopt regulations relating to appeals by managed care organizations of penalties imposed by the Department, including regulations providing for an appeal to the Office of Administrative Hearings.
(m)
(1)
Subject to paragraph (3) of this subsection, the Department shall delegate responsibility for maintaining the ombudsman program for a county to that county’s local health department on the request of the local health department.
(2)
A local health department may not subcontract the ombudsman program.
(3)
Before the Department delegates responsibility to a local health department to maintain the ombudsman program for a county, a local health department that is also a Medicaid provider must receive the approval of the Secretary and the local governing body.
(n)
A managed care organization may not:
(1)
Without authorization by the Department, enroll an individual who at the time is a Program recipient; or
(2)
Have face–to–face or telephone contact with, or otherwise solicit, an individual who at the time is a Program recipient before the Program recipient enrolls in the managed care organization unless:
(i)
Authorized by the Department; or
(ii)
The Program recipient initiates contact.
(o)
(1)
The Department shall be responsible for enrolling Program recipients into managed care organizations.
(2)
The Department may contract with an entity to perform the enrollment function.
(3)
The Department or its enrollment contractor shall administer a health risk assessment developed by the Department to ensure that individuals who need special or immediate health care services will receive the services on a timely basis.
(4)
The Department or its enrollment contractor:
(i)
May administer the health risk assessment only after the Program recipient has chosen a managed care organization; and
(ii)
Shall forward the results of the health risk assessment to the managed care organization chosen by the Program recipient within 5 business days.
(p)
For a managed care organization with which the Secretary contracts to provide services to Program recipients under this section, the Secretary shall establish a mechanism to initially ensure that each historic provider that meets the Department’s quality standards has the opportunity to continue to serve Program recipients as a subcontractor of at least one managed care organization.
(q)
(1)
The Department shall make capitation payments to each managed care organization as provided in this subsection.
(2)
In consultation with the Insurance Commissioner, the Secretary shall:
(i)
Set capitation payments at a level that is actuarially adjusted to the benefits provided; and
(ii)
Actuarially adjust the capitation payments to reflect the relative risk assumed by the managed care organization.
(3)
In actuarially adjusting capitation payments under paragraph (2)(ii) of this subsection, the Secretary, in consultation with the Insurance Commissioner, shall take into account, to the extent allowed under federal law, the expenses incurred by the managed care organization applicable to the business of providing care to enrolled individuals.
(r)
(1)
School–based clinics and managed care organizations shall collaborate to provide continuity of care to enrollees.
(2)
School–based clinics shall be defined by the Department in consultation with the State Department of Education.
(3)
Each managed care organization shall require a school–based clinic to provide to the managed care organization information, as specified by the Department, about an encounter with an enrollee of the managed care organization before paying the school–based clinic.
(4)
On receipt of information specified by the Department, the managed care organization shall pay, at Medicaid–established rates, school–based clinics for covered services provided to enrollees of the managed care organization.
(5)
The Department shall work with managed care organizations and school–based clinics to develop collaboration standards, guidelines, and a process to ensure that the services provided are covered and medically appropriate and that the process provides for timely notification among the parties.
(6)
Each managed care organization shall maintain records of all health care services:
(i)
Provided to its enrollees by school–based clinics; and
(ii)
For which the managed care organization has been billed.
(s)
The Department shall establish standards for the timely delivery of services to enrollees.
(t)
(1)
The Department shall establish a delivery system for specialty mental health services for enrollees of managed care organizations.
(2)
The Behavioral Health Administration shall:
(i)
Design and monitor the delivery system;
(ii)
Establish performance standards for providers in the delivery system; and
(iii)
Establish procedures to ensure appropriate and timely referrals from managed care organizations to the delivery system that include:
(1)
Specification of the diagnoses and conditions eligible for referral to the delivery system;
(2)
Training and clinical guidance in appropriate use of the delivery system for managed care organization primary care providers;
(3)
Preauthorization by the utilization review agent of the delivery system; and
(4)
Penalties for a pattern of improper referrals.
(3)
The Department shall collaborate with managed care organizations to develop standards and guidelines for the provision of specialty mental health services.
(4)
The delivery system shall:
(i)
Provide all specialty mental health services needed by enrollees;
(ii)
For enrollees who are dually diagnosed, coordinate the provision of substance use disorder treatment services provided by the managed care organizations of the enrollees;
(iii)
Consist of a network of qualified mental health professionals from all core disciplines;
(iv)
Include linkages with other public service systems; and
(v)
Comply with quality assurance, enrollee input, data collection, and other requirements specified by the Department in regulation.
(5)
The Department may contract with a managed care organization for delivery of specialty mental health services if the managed care organization meets the performance standards adopted by the Department in regulations.
(6)
The provisions of § 15–1005 of the Insurance Article apply to the delivery system for specialty mental health services established under this subsection and administered by an administrative services organization.
(7)
The Department and the Behavioral Health Administration shall ensure that the delivery system has an adequate network of providers available to provide substance use disorder treatment for children under the age of 18 years.
(u)
The Department shall include a definition of medical necessity in its quality and access standards.
(v)
(1)
The Department shall adopt regulations relating to enrollment, disenrollment, and enrollee appeals.
(2)
Program recipients shall have the right to choose:
(i)
The managed care organization with which they are enrolled; and
(ii)
The primary care provider to whom they are assigned within the managed care organization.
(3)
If a recipient is disenrolled and reenrolls within 120 days after the recipient’s disenrollment, the Department shall:
(i)
Assign the recipient to the managed care organization in which the recipient previously was enrolled; and
(ii)
Require the managed care organization to assign the recipient to the primary care provider of record at the time of the recipient’s disenrollment.
(4)
Whenever a recipient has to select a new managed care organization because the recipient’s managed care organization has departed from the program established under subsection (a) of this section, the departing managed care organization:
(i)
Shall provide a written notice to the recipient 60 days before departing from the program established under subsection (a) of this section;
(ii)
Shall include in the notice the name and provider number of the primary care provider assigned to the recipient and the telephone number of the enrollment broker; and
(iii)
Within 30 days after departing from the program, shall provide the Department with a list of enrollees and the name of each enrollee’s primary care provider.
(5)
On receiving the list provided by the managed care organization, the Department shall provide the list to:
(i)
The enrollment broker to assist and provide outreach to recipients in selecting a managed care organization; and
(ii)
The remaining managed care organizations for the purpose of linking recipients with a primary care provider in accordance with federal law and regulation.
(6)
Subject to subsection (dd)(4) and (5) of this section, an enrollee may disenroll from a managed care organization:
(i)
Without cause in the month following the anniversary date of the enrollee’s enrollment; and
(ii)
For cause, at any time as determined by the Secretary.
(w)
The Department or its subcontractor, to the extent feasible in its marketing or enrollment programs, shall hire individuals receiving assistance under the program of Aid to Families with Dependent Children established under Title IV, Part A of the Social Security Act, or the successor to the program.
(x)
The Department shall disenroll an enrollee who is a child in State–supervised care if the child is transferred to an area outside the territory of the managed care organization.
(y)
The Secretary shall adopt regulations to carry out this section.
(z)
A managed care organization shall provide coverage for hearing loss screenings of newborns provided by a hospital before discharge.
(aa)
(1)
The Department shall provide enrollees and health care providers with an accurate directory or other listing of all available providers:
(i)
In written form, made available on request; and
(ii)
On an Internet database.
(2)
The Department shall update the Internet database at least every 30 days.
(3)
The written directory shall include a conspicuous reference to the Internet database.
(bb)
A managed care organization may not apply a prior authorization requirement for a prescription drug used as postexposure prophylaxis for the prevention of HIV if the prescription drug is prescribed for use in accordance with Centers for Disease Control and Prevention guidelines.
(cc)
The Secretary shall adopt regulations for pharmacy benefits managers that contract with managed care organizations that establish requirements for conducting audits of pharmacies or pharmacists that are:
(1)
To the extent practicable, substantively similar to the audit provisions under § 15–1629 of the Insurance Article; and
(2)
Consistent with federal law.
(dd)
(1)
The Department shall establish mechanisms for:
(i)
Identifying a Program recipient’s primary care provider at the time of enrollment into a managed care program; and
(ii)
Maintaining continuity of care with the primary care provider if:
(1)
The provider has a contract with a managed care organization or a contracted medical group of a managed care organization to provide primary care services; and
(2)
The recipient desires to continue care with the provider.
(2)
If a Program recipient enrolls in a managed care organization and requests assignment to a particular primary care provider who has a contract with the managed care organization or a contracted group of the managed care organization, the managed care organization shall assign the recipient to the primary care provider.
(3)
(i)
A Program recipient may request a change of primary care providers within the same managed care organization at any time.
(ii)
If the primary care provider has a contract with the managed care organization or a contracted group of the managed care organization, the managed care organization shall honor a request made under subparagraph (i) of this paragraph.
(4)
In accordance with the federal Health Care Financing Administration’s guidelines, a Program recipient may elect to disenroll from a managed care organization if the managed care organization terminates its contract with the Department.
(5)
A Program recipient may disenroll from a managed care organization to maintain continuity of care with a primary care provider if:
(i)
The contract between the primary care provider and the managed care organization or contracted group of the managed care organization terminates because:
(1)
The managed care organization or contracted group of the managed care organization terminates the provider’s contract for a reason other than quality of care or the provider’s failure to comply with contractual requirements related to quality assurance activities;
(2)
(A)
The managed care organization or contracted group of the managed care organization reduces the primary care provider’s capitated or applicable fee for services rates;
(B)
The reduction in rates is greater than the actual change in rates or capitation paid to the managed care organization by the Department; and
(C)
The provider and the managed care organization or contracted group of the managed care organization are unable to negotiate a mutually acceptable rate; or
(3)
The provider contract between the provider and the managed care organization is terminated because the managed care organization is acquired by another entity; and
(ii)
(1)
The Program recipient desires to continue to receive care from the primary care provider;
(2)
The provider contracts with at least one other managed care organization or contracted group of a managed care organization; and
(3)
The enrollee notifies the Department or the Department’s designee of the enrollee’s intention within 90 days after the contract termination.
(6)
The Department shall provide timely notification to the affected managed care organization of an enrollee’s intention to disenroll under the provisions of paragraph (5) of this subsection.
Md. Code Ann., Health-Gen. § 15-103.2 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.2LinkCopy Citation
(a)
In this section, “Committee” means the Maryland Medicaid Advisory Committee.
(b)
The Department shall establish the Maryland Medicaid Advisory Committee.
(c)
(1)
The Committee shall be composed of not more than 25 members.
(2)
The majority of the members of the Committee shall be enrollees or enrollee advocates.
(3)
At least five members of the Committee shall be enrollees representative of the entire Medicaid population.
(4)
The Committee members shall include:
(i)
At least five current or former enrollees or the parents or guardians of current or former enrollees;
(ii)
Providers who are familiar with the medical needs of low–income population groups, including board–certified physicians;
(iii)
Hospital representatives;
(iv)
At least five but not more than 10 advocates for the Medicaid population, including representatives of special needs populations, such as:
(1)
Children with special needs;
(2)
Individuals with physical disabilities;
(3)
Individuals with developmental disabilities;
(4)
Individuals with mental illness;
(5)
Individuals with brain injuries;
(6)
Medicaid and Medicare dual eligibles;
(7)
Individuals who are homeless or have experienced homelessness;
(8)
Individuals enrolled in home– and community–based services waivers;
(9)
Elderly individuals;
(10)
Low–income individuals and individuals receiving benefits through the Temporary Assistance for Needy Families Program; and
(11)
Individuals receiving substance use treatment services;
(v)
Two members of the Senate Finance Committee, appointed by the President of the Senate; and
(vi)
Three members of the House of Delegates, appointed by the Speaker of the House.
(5)
A designee of each of the following shall serve as an ex officio member of the Committee:
(i)
The Secretary of Human Services;
(ii)
The Executive Director of the Maryland Health Care Commission; and
(iii)
The Maryland Association of County Health Officers.
(6)
The Secretary shall appoint nonvoting members from managed care organizations who may participate in Committee meetings, unless the Committee meets in closed session as provided in § 3–305 of the General Provisions Article.
(7)
(i)
Except as specified in paragraphs (4)(v) and (vi) and (5) of this subsection, the members of the Committee shall be appointed by the Secretary and serve for a 4–year term.
(ii)
In making appointments to the Committee, the Secretary shall provide for continuity and rotation.
(iii)
In appointing consumer members to the Committee, the Secretary shall seek recommendations from:
(1)
The State Protection and Advocacy System Organization;
(2)
The Statewide Independent Living Council;
(3)
The Developmental Disabilities Council;
(4)
The Department of Disabilities;
(5)
The Department of Aging;
(6)
Consumer advocacy organizations; and
(7)
The public.
(d)
(1)
Except as provided in paragraph (2) of this subsection, a member of the Committee:
(i)
May not receive compensation; but
(ii)
Is entitled to reimbursement for expenses under the Standard State Travel Regulations, as provided in the State budget.
(2)
A member of the Committee who is an enrollee is entitled to reimbursement for:
(i)
Expenses for personal and dependent care incurred during the meeting and during travel time to and from the meeting;
(ii)
Expenses for cognitive supports related to the meeting; and
(iii)
Appropriate transportation to and from the meeting.
(3)
On request, the Department shall provide for a dedicated Department staff person:
(i)
To review meeting materials with enrollee members in advance of a meeting by telephone or in person; and
(ii)
To provide referrals to advocacy organizations.
(e)
(1)
The Secretary shall appoint the chair of the Committee.
(2)
The Department shall provide staff for the Committee.
(3)
The Committee shall determine the times and places of its meetings.
(4)
(i)
The chair of the Committee and the staff for the Committee shall provide the agenda, minutes, and any written materials to be presented or discussed at a meeting to the members of the Committee at least 5 days before the meeting.
(ii)
The agenda, minutes, and written materials shall be provided to members of the Committee in a manner and format that reasonably accommodates the specific needs of the member.
(f)
In addition to any duties imposed by federal law and regulation, the Committee shall:
(1)
Advise the Secretary on the implementation, operation, and evaluation of managed care programs under this section;
(2)
Review and make recommendations on the regulations developed to implement managed care programs under § 15–103.1 of this subtitle;
(3)
Review and make recommendations on the standards used in contracts between the Department and managed care organizations;
(4)
Review and make recommendations on the Department’s oversight of quality assurance standards;
(5)
Review data collected by the Department from managed care organizations participating in the Program and data collected by the Maryland Health Care Commission;
(6)
Promote the dissemination of managed care organization performance information, including loss ratios, to enrollees in a manner that facilitates quality comparisons and uses layman’s language;
(7)
Assist the Department in evaluating the enrollment process; and
(8)
Review reports of the ombudsmen.
Md. Code Ann., Health-Gen. § 15-103.3 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.3LinkCopy Citation
The Program shall use its leverage as a high volume purchaser to promote the cost effectiveness of Maryland’s health care system.
Md. Code Ann., Health-Gen. § 15-103.4 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.4LinkCopy Citation
(a)
The Department shall issue a request for proposals for the administration of dental services for Program recipients for the purpose of comparing and evaluating the performance and cost of dental services provided by a managed care organization and the performance and cost of dental services provided by a dental managed care organization that is separate from a managed care organization.
(b)
The Department shall provide access to Program recipients for dental services to increase utilization of dental services in accordance with utilization targets that the Department by regulation establishes in an oral health care plan.
(c)
The access required under subsection (b) of this section may be through a managed care organization or a dental managed care organization that is separate from a managed care organization.
Md. Code Ann., Health-Gen. § 15-103.5 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.5LinkCopy Citation
(a)
There is a HealthChoice Performance Incentive Fund established in the Department.
(b)
(1)
The Department shall pay all fines collected under § 15–103.1(i)(3)(v) of this subtitle and penalties collected under § 15–103.9(e)(2)(iv) of this subtitle to the Comptroller of the State.
(2)
The Comptroller shall distribute the fines to the Fund.
(c)
(1)
The Fund shall be used exclusively for the provider reimbursement budget under the HealthChoice Program, including providing financial incentives designed to improve the quality of care to managed care organizations that exceed performance targets.
(2)
The Fund is a continuing nonlapsing fund not subject to § 7–302 of the State Finance and Procurement Article.
(3)
Except as provided in paragraph (4) of this subsection, any unspent portions of the Fund may not be transferred or revert to the General Fund of the State, but shall remain in the Fund to be used for the purposes specified in this section.
(4)
At the end of each fiscal year, any amount in excess of $5 million shall revert to the General Fund.
(d)
(1)
The Secretary or the Secretary’s designee shall administer the Fund.
(2)
The Secretary shall adopt regulations to carry out the provisions of this section, including the distribution of money from the Fund to managed care organizations.
(e)
The Legislative Auditor shall audit the accounts and transactions of the Fund as provided in § 2–1220 of the State Government Article.
Md. Code Ann., Health-Gen. § 15-103.6 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.6LinkCopy Citation
(a)
A managed care organization may deem a health care provider credentialed for a period of not more than 6 months from the date of receipt of a completed application if:
(1)
The health care provider:
(i)
Has been credentialed by another entity in the State that is required to credential health care providers; and
(ii)
Has submitted an application to participate in the managed care organization’s provider panel; and
(2)
The managed care organization verifies that the health care provider was credentialed and remains in good standing with at least one entity that credentialed the health care provider.
(b)
An entity that has credentialed a health care provider may not refuse a request by a managed care organization to verify that the health care provider is credentialed and in good standing.
(c)
Nothing in this section may be construed to relieve the managed care organization from fully credentialing its health care providers.
Md. Code Ann., Health-Gen. § 15-103.7 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.7LinkCopy Citation
(a)
For the calendar year prior to the report date under subsection (b) of this section, the Department shall review the rates paid to providers under the federal Medicare fee schedule and compare the rates under the Medicare fee schedule to the fee–for–service rates paid to similar providers for the same services under the Maryland Medical Assistance Program and the rates paid to managed care organization providers for the same services under the Maryland Medical Assistance Program.
(b)
On or before January 1, 2010, and each January 1 thereafter, the Department shall report, in accordance with § 2–1257 of the State Government Article, to the Senate Finance Committee and the House Health and Government Operations Committee on:
(1)
The review and comparison under subsection (a) of this section;
(2)
Whether the fee–for–service rates and managed care organization provider rates will exceed the rates paid under the Medicare fee schedule for the period covered by the review required under subsection (a) of this section;
(3)
An analysis of the fee–for–service reimbursement rates paid in other states and how those rates compare with those in the State;
(4)
A schedule for bringing the State’s fee–for–service reimbursement rates to a level that assures that all health care providers are reimbursed adequately to provide access to care; and
(5)
An analysis of the estimated costs of implementing the schedule and any proposed changes to the fee–for–service reimbursement rates for the Maryland Medical Assistance Program and the Maryland Children’s Health Program.
Md. Code Ann., Health-Gen. § 15-103.8 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.8LinkCopy Citation
(a)
(1)
Subject to paragraph (2) of this subsection, on or before June 30, 2017, the Department shall adopt regulations necessary to ensure that the Program is in compliance with the federal Mental Health Parity and Addiction Equity Act and the federal Patient Protection and Affordable Care Act.
(2)
Except as provided in § 15–103.10 of this subtitle, the Department is not required to adopt regulations under paragraph (1) of this subsection for any change that may be made through a process other than the regulatory process.
(b)
The regulations adopted under subsection (a) of this section shall include standards regarding treatment limitations for specialty mental health and substance use disorder services that comply with the federal Mental Health Parity and Addiction Equity Act and the federal Patient Protection and Affordable Care Act, as amended by the federal Health Care and Education Reconciliation Act of 2010, and relate to:
(1)
The scope of benefits for:
(i)
Telehealth services; and
(ii)
Residential treatment programs that are not institutions for mental disease;
(2)
Service notification and authorization requirements;
(3)
Licensed specialty mental health or substance use disorder program billing for:
(i)
Services provided by physicians, advanced practice nurses, and physician assistants;
(ii)
Services provided by a licensed specialty mental health or substance use disorder program at a location that is not the primary location at which the program is licensed; and
(iii)
Separate levels of service provided within a single day or week; and
(4)
Reimbursement rates.
(c)
The treatment limitations for specialty mental health and substance use disorder services comply with the federal Mental Health Parity and Addiction Equity Act and the federal Patient Protection and Affordable Care Act, as amended by the federal Health Care and Education Reconciliation Act of 2010, if the operable processes, strategies, evidentiary standards, or other factors used in applying a treatment limitation to specialty mental health or substance use disorder services, as written and applied, are comparable to and no more restrictive than, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the treatment limitation to medical and surgical services.
Md. Code Ann., Health-Gen. § 15-103.9 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.9LinkCopy Citation
(a)
In this section, “Program” means the program established by the Department under subsection (b) of this section.
(b)
(1)
The Department shall establish a value–based purchasing program that awards financial incentives to and assesses penalties on managed care organizations based on the organization’s performance on health measures established by the Department.
(2)
The Department shall, in accordance with this section, establish criteria to implement the Program, including the establishment of performance targets, award of incentives, and collection of penalties.
(c)
Not more than 1% of the amount of capitated payments received by a managed care organization each year shall be subject to the collection of penalties under the Program.
(d)
For each measurement year, beginning January 1, 2021, the Department may not in any calendar year pay a total amount of incentives to managed care organizations under the Program in an amount that exceeds:
(1)
The total amount of penalties the Department collects from managed care organizations under the Program; and
(2)
Any additional funds allocated by the Department to support the Program.
(e)
(1)
For each measurement year, beginning January 1, 2021, the Department shall base the initial distribution of funding awarded under the Program to a managed care organization in each calendar year on the number of performance targets that the managed care organization meets or exceeds.
(2)
For each measurement year, beginning January 1, 2021, if the total amount of penalties that the Department collects under the Program exceeds the total amount of incentive funding awarded in the initial distribution of funds in a calendar year under the Program, the remaining funds shall be allocated as follows:
(i)
40% to managed care organizations that have met or exceeded more performance targets than the managed care organization has not met;
(ii)
25% to managed care organizations that the Department determines have demonstrated performance improvement in the measurement year, if the managed care organizations use the funding to target performance improvement in areas identified by the Department;
(iii)
25% for health improvement programs under the Maryland Medicaid Managed Care Program, with the funding used to fund enhancements in:
(1)
Areas where the Maryland Medicaid Managed Care Program as a whole underperforms as compared to equivalent programs in other states; or
(2)
Areas determined by the Department to be a State health priority;
(iv)
Except as provided in item (v) of this paragraph, 10% to establish a reserve in the HealthChoice Performance Incentive Fund to be used in any calendar year in which the amount of penalties the Department collects under the Program are insufficient to pay incentives earned by managed care organizations; and
(v)
If the Department may not allocate funds, in whole or in part, in accordance with item (iv) of this paragraph because of the limitation in paragraph (3) of this subsection, the Department shall equally allocate the remaining funds for use under items (i), (ii), and (iii) of this paragraph.
(3)
The Department may not allocate funds under paragraph (2)(iv) of this subsection in a manner that causes the balance in the HealthChoice Performance Incentive Fund to exceed $5 million.
(f)
Subject to the provisions of this section, the Department may modify the Program if the Department:
(1)
Adopts by regulation any changes to the core set of performance measures and the methodology for penalties, rewards, disincentives, or incentives under subsection (e)(1) and (2)(i) of this section before the calendar year for which the managed care organizations will be held accountable for the standard compliance with the performance measures; and
(2)
Notifies each managed care organization of the core set of performance measures and targets under subsection (e)(1) and (2)(i) of this section at least 3 months before the calendar year for which the managed care organization will be held accountable to the standard for compliance with the performance measures.
(g)
Any penalty or capitation adjustment imposed under this section on a managed care organization may not be accomplished or implemented by withholding a capitation payment.
(h)
The Department shall adopt regulations to carry out this section.
Md. Code Ann., Health-Gen. § 15-103.10 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.10LinkCopy Citation
(a)
Notwithstanding any other provision of law, the Department may not limit or restrict a Program recipient’s admission for inpatient care at a special psychiatric hospital or an acute general care hospital with separately identified inpatient psychiatric service unless the Department:
(1)
Bases the limit or restriction on the medical necessity of the admission; and
(2)
Establishes the limit or restriction through regulation.
(b)
On or before July 1 each year, beginning in 2024, the Department shall report to the Senate Finance Committee and the House Health and Government Operations Committee, in accordance with § 2–1257 of the State Government Article, on, for the immediately preceding fiscal year:
(1)
The average length of stay for Program recipients for Serious Mental Illness Institute of Mental Disease services and for Substance Use Disorder Institute of Mental Disease services as reported to the Centers for Medicare and Medicaid Services;
(2)
Any corrective action plans and any limits on days of stay required by the Centers for Medicare and Medicaid Services;
(3)
Any federal funding withheld and any additional State funding required due to subsection (a) of this section;
(4)
Data on the effect of subsection (a) of this section on the length of emergency department stays among Program recipients; and
(5)
Data on whether Program recipients receiving Institute of Mental Disease services were transferred to another facility and the type of facility to which they were transferred.
Md. Code Ann., Health-Gen. § 15-103.11 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–103.11LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Ex parte redetermination” means a process by which the Department determines a Program recipient’s eligibility to continue to receive services using existing data, without requiring the Program recipient to submit additional information.
(3)
“Home– and community–based services” means services authorized under a Medicaid State Plan option or waiver under § 1115 or § 1915(c), (i), or (k) of the federal Social Security Act.
(4)
“Procedural disenrollment” means the termination of a Program recipient’s eligibility to receive services based on reasons related to the renewal process and not on a determination of ineligibility.
(b)
The Department shall comply with the requirements of 42 C.F.R. § 435.912 related to the timely determination and redetermination of Program eligibility, including processing an application:
(1)
If a determination of disability is not required, within 45 days after the receipt of the application; and
(2)
If a determination of disability is required, within 90 days after the receipt of the application.
(c)
The Department shall conduct ex parte redeterminations and use all procedures authorized under 42 C.F.R. § 435.916 to prevent procedural disenrollment of individuals receiving home– and community–based services.
(d)
In accordance with 42 C.F.R. § 435.905 and subject to subsection (e) of this section, the Department shall provide, in electronic and paper formats, and orally as an accommodation, the following information to all applicants and other individuals on request:
(1)
Requirements for Program eligibility;
(2)
Available Program services; and
(3)
The rights and responsibilities of applicants and Program recipients.
(e)
(1)
The Department shall provide the information required under subsection (d) of this section in plain language and in a manner that is timely and accessible to individuals who are:
(i)
Limited English proficient through the provision of language services, including oral interpretation and written translations, at no cost to the individual; or
(ii)
Living with disabilities through the provision of auxiliary aids and services at no cost to the individual in accordance with the federal Americans with Disabilities Act and § 504 of the federal Rehabilitation Act of 1973.
(2)
The Department shall provide taglines in non–English languages to inform individuals of:
(i)
The availability of the accessible information and language services under this section; and
(ii)
How to access the information and services.
(f)
(1)
If a Program recipient is procedurally disenrolled from home– and community–based services due to a failure by the Department to redetermine eligibility in a timely manner after the recipient has timely returned information required under 42 C.F.R. § 435.916(b)(2)(i)(B) and 42 C.F.R. § 435.952(c), the Department shall reinstate the Program recipient’s eligibility and the provision of home– and community–based services and authorize enrollment retroactively to the date of disenrollment pending the Department’s completion of the redetermination process.
(2)
This subsection may not be construed to limit the Department’s authority or diminish the Department’s responsibility to reinstate the eligibility of and the provision of home– and community–based services to a Program recipient who has been disenrolled for a reason other than a failure by the Department to redetermine eligibility in a timely manner.
(g)
Subject to federal approval, the Department shall reserve capacity in home– and community–based services waivers for services needed by Program recipients with developmental disabilities who:
(1)
Were disenrolled from the Maryland Medicaid Home and Community–Based Services waiver program on or after January 1, 2024;
(2)
Have had Program eligibility reinstated; and
(3)
Have requested the reinstatement of waiver services.
(h)
(1)
The Department may not procedurally disenroll an individual from the Program or home– and community–based services solely based on missing documentation, a missing signature, or incomplete information unless the Department has:
(i)
Exhausted all ex parte verification processes required under 42 C.F.R. § 435.916;
(ii)
Provided a clear, specific, and accessible written notice identifying the exact information required; and
(iii)
Provided the Program recipient with a reasonable opportunity to supply the information.
(2)
If the Department violates paragraph (1) of this subsection, a Program recipient’s home– and community–based services shall continue without interruption.
(i)
If the Department disenrolls a Program recipient in violation of this section, the Department shall:
(1)
Automatically reinstate Program and home– and community–based services retroactive to the date of disenrollment; and
(2)
Treat the Program recipient as continuously enrolled.
(j)
(1)
On or before January 1, 2027, and quarterly thereafter, the Department shall:
(i)
Submit to the General Assembly, in accordance with § 2–1257 of the State Government Article, a report regarding Program recipients who receive home– and community–based services; and
(ii)
Post each report submitted under item (i) of this paragraph on the Department’s website.
(2)
The reports required under paragraph (1) of this subsection shall include:
(i)
The total number of Program recipients for whom a redetermination of eligibility was initiated;
(ii)
The total number of Program recipients for whom Program coverage is renewed;
(iii)
Of the Program recipients whose eligibility is renewed, the total number whose coverage was renewed based on an ex parte redetermination;
(iv)
The total number of Program recipients whose eligibility was reinstated in accordance with subsection (f) of this section;
(v)
The total number of Program recipients whose eligibility was terminated;
(vi)
The total number of Program recipients whose eligibility was terminated for procedural reasons;
(vii)
The total number of Program recipients whose eligibility was terminated due to a failure by the Department to redetermine eligibility in a timely manner; and
(viii)
The mean and median processing times for redeterminations of eligibility.
Md. Code Ann., Health-Gen. § 15-104 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–104LinkCopy Citation
The Secretary may contract with the Department of Human Services to provide medical services to those individuals for whom:
(1)
Funds are appropriated to the Department of Human Services; and
(2)
The Department of Human Services is responsible under the appropriation.
Md. Code Ann., Health-Gen. § 15-105 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–105LinkCopy Citation
(a)
In this section, “dual eligibility” means simultaneous eligibility for health insurance coverage under both the Program and Medicare and for which the Department may obtain federal matching funds.
(b)
The Department shall adopt rules and regulations for the reimbursement of providers under the Program. However, except for an invoice that must be submitted to a Medicare intermediary or Medicare carrier for an individual with dual eligibility, payment may not be made for an invoice that is received more than 1 year after the dates of the services given.
(c)
A provider who fails to submit an invoice within the required time may not recover the amount later from the Program recipient.
(d)
(1)
The Department shall adopt regulations for the reimbursement of specialty outpatient treatment and diagnostic services rendered to Program recipients at a freestanding clinic owned and operated by a hospital that is under a capitation agreement approved by the Health Services Cost Review Commission.
(2)
(i)
Except as provided in subparagraph (ii) of this paragraph, the reimbursement rate under paragraph (1) of this subsection shall be set according to Medicare standards and principles for retrospective cost reimbursement as described in 42 C.F.R. Part 413 or on the basis of charges, whichever is less.
(ii)
The reimbursement rate for hospital outpatient oncology, diagnostic, and rehabilitative services that the hospital transferred to an off–site facility prior to January 1, 1999, shall be set according to the rates approved by the Health Services Cost Review Commission if:
(1)
The transfer of services was due to zoning restrictions at the hospital campus;
(2)
The off–site facility is surveyed as part of the hospital for purposes of accreditation by the Joint Commission; and
(3)
The hospital notifies the Health Services Cost Review Commission in writing by June 1, 2013, that the hospital would like the services provided at the off–site facility to be subject to Title 19, Subtitle 2 of this article.
(e)
(1)
In this subsection, “provider” means a community–based program or an individual health care practitioner providing outpatient mental health treatment.
(2)
For an individual with dual eligibility, the Program shall reimburse a provider the entire amount of the Program fee for outpatient mental health treatment, including any amount ordinarily withheld as a psychiatric exclusion and any copayment not covered under Medicare.
(f)
This section has no effect if its operation would cause this State to lose any federal funds.
(g)
The Program shall pay the rates set by the Health Services Cost Review Commission for hospital services, as defined in § 19–201 of this article, provided at:
(1)
A freestanding medical facility pilot project authorized under § 19–3A–07 of this article prior to January 1, 2008; and
(2)
A freestanding medical facility issued a certificate of need by the Maryland Health Care Commission after July 1, 2015.
Md. Code Ann., Health-Gen. § 15-105.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–105.1LinkCopy Citation
(a)
This section does not apply to a person providing pharmacy benefit manager services.
(b)
If a pharmacy is required to submit a request for payment electronically to the Department under § 15-105(b) of this subtitle, then the pharmacy may choose to be reimbursed electronically, and in that event, the Department shall reimburse the pharmacy electronically under the Program.
Md. Code Ann., Health-Gen. § 15-105.2 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–105.2LinkCopy Citation
The Program shall reimburse health care providers in accordance with the requirements of Title 19, Subtitle 1, Part IV of this article.
Md. Code Ann., Health-Gen. § 15-106 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–106LinkCopy Citation
(a)
(1)
In cooperation with the professional organizations whose members provide health care under the Program, the Secretary shall establish a system of review for all health care that is provided.
(2)
The review shall include a study of the quality of care and the proper use of the services by the Program recipient or the provider.
(b)
A member of an appointed committee of any of these professional organizations or an appointed member of a committee of a medical staff of a licensed hospital shall have the immunity from liability described under § 5-628 of the Courts and Judicial Proceedings Article.
Md. Code Ann., Health-Gen. § 15-107 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–107LinkCopy Citation
(a)
The Department may require facilities that participate in the Program to submit cost reports, as defined by the Department, within the time set by the Department.
(b)
If a report is not submitted within that time, the Department shall withhold from the facility up to 10 percent of current interim payments for the calendar month in which the report is due and any later calendar months until the report is submitted.
Md. Code Ann., Health-Gen. § 15-107.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–107.1LinkCopy Citation
(a)
Beginning in 2026, the Department shall conduct the in–State cost–of–dispensing survey at least once every 3 years.
(b)
On or before December 1 each year in which the survey required under this section is conducted, the Department shall report the results of the survey to the General Assembly, in accordance with § 2–1257 of the State Government Article.
Md. Code Ann., Health-Gen. § 15-108 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–108LinkCopy Citation
(a)
In this section, “board” means an appeal board established under this section.
(b)
(1)
The Secretary may:
(i)
Establish one or more boards for purposes of this section; and
(ii)
Designate the jurisdiction of a board.
(2)
A board shall consist of 3 members.
(3)
Of the 3 board members:
(i)
2 shall be appointed by the Secretary; and
(ii)
1 shall be chosen by the appointed members.
(4)
Of the 2 appointed members of a board:
(i)
1 shall be a representative of the industry affected who is an individual knowledgeable in Medicare and Medicaid reimbursement principles; and
(ii)
1 shall be an individual who is employed by this State and knowledgeable in Medicare and Medicaid reimbursement principles and who does not participate directly in the field verifications.
(c)
(1)
If the Department or an agent of the Department does a field verification of the costs and allowable charges of a facility that participates in the Program, the Department or agent shall notify the facility of the results of the field verification.
(2)
Within 60 days after the facility receives the notification required under paragraph (1) of this subsection, the Department shall pay the facility the amount the Department has determined is due the facility by the Department regardless of whether or not the facility files an appeal.
(d)
(1)
A facility may appeal the results of a field verification by filing written notice with the appropriate board within 30 days after the facility receives the notice from the Department or its agent.
(2)
(i)
Within 30 days after the filing of an appeal to the board by a facility that the Department has determined owes money to the State, the Department shall recalculate the amount that is due to the State based on the field verification, exclusive of the amount in controversy which is subject to the appeal, and shall notify the facility of that amount.
(ii)
Subject to the provisions of subparagraphs (iii) and (iv) of this paragraph, payment for the amount due the State, if any, after the recalculation shall be made within 60 days after the facility receives notification of the recalculation.
(iii)
If a facility requests a longer payment schedule within 60 days after the facility receives notification of the recalculation, the Department may establish, after consultation with the facility, a longer payment schedule.
(iv)
The Department shall establish a longer payment schedule if, in the Department’s reasonable judgment, failure to grant a longer payment schedule would:
(1)
Result in financial hardship to the facility; or
(2)
Have an adverse effect on the quality of patient care furnished by the facility.
(3)
(i)
If a facility files an appeal, the portion of the amount in controversy that is actually paid shall be subject to an award of interest that is:
(1)
Calculated from the date the appeal was filed through the date of payment; and
(2)
Determined in accordance with a rate of interest established by regulation.
(ii)
Interest paid by a facility under subparagraph (i) of this paragraph is not an allowable cost.
(iii)
Interest paid to a facility under subparagraph (i) of this paragraph is not subject to any offset or other reduction against otherwise allowable costs.
(4)
If a facility other than a hospital, or if the Department is aggrieved by a final decision of the board under this section, the facility or the Department shall place any money due from the facility or from the Department in an interest bearing escrow account. The money shall remain in escrow until a final decision has been rendered.
(5)
Upon a final determination of the dispute, the appropriate person administering the escrow account shall distribute the money in that account, including any interest accrued, in conformity with the final determination.
(e)
(1)
After the Department receives the findings of a board, the Department shall determine the amount that is due either to this State or to the facility and notify the facility of that amount.
(2)
If the facility has accepted the determination made under paragraph (1) of this subsection, within 60 days after the facility receives the notification under paragraph (1) of this subsection the Department shall pay the amount the Department has determined is due the facility, if any.
(3)
Subject to the provisions of paragraphs (4) and (5) of this subsection, within 60 days after the facility receives notification, the facility shall pay the amount due the Department, if any.
(4)
If a facility requests a longer payment schedule within 30 days after the facility receives notification of the amount due the Department, the Department may establish, after consultation with the facility, a longer payment schedule.
(5)
The Department shall establish a longer payment schedule if, in the Department’s reasonable judgment, failure to grant a longer payment schedule would:
(i)
Result in financial hardship to the facility; or
(ii)
Have an adverse effect on the quality of patient care furnished by the facility.
(f)
(1)
The Department or any facility aggrieved by a reimbursement decision of the board under this section may take a direct judicial appeal.
(2)
The appeal shall be made as provided for judicial review of final decisions in the Administrative Procedure Act.
Md. Code Ann., Health-Gen. § 15-109 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–109LinkCopy Citation
(a)
An individual is not ineligible under the Program solely because Social Security benefits received by the individual are increased, unless:
(1)
The individual is considered ineligible because of the increase under applicable rules or regulations of the United States Department of Health and Human Services; and
(2)
As to that individual, federal matching funds for the State Program are not available.
(b)
Except as provided in § 15–103(b)(2) of this subtitle, to determine eligibility under the Program, the Department annually shall set the allowable yearly income levels in amounts at least equal to the following:
(1)
Family of 1 – $2,500.
(2)
Family of 2 – $3,000.
(3)
Family of 3 – $3,500.
(4)
Family of 4 – $4,000.
(5)
Family of 5 or more – $4,500 plus an increase of $500 for each family member in excess of 5.
(c)
This section is effective only to the extent that its provisions do not conflict with federal requirements for the administration of the Program in this State.
(d)
As a condition of eligibility for medical assistance, a recipient is deemed to have assigned to the Secretary of Health or the Secretary’s designee any rights to payment for medical care services from any third party who has the legal liability to make payments for those services, to the extent of any payments made by the Department on behalf of the recipient.
(e)
(1)
Each resident of a nursing home who is a recipient of medical assistance shall receive a personal needs allowance.
(2)
After a determination of income eligibility is made for a nursing home resident under the Program, the personal needs allowance shall be deducted from the total income of the resident.
(3)
The personal needs allowance for each resident of a nursing home who is a recipient of medical assistance shall be:
(i)
If on or before June 30, 2002, the federal Centers for Medicare and Medicaid Services approve the Department’s application for an amendment to the State’s existing § 1115 demonstration waiver necessary to implement the Maryland Pharmacy Discount Program established under § 15–124.1 of this subtitle:
(1)
Beginning April 1, 2003, $50 per month;
(2)
Beginning July 1, 2004, $60 per month; and
(3)
Beginning July 1, 2005, adjusted annually by an amount not exceeding 5% to reflect the percentage by which benefits under Title II of the Social Security Act (42 U.S.C. 401 et seq.) are increased by the federal government to reflect changes in the cost of living, as that percentage change is reported in the Federal Register in accordance with 42 U.S.C. 415(a)(1)(D); or
(ii)
If on or before June 30, 2002, the federal Centers for Medicare and Medicaid Services do not approve the Department’s application for an amendment to the State’s existing § 1115 demonstration waiver necessary to implement the Maryland Pharmacy Discount Program established under § 15–124.1 of this subtitle:
(1)
Beginning July 1, 2003, $50 per month;
(2)
Beginning July 1, 2004, $60 per month; and
(3)
Beginning July 1, 2005, adjusted annually by an amount not exceeding 5% to reflect the percentage by which benefits under Title II of the Social Security Act (42 U.S.C. 401 et seq.) are increased by the federal government to reflect changes in the cost of living, as that percentage change is reported in the Federal Register in accordance with 42 U.S.C. 415(a)(1)(D).
(4)
The Secretary shall adopt regulations to implement this subsection.
(f)
Subject to the confidentiality requirements of State and federal law, the courts of this State shall admit a certified copy of a 206N form, also known as a long–term care transaction form, into evidence.
Md. Code Ann., Health-Gen. § 15-109.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–109.1LinkCopy Citation
(a)
The Department, in consultation with the Office of the Attorney General, shall:
(1)
Develop and implement a plan for making the advance directive information sheet developed under § 5–615 of this article widely available; and
(2)
Make the information sheet described in item (1) of this subsection available in a conspicuous location in each local health department, in each local department of social services, and in community health centers.
(b)
The Department shall implement the plan on or before January 1, 2017.
(c)
During the development of the plan under subsection (a) of this section and the information sheet under § 5–615 of this article, the Office of the Attorney General shall consult with any interested party including the State Advisory Council on Serious Illness Care.
(d)
The Department shall offer:
(1)
The information sheet developed under § 5–615 of this article as part of the monthly enrollment packet mailed to a recipient by the enrollment broker; and
(2)
The use of electronic advance directives to a recipient through an advance directives service that:
(i)
Is approved by the Maryland Health Care Commission and the Department; and
(ii)
Meets the technology, security, and privacy standards established by the Maryland Health Care Commission.
Md. Code Ann., Health-Gen. § 15-109.2 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–109.2LinkCopy Citation
To the extent authorized by federal law or regulation, if a Program recipient who is at least 21 years old but is under the age of 65 years is incarcerated or is admitted to an institution for the treatment of mental disease, the Department:
(1)
Shall suspend Program benefits for that individual while the individual is incarcerated or is in the institution; and
(2)
May not terminate Program benefits for that individual based on the incarceration of the individual or on the admission of the individual to the institution.
Md. Code Ann., Health-Gen. § 15-110 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–110LinkCopy Citation
The Department shall reimburse acute general and chronic care hospitals that participate in the Program for care provided to Program recipients in accordance with rates that the Health Services Cost Review Commission approves under Title 19, Subtitle 2 of this article, if the United States Department of Health and Human Services approves this method of reimbursement.
Md. Code Ann., Health-Gen. § 15-111 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–111LinkCopy Citation
(a)
The Department may authorize reimbursement of a licensed day care center for the elderly or medically handicapped adults for medical care that the center provides to a Program recipient who is certified as requiring nursing home care.
(b)
(1)
Reimbursement under this section is subject to the availability of federal funds.
(2)
The reimbursement rate for medical day care:
(i)
May not exceed a maximum per diem rate established by regulation of the Department; and
(ii)
Shall cover the following:
(1)
Administrative overhead;
(2)
Drugs, supplies, and equipment;
(3)
Food;
(4)
Medical services;
(5)
Staff; and
(6)
Transportation.
Md. Code Ann., Health-Gen. § 15-112 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–112LinkCopy Citation
After consultation with the State Board of Pharmacy, the Secretary may authorize reimbursement of a physician for the dispensing of drugs to Program recipients, on the same basis as a licensed pharmacist if:
(1)
The physician dispenses drugs on a regular basis in the physician’s office; and
(2)
There is no pharmacy within 10 miles of that office.
Md. Code Ann., Health-Gen. § 15-113 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–113LinkCopy Citation
(a)
In this section, “incarcerated individual of a public institution” has the meaning stated in Title 42, § 435.1009 of the Code of Federal Regulations (1978 edition).
(b)
(1)
If an incarcerated individual of a public institution is eligible for federally funded Medicaid benefits, the Department shall pay the custodial authority for any medical care that is provided to the incarcerated individual during the month when the individual became an incarcerated individual.
(2)
Payments under this subsection shall be made in accordance with applicable rules and regulations for the Program.
(c)
The Department shall be reimbursed for the nonfederal cost of medical care by either the State or local authority that is responsible for the incarcerated individual of a public institution.
Md. Code Ann., Health-Gen. § 15-114 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–114LinkCopy Citation
(a)
In this section, “related institution” includes any of the following facilities, as classified from time to time by law, rule, or regulation:
(1)
A comprehensive care facility;
(2)
An extended care facility;
(3)
An intermediate care facility; and
(4)
A skilled nursing facility.
(b)
This section applies only to the extent that federal funds are available for reimbursement under this section.
(c)
Except as provided in subsection (f) of this section, and in accordance with subsection (e) of this section, the Department shall reimburse each hospital–based related institution that:
(1)
Is a distinct part of an acute or chronic hospital; and
(2)
On and after July 1, 1980, is licensed as a related institution.
(d)
(1)
The Health Services Cost Review Commission shall determine rates for fiscal years 1986, 1987, 1988, and 1989 for purposes of the reimbursement formula established under subsection (e) of this section and shall inform the Department of the reimbursement rates prior to the beginning of the respective fiscal year.
(2)
The rates determined by the Health Services Cost Review Commission under this section shall be the rates that would have been in effect during the respective fiscal year if the hospital–based related institution had remained under the full rate jurisdiction of the Health Services Cost Review Commission.
(e)
The reimbursement required by this section shall be in accordance with the following formula:
(1)
For the period from July 1, 1985 through June 30, 1986, a per diem rate calculated as the sum of:
(i)
80% of the rate determined by the Health Services Cost Review Commission under subsection (d) of this section; and
(ii)
20% of the per diem rate of the hospital–based related institution determined under the Program regulations applicable to skilled and intermediate care nursing facilities.
(2)
For the period from July 1, 1986 through June 30, 1987, a per diem rate calculated as the sum of:
(i)
60% of the rate determined by the Health Services Cost Review Commission under subsection (d) of this section; and
(ii)
40% of the per diem rate of the hospital–based related institution determined under the Program regulations applicable to skilled and intermediate care nursing facilities.
(3)
For the period from July 1, 1987 through June 30, 1988, a per diem rate calculated as the sum of:
(i)
40% of the rate determined by the Health Services Cost Review Commission under subsection (d) of this section; and
(ii)
60% of the per diem rate of the hospital–based related institution determined under the Program regulations applicable to skilled and intermediate care nursing facilities.
(4)
For the period from July 1, 1988 through June 30, 1989, a per diem rate calculated as the sum of:
(i)
20% of the rate determined by the Health Services Cost Review Commission under subsection (d) of this section; and
(ii)
80% of the per diem rate of the hospital–based related institution determined under the Program regulations applicable to skilled and intermediate care nursing facilities.
(5)
Beginning July 1, 1989, the Department shall reimburse at rates determined under the Program regulations applicable to skilled and intermediate care nursing facilities.
(f)
(1)
In this subsection, “management firm” means an organization that:
(i)
Is intended to have or has full responsibility and control for the day–to–day operations of a nursing home or related institution; and
(ii)
Is under contract with:
(1)
An applicant for a license from the Secretary to establish, operate, or continue the operation of an existing nursing home or related institution; or
(2)
A holder of a license from the Secretary to operate a nursing home or related institution.
(2)
The Department may not reimburse a nursing home or related institution if the nursing home or related institution or a management firm of a nursing home or related institution knowingly employs or retains as a consultant an individual who, for an activity described in § 9–314(b)(8), (9), or (10) of the Health Occupations Article, has:
(i)
Surrendered a nursing home administrator license under § 9–313 of the Health Occupations Article; or
(ii)
Had a nursing home administrator license revoked under § 9–314 of the Health Occupations Article.
Md. Code Ann., Health-Gen. § 15-114.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–114.1LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Emergency medical services provider” has the meaning stated in § 13–561 of the Education Article.
(3)
“Emergency service transporter” means a public entity or volunteer fire, rescue, or emergency medical service that provides emergency medical services.
(4)
“Low–acuity health condition” means an illness, an injury, or a condition serious enough that a reasonable person would seek care immediately, but not so severe as to require emergency room care.
(5)
“Mobile integrated health service” means a community–based preventive, primary, chronic, preadmission, or postadmission health care service or transport provided by an emergency medical services provider to an individual.
(b)
(1)
Subject to paragraph (2) of this subsection, if an emergency service transporter charges for its services and requests reimbursement from the Program, the Department shall reimburse the emergency service transporter, in an amount as specified by regulations adopted by the Department, for the cost of:
(i)
Transportation the emergency service transporter provides to a Program recipient to a facility in response to a 911 call; and
(ii)
Medical services the emergency service transporter provides to the Program recipient in response to a 911 call.
(2)
The Department shall:
(i)
Increase the amount of reimbursement authorized under paragraph (1) of this subsection for the cost of transportation and medical services by $50 in fiscal year 2023; and
(ii)
Pay at least the amount established under item (i) of this paragraph in each subsequent fiscal year.
(c)
(1)
Subject to paragraph (3) of this subsection, the Department shall reimburse an emergency service transporter for mobile integrated health services provided to a Program recipient in an amount as specified by regulations adopted by the Department that is at least $100 per interaction.
(2)
The services subject to reimbursement under paragraph (1) of this subsection shall include:
(i)
Health care services, including health assessments, remote medical diagnostics, chronic disease monitoring and education, medication compliance, immunizations and vaccinations, laboratory specimen collection, hospital discharge follow–up care, and minor medical procedures, provided by an emergency medical services provider that are:
(1)
Within the scope of practice of the emergency medical services provider;
(2)
Provided in a home or another community–based setting to a Program recipient who does not require emergency medical transport; and
(3)
Consistent with the protocols issued by the Emergency Medical Services Board; and
(ii)
Transportation provided by the emergency service transporter to a Program recipient with a low–acuity health condition to a location in which urgent health care services are provided to individuals.
(3)
The Department shall:
(i)
Increase the amount of reimbursement authorized under paragraph (1) of this subsection for the cost of transportation and medical services by $50 in fiscal year 2023; and
(ii)
Pay at least the amount established under item (i) of this paragraph in each subsequent fiscal year.
(d)
The Department shall adopt any regulations necessary to carry out this section.
Md. Code Ann., Health-Gen. § 15-114.2 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–114.2LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce socially significant improvements in human behavior.
(ii)
“Applied behavior analysis” includes the direct observations, measurement, and functional analysis of the relations between environment and behavior.
(3)
“Autism spectrum disorder” means a group of developmental disorders:
(i)
Characterized by persistent deficits in social communication and social interaction across multiple contexts;
(ii)
Characterized by restricted, repetitive patterns of behavior, interests, or activities; and
(iii)
Whose symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
(4)
“Behavior technician” means an individual who:
(i)
Delivers applied behavior analysis services that are provided to individuals with autism spectrum disorder under the supervision of:
(1)
A licensed psychologist;
(2)
A board certified behavior analyst–doctoral; or
(3)
A board certified behavior analyst; and
(ii)
Meets the requirements for providing behavior analysis services under the Program established by the Department in regulation.
(5)
“Board certified behavior analyst” means a licensed professional who:
(i)
Renders and provides direction for applied behavior analysis services that are provided to individuals with autism spectrum disorder; and
(ii)
Has obtained a Board Certified Behavior Analyst certification.
(6)
“Board certified behavior analyst–doctoral” means a licensed professional who:
(i)
Renders and provides direction for applied behavior analysis treatments that are provided to individuals with autism spectrum disorder; and
(ii)
Has obtained a Board Certified Behavior Analyst–Doctoral certification.
(b)
(1)
The Department shall provide reimbursement for applied behavior analysis services provided by behavior technicians to Program recipients with autism spectrum disorder.
(2)
Except as provided under paragraph (3) of this subsection, the Department may not require as a condition of reimbursement under the Program that an individual receive a certification from a credentialing entity recognized by the Department to provide applied behavior analysis services as a behavior technician.
(3)
The Department may require as a condition of reimbursement under the Program that an individual obtain a current certification issued by a credentialing entity recognized by the Department to provide applied behavior analysis services as a behavior technician within 150 days after the individual begins providing applied behavior analysis services to Program recipients as a behavior technician and maintain the certification.
(c)
The Department shall adopt regulations necessary to carry out this section.
Md. Code Ann., Health-Gen. § 15-115 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–115LinkCopy Citation
(a)
The Department may not place a Program recipient in a skilled or intermediate nursing facility if, because of the condition of the Program recipient, the placement would cause undue risk to the Program recipient.
(b)
To provide a basis for evaluating the placement of Program recipients who need skilled or intermediate nursing care in skilled or intermediate nursing facilities, a Program recipient may be placed only in a nursing facility that has a transfer agreement with a general hospital.
Md. Code Ann., Health-Gen. § 15-116 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–116LinkCopy Citation
The Department shall reimburse skilled nursing facilities for services provided to indigent or medically indigent patients under the age of 21 years.
Md. Code Ann., Health-Gen. § 15-117 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–117LinkCopy Citation
(a)
In this section, “leave of absence” includes:
(1)
A visit with friends or relatives; and
(2)
A leave to participate in a State approved therapeutic or rehabilitative program.
(b)
To ensure that a bed is reserved for a Program recipient who is on leave of absence from a nursing facility that has made a provider agreement with the Department, the facility shall receive payment for each day that the Program recipient is absent and a bed is reserved and made available for the return of that Program recipient.
(c)
(1)
Payments under subsection (b) of this section may not be made for more than 18 days in any calendar year.
(2)
Notwithstanding any rule or regulation, a leave of absence is not subject to any requirement that it may not exceed a particular number of days a visit, except that the leave of absence may not exceed a total of 18 days during any calendar year.
(d)
Payments required under this section:
(1)
Shall be made according to the per diem payment procedures that the Department sets; and
(2)
May not include payment for nursing services.
(e)
A nursing facility may not make additional charges against a Program recipient because the Program recipient is absent temporarily from the nursing facility.
Md. Code Ann., Health-Gen. § 15-118 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–118LinkCopy Citation
(a)
(1)
Unless the prescriber directs otherwise on the form or on an attached signed certification of need, the generic form of the drug authorized under § 12-504 of the Health Occupations Article shall be used to fill the prescription.
(2)
If the appropriate generic drug is not generally available, the Department may waive the requirement for generic substitution under paragraph (1) of this subsection.
(b)
(1)
Except as provided under paragraph (2) of this subsection, the Program shall establish maximum reimbursement levels for the drug products for which there is a generic equivalent authorized under § 12-504 of the Health Occupations Article, based on the cost of the generic product.
(2)
If a prescriber directs a specific brand name drug, the reimbursement level shall be based on the cost of the brand name product.
(c)
(1)
Except as provided under paragraph (4) of this subsection and unless the change is made by an emergency regulation, the Program shall notify all pharmacies under contract with the Program in writing of changes in the Pharmaceutical Benefit Program rules or requirements at least 30 days before the change is effective.
(2)
Changes that require 30 days’ advance written notice under paragraph (1) of this subsection are:
(i)
Exclusion of coverage for classes of drugs as specified by contract;
(ii)
Changes in prior or preauthorization procedures; and
(iii)
Selection of new prescription claims processors.
(3)
If the Program fails to provide advance notice as required under paragraph (1) of this subsection, it shall honor and pay in full any claim under the Program rules or requirements that existed before the change for 30 days after the postmarked date of the notice.
(4)
Notwithstanding any other provision of law, the notice requirements of this subsection do not apply to the addition of new generic drugs authorized under § 12-504 of the Health Occupations Article.
(d)
The Secretary shall adopt regulations to carry out the provisions of this section.
(e)
Except for a prescription for a prescription drug that contains a substance listed in Schedule II or that is determined by the Secretary to present an emerging threat in the State because of increasing abuse or diversion, the provisions of § 21-220(b)(1) of this article shall apply to the Program.
Md. Code Ann., Health-Gen. § 15-118.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–118.1LinkCopy Citation
The Secretary may not consider drugs prescribed to treat diabetes, HIV, or AIDS to be specialty drugs for the purpose of providing services under the Program.
Md. Code Ann., Health-Gen. § 15-120 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–120LinkCopy Citation
(a)
If a Program recipient has a cause of action against a person, the Department shall be subrogated to that cause of action to the extent of any payments made by the Department on behalf of the Program recipient that result from the occurrence that gave rise to the cause of action.
(b)
(1)
An attorney representing a Program recipient in a cause of action to which the Department has a right of subrogation shall notify the Department prior to filing a claim, commencing an action, or negotiating a settlement.
(2)
The attorney shall notify the Department in advance of the resolution of a cause of action and shall allow the Department 3 business days from the receipt of the notice to establish its subrogated interest.
(3)
This subsection may not be construed to create a cause of action for notifying or failing to notify the Department.
(c)
(1)
Any Program recipient or attorney, guardian, or personal representative of a Program recipient who receives money in settlement of or under a judgment or award in a cause of action in which the Department has a subrogation claim shall, after receiving written notice of the subrogation claim, hold that money, for the benefit of the Department, to the extent required for the subrogation claim, after deducting applicable attorney’s fees and litigation costs.
(2)
A person who, after written notice of a subrogation claim and possible liability under this paragraph, disposes of the money, without the written approval of the Department, is liable to the Department for any amount that, because of the disposition, is not recoverable by the Department.
(3)
The Department may compromise or settle and release its subrogation claim if, in its judgment, collection of the claim will cause substantial hardship:
(i)
To the Program recipient; or
(ii)
In a wrongful death action, to the surviving dependents of a deceased Program recipient.
(4)
(i)
The Department is not liable for payment of or contribution to any attorney’s fees or litigation costs of any Program recipient or attorney, guardian, or personal representative of any Program recipient.
(ii)
The deduction of applicable attorney’s fees and litigation costs under paragraph (1) of this subsection may not be considered as payment for or contribution to those fees or costs by the Department.
(d)
Any action brought under this section is not exclusive and is independent of and in addition to any right, remedy, or cause of action available to the State, the Department, any other State agency, or a Program recipient or any other individual.
(e)
(1)
(i)
In this subsection the following words have the meanings indicated.
(ii)
“Cigarette” means any roll of tobacco wrapped in:
(1)
Paper;
(2)
A substance not containing tobacco; or
(3)
A substance containing tobacco which because of its appearance, the type of tobacco used in the filler, or its packaging and labeling, is likely to be used by the consumers of ordinary paper–wrapped cigarettes.
(iii)
(1)
“Manufacturer of a tobacco product” means a designer, producer, or processor of a tobacco product engaged in the marketing or promotion of a tobacco product.
(2)
“Manufacturer of a tobacco product” includes an entity not otherwise a manufacturer of a tobacco product that imports a tobacco product or otherwise holds itself out as a manufacturer of a tobacco product.
(3)
“Manufacturer of a tobacco product” does not include:
(A)
A grower, buyer, dealer, distributor, or wholesaler of leaf tobacco; or
(B)
A retailer, distributor, or wholesaler of a tobacco product.
(iv)
“Smokeless tobacco” means a product that consists of cut, ground, powdered, or leaf tobacco that is intended to be placed in the oral cavity.
(v)
“Tobacco product” means cigarettes or smokeless tobacco.
(2)
In any action under this section or pursuant to any other right, remedy, or cause of action brought by the State against a manufacturer of a tobacco product, the causation and the amount of medical assistance expenditures attributable to the use of a tobacco product may be proved or disproved by evidence of statistical analysis, without proof of the causation or the amount of expenditures for any particular Program recipient or any other individual.
(3)
Nothing contained in paragraph (2) of this subsection prohibits or limits the right of any party to introduce any other evidence, otherwise admissible, that supports or rebuts the evidence of statistical analysis described in paragraph (2) of this subsection.
Md. Code Ann., Health-Gen. § 15-121 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–121LinkCopy Citation
(a)
In accordance with applicable federal law and rules and regulations, including those under Title XIX of the Social Security Act, the Department may make claim against the estate of a deceased Program recipient for the amount of any medical assistance payments under this title.
(b)
The claim shall be waived by the Department if, in its judgment, enforcement of the claim will cause substantial hardship to the surviving dependents of the deceased.
Md. Code Ann., Health-Gen. § 15-121.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–121.1LinkCopy Citation
(a)
If a Program recipient has a claim for any medical, hospital or disability benefits under §§ 19-505 and 19-506 of the Insurance Article, the Department shall be subrogated to that claim to the extent of any payments made by the Department on behalf of the Program recipient that results from the occurrence that gave rise to the claim less:
(1)
Applicable attorney’s fees; and
(2)
Any rights for loss of income.
(b)
(1)
An attorney representing a Program recipient under this subtitle on a claim to which the Department has a right of subrogation shall notify the Department prior to filing the claim.
(2)
This subsection may not be construed to create a cause of action for notifying or failing to notify the Department.
(c)
(1)
Any Program recipient or attorney, guardian, or personal representative of a Program recipient who receives money for a claim to which the Department has a subrogation claim shall, after receiving written notice of the subrogation claim, hold that money, for the benefit of the Department, to the extent required for the subrogation claim, after deducting applicable attorney’s fees.
(2)
A person who, after written notice of a subrogation claim from the Department and possible liability under this paragraph, disposes of the money, without the written approval of the Department, is liable to the Department for any amount that, because of the disposition, is not recoverable by the Department.
(3)
The Department may compromise or settle and release its subrogation claim if, in its judgment, collection of the claim will cause substantial hardship to the Program recipient or in a wrongful death action, the surviving dependent of a deceased Program recipient.
Md. Code Ann., Health-Gen. § 15-121.2 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–121.2LinkCopy Citation
(a)
If a Program recipient has a claim for any medical, hospital, or disability benefits under §§ 19-509 and 19-510 of the Insurance Article, the Department shall be subrogated to that claim to the extent of any payments made by the Department on behalf of the Program recipient that results from the occurrence that gave rise to the claim, less applicable attorney’s fees.
(b)
(1)
An attorney representing a Program recipient under this subtitle on a claim to which the Department has a right of subrogation shall notify the Department prior to filing the claim.
(2)
This subsection may not be construed to create a cause of action for notifying or failing to notify the Department.
(c)
(1)
Any Program recipient, attorney, guardian, or personal representative of a Program recipient who receives money for a claim to which the Department has a subrogation claim shall, after receiving written notice of the subrogation claim, hold that money, for the benefit of the Department, to the extent required for the subrogation claim, after deducting applicable attorney’s fees.
(2)
A person who, after written notice of a subrogation claim from the Department and possible liability under this paragraph, disposes of the money, without the written approval of the Department, is liable to the Department for any amount that, because of the disposition, is not recoverable by the Department.
(3)
The Department may compromise or settle and release its subrogation claim if, in its judgment, collection of the claim will cause substantial hardship to the Program recipient or in a wrongful death action, the surviving dependent of a deceased Program recipient.
Md. Code Ann., Health-Gen. § 15-121.3 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–121.3LinkCopy Citation
The Department may assign its right of subrogation under §§ 15-120, 15-121.1, and 15-121.2 of this subtitle to a managed care organization.
Md. Code Ann., Health-Gen. § 15-122 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–122LinkCopy Citation
(a)
(1)
The spouse of a Program recipient is responsible for payments for the health care needs of the Program recipient to the extent that the spouse is able to pay any of the cost of care. Except as provided in paragraph (2) of this subsection, the total liability shall be limited to the amount spent for the care under the Program.
(2)
In any case in which eligibility was based on the spouse’s refusal to pay for the Program recipient’s care, the liability of the spouse may include:
(i)
The amount spent for care by the Program;
(ii)
Administrative and enforcement costs incurred by the Program related to pursuing reimbursement from the spouse; and
(iii)
Any penalties established by the Secretary by regulation for a violation of this section not to exceed $50 per day for each day a violation exists.
(b)
(1)
The Secretary shall adopt rules and regulations that set standards for payment by the spouse based on the ability of the spouse to pay all or part of the cost of care. To determine reasonably the ability to pay, the Secretary shall evaluate available income, ordinary living expenses, special expenses, and assets, other than the homestead of the spouse and its appurtenances.
(2)
Notwithstanding the standards established under paragraph (1) of this subsection, the spouse may also be liable for costs and penalties under subsection (a)(2) of this section.
(c)
(1)
The Secretary may collect the money owed.
(2)
The Central Collection Unit in the Department of Budget and Management shall collect delinquent accounts and debts.
Md. Code Ann., Health-Gen. § 15-122.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–122.1LinkCopy Citation
(a)
In this section, “participating provider” means any facility that participates in the Program and is:
(1)
A skilled nursing facility;
(2)
A comprehensive care facility; or
(3)
An intermediate care facility.
(b)
A participating provider shall not be required to repay the State for any depreciation for which the provider has been reimbursed as an allowable expense and which could otherwise be recaptured by the State upon a sale, scrapping, trade-in, donation, exchange, demolition, or abandonment of a facility, or involuntary conversion of a facility such as condemnation, fire, theft, or other casualty.
(c)
This section has no effect if its operation would cause this State to lose any federal funds.
Md. Code Ann., Health-Gen. § 15-122.2 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–122.2LinkCopy Citation
(a)
In this section, “converted funds” means the amount received in payment by a person from an insurer for the cost of health services provided to a child which was not used to reimburse the Department for Medicaid costs incurred.
(b)
Each year the Department may refer to the Central Collection Unit of the Department of Budget and Management for certification to the State Comptroller the name of any person who has received converted funds for the interception of any State tax refund.
(c)
The Department shall notify the person certified under subsection (b) of this section that a certification has been made by the Department.
(d)
The certification by the Central Collection Unit shall include, if known:
(1)
The full name of the person certified and any other names known to be used by that person;
(2)
The address and the Social Security number of the person certified; and
(3)
The amount of the converted funds.
(e)
The State Comptroller shall:
(1)
Pay to the Department any income tax refund due to the person certified in an amount not more than the amount certified by the Department;
(2)
Pay to the person certified any part of the income tax refund over the amount of the converted funds; and
(3)
Notify the person certified of:
(i)
The amount paid to the Department; and
(ii)
The rights of the person certified under subsection (b) of this section.
(f)
(1)
On receipt of a notice of intercept from the State Comptroller, any person certified by the Department who disputes the existence or amount of the converted funds may file an appeal in accordance with Title 10 of the State Government Article.
(2)
If the Department finds that an excessive amount was withheld from the person’s income tax refund, the Department promptly shall pay to the taxpayer the excess amount withheld.
(g)
The Comptroller shall honor refund interception requests in the following order:
(1)
A refund interception request to collect an unpaid State, county, or municipal tax;
(2)
A refund interception request under § 10-113 of the Family Law Article for arrears of support payments;
(3)
A refund interception request for converted funds under this subtitle; and
(4)
Any other refund interception request.
(h)
The Secretary and the State Comptroller may adopt regulations to carry out this section.
Md. Code Ann., Health-Gen. § 15-122.3 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–122.3LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Available income” means the portion of income of a Program recipient that the Program recipient is required to contribute to the cost of care for the Program recipient under the Program.
(3)
“Disabled person” has the meaning stated in § 13–101 of the Estates and Trusts Article.
(4)
“Guardian” means:
(i)
A guardian of the person; or
(ii)
A guardian of the property.
(5)
“Guardian of the person” means a person who has been appointed by a court as a guardian of the person of a disabled person under § 13–705 of the Estates and Trusts Article.
(6)
“Guardian of the property” means a person who has been appointed by a court as a guardian of the property of a disabled person under § 13–201 of the Estates and Trusts Article.
(7)
“Guardianship services” means services provided to a recipient who is a disabled person by a guardian while acting in the capacity as a guardian.
(8)
“Recipient” means a Program recipient who receives long–term care services and supports under the Program.
(b)
Subject to subsection (c) of this section, when determining the available income of a recipient who is a disabled person and has a guardian, the Department shall include as part of the personal needs allowance guardianship fees payable for guardianship services.
(c)
The personal needs allowance for guardianship fees shall be as follows:
(1)
If one person is serving as both the guardian of the person and the guardian of the property of the recipient, the personal needs allowance shall be $50 per month; and
(2)
If one person is serving as the guardian of the person of the recipient and a different person is serving as the guardian of the property of the recipient, the personal needs allowance shall be $50 per month for each guardian.
Md. Code Ann., Health-Gen. § 15-123 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–123LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Convicted” includes being convicted after a plea of nolo contendere.
(3)
“Fraud” includes the commission of or an attempt or conspiracy to commit the crimes of:
(i)
Concealment of medical records;
(ii)
Violation of Title 8, Subtitle 5, Part II of the Criminal Law Article;
(iii)
False representations relating to Medicaid health plans;
(iv)
Misappropriation by a fiduciary; and
(v)
Theft.
(b)
A health care provider who is convicted of fraud in connection with the Program or a similar federal or State program is ineligible for further payment under the Program.
Md. Code Ann., Health-Gen. § 15-124.2 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–124.2LinkCopy Citation
(a)
In this section, “Program” means the Maryland Medbank Program established under this section.
(b)
There is a Maryland Medbank Program.
(c)
The purpose of the Program is to improve the health status of individuals throughout the State who lack prescription drug coverage by providing access to medically necessary prescription drugs through patient assistance programs sponsored by pharmaceutical drug manufacturers.
(d)
(1)
Subject to paragraph (2) of this subsection, the Program shall be administered by the Medbank of Maryland, Inc.
(2)
The Medbank of Maryland, Inc. shall contract with one or more government or nonprofit entities to operate the Program.
(e)
(1)
The Program shall be funded through a grant provided by the Department.
(2)
Program funds may be used in part to:
(i)
Purchase interim supplies of prescription drugs for enrollees who have applied to participate in a manufacturer’s patient assistance program but have not yet received the approved prescription drug; and
(ii)
Distribute medication to enrollees who have been approved to participate in a manufacturer’s patient assistance program.
(f)
(1)
The Medbank of Maryland, Inc. shall ensure that the Program is available to residents in each of the following geographic regions of the State:
(i)
Western Maryland;
(ii)
The Eastern Shore;
(iii)
The Baltimore metropolitan area;
(iv)
The Maryland counties in the Washington, D.C. metropolitan area; and
(v)
Southern Maryland, including Anne Arundel County.
(2)
Medbank of Maryland, Inc. shall be the central coordinating office for the State.
(g)
Eligibility for the Program shall be limited only by the criteria established by pharmaceutical manufacturers for their patient assistance programs.
(h)
(1)
The Department shall require detailed financial reports at least quarterly from Medbank of Maryland, Inc.
(2)
The Medbank of Maryland, Inc. shall release funds to the entities that operate the Program as needed and justified by the quarterly reports filed in accordance with paragraph (1) of this subsection.
Md. Code Ann., Health-Gen. § 15-124.3 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–124.3LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Enrollee” means an individual who is enrolled in the Program.
(3)
“Medicare Modernization Act” means the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
(4)
“Medicare Part D prescription drug benefit” means the prescription drug benefit established by the Medicare Modernization Act under Part D of the federal Medicare Program.
(5)
“Prescription drug plan” means a private health plan that provides a Medicare Part D prescription drug benefit in accordance with the requirements of the Medicare Modernization Act.
(6)
“Program” means the Medicare Option Prescription Drug Program established under this section.
(b)
There is a Medicare Option Prescription Drug Program within the Maryland Medical Assistance Program.
(c)
The purpose of the Program is to:
(1)
Assist low–income Medicare eligible individuals to make a seamless transition to, and coordinate prescription drug coverage with, the Medicare Part D prescription drug benefit; and
(2)
Minimize the cost–sharing burden on the individuals.
(d)
The Program shall be administered and operated by the Department as permitted by federal law or waiver.
(e)
(1)
The Program shall be open to any individual who:
(i)
Is a resident of the State;
(ii)
Is a Medicare beneficiary;
(iii)
Is not enrolled in a Medicare Advantage Plan or other public or private insurance program, except for Medicaid and the Maryland Pharmacy Assistance Program, that provides prescription drug benefits at the time that the individual applies for enrollment in the Program;
(iv)
Has an annual household income below 150 percent of the federal poverty level; and
(v)
Meets the asset test established by the Medicare Modernization Act under Medicare Part D.
(2)
Individuals who are dually eligible for Medicare and Medicaid, or Medicare and the Maryland Pharmacy Assistance Program, may be enrolled automatically in the Program, provided that they may elect to opt out of the Program.
(3)
Enrollment in the Program for individuals who are dually eligible for Medicare and Medicaid shall begin not later than the date on which the auto–enrollment period for the federal Medicare Part D Program begins.
(4)
The Department shall determine the procedures for automatic enrollment in, and election to opt out of, the Program.
(5)
Individuals who meet the eligibility requirements of paragraph (1) of this subsection but who are not dually eligible for Medicare and either Medicaid or the Maryland Pharmacy Assistance Program may apply for enrollment in the Medicare Option Prescription Drug Program by submitting an application to the Department.
(f)
The Department may:
(1)
Enter into a contract with one or more prescription drug plans to coordinate the prescription drug benefits provided under the Program and the Medicare Part D prescription drug benefit;
(2)
Require a pharmaceutical manufacturer to provide rebates in an amount not less than the rebates provided to the Medicaid Program under § 1927(c) of Title XIX of the Social Security Act (42 U.S.C. § 1396r–8) as a condition of the pharmaceutical manufacturer’s products being available to enrollees;
(3)
Enroll eligible individuals into a prescription drug plan under contract with the Department, with an opt–out provision at the individual’s discretion;
(4)
Specify procedures for individuals to apply for enrollment in the Program;
(5)
Contract with a private entity to assist in administration of the Program or negotiations with prescription drug plans; and
(6)
Pay all or part of the premiums, deductibles, coinsurance payments, and copayments required under the Medicare Part D Program for enrollees.
(g)
Subject to available funds, the Program established under this subtitle shall provide benefits to the maximum number of individuals eligible for enrollment in the Program.
(h)
The Secretary shall adopt regulations to implement the Program.
Md. Code Ann., Health-Gen. § 15-125 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–125LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Children” means individuals under the age of 12 years.
(3)
“Youth” means an individual at least 12 years old and under the age of 22 years.
(b)
The Department is the agency of this State to administer a program of services for children and youth who have or are suspected of having special health care needs.
(c)
The purpose of this program is to provide reimbursement for medical, diagnostic, corrective, and other services and care to children and youth who have or are suspected of having special health care needs.
(d)
The Department may:
(1)
Prepare and administer detailed plans for these purposes;
(2)
Adopt rules and regulations for administering these plans;
(3)
Receive and, in accordance with these plans, spend all funds made available to the Department for these purposes; and
(4)
Cooperate with the federal government in extending and improving these services and in administering these plans.
Md. Code Ann., Health-Gen. § 15-126 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–126LinkCopy Citation
The Secretary shall provide educational programs to meet the needs of each physically or mentally handicapped child in the custody of the Department. The cost for each child shall be included and identified in the budget of the Department as submitted to the General Assembly by the Governor.
Md. Code Ann., Health-Gen. § 15-128 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–128LinkCopy Citation
The Department may provide reimbursement, under the Maryland Medical Assistance Program, for services provided by a hospice care program, as defined in § 19-901 of this article.
Md. Code Ann., Health-Gen. § 15-129 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–129LinkCopy Citation
(a)
In this section, “durable medical equipment” means durable medical equipment listed in the medical assistance provider fee manual, as provided in regulations adopted by the Department.
(b)
To determine whether the prices charged for durable medical equipment provided to Program recipients are reasonable, the Department shall establish regulations and procedures for reviewing the prices of durable medical equipment every 3 years.
(c)
The Department, to the extent feasible and appropriate, shall recover all durable medical equipment from Program recipients that:
(1)
Was purchased by the Department; and
(2)
Is no longer required by the recipient.
(d)
Except as provided in subsection (e) of this section and to the extent feasible and appropriate, the Department shall reuse the durable medical equipment recovered under subsection (c) of this section to meet the needs of other Program recipients for the same durable medical equipment.
(e)
If the durable medical equipment recovered under subsection (c) of this section is not in a condition that would enable another Program recipient to use it, the Department may give the equipment to any organization that will:
(1)
Repair or attempt to repair the equipment; and
(2)
Provide the equipment at no charge to other persons who require the same equipment.
Md. Code Ann., Health-Gen. § 15-130 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–130LinkCopy Citation
(a)
In this section, “seriously emotionally disturbed” means a condition that is:
(1)
Manifest in an individual younger than 18 years or, if the individual is in a residential treatment center, younger than 21 years;
(2)
Diagnosed according to the current diagnostic classification system that is recognized by the Secretary; and
(3)
Characterized by a functional impairment that substantially interferes with or limits the child’s role or functioning in the family, school, or community activities.
(b)
(1)
The Department shall apply to the Health Care Financing Administration of the federal Department of Health and Human Services for a home– and community–based services waiver under § 1915(c) of the federal Social Security Act in order to receive federal matching funds for services to seriously emotionally disturbed individuals who would otherwise require institutionalization in a residential treatment center.
(2)
The Department shall apply to the Health Care Financing Administration of the federal Department of Health and Human Services for a home– and community–based services waiver under § 1915(c) of the federal Social Security Act in order to receive federal matching funds for services to autistic children aged 1 through 21 years who would otherwise require institutionalization in an institution for the developmentally disabled.
(c)
In accordance with subsection (b)(1) and (2) of this section, the services to be provided for seriously emotionally disturbed individuals or autistic children may include:
(1)
Respite services;
(2)
Family training and education;
(3)
Day treatment services;
(4)
Therapeutic integration services;
(5)
Intensive individual support services;
(6)
Therapeutic living services;
(7)
Intensive in–home intervention services; and
(8)
Specialized case management services.
(d)
The State matching funds required to cover the Medicaid costs under the waiver for autistic children shall be certified or otherwise provided by the Maryland State Department of Education, local school systems, and local lead agencies.
(e)
The State matching funds required to cover the Medicaid costs under the waiver for seriously emotionally disturbed individuals shall be certified or otherwise provided by the Maryland State Department of Education, local school systems, local lead agencies, and the Behavioral Health Administration.
Md. Code Ann., Health-Gen. § 15-130.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–130.1LinkCopy Citation
(a)
The Department shall apply to the Centers for Medicare and Medicaid Services of the federal Department of Health and Human Services for a psychiatric residential treatment demonstration waiver if the Centers announce in the Federal Register that the Centers are accepting applications for such a waiver.
(b)
The waiver application required by subsection (a) of this section shall:
(1)
Provide for services for a minimum of 150 individuals; or
(2)
Provide for services for the maximum number of individuals that the Centers for Medicare and Medicaid Services allows, if the maximum number of individuals that the Centers allow to receive services under the waiver is fewer than 150 individuals.
(c)
During the waiver application process, the Department shall conduct an analysis of both the short-term and long-term costs and benefits of implementing the waiver.
(d)
The Department shall report to the General Assembly, in accordance with § 2-1257 of the State Government Article, every 6 months concerning the status of the Department’s application required under this section until the waiver is approved or denied.
(e)
(1)
If the Centers for Medicare and Medicaid Services approve the waiver application required under this section, the Department shall report to the General Assembly, in accordance with § 2-1257 of the State Government Article, on its decision on whether to implement the waiver.
(2)
The report required under this subsection shall include a summary of the analysis required under subsection (c) of this section.
Md. Code Ann., Health-Gen. § 15-131 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–131LinkCopy Citation
(a)
The Department shall investigate development of integrated care systems and the feasibility and desirability of applying for a home- and community-based services waiver in order to maximize federal matching funds for the provision of services to adults who:
(1)
Have functional disabilities, including Alzheimer’s disease and related disorders;
(2)
Have family income not greater than 200% of the federal poverty level; and
(3)
Would otherwise require nursing home institutionalization.
(b)
The services covered under the waiver under this section may include:
(1)
Routine and emergency respite care;
(2)
Adult day care;
(3)
Personal care;
(4)
Case management; and
(5)
Homemaker services.
(c)
The Department may place a reasonable limit on the number of individuals or on the geographic area of the State included in the waiver under this section.
Md. Code Ann., Health-Gen. § 15-132 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–132LinkCopy Citation
(a)
(1)
In this section the following terms have the meanings indicated.
(2)
“Assisted living program” has the meaning stated in § 19–1801 of this article.
(3)
“Assisted living services” means services provided by an assisted living program as defined in regulations adopted by the Department.
(4)
“Case management services” means services that assist waiver eligible individuals in gaining access to needed waiver services and other needed medical, social, housing, and other supportive services.
(5)
“Health related care and services” includes:
(i)
24–hour supervision and observation by a licensed care provider;
(ii)
Medication administration;
(iii)
Inhalation therapy;
(iv)
Bladder and catheter management;
(v)
Assistance with suctioning; or
(vi)
Assistance with treatment of skin disorders and dressings.
(6)
“Home health care services” means those services defined in § 19–401 of this article and in 42 C.F.R. 440.70.
(7)
“Medically and functionally impaired” means an individual who is assessed by the Department to require services provided by a nursing facility as defined in this section, and who, but for the receipt of these services, would require admission to a nursing facility within 30 days.
(8)
“Nursing facility” means a facility that provides skilled nursing care and related services, rehabilitation services, and health related care and services above the level of room and board needed on a regular basis in accordance with § 1919 of the federal Social Security Act.
(9)
“Waiver” means a home– and community–based services waiver under § 1915(c) of the federal Social Security Act, submitted by the Department to the Centers for Medicare and Medicaid Services.
(10)
“Waiver services” means the services covered under an approved waiver that:
(i)
Are needed and chosen by an eligible waiver participant as an alternative to admission to or continued stay in a nursing facility;
(ii)
Are part of a plan of service approved by the program;
(iii)
Assure the waiver participant’s health and safety in the community; and
(iv)
Cost no more per capita to receive services in the community than in a nursing facility.
(b)
(1)
If authorized by the Centers for Medicare and Medicaid Services, an individual shall be determined medically eligible to receive services if the individual requires:
(i)
Skilled nursing care or other related services;
(ii)
Rehabilitation services; or
(iii)
Health–related services above the level of room and board that are available only through nursing facilities, including individuals who because of severe cognitive impairments or other conditions:
(1)
(A)
Are currently unable to perform at least two activities of daily living without hands–on assistance or standby assistance from another individual; and
(B)
Have been or will be unable to perform at least two activities of daily living for a period of at least 90 days due to a loss of functional capacity; or
(2)
Need substantial supervision for protection against threats to health and safety due to severe cognitive impairment.
(2)
The Department shall adopt regulations to carry out the provisions of this subsection.
(c)
The Department’s waiver shall include the following:
(1)
A cap on waiver participation of not fewer than 7,500 individuals;
(2)
A plan for waiver participation of not fewer than 7,500 individuals;
(3)
Financial eligibility criteria which include:
(i)
The current federal and State medical assistance long–term care rules for using services provided by a nursing facility, per §§ 1902, 1919, and 1924 of the federal Social Security Act, and applicable regulations adopted by the Department;
(ii)
Medically needy individuals using services provided by a nursing facility under the current federal and State medical assistance eligibility criteria governed by regulations adopted by the Department and § 1919 of the federal Social Security Act; and
(iii)
Categorically needy individuals with income up to 300% of the applicable payment rate for supplemental security income;
(4)
Waiver services that include at least the following:
(i)
Assisted living services;
(ii)
Case management services;
(iii)
Family training;
(iv)
Dietitian and nutritionist services;
(v)
Medical day care services; and
(vi)
Senior center plus services;
(5)
The opportunity to provide eligible individuals with waiver services under this section as soon as they are available without waiting for placement slots to open in the next fiscal year;
(6)
An increase in participant satisfaction;
(7)
The forestalling of functional decline;
(8)
A reduction in Medicaid expenditures by reducing utilization of services; and
(9)
The enhancement of compliance with the decision of the United States Supreme Court in the case of Olmstead v. L.C. (1999) by offering cost–effective community–based services in the most appropriate setting.
(d)
This section may not be construed to affect, interfere with, or interrupt any services reimbursed through the Program under this title.
(e)
(1)
(i)
If the Department maintains a waiting list or registry, each month the Department shall send a waiver application:
(1)
If there are fewer than 600 individuals on the waiting list or registry, to all individuals on the waiting list or registry; and
(2)
If there are 600 or more individuals on the waiting list or registry, to at least 600 individuals on the waiting list or registry.
(ii)
A waiver application sent under subparagraph (i) of this paragraph shall state clearly and conspicuously that:
(1)
The applicant must submit the application within 6 weeks after receiving the application; and
(2)
The applicant is required to meet all of the eligibility criteria for participation in the waiver within 6 months after submitting the application.
(2)
If a person determined to be eligible to receive waiver services under this section desires to receive waiver services and an appropriate placement is available, the Department shall authorize the placement.
(f)
The Department, in consultation with representatives of the affected industry and advocates for waiver candidates, and with the approval of the Department of Aging, shall adopt regulations to implement this section.
Md. Code Ann., Health-Gen. § 15-132.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–132.1LinkCopy Citation
(a)
In this section, “self-employed provider” means an individual who:
(1)
Provides health care services as an attendant, personal care aide, personal care provider, or respite care worker to Program recipients participating in:
(i)
The Home- and Community-Based Services Waiver for Older Adults Program; or
(ii)
The Medical Assistance Personal Care Program; and
(2)
Is not employed by an agency.
(b)
To the extent allowed under federal law, the Department shall provide voluntary withholding of federal income taxes under the Internal Revenue Code and State income taxes under Title 10 of the Tax - General Article for self-employed providers.
(c)
Nothing in this section shall be construed to alter a self-employed provider’s contractual relationship with the Department or to confer to the self-employed provider any status of employment or benefits commensurate with that status.
Md. Code Ann., Health-Gen. § 15-133 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–133LinkCopy Citation
(a)
The State shall apply to the Health Care Financing Administration of the United States Department of Health and Human Services for grants to assist states in improving home– and community–based service systems, including:
(1)
Real choice system change grants;
(2)
Nursing facility transition grants and “access housing” grants; and
(3)
Community–based attendant services with consumer control grants.
(b)
The Department shall seek input from eligible individuals, the individuals’ representatives, and service providers in developing and implementing the Program.
(c)
On or before July 1, 2001, the Department shall notify the Health Care Financing Administration of the United States Department of Health and Human Services of Maryland’s intent to expand the current Medicaid home– and community–based waiver for adults with physical disabilities, under § 1915(c) of the federal Social Security Act to redirect funds to develop appropriate funding for this Program.
Md. Code Ann., Health-Gen. § 15-134 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–134LinkCopy Citation
(a)
If the Department applies for a Medical Assistance Program waiver, modifies or amends an existing Medical Assistance Program waiver, or amends the Medicaid State Plan, the Department shall give notice of the application or amendment by:
(1)
Publication in the Maryland Register; and
(2)
Submission of the application or amendment to the Medicaid Advisory Committee for discussion at a Medicaid Advisory Committee meeting.
(b)
For 30 days following publication of any notice published under subsection (a) of this section, the Department shall:
(1)
Make the Medical Assistance Program waiver application or amendment to the Medicaid State Plan available to the public during business hours; and
(2)
Provide an opportunity to receive public comments on the Medical Assistance Program waiver application or amendment to the Medicaid State Plan.
(c)
If the Department submits to the federal Centers for Medicare and Medicaid Services an amendment to the Medicaid State Plan or Medical Assistance Program waiver application, the Department shall submit a copy of the amendment or waiver application to the members of the Medicaid Advisory Committee no later than five business days after the Department submits the amendment or waiver application to the federal Centers for Medicare and Medicaid Services.
(d)
Subject to the limitations of the State budget and notwithstanding any other provision of law, the following are effective on the date specified in a Maryland Register notice:
(1)
Amendments or modifications to the Medicaid State Plan or Medical Assistance Program; and
(2)
Medical Assistance Program waiver applications and modifications.
Md. Code Ann., Health-Gen. § 15-134.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–134.1LinkCopy Citation
(a)
In this section, “legal resident” means an individual who maintains the State as the individual’s principal establishment, home of record, or permanent home and to where, whenever absent due to uniformed services obligation, the individual intends to return.
(b)
A dependent of a legal resident of the State who is determined eligible to receive home– and community–based waiver services or other waiver services from the Department under this title shall retain eligibility for the services:
(1)
Regardless of whether the legal resident leaves the State due to the legal resident’s uniformed services assignment outside the State; and
(2)
If the dependent is otherwise eligible for the services.
(c)
If a dependent of a legal resident is on a waiting list for home– and community–based waiver services or other waiver services to be provided under this title, the Department shall allow the dependent to remain on the waiting list for services while the legal resident is outside the State due to the legal resident’s uniformed services assignment outside the State.
(d)
The Department shall reinstate services provided under this title to a dependent who resides with the legal resident while the legal resident is outside the State due to the legal resident’s uniformed services assignment outside the State:
(1)
On the relocation of the dependent to the State; and
(2)
If a request for services is made.
Md. Code Ann., Health-Gen. § 15-135 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–135LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Designated protection and advocacy systems agency” means a protection and advocacy systems agency that is designated as an independent advocate for individuals with disabilities under the federal Developmental Disabilities Act.
(3)
“Nursing facility” has the meaning stated in § 15–132(a)(8) of this subtitle.
(4)
“Resident” means an individual receiving long–term care in a nursing facility.
(b)
(1)
A social worker shall provide to each resident information that:
(i)
Explains the availability of services under home– or community–based waiver programs in the State that could enable the resident to live in the community;
(ii)
Explains that if the resident’s care is partially or fully reimbursed by the Program, the resident may be able to receive long–term care services in the community instead of in the nursing facility;
(iii)
Provides information regarding how to obtain case management services or evaluation services related to home– and community–based waiver programs or other options for receiving long–term care services in the community;
(iv)
If written, is in large, easily legible type and in formats accessible to the resident; and
(v)
Includes a list of legal, advocacy, and government agency resources.
(2)
The Department, in consultation with the State agencies that implement the home– and community–based services programs, shall prepare, distribute, and update as necessary the information required under paragraph (1) of this subsection.
(3)
The information required under paragraph (1) of this subsection shall be made available to the resident:
(i)
Upon admission and discharge of the resident; and
(ii)
When the resident indicates a preference to live in the community, either during the resident’s quarterly assessment or at any other time.
(4)
The social worker shall request that the resident sign an acknowledgment of receipt of the information provided by the social worker that shall be kept in the resident’s medical record.
(c)
If a resident indicates an interest in or a preference for living in the community, the nursing facility shall refer the resident to the Department, or the Department’s designee, for further assistance.
(d)
The Department, or the Department’s designee, shall review the quarterly assessments submitted to the Center for Medicare and Medicaid Services of the U.S. Department of Health and Human Services by each nursing facility that participates in the Program to identify individuals indicating a preference to live in the community.
(e)
If a resident who would qualify for home– and community–based waiver services under § 15–137 of this subtitle indicates an interest or preference for living in the community, the Department, or the Department’s designee, shall provide the resident with:
(1)
Additional information regarding home– and community–based services, including services available under a medical assistance waiver and their right to access services under § 15–137 of this subtitle; and
(2)
Assistance in:
(i)
Completing any application forms or process, as needed; and
(ii)
Moving from a nursing facility to a community–based setting appropriate to the resident’s needs and expressed wishes.
(f)
(1)
Subject to paragraph (3) of this subsection, employees or representatives of designated protection and advocacy systems agencies and of certified centers for independent living shall have reasonable and unaccompanied access to residents of public or private nursing facilities in the State that receive reimbursement under the Program for the purpose of providing information, training, and referral to programs and services addressing the needs of people with disabilities, including participation in programs that would enable individuals with disabilities to live outside the nursing facility.
(2)
Employees or representatives of designated protection and advocacy systems agencies and of certified centers for independent living shall maintain the confidentiality of the residents and may not disclose the information provided to or by a resident, except with the express consent of the resident or the resident’s legal guardian or health care representative.
(3)
Public or private nursing facilities may require the employees or representatives of designated protection and advocacy systems agencies and of certified centers for independent living to provide proof of their employment before authorizing the access required under paragraph (1) of this subsection.
(g)
On or before January 1 of each year, the Department, and the Department’s designee, shall report to the Governor and the General Assembly, in accordance with § 2–1257 of the State Government Article, on:
(1)
The Department’s efforts to promote home– and community–based services;
(2)
The number of nursing facility residents referred or identified under subsections (c) and (d) of this section in the previous year;
(3)
The number of nursing facility residents who transitioned from nursing facilities to home– and community–based waiver services;
(4)
Any obstacles the Department confronted in assisting nursing home residents to make the transition from a nursing facility to a community–based residence; and
(5)
The Department’s recommendations for removing the obstacles.
Md. Code Ann., Health-Gen. § 15-136 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–136LinkCopy Citation
(a)
The Department shall use existing resources to establish a toll free Maryland Pharmacy Access Hotline that:
(1)
Operates during regular business hours; and
(2)
During nonbusiness hours allows callers to leave a message.
(b)
(1)
The Department shall distribute to all Program recipients information about the Maryland Pharmacy Access Hotline.
(2)
The information shall state clearly in easily readable print:
(i)
The toll free telephone number of the hotline; and
(ii)
That the Program recipient should call the telephone number if the Program recipient is having problems getting necessary medicines.
(c)
The Department shall notify all health care providers who participate in the Program about the Maryland Pharmacy Access Hotline.
(d)
The Department shall:
(1)
Develop a methodology to track the number and type of calls received by the Maryland Pharmacy Access Hotline; and
(2)
Provide a quarterly report to the Pharmacy and Therapeutics Committee that summarizes the number and type of calls received by the Maryland Pharmacy Access Hotline.
Md. Code Ann., Health-Gen. § 15-137 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–137LinkCopy Citation
(a)
The Department may not deny an individual access to a home– and community–based services waiver due to a lack of funding for waiver services if:
(1)
(i)
The individual is living in a nursing facility at the time of the application for waiver services;
(ii)
At least 30 consecutive days of the individual’s nursing facility stay are eligible to be paid for by the Program;
(iii)
The individual meets all of the eligibility criteria for participation in the home– and community–based services waiver; and
(iv)
The home– and community–based services provided to the individual would qualify for federal matching funds; or
(2)
(i)
The individual is living at home or in the community at the time of the application for waiver services;
(ii)
The individual received home– and community–based services through Community First Choice for at least 30 consecutive days;
(iii)
The individual will be or has been terminated from participation in the Program on becoming entitled to or enrolled in Medicare Part A or enrolled in Medicare Part B;
(iv)
The individual meets all of the eligibility criteria for participation in the home– and community–based services waiver within 6 months after the completion of the application; and
(v)
The home– and community–based services provided to the individual would qualify for federal matching funds.
(b)
Nothing in this section is intended to result in a reduction of federal funds available to the Department.
Md. Code Ann., Health-Gen. § 15-138 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–138LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“EID Program” means the Employed Individuals with Disabilities Program operated under the Maryland Medical Assistance Program.
(3)
“Independence account” means a financial account designated by a recipient of EID Program services:
(i)
That consists of earned income of a recipient or funds from other sources deposited by or for the recipient;
(ii)
For which there is an upper limit of the total amount of earned income received by the recipient in an enrollment year and deposited into the account; and
(iii)
For which there are no restrictions under the EID Program on how funds may be expended by the recipient.
(b)
The Department shall provide health care services for individuals under the EID Program in accordance with this section.
(c)
The Department shall:
(1)
Provide EID Program services to qualified applicants, including existing Program recipients, who are at least 16 years old;
(2)
For initial applications to receive EID Program services, accept documents to verify income and resources that are dated up to 30 days before the date the application is received;
(3)
Transition Program recipients who become eligible for the EID Program in a manner that is least disruptive to the recipient’s access to services;
(4)
Ensure that the application process for the EID Program, to the extent authorized by the Centers for Medicare and Medicaid Services, provides maximum flexibility and plain language information for applicants, including:
(i)
Instructions for completing the application;
(ii)
A description of documents the applicant must enclose with the application; and
(iii)
Notice to the applicant of approval or denial of an application; and
(5)
Establish a premium contribution for EID Program services.
(d)
Subject to subsection (e) of this section, the Department may adopt regulations that develop specific eligibility criteria for participation in the EID Program.
(e)
The Department may not:
(1)
Limit eligibility to receive EID Program services based on:
(i)
The earned or unearned income of the applicant or the applicant’s spouse;
(ii)
Any assets or resources of the applicant’s or recipient’s spouse that are not joint assets for a recipient;
(iii)
Any retirement account assets or resources for an applicant or a recipient; or
(iv)
Any assets or resources in an independence account established for a recipient of EID Program services; or
(2)
Establish as a prerequisite for eligibility to receive EID Program services that an applicant apply for Social Security Disability Insurance benefits when the applicant does not receive the benefits and has earnings that are above the substantial gainful activity level established by the Social Security Administration.
(f)
The Department shall:
(1)
Meet with a State–based coalition of disability advocates twice a year to receive feedback on and discuss any needed changes to the EID Program; and
(2)
Request feedback from the coalition before providing any information or materials on the EID Program to the public.
(g)
The Department shall apply to the Centers for Medicare and Medicaid Services for any amendments to the State plan, waivers, or other federal approvals necessary to implement the requirements of this section.
Md. Code Ann., Health-Gen. § 15-139 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–139LinkCopy Citation
(a)
On or before December 1, 2003, the Department shall submit an application to the Centers for Medicare and Medicaid Services to amend the State Medical Assistance Program to allow the Department to receive federal matching funds for part of the nonroom–and–board portion of the costs of all eligible residential care that are related to the therapeutic components of care provided by State and local agencies through public or private providers to individuals under the age of 21 years.
(b)
The application submitted by the Department under subsection (a) of this section:
(1)
Shall apply to a residential care placement providing therapeutic or rehabilitative services in addition to room and board services to an individual who is:
(i)
Under the age of 21 years; and
(ii)
In the care or custody of, committed to, or voluntarily placed by any State or local agency in the State; and
(2)
Shall include placements in residential programs that have rates set by the interagency rates committee.
(c)
(1)
For each fiscal year, the Governor may provide funds in the budget for the Children’s Cabinet Interagency Fund established under Title 8, Subtitle 5 of the Human Services Article, to be used by the Children’s Cabinet to create an interagency pool of funds to provide services to children with disabilities.
(2)
The pool of interagency funds established under this subsection shall be used to fund the community–based services and community–based out–of–home placements needed by children with mental or developmental disabilities not in State custody, regardless of eligibility for the State Medical Assistance Program, if:
(i)
The child is in an out–of–home placement and has been recommended for discharge but the child’s family is unwilling or unable to have the child return home; or
(ii)
The child remains in the home but the child’s family is unable to provide appropriate care for the child without additional services and the child is either at risk of requiring an out–of–home placement or the treating professionals have recommended an out–of–home placement.
(d)
(1)
The Governor’s Office for Children shall adopt regulations to carry out the provisions of subsection (c)(2) of this section.
(2)
The regulations shall:
(i)
Include the criteria for eligibility and for prioritization of eligible children; and
(ii)
Be developed with input from parents of a child with disabilities, groups representing families of potentially eligible children, advocacy organizations, the protection and advocacy system for persons with disabilities, providers, local agencies serving children with disabilities, and Subcabinet agencies.
(e)
(1)
Nothing in this section is intended to result in the reduction of federal funds available to the Department of Human Services or the Department of Juvenile Services under Title IV–E of the Social Security Act for the room and board costs of eligible residential care.
(2)
If, as a result of actions taken under this section, the federal matching funds available to the Department of Human Services and the Department of Juvenile Services under Title IV–E of the Social Security Act are reduced because the percentage of residential care costs allocated to Title IV–E is reduced, the Governor shall adjust the amount of funds provided under subsection (c) of this section to prevent any resulting loss to the Department of Human Services and the Department of Juvenile Services.
(3)
The adjustment of funds under paragraph (2) of this subsection shall be based on determining the amount of Title IV–E reimbursement that would have been received by the Department of Human Services and the Department of Juvenile Services prior to October 1, 2003 using the current percentage of residential care costs that is allocated to Title IV–E.
Md. Code Ann., Health-Gen. § 15-140 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–140LinkCopy Citation
The Department shall apply to the Centers for Medicare and Medicaid Services for a State plan amendment to the Family Planning Program that:
(1)
Provides, subject to the limitations of the State budget, family planning services to an individual whose individual income is at or below 250% of the poverty level, as allowed by federal law;
(2)
Does not impose age limitations on individuals who are able to receive family planning services;
(3)
Establishes a presumptive eligibility process for enrollment in the Family Planning Program; and
(4)
Exempts the Family Planning Program from federal coordination of benefits requirements if authorized under federal law.
Md. Code Ann., Health-Gen. § 15-141.1 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–141.1LinkCopy Citation
(a)
In this section, “Collaborative Care Model” means an evidence–based approach for integrating somatic and behavioral health services in primary care settings that includes:
(1)
Care coordination and management;
(2)
Regular, proactive outcome monitoring and treatment for outcome targets using standardized outcome measurement rating scales and electronic tools, such as patient tracking; and
(3)
Regular systematic psychiatric and substance use disorder caseload reviews and consultation with a psychiatrist, an addiction medicine specialist, or any other behavioral health medicine specialist as allowed under federal regulations governing the model.
(b)
This section may not be construed to prohibit referrals from a primary care provider to a specialty behavioral health care provider.
(c)
The Department shall implement and provide reimbursement for services provided in accordance with the Collaborative Care Model statewide in primary care settings that provide health care services to Program recipients.
(d)
The Department may not impose a copayment, coinsurance, or deductible requirement for services provided in accordance with the Collaborative Care Model statewide in primary care settings that provide health care services to Program recipients.
Md. Code Ann., Health-Gen. § 15-141.2 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–141.2LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Distant site” means a site at which the distant site health care provider is located at the time the health care service is provided through telehealth.
(3)
“Distant site provider” means the health care provider who provides medically necessary services to a patient at an originating site from a different physical location than the location of the patient.
(4)
“Health care provider” means:
(i)
A person who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care in the ordinary course of business or practice of a profession or in an approved education or training program;
(ii)
A mental health and substance use disorder program licensed in accordance with § 7.5–401 of this article;
(iii)
A person licensed under Title 7, Subtitle 9 of this article to provide services to an individual with developmental disability or a recipient of individual support services; or
(iv)
A provider as defined under § 16–201.4 of this article to provide services to an individual receiving long–term care services.
(5)
“Originating site” means the location of the Program recipient at the time the health care service is provided through telehealth.
(6)
“Remote patient monitoring services” means the use of synchronous or asynchronous digital technologies that collect or monitor medical, patient–reported, and other forms of health care data for Program recipients at an originating site and electronically transmit that data to a distant site provider to enable the distant site provider to assess, diagnose, consult, treat, educate, provide care management, suggest self–management, or make recommendations regarding the Program recipient’s health care.
(7)
(i)
“Telehealth” means the delivery of medically necessary somatic, dental, or behavioral health services to a patient at an originating site by a distant site provider through the use of technology–assisted communication.
(ii)
“Telehealth” includes:
(1)
Synchronous and asynchronous interactions;
(2)
An audio–only telephone conversation between a health care provider and a patient that results in the delivery of a billable, covered health care service; and
(3)
Remote patient monitoring services.
(iii)
“Telehealth” does not include the provision of health care services solely through:
(1)
Except as provided in subparagraph (ii)2 of this paragraph, an audio–only telephone conversation;
(2)
An e–mail message; or
(3)
A facsimile transmission.
(b)
The Program shall:
(1)
Provide health care services appropriately delivered through telehealth to Program recipients regardless of the location of the Program recipient at the time telehealth services are provided; and
(2)
Allow a distant site provider to provide health care services to a Program recipient from any location at which the health care services may be appropriately delivered through telehealth.
(c)
The services required to be provided under subsection (b) of this section shall include counseling and treatment for substance use disorders and mental health conditions.
(d)
The Program may not:
(1)
Exclude from coverage a health care service solely because it is provided through telehealth and is not provided through an in–person consultation or contact between a health care provider and a patient; or
(2)
Exclude from coverage a behavioral health care service provided to a Program recipient in person solely because the service may also be provided through telehealth.
(e)
The Program may undertake utilization review, including preauthorization, to determine the appropriateness of any health care service whether the service is delivered through an in–person consultation or through telehealth if the appropriateness of the health care service is determined in the same manner.
(f)
The Program may not distinguish between Program recipients in rural or urban locations in providing coverage under the Program for health care services delivered through telehealth.
(g)
(1)
Subject to paragraph (3) of this subsection, the Program shall reimburse a health care provider for the diagnosis, consultation, and treatment of a Program recipient for a health care service covered by the Program that can be appropriately provided through telehealth.
(2)
This subsection does not require the Program to reimburse a health care provider for a health care service delivered in person or through telehealth that is:
(i)
Not a covered health care service under the Program; or
(ii)
Delivered by an out–of–network provider unless the health care service is a self–referred service authorized under the Program.
(3)
(i)
When appropriately provided through telehealth, the Program shall provide reimbursement in accordance with paragraph (1) of this subsection on the same basis and the same rate as if the health care service were delivered by the health care provider in person.
(ii)
The reimbursement required under subparagraph (i) of this paragraph does not include:
(1)
Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
(2)
Any room and board fees.
(h)
(1)
The Department may specify in regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this section.
(2)
If the Department specifies by regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this subsection, the regulations shall include all types of health care providers that appropriately provide telehealth services.
(3)
For the purpose of reimbursement and any fidelity standards established by the Department, a health care service provided through telehealth is equivalent to the same health care service when provided through an in–person consultation.
(i)
Subject to subsection (g)(2) of this section, the Program or a managed care organization that participates in the Program may not impose as a condition of reimbursement of a covered health care service delivered through telehealth that the health care service be provided by a third–party vendor designated by the Program.
(j)
The Department may adopt regulations to carry out this section.
(k)
The Department shall obtain any federal authority necessary to implement the requirements of this section, including applying to the Centers for Medicare and Medicaid Services for an amendment to any of the State’s § 1115 waivers or the State plan.
(l)
This section may not be construed to supersede the authority of the Health Services Cost Review Commission to set the appropriate rates for hospitals, including setting the hospital facility fee for hospital–provided telehealth.
Md. Code Ann., Health-Gen. § 15-141.3 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–141.3LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Certified violence prevention professional” means a prevention professional who meets the requirements of subsection (c) of this section.
(3)
“Community violence” means intentional acts of interpersonal violence committed in public areas by individuals who are not family members or intimate partners of the victim.
(4)
(i)
“Community violence prevention services” means evidence–based, trauma–informed, supportive, and nonpsychotherapeutic services provided by a certified violence prevention professional, within or outside a clinical setting, for the purpose of promoting improved health outcomes and positive behavioral change, preventing injury recidivism, and reducing the likelihood that an individual who is the victim of community violence will commit or promote violence.
(ii)
“Community violence prevention services” includes peer support and counseling, mentorship, conflict mediation, crisis intervention, targeted case management referrals to certified or licensed health care professionals or social services providers, patient education, and screening services to victims of violence.
(5)
“Interpersonal violence” means the intentional use of physical force or power against another individual by an individual or a small group of individuals.
(6)
“Prevention professional” has the meaning provided by the National Uniform Claim Committee, or its successor, under Code Number 405300000X.
(b)
The Program shall provide community violence prevention services to Program recipients who have:
(1)
(i)
Been exposed to community violence; or
(ii)
A personal history of injury sustained as a result of an act of community violence; and
(2)
Been referred by a certified or licensed health care provider or social services provider to a certified violence prevention professional to receive community violence prevention services after the provider makes a determination that the Program recipient is at an elevated risk of violent injury or retaliation resulting from another act of community violence.
(c)
A prevention professional seeking certification as a certified violence prevention professional shall:
(1)
Complete an accredited training and certification program for certified violence prevention professionals, approved in accordance with subsection (d) of this section; and
(2)
Maintain the certification completed under item (1) of this subsection.
(d)
On or before January 1, 2023, the Department shall approve at least one accredited training and certification program for certified violence prevention professionals, which shall include:
(1)
At least 35 hours of initial training, addressing the following:
(i)
The profound effects of trauma and violence and the basics of trauma–informed care;
(ii)
Community violence prevention strategies, including conflict mediation and retaliation prevention related to community violence;
(iii)
Case management and advocacy practices; and
(iv)
Patient privacy and the federal Health Insurance Portability and Accountability Act of 1996; and
(2)
At least 6 hours of continuing education every 2 years.
(e)
An entity that employs or contracts with a certified violence prevention professional to provide community violence prevention services shall:
(1)
Maintain documentation that the certified violence prevention professional has met the requirements of subsection (c) of this section; and
(2)
Ensure that the certified violence prevention professional is providing community violence prevention services in compliance with any applicable standard of care, rule, regulation, and State or federal law.
(f)
This section may not be construed to alter the scope of practice for any health care professional.
Md. Code Ann., Health-Gen. § 15-141.4 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–141.4LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
“Birthing parent” means the individual giving birth and who is receiving doula services throughout the parent’s pregnancy, including the prenatal, labor, and postpartum periods.
(3)
“Certified doula” means a trained nonmedical professional who provides continuous physical, emotional, and informational support to the birthing parent throughout the prenatal, labor, and postpartum periods who has received a certification to perform doula services approved by the Program.
(4)
“Doula services” means continuous and nonclinical physical, emotional, and informational support, based on evidence–based practices and with respect for individual care needs, culture, and family traditions, to a birthing parent provided by a certified doula, including:
(i)
Education and guidance, supplementing the services of health care providers, on childbirth, coping skills for new parents, breastfeeding, infant feeding, infant soothing, and making informed decisions about childbirth and postpartum care;
(ii)
Prenatal coaching;
(iii)
Support for other individuals providing care for a birthing parent, including a birthing parent’s partner and family members; and
(iv)
Facilitation of access to resources that can improve birth–related outcomes, including ongoing home visiting services, transportation, housing, the Special Supplemental Nutrition Program for Women, Infants and Children, the Supplemental Nutrition Assistance Program WIC, intimate partner violence resources, and alcohol, tobacco, and drug cessation.
(5)
“Home” means the residence of the birthing parent.
(6)
“Labor and delivery” means the period during which the fetus, membranes, umbilical cord, and placenta are expelled from the uterus through vaginal birth or through surgical delivery by a cesarean section.
(7)
“Medically indicated” means that a service or benefit meets the coverage requirements set by the Department.
(8)
“Participating doula” means an individual who:
(i)
Meets the certification requirements as provided in subsection (d) of this section; and
(ii)
Is authorized by the Department to provide health care services to a Program recipient.
(9)
“Provider” means an individual, an association, a partnership, or an incorporated or unincorporated group of doulas certified to provide doula services and who, through an appropriate agreement with the Department, has been identified as a Program provider by the issuance of an individual account number.
(b)
This section may not be construed to limit the authority of the Health Services Cost Review Commission to set the appropriate rates for hospital services.
(c)
The Department shall:
(1)
Ensure that doulas providing care under the Program are participating doulas;
(2)
Review participation in the Program of participating doulas and Program recipients; and
(3)
Evaluate the effectiveness of doula services covered by the Program.
(d)
A provider shall:
(1)
Be certified by an organization approved by the Department; and
(2)
Present proof to the Department of completion of the associated certification from at least one organization before providing doula services through the Program.
(e)
To participate in the Program, a provider shall:
(1)
Meet the requirements of COMAR 10.09.36.03 to participate in the Program;
(2)
Maintain up–to–date certification as required by the Program; and
(3)
Hold adequate liability insurance.
(f)
(1)
The Program shall cover doula services that:
(i)
Are medically indicated;
(ii)
Are provided during the prenatal, labor and delivery, or postpartum period of a birthing parent; and
(iii)
If provided remotely, comply with the telehealth requirements in COMAR 10.09.49 and other relevant State and federal law.
(2)
Doula services covered by the Program are subject to any limitations adopted by the Department.
(g)
(1)
A provider shall submit a request for payment in the format designated by the Program.
(2)
The Program may return to the provider, before payment, any invoices that are not properly:
(i)
Signed;
(ii)
Completed; or
(iii)
Accompanied by properly completed forms required by the Program.
(3)
(i)
A provider may charge the Program and the Program shall reimburse a provider.
(ii)
A charge by a provider may be different from a customary charge by the provider for the same service.
(iii)
The Program shall pay for covered services at a rate equal to the lesser of:
(1)
The customary charge the provider charges to the general public, unless the services are free to individuals not covered by the Program; or
(2)
The Program’s fee schedule.
(h)
A managed care organization that participates in the Program shall provide medically indicated doula services to pregnant and postpartum enrollees.
Md. Code Ann., Health-Gen. § 15-141.5 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–141.5LinkCopy Citation
(a)
Subject to subsections (b) and (c) of this section, the Program shall provide remote ultrasound procedures and remote fetal nonstress tests using current procedural terminology codes if:
(1)
The patient is in a residence or a location other than the office of the patient’s provider; and
(2)
The provider follows the same standard of care that the provider would follow when providing the services on–site.
(b)
The Program shall require that a provider offering a remote ultrasound procedure or remote fetal nonstress test use digital technology:
(1)
To collect any health data from the patient and electronically transmit the information in a secure manner to a health care provider in a different location for interpretation and recommendations;
(2)
That is compliant with the federal Health Insurance Portability and Accountability Act of 1996; and
(3)
That is approved by the federal Food and Drug Administration.
(c)
(1)
The Program shall provide reimbursement for a remote fetal nonstress test in the same manner as an on–site fetal nonstress test.
(2)
A remote fetal nonstress test for which reimbursement is provided under paragraph (1) of this subsection shall require the use of remote monitoring solutions that are cleared by the federal Food and Drug Administration for on–label use for monitoring:
(i)
Fetal heart rate;
(ii)
Maternal heart rate; and
(iii)
Uterine activity.
(d)
The Program shall issue guidance for Program providers to carry out this section.
Md. Code Ann., Health-Gen. § 15-141.6 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–141.6LinkCopy Citation
(a)
In this section, “eligible Program recipient” means a Program recipient who:
(1)
Is pregnant;
(2)
Is postpartum; or
(3)
Has been diagnosed with:
(i)
Chronic kidney disease;
(ii)
Diabetes;
(iii)
Heart disease; or
(iv)
A cardiometabolic disease.
(b)
The Program shall provide coverage for self–measured blood pressure monitoring for all eligible Program recipients, including:
(1)
The provision of validated home blood pressure monitors; and
(2)
Reimbursement of health care provider and other staff time used for patient training, transmission of blood pressure data, interpretation of blood pressure readings and reporting, remote patient monitoring, and the delivery of co–interventions, including educational materials or classes.
Md. Code Ann., Health-Gen. § 15-142 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–142LinkCopy Citation
(a)
In this section, “Fund” means the Fair Share Health Care Fund.
(b)
There is a Fair Share Health Care Fund.
(c)
The purpose of the Fund is to support the operations of the Program.
(d)
(1)
The Fund is a special, nonlapsing fund that is not subject to § 7-302 of the State Finance and Procurement Article.
(2)
The Treasurer shall hold the Fund separately, and the Comptroller shall account for the Fund.
(e)
The Fund consists of:
(1)
Any revenue received from payments made by employers under Title 8.5 of the Labor and Employment Article; and
(2)
Any other money from any other source accepted for the benefit of the Fund.
(f)
The Fund may be used only to support the operations of the Program.
(g)
(1)
The Treasurer shall invest the money of the Fund in the same manner as other State money may be invested.
(2)
Any investment earnings of the Fund shall be retained to the credit of the Fund.
(h)
The Fund shall be subject to an audit by the Office of Legislative Audits as provided for in § 2-1220 of the State Government Article.
Md. Code Ann., Health-Gen. § 15-143 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–143LinkCopy Citation
The Governor shall include in the budget bill for fiscal year 2008 at least $3,000,000 in General Fund State support for an immigrant health initiative to provide health care services for all legal immigrant children under the age of 18 years and pregnant women who meet program eligibility standards and arrived in the United States on or after August 22, 1996.
Md. Code Ann., Health-Gen. § 15-145 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–145LinkCopy Citation
(a)
In this section, “carrier” means:
(1)
A health insurer;
(2)
A nonprofit health service plan;
(3)
A health maintenance organization;
(4)
A dental plan organization; and
(5)
Any other person included as a third party in § 1902(a)(25)(A) of the Social Security Act, as amended by the federal Deficit Reduction Act of 2005.
(b)
(1)
A carrier shall provide, at the request of the Department, information about individuals who are eligible for benefits under the Program or are Program recipients so that the Department may determine whether an individual, the spouse of an individual, or the dependent of an individual is receiving health care coverage from a carrier and the nature of that coverage.
(2)
A carrier shall provide the information required under this subsection in a manner prescribed by the Department.
(c)
A carrier shall accept the Program’s right of recovery and the assignment to the Program of any right of an individual or other entity to payment from the carrier for an item or service for which payment has been made under the Program if the carrier has a legal obligation to make payment for the item or service.
(d)
As a condition of doing business in the State, a carrier shall comply with the requirements set forth in § 42 U.S.C. 1396a(a)(25)(I)(i) through (iv).
(e)
A carrier subject to this section may not reject, deny, limit, cancel, refuse to renew, increase the rates of, affect the terms or conditions of, or otherwise affect a health insurance policy or contract for a reason based wholly or partly on:
(1)
The eligibility of the individual for receiving benefits under the Program; or
(2)
The receipt by an individual of benefits under the Program.
Md. Code Ann., Health-Gen. § 15-146 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–146LinkCopy Citation
(a)
In this section, “home– and community–based waiver services” includes services provided under the Living at Home Waiver, the Older Adults Waiver, and the Medical Day Care Waiver.
(b)
At least 90 days prior to making any change to medical eligibility for Program long–term care services, including nursing facility services, home– and community–based waiver services, and other services that require a nursing facility level of care, the Department shall provide a report to:
(1)
The Senate Finance Committee and the House Health Committee, in accordance with § 2–1257 of the State Government Article; and
(2)
The Medicaid Advisory Committee.
(c)
The report required under subsection (b) of this section shall include:
(1)
The details of the intended change in medical eligibility;
(2)
A description of how the intended change will affect current medical eligibility;
(3)
The intended effective date of the change; and
(4)
Whether the change will be pursued through departmental policy, by regulation, or by statute.
(d)
The Department shall discuss any report submitted to the Medicaid Advisory Committee under subsection (b) of this section at a meeting of the Medicaid Advisory Committee.
Md. Code Ann., Health-Gen. § 15-147 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–147LinkCopy Citation
Notwithstanding § 5–504 of the General Provisions Article, a former official or employee may not be considered to have participated significantly in a contract if the former official or employee:
(1)
Did not develop a request for proposals resulting in the contract;
(2)
Did not participate in an evaluation committee or other State entity charged with selecting a contractor for the contract; and
(3)
Participated only by providing support or other assistance as directed by a senior manager after contract award as part of the transition process from a State–run Medicaid Management Information System to a private contracted operation.
Md. Code Ann., Health-Gen. § 15-148 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–148LinkCopy Citation
(a)
Except for a drug or device for which the U.S. Food and Drug Administration has issued a black box warning, the Program may not apply a prior authorization requirement for a contraceptive drug or device that is:
(1)
(i)
An intrauterine device; or
(ii)
An implantable rod;
(2)
Approved by the U.S. Food and Drug Administration; and
(3)
Obtained under a prescription written by an authorized prescriber.
(b)
The Program shall provide coverage for a single dispensing to an enrollee of a supply of prescription contraceptives for a 12–month period.
Md. Code Ann., Health-Gen. § 15-149 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–149LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications using behavioral stimuli and consequences to produce significant improvements in human behavior.
(ii)
“Applied behavior analysis” includes the direct observations, measurement, and functional analysis of the relations between environment and behavior.
(3)
“Early and periodic screening, diagnosis, and treatment (EPSDT)” means the provision, to individuals under the age of 21 years, of preventive health care under 42 C.F.R. Part 441, Subpart B, as amended, and other health care services, diagnostic services, and treatment services that are necessary to correct or ameliorate defects, physical and mental illnesses, and conditions discovered by those screening services.
(b)
This section applies to EPSDT services available to Program recipients.
(c)
(1)
Subject to paragraph (2) of this subsection, the Department may not condition reimbursement of applied behavior analysis services provided to a Program recipient on the presence or availability of the parent or caregiver of the Program recipient in the setting where the applied behavior analysis services are provided to the Program recipient.
(2)
Paragraph (1) of this subsection does not prohibit the Program from establishing reasonable standards for the involvement of a parent or caregiver, including requiring notification from the parent or caregiver of the decision of the parent or caregiver not to be present or available when the Program provides applied behavior analysis services to a Program recipient.
(d)
On or before December 1, 2021, the Department, in consultation with stakeholders, shall adopt regulations to implement the provisions of this section.
Md. Code Ann., Health-Gen. § 15-150 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–150LinkCopy Citation
(a)
(1)
(i)
The Department shall develop plans to reduce the waitlists for the following waiver programs by 50%, beginning in fiscal year 2024:
(1)
The Community Pathways Waiver;
(2)
The Community Supports Waiver;
(3)
The Family Supports Waiver;
(4)
The Brain Injury Waiver;
(5)
The Home– and Community–Based Options Waiver;
(6)
The Medical Day Care Services Waiver; and
(7)
The Model Waiver for Medically Fragile Children.
(ii)
The Department shall develop a plan to reduce the registry for the Autism Waiver that includes conducting eligibility determinations of individuals on the registry and, beginning in fiscal year 2024, providing services to at least 50% of individuals determined eligible.
(2)
The plans required under this subsection shall include:
(i)
An assessment of whether each waiver program needs to recruit and retain new providers;
(ii)
Measures to recruit and retain providers for each waiver program to expand the capacity of the programs;
(iii)
Any changes in reimbursement rates needed to ensure provider capacity to provide services under the waiver programs;
(iv)
The expected time frame for conducting eligibility determinations for the Autism Waiver;
(v)
The expected time frame for reducing the waitlist or registry for each waiver program by 50%; and
(vi)
The projected cost of the measures to be implemented under the plans.
(3)
Provisions of the plans relating to the Autism Waiver shall be developed in conjunction with the Maryland State Department of Education.
(b)
On or before January 1, 2023, the Department shall submit the plans to the Governor and, in accordance with § 2–1257 of the State Government Article, the chairs of the Senate Budget and Taxation Committee, the Senate Education, Health, and Environmental Affairs Committee, the Senate Finance Committee, the House Appropriations Committee, and the House Health and Government Operations Committee.
(c)
(1)
Beginning in fiscal year 2024, the Governor shall include in the annual budget bill sufficient funds to carry out this section.
(2)
Funding included in the annual budget bill under paragraph (1) of this subsection may be allocated to programs identified under subsection (a) of this section for the purpose of hiring and retaining providers.
Md. Code Ann., Health-Gen. § 15-151 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–151LinkCopy Citation
(a)
(1)
In this section the following words have the meanings indicated.
(2)
(i)
“Gender–affirming treatment” means any medically necessary treatment consistent with current clinical standards of care prescribed by a licensed health care provider for the treatment of a condition related to the individual’s gender identity.
(ii)
“Gender–affirming treatment” includes:
(1)
Hormone therapy, hormone blockers, and puberty blockers;
(2)
Hair alteration for the purposes of altering secondary sex characteristics and surgical site preparation;
(3)
Alterations to voice, voice therapy, and voice lessons;
(4)
Alterations to abdomen, chest, trunk, and buttocks;
(5)
Alterations to the face and neck;
(6)
Alterations to the genitals and gonads;
(7)
Laser treatment for scars from gender–affirming treatment;
(8)
Standard fertility preservation procedures, as set forth in § 15–810.1 of the Insurance Article;
(9)
Revisions to previous treatments and reversal of treatments;
(10)
Combinations of gender–affirming procedures; and
(11)
Other treatments as prescribed to suppress the development of endogenous secondary sex characteristics, align the individual’s appearance or physical body with gender identity, and alleviate symptoms of clinically significant distress resulting from gender dysphoria.
(iii)
“Gender–affirming treatment” may include treatment described in the current clinical standards of care for gender–affirming treatment published by the World Professional Association for Transgender Health.
(3)
“Gender identity” has the meaning stated in § 20–101 of the State Government Article.
(b)
It is the intent of the General Assembly that the Program provide gender–affirming treatment to all Program recipients for whom gender–affirming treatment is medically necessary, including transgender, nonbinary, intersex, two–spirit, and other gender diverse individuals.
(c)
(1)
The Program shall provide coverage for medically necessary gender–affirming treatment in a nondiscriminatory manner.
(2)
The gender–affirming treatment shall be assessed according to nondiscriminatory criteria that are consistent with current clinical standards of care.
(3)
The Program may not deny or limit coverage for gender–affirming treatment when that treatment is:
(i)
Prescribed to a Program recipient because of, related to, or consistent with the recipient’s gender identity;
(ii)
Medically necessary; and
(iii)
Prescribed in accordance with current clinical standards of care.
(4)
The Program may not deny or limit coverage for gender–affirming treatment based on the Program recipient’s gender identity.
(5)
The Program may not exclude gender–affirming treatment, including revisions to prior gender–affirming treatment, on the basis that the treatment is a cosmetic service.
(6)
The Program may not establish a categorical exclusion for a particular gender–affirming treatment.
(7)
The Program may not issue an adverse benefit determination denying or limiting access to gender–affirming treatment unless a health care provider with experience prescribing or delivering gender–affirming treatment has reviewed and confirmed the appropriateness of the adverse benefit determination.
(d)
(1)
On or before December 1 each year, beginning in 2024, each managed care organization shall submit to the Department a report that includes, for each health care provider offering gender–affirming treatment with which the managed care organization has an active contract and that consents to the inclusion:
(i)
The name and location of the health care provider;
(ii)
The types of gender–affirming treatment provided by the health care provider; and
(iii)
Whether the health care provider consents to being publicly listed as part of the Department’s annual report required under paragraph (2) of this subsection.
(2)
(i)
On or before January 1 each year, beginning in 2025, the Department shall compile an annual report on geographic access to gender–affirming treatment across the State.
(ii)
The report shall include, for each health care provider offering gender–affirming treatment to Program recipients and whose consent to the inclusion is indicated in a report submitted under paragraph (1) of this subsection:
(1)
The name and location of the health care provider;
(2)
The managed care organizations that have active contracts with the health care provider; and
(3)
The types of gender–affirming treatment provided by the health care provider.
(iii)
The Department shall publish the report in a conspicuous manner on the Department’s website.
(3)
The Department and each managed care organization shall include the name, location, and types of services for each provider offering gender–affirming treatment in their provider directories.
Md. Code Ann., Health-Gen. § 15-152 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–152LinkCopy Citation
(a)
The Program shall provide coverage for services rendered to an enrollee by a licensed pharmacist acting within the pharmacist’s lawful scope of practice to the same extent as services rendered by any other licensed health care provider.
(b)
Reimbursement for services provided under subsection (a) of this section may not be conditioned on whether the licensed pharmacist is:
(1)
Employed by a physician, pharmacy, or facility; or
(2)
Acting under a physician’s orders.
Md. Code Ann., Health-Gen. § 15-153 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–153LinkCopy Citation
The Department shall annually evaluate reimbursement rates for dental services.
Md. Code Ann., Health-Gen. § 15-154 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–154LinkCopy Citation
(a)
Unless the child’s family has requested that the child be removed, a child on the registry for the Autism Waiver shall remain on the registry if the child’s family relocates out of the State for uniformed services assignment.
(b)
If a child on the registry for the Autism Waiver becomes eligible for services through the waiver while the child’s family is out of the State for uniformed services assignment, the child shall be eligible for services through the waiver if the family relocates to the State.
Md. Code Ann., Health-Gen. § 15-155 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–155LinkCopy Citation
(a)
In this section, “prenatal risk assessment form” means a standardized form developed by the Department in accordance with the Centers for Medicare and Medicaid Services guidelines for use by a licensed health care provider to evaluate risk factors for the health of a pregnant patient.
(b)
A provider who receives reimbursement from the Program for providing obstetric services to a patient shall complete a prenatal risk assessment form for the patient during the initial visit with the patient.
(c)
After completing a prenatal risk assessment form in accordance with subsection (b) of this section, the provider shall submit the form to the local health department for the county in which the patient resides.
(d)
On or before October 1 each year, each local health department shall submit to the Department a report that includes the number and type of referrals made to patients that were based on the information from the prenatal risk assessment form completed in accordance with subsection (b) of this section.
(e)
The Department shall establish a process for a provider to submit a prenatal risk assessment form electronically.
Md. Code Ann., Health-Gen. § 15-156 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–156LinkCopy Citation
(a)
In this section, “personal care aide” means an individual who provides personal assistance services through a residential service agency.
(b)
(1)
Except as provided in paragraph (2) of this subsection, this section applies only to personal assistance services provided through a residential service agency under Community First Choice, Community Options, Community Personal Assistance Services, and any other home– and community–based services administered by the Department.
(2)
This section does not apply to personal care services provided through the Developmental Disabilities Administration.
(c)
(1)
On or before September 1 each year, beginning in 2025, each residential service agency shall submit to the Maryland Department of Labor a report in the form and manner required by the Maryland Department of Labor.
(2)
The annual report required under paragraph (1) of this subsection shall include:
(i)
Documentation of the residential service agency’s:
(1)
Average wage rate for personal care aides; and
(2)
Highest and lowest wage rates for personal care aides; and
(ii)
Any other information that the Maryland Department of Labor determines appropriate.
(3)
The annual report required under paragraph (1) of this subsection shall be signed by an authorized representative of the residential service agency.
Md. Code Ann., Health-Gen. § 15-157 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–157LinkCopy Citation
(a)
In this section, “Fund” means the Medicaid Primary Care Program Fund.
(b)
There is a Medicaid Primary Care Program Fund in the Department.
(c)
The purpose of the Fund is to serve as the foundation for advancing primary care in the State under the Advancing All–Payer Health Equity Approaches and Development (AHEAD) model.
(d)
The Department shall administer the Fund.
(e)
(1)
The Fund is a special, nonlapsing fund that is not subject to § 7–302 of the State Finance and Procurement Article.
(2)
The State Treasurer shall hold the Fund separately, and the Comptroller shall account for the Fund.
(f)
The Fund consists of:
(1)
Money appropriated in the State budget to the Fund;
(2)
Hospital payments administered on a one–time basis, through a uniform and broad–based assessment via the Medicare savings component for calendar year 2023 by the Health Services Cost Review Commission; and
(3)
Any other money from any other source accepted for the benefit of the Fund.
(g)
The Fund may be used to:
(1)
Implement a Medicaid primary care advanced payment model program as required under the AHEAD cooperative agreement; and
(2)
Support primary care providers serving enrollees of the Medical Assistance Program through investments that include increased reimbursement for evaluation and management codes, care management fees to eligible practices, and quality incentives.
(h)
(1)
The State Treasurer shall invest the money of the Fund in the same manner as other State money may be invested.
(2)
Any interest earnings of the Fund shall be credited to the General Fund of the State.
(i)
Expenditures from the Fund may be made only in accordance with the State budget.
Md. Code Ann., Health-Gen. § 15-158 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–158LinkCopy Citation
(a)
(1)
Subject to paragraph (2) of this subsection, the Program may not require prior authorization for a transfer to a special pediatric hospital.
(2)
At the request of a special pediatric hospital, the Program and the Maryland Children’s Health Program shall provide a prior authorization determination regarding a transfer to a special pediatric hospital within 3 business days after the request is received.
(b)
(1)
On or before December 31, 2026, the Department shall adopt regulations establishing a retrospective review process for special pediatric hospitals.
(2)
The regulations adopted under paragraph (1) of this subsection shall:
(i)
Provide for a peer–to–peer reconsideration of a medical necessity determination made by the Department or its agent on request of a pediatric specialty hospital;
(ii)
Provide for retrospective review of any medical necessity determination issued by the Department or its agent denying:
(1)
Admission to a special pediatric hospital on or after January 1, 2025; or
(2)
Reimbursement for inpatient services or outpatient services provided by a special pediatric hospital on or after January 1, 2025;
(iii)
Comply with Title 10, Subtitle 2 of the State Government Article; and
(iv)
Provide that the retrospective review process be conducted by a licensed physician.
Md. Code Ann., Health-Gen. § 15-159 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–159LinkCopy Citation
If the Program covers the delivery of anesthesia for a procedure for which a licensed medical professional issues an order, the Program:
(1)
Shall provide coverage for:
(i)
The delivery of anesthesia for the entire duration of the procedure; and
(ii)
Medical care related to the delivery of anesthesia for the procedure that is provided immediately before and after the procedure; and
(2)
May not establish, implement, or enforce a policy, practice, or procedure that places time limitations on the delivery of anesthesia.
Md. Code Ann., Health-Gen. § 15-160 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–160LinkCopy Citation
(a)
In this section, “database” means the employment training and opportunity database developed and maintained under subsection (b) of this section.
(b)
(1)
The Department shall develop and maintain an employment training and opportunity database.
(2)
The purpose of the database is to provide individuals in the State with assistance in finding employment training and other opportunities that may enable the individuals to become eligible and maintain eligibility for:
(i)
The Program; and
(ii)
The Supplemental Nutrition Assistance Program.
(3)
In developing and maintaining the database, the Department shall coordinate with the following entities:
(i)
The Maryland Department of Labor;
(ii)
The Department of Human Services;
(iii)
The Department of Service and Civic Innovation;
(iv)
The Maryland Chamber of Commerce;
(v)
Labor unions;
(vi)
Trade associations;
(vii)
Educational institutions;
(viii)
Local workforce development boards; and
(ix)
Any other entity that the Department determines appropriate.
(c)
The database shall include:
(1)
Vocational, workforce training, and job placement programs available in the State;
(2)
Information regarding how to apply for a vocational, workforce training, or job placement program included in the database under item (1) of this subsection; and
(3)
A mechanism that allows an individual to directly contact the vocational, workforce training, or job placement program in which the individual is interested.
(d)
The Department shall:
(1)
Make the database available to the public on a dedicated page on the Department’s website;
(2)
Assist individuals in enrolling in vocational, workforce training, and job placement programs listed in the database; and
(3)
Update the database at least every 30 days.
Md. Code Ann., Health-Gen. § 15-161 (2026)
Title 15. Assistance Programs
Subtitle 1. Medical and Pharmacy Assistance Programs
§ 15–161LinkCopy Citation
(a)
In this section, “comprehensive coverage for the treatment of obesity” includes coverage for intensive behavioral therapy, bariatric surgery, and any medication approved by the federal Food and Drug Administration with an indication for chronic weight management in patients with obesity.
(b)
The Program may provide comprehensive coverage for the treatment of obesity.
(c)
The Program may undertake utilization management to determine the medical necessity and appropriateness for treatment of obesity under this section if the determinations are made in the same manner as determinations are made for the treatment of any other illness, condition, or disorder covered by the Program.
(d)
If the Department elects to provide comprehensive coverage for the treatment of obesity under this section, the Department shall provide notice to Program recipients.