# Health - General (GHG)

## Title 19. Health Care Facilities

### Subtitle 1. Health Care Planning and Systems Regulation

#### Section 19-101

In this subtitle, "Commission" means the Maryland Health Care Commission.

#### Section 19-102

(a) The General Assembly finds that the health care regulatory system in this State is a highly complex structure that needs to be constantly reevaluated and modified in order to better reflect and be more responsive to the ever changing health care environment and the needs of the citizens of this State.

(b) The purpose of this subtitle is to establish a streamlined health care regulatory system in this State in a manner such that a single State health policy can be better articulated, coordinated, and implemented in order to better serve the citizens of this State.

#### Section 19-103

(a) There is a Maryland Health Care Commission.

(b) The Commission is an independent commission that functions in the Department.

(c) The purpose of the Commission is to:

  (1) Develop health care cost containment strategies to help provide access to appropriate quality health care services for all Marylanders, after consulting with the Health Services Cost Review Commission;

  (2) Promote the development of a health regulatory system that provides, for all Marylanders, financial and geographic access to quality health care services at a reasonable cost by:

    (i) Advocating policies and systems to promote the efficient delivery of and improved access to health care services; and

    (ii) Enhancing the strengths of the current health care service delivery and regulatory system;

  (3) Facilitate the public disclosure of medical claims data for the development of public policy;

  (4) Establish and develop a medical care database on health care services rendered by health care practitioners;

  (5) Encourage the development of clinical resource management systems to permit the comparison of costs between various treatment settings and the availability of information to consumers, providers, and purchasers of health care services;

  (6) In accordance with Title 15, Subtitle 12 of the Insurance Article, develop a uniform set of effective benefits to be included in the Comprehensive Standard Health Benefit Plan;

  (7) Analyze the medical care database and provide, in aggregate form, an annual report on the variations in costs associated with health care practitioners;

  (8) Ensure utilization of the medical care database as a primary means to compile data and information and annually report on trends and variances regarding fees for service, cost of care, regional and national comparisons, and indications of malpractice situations;

  (9) Establish standards for the operation and licensing of medical care electronic claims clearinghouses in Maryland;

  (10) Reduce the costs of claims submission and the administration of claims for health care practitioners and payors;

  (11) Determine the cost of mandated health insurance services in the State in accordance with Title 15, Subtitle 15 of the Insurance Article;

  (12) Promote the availability of information to consumers on charges by practitioners and reimbursements from payors;

  (13) Oversee and administer the Maryland Trauma Physician Services Fund in conjunction with the Health Services Cost Review Commission; and

  (14) Establish policies and standards to protect the confidentiality of patient and health care practitioner information related to legally protected health care as defined in Sec. 4-301 of this article.

(d) The Commission shall coordinate the exercise of its functions with the Department and the Health Services Cost Review Commission to ensure an integrated, effective health care policy for the State.

#### Section 19-104

(a)

  (1) The Commission shall consist of 15 members appointed by the Governor with the advice and consent of the Senate.

  (2) Of the 15 members:

    (i) Eight shall be individuals who do not have any connection with the management or policy of a health care provider or payor; and

    (ii) Of the remaining seven members:

      (1) Two shall be physicians;

      (2) Two shall be payors, as defined in Sec. 19-132 of this subtitle;

      (3) One shall be an administrator of a hospital, as defined in Sec. 19-301 of this title;

      (4) One shall be a nursing home administrator in the State; and

      (5) One shall be a nonphysician health care practitioner.

(b)

  (1) The term of a member is 4 years.

  (2) The terms of members are staggered as required by the terms provided for members of the Commission on October 1, 1999.

  (3) At the end of a term, a member continues to serve until a successor is appointed and qualifies.

  (4) A member who is appointed after a term has begun serves only for the rest of the term and until a successor is appointed and qualifies.

  (5) The Governor may remove a member for neglect of duty, incompetence, or misconduct.

  (6) A member may not serve more than two consecutive terms.

(c) When appointing members to the Commission, the Governor shall:

  (1) Assure that:

    (i) At least four members are residents of different counties with a population of 300,000 or more; and

    (ii) At least three members are residents of different counties with a population of less than 300,000, of which at least:

      (1) One shall be a resident of the Eastern Shore;

      (2) One shall be a resident of Allegany County, Garrett County, Washington County, Carroll County, or Frederick County; and

      (3) One shall be a resident of Southern Maryland; and

  (2) To the extent practicable, assure geographic balance and promote racial, ethnic, and gender diversity in the Commission's membership.

#### Section 19-105

(a) The Governor shall appoint the chairman of the Commission.

(b) The chairman may appoint a vice chairman for the Commission.

#### Section 19-106

(a) With the approval of the Governor, the Commission shall appoint an executive director who shall be the chief administrative officer of the Commission.

(b) The executive director, the deputy directors, and the principal section chiefs serve at the pleasure of the Commission.

(c)

  (1) The executive director, the deputy directors, and the principal section chiefs shall be executive service or management service employees.

  (2) The Commission, in consultation with the Secretary, shall determine the appropriate job classification and, subject to the State budget, the compensation for the executive director, the deputy directors, and the principal section chiefs.

(d) Under the direction of the Commission, the executive director shall perform any duty or function that the Commission requires.

#### Section 19-107

(a)

  (1) A majority of the full authorized membership of the Commission is a quorum.

  (2) The decision of the Commission shall be by a majority of the quorum present and voting.

(b) The Commission shall meet at least six times each year, at the times and places that it determines.

(c) Each member of the Commission is entitled to:

  (1) Compensation in accordance with the State budget; and

  (2) Reimbursement for expenses under the Standard State Travel Regulations, as provided in the State budget.

(d)

  (1) The Commission may employ a staff in accordance with the State budget.

  (2) The Commission, in consultation with the Secretary, may set the compensation of a Commission employee in a position that:

    (i) Is unique to the Commission;

    (ii) Requires specific skills or experience to perform the duties of the position; and

    (iii) Does not require the employee to perform functions that are comparable to functions performed in other units of the Executive Branch of State government.

  (3) The Secretary of Budget and Management, in consultation with the Secretary, shall determine the positions for which the Commission may set compensation under paragraph (2) of this subsection.

#### Section 19-108

(a) In addition to the duties set forth elsewhere in this subtitle, the Commission:

  (1) Shall adopt regulations specifying the Comprehensive Standard Health Benefit Plan to apply under Title 15, Subtitle 12 of the Insurance Article; and

  (2) On or before March 1, 2008, in consultation with the Department, shall propose regulations to:

    (i) Specify the components of wellness benefits, offered under Title 15, Subtitle 12 of the Insurance Article, that include incentives or differential cost-sharing for employees based on their participation in wellness activities; and

    (ii) Require small employers receiving a subsidy of small employer health benefit plan premium contributions under Title 15, Subtitle 12A of the Insurance Article to agree to purchase a wellness benefit.

(b) In carrying out its duties under this section, the Commission shall comply with the provisions of Sec. 15-1207 and Title 15, Subtitle 12A of the Insurance Article.

#### Section 19-108.1

(a) In addition to the duties set forth elsewhere in this subtitle, the Commission shall maintain on its website an application that a small business may use to compare premiums of health benefit plans offered by health insurance carriers under Title 15, Subtitle 12 of the Insurance Article.

(b) The application required under this section shall provide information on:

  (1) Premiums for health benefit plans sold under Title 15, Subtitle 12 of the Insurance Article, categorized by age bands; and

  (2) Premiums for health benefit plans sold under Title 15, Subtitle 12 of the Insurance Article that include riders typically purchased by small employers in the State.

(c) The Commission shall update the information required under this section at least quarterly.

#### Section 19-108.2

(a)

  (1) In this section the following words have the meanings indicated.

  (2) ''Health care service" has the meaning stated in Sec. 15-10A-01 of the Insurance Article.

  (3) "Payor" means:

    (i) An insurer or nonprofit health service plan that provides hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies or contracts that are issued or delivered in the State;

    (ii) A health maintenance organization that provides hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State; or

    (iii) A pharmacy benefits manager that is registered with the Maryland Insurance Commissioner.

  (4) "Provider" has the meaning stated in Sec. 19-7A-01 of this title.

  (5) "Step therapy or fail-first protocol" has the meaning stated in Sec. 15-142 of the Insurance Article.

(b) In addition to the duties stated elsewhere in this subtitle, the Commission shall work with payors and providers to attain benchmarks for:

  (1) Standardizing and automating the process required by payors for preauthorizing health care services; and

  (2) Overriding a payor's step therapy or fail-first protocol.

(c) The benchmarks described in subsection (b) of this section shall include:

  (1) On or before October 1, 2012 ("Phase 1"), establishment of online access for providers to each payor's:

    (i) List of health care services that require preauthorization; and

    (ii) Key criteria for making a determination on a preauthorization request;

  (2) On or before March 1, 2013 ("Phase 2"), establishment by each payor of an online process for:

    (i) Accepting electronically a preauthorization request from a provider; and

    (ii) Assigning to a preauthorization request a unique electronic identification number that a provider may use to track the request during the preauthorization process, whether or not the request is tracked electronically, through a call center, or by fax;

  (3) On or before July 1, 2013 ("Phase 3"), establishment by each payor of an online preauthorization system to approve:

    (i) In real time, electronic preauthorization requests for pharmaceutical services:

      (1) For which no additional information is needed by the payor to process the preauthorization request; and

      (2) That meet the payor's criteria for approval;

    (ii) Within 1 business day after receiving all pertinent information on requests not approved in real time, electronic preauthorization requests for pharmaceutical services that:

      (1) Are not urgent; and

      (2) Do not meet the standards for real-time approval under item (i) of this item; and

    (iii) Within 2 business days after receiving all pertinent information, electronic preauthorization requests for health care services, except pharmaceutical services, that are not urgent;

  (4) On or before July 1, 2015, establishment, by each payor that requires a step therapy or fail-first protocol, of a process for a provider to override the step therapy or fail-first protocol of the payor; and

  (5) On or before July 1, 2015, utilization by providers of:

    (i) The online preauthorization system established by payors; or

    (ii) If a national transaction standard has been established and adopted by the health care industry, as determined by the Commission, the provider's practice management, electronic health record, or e-prescribing system.

(d) The benchmarks described in subsections (b) and (c) of this section do not apply to preauthorizations of health care services requested by providers employed by a group model health maintenance organization as defined in Sec. 19-713.6 of this title.

(e) The online preauthorization system described in subsection (c)(3) of this section shall:

  (1) Provide real-time notice to providers about preauthorization requests approved in real time; and

  (2) Provide notice to providers, within the time frames specified in subsection (c)(3)(ii) and (iii) of this section and in a manner that is able to be tracked by providers, about preauthorization requests not approved in real time.

(f)

  (1) The Commission shall establish by regulation a process through which a payor or provider may be waived from attaining the benchmarks described in subsections (b) and (c) of this section for extenuating circumstances.

  (2) For a provider, the extenuating circumstances may include:

    (i) The lack of broadband Internet access;

    (ii) Low patient volume; or

    (iii) Not making medical referrals or prescribing pharmaceuticals.

  (3) For a payor, the extenuating circumstances may include:

    (i) Low premium volume; or

    (ii) For a group model health maintenance organization, as defined in Sec. 19-713.6 of this title, preauthorizations of health care services requested by providers not employed by the group model health maintenance organization.

(g)

  (1) On or before October 1, 2012, the Commission shall reconvene the multistakeholder workgroup whose collaboration resulted in the 2011 report "Recommendations for Implementing Electronic Prior Authorizations".

  (2) The workgroup shall:

    (i) Review the progress to date in attaining the benchmarks described in subsections (b) and (c) of this section; and

    (ii) Make recommendations to the Commission for adjustments to the benchmark dates.

(h) If necessary to attain the benchmarks, the Commission may adopt regulations to:

  (1) Adjust the Phase 2 or Phase 3 benchmark dates;

  (2) Require payors and providers to comply with the benchmarks; and

  (3) Establish penalties for noncompliance.

#### Section 19-108.3

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Carrier" includes insurers, nonprofit health service plans, health maintenance organizations, third-party administrators, and pharmacy benefits managers.

  (3) "Health care provider" includes hospitals, physicians, nurse practitioners, pharmacists, and other persons entitled to reimbursement under Sec. 15-701(a) of the Insurance Article.

  (4) "Workgroup" means the Health Care Provider-Carrier Workgroup.

(b) The Commission shall establish a Health Care Provider-Carrier Workgroup.

(c) The purpose of the Workgroup is to provide a mechanism for health care providers and carriers to resolve disputes on issues over which no State agency has statutory or regulatory authority.

(d) The Workgroup shall be composed of representatives of:

  (1) Professional organizations or associations of health care providers who bill and receive reimbursement for health care services from carriers;

  (2) Carriers or organizations or trade associations representing carriers that reimburse health care providers for health care services provided under health benefit plans; and

  (3) Subject to subsection (e)(1)(iii) of this section, consumer organizations.

(e)

  (1) The Commission shall invite the following to appoint members to the Workgroup:

    (i) Professional organizations or associations of health care providers;

    (ii) Carriers or organizations or trade associations representing carriers; and

    (iii) When appropriate to the issue under discussion, consumer organizations.

  (2) Membership in the Workgroup may change depending on the issues before the Workgroup.

  (3) The size of the Workgroup shall be at the discretion of the Commission but large enough to represent the appropriate range of stakeholders.

(f) Workgroup members may not receive compensation or reimbursement for serving on the Workgroup.

(g) The Workgroup shall meet at least quarterly.

(h) Commission staff shall facilitate Workgroup meetings and provide research and other support to the Workgroup.

(i)

  (1) At least annually, Commission staff shall solicit issues for consideration by the Workgroup.

  (2) Issues shall be solicited from:

    (i) Members of the General Assembly;

    (ii) Professional organizations or associations of health care providers and carriers or organizations or trade associations representing carriers;

    (iii) State agencies, including the Department, health occupations boards, the Maryland Insurance Administration, and the Commission; and

    (iv) Consumer organizations.

(j) After soliciting issues under subsection (i) of this section, Commission staff shall select the issues to be considered by the Workgroup.

(k) Commission staff shall:

  (1) Research each issue before the issue is considered by the Workgroup;

  (2) Use the results of the research to inform Workgroup meetings;

  (3) Facilitate Workgroup meetings in a way that promotes resolution of disputes on issues and is satisfactory to the members of the Workgroup; and

  (4) On or before January 1, 2016, and each year thereafter, submit a report to the Commission and, in accordance with Sec. 2-1257 of the State Government Article, the Senate Finance Committee and the House Health and Government Operations Committee regarding the issues considered by the Workgroup during the preceding year and the outcome of the Workgroup's consideration of each issue.

#### Section 19-108.4

(a) In this section, "primary care" means health care provided in the following fields' outpatient settings:

  (1) Family medicine;

  (2) General pediatrics;

  (3) Primary care internal medicine;

  (4) Primary care obstetrics and gynecology;

  (5) Primary care nurse practitioner services; and

  (6) Primary care midwifery.

(b) On or before December 1 each year, beginning in 2024, the Commission shall provide a report to the Governor and, in accordance with Sec. 2-1257 of the State Government Article, the General Assembly that includes:

  (1) An analysis of primary care investment over the immediately preceding year, including data stratified by zip code and county, in relation to total health care spending over the previous year;

  (2) Ways to improve the quality of and access to primary care services, with special attention to increasing health care equity, reducing health care disparities, and avoiding increased costs to patients and the health care system; and

  (3) Any findings and recommendations of the Commission.

(c)

  (1) The Commission shall form a workgroup to develop the report required under subsection (b) of this section, including by interpreting the results of the required analysis and making the recommendations.

  (2) The workgroup required under this subsection shall include representatives of:

    (i) The Maryland Primary Care Program;

    (ii) The Health Services Cost Review Commission;

    (iii) The Maryland Insurance Administration;

    (iv) The Health Care Financing Division of the Maryland Department of Health;

    (v) The primary care community, including from the Maryland Academy of Family Physicians, the Maryland Chapter of the American Academy of Pediatrics, the Maryland Section of the American College of Obstetricians and Gynecologists, the Maryland Nurses Association, the Maryland Affiliate - American College of Nurse Midwives, the Maryland Community Health System, and the MidAtlantic Association of Community Health Centers;

    (vi) Payors of primary care services, including carriers and managed care organizations;

    (vii) Health services researchers with expertise in primary care; and

    (viii) Other interested stakeholders.

#### Section 19-108.5

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Carrier" has the meaning stated in Sec. 15-1301 of the Insurance Article.

  (3) "Health care provider" has the meaning stated in Sec. 19-108.3 of this subtitle.

(b)

  (1) On or before July 1, 2026, a carrier shall establish and maintain an online process that:

    (i) Links directly to all e-prescribing systems and electronic health record systems that use the National Council for Prescription Drug Programs SCRIPT standard and the National Council for Prescription Drug Programs Real Time Benefit Standard;

    (ii) Can accept electronic prior authorization requests from a health care provider;

    (iii) Can approve electronic prior authorization requests:

      (1) For which no additional information is needed by the carrier to process the prior authorization request;

      (2) For which no clinical review is required; and

      (3) That meet the carrier's criteria for approval; and

    (iv) Links directly to real-time patient out-of-pocket costs, including copayment, deductible, and coinsurance costs, and more affordable medication alternatives made available by the carrier.

  (2) A carrier may not:

    (i) Impose a fee or charge on a person for accessing the online process required under paragraph (1) of this subsection; or

    (ii) Access, without health care provider consent, health care provider data via the online process other than for the insured or enrollee.

(c) On or before July 1, 2025, a carrier shall:

  (1) On request of a health care provider, provide contact information for each third-party vendor or other entity that the carrier will use to meet the requirements of subsection (b) of this section; and

  (2) Post the contact information required to be provided under item (1) of this subsection on its website.

(d)

  (1) On or before July 1, 2026, each health care provider shall ensure that each e-prescribing system or electronic health record system owned or contracted for by the health care provider to maintain a health record of an insured or enrollee has the ability to access, at the point of prescribing:

    (i) The electronic prior authorization process established by a carrier under subsection (b) of this section; and

    (ii) The real-time patient out-of-pocket cost information and available medication alternatives required under subsection (b) of this section.

  (2) The Commission shall establish by regulation a process through which a health care provider may request and receive a waiver of compliance from the requirements of this subsection.

(e)

  (1) On or before July 1, 2026, each carrier, or a pharmacy benefits manager on behalf of the carrier, shall:

    (i) Provide real-time patient-specific benefit information to insureds and enrollees and contracted health care providers, including any out-of-pocket costs and more affordable medication alternatives or prior authorization requirements; and

    (ii) Ensure that the information provided under item (i) of this paragraph is accurate.

  (2) Each carrier, or a pharmacy benefits manager on behalf of the carrier, shall make available the information required to be provided under paragraph (1) of this subsection to the health care provider at the point of prescribing in an accessible and understandable format, such as through the health care provider's e-prescribing system or electronic health record system that the carrier, pharmacy benefits manager, or designated subcontractor has adopted that uses the National Council for Prescription Drug Programs SCRIPT standard and the National Council for Prescription Drug Programs Real Time Benefit Standard from which the health care provider makes the request.

#### Section 19-108.6

On or before December 1 every 4 years, beginning in 2026, the Commission shall submit a report to the Governor and, in accordance with Sec. 2-1257 of the State Government Article, the General Assembly that includes:

(1) Advances or developments in the area of telehealth, including:

  (i) Evolving modalities of telehealth delivery; and

  (ii) Changes in the costs of delivering telehealth services; and

(2) Any findings or recommendations of the Commission.

#### Section 19-109

(a) In addition to the powers set forth elsewhere in this subtitle, the Commission may:

  (1) Adopt rules and regulations to carry out the provisions of this subtitle;

  (2) Create committees from among its members;

  (3) Appoint advisory committees, which shall include consumers and may include representatives of interested public or private organizations, to make recommendations to the Commission on community-based services, long-term care, acute patient services, ambulatory surgical services, specialized health care services, residential treatment centers for emotionally disturbed children and adolescents, mental health and alcohol and drug abuse services, and any other topic or issue that the Commission considers necessary;

  (4) Apply for and accept any funds, property, or services from any person or government agency;

  (5) Subject to subsection (d) of this section, award any funds received from any person or government agency;

  (6) Make agreements with a grantor or payor or with a grantee or payee of funds, property, or services, including an agreement to make any study, plan, demonstration, or project;

  (7) Publish and give out any information that relates to the financial aspects of health care and is considered desirable in the public interest; and

  (8) Subject to the limitations of this subtitle, exercise any other power that is reasonably necessary to carry out the purposes of this subtitle, including adopting regulations that set reasonable deadlines for filing of information or reports required under this subtitle and impose reasonable penalties for failure to file information or reports as required.

(b) In addition to the duties set forth elsewhere in this subtitle, the Commission shall:

  (1) Adopt rules and regulations that relate to its meetings, minutes, and transactions;

  (2) Keep minutes of each meeting;

  (3) Prepare annually a budget proposal that includes the estimated income of the Commission and proposed expenses for its administration and operation;

  (4) Beginning December 1, 2000, and each December 1 thereafter, submit to the Governor, the Secretary, and, subject to Sec. 2-1257 of the State Government Article, the General Assembly an annual report on the operations and activities of the Commission during the preceding fiscal year, including:

    (i) A copy of each summary, compilation, and supplementary report required by this subtitle; and

    (ii) Any other fact, suggestion, or policy recommendation that the Commission considers necessary;

  (5) Except for confidential or privileged medical or patient information, make:

    (i) Each report filed and each summary, compilation, and report required under this subtitle available for public inspection at the office of the Commission during regular business hours; and

    (ii) Each summary, compilation, and report available to any other State agency on request; and

  (6) In collaboration with the Office of Health Care Quality, develop a process to receive the following information and publish it on the Commission's Maryland Quality Reporting website for each applicable facility:

    (i) The date of the Office's most recent inspection; and

    (ii) Any associated ratings or other quality metrics calculated.

(c)

  (1) The Commission may contract with a qualified, independent third party for any service necessary to carry out the powers and duties of the Commission.

  (2) Unless permission is granted specifically by the Commission, a third party hired by the Commission may not release, publish, or otherwise use any information to which the third party has access under its contract.

(d)

  (1) In awarding funds under subsection (a)(5) of this section, the Commission shall:

    (i) Use a competitive process that affords interested persons an opportunity to submit a proposal for funding; and

    (ii) Evaluate proposals for funding using a panel that consists of internal and external evaluators.

  (2) The Commission shall:

    (i) Provide on its website information that is easily accessible to the general public about funds to be awarded under subsection (a)(5) of this section and how to submit a proposal; and

    (ii) Submit, in accordance with Sec. 2-1257 of the State Government Article, an annual report to the General Assembly listing all funds awarded under subsection (a)(5) of this section.

#### Section 19-110

(a) Except as expressly provided in this subtitle, the power of the Secretary over plans, proposals, and projects of units in the Department does not include the power to disapprove or modify any regulation, decision, or determination that the Commission makes under authority specifically delegated by law to the Commission.

(b)

  (1) The power of the Secretary to transfer, by rule, regulation, or written directive, any staff, functions, or funds of units in the Department does not apply to any staff, function, or funds of the Commission.

  (2) The Secretary may assess an administrative charge, consistent with the indirect cost charge assessed to federal grants, to fund services provided to the Commission by the Executive Branch.

(c)

  (1) The power of the Secretary over the procurement procedure for units in the Department does not apply to the procurement procedure for the Commission.

  (2) Subject to the provisions of paragraph (1) of this subsection, any procurement for services to be performed or for supplies to be delivered to the Commission is subject to the purposes and requirements of the State Finance and Procurement Article.

#### Section 19-111

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Fund" means the Maryland Health Care Commission Fund.

  (3) "Health benefit plan" has the meaning stated in Sec. 15-1201 of the Insurance Article.

  (4) "Health care practitioner" means any individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.

  (5) "Nursing home" means a related institution that is classified as a nursing home.

  (6) "Payor" means:

    (i) A health insurer or nonprofit health service plan that holds a certificate of authority and provides health insurance policies or contracts in the State in accordance with this article or the Insurance Article; or

    (ii) A health maintenance organization that holds a certificate of authority in the State.

(b) Subject to the provisions of subsection (d) of this section, the Commission shall assess a fee on:

  (1) All hospitals;

  (2) All nursing homes;

  (3) All payors; and

  (4) All health care practitioners.

(c)

  (1) The total fees assessed by the Commission may not exceed $20,000,000.

  (2)

    (i) The fees assessed by the Commission shall be used exclusively to cover the actual documented direct costs of fulfilling the statutory and regulatory duties of the Commission in accordance with the provisions of this subtitle.

    (ii) The costs of the Commission include the administrative costs incurred by the Department on behalf of the Commission.

    (iii) The amount to be paid by the Commission to the Department for administrative costs, not to exceed 30.5% of the salaries of the Commission, shall be based on indirect costs or services benefiting the Commission, less overhead costs paid directly by the Commission.

  (3) The Commission shall pay all funds collected from the fees assessed in accordance with this section into the Fund.

  (4) The fees assessed may be expended only for purposes authorized by the provisions of this subtitle.

  (5) The amount in paragraph (1) of this subsection limits only the total fees the Commission may assess in a fiscal year.

(d) In determining assessments of the total fees, the Commission shall:

  (1) Use a methodology that accounts for the portion of the Commission's workload attributable to each industry assessed; and

  (2) Recalculate workload distribution every 4 years.

(e)

  (1) The fees assessed in accordance with this section on health care practitioners shall be:

    (i) Included in the licensing fee paid to the health care practitioner's licensing board; and

    (ii) Transferred by the health care practitioner's licensing board to the Commission on a quarterly basis.

  (2) The Commission may adopt regulations that waive the fee assessed under this section for a specific class of health care practitioners.

  (3)

    (i) Subject to subparagraph (ii) of this paragraph, the Commission shall adopt regulations to permit a waiver of the fee assessment requirements for certain health care practitioners.

    (ii) In adopting regulations to permit a waiver of the fee assessment requirements for certain health care practitioners, the Commission shall:

      (1) Consider the hourly wages of the health care practitioners; and

      (2) Give preference to exempting health care practitioners with an average hourly wage substantially below that of other health care practitioners.

(f)

  (1) There is a Maryland Health Care Commission Fund.

  (2) The Fund is a special continuing, nonlapsing fund that is not subject to Sec. 7-302 of the State Finance and Procurement Article.

  (3) The Treasurer shall separately hold, and the Comptroller shall account for, the Fund.

  (4) The Fund shall be invested and reinvested in the same manner as other State funds.

  (5) Any investment earnings shall be retained to the credit of the Fund.

  (6) The Fund shall be subject to an audit by the Office of Legislative Audits as provided for in Sec. 2-1220 of the State Government Article.

  (7) This section may not be construed to prohibit the Fund from receiving funds from any other source.

  (8) The Fund shall be used only to provide funding for the Commission and for the purposes authorized under this subtitle.

(g) The Commission shall:

  (1)

    (i) Assess fees on payors in a manner that apportions the total amount of the fees to be assessed on payors under subsection (d)(1) of this section among each payor based on the ratio of each payor's total premiums written in the State for health benefit plans to the total written premiums of all payors written in the State; and

    (ii) On or before June 30 of each year, assess each payor a fee in accordance with item (i) of this item;

  (2)

    (i) Assess fees for each hospital equal to the sum of:

      (1) The amount equal to one-half of the total fees to be assessed on hospitals under subsection (d)(1) of this section times the ratio of admissions of the hospital to total admissions of all hospitals; and

      (2) The amount equal to one-half of the total fees to be assessed on hospitals under subsection (d)(1) of this section times the ratio of gross operating revenue of each hospital to total gross operating revenues of all hospitals;

    (ii) Establish minimum and maximum assessments; and

    (iii) On or before June 30 of each year, assess each hospital a fee in accordance with item (i) of this item; and

  (3)

    (i) Assess fees for each nursing home equal to the sum of:

      (1) The amount equal to one-half of the total fees to be assessed on nursing homes under subsection (d)(1) of this section times the ratio of admissions of the nursing home to total admissions of all nursing homes; and

      (2) The amount equal to one-half of the total fees to be assessed on nursing homes under subsection (d)(1) of this section times the ratio of gross operating revenue of each nursing home to total gross operating revenues of all nursing homes;

    (ii) Establish minimum and maximum assessments; and

    (iii) On or before June 30 of each year, assess each nursing home a fee in accordance with item (i) of this item.

(h)

  (1) On or before September 1 of each year, each payor, hospital, and nursing home assessed under this section shall make payment to the Commission.

  (2) The Commission shall make provisions for partial payments.

(i) Any bill not paid within 30 days of the payment due date may be subject to an interest penalty to be determined and collected by the Commission.

#### Section 19-112

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Center" means a Patient Safety Center designated by the Commission.

  (3) "Fund" means the Maryland Patient Safety Center Fund.

(b)

  (1) On or before December 31, 2025, the Commission shall designate a Center for the State.

  (2) The Center designated under paragraph (1) of this subsection shall continue to act as the State-designated Center for the duration of the designation period, as determined by the Commission, if the Center continuously meets the standards and requirements established by the Commission.

(c) The designated Center shall:

  (1) Develop, coordinate, and implement patient safety initiatives across the State;

  (2) Be a model for patient safety innovation and implementation in the State;

  (3) Convene health care providers, patients, and families to:

    (i) Improve the quality of health care and reduce preventable and avoidable harm; and

    (ii) Provide safe and equitable health care for State citizens; and

  (4) Share information relating to best practices among providers and patients in the State.

(d)

  (1) There is a Patient Safety Center Fund.

  (2) The purpose of the Fund is to subsidize a portion of the costs of the Center so that the Center may perform the duties described under subsection (c) of this section.

  (3) The Commission shall administer the Fund.

  (4)

    (i) The Fund is a special, nonlapsing fund that is not subject to Sec. 7-302 of the State Finance and Procurement Article.

    (ii) The State Treasurer shall hold the Fund separately, and the Comptroller shall account for the Fund.

  (5) The Fund consists of:

    (i) Money appropriated in the State budget to the Fund;

    (ii) Interest earnings; and

    (iii) Any other money from any other source accepted for the benefit of the Fund.

  (6) The Fund may be used only to subsidize a portion of the costs of the Center so that the Center may perform the duties described under subsection (c) of this section.

  (7)

    (i) The State Treasurer shall invest the money of the Fund in the same manner as other State money may be invested.

    (ii) Any interest earnings of the Fund shall be credited to the Fund.

(e)

  (1)

    (i) For fiscal years 2023 through 2025, the Governor shall include in the annual budget bill an appropriation of $1,000,000 for the Fund.

    (ii) For fiscal year 2027 and each fiscal year thereafter, the Governor shall include in the annual budget bill an appropriation of $1,000,000 for the Fund.

  (2) The Commission may provide an annual grant from the Fund to the Center in the amount appropriated under paragraph (1) of this subsection, plus any interest and other income distributed to the Fund.

  (3) Expenditures from the Fund may be made only in accordance with the State budget.

  (4) Money expended from the Fund for the Center is supplemental to, and is not intended to take the place of, funding that otherwise would be appropriated for the Center.

(f) On or before October 1 each year, the Commission, in conjunction with the Center, shall report to the Senate Finance Committee and the House Health and Government Operations Committee, in accordance with Sec. 2-1257 of the State Government Article, on:

  (1) The Center's statewide activities related to the development, coordination, and implementation of patient safety initiatives; and

  (2) How the Center's statewide initiatives align with State-designated priorities.

#### Section 19-114

(a) In this Part II of this subtitle the following words have the meanings indicated.

(a-1) "Acquisition" means:

  (1) A transfer of stock or assets that results in a change of the person that controls a health care facility; or

  (2) The transfer of more than 25% of stock or ownership interest in a health care facility.

(b) "Ambulatory surgical facility" means any center, service, office, facility, or office of one or more health care practitioners or a group practice that:

  (1) Has three or more operating rooms;

  (2) Operates primarily for the purpose of providing surgical services to patients who do not require overnight hospitalization; and

  (3) Seeks reimbursement from payors as an ambulatory surgical facility.

(c) "Certificate of need" means a certification of public need issued by the Commission under this Part II of this subtitle for a health care project.

(d)

  (1) "Health care facility" means:

    (i) A hospital, as defined in Sec. 19-301 of this title;

    (ii) A limited service hospital, as defined in Sec. 19-301 of this title;

    (iii) A related institution, as defined in Sec. 19-301 of this title;

    (iv) An ambulatory surgical facility;

    (v) An inpatient facility that is organized primarily to help in the rehabilitation of disabled individuals, through an integrated program of medical and other services provided under competent professional supervision;

    (vi) A home health agency, as defined in Sec. 19-401 of this title;

    (vii) A hospice, as defined in Sec. 19-901 of this title;

    (viii) A freestanding medical facility, as defined in Sec. 19-3A-01 of this title; and

    (ix) Any other health institution, service, or program for which this Part II of this subtitle requires a certificate of need.

  (2) "Health care facility" does not include:

    (i) A hospital or related institution that is operated, or is listed and certified, by the First Church of Christ Scientist, Boston, Massachusetts;

    (ii) For the purpose of providing an exception to the requirement for a certificate of need under Sec. 19-120 of this subtitle, a facility to provide comprehensive care constructed by a provider of continuing care, as defined in Sec. 10-401 of the Human Services Article, if:

      (1) Except as provided under Sec. 19-123 of this subtitle, the facility is for the exclusive use of the provider's subscribers who have executed continuing care agreements, including continuing care at home agreements, and paid entrance fees that are at least equal to the lowest entrance fee charged for an independent living unit, an assisted living unit, or a continuing care at home agreement before entering the continuing care community, regardless of the level of care needed by the subscribers at the time of admission;

      (2) The facility is located on the campus of the continuing care community; and

      (3) The number of comprehensive care nursing beds in the community does not exceed:

      (A) 24 percent of the number of independent living units in a community having less than 300 independent living units; or

      (B) 20 percent of the number of independent living units in a community having 300 or more independent living units;

    (iii) For the purpose of providing an exception to the requirement for a certificate of need under Sec. 19-120 of this subtitle, a facility to provide comprehensive care that:

      (1) Is owned and operated by the Maryland Department of Veterans and Military Families; and

      (2) Restricts admissions to individuals who meet the residency requirements established by the Maryland Department of Veterans and Military Families and are:

      (A) Veterans who were discharged or released from the uniformed services under honorable conditions;

      (B) Former members of a reserve component, as defined in Sec. 9-901 of the State Government Article; or

      (C) Nonveteran spouses of eligible veterans;

    (iv) Except for a facility to provide kidney transplant services or programs, a kidney disease treatment facility, as defined by rule or regulation of the United States Department of Health and Human Services;

    (v) Except for kidney transplant services or programs, the kidney disease treatment stations and services provided by or on behalf of a hospital or related institution; or

    (vi) The office of one or more individuals licensed to practice dentistry under Title 4 of the Health Occupations Article, for the purposes of practicing dentistry.

(e) "Health care practitioner" means any individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.

(f) "Health service area" means an area of this State that the Governor designates as appropriate for planning and developing of health services.

(g) "Local health planning agency" means the health department of a jurisdiction or a body designated by the local health department to perform health planning functions.

(h) "State health plan" means the State health plan for facilities and services.

#### Section 19-115

(a) In addition to the duties set forth elsewhere in this subtitle, in this Part II of this subtitle, the Commission shall:

  (1) Act as the State agency to represent the State under Title VI of the federal Public Health Service Act; and

  (2) Periodically participate in or perform analyses and studies that relate to:

    (i) Adequacy of services and financial resources to meet the needs of the population;

    (ii) Distribution of health care resources;

    (iii) Allocation of health care resources;

    (iv) Costs of health care in relationship to available financial resources; or

    (v) Any other appropriate matter.

(b) In addition to the duties set forth elsewhere in this Part II of this subtitle, the Governor shall direct, as necessary, a State officer or agency to cooperate in carrying out the functions of the Commission.

(c) This State recognizes the federal act and any amendment to the federal act that does not require State legislation to be effective. However, if the federal act is repealed or expires, this Part II of this subtitle remains in effect.

#### Section 19-116

(a)

  (1) The Secretary shall provide for a study of systems capacity in health services.

  (2) The study shall:

    (i) Determine for all health delivery facilities and settings where capacity should be increased or decreased to better meet the needs of the population;

    (ii) Examine and describe the implementation methods and tools by which capacity should be altered to better meet the needs; and

    (iii) Assess the impact of those methods and tools on the communities and health care delivery system.

(b)

  (1) In addition to information that an applicant for a certificate of need must provide, the Commission may request, collect, and report any statistical or other information that:

    (i) Is needed by the Commission to perform its duties described in this Part II of this subtitle; and

    (ii) Is described in regulations of the Commission.

  (2) If a health care facility fails to provide information as required in this subsection, the Commission may:

    (i) Impose a penalty of not more than $100 per day for each day the violation continues after consideration of the willfulness and seriousness of the withholding, as well as any past history of withholding of information;

    (ii) Issue an administrative order that requires the applicant to provide the information; or

    (iii) Apply to the circuit court in the county in which the facility is located for legal relief considered appropriate by the Commission.

  (3) The Commission may send to the Department or a local health planning agency any statistical or other information the Commission is authorized to collect under paragraph (1) of this subsection.

#### Section 19-117

(a) In accordance with criteria that the Commission sets, the Governor shall designate health service areas in this State.

(b) After a 1-year period, the Governor may review or revise the boundaries of a health service area or increase the number of health service areas, on the Governor's initiative, at the request of the Commission, at the request of a local government, or at the request of a local health planning agency. Revisions to boundaries of health service areas shall be done in accordance with the criteria established by the Commission and with the approval of the legislature.

(c) Within 45 days of receipt of the State health plan or a change in the State health plan, the plan becomes effective unless the Governor notifies the Commission of the Governor's intent to modify or revise the State health plan adopted by the Commission.

#### Section 19-118

(a)

  (1) On or before October 1 each year, the Commission shall adopt a State health plan.

  (2) The plan shall:

    (i) Be consistent with the Maryland All Payer Model Contract;

    (ii) Include methodologies, standards, and criteria for certificate of need review; and

    (iii) Prioritize conversion of acute capacity to alternative uses where appropriate.

(b) Annually or on petition by any person, the Commission shall:

  (1) Assess each State health plan chapter;

  (2) Determine the chapter or chapters of the State health plan that should be reviewed and revised;

  (3) Establish, at a public meeting, the priority order and timeline of the State health plan chapter review and revision; and

  (4) Publish any changes in the State health plan that the Commission considers necessary, subject to the review and approval granted to the Governor under this subtitle.

(c) The Commission shall adopt rules and regulations that ensure broad public input, public hearings, and consideration of local health plans in development of the State health plan.

(d)

  (1) The Commission shall develop standards and policies consistent with the State health plan that relate to the certificate of need program.

  (2) The standards:

    (i) Shall address the availability, accessibility, cost, and quality of health care; and

    (ii) Are to be reviewed and revised periodically to reflect new developments in health planning, delivery, and technology.

  (3) In adopting standards regarding cost, efficiency, cost-effectiveness, or financial feasibility, the Commission shall take into account the relevant methodologies of the Health Services Cost Review Commission.

(e) Annually, the Secretary shall make recommendations to the Commission on the plan. The Secretary may review and comment on State specifications to be used in the development of the State health plan.

(f) All State agencies and departments, directly or indirectly involved with or responsible for any aspect of regulating, funding, or planning for the health care industry or persons involved in it, shall carry out their responsibilities in a manner consistent with the State health plan and available fiscal resources.

(g) In carrying out their responsibilities under this Part II of this subtitle for hospitals, the Commission and the Secretary shall recognize, but may not apply, develop, or duplicate standards or requirements related to quality which have been adopted and enforced by national or State licensing or accrediting authorities.

(h) The Commission shall transfer to the Maryland Department of Health health planning functions and necessary staff resources for licensed entities in the State health plan that are not required to obtain a certificate of need or an exemption from the certificate of need program.

#### Section 19-119

(a) The Commission shall develop and adopt an institution-specific plan to guide possible capacity reduction.

(b) The institution-specific plan shall address:

  (1) Accurate bed count data for licensed beds and staffed and operated beds;

  (2) Cost data associated with all hospital beds and associated services on a hospital-specific basis;

  (3) Migration patterns and current and future projected population data;

  (4) Accessibility and availability of beds;

  (5) Quality of care;

  (6) Current health care needs, as well as growth trends for such needs, for the area served by each hospital;

  (7) Hospitals in high growth areas; and

  (8) Utilization.

(c) In the development of the institution-specific plan the Commission shall give priority to the conversion of acute capacity to alternative uses where appropriate.

(d)

  (1) The Commission shall use the institution-specific plan in reviewing certificate of need applications for conversion, expansion, consolidation, or introduction of hospital services in conjunction with the State health plan.

  (2) If there is a conflict between the State health plan and any rule or regulation adopted by the Commission in accordance with Title 10, Subtitle 1 of the State Government Article to implement an institution-specific plan that is developed for identifying any excess capacity in beds and services, the provisions of whichever plan that is most recently adopted shall control.

  (3) Immediately upon adoption of the institution-specific plan the Commission shall begin the process of incorporating the institution-specific plan into the State health plan and shall complete the incorporation within 12 months.

  (4) A State health plan developed or adopted after the incorporation of the institution-specific plan into the State health plan shall include the criteria in subsection (b) of this section in addition to the criteria in Sec. 19-118 of this subtitle.

#### Section 19-120

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Consolidation" and "merger" include increases and decreases in bed capacity or services among the components of an organization that:

    (i) Operates more than one health care facility; or

    (ii) Operates one or more health care facilities and holds an outstanding certificate of need to construct a health care facility.

  (3)

    (i) "Health care service" means any clinically related patient service.

    (ii) "Health care service" includes a medical service.

  (4) "Hospital capital threshold" means the lesser of:

    (i) 25% of the hospital's gross regulated charges for the immediately preceding year; or

    (ii) $50,000,000.

  (5) "Limited service hospital" means a health care facility that:

    (i) Is licensed as a hospital on or after January 1, 1999;

    (ii) Changes the type or scope of health care services offered by eliminating the facility's capability to admit or retain patients for overnight hospitalization;

    (iii) Retains an emergency or urgent care center; and

    (iv) Complies with the regulations adopted by the Secretary under Sec. 19-307.1 of this title.

  (6) "Medical service" means:

    (i) Any of the following categories of health care services:

      (1) Medicine, surgery, gynecology, addictions;

      (2) Obstetrics;

      (3) Pediatrics;

      (4) Psychiatry;

      (5) Rehabilitation;

      (6) Chronic care;

      (7) Comprehensive care;

      (8) Extended care;

      (9) Intermediate care; or

      (10) Residential treatment; or

    (ii) Any subcategory of the rehabilitation, psychiatry, comprehensive care, or intermediate care categories of health care services for which need is projected in the State health plan.

(b) The Commission may set an application fee for a certificate of need for health care facilities not assessed a user fee under this subtitle.

(c) The Commission shall adopt rules and regulations for applying for and issuing certificates of need.

(d) The Commission may adopt, after October 1, 1983, new thresholds or methods for determining the circumstances or minimum cost requirements under which a certificate of need application must be filed.

(e)

  (1) A person shall have a certificate of need issued by the Commission before the person develops, operates, or participates in any of the health care projects for which a certificate of need is required under this section.

  (2) A certificate of need issued before January 13, 1987, may not be rendered wholly or partially invalid solely because certain conditions have been imposed, if an appeal concerning the certificate of need, challenging the power of the Commission to impose certain conditions on a certificate of need, has not been noted by an aggrieved party before January 13, 1987.

(f) Except as provided in subsections (g)(2)(iii) and (p) of this section, a certificate of need is required before a new health care facility is built, developed, or established.

(g)

  (1) A certificate of need is required before an existing or previously approved, but unbuilt, health care facility is moved to another site.

  (2) This subsection does not apply if:

    (i) The Commission adopts limits for relocations and the proposed relocation does not exceed those limits;

    (ii) The relocation is the result of a partial or complete replacement of an existing hospital or related institution, as defined in Sec. 19-301 of this title, and the relocation is to another part of the site or immediately adjacent to the site of the existing hospital or related institution;

    (iii) Subject to the provisions of subsections (i) and (j) of this section, the relocation is of an existing health care facility owned or controlled by a merged asset system and is to:

      (1) A site within the primary service area of the health care facility to be relocated if:

      (A) The proposed relocation is not across county boundaries; and

      (B) At least 45 days prior to the proposed relocation, notice is filed with the Commission;

      (2) A site outside the primary service area of the health care facility to be relocated but within the primary service area of the merged asset system if:

      (A) At least 45 days prior to the proposed relocation, notice is filed with the Commission; and

      (B) The Commission in its sole discretion, and in accordance with the criteria adopted by regulation, finds that the relocation is in the public interest, is not inconsistent with the State health plan, and will result in the more efficient and effective delivery of health care services; or

      (3) For a limited service hospital, a site within the immediate area as defined in regulation by the Commission; or

    (iv) The relocation involves moving a portion of a complement of comprehensive care beds previously approved by the Commission after January 1, 1995, for use in a proposed new related institution, as defined in Sec. 19-301 of this title, but unbuilt on October 1, 1998, if:

      (1) The comprehensive care beds that were originally approved by the Commission in a prior certificate of need review were approved for use in a proposed new related institution to be located in a municipal corporation within Carroll County in which a related institution is not located;

      (2) The comprehensive care beds being relocated will be used to establish an additional new related institution that is located in another municipal corporation within Carroll County in which a related institution is not located;

      (3) The comprehensive care beds not being relocated are intended to be used to establish a related institution on the original site; and

      (4) Both the previously approved comprehensive care beds for use on the original site and the relocated comprehensive care beds for use on the new site will be used as components of single buildings on each site that also offer independent or assisted living residential units.

  (3) Notwithstanding any other provision of this subtitle, a certificate of need is not required for a relocation described under paragraph (2)(iv) of this subsection.

(h)

  (1) A certificate of need is required before the bed capacity of a health care facility is changed.

  (2) This subsection does not apply to any increase or decrease in bed capacity if:

    (i) For a health care facility that is not a hospital, during a 2-year period the increase or decrease would not exceed the lesser of 10 percent of the total bed capacity or 10 beds;

    (ii)

      (1) The increase or decrease would change the bed capacity for an existing medical service; and

      (2)

        (A) The change would not increase total bed capacity;

      (B) The change is maintained for at least a 1-year period; and

      (C) At least 45 days prior to the change, the hospital provides written notice to the Commission describing the change and providing an updated inventory of the hospital's licensed bed complement;

    (iii)

      (1) At least 45 days before increasing or decreasing bed capacity, written notice of intent to change bed capacity is filed with the Commission;

      (2) The Commission in its sole discretion finds that the proposed change:

      (A) Is pursuant to the consolidation or merger of two or more health care facilities, conversion of a health care facility or part of a facility to a nonhealth-related use, or a change in bed capacity at an intermediate care facility that offers medically managed residential substance use disorder treatment services and has a current license issued by the Secretary;

      (B) Is not inconsistent with the State health plan or the institution-specific plan developed by the Commission;

      (C) Will result in the delivery of more efficient and effective health care services; and

      (D) Is in the public interest; and

      (3) Within 45 days of receiving notice, the Commission notifies the health care facility of its finding;

    (iv) The increase or decrease in bed capacity is the result of the annual licensed bed recalculation provided under Sec. 19-307.2 of this title; or

    (v)

      (1) The increase or decrease in bed capacity will occur in an existing general hospice program that has a current license issued by the Secretary; and

      (2) At least 45 days before increasing or decreasing bed capacity, written notice of the intent to change bed capacity is filed with the Commission.

(i)

  (1) Except as provided in paragraph (2) of this subsection, for a hospital located in a county with three or more hospitals, a certificate of need is not required before the bed capacity is increased or decreased if the change:

    (i) Occurs on or after July 1, 2000;

    (ii) Is between hospitals in a merged asset system located within the same health service area;

    (iii) Does not involve comprehensive or extended care beds; and

    (iv) Does not occur earlier than 45 days after a notice of intent to reallocate bed capacity is filed with the Commission.

  (2) A hospital may not create a new health care service through the relocation of beds from one county to another county pursuant to this subsection.

(j)

  (1) A certificate of need is required before the type or scope of any health care service is changed if the health care service:

    (i) Is offered:

      (1) By a health care facility;

      (2) In space that is leased from a health care facility; or

      (3) In space that is on land leased from a health care facility; or

    (ii) Results in a change in operating room capacity in a hospital, a freestanding medical facility, or an ambulatory surgical facility.

  (2) This subsection does not apply if:

    (i) The Commission adopts limits for changes in health care services and the proposed change would not exceed those limits;

    (ii) The proposed change and the annual operating revenue that would result from the addition is entirely associated with the use of medical equipment;

    (iii) The proposed change would establish, increase, or decrease a health care service and the change would not result in the:

      (1) Establishment of a new medical service or elimination of an existing medical service;

      (2) Establishment of a cardiac surgery, organ transplant surgery, or burn or neonatal intensive health care service;

      (3) Except as provided in Sec. 19-120.1 of this subtitle, establishment of percutaneous coronary intervention services;

      (4) Establishment of a home health program, hospice program, or freestanding ambulatory surgical center or facility; or

      (5) Expansion of a comprehensive care, extended care, intermediate care, residential treatment, psychiatry, or rehabilitation medical service, except for an expansion related to an increase in total bed capacity in accordance with subsection (h)(2)(i) of this section; or

    (iv)

      (1) At least 45 days before increasing or decreasing the volume of one or more health care services, written notice of intent to change the volume of health care services is filed with the Commission;

      (2) The Commission in its sole discretion finds that the proposed change:

      (A) Is pursuant to:

      (I) The consolidation or merger of two or more health care facilities;

      II.    The conversion of a health care facility or part of a facility to a nonhealth-related use;

      III.    The conversion of a hospital to a limited service hospital; or

      IV.    The conversion of a licensed general hospital to a freestanding medical facility in accordance with subsection (o)(3) of this section;

      (B) Is not inconsistent with the State health plan or the institution-specific plan developed and adopted by the Commission;

      (C) Will result in the delivery of more efficient and effective health care services; and

      (D) Is in the public interest; and

      (3) Within 45 days of receiving notice under item 1 of this item, the Commission notifies the health care facility of its finding.

  (3) Notwithstanding the provisions of paragraph (2) of this subsection, a certificate of need is required:

    (i) Before an additional home health agency, branch office, or home health care service is established by an existing health care agency or facility;

    (ii) Before an existing home health agency or health care facility establishes a home health agency or home health care service at a location in the service area not included under a previous certificate of need or license;

    (iii) Before a transfer of ownership of any branch office of a home health agency or home health care service of an existing health care facility that separates the ownership of the branch office from the home health agency or home health care service of an existing health care facility which established the branch office; or

    (iv) Before the expansion of a home health service or program by a health care facility that:

      (1) Established the home health service or program without a certificate of need between January 1, 1984, and July 1, 1984; and

      (2) During a 1-year period, the annual operating revenue of the home health service or program would be greater than $333,000 after an annual adjustment for inflation, based on an appropriate index specified by the Commission.

(k)

  (1) A certificate of need is required before any of the following capital expenditures are made by or on behalf of a hospital:

    (i) Any expenditure that, under generally accepted accounting principles, is not properly chargeable as an operating or maintenance expense, if:

      (1) The expenditure is made as part of an acquisition, improvement, or expansion, and, after adjustment for inflation as provided in the regulations of the Commission, the total expenditure, including the cost of each study, survey, design, plan, working drawing, specification, and other essential activity, is more than the hospital capital threshold;

      (2) The expenditure is made as part of a replacement of any plant and equipment of the hospital and is more than the hospital capital threshold after adjustment for inflation as provided in the regulations of the Commission;

      (3) The expenditure results in a substantial change in the bed capacity of the hospital; or

      (4) The expenditure results in the establishment of a new medical service in a hospital that would require a certificate of need under subsection (i) of this section; or

    (ii) Any expenditure that is made to lease or, by comparable arrangement, obtain any plant or equipment for the hospital, if:

      (1) The expenditure is made as part of an acquisition, improvement, or expansion, and the total expenditure, including the cost of each study, survey, design, plan, working drawing, specification, and other essential activity, is more than the hospital capital threshold;

      (2) The expenditure is made as part of a replacement of any plant and equipment and is more than the hospital capital threshold after adjustment for inflation as provided in the regulations of the Commission;

      (3) The expenditure results in a substantial change in the bed capacity of the hospital; or

      (4) The expenditure results in the establishment of a new medical service in a hospital that would require a certificate of need under subsection (i) of this section.

  (2) A certificate of need is required before any of the following capital expenditures are made by or on behalf of a health care facility other than a hospital:

    (i) Any expenditure that, under generally accepted accounting principles, is not properly chargeable as an operating or maintenance expense, if:

      (1) The expenditure results in a substantial change in the bed capacity of the health care facility other than a hospital; or

      (2) The expenditure results in the establishment of a new medical service in a health care facility other than a hospital that would require a certificate of need under subsection (i) of this section; or

    (ii) Any expenditure that is made to lease or, by comparable arrangement, obtain any plant or equipment for the health care facility other than a hospital, if:

      (1) The expenditure results in a substantial change in the bed capacity of the health care facility other than a hospital; or

      (2) The expenditure results in the establishment of a new medical service in a health care facility other than a hospital that would require a certificate of need under subsection (i) of this section.

  (3) A certificate of need is required before any equipment or plant is donated to a health care facility, if a certificate of need would be required under paragraph (1) or (2) of this subsection for an expenditure by the health care facility to acquire the equipment or plant directly.

  (4) A certificate of need is required before any equipment or plant is transferred to a health care facility at less than fair market value if a certificate of need would be required under paragraph (1) or (2) of this subsection for the transfer at fair market value.

  (5) A certificate of need is required before a person acquires a health care facility if a certificate of need would be required under paragraph (1) or (2) of this subsection for the acquisition by or on behalf of the health care facility.

  (6) This subsection does not apply to:

    (i) Site acquisition;

    (ii) An acquisition of a health care facility if:

      (1) At least 30 days before making the contractual arrangement to acquire the facility, written notice of the intent to make the arrangement is filed with the Commission and the Commission does not find, within 30 days after the Commission receives notice, that the health services or bed capacity of the facility will be changed, provided that, for a merger with or acquisition of an existing general hospice, the purchaser of the general hospice may only acquire the authority to provide home-based hospice services in jurisdictions in which the seller of the general hospice is licensed to provide home-based hospice services; and

      (2) For an acquisition of a nursing home, the acquisition has been approved in accordance with Sec. 19-120.2 of this subtitle;

    (iii) Acquisition of business or office equipment that is not directly related to patient care;

    (iv) Capital expenditures to the extent that they are directly related to the acquisition and installation of major medical equipment;

    (v) A capital expenditure made as part of a consolidation or merger of two or more health care facilities, or conversion of a health care facility or part of a facility to a nonhealth-related use if:

      (1) At least 45 days before an expenditure is made, written notice of intent is filed with the Commission;

      (2) Within 45 days of receiving notice, the Commission in its sole discretion finds that the proposed consolidation, merger, or conversion:

      (A) Is not inconsistent with the State health plan or the institution-specific plan developed by the Commission as appropriate;

      (B) Will result in the delivery of more efficient and effective health care services; and

      (C) Is in the public interest; and

      (3) Within 45 days of receiving notice, the Commission notifies the health care facility of its finding;

    (vi) A capital expenditure by a nursing home for equipment, construction, or renovation that:

      (1) Is not directly related to patient care; and

      (2) Is not directly related to any change in patient charges or other rates;

    (vii) A capital expenditure by a hospital, as defined in Sec. 19-301 of this title, for equipment, construction, or renovation that:

      (1) Is not directly related to patient care; and

      (2) Does not increase patient charges or hospital rates;

    (viii) A capital expenditure by a hospital, as defined in Sec. 19-301 of this title, for a project in excess of the hospital capital threshold and is for construction or renovation that:

      (1) May be related to patient care;

      (2) Does not require, over the entire period or schedule of debt service associated with the project, a total cumulative increase in patient charges or hospital rates of more than $1,500,000 for the capital costs associated with the project as determined by the Commission, after consultation with the Health Services Cost Review Commission;

      (3) At least 45 days before the proposed expenditure is made, the hospital notifies the Commission;

      (4)

        (A) Within 45 days of receipt of the relevant financial information, the Commission makes the financial determination required under item 2 of this item; or

      (B) The Commission has not made the financial determination required under item 2 of this item within 60 days of the receipt of the relevant financial information; and

      (5) The relevant financial information to be submitted by the hospital is defined in regulations adopted by the Commission, after consultation with the Health Services Cost Review Commission;

    (ix) A plant donated to a hospital, as defined in Sec. 19-301 of this title, that does not require a cumulative increase in patient charges or hospital rates of more than $1,500,000 for capital costs associated with the donated plant as determined by the Commission, after consultation with the Health Services Cost Review Commission, if:

      (1) At least 45 days before the proposed donation is made, the hospital notifies the Commission;

      (2)

        (A) Within 45 days of receipt of the relevant financial information, the Commission makes the financial determination required under this item (ix) of this paragraph; or

      (B) The Commission has not made the financial determination required under this item (ix) of this paragraph within 60 days of the receipt of the relevant financial information; and

      (3) The relevant financial information to be submitted by the hospital is defined in regulations adopted by the Commission after consultation with the Health Services Cost Review Commission; or

    (x) A capital expenditure made as part of a conversion of a licensed general hospital to a freestanding medical facility in accordance with subsection (o)(3) of this section.

  (7) Paragraph (6)(vi), (vii), (viii), (ix), and (x) of this subsection may not be construed to permit a facility to offer a new health care service for which a certificate of need is otherwise required.

(l)

  (1) A certificate of need is not required to close any health care facility or part of a health care facility if at least 90 days before the closing or if at least 45 days before the partial closing of the health care facility, including a State hospital, a person proposing to close all or part of the health care facility files notice of the proposed closing or partial closing with the Commission.

  (2) A hospital shall hold a public informational hearing in the county where the hospital is located if the hospital:

    (i) Files a notice of the proposed closing of the hospital with the Commission;

    (ii) Requests an exemption from the Commission under subsection (o)(3) of this section to convert to a freestanding medical facility; or

    (iii) Is located in a county with fewer than three hospitals and files a notice of the partial closing of the hospital with the Commission.

  (3) The Commission may require a health care facility other than a hospital described in paragraph (2) of this subsection that files notice of its proposed closing or partial closing to hold a public informational hearing in the county where the health care facility is located.

  (4) A public informational hearing required under paragraph (2) or (3) of this subsection shall be held by the health care facility, in consultation with the Commission, within 30 days after:

    (i) The health care facility files with the Commission a notice of its proposed closing or partial closing; or

    (ii) The hospital files with the Commission a notice of intent to convert to a freestanding medical facility.

  (5)

    (i) The Commission shall establish by regulation requirements for a public informational hearing required under paragraph (2) or (3) of this subsection.

    (ii) For a hospital proposing to close, partially close, or convert to a freestanding medical facility, the regulations shall require the hospital to address:

      (1) The reasons for the closure, partial closure, or conversion;

      (2) The plan for transitioning acute care services previously provided by the hospital to residents of the hospital service area;

      (3) The plan for addressing the health care needs of the residents of the hospital service area;

      (4) The plan for retraining and placing displaced employees;

      (5) The plan for the hospital's physical plant and site; and

      (6) The proposed timeline for the closure, partial closure, or conversion to a freestanding medical facility.

  (6) Within 10 working days after a public informational hearing held by a hospital under this subsection, the hospital shall provide a written summary of the hearing to:

    (i) The Governor;

    (ii) The Secretary;

    (iii) The governing body of the county in which the hospital is located;

    (iv) The local health department and the local board of health or similar body for the county in which the hospital is located;

    (v) The Commission; and

    (vi) Subject to Sec. 2-1257 of the State Government Article, the Senate Finance Committee, the House Health and Government Operations Committee, and the members of the General Assembly who represent the district in which the hospital is located.

(m)

  (1) Notwithstanding any other provision of this section, the Commission shall consider the special needs and circumstances of a county where a medical service, as defined in this section, does not exist; and

  (2) The Commission shall consider and may approve under this subsection a certificate of need application to establish, build, operate, or participate in a health care project to provide a new medical service in a county if the Commission, in its sole discretion, finds that:

    (i) The proposed medical service does not exist in the county that the project would be located;

    (ii) The proposed medical service is necessary to meet the health care needs of the residents of that county;

    (iii) The proposed medical service would have a positive impact on the existing health care system;

    (iv) The proposed medical service would result in the delivery of more efficient and effective health care services to the residents of that county; and

    (v) The application meets any other standards or regulations established by the Commission to approve applications under this subsection.

(n) The Commission may not issue a certificate of need or a determination with respect to an acquisition that authorizes a general hospice to provide home-based hospice services on a statewide basis.

(o)

  (1) Except as provided in paragraphs (2) and (3) of this subsection, a person shall have a certificate of need issued by the Commission before a person establishes or operates a freestanding medical facility.

  (2) A certificate of need is not required for the establishment or operation of a freestanding medical facility pilot project established under Sec. 19-3A-07 of this title.

  (3)

    (i) A certificate of need is not required to establish or operate a freestanding medical facility if:

      (1) The freestanding medical facility is established as the result of the conversion of a licensed general hospital;

      (2) Through the conversion, the licensed general hospital will eliminate the capability of the hospital to admit or retain patients for overnight hospitalization, except for observation stays;

      (3) Except as provided in subparagraph (ii) of this paragraph, the freestanding medical facility will remain on the site of, or on a site adjacent to, the licensed general hospital;

      (4) At least 60 days before the conversion, written notice of intent to convert the licensed general hospital to a freestanding medical facility is filed with the Commission;

      (5) The Commission in its sole discretion finds that the conversion:

      (A) Is consistent with the State health plan;

      (B) Will result in the delivery of more efficient and effective health care services;

      (C) Will maintain adequate and appropriate delivery of emergency care within the statewide emergency medical services system as determined by the State Emergency Medical Services Board; and

      (D) Is in the public interest; and

      (6) Within 60 days after receiving notice under item 4 of this subparagraph, the Commission notifies the licensed general hospital of the Commission's findings.

    (ii) The Commission may approve a site for a freestanding medical facility that is not on the site of, or on a site adjacent to, the licensed general hospital if:

      (1) The licensed general hospital is:

      (A) The only hospital in the county; or

      (B) One of two hospitals in the county that are part of the same merged asset system, and are the only two hospitals in the county; and

      (2) The site is within a 5-mile radius and in the primary service area of the licensed general hospital.

    (iii) Notwithstanding subparagraph (i) of this paragraph, a licensed general hospital located in Kent County may not convert to a freestanding medical facility in accordance with subparagraph (i) of this paragraph before July 1, 2020.

(p) A certificate of need is not required for the establishment or operation of an intermediate care facility that offers medically managed residential substance use disorder treatment services if:

  (1) Written notice of the intent to establish or operate the intermediate care facility is filed with the Commission at least 45 days before establishment; and

  (2) The Commission in its sole discretion finds that the proposed intermediate care facility:

    (i) Is not inconsistent with the State health plan;

    (ii) Will result in the delivery of more efficient and effective health care services; and

    (iii) Is in the public interest.

#### Section 19-120.1

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Certificate of conformance" means an approval issued by the Commission that allows an acute general hospital to establish emergency PCI services or elective PCI services without a certificate of need.

  (3) "Certificate of ongoing performance" means an approval issued by the Commission that the cardiac surgery services, emergency PCI services, or elective PCI services provided by an acute general hospital meet standards evidencing continued quality.

  (4) "Elective PCI" (also known as "nonprimary PCI") includes PCI provided to a patient who is not suffering from an acute coronary syndrome, but whose condition is appropriately treated with PCI based on regulations established by the Commission.

  (5) "Emergency PCI" (also known as "primary PCI") includes PCI capable of relieving coronary vessel narrowing associated with STEMI or, as defined by the Commission in regulations, STEMI equivalent.

  (6) "PCI" means percutaneous coronary intervention.

  (7)

    (i) "Percutaneous coronary intervention" means a procedure in which a catheter is inserted into a blood vessel and guided to the site of the narrowing of a coronary artery to relieve coronary narrowing.

    (ii) "Percutaneous coronary intervention" includes a variety of catheter-based techniques, including balloon angioplasty.

  (8) "STEMI" (ST-segment-elevation myocardial infarction) means a type of heart attack or myocardial infarction that is caused by a prolonged period of blocked blood supply, which affects a large area of the heart muscle and causes changes on an electrocardiogram and in the blood levels of key chemical markers.

(b)

  (1) Beginning July 1, 2012, before an acute general hospital may establish emergency PCI services or elective PCI services, the hospital shall obtain a certificate of conformance from the Commission.

  (2) The Commission may not issue a certificate of conformance unless the Commission finds that the proposed emergency PCI services or proposed elective PCI services:

    (i) Are consistent with the State Health Plan for Facilities and Services;

    (ii) Will result in the delivery of more efficient and effective health care services; and

    (iii) Are in the public interest.

(c) Notwithstanding subsection (b) of this section, a certificate of conformance is not required for an acute general hospital to establish emergency PCI services if:

  (1) The acute general hospital was providing emergency PCI services on January 1, 2012; and

  (2) The Commission determines that the emergency PCI services are consistent with the State Health Plan for Facilities and Services.

(d) Notwithstanding subsection (b) of this section, a certificate of conformance is not required for an acute general hospital to establish elective PCI services if:

  (1) On January 1, 2012, the acute general hospital was providing elective PCI services through the C-PORT E registry under authority of a research waiver issued by the Commission;

  (2) The Commission finds that the C-PORT E study produced results that should guide public policy; and

  (3) The Commission determines that the elective PCI services provided by the acute general hospital continue to be consistent with:

    (i) The requirements of the C-PORT E registry; and

    (ii) Except for the requirements under COMAR 10.24.05.05, the requirements for maintaining a research waiver under COMAR 10.24.05 and 10.24.17, Table A-1.

(e)

  (1) This subsection applies to an acute general hospital that provides cardiac surgery or PCI services under:

    (i) A certificate of need issued under Sec. 19-120 of this subtitle;

    (ii) A certificate of conformance issued under this section; or

    (iii) An exception from the certificate of conformance requirements under subsection (c) or (d) of this section.

  (2) An acute general hospital shall obtain and maintain a certificate of ongoing performance to continue to provide:

    (i) Cardiac surgery services;

    (ii) Emergency PCI services; or

    (iii) Elective PCI services.

(f) An acute general hospital that is providing elective PCI services under a research waiver issued by the Commission and does not meet the requirements of subsection (d) of this section shall obtain a certificate of conformance for its elective PCI services before the acute general hospital may obtain a certificate of ongoing performance to provide the elective PCI services.

(g)

  (1) The Commission shall adopt regulations through an update to the State Health Plan for Facilities and Services to implement this section.

  (2) The regulations shall:

    (i) Address quality, access, and cost;

    (ii) Establish a process and minimum standards for obtaining a certificate of conformance;

    (iii) Establish a process and minimum standards for obtaining and maintaining a certificate of ongoing performance;

    (iv) Set an appropriate time period for the expiration of a certificate of ongoing performance;

    (v) Require, as a condition of the issuance of a certificate of conformance or a certificate of ongoing performance, that an acute general hospital agree to voluntarily relinquish its authority to provide cardiac surgery services, emergency PCI services, or elective PCI services if the hospital fails to meet the applicable standards established by the Commission;

    (vi) Establish a process for an acute general hospital that is out of compliance with minimum standards for a certificate of ongoing performance to return to good standing;

    (vii) Require that an acute general hospital, except for an acute general hospital located in a part of the State that does not have sufficient access to emergency PCI services, have provided emergency PCI services in accordance with established standards before seeking a certificate of conformance for elective PCI services;

    (viii) Prohibit an acute general hospital from providing elective PCI services unless the acute general hospital also provides emergency PCI services;

    (ix) Incorporate, to the extent appropriate, the standards for cardiac surgery services, emergency PCI services, and elective PCI services recommended by the clinical advisory group established under paragraph (3) of this subsection;

    (x) Include requirements for peer or independent review, consistent with the ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions), of difficult or complicated cases and for randomly selected cases; and

    (xi) For a certificate of conformance for elective PCI services, give weight to the experience, performance, investment, and scope of interventional capabilities of an applicant hospital that was providing emergency PCI services on January 1, 2012.

  (3)

    (i) The Commission shall establish a clinical advisory group to advise the Commission and recommend standards for cardiac surgery services, emergency PCI services, and elective PCI services for inclusion in regulations adopted under this subsection.

    (ii) The clinical advisory group shall be composed of experts in cardiac surgery services and PCI services, including:

      (1) Clinicians and representatives from hospitals in the State with and without on-site cardiac surgery services and with and without PCI services;

      (2) At least one representative of an acute general hospital that is not part of a merged asset system and provides only emergency PCI services; and

      (3) Other persons with needed expertise from inside and outside the State.

  (4)

    (i) On or before September 30, 2013, after obtaining advice from the clinical advisory group and other appropriate stakeholders, the Commission shall:

      (1) Develop recommended regulations under this subsection;

      (2) Post the recommended regulations on its website for public comment; and

      (3) Submit the recommended regulations to the Governor and, in accordance with Sec. 2-1257 of the State Government Article, the Senate Finance Committee and the House Health and Government Operations Committee.

    (ii) The Senate Finance Committee and the House Health and Government Operations Committee shall have 60 days from receipt of the recommended regulations for review and comment.

#### Section 19-120.2

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Executive Director" means the Executive Director of the Commission.

  (3) "Nursing home" has the meaning stated in Sec. 19-1401 of this title.

  (4) "Request for acquisition" means a request for the Commission to approve the acquisition of a nursing home.

(b) A person shall provide notice to the Commission at least 30 days before the closing of a change of ownership of a nursing home that:

  (1) Involves at least a 5% transfer in ownership interest; and

  (2) Is not an acquisition that requires approval under subsection (c) of this section.

(c)

  (1) This subsection does not apply to an acquisition that involves only changes of ownership interests among existing owners of a nursing home.

  (2) At least 60 days before the closing date of the acquisition of a nursing home, a person shall:

    (i) Submit to the Commission a request for acquisition; and

    (ii) Provide notice to the residents, resident representatives, and employees of the nursing home that:

      (1) The request for acquisition was submitted to the Commission; and

      (2) There will be an opportunity to submit comments in accordance with subsection (f) of this section.

(d)

  (1) The Executive Director shall review a completed request for acquisition within 45 days after receiving the completed request from the applicant.

  (2) The Executive Director, in consultation with the Secretary or the Secretary's designee, may:

    (i) Approve the acquisition;

    (ii) Approve the acquisition with conditions;

    (iii) Deny the acquisition; or

    (iv) Refer the request for acquisition to the Commission for a final decision.

(e) To approve a request submitted under subsection (c) of this section, the Executive Director must find that the acquisition:

  (1) Is consistent with the State Health Plan; and

  (2) Subject to subsection (f) of this section, is in the public interest.

(f) In determining whether an acquisition of a nursing home is in the public interest, the Executive Director shall:

  (1) Solicit and accept comments from individuals who:

    (i) Reside in the nursing home;

    (ii) Have family members who reside in the nursing home; or

    (iii) Are employees of the nursing home; and

  (2) Consult with the Attorney General on whether the acquisition raises public interest concerns.

(g) If the Executive Director refers a request for acquisition to the Commission under subsection (d)(2)(iv) of this section, the Commission shall use the criteria specified in subsections (e) and (f) of this section and regulations adopted by the Commission to make a final decision within 60 days after receiving the completed request from the applicant.

(h) If the Executive Director denies a request for acquisition or imposes a condition on the approval of the acquisition, a person that is a party to the acquisition may submit a written request for the Commission to review the decision in accordance with regulations adopted by the Commission.

(i)

  (1) A decision of the Commission under subsection (g) or (h) of this section shall be a final decision for the purpose of judicial review.

  (2) A person that is a party to the acquisition may take a direct judicial appeal within 30 days after the Commission makes the final decision.

  (3) The Commission shall send each final decision to the Secretary, the Secretary of Aging, the Office of Health Care Quality, the Office of the Attorney General, and the State Long-Term Care Ombudsman.

(j)

  (1) On or before July 1 immediately following the acquisition of a nursing home and each year for 3 years thereafter, the person that acquired the nursing home shall submit a report to the Commission in accordance with regulations adopted by the Commission.

  (2) The Commission shall provide the report required under paragraph (1) of this subsection to the Secretary, the Secretary of Aging, the Office of Health Care Quality, the Office of the Attorney General, and the State Long-Term Care Ombudsman.

(k)

  (1) The Commission shall adopt regulations through an update to the State Health Plan for Facilities and Services to carry out the provisions of this section.

  (2) The regulations adopted under this subsection shall:

    (i) Require the person that acquired ownership of a nursing home to:

      (1) Reduce the number of resident rooms in the nursing home that contain more than two beds in accordance with standards established by the Commission; or

      (2) Receive a waiver from the requirement established under item 1 of this item from the Executive Director in accordance with standards established by the Commission;

    (ii)

      (1) If necessary, allow the person that acquired ownership of a nursing home to temporarily delicense beds for at least 3 years immediately following the acquisition to reduce the number of resident rooms that contain more than two beds; and

      (2) Authorize the Commission to extend the period the beds are temporarily delicensed beyond 3 years for good cause shown, including demonstrated progress toward eliminating multibedded rooms by expanding the existing facility or transferring the beds to another facility within a merged asset system in the same jurisdiction;

    (iii) Establish standards for the evaluation of the quality of the nursing homes currently or previously owned, whether in the State or outside the State, by the person that submitted a request for acquisition; and

    (iv) Subject to paragraph (3) of this subsection, establish criteria for the Executive Director and the Commission to consider when making a decision regarding a request for acquisition.

  (3) The criteria established by the Commission under paragraph (2)(iv) of this subsection shall require that the Commission take into consideration whether any nursing home currently or previously owned, within or outside the State, by the person submitting the request, for the period of 3 years immediately preceding the submission of the request:

    (i) Maintained a quality assessment and assurance committee that met at least quarterly;

    (ii) Was the subject of an enforcement action, a special focus facility designation, or a deficiency involving serious or immediate threat, actual harm, or immediate jeopardy to a resident; or

    (iii) Was the subject of a lawsuit judgment, or an arbitration finding, following a complaint filed by a resident, resident representative, or a government agency.

#### Section 19-121

(a) In this section, "health maintenance organization" means a health maintenance organization under Subtitle 7 of this title.

(b)

  (1) A health maintenance organization or a health care facility that either controls, directly or indirectly, or is controlled by a health maintenance organization shall have a certificate of need before the health maintenance organization or health care facility builds, develops, operates, purchases, or participates in building, developing, operating, or establishing:

    (i) A hospital, as defined in Sec. 19-301 of this title; and

    (ii) Any other health care project for which a certificate of need is required under Sec. 19-120 of this subtitle unless at least 90% of the patients who will receive health care services from the project will be individuals enrolled in that health maintenance organization.

  (2) Notwithstanding paragraph (1)(ii) of this subsection, a health maintenance organization or a health care facility that either controls, directly or indirectly, or is controlled by a health maintenance organization is not required to obtain a certificate of need before purchasing an existing ambulatory surgical facility or center, as defined in Sec. 19-114(b) of this subtitle.

(c) An application for a certificate of need by a health maintenance organization or by a health care facility that either controls, directly or indirectly, or is controlled by, a health maintenance organization shall be approved if the Commission finds that the application:

  (1) Documents that the project is necessary to meet the needs of enrolled members and reasonably anticipated new members for the services proposed to be provided by the applicant; and

  (2) Is not inconsistent with those sections of the State health plan or those sections of the institution-specific plan that govern hospitals, as defined in Sec. 19-301 of this title, and ambulatory surgical facilities or centers, as defined in Sec. 19-114(b) of this subtitle, or health care projects for which a certificate of need is required under subsection (b)(1)(ii) of this section.

#### Section 19-122

A certificate of need is not required to delete, expand, develop, operate, or participate in a health care project for domiciliary care.

#### Section 19-123

Notwithstanding the provisions of Sec. 19-114(d)(2)(ii) of this subtitle, a continuing care community does not lose its exemption from certificate of need requirements when the continuing care community admits an individual directly to a nursing facility within the continuing care community if:

(1) The admittee's spouse or relative is admitted at the same time under a joint contract to an independent living unit or assisted living unit within the continuing care community; or

(2) An individual having a long-term significant relationship with the admittee is admitted at the same time under a joint contract to an independent living unit or assisted living unit within the continuing care community.

#### Section 19-124

(a) Notwithstanding the provisions of Sec. 19-114(d)(2)(ii) of this part, a continuing care community that qualifies for an exemption from a certificate of need under Sec. 19-114(d)(2)(ii) of this part may admit a subscriber directly into a comprehensive care nursing bed only if, at the time of admission, the subscriber has the potential for an eventual transfer to an independent living unit or an assisted living unit, as determined by the subscriber's personal physician who is not an owner or employee of the continuing care retirement community.

(b) Notwithstanding the provisions of subsection (a) of this section and Sec. 19-114(d)(2)(ii) of this part, the total number of comprehensive care nursing beds occupied by subscribers who have been directly admitted to a comprehensive care nursing bed may not exceed 20 percent of the total number of comprehensive care nursing beds that are available in the continuing care nursing facility.

(c) Notwithstanding the provisions of subsections (a) and (b) of this section and Sec. 19-114(d)(2)(ii) of this part, a continuing care retirement community that qualifies for an exemption from a certificate of need under Sec. 19-114(d)(2)(ii) of this part may not admit a subscriber directly into a comprehensive care nursing bed if the direct admission would cause the occupancy of the comprehensive care nursing beds in the continuing care community to exceed 95 percent of full capacity.

#### Section 19-125

A certificate of need is required before an ambulatory care facility:

(1) Offers any health service:

  (i) Through a health care facility;

  (ii) In space leased from a health care facility; or

  (iii) In space on land leased from a health care facility;

(2) To provide those services, makes an expenditure, if a certificate of need would be required under Sec. 19-120(k) of this subtitle for the expenditure by or on behalf of a health care facility; or

(3) Does anything else for which the federal act requires a certificate of need and that the Commission has not exempted from that requirement.

#### Section 19-126

(a) If the Commission receives an application for a certificate of need for a change in the bed capacity of a health care facility, as required under Sec. 19-120 of this subtitle, or for a health care project that would create a new health care service or abolish an existing health care service, the Commission shall give notice of the filing by publication in the Maryland Register and give the following notice to:

  (1) Each member of the General Assembly in whose district the action is planned;

  (2) Each member of the governing body for the county where the action is planned;

  (3) The county executive, mayor, or chief executive officer, if any, in whose county or city the action is planned; and

  (4) Any health care provider, third party payor, local planning agency, or any other person the Commission knows has an interest in the application.

(b) Failure to give notice shall not adversely affect the application.

(c)

  (1) All decisions of the Commission on an application for a certificate of need, except in emergency circumstances posing a threat to public health, shall be consistent with the State health plan and the standards for review established by the Commission.

  (2) The mere failure of the State health plan to address any particular project or health care service shall not alone be deemed to render the project inconsistent with the State health plan.

  (3) Unless the Commission finds that the facility or service for which the proposed expenditure is to be made is not needed or is not consistent with the State health plan, the Commission shall approve an application for a certificate of need required under Sec. 19-120(k) of this subtitle to the extent that the expenditure is to be made to:

    (i) Eliminate or prevent an imminent safety hazard, as defined by federal, State, or local fire, building, or life safety codes or regulations;

    (ii) Comply with State licensing standards; or

    (iii) Comply with accreditation standards for reimbursement under Title XVIII of the Social Security Act or under the State Medical Assistance Program approved under Title XIX of the Social Security Act.

(d)

  (1) The Commission alone shall have final nondelegable authority to act upon an application for a certificate of need, except as provided in this subsection.

  (2) A majority of the full authorized membership of the Commission shall be a quorum to act on an application for a certificate of need.

  (3) After an application is filed, the staff of the Commission:

    (i) Shall review the application for completeness within 10 working days of the filing of the application; and

    (ii) May request further information from the applicant.

  (4) The Commission may delegate to a reviewer the responsibility for review of an application for a certificate of need, including:

    (i) The holding of an evidentiary hearing if the Commission, in accordance with criteria it has adopted by regulation, considers an evidentiary hearing appropriate due to the magnitude of the impact the proposed project may have on the health care delivery system; and

    (ii) Preparation of a recommended decision for consideration by the full Commission.

  (5) The Commission shall designate a single Commissioner to act as a reviewer for the application and any competing applications.

  (6) The Commission shall delegate to its staff the responsibility for an initial review of an application, including, in the event that no written comments on an application are submitted by any interested party other than the staff of the Commission, the preparation of a recommended decision for consideration by the full Commission.

  (7) Any "interested party" may submit written comments on the application in accordance with procedural regulations adopted by the Commission.

  (8) The Commission shall define the term "interested party" to include, at a minimum:

    (i) The staff of the Commission;

    (ii) Any applicant who has submitted a competing application;

    (iii) Any other person who can demonstrate that the person would be adversely affected by the decision of the Commission on the application;

    (iv) A local health planning agency for a jurisdiction or region in which the proposed facility or service will be located; and

    (v) In the review of a replacement acute general hospital project proposed by or on behalf of a regional health system that serves multiple contiguous jurisdictions, a jurisdiction within the region served by the regional health system that does not contain the proposed replacement acute general hospital project.

  (9) The reviewer shall review the application, any written comments on the application, and any other materials permitted by this section or by the Commission's regulations, and present a recommended decision on the application to the full Commission.

  (10)

    (i) An applicant and any interested party may request the opportunity to present oral argument to the reviewer, in accordance with regulations adopted by the Commission, before the reviewer prepares a recommended decision on the application for consideration by the full Commission.

    (ii) The reviewer may grant, deny, or impose limitations on an interested party's request to present oral argument to the reviewer.

  (11) Any interested party who has submitted written comments under paragraph (7) of this subsection may submit written exceptions to the proposed decision and make oral argument to the Commission, in accordance with regulations adopted by the Commission, before the Commission takes final action on the application.

  (12) The Commission shall, after determining that the recommended decision is complete, vote to approve, approve with conditions, or deny the application on the basis of the recommended decision, the record before the staff or the reviewer, and exceptions and arguments, if any, before the Commission.

  (13) The decision of the Commission shall be by a majority of the quorum present and voting.

(e) Where the State health plan identifies a need for additional hospital bed capacity in a region or subregion, in a comparative review of 2 or more applicants for hospital bed expansion projects, a certificate of need shall be granted to 1 or more applicants in that region or subregion that:

  (1) Have satisfactorily met all applicable standards;

  (2)

    (i) Have within the preceding 10 years voluntarily delicensed the greater of 10 beds or 10 percent of total licensed bed capacity to the extent of the beds that are voluntarily delicensed; or

    (ii) Have been previously granted a certificate of need which was not recertified by the Commission within the preceding 10 years; and

  (3) The Commission finds at least comparable to all other applicants.

(f)

  (1) If any party or interested person requests an evidentiary hearing with respect to a certificate of need application for any health care facility other than an ambulatory surgical facility and the Commission, in accordance with criteria it has adopted by regulation, considers an evidentiary hearing appropriate due to the magnitude of the impact that the proposed project may have on the health care delivery system, the Commission or a committee of the Commission shall hold the hearing in accordance with the contested case procedures of the Administrative Procedure Act.

  (2) Except as provided in this section or in regulations adopted by the Commission to implement the provisions of this section, the review of an application for a certificate of need for an ambulatory surgical facility is not subject to the contested case procedures of Title 10, Subtitle 2 of the State Government Article.

(g)

  (1) An application for a certificate of need shall be acted upon by the Commission no later than 150 days after the application was docketed.

  (2) If an evidentiary hearing is not requested, the Commission's decision on an application shall be made no later than 90 days after the application was docketed.

(h)

  (1) The applicant or any aggrieved party, as defined in Sec. 19-128(a) of this subtitle, may petition the Commission within 15 days for a reconsideration.

  (2) The Commission shall decide whether or not it will reconsider its decision within 30 days of receipt of the petition for reconsideration.

  (3) The Commission shall issue its reconsideration decision within 30 days of its decision on the petition.

(i)

  (1) Except as provided in paragraph (2) of this subsection, if the Commission does not act on an application within the required period, the applicant may file with a court of competent jurisdiction within 60 days after expiration of the period a petition to require the Commission to act on the application.

  (2)

    (i) This paragraph does not apply to an application for a certificate of need involving:

      (1) The establishment of a health care facility;

      (2) The relocation of a health care facility; or

      (3) The introduction by a hospital of cardiac surgery or organ transplantation.

    (ii) A certificate of need filed after October 1, 2019, shall be deemed approved if:

      (1) The certificate of need is uncontested; and

      (2) Final action by the Commission does not occur within 120 days after the application for the certificate of need was docketed.

#### Section 19-127

The circuit court for the county where a health care project is being developed or operated in violation of this Part II of this subtitle may enjoin further development or operation.

#### Section 19-128

(a)

  (1) In this section, "aggrieved party" means:

    (i) An interested party who presented written comments on the application to the Commission and who would be adversely affected by the decision of the Commission on the project; or

    (ii) The Secretary.

  (2) The grounds for appeal by the Secretary shall be that the decision is inconsistent with the State health plan or adopted standards.

(b)

  (1) A decision of the Commission shall be the final decision for purposes of judicial review.

  (2) A request for a reconsideration will stay the final decision of the Commission for purposes of judicial review until a decision is made on the reconsideration.

(c) An aggrieved party may take a direct judicial appeal within 30 days of the final decision of the Commission.

(d) The Commission is a necessary party to an appeal at all levels of the appeal.

(e) In the event of an adverse decision that affects its final decision, the Commission may apply within 30 days by writ of certiorari to the Court of Appeals for review where:

  (1) Review is necessary to secure uniformity of decision, as where the same statute has been construed differently by 2 or more judges; or

  (2) There are other special circumstances that render it desirable and in the public interest that the decision be reviewed.

#### Section 19-129

(a) Notwithstanding the fact that a merger or consolidation may limit free economic competition, the Commission may approve the merger or consolidation of 2 or more hospitals if the merger or consolidation:

  (1) Is not inconsistent with the State health plan or any institution-specific plan;

  (2) Will result in the delivery of more efficient and effective hospital services; and

  (3) Is in the public interest.

(b) Notwithstanding the fact that a merger or consolidation or the joint ownership and operation of major medical equipment may limit free economic competition, a hospital may engage in a merger or consolidation or the joint ownership of major medical equipment that has been approved by the Commission under this section.

#### Section 19-130

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Fund" means the Maryland Trauma Physician Services Fund.

  (3) "Maryland Trauma Specialty Referral Centers" means:

    (i) The Johns Hopkins Health System Burn Program;

    (ii) The Eye Trauma Center at the Wilmer Eye Institute at The Johns Hopkins Hospital; and

    (iii) The Curtis National Hand Center at Union Memorial Hospital.

  (4) "Reasonable compensation equivalent" means the limitation on the cost established by the Centers for Medicare and Medicaid Services that a provider may claim for compensation of services.

  (5) "Rehabilitation hospital" means a facility classified as a special rehabilitation hospital as described in Sec. 19-307 of this title that is affiliated with a trauma center by common ownership.

  (6)

    (i) "Trauma center" means a facility designated by the Maryland Institute for Emergency Medical Services Systems as:

      (1) The State primary adult resource center;

      (2) A Level I trauma center;

      (3) A Level II trauma center;

      (4) A Level III trauma center;

      (5) A pediatric trauma center; or

      (6) The Maryland Trauma Specialty Referral Centers.

    (ii) "Trauma center" includes an out-of-state pediatric trauma center that has entered into an agreement with the Maryland Institute for Emergency Medical Services Systems.

  (7) "Trauma health care practitioner" means a health care practitioner licensed under the Health Occupations Article who provides care in a trauma center or in a rehabilitation hospital to trauma patients on the State trauma registry as defined by the Maryland Institute for Emergency Medical Services Systems.

  (8) "Trauma physician" means a physician who provides care in a trauma center or in a rehabilitation hospital to trauma patients on the State trauma registry as defined by the Maryland Institute for Emergency Medical Services Systems.

  (9) "Uncompensated care" means care provided by a trauma physician or a trauma health care practitioner to a trauma patient on the State trauma registry who:

    (i) Has no health insurance, including Medicare Part B coverage;

    (ii) Is not eligible for medical assistance coverage; and

    (iii) Has not paid the trauma physician or trauma health care practitioner for care provided by the trauma physician or trauma health care practitioner, after documented attempts by the trauma physician or trauma health care practitioner to collect payment.

(b)

  (1) There is a Maryland Trauma Physician Services Fund.

  (2) The purpose of the Fund is to subsidize the documented costs:

    (i) Of uncompensated care incurred by a trauma physician or trauma health care practitioner in providing trauma care to a trauma patient on the State trauma registry;

    (ii) Of undercompensated care incurred by a trauma physician or trauma health care practitioner in providing trauma care to an enrollee of the Maryland Medical Assistance Program who is a trauma patient on the State trauma registry;

    (iii) Incurred by a trauma center to maintain trauma physicians on-call as required by the Maryland Institute for Emergency Medical Services Systems;

    (iv) Incurred by the State primary adult resource center to maintain trauma surgeons, orthopedic surgeons, neurosurgeons, and anesthesiologists on-call and on standby as required by the Maryland Institute for Emergency Medical Services Systems; and

    (v) Incurred by the Commission and the Health Services Cost Review Commission to administer the Fund and audit reimbursement requests to assure appropriate payments are made from the Fund.

  (3) The Commission and the Health Services Cost Review Commission shall administer the Fund.

  (4) The Fund is a special, nonlapsing fund that is not subject to Sec. 7-302 of the State Finance and Procurement Article.

  (5) Interest on and other income from the Fund shall be separately accounted for and credited to the Fund, and are not subject to Sec. 6-226(a) of the State Finance and Procurement Article.

(c) The Fund consists of:

  (1) Motor vehicle registration surcharges paid into the Fund in accordance with Sec. 13-954(b)(2) of the Transportation Article;

  (2) At least 20% of the fines collected under Sec. 21-902(a)(1), (b)(2), (c)(2), and (d)(1) of the Transportation Article; and

  (3) Any other money transferred from the General Fund of the State.

(d)

  (1) Disbursements from the Fund shall be made in accordance with a methodology established jointly by the Commission and the Health Services Cost Review Commission to calculate costs incurred by trauma physicians and trauma centers that are eligible to receive reimbursement under subsection (b) of this section.

  (2) The Fund shall transfer to the Maryland Department of Health an amount sufficient to fully cover the State's share of expenditures for the costs of undercompensated care incurred by a trauma physician in providing trauma care to an enrollee of the Maryland Medical Assistance Program who is a trauma patient on the State trauma registry.

  (3) The methodology developed under paragraph (1) of this subsection shall:

    (i) Take into account:

      (1) The amount of uncompensated care provided by trauma physicians;

      (2) The amount of undercompensated care attributable to the treatment of Medicaid enrollees in trauma centers;

      (3) The cost of maintaining trauma physicians on-call;

      (4) The number of patients served by trauma physicians in trauma centers;

      (5) The number of Maryland residents served by trauma physicians in trauma centers; and

      (6) The extent to which trauma-related costs are otherwise subsidized by hospitals, the federal government, and other sources; and

    (ii) Include an incentive to encourage hospitals to continue to subsidize trauma-related costs not otherwise included in hospital rates.

  (4) The methodology developed under paragraph (1) of this subsection shall use the following parameters to determine the amount of reimbursement made to trauma physicians and trauma centers from the Fund:

    (i)

      (1) The cost incurred by a Level II trauma center to maintain trauma surgeons, orthopedic surgeons, and neurosurgeons on-call shall be reimbursed:

      (A) At a rate of up to 60% of the reasonable compensation equivalent hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare economic index as designated by the Centers for Medicare and Medicaid Services; and

      (B) For the minimum number of trauma physicians required to be on-call, as specified by the Maryland Institute for Emergency Medical Services Systems in its criteria for Level II trauma centers;

      (2) The cost incurred by a Level III trauma center to maintain trauma surgeons, orthopedic surgeons, neurosurgeons, and anesthesiologists on-call shall be reimbursed:

      (A) At a rate of up to 60% of the reasonable compensation equivalent hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare economic index as designated by the Centers for Medicare and Medicaid Services; and

      (B) For the minimum number of trauma physicians required to be on-call, as specified by the Maryland Institute for Emergency Medical Services Systems in its criteria for Level III trauma centers;

      (3) The cost incurred by a Level I trauma center or pediatric trauma center to maintain trauma surgeons, orthopedic surgeons, and neurosurgeons on-call when a post-graduate resident is attending in the trauma center shall be reimbursed:

      (A) At a rate of up to 60% of the reasonable compensation equivalent hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare economic index as designated by the Centers for Medicare and Medicaid Services; and

      (B) When a post-graduate resident is authorized to be in the trauma center, as specified by the Maryland Institute for Emergency Medical Services Systems in its criteria for Level I trauma centers or pediatric trauma centers;

      (4) The cost incurred by a Maryland Trauma Specialty Referral Center to maintain trauma surgeons on-call in the specialty of the Center when a post-graduate resident is attending in the Center shall be reimbursed:

      (A) At a rate of up to 60% of the reasonable compensation equivalent hourly rate for the specialty, inflated to the current year by the physician compensation component of the Medicare economic index as designated by the Centers for Medicare and Medicaid Services; and

      (B) When a post-graduate resident is authorized to be in the Center, as specified by the Maryland Institute for Emergency Medical Services Systems in its criteria for a Maryland Trauma Specialty Referral Center; and

      (5)

        (A) A Level II trauma center is eligible for a maximum of 26,280 hours of trauma on-call per year;

      (B) A Level III trauma center is eligible for a maximum of 35,040 hours of trauma on-call per year;

      (C) A Level I trauma center shall be eligible for a maximum of 4,380 hours of trauma on-call per year;

      (D) A pediatric trauma center shall be eligible for a maximum of 4,380 hours of trauma on-call per year; and

      (E) A Maryland Trauma Specialty Referral Center shall be eligible for a maximum of 2,190 hours of trauma on-call per year;

    (ii) The cost of undercompensated care incurred by a trauma physician in providing trauma care to enrollees of the Maryland Medical Assistance Program who are trauma patients on the State trauma registry shall be reimbursed at a rate of up to 100% of the Medicare payment for the service, minus any amount paid by the Maryland Medical Assistance Program;

    (iii) The cost of uncompensated care incurred by a trauma physician in providing trauma care to trauma patients on the State trauma registry shall be reimbursed at a rate of 100% of the Medicare payment for the service, minus any recoveries made by the trauma physician for the care;

    (iv) The Commission, in consultation with the Health Services Cost Review Commission, may establish a payment rate for uncompensated care incurred by a trauma physician in providing trauma care to trauma patients on the State trauma registry that is above 100% of the Medicare payment for the service if:

      (1) The Commission determines that increasing the payment rate above 100% of the Medicare payment for the service will address an unmet need in the State trauma system; and

      (2) The Commission reports on its intention to increase the payment rate to the Senate Finance Committee and the House Health and Government Operations Committee, in accordance with Sec. 2-1257 of the State Government Article, at least 60 days before any adjustment to the rate;

    (v) The Commission shall develop guidelines for the reimbursement of the documented costs of the State primary adult resource center under subsection (b)(2)(iv) of this section;

    (vi) The Commission, in consultation with the Health Services Cost Review Commission, may change the percentage of the reasonable compensation equivalent paid to trauma hospitals if:

      (1) The Commission determines that the projected revenue to be collected in the Fund is adequate to support the proposed increase in the percentage of reasonable compensation equivalent inflated to the current year by the physician compensation component of the Medicare economic index; and

      (2) The Commission reports on its intention to change the percentage of reasonable compensation equivalent to be paid for on-call costs to the Senate Finance Committee and the House Health and Government Operations Committee, in accordance with Sec. 2-1257 of the State Government Article, at least 60 days before any adjustment to the allowable hours;

    (vii) The Commission, in consultation with the Health Services Cost Review Commission, may change the number of allowable hours of trauma on-call each year if the Commission reports on its intention to change the number of allowable hours to the Senate Finance Committee and the House Health and Government Operations Committee, in accordance with Sec. 2-1257 of the State Government Article, at least 60 days before any adjustment to the allowable hours;

    (viii) The Commission may modify the percentage paid of the reasonable compensation equivalent for on-call hours not more than once each year; and

    (ix) The total reimbursement to emergency physicians from the Fund may not exceed $300,000 annually.

  (5) In order to receive reimbursement, a trauma physician or trauma health care practitioner in the case of costs of uncompensated care under subsection (b)(2)(i) of this section, or a trauma center in the case of on-call costs under subsection (b)(2)(iii) of this section, shall apply to the Fund on a form and in a manner approved by the Commission and the Health Services Cost Review Commission.

  (6)

    (i) The Commission and the Health Services Cost Review Commission shall adopt regulations that specify the information that trauma physicians, trauma health care practitioners, and trauma centers must submit to receive money from the Fund.

    (ii) The information required shall include:

      (1) The name and federal tax identification number of the trauma physician rendering the service;

      (2) The date of the service;

      (3) Appropriate codes describing the service;

      (4) Any amount recovered for the service rendered;

      (5) The name of the trauma patient;

      (6) The patient's trauma registry number; and

      (7) Any other information the Commission and the Health Services Cost Review Commission consider necessary to disburse money from the Fund.

    (iii) It is the intent of the General Assembly that trauma physicians and trauma centers shall cooperate with the Commission and the Health Services Cost Review Commission by providing information required under this paragraph in a timely and complete manner.

(e)

  (1) Except as provided in paragraph (2) of this subsection and notwithstanding any other provision of law, expenditures from the Fund for costs incurred in any fiscal year may not exceed revenues of the Fund.

  (2)

    (i) The Commission, in consultation with the Health Services Cost Review Commission and the Maryland Institute for Emergency Medical Services Systems, shall develop a process for the award of grants to Level I, Level II, and Level III trauma centers in the delivery of trauma care.

    (ii)

      (1) The Commission shall issue grants under this paragraph from any balance carried over to the Fund from prior fiscal years.

      (2) The total amount of grants awarded under this paragraph in a fiscal year may not reduce the balance remaining in the Fund at the end of the fiscal year to less than 15% of the revenue collected in that fiscal year.

    (iii) The process developed by the Commission for the award of grants under this paragraph shall include:

      (1) Grant applications and review and selection criteria for the award of grants;

      (2) Review by the Commission, if necessary, for any project that exceeds certificate of need thresholds; and

      (3) Any other procedure determined necessary by the Commission.

    (iv) Before awarding grants under this subsection in a fiscal year, the Commission shall report to the Senate Finance Committee and the House Health and Government Operations Committee, in accordance with Sec. 2-1257 of the State Government Article, on the process that the Commission has developed for awarding grants in that fiscal year.

(f) On or before November 1 of each year, the Commission and the Health Services Cost Review Commission shall report to the General Assembly, in accordance with Sec. 2-1257 of the State Government Article, on:

  (1) The amount of money in the Fund on the last day of the previous fiscal year;

  (2) The amount of money applied for by trauma physicians, trauma health care practitioners, and trauma centers during the previous fiscal year;

  (3) The amount of money distributed in the form of trauma physician, trauma health care practitioner, and trauma center reimbursements during the previous fiscal year;

  (4) Any recommendations for altering the manner in which trauma physicians, trauma health care practitioners, and trauma centers are reimbursed from the Fund;

  (5) The costs incurred in administering the Fund during the previous fiscal year;

  (6) The amount that each hospital that participates in the Maryland trauma system and that has a trauma center contributes toward the subsidization of trauma-related costs for its trauma center;

  (7) The costs that hospitals reported to the Health Services Cost Review Commission and are accounted for in the global budgets of the hospitals for each of the following:

    (i) Trauma standby;

    (ii) Allowable trauma center costs for reimbursing the trauma director and trauma staff;

    (iii) Maintaining Maryland Institute for Emergency Medical Services Systems trauma protocols;

    (iv) Maintaining specialized trauma staff;

    (v) Procuring specialized trauma equipment; and

    (vi) Providing trauma education and training; and

  (8) Any improvements made by trauma centers as a result of an increase in funding.

(g) The Commission shall award an annual grant from the Fund in the amount up to $1,800,000 to Level I pediatric trauma centers as follows:

  (1) Up to $900,000 to Johns Hopkins Children's Center; and

  (2) Up to $900,000 to Children's National Medical Center.

#### Section 19-132

(a) In this Part III of this subtitle the following words have the meanings indicated.

(b) "Ambulatory surgical facility" has the meaning stated in Sec. 19-3B-01 of this title.

(c) "Carrier" means:

  (1) An insurer or nonprofit health service plan that holds a certificate of authority and provides health insurance policies or contracts in the State in accordance with the Insurance Article; or

  (2) A health maintenance organization that holds a certificate of authority in the State.

(d) "Comprehensive standard health benefit plan" means the comprehensive standard health benefit plan adopted in accordance with Sec. 15-1207 of the Insurance Article.

(e)

  (1) "Health benefit plan" means a hospital or medical policy, contract, or certificate issued by a carrier.

  (2) "Health benefit plan" does not include:

    (i) Coverage for accident or disability income insurance;

    (ii) Coverage issued as a supplement to liability insurance;

    (iii) Liability insurance, including general liability insurance and automobile liability insurance;

    (iv) Workers' compensation or similar insurance;

    (v) Automobile or property medical payment insurance;

    (vi) Credit-only insurance;

    (vii) Coverage for on-site medical clinics;

    (viii) Dental or vision insurance;

    (ix) Long-term care insurance or benefits for nursing home care, home health care, community-based care, or any combination of these;

    (x) Coverage only for a specified disease or illness;

    (xi) Hospital indemnity or other fixed indemnity insurance; or

    (xii) The following benefits if offered as a separate insurance policy:

      (1) Medicare supplemental health insurance, as defined in Sec. 1882(g)(1) of the Social Security Act;

      (2) Coverage supplemental to the coverage provided under Chapter 55 of Title 10 of the United States Code; or

      (3) Similar supplemental coverage provided to coverage under an employer sponsored plan.

(f) "Health care practitioner" means any individual who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide health care services.

(g)

  (1) "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; or

    (ii) A facility where health care is provided to patients or recipients, including:

      (1) A facility, as defined in Sec. 10-101(g) of this article;

      (2) A hospital, as defined in Sec. 19-301 of this title;

      (3) A related institution, as defined in Sec. 19-301 of this title;

      (4) A health maintenance organization, as defined in Sec. 19-701(g) of this title;

      (5) An outpatient clinic; and

      (6) A medical laboratory.

  (2) "Health care provider" includes the agents and employees of a facility who are licensed or otherwise authorized to provide health care, the officers and directors of a facility, and the agents and employees of a health care provider who are licensed or otherwise authorized to provide health care.

(h) "Health care service" means any health or medical care procedure or service rendered by a health care practitioner that:

  (1) Provides testing, diagnosis, or treatment of human disease or dysfunction; or

  (2) Dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of human disease or dysfunction.

(i) "Hospital" has the meaning stated in Sec. 19-301 of this title.

(j)

  (1) "Mandated health insurance service" means a legislative proposal or statute that would require a particular health care service to be provided or offered in a health benefit plan, by a carrier or other organization authorized to provide health benefit plans in the State.

  (2) "Mandated health insurance service", as applicable to all carriers, does not include services enumerated to describe a health maintenance organization under Sec. 19-701(g)(2) of this title.

(k) "Nursing facility" has the meaning stated in Sec. 19-1401 of this title.

(l)

  (1) "Office facility" means the office of one or more health care practitioners in which health care services are provided to individuals.

  (2) "Office facility" includes a facility that provides:

    (i) Ambulatory surgery;

    (ii) Radiological or diagnostic imagery; or

    (iii) Laboratory services.

  (3) "Office facility" does not include any office, facility, or service operated by a hospital and regulated under Part II of this subtitle.

(m) "Payor" means:

  (1) A health insurer or nonprofit health service plan that holds a certificate of authority and provides health insurance policies or contracts in the State in accordance with this article or the Insurance Article;

  (2) A health maintenance organization that holds a certificate of authority in the State; or

  (3) For the purposes of this Part III of this subtitle only, a person that is registered as an administrator under Title 8, Subtitle 3 of the Insurance Article.

#### Section 19-133

(a) In this section, "code" means:

  (1) The applicable Current Procedural Terminology (CPT) code as adopted by the American Medical Association; or

  (2) If a CPT code is not available, the applicable code under an appropriate uniform coding scheme approved by the Commission.

(b) The Commission shall establish a Maryland medical care data base to compile statewide data on health services rendered by health care practitioners and facilities selected by the Commission.

(c) In addition to any other information the Commission may require by regulation, the medical care data base shall:

  (1) Collect for each type of patient encounter with a health care practitioner or facility designated by the Commission:

    (i) The demographic characteristics of the patient;

    (ii) The principal diagnosis;

    (iii) The procedure performed;

    (iv) The date and location of where the procedure was performed;

    (v) The charge for the procedure;

    (vi) If the bill for the procedure was submitted on an assigned or nonassigned basis;

    (vii) If applicable, a health care practitioner's universal identification number; and

    (viii) If the health care practitioner rendering the service is a certified registered nurse anesthetist or certified nurse midwife, identification modifiers for the certified registered nurse anesthetist or certified nurse midwife;

  (2) Collect appropriate information relating to prescription drugs for each type of patient encounter with a pharmacist designated by the Commission; and

  (3) Collect appropriate information relating to health care costs, utilization, or resources from payors and governmental agencies.

(d)

  (1) The Commission shall adopt regulations governing the access and retrieval of all medical claims data and other information collected and stored in the medical care data base and any claims clearinghouse licensed by the Commission and may set reasonable fees covering the costs of accessing and retrieving the stored data.

  (2) These regulations shall ensure that confidential or privileged patient information is kept confidential.

  (3) Records or information protected by the privilege between a health care practitioner and a patient, or otherwise required by law to be held confidential, shall be filed in a manner that does not disclose the identity of the person protected.

(e)

  (1) To the extent practicable, when collecting the data required under subsection (c) of this section, the Commission shall utilize any standardized claim form or electronic transfer system being used by health care practitioners, facilities, and payors.

  (2) The Commission shall develop appropriate methods for collecting the data required under subsection (c) of this section on subscribers or enrollees of health maintenance organizations.

(f) Until the provisions of Sec. 19-134 of this subtitle are fully implemented, where appropriate, the Commission may limit the data collection under this section.

(g)

  (1) By October 1, 1995 and each year thereafter, the Commission shall publish an annual report on those health care services selected by the Commission that:

    (i) Describes the variation in fees charged by health care practitioners and facilities on a statewide basis and in each health service area for those health care services; and

    (ii) Describes the geographic variation in the utilization of those health care services.

  (2)

    (i) On an annual basis, the Commission shall publish:

      (1) The total reimbursement for all health care services over a 12-month period;

      (2) The total reimbursement for each health care specialty over a 12-month period;

      (3) The total reimbursement for each code over a 12-month period; and

      (4) The annual rate of change in reimbursement for health services by health care specialties and by code.

    (ii) In addition to the information required under subparagraph (i) of this paragraph, the Commission may publish any other information that the Commission deems appropriate, including information on capitated health care services.

(h) In developing the medical care data base, the Commission shall consult with representatives of the Health Services Cost Review Commission, health care practitioners, payors, and hospitals to ensure that the medical care data base is compatible with information collected by the Health Services Cost Review Commission.

(i) The Commission, in consultation with the Insurance Commissioner, payors, health care practitioners, and hospitals, may adopt by regulation standards for the electronic submission of data and submission and transfer of the uniform claims forms established under Sec. 15-1003 of the Insurance Article.

#### Section 19-134

(a)

  (1) In order to more efficiently establish a medical care data base under Sec. 19-133 of this subtitle, the Commission shall establish standards for the operation of one or more medical care electronic claims clearinghouses in Maryland and may license those clearinghouses meeting those standards.

  (2) In adopting regulations under this subsection, the Commission shall consider appropriate national standards.

  (3) The Commission may limit the number of licensed claims clearinghouses to assure maximum efficiency and cost effectiveness.

  (4) The Commission, by regulation, may charge a reasonable licensing fee to operate a licensed claims clearinghouse.

  (5) Health care practitioners in Maryland, as designated by the Commission, shall submit, and payors of health care services in Maryland as designated by the Commission shall receive claims for payment and any other information reasonably related to the medical care data base electronically in a standard format as required by the Commission whether by means of a claims clearinghouse or other method approved by the Commission.

  (6) The Commission shall establish reasonable deadlines for the phasing in of electronic transmittal of claims from those health care practitioners designated under paragraph (5) of this subsection.

  (7) As designated by the Commission, payors of health care services in Maryland and Medicaid and Medicare shall transmit explanations of benefits and any other information reasonably related to the medical care data base electronically in a standard format as required by the Commission whether by means of a claims clearinghouse or other method approved by the Commission.

(b) The Commission may collect the medical care claims information submitted to any licensed claims clearinghouse for use in the data base established under Sec. 19-133 of this subtitle.

(c)

  (1) The Commission shall:

    (i) Establish and implement a system to comparatively evaluate the quality of care and performance of categories of health benefit plans as determined by the Commission on an objective basis; and

    (ii) Annually publish the summary findings of the evaluation.

  (2) The purpose of the evaluation system established under this subsection is to assist carriers to improve care by establishing a common set of quality and performance measurements and disseminating the findings to carriers and other interested parties.

  (3) The system, where appropriate, shall:

    (i) Solicit performance information from enrollees of health benefit plans;

    (ii) Establish and incorporate a standard set of measures regarding racial and ethnic variations in quality and outcomes; and

    (iii) Include information on the actions taken by carriers to track and reduce health disparities, including whether the health benefit plan provides culturally appropriate educational materials for its members.

  (4)

    (i) The Commission shall adopt regulations to establish the system of evaluation provided under this subsection.

    (ii) Before adopting regulations to implement an evaluation system under this subsection, the Commission shall consider recommendations of nationally recognized organizations that are involved in quality of care and performance measurement.

    (iii) In implementing paragraph (3)(ii) and (iii) of this subsection, the Commission shall consult with appropriate stakeholders, including at least one representative of a carrier that does business predominantly in the State and a carrier that does business in the State and nationally, to determine national standards for evaluating the effectiveness of carriers in addressing health disparities and to fulfill the purposes of paragraph (3)(ii) and (iii) of this subsection in a manner that can be easily replicated in other states.

  (5) The Commission may contract with a private, nonprofit entity to implement the system required under this subsection provided that the entity is not an insurer.

  (6) The annual evaluation summary required under paragraph (1) of this subsection shall include to the extent feasible information on racial and ethnic variations.

(d)

  (1) The Commission, in consultation with the Maryland Department of Health and the Department of Aging, shall:

    (i) On or before July 1, 2001, develop and implement a system to comparatively evaluate the quality of care and performance of nursing facilities on an objective basis; and

    (ii) Annually publish the summary findings of the evaluation.

  (2)

    (i) The purpose of the comparative evaluation system established under this subsection is to improve the quality of care provided by nursing facilities by establishing a common set of performance measures and disseminating the findings of the comparative evaluation to nursing facilities, consumers, and other interested parties.

    (ii) In developing the comparative evaluation system, the Commission shall consider the health status of the population served.

  (3)

    (i) The system, as appropriate, shall solicit performance information from consumers and their families.

    (ii) On or before October 1, 2007, to the extent feasible, the system shall incorporate racial and ethnic variations.

  (4) The Commission may adopt regulations to establish the comparative evaluation system provided under this subsection.

(e)

  (1) The Commission may:

    (i) On or before July 1, 2001, develop and implement a system to comparatively evaluate the quality of care outcomes and performance measurements of hospitals and ambulatory surgical facilities on an objective basis; and

    (ii) Annually publish the summary findings of the evaluation.

  (2)

    (i) The purpose of a comparable performance measurement system established under this subsection is to improve the quality of care provided by hospitals and ambulatory surgical facilities by establishing a common set of performance measurements and disseminating the findings of the performance measurements to hospitals, ambulatory surgical facilities, consumers, and interested parties.

    (ii) In developing the performance measurement system, the Commission shall consider the geographic location, urban or rural orientation, and teaching or nonteaching status of the hospital and the ambulatory surgical facilities, and the health status of the population served.

  (3)

    (i) The system, where appropriate, shall solicit performance information from consumers.

    (ii) On or before October 1, 2007, to the extent feasible, the system shall incorporate racial and ethnic variations.

  (4)

    (i) The Commission may adopt regulations to establish the system of evaluation provided under this subsection.

    (ii) Before adopting regulations to implement an evaluation system under this subsection, the Commission shall:

      (1) Consider the performance measurements of appropriate accreditation organizations, State licensure regulations, Medicare certification regulations, the quality indicator project of the Association of Maryland Hospitals and Health Systems, and any other relevant performance measurements; and

      (2) Evaluate the desirability and feasibility of developing a consumer clearinghouse on health care information using existing available data.

  (5) The Commission may contract with a private entity to implement the system required under this subsection provided that the entity is not a hospital or an ambulatory surgical facility.

  (6)

    (i) The comparable evaluation system established under this subsection shall include health care-associated infection information from hospitals.

    (ii) The comparable evaluation system shall adhere, to the extent possible, to the current recommendations of the federal Centers for Disease Control and Prevention (CDC) and the CDC Healthcare Infection Control Practices Advisory Committee regarding public reporting of health care-associated infections.

(f)

  (1) The Commission shall compile data on:

    (i) Racial and ethnic disparities in insurance coverage for low-income, nonelderly individuals;

    (ii) The racial and ethnic composition of the physician population compared to the racial and ethnic composition of the State's population; and

    (iii) Morbidity and mortality rates based on race and ethnicity for cardiovascular disease, cancer, diabetes, HIV/AIDS, infant mortality, asthma, and other diseases the Commission identifies.

  (2) The Commission shall:

    (i) Provide the racial and ethnic information compiled under this subsection to the Office of Minority Health and Health Disparities; and

    (ii) Analyze the information jointly with the Office of Minority Health and Health Disparities for publication in the "Health Care Disparities Policy Report Card" required under Sec. 20-1006(b)(2) of this article.

  (3)

    (i) The Commission shall evaluate the feasibility of obtaining information from urban and rural populations in order to identify geographic disparities.

    (ii) If the Commission is able to obtain the information described in subparagraph (i) of this paragraph, the Commission shall provide the information to the Office of Minority Health and Health Disparities.

(g) For purposes of this section, the Commission shall collect racial and ethnic information and data that is reasonably collectable from any national, State, or county source that is reasonably available.

#### Section 19-135

(a) The Commission may implement a system to encourage health care practitioners to voluntarily control the costs of health care services.

(b) The Commission may require health care practitioners of selected health care specialties to cooperate with licensed operators of clinical resource management systems that allow health care practitioners to critically analyze their charges and utilization of services in comparison to their peers.

(c) If the Commission determines that clinical resource management systems are not available in the private sector, the Commission, in consultation with interested parties including payors, health care practitioners, and the Association of Maryland Hospitals and Health Systems, may develop a clinical resource management system.

(d) The Commission may adopt regulations to govern the licensing of clinical resource management systems to ensure the accuracy and confidentiality of information provided by the system.

#### Section 19-136

In any matter that relates to the utilization or cost of health care services rendered by health care practitioners or office facilities, the Commission may:

(1) Hold a public hearing;

(2) Conduct an investigation; or

(3) Require the filing of any reasonable information.

#### Section 19-137

If the Commission considers a further investigation necessary or desirable to authenticate information in a report that a health care practitioner or office facility files under this subtitle, the Commission may make necessary further examination of the records or accounts of the health care practitioner or office facility, in accordance with the regulations of the Commission.

#### Section 19-142

(a) In this Part IV of this subtitle the following words have the meanings indicated.

(b) "Carrier" means:

  (1) An insurer;

  (2) A nonprofit health service plan;

  (3) A health maintenance organization; or

  (4) Any other person that provides health benefit plans subject to regulation by the State.

(c) "Electronic health record" means an electronic record of health-related information on an individual that:

  (1) Includes patient demographic and clinical health information; and

  (2) Has the capacity to:

    (i) Provide clinical decision support;

    (ii) Support physician order entry;

    (iii) Capture and query information relevant to health care quality; and

    (iv) Exchange electronic health information with and integrate the information from other sources.

(d)

  (1) "Health benefit plan" means a hospital or medical policy, contract, or certificate issued by a carrier.

  (2) "Health benefit plan" does not include:

    (i) Coverage for accident or disability income insurance;

    (ii) Coverage issued as a supplement to liability insurance;

    (iii) Liability insurance, including general liability insurance and automobile liability insurance;

    (iv) Workers' compensation or similar insurance;

    (v) Automobile or property medical payment insurance;

    (vi) Credit-only insurance;

    (vii) Coverage for on-site medical clinics;

    (viii) Dental or vision insurance;

    (ix) Long-term care insurance or benefits for nursing home care, home health care, community-based care, or any combination of these;

    (x) Coverage only for a specified disease or illness;

    (xi) Hospital indemnity or other fixed indemnity insurance; or

    (xii) The following benefits if offered as a separate insurance policy:

      (1) Medicare supplemental health insurance, as defined in Sec. 1882(g)(1) of the Social Security Act;

      (2) Coverage supplemental to the coverage provided under Chapter 55 of Title 10, U.S.C.; or

      (3) Similar supplemental coverage provided to coverage under an employer-sponsored plan.

(e)

  (1) "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; or

    (ii) A facility where health care is provided to patients or recipients, including:

      (1) A facility, as defined in Sec. 10-101(g) of this article;

      (2) A hospital, as defined in Sec. 19-301 of this title;

      (3) A related institution, as defined in Sec. 19-301 of this title;

      (4) An outpatient clinic;

      (5) A freestanding medical facility, as defined in Sec. 19-3A-01 of this title;

      (6) An ambulatory surgical facility, as defined in Sec. 19-3B-01 of this title; and

      (7) A nursing home, as defined in Sec. 19-1401 of this title.

  (2) "Health care provider" does not include a health maintenance organization as defined in Sec. 19-701 of this title.

(f) "Health information exchange" has the meaning stated in Sec. 4-301 of this article.

(g) "Management service organization" means an organization that offers one or more hosted electronic health record solutions and other management services to multiple health care providers.

(h) "State-designated health information exchange" means the health information exchange designated by the Maryland Health Care Commission and the Health Services Cost Review Commission under Sec. 19-143 of this subtitle.

(i)

  (1) "State-regulated payor" means a carrier issuing or delivering health benefit plans in the State.

  (2) "State-regulated payor" does not include a managed care organization as defined in Title 15, Subtitle 1 of this article.

#### Section 19-143

(a)

  (1) On or before October 1, 2009, the Commission and the Health Services Cost Review Commission shall designate a health information exchange for the State.

  (2) The Secretary, to align funding opportunities with the purposes of this section and the development and effective operation of the State-designated health information exchange, may provide grants to the State-designated health information exchange.

(b)

  (1) On or before September 1, 2011, the Commission, in consultation with the Department, payors, and health care providers, shall adopt regulations that require State-regulated payors to provide incentives to health care providers to promote the adoption and meaningful use of electronic health records.

  (2) Incentives required under the regulations:

    (i) Shall have monetary value;

    (ii) Shall facilitate the use of electronic health records by health care providers in the State;

    (iii) To the extent feasible, shall recognize and be consistent with existing payor incentives that promote the adoption and meaningful use of electronic health records;

    (iv) Shall take into account:

      (1) Incentives provided to health care providers under Medicare and Medicaid; and

      (2) Any grants or loans that are available to health care providers from the federal government;

    (v) May include:

      (1) Increased reimbursement for specific services;

      (2) Lump sum payments;

      (3) Gain-sharing arrangements;

      (4) Rewards for quality and efficiency;

      (5) In-kind payments; and

      (6) Other items or services to which a specific monetary value can be assigned; and

    (vi) Shall be paid in cash, unless the State-regulated payor and the health care provider agree on an incentive of equivalent value.

  (3) The regulations need not require incentives for the adoption and meaningful use of electronic health records for each type of health care provider listed in Sec. 19-142(e) of this subtitle.

  (4) If federal law is amended to allow the State to regulate payments made by entities that self-insure their health benefit plans, regulations adopted under this section shall apply to those entities to the same extent to which they apply to State-regulated payors.

  (5) Regulations adopted under this subsection:

    (i) May not require a group model health maintenance organization, as defined in Sec. 19-713.6 of this title, to provide an incentive to a health care provider who is employed by the multispecialty group of physicians under contract with the group model health maintenance organization; and

    (ii) Shall allow a State-regulated payor to:

      (1) Request information from a health care provider to validate the health care provider's incentive claim; and

      (2) If the State-regulated payor determines that a duplicate incentive payment or an overpayment has been made, reduce the incentive amount.

  (6) The Commission may:

    (i) Audit the State-regulated payor or the health care provider for compliance with the regulations adopted under this subsection; and

    (ii) If it finds noncompliance, request corrective action.

  (7) It is the intent of the General Assembly that the State Employee and Retiree Health and Welfare Benefits Program support the incentives provided under this subsection through contracts between the Program and the third party administrators arranging for the delivery of health care services to members covered under the Program.

(c) The Health Services Cost Review Commission, in consultation with hospitals, payors, and the federal Centers for Medicare and Medicaid Services, shall take the actions necessary to:

  (1) Assure that hospitals in the State receive the payments provided under Sec. 4102 of the federal American Recovery and Reinvestment Act of 2009 and any subsequent federal rules and regulations; and

  (2) Implement any changes in hospital rates required by the federal Centers for Medicare and Medicaid Services to ensure compliance with Sec. 4102 of the federal American Recovery and Reinvestment Act of 2009 and any subsequent federal rules and regulations.

(d) The Department, in consultation with the Commission, shall develop a mechanism to assure that health care providers that participate in the Maryland Medical Assistance Program receive the payments provided for adoption and use of electronic health records technology under Sec. 4201 of the federal American Recovery and Reinvestment Act of 2009 and any subsequent federal rules and regulations.

(e)

  (1) On or before October 1, 2012, the Commission shall designate one or more management service organizations to offer services throughout the State.

  (2) The Commission may use federal grants and loans to help subsidize the use of the designated management service organizations by health care providers.

(f) On and after the later of January 1, 2015, or the date established for the imposition of penalties under Sec. 4102 of the federal American Recovery and Reinvestment Act of 2009:

  (1) Each health care provider using an electronic health record that seeks payment from a State-regulated payor shall use electronic health records that are:

    (i) Certified by a national certification organization designated by the Commission; and

    (ii) Capable of connecting to and exchanging data with the State-designated health information exchange; and

  (2) The incentives required under subsection (b) of this section may include reductions in payments to a health care provider that does not use electronic health records that meet the requirements of paragraph (1) of this subsection.

#### Section 19-144

(a) To facilitate the use of Web-based technology for electronic advance directives, the Maryland Health Care Commission shall develop criteria for recognizing electronic advance directives services that are authorized to connect to the State-designated health information exchange.

(b) To be authorized to connect to the State-designated health information exchange, an electronic advance directives service shall:

  (1) Be recognized by the Maryland Health Care Commission;

  (2) Be responsible for all costs associated with connecting to the State-designated health information exchange; and

  (3) Store electronic advance directives that are received by facsimile or other electronic means.

(c) The State-designated health information exchange may charge electronic advance directives services recognized by the Maryland Health Care Commission a fee for connecting to the State-designated health information exchange.

(d) The State-designated health information exchange shall ensure that electronic advance directives services do not have access to information stored on the State-designated health information exchange.

#### Section 19-145

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Dispenser" means a person authorized by law to dispense, as defined in Sec. 12-101 of the Health Occupations Article, a prescription drug to a patient or the patient's agent in the State.

  (3) "Noncontrolled prescription drug" means a prescription drug, as defined in Sec. 21-201 of this article, that is not a controlled dangerous substance designated under Title 5, Subtitle 4 of the Criminal Law Article.

  (4) "State-designated health information exchange" has the meaning stated in Sec. 4-301 of this article.

(b) The State-designated health information exchange shall operate as a health data utility for the State.

(c) The purposes of the health data utility include:

  (1) The collection, aggregation, and analysis of clinical information, public health data, and health administrative and operations data to assist the Department, local health departments, the Commission, and the Health Services Cost Review Commission in the evaluation of public health interventions and health equity;

  (2) The communication of data between public health officials and health care providers to advance disease control and health equity; and

  (3) The enhancement and acceleration of the interoperability of health information throughout the State.

(d) Dispensers shall provide data to the State-designated health information exchange.

(e)

  (1) The purpose of this subsection is to:

    (i) Authorize individuals and organizations involved in the treatment and care coordination of patients to access, as legally authorized, a patient's medication history, including medications prescribed for the patient; and

    (ii) Assist health care providers, care managers, the Department, and local health departments to understand and promote matters of health equity and treatment efficacy.

  (2) After dispensing a noncontrolled prescription drug, a dispenser shall submit prescription information to the State-designated health information exchange.

  (3) The prescription information shall be submitted:

    (i) By electronic means;

    (ii) Without unduly increasing the workload and expense on a dispenser;

    (iii) In a manner that minimizes burden and duplication by being as compatible as possible with existing federal standards for data submission practices, including technology software of dispensers; and

    (iv) As otherwise required by regulations adopted by the Commission.

  (4) The State-designated health information exchange may not impose any fees or other assessments on dispensers to support the operation of the exchange.

  (5) The State-designated health information exchange shall make prescription information submitted under this subsection available for purposes of treatment and care coordination of a patient.

(f) The State-designated health information exchange may provide data, as allowed by law, for public health purposes that may include:

  (1) Improving health equity through access to prescription medications, including for the treatment of infectious disease;

  (2) Assisting programs led by health care providers and the Department, local health departments, the Commission, and the Health Services Cost Review Commission to identify opportunities for quality improvement, including for stewardship of antibiotic medications; and

  (3) Conducting case investigations and related activities.

(g) Information submitted to the State-designated health information exchange or provided by the State-designated health information exchange under this section shall be submitted or provided, to the extent practicable, in as near to real time as possible.

(h)

  (1) The Commission, in consultation with appropriate stakeholders, shall adopt regulations to carry out this section.

  (2) The regulations shall take into account consumer perspective and include:

    (i) The specific data required to be provided under subsection (d) of this section;

    (ii) The specific prescription information required to be submitted under subsection (e) of this section;

    (iii) The time frame for submitting prescription information under subsection (e) of this section;

    (iv) The electronic means and manner by which prescription information is to be submitted under subsection (e) of this section;

    (v) Prescription information submission requirements that align with the data submission requirements on dispensers of monitored prescription drugs under Title 21, Subtitle 2A of this article; and

    (vi) Identification and necessary suppression of information related to providers or medications that are determined to have significant potential to cause harm.

(i)

  (1) The State-designated health information exchange shall establish a consumer advisory council to bring the perspectives of individuals and organizations with an interest in protecting consumers into the delivery of services provided by the State-designated health information exchange.

  (2) In selecting members, the State-designated health information exchange shall consider diversity of experience.

  (3) The consumer advisory council established under paragraph (1) of this subsection shall:

    (i) Consist of a minimum of six members, including at least four consumer representatives and two staff representatives, and maintain a ratio of consumer representatives to nonconsumer representatives of at least two to one;

    (ii) Identify and report consumer privacy concerns to senior leadership of the State-designated health information exchange;

    (iii) Advise on efforts to educate consumers on data exchange policies, including options for consumers to opt out of disclosure of protected health information;

    (iv) Meet at least 3 times each year; and

    (v) Adopt and maintain a charter to be posted online that includes the purpose, members, and meeting schedule of the consumer advisory council.

#### Section 19-145.1

(a)

  (1) In this section the following words have the meanings indicated.

  (2)

    (i) "Advance care planning document" means a document that indicates an individual's preferences for the receipt of health care.

    (ii) "Advance care planning document" includes:

      (1) An advance directive; and

      (2) A Medical Orders for Life-Sustaining Treatment form.

  (3) "Carrier" means:

    (i) An insurer;

    (ii) A nonprofit health service plan; and

    (iii) A health maintenance organization.

  (4) "Electronic advance care planning document" means an electronic version of an advance care planning document that is able to be uploaded or saved to the electronic platform developed under subsection (b)(2)(i) of this section.

  (5) "Health care provider" means:

    (i) A health care practitioner who is licensed or certified under the Health Occupations Article to provide health care in the ordinary course of business;

    (ii) A set of health care practitioners, as defined in Sec. 15-113 of this article;

    (iii) A health care facility as defined in Sec. 19-114 of this subtitle;

    (iv) A nursing facility, as defined in Sec. 19-301 of this title; or

    (v) An assisted living program, as defined in Sec. 19-1801 of this title.

(b)

  (1) The Commission shall coordinate the accessibility of electronic advance care planning documents in the State.

  (2) The coordination provided by the Commission under this subsection shall include:

    (i) Collaboration with the State-designated health information exchange to develop an electronic platform through which:

      (1) Individuals can upload or save advance care planning documents;

      (2) Individuals can update electronic advance care planning documents; and

      (3) Health care providers can access electronic advance care planning documents as appropriate;

    (ii) Identification of options meeting federal, State, and industry cybersecurity standards that may be taken by carriers, managed care organizations, and health care providers to:

      (1) Encourage members, enrollees, and patients to create, upload or save, and update advance care planning documents; and

      (2) Make tools, which may include electronic advance directives services recognized by the Commission under Sec. 19-144 of this subtitle, accessible to members, enrollees, and patients that allow them to create, upload or save, and update electronic advance care planning documents;

    (iii) Development and implementation of quality measures endorsed or designated for testing by a national quality measurement organization to measure the effectiveness of the options identified under item (ii) of this paragraph; and

    (iv) Inclusion of a distinct tab on the State-designated health information exchange website that provides:

      (1) Access to the advance directive information sheet developed under Sec. 5-615 of this article;

      (2) The electronic means to create, execute, and store an advance directive or health care designation; and

      (3) The capability to upload or save an advance care planning document to the electronic platform developed in accordance with item (i) of this paragraph and update existing electronic advance care planning documents.

  (3) As the Commission identifies options under paragraph (2)(ii) of this subsection, the Commission may explore whether carriers, managed care organizations, and health care providers with secure member authentication websites can link between the website of the carrier, managed care organization, or health care provider and the State-designated health information exchange website.

  (4) In developing the electronic platform in accordance with paragraph (2)(i) of this subsection, the Commission and the State-designated health information exchange:

    (i) Shall consult with other State agencies and stakeholders, as appropriate; and

    (ii) Subject to available funds, may contract with a third-party vendor, as appropriate.

  (5) The electronic platform developed in accordance with paragraph (2)(i) of this subsection shall:

    (i) Provide an individual with disabilities with nonvisual access in a way that is fully and equally accessible to and independently usable by the individual with disabilities so that the individual is able to acquire the same information, engage in the same interactions, and enjoy the same services as users without disabilities, with substantially equivalent ease of use; and

    (ii) Be consistent with the standards of Sec. 508 of the federal Rehabilitation Act of 1973.

(c) As an option under subsection (b)(2)(ii) of this section, a carrier, managed care organization, or health care provider may contract with an electronic advance directives service if the service:

  (1) Is approved by the Maryland Health Care Commission under Sec. 19-144 of this subtitle; and

  (2) Meets the technology, security, and privacy standards set by the Commission.

(d) The Commission may adopt regulations to carry out this section.

#### Section 19-146

(a) In this Part V of this subtitle the following words have the meanings indicated.

(b) "Carrier" has the meaning stated in Sec. 15-1301 of the Insurance Article.

(c) "Enrollee" means an individual entitled to health benefits from a carrier.

(d) "Physician rating system" has the meaning stated in Sec.  15-1701 of the Insurance Article.

(e) "Ratings examiner" means an independent entity that is approved by the Commission to review physician rating systems.

#### Section 19-147

(a) The Commission shall approve an entity that meets the requirements of this section to be a ratings examiner.

(b) To be approved by the Commission as a ratings examiner, an entity examining a physician rating system shall require a physician rating system to:

  (1) Use only quality of performance and cost efficiency as measurement categories;

  (2) Calculate and disclose separately measures of cost efficiency and quality of performance;

  (3) Disclose clearly to physicians and enrollees the proportion of the component score for cost efficiency and quality of performance in each combined score;

  (4) In determining quality of performance, use measures:

    (i) That are based on nationally recognized, evidence-based or consensus-based clinical recommendations or guidelines; or

    (ii) When available, that are endorsed by entities whose work in physician quality of performance is generally accepted in the health care system;

  (5) Disclose to physicians who are subject to the physician rating system:

    (i) The measurements for each criterion and the relative weight of each criterion and measurement in the overall rating of the physician;

    (ii)

      (1) The basis for the carrier's quality of performance ratings;

      (2) The data used to determine the quality of performance ratings; and

      (3) The relative weight or relevance of quality of performance to the overall rating of a physician in the physician rating system;

    (iii) The basis for determining whether there is a sufficient number of patients and episodes of care for a given disease state and specialty to generate reliable ratings for a physician; and

    (iv) The methodology used to determine how data is attributed to a physician;

  (6) Use appropriate risk adjustments to account for the characteristics of the patient population seen by a physician in determining the quality of performance and cost efficiency of the physician;

  (7) In measuring the cost efficiency of the performance of a physician:

    (i) Compare physicians within the same specialty within the appropriate geographical market; and

    (ii) Use appropriate and comprehensive episode of care computer software to evaluate the cost efficiency of the performance of a physician;

  (8)

    (i) Include an appeals process that a physician subject to the physician rating system may use to appeal the rating received under the physician rating system; and

    (ii) Based on the outcome of an appeal, make any necessary corrections to the data used to rate the physician in the physician rating system; and

  (9) Disclose to physicians and enrollees how the perspectives of enrollees, consumer advocates, employers, labor unions, and physicians were incorporated into the development of the physician rating system.

(c) Notwithstanding subsection (b) of this section, an entity that has a physician performance rating certification program approved after August 1, 2008, by a national consortium of employer, consumer, and labor organizations working toward a common goal to ensure that all Americans have access to publicly reported health care performance information:

  (1) Is deemed to be a ratings examiner under this part; and

  (2) Is deemed to meet the requirements of subsection (b) of this section.

### Subtitle 1B. Community Integrated Medical Home Program

#### Section 19-1B-01

(a) In this subtitle the following words have the meanings indicated.

(b) "Advisory body" means the Community Integrated Medical Home Program advisory body.

(c) "Carrier" has the meaning stated in Sec. 15-1801 of the Insurance Article.

(d) "Commission" means the Maryland Health Care Commission.

(e) "Community integrated medical home" means a certified participating patient centered medical home integrated with community-based services and supports provided by certified entities to address social as well as medical determinants of health.

(f) "Managed care organization" has the meaning stated in Sec. 15-101 of this article.

(g) "Patient centered medical home" means a primary care practice organized to provide a first, coordinated, ongoing, and comprehensive source of care to patients to:

  (1) Foster a partnership with a qualifying individual;

  (2) Coordinate health care services for a qualifying individual; and

  (3) Exchange medical information with carriers, other providers, and qualifying individuals.

#### Section 19-1B-02

(a) There is a Community Integrated Medical Home Program.

(b) The mission of the Community Integrated Medical Home Program is to:

  (1) Keep Maryland families healthy through the use of innovative mapping tools that allow better targeting of resources to those in need;

  (2) Coordinate comprehensive services provided by a participating patient centered medical home with public health resources in local communities across the State; and

  (3) Provide complementary support for qualified individuals between office visits.

(c) The Community Integrated Medical Home Program shall be administered jointly by the Commission and the Department.

#### Section 19-1B-03

(a) There is a Community Integrated Medical Home Program advisory body.

(b) The advisory body shall make recommendations concerning:

  (1) The model, standards, and scope of services for the Community Integrated Medical Home Program;

  (2) The essential elements for implementing the Community Integrated Medical Home Program, including those necessary to attract patient centered medical homes, carriers, managed care organizations, and other payors to participate in the Program;

  (3) The extent and nature of the relationship between the Community Integrated Medical Home Program and patient centered medical homes, carriers, managed care organizations, and other payors; and

  (4) How the Community Integrated Medical Home Program can be financially self-sustaining.

(c) The advisory body shall include interested stakeholders representing health care provider organizations, consumer advocacy organizations, health professional associations, health occupations boards, carriers, and managed care organizations.

(d) The Commission and the Secretary, in consultation, shall:

  (1) Appoint the members of the advisory body; and

  (2) Determine the frequency and location of meetings of the advisory body.

### Subtitle 1C. Safety and Community Relations Plans

#### Section 19-1C-01

(a) Before the Department approves the operation of a facility under this title, including by granting a license to the facility, the Department shall require the facility to establish and implement:

  (1) A safety plan for the safety of the individuals served by the facility; and

  (2) A community relations plan, if the facility is:

    (i) Accredited by an accreditation organization, as defined in Sec. 19-2301 of this title; and

    (ii) Required by the accreditation organization to establish and implement a community relations plan.

(b) The Department may authorize a facility to satisfy the requirement under:

  (1) Subsection (a)(1) of this section by implementing a safety plan established for the facility for another purpose, including an emergency plan; and

  (2) Subsection (a)(2) of this section by implementing the community relations plan required by the accreditation organization.

(c) A facility in operation on or before September 30, 2021, shall submit a safety plan on or before October 1, 2023, in accordance with this section.

(d) Each facility shall revise its safety plan not less than every 5 years.

(e) A facility may satisfy the requirement under subsection (c) of this section by implementing a safety or emergency plan established for the facility for another purpose.

### Subtitle 2. Health Services Cost Review Commission

#### Section 19-201

(a) In this subtitle the following words have the meanings indicated.

(b) "All-payer model contract" means the payment model demonstration agreement authorized under Sec. 1115A of the Social Security Act, including any amendments to the agreement, between the State and the federal Center for Medicare and Medicaid Innovation.

(c) "Commission" means the State Health Services Cost Review Commission.

(d) "Facility" means, whether operated for a profit or not:

  (1) Any hospital; or

  (2) Any related institution.

(e)

  (1) "Hospital services" means:

    (i) Inpatient hospital services as enumerated in Medicare Regulation 42 C.F.R. Sec. 409.10, as amended;

    (ii) Emergency services, including services provided at a freestanding medical facility licensed under Subtitle 3A of this title;

    (iii) Outpatient services provided at a hospital;

    (iv) Outpatient services, as specified by the Commission in regulation, provided at a freestanding medical facility licensed under Subtitle 3A of this title that has received:

      (1) A certificate of need under Sec. 19-120(o)(1) of this title; or

      (2) An exemption from obtaining a certificate of need under Sec. 19-120(o)(3) of this title; and

    (v) Identified physician services for which a facility has Commission-approved rates on June 30, 1985.

  (2) "Hospital services" includes a hospital outpatient service:

    (i) Of a hospital that, on or before June 1, 2015, is under a merged asset hospital system;

    (ii) That is designated as a part of another hospital under the same merged asset hospital system to make it possible for the hospital outpatient service to participate in the 340B Program under the federal Public Health Service Act; and

    (iii) That complies with all federal requirements for the 340B Program and applicable provisions of 42 C.F.R. Sec. 413.65.

  (3) "Hospital services" does not include:

    (i) Outpatient renal dialysis services; or

    (ii) Outpatient services provided at a limited service hospital as defined in Sec. 19-301 of this title, except for emergency services.

(f)

  (1) "Related institution" means an institution that is licensed by the Department as:

    (i) A comprehensive care facility that is currently regulated by the Commission; or

    (ii) An intermediate care facility-intellectual disability.

  (2) "Related institution" includes any institution in paragraph (1) of this subsection, as reclassified from time to time by law.

#### Section 19-202

There is a State Health Services Cost Review Commission. The Commission is an independent commission that functions in the Department.

#### Section 19-203

(a)

  (1) The Commission consists of 7 members appointed by the Governor with the advice and consent of the Senate.

  (2) Of the 7 members, 4 shall be individuals who do not have any connection with the management or policy of any facility.

(b) Each member shall be interested in problems of health care.

(c)

  (1) The term of a member is 4 years.

  (2) The terms of members are staggered as required by the terms provided for members of the Commission on July 1, 1982. The terms of those members end as follows:

    (i) 2 in 1983;

    (ii) 1 in 1984;

    (iii) 2 in 1985; and

    (iv) 2 in 1986.

  (3) At the end of a term, a member continues to serve until a successor is appointed and qualifies.

  (4) A member who is appointed after a term has begun serves only for the rest of the term and until a successor is appointed and qualifies.

  (5) A member who serves 2 consecutive full 4-year terms may not be reappointed for 4 years after completion of those terms.

  (6) When appointing a member to fill a vacancy due to the expiration of a member's term, the Governor shall give consideration to, and make appointments when appropriate, that would promote the racial, gender, and geographic diversity of the Commission.

#### Section 19-204

Annually, from among the members of the Commission:

(1) The Governor shall appoint a chairman; and

(2) The chairman shall appoint a vice chairman.

#### Section 19-205

(a) With the approval of the Governor, the Commission shall appoint an Executive Director, who is the chief administrative officer of the Commission.

(b) The Executive Director serves at the pleasure of the Commission.

(c) Under the direction of the Commission, the Executive Director shall perform any duty or function that the Commission requires.

#### Section 19-206

(a) A majority of the full authorized membership of the Commission is a quorum. However, the Commission may not act on any matter unless at least 4 members in attendance concur.

(b) The Commission shall meet at least 6 times a year, at the times and places that it determines.

(c) Each member of the Commission is entitled to:

  (1) Compensation in accordance with the State budget; and

  (2) Reimbursement for expenses under the Standard State Travel Regulations, as provided in the State budget.

(d)

  (1) The Commission may employ a staff in accordance with the State budget.

  (2) The Commission, in consultation with the Secretary, may set the compensation of a Commission employee in a position that:

    (i) Is unique to the Commission;

    (ii) Requires specific skills or experience to perform the duties of the position; and

    (iii) Does not require the employee to perform functions that are comparable to functions performed in other units of the Executive Branch of State government.

  (3) The Secretary of Budget and Management, in consultation with the Commission, shall determine the positions for which the Commission may set compensation under paragraph (2) of this subsection.

  (4) The Deputy Director and each principal section chief of the Commission serve at the pleasure of the Commission.

  (5) The Commission, in consultation with the Secretary, may determine the appropriate job classifications for the Executive Director, Deputy Director, and each principal section chief of the Commission.

#### Section 19-207

(a) In addition to the powers set forth elsewhere in this subtitle, the Commission may:

  (1) Adopt rules and regulations to carry out the provisions of this subtitle;

  (2) Create committees from among its members;

  (3) Appoint advisory committees, which may include individuals and representatives of interested public or private organizations;

  (4) Apply for and accept any funds, property, or services from any person or government agency;

  (5) Make agreements with a grantor or payor of funds, property, or services, including an agreement to make any study, plan, demonstration, or project;

  (6) Publish and give out any information that relates to the financial aspects of health care and is considered desirable in the public interest; and

  (7) Subject to the limitations of this subtitle, exercise any other power that is reasonably necessary to carry out the purposes of this subtitle.

(b) In addition to the duties set forth elsewhere in this subtitle, the Commission shall:

  (1) Adopt rules and regulations that relate to its meetings, minutes, and transactions;

  (2) Keep minutes of each meeting;

  (3) Prepare annually a budget proposal that includes the estimated income of the Commission and proposed expenses for its administration and operation;

  (4) Within a reasonable time after the end of each facility's fiscal year or more often as the Commission determines, prepare from the information filed with the Commission any summary, compilation, or other supplementary report that will advance the purposes of this subtitle;

  (5) Periodically participate in or do analyses and studies that relate to:

    (i) Health care costs;

    (ii) The financial status of any facility; or

    (iii) Any other appropriate matter;

  (6) On or before May 1 of each year, submit to the Governor, to the Secretary, and, subject to Sec. 2-1257 of the State Government Article, to the General Assembly an annual report on the operations and activities of the Commission during the preceding fiscal year, including:

    (i) A copy of each summary, compilation, and supplementary report required by this subtitle;

    (ii) Budget information regarding the Health Services Cost Review Commission Fund, including:

      (1) Any balance remaining in the Fund at the end of the previous fiscal year; and

      (2) The percentage of the total annual costs of the Commission that is represented by the balance remaining in the Fund at the end of the previous fiscal year;

    (iii) A summary of the Commission's role in hospital quality of care activities, including information about the status of any pay for performance initiatives;

    (iv) An update on the status of the State's compliance with the provisions of the all-payer model contract that includes:

      (1) Performance in limiting inpatient and outpatient hospital per capita cost growth for all payers;

      (2) Annual progress toward achieving the State's financial targets established by the all-payer model contract;

      (3) A summary of the work conducted, recommendations made, including recommendations made by workgroups created to provide technical input and advice, and Commission action on activities related to the all-payer model contract;

      (4) Actions approved by the Commission to promote alternative methods of rate determination and payment of an experimental nature, as authorized under Sec. 19-219(c)(2) of this subtitle;

      (5) Reports submitted to the federal Center for Medicare and Medicaid Innovation relating to the all-payer model contract;

      (6) Any known adverse consequences in implementing the all-payer model contract, as reported to the federal Center for Medicare and Medicaid Innovation, that may negatively impact quality of or access to care, and the actions taken by the Commission to mitigate the consequences; and

      (7) Annual progress made in the development of public and private partnerships between hospitals and other entities, including community-based physicians, community-based organizations, and other post-acute care providers, to achieve the population health goals established with the federal Center for Medicare and Medicaid Innovation; and

    (v) Any other fact, suggestion, or policy recommendation that the Commission considers necessary;

  (7) Oversee and administer the Maryland Trauma Physician Services Fund in conjunction with the Maryland Health Care Commission; and

  (8) If the Centers for Medicare and Medicaid Services issues a warning notice related to a "triggering event" as described in the all-payer model contract, provide written notification to the Governor, the Secretary, and, subject to Sec. 2-1257 of the State Government Article, the General Assembly within 15 days after the issuance of the notice.

(c)

  (1) The Commission shall set deadlines for the filing of reports required under this subtitle.

  (2) The Commission may adopt rules or regulations that impose penalties for failure to file a report as required.

  (3) The amount of any penalty under paragraph (2) of this subsection may not be included in the costs of a facility in regulating its rates.

(d) Except for privileged medical information, the Commission shall make:

  (1) Each report filed and each summary, compilation, and report required under this subtitle available for public inspection at the office of the Commission during regular business hours; and

  (2) Each summary, compilation, and report available to any agency on request.

(e)

  (1) The Commission may contract with a qualified, independent third party for any service necessary to carry out the powers and duties of the Commission.

  (2) Unless permission is granted specifically by the Commission, a third party hired by the Commission may not release, publish, or otherwise use any information to which the third party has access under its contract.

#### Section 19-208

(a) The power of the Secretary over plans, proposals, and projects of units in the Department does not include the power to disapprove or modify any decision or determination that the Commission makes under authority specifically delegated by law to the Commission.

(b)

  (1) The power of the Secretary to transfer by rule, regulation, or written directive, any staff, functions, or funds of units in the Department does not apply to any staff, function, or funds of the Commission.

  (2) The Secretary may assess an administrative charge on the Commission to fund services provided to the Commission by the Department.

  (3) The amount to be paid by the Commission to the Department for administrative costs, not to exceed 30.5% of the salaries of the Commission, shall be based on indirect costs or services benefiting the Commission, less overhead costs paid directly by the Commission.

(c)

  (1) The power of the Secretary over the procurement procedure for units in the Department does not apply to the procurement procedure for the Commission.

  (2) Subject to the provisions of paragraph (1) of this subsection, any procurement for services to be performed or for supplies to be delivered to the Commission is subject to the purposes and requirements of the State Finance and Procurement Article.

#### Section 19-210

(a) In this section, "Fund" means the Maternal and Child Health Population Health Improvement Fund.

(b) There is a Maternal and Child Health Population Health Improvement Fund.

(c) The purpose of the Fund is to invest in maternal and child population health improvements through the Medical Care Programs Administration and the Prevention and Health Promotion Administration.

(d) The Department and the Commission shall administer the Fund.

(e)

  (1) The Fund is a special, nonlapsing fund that is not subject to Sec. 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) A uniform, broad-based assessment of a reasonable amount in hospital rates in order to invest in maternal and child population health improvements under Sec. 19-207 of this subtitle;

  (2) Interest earnings; and

  (3) Any other money from any other source accepted for the benefit of the Fund.

(g) The Fund may be used only for expenses associated with maternal and child health population health improvements through December 31, 2027.

(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 Fund.

(i) Expenditures from the Fund may be made only:

  (1) In accordance with the State budget; and

  (2) After the approval of a majority of the members of the Commission.

(j) Money expended from the Fund is supplemental to and is not intended to take the place of funding that would otherwise be appropriated for the Maryland Medical Assistance Program.

(k) The Fund is subject to audit by the Office of Legislative Audits as provided in Sec. 2-1220 of the State Government Article.

#### Section 19-211

(a)

  (1) Except for a facility that is operated or is listed and certified by the First Church of Christ Scientist, Boston, Massachusetts, the Commission has jurisdiction over hospital services offered by or through all facilities.

  (2) The jurisdiction of the Commission over any identified physician service shall terminate for a facility on the request of the facility.

  (3) The rate approved for an identified physician service may not exceed the rate on June 30, 1985, adjusted by an appropriate index of inflation.

(b) The Commission may not set rates for related institutions until:

  (1) State law authorizes the State Medical Assistance Program to reimburse related institutions at Commission rates; and

  (2) The United States Department of Health and Human Services agrees to accept Commission rates as a method of providing federal financial participation in the State Medical Assistance Program.

(c) The Commission shall set rates for hospital services provided at:

  (1) A freestanding medical facility pilot project authorized under Subtitle 3A of this title prior to January 1, 2008; and

  (2) A freestanding medical facility licensed under Subtitle 3A of this title.

#### Section 19-212

The Commission shall:

(1) Require each facility to disclose publicly:

  (i) Its financial position; and

  (ii) As computed by methods that the Commission determines, the verified total costs incurred and revenue generated by the facility in providing health services;

(2) Review for reasonableness and certify the rates and revenue of each facility;

(3) Keep informed as to whether a facility has enough resources to meet its financial requirements;

(4) Concern itself with solutions if a facility does not have enough resources;

(5) Assure each purchaser of health care facility services that:

  (i) The total costs of all hospital services offered by or through a facility are reasonable;

  (ii) The aggregate rates of the facility are related reasonably to the aggregate costs of the facility; and

  (iii) Rates are set equitably among all purchasers of services without undue discrimination;

(6) Develop guidelines for the establishment of global budgets for each facility under Maryland's all-payer model contract, including guidelines to prevent facilities from taking actions to meet a budget that the Commission determines would have adverse consequences for recipients or purchasers of services;

(7) Receive confirmation from Commission staff that facility global budget agreements, as they are developed, are consistent with the guidelines; and

(8) After review by the Commission for compliance with the guidelines, post each executed global budget agreement on the Commission's website.

#### Section 19-213

(a) In this section, "facilities" means hospitals and related institutions whose rates have been approved by the Commission.

(b) The Commission shall assess and collect user fees on facilities as defined in this section.

(c)

  (1) The total fees assessed by the Commission may not exceed the greater of:

    (i)

      (0) 1% of the immediately preceding fiscal year's budgeted, regulated, gross hospital revenue; or

    (ii) The largest amount determined under this paragraph for a fiscal year during the immediately preceding 5 fiscal years.

  (2) The total user fees assessed by the Commission may not exceed the Special Fund appropriation for the Commission by more than 20%.

  (3) The user fees assessed by the Commission shall be used exclusively to cover the actual documented direct costs of fulfilling the statutory and regulatory duties of the Commission in accordance with the provisions of this subtitle and any administrative costs for services to the Commission provided by the Department.

  (4) The Commission shall pay all funds collected from fees assessed in accordance with this section into the Health Services Cost Review Commission Fund.

  (5) The user fees assessed by the Commission may be expended only for purposes authorized by the provisions of this subtitle.

  (6) The amount specified in paragraph (1) of this subsection limits only the total user fees the Commission may assess in a fiscal year.

(d)

  (1) There is a Health Services Cost Review Commission Fund.

  (2) The Fund is a special continuing, nonlapsing fund that is not subject to Sec. 7-302 of the State Finance and Procurement Article.

  (3) The Treasurer shall separately hold, and the Comptroller shall account for, the Fund.

  (4) The Fund shall be invested and reinvested in the same manner as other State funds.

  (5) Any investment earnings shall be retained to the credit of the Fund.

  (6) The Fund shall be subject to an audit by the Office of Legislative Audits as provided for in Sec. 2-1220 of the State Government Article.

  (7) This section may not be construed to prohibit the Fund from receiving funds from any other source.

  (8)

    (i) The Fund shall be used only to provide funding for the Commission and for the purposes authorized under this subtitle.

    (ii) The costs of the Commission include the administrative costs incurred by the Department on behalf of the Commission.

(e) The Commission shall:

  (1) Assess user fees for each facility equal to the sum of:

    (i) The amount equal to one half of the total user fees times the ratio of admissions of the facility to total admissions of all facilities; and

    (ii) The amount equal to one half of the total user fees times the ratio of gross operating revenue of each facility to total gross operating revenues of all facilities;

  (2) Establish minimum and maximum assessments; and

  (3) Assess each facility on or before June 30 of each year.

(f)

  (1) On or before September 1 of each year, each facility assessed under this section shall make payment to the Commission.

  (2) The Commission shall make provision for partial payments.

(g) Any bill not paid within 30 days of an agreed payment date may be subject to an interest penalty to be determined by the Commission.

(h)

  (1) This section shall terminate and be of no effect on the first day of July following the cessation of a waiver by law or agreement for Medicare and Medicaid between the State of Maryland and the federal government.

  (2)

    (i) If notice of intent to terminate is made by the federal government to this State before the first day of an intervening session of the Maryland General Assembly, this section shall expire June 30 of the following calendar year.

    (ii) Under no circumstances shall less than 7 calendar months occur between notice of termination and expiration of this section.

#### Section 19-214

(a) The Commission shall assess the underlying causes of hospital uncompensated care and make recommendations to the General Assembly on the most appropriate alternatives to:

  (1) Reduce uncompensated care; and

  (2) Assure the integrity of the payment system.

(b) The Commission may adopt regulations establishing alternative methods for financing the reasonable total costs of hospital uncompensated care and the disproportionate share hospital payment provided that the alternative methods:

  (1) Are in the public interest;

  (2) Will equitably distribute the reasonable costs of uncompensated care and the disproportionate share hospital payment;

  (3) Will fairly determine the cost of reasonable uncompensated care and the disproportionate share hospital payment included in hospital rates;

  (4) Will continue incentives for hospitals to adopt fair, efficient, and effective credit and collection policies; and

  (5) Will not result in significantly increasing costs to Medicare or termination of the all-payer model contract.

(c) Any funds generated through hospital rates under an alternative method adopted by the Commission in accordance with subsection (b) of this section may only be used to finance the delivery of hospital uncompensated care and the disproportionate share hospital payment.

(d)

  (1) Each year, the Commission shall assess a uniform, broad-based, and reasonable amount in hospital rates to reflect the aggregate reduction in hospital uncompensated care realized from the expansion of health care coverage under Chapter 7 of the Acts of the 2007 Special Session of the General Assembly.

  (2)

    (i)

      (1) The Commission shall ensure that the assessment amount equals 1.25% of projected regulated net patient revenue.

      (2) Each hospital shall remit its assessment amount to the Health Care Coverage Fund established under Sec. 15-701 of this article.

    (ii) Any savings realized in averted uncompensated care as a result of the expansion of health care coverage under Chapter 7 of the Acts of the 2007 Special Session of the General Assembly that are not subject to the assessment under paragraph (1) of this subsection shall be shared among purchasers of hospital services in a manner that the Commission determines is most equitable.

  (3)

    (i) Funds generated from the assessment under this subsection may be used only to supplement coverage under the Medical Assistance Program beyond the eligibility requirements in existence on January 1, 2008.

    (ii) Any funds remaining after the expenditure of funds under subparagraph (i) of this paragraph has been made may be used for the general operations of the Medicaid program.

#### Section 19-214.1

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Financial hardship" means medical debt, incurred by a family over a 12-month period, that exceeds 25% of family income.

  (3) "Medical debt" means out-of-pocket expenses, including co-payments, coinsurance, and deductibles, for medical costs.

  (4) "Medically necessary care" means care that is:

    (i) Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;

    (ii) Consistent with accepted standards of good medical practice; and

    (iii) Not primarily for the convenience of the patient, the patient's family, or the provider.

(b)

  (1) The Commission shall require each acute care hospital and each chronic care hospital in the State under the jurisdiction of the Commission to develop a financial assistance policy for providing free and reduced-cost care to patients who lack health care coverage or whose health care coverage does not pay the full cost of the hospital bill.

  (2) The financial assistance policy shall provide, at a minimum:

    (i) Free medically necessary care to patients with family income at or below 200% of the federal poverty level, calculated at the time of service or updated, as appropriate, to account for any change in financial circumstances of the patient that occurs within 240 days after the initial hospital bill is provided;

    (ii) Reduced-cost medically necessary care to low-income patients with family income above 200% of the federal poverty level, calculated at the time of service or updated, as appropriate, to account for any change in financial circumstances of the patient that occurs within 240 days after the initial hospital bill is provided;

    (iii) A description of the availability of the payment plan required under Sec. 19-214.2(d) of this subtitle; and

    (iv) A mechanism for a patient to request the hospital to reconsider the denial of free or reduced-cost care that includes in the request:

      (1) The Health Education and Advocacy Unit is available to assist the patient or the patient's authorized representative in filing and mediating a reconsideration request; and

      (2) The address, phone number, facsimile number, e-mail address, mailing address, and website of the Health Education and Advocacy Unit.

  (3)

    (i) The Commission by regulation may establish income thresholds higher than those under paragraphs (2) and (4) of this subsection.

    (ii) In establishing income thresholds that are higher than those under paragraph (2) of this subsection for a hospital, the Commission shall take into account:

      (1) The patient mix of the hospital;

      (2) The financial condition of the hospital;

      (3) The level of bad debt experienced by the hospital; and

      (4) The amount of charity care provided by the hospital.

  (4) Subject to income thresholds set under paragraph (3) of this subsection, the financial assistance policy required under this subsection shall provide reduced-cost medically necessary care to patients with family income below 500% of the federal poverty level who have a financial hardship.

  (5)

    (i) If a patient is eligible for reduced-cost medically necessary care under paragraph (2)(ii) of this subsection, the hospital shall, at a minimum, reduce the patient's out-of-pocket expenses for the regulated hospital service:

      (1) For a patient with family income of at least 201% but not more than 250% of the federal poverty level, by 75%; and

      (2) For a patient with family income of more than 250% but not more than 300% of the federal poverty level, by 60%.

    (ii) If a patient is eligible for reduced-cost medically necessary care under paragraph (4) of this subsection, the hospital shall, at a minimum, reduce the patient's out-of-pocket expenses for the regulated hospital service:

      (1) For a patient with family income of at least 201% but not more than 250% of the federal poverty level, by 75%;

      (2) For a patient with family income of more than 250% but not more than 300% of the federal poverty level, by 60%;

      (3) For a patient with family income of more than 300% but not more than 350% of the federal poverty level, by 50%;

      (4) For a patient with family income of more than 350% but not more than 400% of the federal poverty level, by 45%;

      (5) For a patient with family income of more than 400% but not more than 450% of the federal poverty level, by 40%; and

      (6) For a patient with family income of more than 450% but not more than 500% of the federal poverty level, by 35%.

  (6) If a patient has received reduced-cost medically necessary care due to a financial hardship, the patient or any immediate family member of the patient living in the same household:

    (i) Shall remain eligible for reduced-cost medically necessary care when seeking subsequent care at the same hospital during the 12-month period beginning on the date on which the reduced-cost medically necessary care was initially received; and

    (ii) To avoid an unnecessary duplication of the hospital's determination of eligibility for free and reduced-cost care, shall inform the hospital of the patient's or family member's eligibility for the reduced-cost medically necessary care.

  (7) The financial assistance policy required under this subsection shall provide presumptive eligibility for free medically necessary care to a patient who is not eligible for the Maryland Medical Assistance Program or Maryland Children's Health Program and:

    (i) Lives in a household with a child who is enrolled in the free and reduced-cost meal program and is eligible for the program based on the household's income;

    (ii) Receives benefits through the federal Supplemental Nutrition Assistance Program;

    (iii) Receives benefits through the State's Energy Assistance Program;

    (iv) Receives benefits through the federal Special Supplemental Food Program for Women, Infants, and Children; or

    (v) Receives benefits from any other social service program as determined by the Department and the Commission.

  (8)

    (i) A hospital may consider only household monetary assets in excess of $100,000 when determining eligibility for free and reduced-cost care under the hospital's financial assistance policy.

    (ii) If a hospital considers household monetary assets under subparagraph (i) of this paragraph, retirement assets that the Internal Revenue Service has granted preferential tax treatment as a retirement account, including deferred-compensation plans qualified under the Internal Revenue Code or nonqualified deferred-compensation plans shall be excluded.

  (9)

    (i) In determining the family income of a patient, a hospital shall apply a definition of household size that consists of the patient and, at a minimum, the following individuals:

      (1) A spouse, regardless of whether the patient and spouse expect to file a joint federal or State tax return;

      (2) Biological children, adopted children, or stepchildren; and

      (3) Anyone for whom the patient claims a personal exemption in a federal or State tax return.

    (ii) For a patient who is a child, the household size shall consist of the child and the following individuals:

      (1) Biological parents, adopted parents, or stepparents or guardians;

      (2) Biological siblings, adopted siblings, or stepsiblings; and

      (3) Anyone for whom the patient's parents or guardians claim a personal exemption in a federal or State tax return.

  (10)

    (i) A hospital shall provide notice of the hospital's financial assistance policy to the patient, the patient's family, or the patient's authorized representative before discharging the patient and in each communication to the patient regarding collection of the hospital bill.

    (ii) The notice required under subparagraph (i) of this paragraph shall state that the patient has up to 240 days after the day the patient receives the initial hospital bill to apply for financial assistance from the hospital.

    (iii)

      (1) The hospital shall obtain documentation ensuring that the patient or the patient's authorized representative acknowledges the patient's receipt of the notice before discharging the patient.

      (2) If a patient chooses not to apply for financial assistance, the patient's documented acknowledgment shall indicate that the patient is not applying on the day of the acknowledgment but may apply within 240 days immediately following the patient's receipt of the initial hospital bill.

  (11) The hospital shall consider any change in the patient's financial circumstance that occurs during the 240-day period following the patient's receipt of the initial hospital bill if the patient informs the hospital of the change in financial circumstance on or before the conclusion of the 240-day period.

(c)

  (1) A hospital shall post a notice in conspicuous places throughout the hospital, including the billing office, informing patients of their right to apply for financial assistance and who to contact at the hospital for additional information.

  (2) The notice required under paragraph (1) of this subsection shall:

    (i) Be in simplified language in at least 10 point type; and

    (ii) Be provided in the patient's preferred language or, if no preferred language is specified, each language spoken by a limited English proficient population that constitutes at least 5% of the overall population within the city or county in which the hospital is located as measured by the most recent census.

(d) The Commission shall:

  (1) Develop a uniform financial assistance application; and

  (2) Require each hospital to use the uniform financial assistance application to determine eligibility for free and reduced-cost care under the hospital's financial assistance policy.

(e) The uniform financial assistance application:

  (1) Shall be written in simplified language; and

  (2) May not require documentation that presents an undue barrier to a patient's receipt of financial assistance.

(f)

  (1) Each hospital shall develop an information sheet that:

    (i) Describes the hospital's financial assistance policy and includes a section that allows for a patient to initial that the patient has been made aware of the financial assistance policy;

    (ii) Describes a patient's rights and obligations with regard to hospital billing and collection under the law;

    (iii) Provides contact information for the individual or office at the hospital that is available to assist the patient, the patient's family, or the patient's authorized representative in order to understand:

      (1) The patient's hospital bill;

      (2) The patient's rights and obligations with regard to the hospital bill;

      (3) How to apply for free and reduced-cost care; and

      (4) How to apply for the Maryland Medical Assistance Program and any other programs that may help pay the bill;

    (iv) Provides contact information for the Maryland Medical Assistance Program;

    (v) Includes a statement that physician charges are not included in the hospital bill and are billed separately; and

    (vi) Informs patients of the right to request and receive a written estimate of the total charges for hospital nonemergency services, procedures, and supplies that reasonably are expected to be provided for professional services by the hospital.

  (2) The information sheet shall:

    (i) Be in simplified language in at least 10 point type; and

    (ii) Be in the patient's preferred language or, if no preferred language is specified, each language spoken by a limited English proficient population that constitutes at least 5% of the overall population within the city or county in which the hospital is located as measured by the most recent census.

  (3) The information sheet shall be provided to the patient, the patient's family, or the patient's authorized representative:

    (i) Before discharge;

    (ii) With the hospital bill;

    (iii) On request; and

    (iv) In each written communication to the patient regarding collection of the hospital bill.

  (4) The hospital bill shall include a reference to the information sheet.

  (5) The Commission shall:

    (i) Establish uniform requirements for the information sheet; and

    (ii) Review each hospital's implementation of and compliance with the requirements of this subsection.

(g) Each hospital shall ensure the availability of staff who are trained to work with the patient, the patient's family, and the patient's authorized representative in order to understand:

  (1) The patient's hospital bill;

  (2) The patient's rights and obligations with regard to the hospital bill, including the patient's rights and obligations with regard to reduced-cost medically necessary care due to a financial hardship;

  (3) How to apply for the Maryland Medical Assistance Program and any other programs that may help pay the hospital bill; and

  (4) How to contact the hospital for additional assistance.

(h) Each hospital shall develop a procedure to determine a patient's eligibility under the hospital's financial assistance policy in which the hospital:

  (1) Determines whether the patient has health insurance;

  (2) Determines whether the patient is presumptively eligible for free or reduced-cost care under subsection (b)(7) of this section;

  (3) Determines whether uninsured patients are eligible for public or private health insurance;

  (4) To the extent practicable, offers assistance to uninsured patients if the patient chooses to apply for public or private health insurance;

  (5) To the extent practicable, determines whether the patient is eligible for other public programs that may assist with health care costs;

  (6) Uses information in the possession of the hospital, if available, to determine whether the patient is qualified for free or reduced-cost care under the hospital's financial assistance policy; and

  (7) When a patient submits a completed application for financial assistance, determines the patient's eligibility under the hospital's financial assistance policy within 14 days after the patient applies for financial assistance and suspends any billing or collections actions while eligibility is being determined.

(i) A hospital may not:

  (1) Use a patient's citizenship or immigration status as an eligibility requirement for financial assistance; or

  (2) Withhold financial assistance or deny a patient's application for financial assistance on the basis of race, color, religion, ancestry or national origin, sex, age, marital status, sexual orientation, gender identity, genetic information, or on the basis of disability.

(j) Each hospital shall submit to the Commission annually at times prescribed by the Commission:

  (1) The hospital's financial assistance policy developed under this section; and

  (2) An annual report on the hospital's financial assistance policy that includes:

    (i) The total number of patients who completed or partially completed an application for financial assistance during the prior year;

    (ii) The total number of inpatients and outpatients who received:

      (1) Free care during the immediately preceding year; and

      (2) Reduced-cost care for the prior year;

    (iii) The total number of patients who received financial assistance during the immediately preceding year by race or ethnicity and gender;

    (iv) The total number of patients who were denied financial assistance during the immediately preceding year by race or ethnicity and gender;

    (v) The total amount of the costs of hospital services provided to patients who received free care; and

    (vi) The total amount of the costs of hospital services provided to patients who received reduced-cost care that was either covered by the hospital as financial assistance or that the hospital charged to the patient.

(k)

  (1) The Commission shall post on its website each hospital's financial assistance policy and annual report.

  (2) The Commission shall compile the reports required under subsection (j) of this section and issue a hospital financial assistance report.

  (3) The hospital financial assistance report required under paragraph (2) of this subsection shall be made available to the public free of charge.

  (4) On or before December 1 each year, the Commission shall submit a copy of the annual hospital financial assistance report issued under paragraph (2) of this subsection, in accordance with Sec. 2-1257 of the State Government Article, to the Senate Finance Committee and the House Health and Government Operations Committee.

#### Section 19-214.2

(a)

  (1) Each hospital annually shall submit to the Commission:

    (i) At times prescribed by the Commission, the hospital's policy on the collection of debts owed by patients; and

    (ii) A report including:

      (1) The total number of patients by race or ethnicity, gender, and zip code of residence against whom the hospital, or a debt collector used by the hospital, filed an action to collect a debt owed on a hospital bill;

      (2) The total number of patients by race or ethnicity, gender, and zip code of residence with respect to whom the hospital has and has not reported or classified a bad debt;

      (3) The total dollar amount of the charges for hospital services provided to patients but not collected by the hospital for patients covered by insurance, including the out-of-pocket costs for patients covered by insurance, and patients without insurance; and

      (4) For hospital debts owed by patients of the hospital that the hospital sold to a governmental unit, contractor, or nonprofit organization under subsection (l) of this section:

      (A) The total dollar amount of the debt sold by the hospital for the reporting year;

      (B) The total dollar amount paid to the hospital by the unit, contractor, or nonprofit organization who purchased the debt; and

      (C) The total number of patients whose debt was sold, in full or in part, to the unit, contractor, or nonprofit organization who purchased the debt.

  (2) The Commission shall post the information submitted under paragraph (1) of this subsection on its website.

(b) The policy submitted under subsection (a)(1) of this section shall:

  (1) Provide for active oversight by the hospital of any contract for collection of debts on behalf of the hospital;

  (2) Except as provided in subsection (l) of this section, prohibit the hospital from selling any debt;

  (3) Describe in detail the consideration by the hospital of patient income, assets, and other criteria;

  (4) Prohibit the hospital from reporting adverse information to a consumer reporting agency;

  (5) Prohibit the hospital from filing a civil action to collect a debt within 240 days after the initial bill is provided;

  (6) Prohibit the hospital from filing a civil action to collect a debt against a patient whose outstanding debt is at or below $500;

  (7) Describe the hospital's procedures for collecting a debt;

  (8) Describe the circumstances in which the hospital will seek a judgment against a patient;

  (9) In accordance with subsection (c) of this section, provide for a refund of amounts collected from a patient or the guarantor of a patient who was later found to be eligible for free care within 240 days after the initial bill was provided;

  (10) If the hospital has obtained a judgment against or reported adverse information to a consumer reporting agency about a patient who later was found to be eligible for free care within 240 days after the initial bill was provided for which the judgment was awarded or the adverse information was reported, require the hospital to seek to vacate the judgment or strike the adverse information;

  (11) Provide a mechanism for a patient to:

    (i) Request the hospital to reconsider the denial of free or reduced-cost care;

    (ii) File with the hospital a complaint against the hospital or a debt collector used by the hospital regarding the handling of the patient's bill; and

    (iii) Allow the patient and the hospital to mutually agree to modify the terms of a payment plan offered under subsection (d) of this section or entered into with the patient;

  (12) For a patient who is eligible for free or reduced-cost care under the hospital's financial assistance policy, prohibit the hospital from:

    (i) Charging interest on the debt owed on a bill for the patient before a court judgment is obtained; or

    (ii) Collecting fees or any other amount that exceeds the approved charge for the hospital service as established by the Commission;

  (13) Require the hospital to dismiss actions pending against a patient for collection of debt that was sold under subsection (l) of this section;

  (14) Prohibit the hospital from:

    (i) Engaging in collection activities on 100% of the outstanding amount of the Commission-set charge for debt sold under subsection (l) of this section; and

    (ii) Collecting on judgments entered into on patient debt that was sold under subsection (l) of this section; and

  (15) Comply with Sec. 24-2502 of this article.

(c)

  (1)

    (i) A hospital shall provide for a refund of amounts exceeding $25 collected from a patient or the guarantor of a patient who was found to be eligible for free care within 240 days after the initial bill is provided to the patient.

    (ii) The hospital shall provide the refund to the patient not later than 30 days after determining that the patient was eligible for free care.

  (2) If a patient is enrolled in a means-tested government health care plan that requires the patient to pay out-of-pocket for hospital services, a hospital's refund policy shall provide for a refund that complies with the terms of the patient's plan.

(d)

  (1) Subject to paragraph (2) of this subsection, a hospital shall provide in writing to each patient who incurs medical debt information about the availability of an installment payment plan for the debt.

  (2) A hospital shall provide the information under paragraph (1) of this subsection to the patient, the patient's family, the patient's authorized representative, or the patient's legal guardian:

    (i) Before the patient is discharged;

    (ii) With the hospital bill;

    (iii) On request; and

    (iv) In each written communication to the patient regarding collection of hospital debt.

  (3)

    (i) The Commission shall develop guidelines, with input from stakeholders, for an income-based payment plan offered under this subsection that includes:

      (1) The amount of medical debt owed to the hospital;

      (2) The duration of the payment plan based on a patient's annual gross income;

      (3) Guidelines for requiring appropriate documentation of income level;

      (4) Guidelines for the payment amount that:

      (A) May not exceed 5% of the patient's federal or State adjusted gross monthly household income that takes into consideration all individuals on the same federal or State tax return; and

      (B) Shall consider financial hardship, as defined in Sec. 19-214.1(a) of this subtitle;

      (5) Guidelines for:

      (A) The determination of possible interest payments for patients who do not qualify for free or reduced-cost care, which may not begin before 240 days after the initial bill is provided; and

      (B) A prohibition on interest payments for patients who qualify for free or reduced-cost care as required under subsection (b)(12) of this section;

      (6) Guidelines for modification of a payment plan that does not create a greater financial burden on the patient; and

      (7) A prohibition on penalties or fees for prepayment or early payment.

    (ii) A hospital may not seek legal action against a patient on a debt owed until the hospital has established and implemented a payment plan policy that complies with the guidelines developed under subparagraph (i) of this paragraph.

  (4)

    (i) A patient shall be deemed to be compliant with a payment plan if the patient makes at least 11 scheduled monthly payments within a 12-month period.

    (ii) If a patient misses a scheduled monthly payment, the patient shall contact the health care facility and identify a plan to make up the missed payment within 1 year after the date of the missed payment.

    (iii) The health care facility may, but may not be required to, waive any additional missed payments that occur within a 12-month period and allow the patient to continue to participate in the income-based payment plan and not refer the outstanding balance owed to a collection agency or for legal action.

  (5)

    (i) A hospital shall demonstrate that it attempted in good faith to meet the requirements of this subsection and the guidelines developed by the Commission under paragraph (3) of this subsection before the hospital:

      (1) Files an action to collect a debt owed on a hospital bill by a patient; or

      (2) Delegates collection activity to a debt collector for a debt owed on a hospital bill by a patient.

    (ii) Subparagraph (i) of this paragraph does not prohibit a hospital from using an eligibility vendor to provide outreach to a patient for purposes of assisting the patient in qualifying for financial assistance.

(e)

  (1) A hospital shall comply with Sec. 24-2502 of this article.

  (2) For at least 240 days after the initial patient bill was provided, a hospital may not report adverse information about a patient to a consumer reporting agency or commence civil action against a patient for nonpayment.

  (3) A hospital shall report the fulfillment of a patient's payment obligation within 60 days after the obligation is fulfilled to any consumer reporting agency to which the hospital had reported adverse information about the patient, including if the debt was sold under subsection (l) of this section.

  (4) A hospital may not commence a civil action against a patient for nonpayment, or delegate collection activity to a debt collector:

    (i) If the hospital was notified in accordance with federal law by the patient or the insurance carrier that an appeal or a review of a health insurance decision is pending within the immediately preceding 60 days;

    (ii) If the hospital is processing a requested reconsideration of the denial of free or reduced-cost care that was appropriately completed by the patient or has completed the reconsideration within the immediately preceding 60 days; or

    (iii) If the hospital sold the debt under subsection (l) of this section.

  (5) By November 1, 2025, a hospital that had reported adverse information about a patient to a consumer reporting agency shall instruct the consumer reporting agency to delete the adverse information about the patient.

(f)

  (1) A hospital may not force the sale or foreclosure of a patient's primary residence to collect a debt owed on a hospital bill.

  (2) A hospital may not request a lien against a patient's primary residence in an action to collect debt owed on a hospital bill.

  (3)

    (i) A hospital may not give notice to a patient under subsection (h) of this section until after 240 days after the initial bill was provided.

    (ii) If a hospital files an action to collect the debt owed on a hospital bill, the hospital may not request the issuance of or otherwise knowingly take action that would cause a court to issue:

      (1) A body attachment against a patient; or

      (2) An arrest warrant against a patient.

  (4) A hospital may not request a writ of garnishment of wages or file an action that would result in an attachment of wages against a patient to collect debt owed on a hospital bill if the patient is eligible for free or reduced-cost care under Sec. 19-214.1 of this subtitle.

  (5)

    (i) A hospital may not make a claim against the estate of a deceased patient to collect a debt owed on a hospital bill if the deceased patient was known by the hospital to be eligible for free care under Sec. 19-214.1 of this subtitle or if the value of the estate after tax obligations are fulfilled is less than half of the debt owed.

    (ii) A hospital may offer the family of the deceased patient the ability to apply for financial assistance.

  (6) A hospital may not file an action to collect a debt owed on a hospital bill by a patient until the hospital determines whether the patient is eligible for free or reduced-cost care under Sec. 19-214.1 of this subtitle.

(g)

  (1) Except as provided in paragraph (2) of this subsection, a spouse or another individual may not be held liable for the debt owed on a hospital bill of an individual who is at least 18 years old.

  (2) An individual may voluntarily consent to assume liability for the debt owed on a hospital bill of any other individual if the consent is:

    (i) Made on a separate document signed by the individual;

    (ii) Not solicited in an emergency room or during an emergency situation; and

    (iii) Not required as a condition of providing any emergency or nonemergency health care services.

(h)

  (1) Subject to paragraph (2) of this subsection, at least 45 days before filing an action against a patient to collect on the debt owed on a hospital bill, a hospital shall send written notice of the intent to file an action to the patient.

  (2) The notice required under paragraph (1) of this subsection shall:

    (i) Be sent to the patient by certified mail and first-class mail;

    (ii) Be in simplified language and in at least 10 point type;

    (iii) Include:

      (1) The name and telephone number of:

      (A) The hospital;

      (B) If applicable, the debt collector; and

      (C) An agent of the hospital authorized to modify the terms of the payment plan, if any;

      (2) The amount required to cure the nonpayment of debt, including past due payments, interest, penalties, and fees;

      (3) A statement recommending that the patient seek debt counseling services;

      (4) Telephone numbers and Internet addresses of the Health Education Advocacy Unit in the Office of the Attorney General, available to assist patients experiencing medical debt;

      (5) An explanation of the hospital's financial assistance policy; and

      (6) Any other relevant information prescribed by the Commission; and

    (iv) Be provided in the patient's preferred language or, if no preferred language is specified, each language spoken by a limited English proficient population that constitutes at least 5% of the population within the jurisdiction in which the hospital is located as measured by the most recent federal census.

  (3) The notice required under this subsection shall be accompanied by:

    (i) An application for financial assistance under the hospital's financial assistance policy, along with instructions for completing the application for financial assistance, and the telephone number to call to confirm receipt of the application;

    (ii) The availability of an income-based payment plan to satisfy the medical debt that is the subject of the hospital debt collection action; and

    (iii) The information sheet required under Sec. 19-214.1(f) of this subtitle.

(i) A complaint by a hospital in an action to collect a debt owed on a hospital bill by a patient shall:

  (1) Include an affidavit stating:

    (i) The date on which the 240-day period required under subsection (f)(3) of this section elapsed and the nature of the nonpayment;

    (ii) That a notice of intent to file an action under subsection (h) of this section:

      (1) Was sent to the patient and the date on which the notice was sent; and

      (2) Accurately reflected the contents required to be included in the notice;

    (iii) That the hospital provided:

      (1) The patient with a copy of the information sheet on the financial assistance policy in accordance with subsection (h)(3)(ii) of this section; and

      (2) Notice of the financial assistance policy as documented under Sec. 19-214.1(f) of this subtitle;

    (iv) That the hospital made a determination regarding whether the patient is eligible for the hospital's financial assistance policy in accordance with Sec. 19-214.1 of this subtitle; and

    (v) That the hospital made a good-faith effort to meet the requirements of subsection (d) of this section; and

  (2) Be accompanied by:

    (i) The original or a certified copy of the hospital bill;

    (ii) A statement of the remaining due and payable debt supported by an affidavit of the plaintiff, the hospital, or the agent or attorney of the plaintiff or hospital;

    (iii) A copy of the most recent hospital bill sent to the patient;

    (iv) If the defendant is eligible for federal Service Members Civil Relief Act benefits, an affidavit that the hospital is in compliance with the Act;

    (v) A copy of the notice of intent to file an action on a hospital bill; and

    (vi) A copy of the patient's signed certified mail acknowledgment of receipt of the written notice of intent to file an action, if received by the hospital.

(j) If a hospital delegates collection activity to a debt collector, the hospital shall:

  (1) Specify the collection activity to be performed by the debt collector through an explicit authorization or contract;

  (2) Require the debt collector to abide by the hospital's credit and collection policy;

  (3) Specify procedures the debt collector must follow if a patient appears to qualify for financial assistance; and

  (4) Require the debt collector to:

    (i) In accordance with the hospital's policy, provide a mechanism for a patient to file with the hospital a complaint against the hospital or the debt collector regarding the handling of the patient's bill;

    (ii) Forward the complaint to the hospital if a patient files a complaint with the debt collector; and

    (iii) Along with the hospital, be jointly and severally responsible for meeting the requirements of this section.

(k)

  (1) The board of directors of each hospital shall review and approve the hospital's financial assistance policy required under Sec. 19-214.1 of this subtitle and debt collection policy required under this section at least every 2 years.

  (2) A hospital may not alter its financial assistance or debt collection policies without approval by the board of directors.

(l)

  (1)

    (i) Subject to paragraph (2) of this subsection, a hospital may sell debt owed to the hospital by a patient for hospital services to a governmental unit or an entity that is under contract with the unit or to a nonprofit organization that is exempt from taxation under Sec. 501(c)(3) of the Internal Revenue Code for the sole purpose of canceling the debt.

    (ii) The contract between the hospital and the governmental unit, contractor, or nonprofit organization purchasing the debt under this subsection shall state that the sole purpose of the sale of the debt is to cancel the debt.

    (iii) The patient is not responsible to the hospital, the governmental unit, the contractor, or the nonprofit organization for any amount of the debt that is sold under this subsection or any interest, fees, or costs associated with the debt or the sale.

  (2) Debt sold under this subsection:

    (i) Must be for hospital services provided at least 2 years before the date of the sale;

    (ii) May not be expected to yield additional reimbursements from a third-party payor;

    (iii) May not be subject to an open appeal with an insurance company; and

    (iv) Must be for an individual whose family income is at or below 500% of the federal poverty level or who has medical debt exceeding 5% of the individual's family income, as determined by the governmental unit, contractor, or nonprofit organization purchasing the debt.

  (3) Debt sold under this subsection may be sold with a reduction of Commission charges.

  (4) The Commission shall treat the amount of payments to hospitals under this subsection as an offset to uncompensated care amounts reported by hospitals.

  (5) The purchaser of the debt shall:

    (i) Notify the patient that the debt has been canceled; and

    (ii) If the hospital obtained a judgment against the patient or reported adverse information to a consumer reporting agency about the patient, seek to vacate the judgment or strike the adverse information.

(m) The Commission shall review each hospital's implementation of and compliance with the hospital's policies and the requirements of this section.

(n)

  (1) On or before February 1 each year, beginning in 2023, the Commission shall compile the information required under subsection (a) of this section and prepare a medical debt collection report based on the compiled information.

  (2) The report required under paragraph (1) of this subsection shall be:

    (i) Made available to the public free of charge; and

    (ii) Submitted to the Senate Finance Committee and the House Health and Government Operations Committee in accordance with Sec. 2-1257 of the State Government Article.

#### Section 19-214.3

(a)

  (1)

    (i) The Commission shall establish a process for a patient or a patient's authorized representative to file with the Commission a complaint against a hospital for an alleged violation of Sec. 19-214.1 or Sec. 19-214.2 of this subtitle.

    (ii) The process established under subparagraph (i) of this paragraph shall:

      (1) Include the option for a patient or a patient's authorized representative to file the complaint jointly with the Commission and the Health Education and Advocacy Unit; and

      (2) Provide the patient or the patient's authorized representative with the following information:

      (A) The Health Education and Advocacy Unit is available to assist the patient or the patient's authorized representative in filing and mediating a reconsideration request; and

      (B) The address, phone number, facsimile number, e-mail address, mailing address, and website of the Health Education and Advocacy Unit.

  (2)

    (i) Subject to subparagraph (ii) of this paragraph, a complaint filed with the Commission is a public record and is subject to reasonable inspection.

    (ii) The Commission shall deny inspection of the complainant's name, address, or any other personal identifying information.

  (3) The filing of a complaint under this subsection does not prevent an individual from:

    (i) Exercising any right or seeking any remedy to which the individual may otherwise be entitled; or

    (ii) Filing a complaint with any other agency or a court.

(b)

  (1) The remedies authorized under this section are in addition to any other statutory, legal, or equitable remedies that may be available and are not intended to be a prerequisite to, or exclusive of, any other remedy.

  (2) An individual or a governmental unit is not required to exhaust the administrative remedy authorized under this subtitle before filing suit.

(c)

  (1) A waiver by any patient or other individual of any protection provided by Sec. 19-214.1, Sec. 19-214.2, or Sec. 19-214.4 of this subtitle or any regulation adopted under this subtitle is null and void as being against the public policy of the State.

  (2) Except as prohibited by federal law, a provision in a hospital's financial assistance policy or agreement between the patient and a hospital that waives any substantive or procedural right or remedy related to conduct prohibited by Sec. 19-214.1, Sec. 19-214.2, or Sec. 19-214.4 of this subtitle or any regulation adopted under this subtitle is null and void as being against the public policy of the State.

(d)

  (1) If a hospital knowingly violates any provision of Sec. 19-214.1 or Sec. 19-214.2 of this subtitle or any regulation adopted under this subtitle, the Commission may impose a fine not to exceed $50,000 per violation.

  (2) Before imposing a fine, the Commission shall consider the appropriateness of the fine in relation to the severity of the violation.

  (3) A violation by a hospital or an outside collection agency of Sec. 19-214.1 or Sec. 19-214.2 of this subtitle or any regulation adopted under this subtitle is an unfair, abusive, and deceptive trade practice under the Maryland Consumer Protection Act.

#### Section 19-214.4

(a) The Commission, in coordination with the Department, the Department of Human Services, the Office of the Comptroller, the State Department of Education, the Health Education and Advocacy Unit, and the Maryland Hospital Association, shall develop a process that:

  (1) Identifies the patients who paid more than $25 for hospital services who may have qualified for free care under Sec. 19-214.1 of this subtitle on the date the hospital service was provided during calendar years 2017 through 2021;

  (2) Provides reimbursement to the patients identified under item (1) of this subsection, which may be applied incrementally;

  (3) Ensures that a patient's alternate address is used if the patient requested an alternate address for safety reasons; and

  (4) Determines how the Commission, the Department, the Department of Human Services, the Office of the Comptroller, and the State Department of Education should share with or disclose relevant information, including tax information, to the minimum extent necessary, to the hospital and in accordance with federal and State confidentiality laws for the purpose of carrying out the process developed under this subsection.

(b) The Health Education Advocacy Unit in the Office of the Attorney General shall assist patients identified under subsection (a) of this section in obtaining reimbursement under this section.

(c)

  (1) The process developed under subsection (a) of this section:

    (i) Shall require each hospital to consider:

      (1) Tax data from the Office of the Comptroller as de facto evidence of a patient's income; and

      (2) Data from the Department, the Department of Human Services, and the State Department of Education as de facto evidence of a patient's presumptive eligibility for free care;

    (ii) Shall require each hospital to provide refunds to patients who qualify under subsection (g)(2) of this section; and

    (iii) May not require a hospital to provide a patient with a refund if the patient previously was denied free care because of a failed asset test for the identified date of service.

  (2) Each hospital shall create a webpage that includes:

    (i) Information about the reimbursement provided in accordance with this section, including the process to be followed by a patient and relevant timelines; and

    (ii) A telephone number and e-mail address that a patient may use to submit questions about the reimbursement process developed under this section.

  (3) If a patient is entitled to a single refund per year under subsection (a) of this section in an amount of $25 or less, the hospital may but is not required to provide the reimbursement.

(d)

  (1) The Commission may modify the process developed under subsection (a) of this section as necessary.

  (2) If reimbursements are provided incrementally and less than 5% of the estimated reimbursements are made each year during the first increment, the Commission is not required to implement additional increments of the process.

(e) The Department, the Department of Human Services, the Office of the Comptroller, the State Department of Education, and each hospital shall report information on the process developed under this section to the Commission, in the time and manner determined by the Commission.

(f)

  (1) Notwithstanding any other provision of law, the Commission, the Department, the Department of Human Services, the Office of the Comptroller, the State Department of Education, and each hospital shall disclose to:

    (i) Each other, to the minimum extent necessary, relevant information, including tax information, necessary for implementation of the process developed under subsection (a) of this section; and

    (ii) The Health Education and Advocacy Unit relevant information necessary for the Health Education and Advocacy Unit to assist patients in obtaining reimbursement under subsection (a) of this section, on receipt of the patient's executed authorization for release of medical information form provided by the Health Education and Advocacy Unit or other authorization form required by the Department of Human Services, the Office of the Comptroller, or the State Department of Education.

  (2) If the Health Education and Advocacy Unit requests information from the Commission, the Department, the Department of Human Services, the Office of the Comptroller, the State Department of Education, or a hospital to assist a patient in obtaining reimbursement under subsection (a) of this section, the Commission, the Department, the Department of Human Services, the Office of the Comptroller, the State Department of Education, or the hospital shall provide the information to the Health Education and Advocacy Unit within 10 business days after the date of the receipt of the request.

  (3) This section may not be construed to make a hospital responsible for the confidentiality of the information in possession of each State entity listed in paragraph (1) of this subsection.

(g)

  (1)

    (i) On or before January 1, 2023, and October 1, 2024, the Commission shall report to the Senate Finance Committee and the House Health and Government Operations Committee, in accordance with Sec. 2-1257 of the State Government Article, on the development and implementation by hospitals of the process required under subsection (a) of this section.

    (ii) If the process developed under subsection (a) of this section requires legislation for implementation, the Commission shall include the legislative recommendations in the report required on or before January 1, 2023, under subparagraph (i) of this paragraph.

    (iii) If the process established under subsection (a) of this section does not require legislation, each hospital shall implement the process developed under subsection (a) of this section on or before January 1, 2023.

  (2)

    (i) Subject to subparagraph (ii) of this paragraph, each hospital the Commission, the Office of the Comptroller, the Department, the Department of Human Services, and the State Department of Education shall implement Option 3 from the "Free Hospital Care Refund Process" report submitted by the Commission in December 2022 as required under paragraph (1)(i) of this subsection and in accordance with this section and Sec. 13-203(c) of the Tax - General Article.

    (ii) Under the process required under subparagraph (i) of this paragraph, a patient shall qualify for refunds who paid an out-of-pocket expense for services based on the following:

      (1) The Office of the Comptroller determining that the patient's family income was at or below 200% of the federal poverty level during the year of service date or dates; or

      (2) The Department of Human Services, the Department, or the State Department of Education determining that during the year of service date or dates, the patient:

      (A) Received benefits through the federal Supplemental Nutrition Assistance Program;

      (B) Received benefits through the State's Energy Assistance Program;

      (C) Received benefits through the federal Special Supplemental Food Program for Women, Infants, and Children; or

      (D) Lived in a household with children enrolled in the free and reduced-cost meal program.

  (3) The Office of the Comptroller, the Department of Human Services, the Department, the State Department of Education, the Commission, and each hospital may not implement the alternative approach included with Option 3 in the report identified under paragraph (2)(i) of this subsection.

(h)

  (1) Each hospital shall reimburse the Commission, the Office of the Comptroller, the Department, the Department of Human Services, the State Department of Education, and the Health Education Advocacy Unit in the Office of the Attorney General for the costs incurred by each State entity in complying with this section.

  (2)

    (i) Reimbursement required under paragraph (1) of this subsection shall be based on the hospital's proportion of the total number of patients who were identified by the State entity as potentially eligible for reimbursement in a designated year, as determined by the Commission.

    (ii) For the purpose of determining the reimbursement due under subparagraph (i) of this paragraph, the State entities identified under paragraph (1) of this subsection shall provide quarterly cost information to the Commission.

  (3) The Commission shall provide each hospital with the reimbursement amount due to the appropriate State entity based on the costs incurred by the entity in complying with this section.

(i)

  (1)

    (i) If a hospital fails to provide refunds to patients who qualify under subsection (g)(2) of this section as required, the Commission may impose a fine not exceeding $50,000 per violation.

    (ii) In determining the amount of a fine to be imposed under subparagraph (i) of this paragraph, the Commission shall consider the appropriateness of the fine in relation to the severity of the violation.

  (2) A violation of this section by a hospital is:

    (i) An unfair, abusive, or deceptive trade practice, as defined under Title 13 of the Commercial Law Article; and

    (ii) Subject to enforcement and penalty provisions of Title 13 of the Commercial Law Article.

#### Section 19-215

(a)

  (1) After public hearings and consultation with any appropriate advisory committee, the Commission shall adopt, by rule or regulation, a uniform accounting and financial reporting system that:

    (i) Includes any cost allocation method that the Commission determines; and

    (ii) Requires each facility to record its income, revenues, assets, expenses, outlays, liabilities, and units of service.

  (2) Each facility shall adopt the uniform accounting and financial reporting system.

(b) In conformity with this subtitle, the Commission may allow and provide for modifications in the uniform accounting and financial reporting system to reflect correctly any differences among facilities in their type, size, financial structure, or scope or type of service.

#### Section 19-216

(a) At the end of the fiscal year for a facility, at least 120 days following a merger or a consolidation, and at any other interval that the Commission sets, the facility shall file:

  (1) A balance sheet that details its assets, liabilities, and net worth;

  (2) A statement of income and expenses;

  (3) The most recent Form 990 that the facility filed with the Internal Revenue Service; and

  (4) Any other report that the Commission requires about costs incurred in providing services.

(b)

  (1) A report under this section shall:

    (i) Be in the form that the Commission requires;

    (ii) Conform to the uniform accounting and financial reporting system adopted under this subtitle; and

    (iii) Be certified by the facility's certified public accountant.

  (2) If the Commission requires, responsible officials of a facility also shall attest that, to the best of their knowledge and belief, the report has been prepared in conformity with the uniform accounting and financial reporting system adopted under Sec. 19-211 of this subtitle.

#### Section 19-217

(a) Except as provided in subsection (c) of this section, a facility shall notify the Commission at least 30 days prior to executing any financial transaction, contract, or other agreement that would:

  (1) Pledge more than 50% of the operating assets of the facility as collateral for a loan or other obligation;

  (2) Result in more than 50% of the operating assets of the facility being sold, leased, or transferred to another person or entity; or

  (3) Result in more than 50% of all corporate voting rights or governance reserve powers being transferred to or assumed by another person or entity.

(b) Except as provided in subsection (c) of this section, the Commission shall publish a notice of the proposed financial transaction, contract, or other agreement reported by a facility in accordance with subsection (a) of this section in a newspaper of general circulation in the area where the facility is located.

(c) The provisions of this section do not apply to any financial transaction, contract, or other agreement made by a facility with any issuer of tax-exempt bonds, including the Maryland Health and Higher Education Facilities Authority, the State, or any county or municipal corporation of the State, if a notice of the proposed issuance of revenue bonds that meets the requirements of Sec. 147(f) of the Internal Revenue Code has been published.

#### Section 19-218

(a) The Commission shall require each facility to give the Commission information that:

  (1) Concerns the total financial needs of the facility;

  (2) Concerns its current and expected resources to meet its total financial needs;

  (3) Includes the effect of any proposal made, under Subtitle 1 of this title, on comprehensive health planning; and

  (4) Includes physician information sufficient to identify practice patterns of individual physicians across all facilities.

(b) The identities of individual physicians are confidential and are not discoverable or admissible in evidence in a civil or criminal proceeding, and may only be disclosed to the following:

  (1) The utilization review committee of a Maryland hospital;

  (2) The Medical and Chirurgical Faculty of the State of Maryland;

  (3) The State Board of Physicians;

  (4) The Office of Health Care Quality in the Department;

  (5) The Maryland Health Care Commission; or

  (6) An investigatory body under the State or federal government.

#### Section 19-219

(a) The Commission may review the costs, and rates, quality, and efficiency of facility services, and make any investigation that the Commission considers necessary to assure each purchaser of health care facility services that:

  (1) The total costs of all hospital services offered by or through a facility are reasonable;

  (2) The aggregate rates of the facility are related reasonably to the aggregate costs of the facility; and

  (3) Except as provided in Sec. 19-214.2(l) of this subtitle, the rates are set equitably among all purchasers or classes of purchasers without undue discrimination or preference.

(b)

  (1) To carry out its powers under subsection (a) of this section, the Commission may review and approve or disapprove the reasonableness of any rate or amount of revenue that a facility sets or requests.

  (2) A facility shall:

    (i) Charge for services only at a rate set in accordance with this subtitle; and

    (ii) Comply with the applicable terms and conditions of the all-payer model contract.

  (3) Consistent with the all-payer model contract, in determining the reasonableness of rates, the Commission may take into account objective standards of efficiency and effectiveness.

(c) Consistent with the all-payer model contract, and notwithstanding any other provision of this subtitle, the Commission may:

  (1) Establish hospital rate levels and rate increases in the aggregate or on a hospital-specific basis;

  (2) Promote and approve alternative methods of rate determination and payment of an experimental nature for the duration of the all-payer model contract; and

  (3) On request of the Secretary, assist in the implementation of federally approved model programs.

#### Section 19-220

(a)

  (1) To have the statistical information needed for rate review and approval, the Commission shall compile all relevant financial and accounting information.

  (2) The information shall include:

    (i) Necessary operating expenses;

    (ii) Appropriate expenses that are incurred in providing services to patients who cannot or do not pay;

    (iii) Incurred interest charges; and

    (iv) Reasonable depreciation expenses that are based on the expected useful life of property or equipment.

(b) The Commission shall define, by regulation, the types and classes of charges that may not be changed, except as specified in Sec. 19-222 of this subtitle.

(c) The Commission shall obtain from each facility its current rate schedule and each later change in the schedule that the Commission requires.

(d) Consistent with the all-payer model contract approved by the federal Center for Medicare and Medicaid Innovation, the Commission shall:

  (1) Permit a nonprofit facility to charge reasonable rates that will permit the facility to provide, on a solvent basis, effective and efficient service that is in the public interest; and

  (2) Permit a proprietary profit-making facility to charge reasonable rates that:

    (i) Will permit the facility to provide effective and efficient service that is in the public interest; and

    (ii) Based on the fair value of the property and investments that are related directly to the facility, include enough allowance for and provide a fair return to the owner of the facility.

(e) In the determination of reasonable rates for each facility, as specified in this section, the Commission shall take into account all of the cost of complying with recommendations made, under Subtitle 1 of this title, on comprehensive health planning.

(f) In reviewing rates or charges or considering a request for change in rates or charges, the Commission shall permit a facility to charge rates that, in the aggregate, will produce enough total revenue to enable the facility to meet reasonably each requirement specified in this section.

(g) Except as otherwise provided by law, in reviewing rates or charges or considering a request for changes in rates or charges, the Commission may not hold executive sessions.

#### Section 19-221

The Commission shall use any reasonable, relevant, or generally accepted accounting principles to determine reasonable rates for each facility.

#### Section 19-222

(a)

  (1) A facility may not change any rate schedule or charge of any type or class defined under Sec. 19-220(b) of this subtitle, unless the facility files with the Commission a written notice of the proposed change that is supported by any information that the facility considers appropriate.

  (2) Unless the Commission orders otherwise in conformity to this section, a change in the rate schedule or charge is effective on the date that the notice specifies. That effective date shall be at least 30 days after the date on which the notice is filed.

(b)

  (1) Commission review of a proposed change may not exceed 150 days after the notice is filed.

  (2) The Commission may hold a public hearing to consider the notice.

  (3) If the Commission decides to hold a public hearing, the Commission:

    (i) Within 65 days after the filing of the notice, shall set a place and date for the hearing; and

    (ii) May suspend the effective date of any proposed change until 30 days after conclusion of the hearing.

  (4) If the Commission suspends the effective date of a proposed change, the Commission shall give the facility a written statement of the reasons for the suspension.

  (5) The Commission:

    (i) May conduct the public hearing without complying with formal rules of evidence; and

    (ii) Shall allow any interested party to introduce evidence that relates to the proposed change, including testimony by witnesses.

(c)

  (1) The Commission may permit a facility to change any rate or charge temporarily, if the Commission considers it to be in the public interest.

  (2) An approved temporary change becomes effective immediately on filing.

  (3) Under the review procedures of this section, the Commission promptly shall consider the reasonableness of the temporary change.

(d) If the Commission modifies a proposed change or approves only part of a proposed change, a facility, without losing its right to appeal the part of the Commission order that denies full approval of the proposed change, may:

  (1) Charge its patients according to the decision of the Commission; and

  (2) Accept any benefits under that decision.

(e) If a change in any rate or charge increase becomes effective because a final determination is delayed because of an appeal or otherwise, the Commission may order the facility:

  (1) To keep a detailed and accurate account of:

    (i) Funds received because of the change; and

    (ii) The persons from whom these funds were collected; and

  (2) As to any funds received because of a change that later is held excessive or unreasonable:

    (i) To refund the funds with interest; or

    (ii) If a refund of the funds is impracticable, to charge over and amortize the funds through a temporary decrease in charges or rates.

(f) A decision by the Commission on any contested change under this section shall comply with the Administrative Procedure Act and shall be only prospective in effect.

(g)

  (1) The State Health Services Cost Review Commission shall provide incentives for merger, consolidation, and conversion and for the implementation of the institution-specific plan developed in accordance with Sec. 19-119 of this title.

  (2) Notwithstanding any of the provisions in this section, on notification of a merger or consolidation by 2 or more hospitals, the Commission shall review the rates of those hospitals that are directly involved in the merger or consolidation in accordance with the rate review and approval procedures provided in Sec. 19-220 of this subtitle and the regulations of the Commission.

  (3) The Commission may provide, as appropriate, for temporary adjustment of the rates of those hospitals that are directly involved in the merger or consolidation, closure, or delicensure in order to provide sufficient funds for an orderly transition. These funds may include:

    (i) Allowances for those employees who are or would be displaced;

    (ii) Allowances to permit a surviving institution in a merger to generate capital to convert a closed facility to an alternate use;

    (iii) Any other closure costs as defined in Sec. 10-340 of the Economic Development Article; or

    (iv) Agreements to allow retention of a portion of the savings that result for a designated period of time.

#### Section 19-223

The Commission shall assess a fee on all hospitals whose rates have been approved by the Commission to pay for:

(1) To the extent provided for in Title 10, Subtitle 3, Part IV of the Economic Development Article, the amounts required by Sec. 10-350 of the Economic Development Article with respect to public obligations or closure costs of a closed or delicensed hospital; and

(2) Funding the Hospital Employees Retraining Fund.

#### Section 19-224

(a) This section applies to each person that is concurrently:

  (1) A trustee, director, or officer of any nonprofit facility in this State; and

  (2) An employee, partner, director, officer, or beneficial owner of 3 percent or more of the capital account or stock of:

    (i) A partnership;

    (ii) A firm;

    (iii) A corporation; or

    (iv) Any other business entity.

(b) Each person specified in subsection (a) of this section shall file with the Commission an annual report that discloses, in detail, each business transaction between any business entity specified in subsection (a)(2) of this section and any facility that the person serves as specified in subsection (a)(1) of this section, if any of the following is $10,000 or more a year:

  (1) The actual or imputed value or worth to the business entity of any transaction between it and the facility; or

  (2) The amount of the contract price, consideration, or other advances by the facility as part of the transaction.

(c) A report under this section shall be:

  (1) Signed and verified; and

  (2) Filed in accordance with the procedures and on the form that the Commission requires.

(d) A person that willfully fails to file any report required by this section is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $500.

#### Section 19-225

(a) In any matter that relates to a facility's cost of services and consistent with the all-payer model contract, the Commission may:

  (1) Hold a public hearing;

  (2) Conduct an investigation;

  (3) Require the filing of any information; or

  (4) Subpoena any witness or evidence.

(b) The Executive Director of the Commission may administer oaths in connection with any hearing or investigation under this section.

#### Section 19-226

(a) If the Commission considers a further investigation necessary or desirable to authenticate information in a report that a facility files under this subtitle, consistent with the all-payer model contract, the Commission may make any necessary further examination of the records or accounts of the facility, in accordance with the rules or regulations of the Commission.

(b) The examination under this section may include a full or partial audit of the records or accounts of the facility that is:

  (1) Provided by the facility; or

  (2) Performed by:

    (i) The staff of the Commission;

    (ii) A third party for the Commission; or

    (iii) The Legislative Auditor.

#### Section 19-227

(a)

  (1) Any person aggrieved by a final decision of the Commission under this subtitle 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.

(b)

  (1) An appeal from a final decision of the Commission under this section shall be taken in the name of the person aggrieved as appellant and against the Commission as appellee.

  (2) The Commission is a necessary party to an appeal at all levels of the appeal.

  (3) The Commission may appeal any decision that affects any of its final decisions to a higher level for further review.

  (4) On grant of leave by the appropriate court, any aggrieved party or interested person may intervene or participate in an appeal at any level.

(c) Any person, government agency, or nonprofit health service plan that contracts with or pays a facility for health care services has standing to participate in Commission hearings and shall be allowed to appeal final decisions of the Commission.

### Subtitle 3. Hospitals and Related Institutions

#### Section 19-301

(a) In this subtitle the following words have the meanings indicated.

(b) "Accredited hospital" means a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations.

(c) "Accredited residential treatment center" means a residential treatment center that is accredited by:

  (1) The Joint Commission on Accreditation of Healthcare Organizations;

  (2) The Commission on Accreditation of Rehabilitation Facilities; or

  (3) The Council on Accreditation.

(d) "Apartment unit" means any space, in a residential building, that is enclosed and self-contained and has a sanitary environment, if the space includes:

  (1) 2 or more rooms;

  (2) A direct exit to a thoroughfare or to a common element leading to a thoroughfare;

  (3) Facilities for living, sleeping, and eating; and

  (4) At least the following facilities for cooking:

    (i) Storage space for food and utensils;

    (ii) A refrigerator;

    (iii) A cook top; and

    (iv) Adequate electrical capacity and outlets for small appliances.

(e)

  (1) "Domiciliary care" means services that are provided to aged or disabled individuals in a protective, institutional or home-type environment.

  (2) "Domiciliary care" includes:

    (i) Shelter;

    (ii) Housekeeping services;

    (iii) Board;

    (iv) Facilities and resources for daily living; and

    (v) Personal surveillance or direction in the activities of daily living.

(f) "Hospital" means an institution that:

  (1) Has a group of at least 5 physicians who are organized as a medical staff for the institution;

  (2) Maintains facilities to provide, under the supervision of the medical staff, diagnostic and treatment services for 2 or more unrelated individuals; and

  (3) Admits or retains the individuals for overnight care.

(g) "License" means a license issued by the Secretary:

  (1) To operate a hospital in this State;

  (2) To operate a related institution in this State; or

  (3) To operate a residential treatment center in this State.

(h) "Limited service hospital" means a health care facility that:

  (1) Is licensed as a hospital on or after January 1, 1999;

  (2) Changes the type or scope of health care services offered by eliminating the facility's capability to admit or retain patients for overnight hospitalization;

  (3) Retains an emergency or urgent care center; and

  (4) Complies with the regulations adopted by the Secretary under Sec. 19-307.1 of this subtitle.

(i) "Nonaccredited hospital" means a hospital not accredited by the Joint Commission on Accreditation of Healthcare Organizations.

(j) "Nonaccredited residential treatment center" means a residential treatment center that is not accredited by:

  (1) The Joint Commission on Accreditation of Healthcare Organizations;

  (2) The Commission on Accreditation of Rehabilitation Facilities; or

  (3) The Council on Accreditation.

(k) "Nursing care" means service for a patient that is:

  (1) Ordered by a physician; and

  (2) Provided or supervised by a registered or practical nurse who is licensed to practice in this State.

(l) "Nursing facility" means a related institution that provides nursing care for 2 or more unrelated individuals.

(m) "Person" includes this State or a county or municipal corporation.

(n)

  (1) "Personal care" means a service that an individual normally would perform personally, but for which the individual needs help from another because of advanced age, infirmity, or physical or mental limitation.

  (2) "Personal care" includes:

    (i) Help in walking;

    (ii) Help in getting in and out of bed;

    (iii) Help in bathing;

    (iv) Help in dressing;

    (v) Help in feeding; and

    (vi) General supervision and help in daily living.

(o)

  (1) "Related institution" means an organized institution, environment, or home that:

    (i) Maintains conditions or facilities and equipment to provide domiciliary, personal, or nursing care for 2 or more unrelated individuals who are dependent on the administrator, operator, or proprietor for nursing care or the subsistence of daily living in a safe, sanitary, and healthful environment; and

    (ii) Admits or retains the individuals for overnight care.

  (2) "Related institution" does not include a nursing facility or visiting nurse service that is conducted only by or for adherents of a bona fide church or religious organization, in accordance with tenets and practices that include reliance on treatment by spiritual means alone for healing.

(p) "Residential treatment center" means a psychiatric institution that provides campus-based intensive and extensive evaluation and treatment of children and adolescents with severe and chronic emotional disturbances who require a self-contained therapeutic, educational, and recreational program in a residential setting.

(q) "Unrelated individual" means anyone who is not:

  (1) A child, grandchild, parent, grandparent, sibling, stepparent, stepchild, or spouse of the proprietor; or

  (2) An in-law of any of these individuals.

#### Section 19-302

(a) This subtitle does not apply to a dispensary or first aid treatment facility that is maintained only to provide services for:

  (1) Employees of a commercial or industrial plant;

  (2) Employees or students of an educational institution; or

  (3) Individuals in a convent, county home, motel, hotel, apartment, or facility, if the individuals are able to live independently.

(b) This subtitle applies to the provision of home health care services by a hospital or related institution to 2 or more unrelated individuals, whether the services are provided directly or under contract with a home health agency.

#### Section 19-303

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Commission" means the Health Services Cost Review Commission.

  (3)

    (i) "Community benefit" means a planned, organized, and measured activity that is intended to meet identified community health needs within a service area.

    (ii) "Community benefit" may include:

      (1) A community health service;

      (2) Health professional education;

      (3) Research;

      (4) A financial contribution;

      (5) A community-building activity, including partnerships with community-based organizations;

      (6) Charity care;

      (7) An activity described under subparagraph (i) of this paragraph that is funded by a foundation;

      (8) A mission-driven health service;

      (9) An operation related to an activity described under subparagraph (i) of this paragraph;

      (10) Financial or in-kind support of the Maryland Behavioral Health Crisis Response System; and

      (11) A community health worker workforce program established in accordance with Sec. 19-303.1 of this subtitle.

  (4) "Community Benefit Reporting Workgroup" means the Community Benefit Reporting Workgroup established in accordance with subsection (b) of this section.

  (5) "Community health needs assessment" means the process required by the Affordable Care Act by which unmet community health care needs and priorities are identified by a nonprofit hospital in accordance with Sec. 501(r)(3) of the Internal Revenue Code.

(b)

  (1) The Commission shall establish a Community Benefit Reporting Workgroup.

  (2) The Community Benefit Reporting Workgroup shall be composed of individuals and stakeholder groups that have knowledge of and are impacted by hospital community benefit spending.

(c) The Commission shall adopt regulations to implement the recommendations of the Community Benefit Reporting Workgroup, that:

  (1) Establish a standard format for reporting the information required under this subsection;

  (2) Specify the date by which each nonprofit hospital is required to submit the annual community benefit report;

  (3) Require each nonprofit hospital to solicit and take into account input received from individuals who represent the broad interests of that community, including individuals with special knowledge of or expertise in public and behavioral health in accordance with Sec. 501(r)(3) of the Internal Revenue Code;

  (4) Require each nonprofit hospital to conduct its community health needs assessment in consultation with community members as recommended by the Community Benefit Reporting Workgroup and to submit an annual community benefits report to the Commission detailing the community benefits provided by the hospital during the preceding year that includes:

    (i) The mission statement of the hospital;

    (ii) A list of the activities that were undertaken by the hospital to address the identified community health needs within the hospital's community;

    (iii) The cost to the hospital of each community benefit activity;

    (iv) A description of how each of the listed activities addresses the community health needs of the hospital's community;

    (v) A description of efforts taken to evaluate the effectiveness of each community benefit activity;

    (vi) A description of gaps in the availability of providers to serve the community;

    (vii) A description of the hospital's efforts to track and reduce health disparities in the community that the hospital serves;

    (viii) A list of the unmet community health needs identified in the most recent community health needs assessment; and

    (ix) A list of tax exemptions the hospital claimed during the immediately preceding taxable year, in accordance with State law.

(d) The Commission shall establish a method through which State and local governing bodies are made aware of the meetings of the Community Benefit Reporting Workgroup.

#### Section 19-303.1

(a) In this section, "community health worker" has the meaning stated in Sec. 13-3701 of this article.

(b)

  (1) A community benefit under Sec. 19-303 of this subtitle may include a partnership between a nonprofit hospital and a community-based organization to establish a community health worker workforce program.

  (2) The primary purpose of a community health worker workforce program shall be to provide services to patients of a nonprofit hospital that are intended to improve health outcomes and address social determinants of health.

(c)

  (1) A partnership established under this section may be executed through a memorandum of understanding between a nonprofit hospital and a community-based organization.

  (2) The memorandum of understanding shall include:

    (i) The program design;

    (ii) Goals for patient health outcomes;

    (iii) Implementation procedures;

    (iv) Criteria for evaluation and impact measurement;

    (v) Data collection, management, and reporting standards and protocols that are in accordance with applicable federal and State laws and regulations, including the federal Health Insurance Portability and Accountability Act; and

    (vi) An agreement between the nonprofit hospital and the community-based organization identifying which party will be responsible for:

      (1) Recruiting and employing the community health worker workforce;

      (2) Supervising the workforce in the settings in which the community health workers will provide services to patients;

      (3) Training the workforce; and

      (4) Providing employer-sponsored health insurance coverage to each community health worker.

(d) A partnership established under this section may provide health insurance coverage to each community health worker for the duration of the program if the individual does not have health insurance coverage and requests coverage.

(e) A nonprofit hospital and a community-based organization may collaborate to identify financial resources to address costs associated with increasing administrative capacity within the community-based organization necessary to participate in the partnership.

(f) Subject to other provisions of law governing community benefits and on the agreement of the parties, a nonprofit hospital may provide financial support to a community-based organization to cover the costs associated with increasing administrative capacity within the community-based organization necessary to participate in the partnership.

#### Section 19-304

(a) A hospital or related institution shall:

  (1) Report an unexpected occurrence related to an individual's medical treatment that results in death or serious disability that is not related to the natural course of the individual's illness or underlying disease condition; and

  (2) Submit the report to the Department within 5 days of the hospital's or related institution's knowledge of the occurrence.

(b) A hospital or related institution may report to the Department an unexpected occurrence or other incident related to an individual's medical treatment that does not result in death or serious disability.

(c) A hospital or related institution shall:

  (1) Conduct a root cause analysis of an occurrence required to be reported under subsection (a) of this section; and

  (2) Unless the Department approves a longer time period, submit the root cause analysis to the Department within 60 days of the hospital's or related institution's knowledge of the occurrence.

(d) If a hospital or related institution fails to comply with subsection (a) or (c) of this section, the Secretary may impose a fine of $500 per day for each day the violation continues.

(e) The Secretary shall adopt regulations to implement this section.

#### Section 19-305

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Adverse event" means an unexpected occurrence that:

    (i) Is related to a resident's medical or behavioral treatment; and

    (ii) Is not related to the natural course of the resident's illness or underlying disease condition.

  (3) "Change in condition" means a significant change in a resident's physical, mental, or psychological status including:

    (i) Life-threatening conditions;

    (ii) Clinical complications including significant somatic symptoms that require the assessment of or treatment by qualified medical personnel;

    (iii) The need to discontinue a medication or treatment because of:

      (1) Adverse consequences; or

      (2) The need to begin a new form of treatment;

    (iv) Evaluation at or admission to a hospital;

    (v) Injuries that require the assessment of or treatment by qualified medical personnel;

    (vi) The use of restraint or seclusion; and

    (vii) Suicide attempts.

(b)

  (1) Within 24 hours, in accordance with State and federal confidentiality laws, a residential treatment center shall attempt to notify a resident and a resident's representative, family member, legal guardian, or custodian of:

    (i) A change in condition;

    (ii) An adverse event; and

    (iii) Corrective action, if appropriate.

  (2) If a residential treatment center sends a notice to an individual under paragraph (1) of this subsection, the individual may send a written response to the residential treatment center instructing the residential treatment center that:

    (i) The individual waives the notification required under paragraph (1) of this subsection; or

    (ii) The individual requires notification only in the circumstances specified in writing by the individual.

(c) A residential treatment center shall document the notification required under subsection (b)(1) of this section and the response of the resident and the resident's representative, family member, legal guardian, or custodian in the resident's medical record.

(d) If the Department determines that a residential treatment center failed to notify a resident and a resident's representative, family member, legal guardian, or custodian under subsection (b)(1) of this section, the Department shall require the residential treatment center, as part of a plan of correction, to notify the resident and the resident's representative, family member, legal guardian, or custodian as soon as possible.

#### Section 19-306

A hospital shall:

(1) Adopt a policy describing the protocol of the hospital when there is an immigration enforcement action at the hospital consistent with the guidance of the Attorney General issued under Sec. 6-111 of the State Government Article;

(2) Make the hospital's immigration enforcement action policy available to all hospital staff members; and

(3) Provide annual training to all hospital staff members to ensure the staff's knowledge and understanding of the immigration enforcement action policy.

#### Section 19-307

(a)

  (1) A hospital shall be classified:

    (i) As a general hospital if the hospital at least has the facilities and provides the services that are necessary for the general medical and surgical care of patients;

    (ii) As a special hospital if the hospital:

      (1) Defines a program of specialized services, such as obstetrics, mental health, tuberculosis, orthopedy, chronic disease, or communicable disease;

      (2) Admits only patients with medical or surgical needs within the program; and

      (3) Has the facilities for and provides those specialized services;

    (iii) As a special rehabilitation hospital if the hospital meets the requirements of this subtitle and Subtitle 12 of this title; or

    (iv) As a limited service hospital if the health care facility:

      (1) Is licensed as a hospital on or after January 1, 1999;

      (2) Changes the type or scope of services offered by eliminating the capability to admit or retain individuals for overnight hospitalization;

      (3) Retains an emergency or urgent care center; and

      (4) Complies with the regulations adopted by the Secretary under Sec. 19-307.1 of this subtitle.

  (2) The Secretary may set, by rule or regulation, other reasonable classifications for hospitals.

(b) A related institution shall be classified:

  (1) As a care home if the related institution provides care to individuals who, because of advanced age or physical or mental disability, require domiciliary care or personal care in a protective environment; or

  (2) As a nursing home if the related institution:

    (i) Provides nursing care for chronically ill or convalescent patients; or

    (ii) Offers to provide 24-hour a day nursing care of patients in a home-type facility such as:

      (1) A convalescent home;

      (2) A nursing unit of a home for the aged;

      (3) A psychiatric nursing home;

      (4) A nursing facility for individuals with disabilities;

      (5) A home for alcoholics; or

      (6) A halfway house.

#### Section 19-307.1

The Department shall adopt regulations for a limited service hospital that include the following standards:

(1) The limited service hospital shall be open 24 hours a day, 7 days a week;

(2) There shall be at least one physician credentialed in emergency medicine at the limited service hospital at all times;

(3) A sufficient number of registered nurses and other health professionals shall be available at the limited service hospital to provide advanced life support;

(4) Basic X-ray and laboratory facilities shall be available at the limited service hospital and operable at all times by one radiology technician and one laboratory technician;

(5) Resuscitation equipment, including monitor, defibrillator, cardiac medications, intubation equipment, and intravenous line equipment shall be available at the limited service hospital and operable at all times;

(6) Standard procedures in accordance with the State Emergency Medical Services Plan shall exist for the immediate transport of individuals in need of hospitalization or other more definitive care;

(7) A specific defined role in the Emergency Medical Services System with appropriate telephone communication shall exist;

(8) Emergency services shall be available to all persons regardless of ability to pay;

(9) Adoption, implementation, and enforcement of a policy shall exist that requires, except in an emergency life-threatening situation where it is not feasible or practicable, compliance by all employees and medical staff involved in patient care services with the Centers for Disease Control and Prevention's guidelines on universal precautions; and

(10) Any other standard that the Secretary deems necessary to ensure the quality of the services provided by a limited service hospital.

#### Section 19-307.2

(a) For a hospital classified as a general hospital, the Secretary shall annually calculate the hospital's licensed bed capacity.

(b) The annual licensed bed calculation for each hospital shall equal 140 percent of the average daily census for the 12-month period immediately preceding the calculation.

(c) If necessary to adequately meet demand for services, a hospital may exceed its licensed bed capacity if:

  (1) On average for the 12-month period, the hospital does not exceed its licensed bed capacity based on the annual calculation; and

  (2) The hospital includes in its monthly report to the Health Services Cost Review Commission the following information:

    (i) The number of days in the month the hospital exceeded its licensed bed capacity; and

    (ii) The number of beds that were in excess on each of those days.

(d) Before July 1, 2000 and each July 1 thereafter, the Secretary shall delicense any licensed hospital beds determined to be excess bed capacity under subsection (b) of this section.

#### Section 19-308

(a) The Secretary shall adopt reasonable rules and regulations that set standards of services for related institutions, accredited hospitals, nonaccredited hospitals, accredited residential treatment centers, and nonaccredited residential treatment centers in the following areas:

  (1) The care of patients;

  (2) The medical supervision of patients;

  (3) The physical environment;

  (4) Disease control;

  (5) Sanitation;

  (6) Safety; and

  (7) Dietary matters.

(b)

  (1) To assure compliance with the standards adopted under this subtitle, the Secretary shall have an inspection made:

    (i) Of each related institution, each accredited hospital or nonaccredited hospital, and each accredited residential treatment center or nonaccredited residential treatment center for which a license is sought; and

    (ii) Periodically of each related institution, each accredited hospital or nonaccredited hospital, and each accredited residential treatment center or nonaccredited residential treatment center for which a license has been issued.

  (2) At least 2 inspections a year of each related institution shall be unannounced.

  (3) The part of a building that contains part of a hospital, residential treatment center, or related institution and any outbuilding are considered part of the facility and are subject to inspection to determine occupancy status for licensing purposes.

  (4) Subject to Sec. 2-1257 of the State Government Article, during each regular session of the General Assembly, the Department shall submit to the General Assembly a report on the inspections.

  (5)

    (i) An employee of the Department may not inform a hospital, residential treatment center, or related institution of any proposed inspection activity, unless the chief of the employee's division directs the employee to do so.

    (ii) An employee who violates any provision of this paragraph is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000 or imprisonment not exceeding 1 year or both.

#### Section 19-308.1

(a)

  (1) In this section, "patient care personnel" means an individual whom a related institution employs to provide health related or personal care services.

  (2) "Patient care personnel" does not include an individual who provides general administrative, nonmedical supervisory, or record keeping services in a related institution.

(b) The Secretary may adopt reasonable rules and regulations that set minimum qualifications for patient care personnel who are not licensed under the Health Occupations Article.

#### Section 19-308.2

(a)

  (1) Subsection (b)(1) of this section is not intended to preempt the requirements of Sec. 10-625 of this article.

  (2) The Department shall adopt guidelines, after consultation with the Maryland Hospital Association, Inc., governing the transfer of patients between hospitals to ensure that transfers of patients between hospitals are accomplished in a medically appropriate manner and in accordance with the health care policies of the State that, at a minimum, require:

    (i) Notification to the receiving hospital before the transfer and confirmation by that hospital that the patient meets that hospital's admissions criteria relating to appropriate bed, physician, and other services necessary to treat the patient;

    (ii) The use of medically appropriate life-support measures that a reasonable and prudent physician exercising ordinary care would use to stabilize the patient before transfer and to sustain the patient during the transfer;

    (iii) The provision of appropriate personnel and equipment that a reasonable and prudent physician exercising ordinary care would use for the transfer; and

    (iv) The transfer of all necessary records for continuing the care for the patient.

(b)

  (1) The Department shall adopt regulations providing for penalties for hospitals that violate provisions of subsection (a) of this section.

  (2) A penalty not exceeding $1,000 may be imposed per violation.

#### Section 19-308.3

(a) In this section "facility" means a related institution that, under the regulations of the Department, is a comprehensive care facility or an extended care facility.

(b) Before a facility may use an application or contract for admission the administrator of the facility shall submit the application or contract for admission to the Department.

(c) Before a facility may make any substantive change in an application or contract for admission that has been submitted under subsection (b) of this section, the administrator of the facility shall submit the proposed change to the Department.

(d) The Department, after consulting with the Department of Aging, shall review the applications and contracts to assure:

  (1) That the rights, responsibilities, and duties of the parties are set forth clearly and legibly;

  (2) That they comply with applicable federal and State laws, including the patient's bill of rights; and

  (3) That they do not contain provisions which are unenforceable because of public policy.

(e)

  (1) Any application or contract for admission submitted by a facility to the Department for review and approval in accordance with the provisions of this section shall be deemed approved if the Department fails to make a decision on the proposed application or contract for admission within 30 days of its submission.

  (2) Any substantive change in an application or contract for admission submitted by a facility to the Department for review and approval in accordance with the provisions of this section shall be deemed approved if the Department fails to make a decision on the proposed substantive change within 15 days of its submission.

  (3) Any decision disapproving any provision of any application or contract shall clearly and with particularity state the grounds for such disapproval.

(f) The Department shall adopt regulations to implement the provisions of this section.

#### Section 19-308.4

(a) Each hospital or nursing facility in the State shall ensure that its employees and any other individuals who provide a health care service within or on the premises of the hospital or nursing facility wear a personal identification tag, except where inappropriate for medical reasons, that indicates in readable text:

  (1) The first name, nickname, last name, or full name of the individual that is commonly used in the hospital or nursing facility; and

  (2) The professional or other title of the individual.

(b) The Secretary may impose a fine not to exceed $25 per violation of this section.

#### Section 19-308.5

(a) Each hospital that provides obstetrical services shall establish a universal newborn hearing screening program to ensure that:

  (1)

    (i) All newborns born in the hospital are screened for hearing loss before discharge; and

    (ii) The results are reported as required under Sec. 13-605 of this article; and

  (2) Before discharge and to the extent practicable, the hospital provides to the parent or legal guardian of a newborn identified as having a hearing loss under item (1)(i) of this subsection a list of resources available for parents of children with hearing loss, including:

    (i) Locations for subsequent testing; and

    (ii) Resources on language and communication mode options for communicating with their child.

(b) The universal newborn hearing screening program established under this section shall consist of at least one of the following screening tests:

  (1) Auditory brain stem response;

  (2) Otoacoustic emissions; or

  (3) Another appropriate screening test recommended by the Advisory Council and approved by the Secretary.

#### Section 19-308.6

(a) The Secretary, in consultation with the Association of Maryland Hospitals and Health Systems and the Maryland Association of Hospital Security and Safety Directors, shall develop a uniform set of emergency security codes for hospitals.

(b) The Secretary shall adopt regulations to implement the uniform set of emergency security codes.

(c) Each hospital in Maryland shall implement the provisions of the uniform set of emergency security codes for hospitals within 2 years of the adoption of the regulations by the Secretary.

#### Section 19-308.7

(a) Unless it is medically inadvisable, each hospital shall allow a pregnant patient to arrange for the donation of the blood extracted from the umbilical cord of the patient's newborn child to a certified public cord blood bank.

(b) A patient who agrees to donate cord blood to a public cord blood bank may not be charged for the costs of collecting, storing, or transporting the cord blood.

(c) A hospital is not required to collect cord blood if in the professional judgment of a licensed physician the collection of the cord blood would threaten the health of the mother or newborn child.

(d) A hospital or hospital employee, including a physician, nurse, or other medical staff, may not be required to collect cord blood if the collection of cord blood conflicts with the bona fide religious practices and beliefs of the hospital or hospital employee.

(e) This section may not be construed to require a hospital to arrange for the donation of blood extracted from umbilical cords.

(f)

  (1) The Department, in consultation with obstetricians, the Maryland Hospital Association, and interested groups, shall develop educational materials concerning the values, uses, and donation of umbilical cord blood for the purposes of paragraph (2) of this subsection.

  (2) Each obstetrician and hospital that provides obstetrical services shall distribute the educational materials described in paragraph (1) of this subsection to pregnant patients.

#### Section 19-308.8

(a) A hospital may discharge a patient:

  (1) Entirely;

  (2) To another level of care, treatment, or services;

  (3) To different health professionals; or

  (4) To settings for continued services.

(b) A hospital's process for transfer or discharge shall be based on a patient's assessed needs.

(c) To facilitate discharge or transfer, the hospital shall:

  (1) Assess a patient's needs;

  (2) Plan for discharge or transfer;

  (3) Facilitate the discharge or transfer process;

  (4) Give the patient or person responsible for providing continuing care to the patient written discharge instructions in a form the patient can understand; and

  (5) Help to ensure that continuity of care, treatment, and services is maintained.

(d) If a hospital fails to comply with the requirements of this section, the Secretary may impose a civil money penalty not to exceed $10,000 for each failure to comply.

(e) A hospital may appeal a civil money penalty imposed under subsection (c) of this section in accordance with Title 10, Subtitle 2 of the State Government Article.

#### Section 19-308.9

(a) Except as provided in subsection (c) of this section, if an individual is treated at a hospital and the hospital conducts a urine drug screening to assist in diagnosing the individual's condition, the hospital shall include testing for fentanyl in the individual's urine drug screening.

(b) If the urine drug screening conducted in accordance with subsection (a) of this section detects fentanyl, the hospital shall report the test results, which shall be deidentified, to the Department through the State-designated health information exchange.

(c) This section does not apply to a hospital that does not have chemical analyzer equipment.

(d) This section does not affect any State law providing civil or criminal immunity to an individual who is in need of medical assistance after ingesting or using alcohol or drugs, or to an individual who in good faith assists another individual who is in need of medical assistance after ingesting or using alcohol or drugs.

#### Section 19-308.10

(a) In this section, "safe sleep environment" means, as described in the most recent American Academy of Pediatrics policy statements, an environment in which a newborn may sleep that reduces the risk of sleep-related infant deaths, including through:

  (1) The use of supine positioning;

  (2) The use of a firm, flat sleep surface;

  (3) The use of room sharing without bed sharing;

  (4) The avoidance of soft bedding and overheating; and

  (5) The avoidance of exposure to smoke.

(b)

  (1) As soon as practicable before a hospital discharges an infant after the birth of the infant, the hospital shall provide oral and written educational resources to the parent or legal guardian on how to provide a safe sleep environment.

  (2) The oral and written educational resources required under paragraph (1) of this subsection may be supplemented by an educational video.

(c)

  (1) As soon as practicable before discharging an infant after the birth of the infant, a hospital shall:

    (i) Ask the infant's parent or legal guardian to describe the sleep environment that the parent or legal guardian will provide at home;

    (ii) Inform the parent or legal guardian of the importance of ensuring that the infant has a safe sleep environment and the risks of suffocation and sudden infant death in unsafe sleep environments; and

    (iii) Document that the educational resources described under subsection (b) of this section and the information described under item (ii) of this paragraph were provided to the parent or legal guardian.

  (2) The hospital shall provide a list of resources available for the parent or legal guardian to obtain the items necessary to provide a safe sleep environment for the infant.

(d) On or before January 1, 2025, each hospital shall establish a process for:

  (1) Providing each parent or legal guardian with:

    (i) Oral and written educational resources as required under subsection (b) of this section; and

    (ii) The information described under subsection (c)(1)(ii) of this section;

  (2) A parent or legal guardian to confirm the receipt of the educational resources provided under subsection (b) of this section; and

  (3) Maintaining records of confirmations made under item (2) of this subsection.

(e)

  (1) On or before January 1, 2025, the Department, in consultation with local health officers, shall develop for distribution to birthing parents and legal guardians a list of resources available by county to obtain the items necessary to provide a safe sleep environment for an infant.

  (2) Each local health department shall provide an updated list of resources to the Department each year to assist the Department in developing the list of resources required under paragraph (1) of this subsection.

#### Section 19-308.11

(a) In this section, "medication for opioid use disorder":

  (1) Means a drug approved by the U.S. Food and Drug Administration for the treatment of opioid use disorder; and

  (2) Does not include a drug administered to mitigate opioid-related overdose symptoms.

(b) Each hospital shall establish and maintain, as part of its emergency services, protocols and capacity to:

  (1) Provide to a patient before discharging the patient appropriate, evidence-based interventions that reduce the risk of subsequent harm and fatality following an opioid-related overdose or a visit for an opioid-related emergency medical condition;

  (2) Possess at least one formulation of each U.S. Food and Drug Administration-approved full opioid agonist and partial opioid agonist used for the treatment of opioid use disorder; and

  (3) Treat a patient who presents in a hospital emergency department for care and treatment of an opioid-related overdose or opioid-related emergency medical condition with a medication for opioid use disorder if the treatment:

    (i) Occurs as recommended by the treating health care practitioner; and

    (ii) Is voluntarily agreed to by the patient.

(c) A protocol established by a hospital under this section shall include:

  (1) Any requirement by the Department regarding prescribing opioid agonist treatment;

  (2) Uniform practices for screening and diagnosing individuals who present with an opioid-related overdose or opioid-related emergency medical condition for an opioid use disorder based on the criteria in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders;

  (3) Uniform practices for offering and administering opioid agonist medication to treat an opioid-related overdose or opioid use disorder; and

  (4) Uniform practices to identify community-based treatment services that are appropriate for:

    (i) Treating opioid use disorders; and

    (ii) Assisting patients to voluntarily access ongoing community-based treatment at discharge.

(d) Before discharging a patient who is diagnosed with an opioid use disorder or administered or prescribed medication for opioid use disorder, a hospital shall:

  (1) Make a referral of the patient to an appropriate provider or facility for a timely appointment, when possible, to voluntarily continue treatment in the community; and

  (2) Work with peer support professionals, as available, or other resources to assist the patient in accessing the identified treatment services.

#### Section 19-309

(a) Notwithstanding any other provisions of this subtitle, each hospital or residential treatment center shall be open to inspections by the Department to investigate and resolve any complaint concerning patient care, safety, medical and nursing supervision, physical environment, sanitation or dietary matters.

(b)

  (1) To resolve expeditiously a complaint that alleges the existence of any nonlife-threatening deficiency, the Department may refer the complaint directly to the hospital or residential treatment center.

  (2) If appropriate, issues relating to the practice of medicine or the licensure or conduct of a health professional shall be referred to the hospital or the residential treatment center and may be referred to the appropriate licensure board for resolution.

  (3) If the Department determines that the hospital or residential treatment center has not satisfactorily addressed the referred complaint or where the complaint alleges the existence of a life-threatening deficiency, the Department shall conduct an independent investigation.

#### Section 19-310

(a)

  (1) In this subsection, "designated requestor" means a hospital employee who has completed a course offered by an organ, tissue, or eye recovery agency on how to approach potential donor families and request organ or tissue donation.

  (2)

    (i) On or before the occurrence of each death in a hospital, the hospital shall contact an appropriate organ, tissue, or eye recovery agency in order to determine the patient's suitability for organ, tissue, or eye donation.

    (ii) The contact and its disposition shall be noted in the patient's medical record.

  (3)

    (i) The appropriate organ, tissue, or eye recovery agency, in consultation with the patient's attending physician or the physician's designee, shall determine the patient's suitability for organ, tissue, or eye donation.

    (ii) If the organ, tissue, or eye recovery agency, in consultation with the patient's attending physician or the physician's designee, determines that donation is not appropriate based on established medical criteria, this determination shall be noted by hospital personnel in the patient's medical record and no further action is necessary.

    (iii) If the organ, tissue, or eye recovery agency, in consultation with the patient's attending physician or the physician's designee, determines that the patient is a suitable candidate for organ, tissue, or eye donation, a representative of the appropriate organ, tissue, or eye recovery agency or a designated requestor shall initiate a request under paragraph (4) of this subsection, if applicable.

  (4)

    (i) Except as provided in the Maryland Revised Uniform Anatomical Gift Act, when an individual dies in a hospital in accordance with Sec. 5-202 of this article, a representative of the appropriate organ, tissue, or eye recovery agency or a designated requestor shall request, with sensitivity and in compliance with Sec. 4-507 of the Estates and Trusts Article, that the individual's representative consent to the donation of all or any of the decedent's organs or tissues as an anatomical donation if suitable.

    (ii) Directions given by a person authorized under Sec. 4-503 of the Estates and Trusts Article to make, amend, revoke, or refuse to make an anatomical gift of a decedent's body or parts shall be recorded in the decedent's medical record.

    (iii) The representative of the appropriate organ, tissue, or eye recovery agency or the designated requestor and the representative of the deceased patient are entitled to protection from civil and criminal liability as provided in Sec. 4-514 of the Estates and Trusts Article.

  (5) In all discussions concerning donations of organs and tissues, the representative of the appropriate organ, tissue, or eye recovery agency or the designated requestor shall show reasonable discretion and sensitivity:

    (i) To the circumstances of the family of the decedent;

    (ii) To the religious beliefs of the decedent; and

    (iii) To the nonsuitability for organ or tissue donation of the decedent.

  (6)

    (i) When a representative of the appropriate organ, tissue, or eye recovery agency or a designated requestor makes a request under paragraph (4)(i) of this subsection, the representative or designated requestor shall document the request and its disposition as required by Sec. 4-508 of the Estates and Trusts Article.

    (ii) Hospital personnel shall note the request and its disposition in the decedent's medical record or death certificate.

  (7) A hospital may not bill the estate of the decedent, a surviving spouse or domestic partner of the decedent, any heirs of the decedent, or an insurer of the decedent for the costs associated with the removal of all or any of the decedent's organs or tissues for the purpose of an anatomical donation.

  (8) After consultation with the Maryland Hospital Association, Inc., the Medical and Chirurgical Faculty of the State of Maryland, Living Legacy Foundation, the Washington Regional Transplant Community, the Medical Eye Bank of Maryland, the Health Facilities Association of Maryland, and Tissue Banks International, the Secretary shall publish guidelines designed to implement this subsection, including guidelines:

    (i) Requiring that, at or near the time of each individual death in a hospital, the hospital contact by telephone an appropriate organ, tissue, or eye recovery agency to determine the suitability of the individual for organ, tissue, and eye donation;

    (ii) Requiring that each hospital designate a person to make the contact; and

    (iii) Identifying the information that the person designated by the hospital shall have available before making the contact.

  (9) The provisions of this subsection shall in no way interfere with the duties of the office of the Chief Medical Examiner. In sudden deaths under the jurisdiction of the office of the Chief Medical Examiner as provided in Sec. 5-309 of this article, notification will be made to the office of the Chief Medical Examiner prior to organ removal.

  (10) The consent of the decedent's representative is not necessary and the provisions of paragraph (4) of this subsection do not apply if Sec. 4-506 of the Estates and Trusts Article precludes the decedent's representative from making an anatomical gift.

  (11) A person who acts in good faith to recover organs or tissues in accordance with a notation on the decedent's driver's license or identification card that the decedent is an organ donor, a gift made in accordance with Sec. 5-604.1 of this article or Title 4, Subtitle 5 of the Estates and Trusts Article, or a gift made in accordance with the anatomical gift laws of another state or country is immune from criminal prosecution and liability for damages in any cause of action related to the recovery and donation of the decedent's organs or tissues.

  (12) The Department shall conduct annual death record reviews at each hospital to determine the hospital's compliance with the provisions of this subsection. The Department may delegate its duty to conduct annual death record reviews to the appropriate organ, tissue, or eye recovery agency serving the region in which a particular hospital is located.

(b)

  (1) Subject to paragraph (2) of this subsection and notwithstanding any other provision of law, a hospital offering bone marrow transplant services shall allow an individual to donate bone marrow to any individual.

  (2) An individual may donate bone marrow to another individual if a licensed physician determines, based on the physician's medical judgment, that the donation of the bone marrow is in the best interests of the donee and there is no substantial risk of medical injury to the donor.

#### Section 19-310.1

(a)

  (1) This section applies to a nursing facility, as defined in Sec. 19-301 of this subtitle, that:

    (i) Has 45 or more beds; and

    (ii) Operates in the State.

  (2) This section does not apply to a nursing home bed in a continuing care retirement community that has obtained a certificate of registration to provide continuing care under Title 10, Subtitle 4 of the Human Services Article.

(b)

  (1) The Department may impose a quality assessment on each freestanding nursing facility subject to this section.

  (2) The amount assessed in the aggregate on all nursing facilities may not exceed 6.0% of the operating revenue for all nursing facilities subject to this section for the previous fiscal quarter.

  (3) The assessment authorized by this section shall be paid by each nursing facility in accordance with this section.

(c)

  (1) On or before the 60th day after each quarter of the State fiscal year, each nursing facility subject to this section shall pay to the Comptroller an amount determined by the Department based on an amount per non-Medicare day of service for the previous fiscal quarter.

  (2) The assessment shall be based on an amount per patient day, not including Medicare days.

(d)

  (1) All amounts collected by the State Comptroller under this section shall be distributed to a special fund, to be used by the Department only to fund reimbursements to nursing facilities under the Medicaid program.

  (2) At least 65% of the funds allocated by the Department as reimbursements to nursing facilities under this section shall be in addition to and may not supplant funds already appropriated for this purpose.

(e) The Department shall adopt regulations to implement this section.

(f) On or before September 1, 2015, and each year thereafter, the Department shall report to the General Assembly, in accordance with Sec. 2-1257 of the State Government Article, on the implementation of this section, including:

  (1) The percentage and amount of the assessment charged to each nursing facility subject to this section;

  (2) The number of nursing facilities subject to this section with a net loss; and

  (3) A comparison of the total amount provided in the Medicaid budget for nursing home reimbursement in the current fiscal year to the actual amount received in the immediately prior fiscal year.

#### Section 19-310.2

On or before July 1, 2014, each hospital that provides emergency medical services shall have a protocol to provide timely access to a sexual assault medical forensic examination by a forensic nurse examiner or a physician to a victim of an alleged rape or sexual offense who arrives at the hospital for treatment.

#### Section 19-310.3

(a) On or before January 1, 2018, each hospital shall have a protocol for discharging a patient who was treated by the hospital for a drug overdose or was identified as having a substance use disorder.

(b) The protocol:

  (1) May include:

    (i) Coordination with peer recovery counselors who can conduct a screening, a brief intervention, and referral to treatment and connection of the patient with community services; and

    (ii) Prescribing opioid overdose reversal drugs approved by the federal Food and Drug Administration for the patient; and

  (2) On or before June 30, 2023, shall require offering opioid overdose reversal drugs approved by the federal Food and Drug Administration, free of charge, to a patient who received treatment for a substance use disorder, opioid use disorder, or nonfatal drug overdose event.

#### Section 19-310.4

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Committee" means the review committee established in accordance with subsection (e) of this section.

  (3) "Program" means the Private Hospital Grant Program.

(b) Except as provided in subsection (f) of this section, this section may not be construed to prohibit an organization from receiving funds from a government source other than the Private Hospital Grant Program.

(c) There is a Private Hospital Grant Program.

(d) The purpose of the Program is to make recommendations to the Governor for funding in the annual State budget for capital projects at private hospitals in the State.

(e)

  (1) The Maryland Hospital Association shall establish a review committee to:

    (i) Develop the process for hospitals in the State to submit requests for funding in the annual budget;

    (ii) Establish eligibility criteria for a hospital to submit a request for funding under the Program;

    (iii) Establish criteria for projects eligible to receive funding under the Program;

    (iv) Establish deadlines for the submission of requests for funding and the determination of projects recommended for funding;

    (v) Develop project scoring and selection criteria guidelines;

    (vi) Review eligible requests for funding; and

    (vii) Make final recommendations for projects to be funded in the annual State budget.

  (2) To the extent practicable, the membership of the committee established under paragraph (1) of this subsection shall reflect the geographic diversity of hospitals in the State.

  (3) The committee shall consult with the Department of Budget and Management and the Department of Legislative Services in:

    (i) Establishing the project funding request process under paragraph (1) of this subsection; and

    (ii) Making recommendations for funding requests.

(f) In consultation with the Department of Budget and Management, the committee may establish conditions under which a request for funding may be rejected for consideration.

(g) The Maryland Hospital Association shall submit the recommendations of the committee to the Governor and the Secretary of Budget and Management.

(h) For fiscal year 2026 and each fiscal year thereafter, the Governor may include in the capital or operating budget bill an appropriation of $20,000,000 for the Private Hospital Grant Program.

#### Section 19-310.5

#### Section 19-310.6

(a)

  (1) Subject to paragraphs (2) and (3) of this subsection, on or before January 1, 2025, each hospital and urgent care center in the State shall implement an evidence-based protocol for the early recognition and treatment of a patient with sepsis, severe sepsis, or septic shock that is based on generally acceptable standards of care.

  (2) The evidence-based protocol implemented for hospitals under paragraph (1) of this subsection shall comply with the Centers for Disease Control and Prevention sepsis guidelines.

  (3) A hospital that is a specialty psychiatric hospital shall establish a process for the screening and early recognition of a patient with sepsis, severe sepsis, or septic shock, and procedures to transfer the patient to the appropriate setting.

(b) A hospital that submits sepsis data to the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting Program is presumed to meet the requirements of subsection (a) of this section.

(c) Each hospital and urgent care center shall:

  (1) Require periodic training in the implementation of the sepsis protocol required under subsection (a) of this section for professional staff with direct patient care responsibilities and, as appropriate, for staff with indirect patient care responsibilities, including laboratory and pharmacy staff; and

  (2) Ensure that the staff receive updated training if the hospital or urgent care center makes a substantive change to the sepsis protocol.

#### Section 19-310.7

(a) In this section, "health system" has the meaning stated in Sec. 15-112(y) of the Insurance Article.

(b) A health system shall comply with Sec. 15-112(y) of the Insurance Article.

#### Section 19-311

A person shall have the approval of the Secretary before the person may:

(1) Build a hospital or related institution; or

(2) Make any conversion, alteration, or addition to the plant or building that will affect the functional structure or normal bed capacity of a hospital or related institution.

#### Section 19-312

To qualify for approval under Part II of this subtitle, the applicant shall satisfy the Secretary that the hospital or related institution will meet the requirements that the Secretary adopts under this subtitle.

#### Section 19-313

An applicant for approval under Part II of this subtitle shall submit to the Secretary:

(1) A written application on the form that the Secretary requires; and

(2) The documents, drawings, and other information that the Secretary requires.

#### Section 19-314

(a)

  (1) The Secretary promptly shall:

    (i) Review each application and the information submitted under Part II of this subtitle; and

    (ii) Investigate the proposed new hospital or related institution or proposed conversion, alteration, or addition.

  (2) Within 30 days after the application is submitted, the Secretary shall give the applicant:

    (i) Notice of approval or disapproval; and

    (ii) In case of disapproval, each reason for the disapproval.

(b) The Secretary shall grant approval under Part II of this subtitle if the hospital or related institution will meet the requirements of this subtitle.

#### Section 19-315

The Maryland Health and Higher Educational Facilities Authority Act provides means to enlarge and establish hospitals and related health care facilities.

#### Section 19-318

(a) A person shall be licensed by the Secretary before the person may operate a hospital or related institution in this State.

(b) A hospital shall be classified as a special rehabilitation hospital before the hospital may provide or hold itself out as providing comprehensive physical rehabilitation services, as defined in Sec. 19-1201 of this title.

#### Section 19-319

(a) To qualify for a license, an applicant and the hospital or related institution to be operated shall meet the requirements of this section.

(b) An applicant who is an individual, and any individual who is applying on behalf of a corporation, association, or government agency shall be:

  (1) At least 18 years old; and

  (2) Of reputable and responsible character.

(c)

  (1) The applicant shall have a certificate of need, as required under Subtitle 1 of this title, for the hospital, residential treatment center, or related institution to be operated.

  (2) The hospital, residential treatment center, or related institution to be operated shall meet the requirements that the Secretary adopts under this subtitle and Subtitle 12 of this title.

(d)

  (1) As a condition of licensure, each hospital shall establish a utilization review program for all patients admitted to the hospital. The utilization review program:

    (i) May be conducted by an independent, nonhospital-affiliated review agent;

    (ii) Shall be performed by registered nurses, medical records technicians, or similar qualified personnel supported and supervised by physicians as may be required;

    (iii) Shall be certified by the Secretary if the program meets the minimum standards established under paragraph (4) of this subsection; and

    (iv) Shall be recertified by the Secretary if the hospital makes any changes to the program after the initial certification.

  (2) Any change made to a certified utilization review program shall be reported to the Secretary by the hospital within 30 days of the date the change was made.

  (3) If a hospital fails to provide the utilization review program required under this subsection, the Secretary may impose the following penalties:

    (i) Delicensure of hospital; or

    (ii) $500 per day for each day the violation continues.

  (4) The Secretary shall, by regulation and in consultation with health care providers and payors, establish minimum standards for a utilization review program, directed at appropriateness and quality of inpatient care, as enumerated in the following items:

    (i) Preadmission review of elective admissions;

    (ii) Postadmission review of emergency admissions;

    (iii) Concurrent or retrospective review of all admissions as appropriate;

    (iv) Preauthorization of certain selected procedures if proposed to be performed on an inpatient basis;

    (v) Continued stay review based on recognized objective criteria;

    (vi) Discharge planning review; and

    (vii) Readmission review.

  (5) A patient may not be charged for any days disallowed as a result of retrospective review under paragraph (4) of this subsection unless the patient refuses to leave the hospital when it is medically appropriate to do so and the disallowed days occur:

    (i) After the hospital has notified the patient in writing of the potential disallowance; or

    (ii) As a direct result of the noncompliance by the patient to treatment or hospital regulations.

  (6) A hospital shall be exempt from requiring a utilization review program for a patient if:

    (i)

      (1) The patient is insured by a third-party payor; and

      (2) The third-party payor has a utilization review program for its subscribers or beneficiaries which meets the minimum standards as adopted in paragraph (4) of this subsection; or

    (ii) The patient is a subscriber or member of a health maintenance organization as defined in Sec. 19-701 of this title.

  (7) Where federal regulations or guidelines for a federally mandated utilization review program for federally insured patients differ from standards established under paragraph (4) of this subsection, the Secretary may waive a specific standard if the program achieves the same objectives as the standards established by the Secretary.

  (8) The Secretary may establish record keeping and reporting requirements:

    (i) To evaluate the effectiveness of hospitals' utilization review programs; and

    (ii) To determine if the utilization review programs are in compliance with the provisions of this section and regulations adopted by the Secretary to administer this section.

(e)

  (1)

    (i) In this subsection the following words have the meanings indicated.

    (ii)

      (1) "Telemedicine" means the use of interactive audio, video, or other telecommunications or electronic technology by a physician in the practice of medicine outside the physical presence of the patient.

      (2) "Telemedicine" does not include:

      (A) An audio-only telephone conversation between a physician and a patient;

      (B) An electronic mail message between a physician and a patient; or

      (C) A facsimile transmission between a physician and a patient.

    (iii) "Uniform standard credentialing form" means:

      (1) The form designated by the Secretary through regulation for credentialing physicians who seek to be employed by or have staff privileges at a hospital; or

      (2) The uniform credentialing form that the Insurance Commissioner designates under Sec. 15-112.1 of the Insurance Article.

  (2) As a condition of licensure, each hospital shall:

    (i) Establish a credentialing process for the physicians who are employed by or who have staff privileges at the hospital; and

    (ii) Use the uniform standard credentialing form as the initial application of a physician seeking to be credentialed.

  (3) Use of the uniform standard credentialing form does not preclude a hospital from requiring supplemental or additional information as part of the hospital's credentialing process.

  (4)

    (i) The Secretary shall, by regulation and in consultation with hospitals, physicians, interested community and advocacy groups, and representatives of the Maryland Defense Bar and Plaintiffs' Bar, establish minimum standards for a credentialing process which shall include:

      (1) A formal written appointment process documenting the physician's education, clinical expertise, licensure history, insurance history, medical history, claims history, and professional experience;

      (2) A requirement that an initial appointment to staff not be complete until the physician has successfully completed a probationary period; and

      (3) Subject to subparagraph (ii) of this paragraph, a formal, written reappointment process to be conducted in accordance with standards of the accreditiation body that accredits a hospital.

    (ii) The reappointment process established under subparagraph (i)3 of this paragraph shall document the physician's pattern of performance by analyzing:

      (1) Claims filed against the physician;

      (2) Data dealing with utilization, quality, and risk;

      (3) Clinical skills;

      (4) Adherence to hospital bylaws, policies, and procedures;

      (5) Compliance with continuing education requirements;

      (6) Mental and physical status; and

      (7) The results of the practitioner performance evaluation process under subsection (i) of this section.

  (5) If requested by the Department, a hospital shall provide documentation that, prior to employing or granting privileges to a physician, the hospital has complied with the requirements of this subsection and that, prior to renewing employment or privileges, the hospital has complied with the requirements of this subsection.

  (6) Notwithstanding any other provision of this subsection, in its credentialing and privileging process for a physician who provides medical services to patients at the hospital only through telemedicine from a distant-site hospital or distant-site telemedicine entity, a hospital may rely on the credentialing and privileging decisions made for the physician by the distant-site hospital or distant-site telemedicine entity, as authorized under 42 C.F.R. Part 482, if:

    (i) The physician who provides medical services through telemedicine holds a license to practice medicine in the State issued under Title 14 of the Health Occupations Article; and

    (ii) The credentialing and privileging decisions with respect to the physician who provides medical services through telemedicine are:

      (1) Approved by the medical staff of the hospital; and

      (2) Recommended by the medical staff of the hospital to the hospital's governing body.

  (7) If a hospital fails to establish or maintain a credentialing process required under this subsection, the Secretary may impose the following penalties:

    (i) Delicensure of the hospital; or

    (ii) $500 per day for each day the violation continues.

(f) As a condition of licensure, each accredited and nonaccredited hospital shall develop a protocol for the procurement of organs and tissues.

(g)

  (1) As a condition of licensure, each hospital shall establish a risk management program.

  (2) The Secretary shall, by regulation and in consultation with hospitals, physicians, interested community and advocacy groups, and representatives of the Maryland Defense Bar and Plaintiffs' Bar establish minimum standards for a risk management program which shall include:

    (i) A board policy statement indicating commitment to the risk management program;

    (ii) A requirement that one person be assigned the responsibility for coordinating the program;

    (iii) An internal staff committee structure to conduct ongoing review and evaluation of risk management activities;

    (iv) A formal written program for addressing patient complaints;

    (v) A documented facility-wide risk reporting system;

    (vi) Ongoing risk management education programs for all staff; and

    (vii) Documentation that the risk management and quality assurance programs share relevant information.

  (3) If a hospital fails to establish or maintain a risk management program required under this subsection, the Secretary may impose the following penalties:

    (i) Delicensure of the hospital; or

    (ii) $500 per day for each day the violation continues.

(h)

  (1) As a condition of licensure, each hospital and related institution shall:

    (i) Adopt, implement, and enforce a policy that requires, except in an emergency life-threatening situation where it is not feasible or practicable, all employees and medical staff involved in patient care services to comply with the Centers for Disease Control and Prevention guidelines on universal precautions; and

    (ii) Display the notice developed under Sec. 1-207 of the Health Occupations Article at the entrance to the hospital or related institution.

  (2) If a hospital or related institution fails to comply with the requirements of this subsection, the Secretary may impose a fine of up to $500 per day per violation for each day a violation continues.

(i)

  (1) As a condition of licensure, each hospital shall establish a practitioner performance evaluation process that objectively evaluates the performance of each member of the medical staff at the hospital.

  (2) The practitioner performance evaluation process shall include a review of care provided to patients at the hospital by the members of the medical staff.

  (3) The review of care shall:

    (i) Be undertaken for cases chosen at random and for cases with unexpected adverse outcomes;

    (ii) Be based on objective review standards;

    (iii) Include a review of the appropriateness of the plan of care for the patient, particularly any medical procedures performed on the patient, in relation to the patient's condition; and

    (iv) Be conducted by members of the medical staff or, at the discretion of the hospital, external reviewers, who:

      (1) Are of the same specialty as the member of the medical staff under review;

      (2) Have been trained to perform practitioner performance evaluation; and

      (3) Are not otherwise associated with the case under review.

  (4) A hospital shall take into account the results of the practitioner performance evaluation process for a member of the medical staff in the reappointment process established under subsection (e) of this section.

  (5) If a hospital fails to comply with the requirements of this subsection, the Secretary may impose a fine of up to $500 per day per violation for each day a violation continues.

(j)

  (1) The Department, in coordination with the Maryland Institute for Emergency Medical Services Systems, shall adopt regulations establishing minimum perinatal care standards that meet or exceed the Maryland Perinatal System Standards for each hospital that provides obstetrical services.

  (2) Each hospital that provides obstetrical services shall comply with the perinatal care standards established by the regulations adopted under paragraph (1) of this subsection as a condition of licensure.

#### Section 19-319.1

As a prerequisite to the licensing of related institutions and each year after the license is issued, the Department shall require each related institution that provides long-term care and programs for patients with Alzheimer's disease and related disorders to have an in-service education program that includes instruction on dementia and the techniques necessary to manage dementia patients with regard to their physical, intellectual, and behavioral manifestations.

#### Section 19-319.2

(a) In this section, "facility" means a special psychiatric hospital or an acute general care hospital with separately identified inpatient psychiatric service.

(b)

  (1) As a condition of licensure, each facility shall adopt written policies and procedures to implement the requirements of Sec.Sec. 10-701 through 10-709 of this article. The policies and procedures:

    (i) May expand the rights provided in Sec.Sec. 10-701 through 10-709 of this article;

    (ii) Shall provide for a mechanism for patients and others to report suspected violations of Sec.Sec. 10-701 through 10-709 of this article to a designated official of the hospital;

    (iii) Shall provide a system for investigating suspected violations; and

    (iv) Shall ensure that there is a timely appropriate response to any suspected violation.

  (2) The Secretary may inspect any document necessary to ensure compliance with this subsection and Sec.Sec. 10-701 through 10-709 of this article.

  (3) If a hospital that is a facility fails to adopt and implement the policies and procedures required by this subsection or maintains a continuing pattern of conditions or practices in knowing violation of Sec.Sec. 10-701 through 10-709 of this article, the Secretary may impose the following penalties, but only after the Secretary has satisfied the conditions in Sec. 19-360 of this subtitle:

    (i) Delicensure of the specialty psychiatric hospital;

    (ii) Delicensure of the separately identified psychiatric service of the acute general care hospital; or

    (iii) A fine not to exceed $500 per day for each day the violation continues.

#### Section 19-320

(a) An applicant for a license shall submit an application to the Secretary.

(b) The application:

  (1) Shall be on the form that the Secretary requires;

  (2) Shall be signed and verified as follows:

    (i) If the application is made for an individual, by the individual; or

    (ii) If the application is made for a corporation, association, or government agency, by 2 officers of the organization; and

  (3) Shall include:

    (i) The name of the applicant;

    (ii) A statement that the applicant meets the requirements of this subtitle;

    (iii) The class of the proposed hospital or related institution;

    (iv) The location of the proposed hospital or related institution;

    (v) The name of the individual who is to be the administrative head of the proposed hospital or related institution; and

    (vi) Any other information that the Secretary requires.

#### Section 19-321

(a) The Secretary shall issue a license to any applicant if the applicant and the hospital or related institution to be operated meet the requirements of this subtitle.

(b) The Secretary shall include on each license that the Secretary issues:

  (1) The name of the hospital or related institution; and

  (2) The classification of the hospital or related institution.

#### Section 19-322

While it is effective, a license authorizes the licensee to operate the hospital or related institution named in the license under the classification set forth in the license.

#### Section 19-324

A license issued under this subtitle is not transferable.

#### Section 19-325

(a) If voluntary efforts to reduce excess capacity prove insufficient, as a last resort the Maryland Health Care Commission and the Health Services Cost Review Commission may petition the Secretary to delicense any hospital or part of a hospital or hospital service based on a finding after a public hearing that the delicensure is consistent with the State health plan or institution-specific plan. The petition shall specify in detail all efforts made by the petitioner to encourage the hospital:

  (1) To reduce its underutilized capacity;

  (2) To merge or consolidate;

  (3) To become more efficient and effective; and

  (4) To convert from acute capacity to alternative uses, where appropriate.

(b) On petition by the Maryland Health Care Commission and the Health Services Cost Review Commission, the Secretary may order that a hospital or part of a hospital or hospital service be delicensed if:

  (1) The Secretary determines that delicensure is the last resort and a hospital or hospital services are excessive or inefficient, which determination is based on and is not inconsistent with the State health plan or institution-specific plan;

  (2) An opportunity for notice and hearing in accordance with the Administrative Procedure Act has been given to the affected hospital, and in the affected political subdivision notice shall be given to the elected public officials and for at least 2 consecutive weeks in a newspaper of general circulation; and

  (3) The hospital is not the sole provider of hospital services in a county for which the Commission and Health Services Cost Review Commission have petitioned for all of the beds of the hospital to be delicensed.

(c) The Maryland Health Care Commission and the Health Services Cost Review Commission are necessary parties to any proceeding in accordance with this section.

(d) Any person who is aggrieved by a final decision of the Secretary under this section may take a direct judicial appeal.

(e) The appeal shall be made as provided for judicial review of final decisions in the Administrative Procedure Act.

(f) The Secretary may participate in any appeal of a decision made in accordance with this section.

(g) In the event of an adverse decision that affects its final decision, the Secretary may apply within 30 days by writ of certiorari to the Court of Appeals for review where:

  (1) Review is necessary to secure uniformity of decision, as where the same statute has been construed differently by 2 or more judges; or

  (2) There are other special circumstances that render it desirable and in the public interest that the decision be reviewed.

#### Section 19-326

If a hospital voluntarily closes, merges, or is delicensed under Sec. 19-325 of this subtitle, the Department of Commerce, in cooperation with the Maryland Health Care Commission, shall assist the hospital and local community in identifying alternative uses for the hospital buildings or sites.

#### Section 19-326.1

If a hospital voluntarily closes, merges, or is delicensed under Sec. 19-325 of this subtitle and workers are displaced:

(1) Each hospital shall pay a fee directly to the Maryland Department of Labor. The fee shall not exceed 0.01 percent of the gross operating revenue for the fiscal year immediately preceding the closure or delicensing of the hospital. A fee shall only be assessed once for each voluntary closure, merger, or delicensure.

(2) The Secretary of Labor shall pay the fees received under this section into the Hospital Employees Training Fund established under Sec. 11-201 of the Labor and Employment Article.

#### Section 19-327

(a)

  (1) The Secretary shall deny a license to any applicant or revoke a license if the applicant or licensee has been convicted of a felony that relates to Medicaid or to a nursing home.

  (2) The Secretary may deny a license to an applicant or revoke a license if the applicant or licensee does not meet the requirements of this subtitle or any rule or regulation that the Secretary adopts under this subtitle.

(b) The Secretary may deny a license to an applicant or revoke a license if the applicant or licensee violates Title 6.5 of the State Government Article.

(c)

  (1) Before any action is taken under this section, the Secretary shall give the applicant or licensee an opportunity for a hearing.

  (2) The hearing notice to be given to the applicant or licensee shall be sent at least 10 days before the hearing.

  (3) The applicant or licensee is entitled to be represented by counsel at the hearing.

#### Section 19-328

(a)

  (1) If the Secretary determines that a life-threatening, health or fire safety deficiency exists in a related institution, the Secretary immediately may restrict new admissions to the related institution for not more than a 30-day period.

  (2) Within 7 days after a request by an aggrieved party, a hearing shall be held to determine the appropriateness of the admissions restriction.

  (3) Within 21 days after admissions are restricted, the related institution shall take steps to correct the deficiency.

(b)

  (1) Unless the Secretary lifts the admissions restriction, within 30 days after admissions are restricted, a hearing shall be held to determine whether the related institution has taken enough steps to correct the deficiency.

  (2) If the Secretary finds that the deficiency still exists, the Secretary may:

    (i) Continue to restrict admissions for not more than 3 consecutive 30-day periods; or

    (ii) Revoke the license of the related institution and move its residents to an appropriate, licensed facility.

  (3) An aggrieved party is entitled to a hearing on each continuation of the admissions restriction. Within 7 days after a request by an aggrieved party, a hearing shall be held to determine the appropriateness of the admissions restriction.

#### Section 19-329

(a)

  (1) If, under a Montgomery or Prince George's county ordinance for licensing related institutions, the county licensing authority proposes to suspend or revoke the county license of a related institution, that authority shall give the Secretary notice of the proposed suspension or revocation and the reasons for it before the authority notifies the related institution.

  (2) If, within 14 days after the Secretary receives the notice, the Secretary disapproves the proposed suspension or revocation, the county licensing authority may not proceed with the action. Otherwise the county licensing authority may proceed with the action.

  (3) If the Secretary disapproves the proposed suspension or revocation, the Secretary shall state, in writing, the reasons for the disapproval.

(b)

  (1) If the Montgomery or Prince George's county licensing authority proposes to restrict new admissions to a related institution, that authority shall give the Secretary as much prior notice of the proposed restriction as possible, so that State and county action may be coordinated.

  (2) The Secretary may become a party to any county administrative or judicial proceeding on the restriction.

#### Section 19-330

(a) Except as provided in this section for an action under Sec. 19-329(a) of this subtitle, any person aggrieved by a final decision of the Secretary in a contested case, as defined in the Administrative Procedure Act, may petition for judicial review as allowed by the Administrative Procedure Act.

(b) A person aggrieved by a final decision of the Secretary under Sec. 19-329(a) of this subtitle may not appeal.

#### Section 19-333

(a) In Part V of this subtitle the following words have the meanings indicated.

(b) "Affiliate" means:

  (1) Each partner of a partnership;

  (2) Each officer, director, and stockholder who has direct or indirect ownership or control of 10 percent or more of the stock of a corporation; or

  (3) Each individual who has direct or indirect ownership of 10 percent or more of a nursing home or community program.

(c) "Community program" means:

  (1) A program which provides residential services and is an alcohol abuse and drug abuse treatment program as defined in Sec. 8-403(a) of this article;

  (2) A program which provides residential services for individuals with a developmental disability as defined in Sec. 7-101(d) and (h) of this article;

  (3) A private group home required to be licensed by the Secretary under Sec. 10-517 of this article;

  (4) A private therapeutic group home for children and adolescents as defined under Sec. 10-920 of this article;

  (5) A private residential treatment center for children and adolescents licensed under Sec. 19-307 of this subtitle;

  (6) A private facility operating living units that house less than 4 persons per unit under Sec. 10-902 of this article;

  (7) A program which provides day habilitation, vocational, or community supported living arrangements services required to be licensed under Sec. 7-903 of this article; or

  (8) A private program that provides outpatient services as set forth in Sec. 10-902 of this article.

(d) "Individual" means a person who is a resident of a nursing home or a community residential program or a person enrolled in a day habilitation or vocational program.

(e) "Nursing home" means a related institution that is classified as a nursing home.

#### Section 19-334

(a) In addition to any other power set forth in this article or the Health Occupations Article, the Secretary may file a petition for appointment of a receiver for a nursing home or community program defined in this subtitle if, after investigation of the Secretary or after investigation at the request of the Secretary of Aging, the Secretary reasonably believes that:

  (1) A person is operating the nursing home or community program without a license for it;

  (2) The nursing home or community program will be closed within 30 days and arrangements to relocate its residents have not been approved by the Secretary;

  (3) The nursing home or community program or its residents have been abandoned; or

  (4) A situation, physical condition, practice, or method of operation presents an imminent danger of death or serious mental or physical harm to the individuals.

(b) A petition under this section shall be filed with the circuit court for the county where the nursing home or community program is located.

#### Section 19-335

(a)

  (1) Except as otherwise provided in subsection (b) of this section, the court shall hold a hearing on a petition under Part V of this subtitle within 10 days after the petition is filed.

  (2) The owner of the nursing home or entity operating the community program shall be given notice of the hearing:

    (i) At least 5 days before the hearing; or

    (ii) At least 3 days before the hearing, by a notice posted conspicuously inside or on the front door of the nursing home or site of the community program, if the Secretary files a statement that:

      (1) Is signed and verified by the Secretary;

      (2) States that the owner or operating entity cannot be found; and

      (3) Sets forth a substantial account of reasonable, good faith efforts to find the owner or operating entity and serve process.

  (3) The owner of the nursing home or operating entity of a community service is entitled to offer evidence at the hearing.

(b)

  (1) A court may appoint a receiver for a nursing home or community program if, from the petition, affidavits, and any evidence offered ex parte, the court finds probable cause to believe that a situation, physical condition, practice, or method of operation presents an imminent danger of death or serious mental or physical harm to the residents and must be remedied immediately to insure their health, safety, and welfare.

  (2) The owner or person then in charge of the nursing home or community program shall be given notice of the appointment of a receiver:

    (i) By service of the notice, within 24 hours after the appointment; or

    (ii) By posting the notice conspicuously inside or on the front door of the nursing home or site of the community program, if the Secretary files a statement that:

      (1) Is signed and verified by the Secretary;

      (2) States that the owner and the person in charge of the nursing home or community program cannot be found; and

      (3) Sets forth a substantial account of reasonable, good faith efforts to find the owner and the person in charge and serve process.

  (3) Unless the owner of the nursing home or entity operating the community program consents to a later date, the court shall hold a hearing on the appointment of the receiver within 5 days after service of process.

#### Section 19-336

(a) After the hearing under Sec. 19-335 of this subtitle, the court may appoint a receiver for the nursing home or community program or continue the appointment of the receiver made ex parte, if the court finds:

  (1) A person is operating the nursing home or community program without a license for it;

  (2) The nursing home or community program will be closed within 30 days and arrangements to relocate its residents have not been approved by the Secretary;

  (3) The nursing home or community program or its residents have been abandoned; or

  (4) A situation, physical condition, practice, or method of operation presents an imminent danger of death or serious mental or physical harm to the individuals.

(b) The court may appoint as receiver any responsible individual other than:

  (1) A State employee;

  (2) An employee of a local government; or

  (3) The owner or administrator of or other individual with a financial interest in the nursing home or community program or agent of any of those individuals.

(c)

  (1) Before the receiver takes charge of the nursing home or community program, the receiver shall file a bond with the court.

  (2) The bond:

    (i) May not exceed the value of the nursing home or community program and its assets; and

    (ii) Shall run to this State for benefit of all persons interested in the faithful performance of the receiver including the individuals.

  (3) Unless the court directs otherwise, the receiver may pay the premium of the bond from the income of the nursing home or community program.

(d) The Secretary may petition the court to appoint a substitute for a receiver who:

  (1) Dies;

  (2) Has a disability;

  (3) Has an adverse interest; or

  (4) Does not make reasonable progress in carrying out the receivership.

#### Section 19-337

(a)

  (1) Except as expressly provided otherwise in this section, each receiver who is appointed under Part V of this subtitle has all of the powers of a receiver who is appointed under Sec. 3-414 of the Corporations and Associations Article.

  (2) The receiver shall perform all acts that are necessary and exercise the powers of the receiver to:

    (i) Correct each condition on which the appointment of the receiver was based;

    (ii) Ensure adequate care for each individual in the nursing home or community program; and

    (iii) Preserve the property of the owner of the nursing home or community program.

(b) The receiver shall report to the court as the court requires.

(c) The receiver of a nursing home or community program shall:

  (1) Give each individual and interested parties with respect to each individual notice of the receivership;

  (2) Preserve all property of and records that relate to an individual and are in the custody of the receiver or the owner or operating entity;

  (3) If an individual is to be discharged or transferred:

    (i) Explain to the individual or guardian of the individual the alternative placements that are available;

    (ii) Help the individual or guardian of the individual to find an alternative placement;

    (iii) Give information about the alternative placement chosen;

    (iv) Transport the individual to the alternative placement; and

    (v) Transfer all property of and records on the individual, including all necessary medical information, to the individual or the alternative placement.

(d) The receiver may use:

  (1) Any private or third-party reimbursements to the nursing home, including any Medicaid or Medicare payments; and

  (2) With the approval of the court, money from the fund established under Sec. 19-338 of this subtitle.

(e) If the structure or furnishings of a nursing home or site of the community program violate State or federal law, the receiver may correct the violation:

  (1) Without the consent of the court, if the cost of the correction does not exceed $3,000; or

  (2) On petition to and with the consent of the court, if the cost of the correction is more than $3,000.

(f)

  (1) The receiver shall pay the principal of and interest on a mortgage or secured transaction unless the holder of the mortgage or the secured party is the owner or an affiliate of the owner.

  (2) On petition of a receiver, the court may:

    (i) Allow the receiver to avoid a lease, mortgage, secured transaction, or other contract that the owner or operating entity made if:

      (1) The person seeking payment under the contract is, or at the time the contract was made was, the owner or an affiliate of the owner; and

      (2) The contract provides for a rent or interest rate substantially exceeding the rent or interest rate that was reasonable when the contract was made; and

    (ii) If the receiver is allowed to avoid the contract, set a reasonable rent or interest rate to be paid on any property that is subject to the contract and is needed to continue operation of the nursing home or community program.

  (3) The court shall hold a hearing on a petition under this subsection within 15 days after the petition is filed.

  (4) Notice of the petition shall be given to all known owners of property that the petition affects:

    (i) By the receiver, at least 10 days before the hearing; or

    (ii) By publication, if the receiver files with the court a statement that:

      (1) Is signed and verified by the receiver;

      (2) States that the owner of the property cannot be found; and

      (3) Sets forth a substantial account of reasonable, good faith efforts to find the owner and serve process.

  (5) The court shall set a rent under this subsection in an amount that is not less than the total current payments of principal and interest required on all mortgages and secured transactions that:

    (i) Affect the property under the contract to be avoided; and

    (ii) Cannot be avoided under this subsection.

  (6) Payment of the rent or interest rate that a court sets under this subsection is a defense in any action against the receiver for payment or for possession of the property. However, the payment does not relieve the owner or operating entity of any liability for the difference between the amount that the receiver pays and the amount that is due under the contract.

(g)

  (1) A receiver is not liable for an injury to person or property that results from the condition of the nursing home or site of the community program.

  (2) A receiver only is liable for any act or omission that constitutes negligence in the fulfillment of the duties as receiver.

(h) A receiver is entitled to the fee that the court finds reasonable.

#### Section 19-338

(a) The Secretary shall determine whether the receivership can be funded by State funds previously designated for the community program. In the event that previously designated funds are available, these funds shall be used for the operation of the receivership.

(b) In the event that there are insufficient funds to operate the receivership, the Secretary may petition the Board of Public Works for sufficient funds to operate the receivership.

(c)

  (1) State funds used to operate a receivership under this section shall be a lien on the community program and its assets if the receiver files a notice of the lien that contains:

    (i) The amount of the lien;

    (ii) The name of the community program to which the lien attaches; and

    (iii) A description of the assets of the community program that are affected by the lien.

  (2) The receiver shall file the notice of lien with:

    (i) The land and chattel records of the county where the sites operated by the community program are located; and

    (ii) The Department of Assessments and Taxation.

  (3) A lien under this subsection:

    (i) Extends to the property of the community program that is described in the notice of lien; and

    (ii) Has priority over any lien or other interest that attaches after the date of the completion of the filings required under this subsection.

#### Section 19-339

(a)

  (1) The owner or operating entity or receiver of a nursing home or community program may petition the court to terminate the receivership.

  (2) The court shall terminate the receivership, if the court finds:

    (i) The grounds for appointment of the receiver under Part V of this subtitle no longer exist; or

    (ii) The nursing home or community program is ready to be closed because all residents have been moved.

(b) A receivership ends automatically 1 year after the court appoints the receiver, unless the court:

  (1) Terminates the receivership sooner; or

  (2) On petition of the Secretary, extends the receivership for an additional 1-year period because the court finds that the grounds for appointment of a receiver under Part V of this subtitle still exist.

(c) The sale of a nursing home or site for a community program or any of its assets does not terminate a receivership of the nursing home or community program.

#### Section 19-342

(a) In this section, "patient" includes an inpatient, an outpatient, and an emergency services patient.

(b) The General Assembly intends to promote the health, safety, and well-being of patients and to foster better communication between patients and health care providers in hospitals through the use of a patient's bill of rights that specifies the ethical and humane treatment the patient has a right to expect.

(c) Each administrator of a hospital shall:

  (1) Provide to each patient in the hospital a written copy of the patient's bill of rights that:

    (i) The hospital adopts under Joint Commission guidelines or guidelines issued by a nationally recognized hospital accreditation organization approved by the Centers for Medicare and Medicaid Services conditions of participation; and

    (ii) Complies with subsection (d) of this section;

  (2) If a patient does not speak English or requires the patient's bill of rights in an alternative format, provide a translator, an interpreter, or another accommodation to assist the patient in understanding and exercising the rights included in the patient's bill of rights;

  (3) Conspicuously post copies of the patient's bill of rights on the hospital's website and in areas that are accessible to patients and visitors, which may include admitting offices, patient floors, patient rooms, the outpatient department, and emergency services waiting areas; and

  (4) Provide annual training to all patient care staff members to ensure the staff's knowledge and understanding of the patient's bill of rights.

(d) The patient's bill of rights shall at a minimum include a statement, in plain language, that a patient has a right to:

  (1) Receive considerate, respectful, and compassionate care;

  (2) Be provided care in a safe environment free from all forms of abuse and neglect, including verbal, mental, physical, and sexual abuse;

  (3) Have a medical screening exam and be provided stabilizing treatment for emergency medical conditions and labor;

  (4) Be free from restraints and seclusion unless needed for safety;

  (5) Be told the names and jobs of the health care team members involved in the patient's care if staff safety is not a concern;

  (6) Have respect shown for the patient's personal values, beliefs, and wishes;

  (7) Be treated without discrimination based on race, color, national origin, ethnicity, age, gender, sexual orientation, gender identity or expression, physical or mental disability, religion, language, or ability to pay;

  (8) Be provided a list of protective and advocacy services when needed;

  (9) Receive information about the patient's hospital and physician charges and ask for an estimate of hospital charges before care is provided and as long as patient care is not impeded;

  (10) Receive information in a manner that is understandable by the patient, which may include:

    (i) Sign and foreign language interpreters;

    (ii) Alternative formats, including large print, braille, audio recordings, and computer files; and

    (iii) Vision, speech, hearing, and other temporary aids as needed, without charge;

  (11) Receive information from the patient's doctor or other health care practitioners about the patient's diagnosis, prognosis, test results, possible outcomes of care, and unanticipated outcomes of care;

  (12) Access the patient's medical records in accordance with HIPAA Notice of Privacy Practices;

  (13) Be involved in the patient's plan of care;

  (14) Be screened, assessed, and treated for pain;

  (15) Refuse care;

  (16) In accordance with hospital visitation policies, have an individual of the patient's choice remain with the patient for emotional support during the patient's hospital stay, choose the individuals who may visit the patient, and change the patient's mind about the individuals who may visit;

  (17) Appoint an individual of the patient's choice to make health care decisions for the patient, if the patient is unable to do so;

  (18) Make or change an advance directive;

  (19) Give informed consent before any nonemergency care is provided, including the benefits and risks of the care, alternatives to the care, and the benefits and risks of the alternatives to the care;

  (20) Agree or refuse to take part in medical research studies, without the agreement or refusal affecting the patient's care;

  (21) Allow or refuse to allow pictures of the patient for purposes other than the patient's care;

  (22) Expect privacy and confidentiality in care discussions and treatments;

  (23) Be provided a copy of the Health Insurance Portability and Accountability Act Notice of Privacy Practices; and

  (24) File a complaint about care and have the complaint reviewed without the complaint affecting the patient's care.

(e) The Office of Health Care Quality shall monitor the compliance of each hospital with the requirements of this section.

#### Section 19-342.1

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Emergency pregnancy-related medical condition" means a medical condition that presents in a pregnant patient through acute symptoms of sufficient severity and for which the absence of immediate medical attention could be reasonably expected to result in:

    (i) Placing the health of the patient in serious jeopardy;

    (ii) Serious impairment to bodily functions; or

    (iii) Serious dysfunction of any bodily organ or body part.

  (3) "Stabilize" means, for an emergency pregnancy-related medical condition, to provide the medical treatment necessary to alleviate the condition or ensure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient from the facility.

(b) This section applies only to a hospital with an emergency department.

(c) If a hospital determines that a patient has an emergency pregnancy-related medical condition, the hospital shall:

  (1) Using the staff and facilities available to the hospital, provide further examination and the treatment required to stabilize the emergency pregnancy-related medical condition, including the termination of a pregnancy when the termination is medically necessary to stabilize the patient; or

  (2) Transfer the patient to another medical facility.

(d) A hospital shall allow the termination of a pregnancy at the hospital if the patient's treating health care practitioner determines termination is medically necessary to stabilize a patient.

(e)

  (1) A hospital is considered to have met the requirements of this section if, after offering further examination and treatment or transfer to the patient or the patient's representative and informing the patient or patient's representative of the risks and benefits of further examination and treatment or transfer:

    (i) A patient or the patient's representative refuses to consent to further examination and treatment; or

    (ii) A patient or the patient's representative refuses to consent to a transfer to another medical facility.

  (2) A hospital shall take reasonable steps to secure written informed consent to the refusal of an examination or treatment or transfer under this subsection from the patient or the patient's representative.

(f) If a patient has an emergency pregnancy-related medical condition that has not been stabilized, the hospital may not transfer the patient unless the transfer is done consistent with 42 U.S.C. Sec. 1395dd.

(g) A hospital may not penalize or take other adverse action, including an action related to discharge, promotion, demotion, suspension, compensation, training opportunities, staff privileges, or admitting privileges, against:

  (1) A treating health care provider if the provider refuses to authorize the transfer of a patient with an emergency pregnancy-related medical condition that has not been stabilized;

  (2) A treating health care provider if the provider's treatment of the patient is consistent with the medical standards of care that, in the provider's clinical judgment, were necessary to stabilize the patient; or

  (3) A hospital employee if the employee reports a violation of this section.

(h) A hospital that negligently violates this section is subject to a civil penalty of:

  (1) For a hospital with 100 or more beds, not more than $50,000 for each violation; or

  (2) For a hospital with fewer than 100 beds, not more than $25,000 for each violation.

(i)

  (1) The Department shall stay a final decision on a potential violation if there is an ongoing federal investigation under 42 U.S.C. Sec. 1395dd regarding the same incident.

  (2) If a federal investigation under 42 U.S.C. Sec. 1395dd results in a fine being imposed for the same incident, the Department shall subtract the amount of the federal fine from the maximum potential fine under this section for the same incident.

  (3)

    (i) Subject to subparagraph (ii) of this paragraph, if a federal investigation under 42 U.S.C. Sec. 1395dd results in a fine being imposed for the same incident within 2 years after the Department imposes a fine under this section, the Department shall refund the hospital an amount equal to the amount of the federal fine.

    (ii) The amount refunded under subparagraph (i) of this paragraph may not exceed the amount of the fine imposed by the Department for the same incident.

#### Section 19-343

(a) In this section and Sec.Sec. 19-344, 19-345, 19-345.1, 19-345.2, and 19-345.3 of this subtitle, "facility" means a related institution that, under the rules and regulations of the Department, is a comprehensive care facility or an extended care facility.

(b)

  (1) The General Assembly intends to promote the interests and well-being of each resident of a facility.

  (2) It is the policy of this State that, in addition to any other rights, each resident of a facility has the following basic rights:

    (i) The right to be treated with consideration, respect, and full recognition of human dignity and individuality;

    (ii) The right to receive treatment, care, and services that are adequate, appropriate, and in compliance with relevant State and federal laws, rules, and regulations;

    (iii) The right to privacy;

    (iv) The right to be free from mental and physical abuse;

    (v) The right to notice, procedural fairness, and humane treatment when being transferred or discharged from a facility;

    (vi) The right to participate in decision making regarding transitions in care, including a transfer or discharge from a facility;

    (vii) The right to expect and receive appropriate assessment, management, and treatment of pain as an integral component of the patient's care;

    (viii) The right to be free from physical and chemical restraints, except for restraints that a physician authorizes for a clearly indicated medical need;

    (ix) The right to receive respect and privacy in a medical care program; and

    (x) The right to manage personal financial affairs.

(c) Each facility shall:

  (1) Post, conspicuously in a public place, the policy set forth in subsection (b) of this section and the provisions in Sec.Sec. 19-344(b) through (m), 19-345, and 19-346(i)(2) of this subtitle;

  (2) Give a copy of the policy and those provisions:

    (i) On admission, to the resident;

    (ii) To the guardian, next of kin, or sponsoring agency of the resident; and

    (iii) To a representative payee of the resident;

  (3) Keep a receipt for the copy that is signed by the person who received the copy; and

  (4) Provide appropriate staff training to carry out the policy and those provisions.

#### Section 19-344

(a) To carry out the policy set forth in Sec. 19-343 of this subtitle, the following procedures are required for all services provided to a resident of a facility.

(b)

  (1) A facility may not require or solicit, as a condition of admission into the facility, the signature of another person, other than the applicant, on the application or contract for admission to the facility, unless:

    (i) The applicant is adjudicated disabled under Title 13, Subtitle 7 of the Estates and Trusts Article; or

    (ii)

      (1) The applicant's physician determines that the applicant is incapable of understanding or exercising the applicant's rights and responsibilities; and

      (2) The applicant's physician records, in the applicant's facility record, the specific reasons for the determination.

  (2) If, in addition to the signature of an applicant, a facility requires the signature of another person on the application or contract for admission to the facility in accordance with the provisions of paragraph (1) of this subsection, the facility shall provide a written statement to be included in the document of the rights, duties, and liabilities of the signer of the document.

  (3)

    (i) A facility may request an applicant for whom a second signature cannot be required or solicited under paragraph (1) of this subsection to execute valid durable powers of attorney designating an attorney in fact to make financial, medical, funeral, and burial decisions in the event of the applicant's disability.

    (ii) A facility may not require the execution of a durable power of attorney as a condition or requirement of admission to the facility.

(c)

  (1) In this subsection, "agent" means a person who manages, uses, or controls the funds or assets that legally may be used to pay the applicant's or resident's share of costs or other charges for the facility's services.

  (2) Except as provided by the Department, a facility may not charge an applicant or resident who is a medical assistance beneficiary, or the applicant's or resident's agent, any amount in addition to the amounts determined by the medical assistance program for services that are covered by medical assistance.

  (3) Unless otherwise agreed, the financial obligation of the applicant's or resident's agent is limited to the amount of the applicant's or resident's funds that are considered available to the agent by the medical assistance program.

  (4)

    (i) A facility may require an applicant, a resident, or the agent of an applicant or resident to agree to distribute any funds, including income or assets of the applicant or resident, which the medical assistance program has determined to be available to pay for the cost of the applicant's or resident's care, to the facility, promptly when due, for the cost of the applicant's or resident's care.

    (ii) For the purpose of this section, funds of the applicant or resident include funds of the applicant or resident that are under the use, ownership, management, or control of the agent.

    (iii) A resident or agent of the resident who has not paid a current obligation for the resident's care may apply to the medical assistance program for a determination of the funds available to pay for the cost of the resident's care.

    (iv) If a request for a determination is made under subparagraph (iii) of this paragraph, the medical assistance program shall make the determination.

    (v) If a resident or agent of a resident who has not paid a current obligation for the resident's care fails to request a determination under subparagraph (iii) of this paragraph, the facility may, without requesting the appointment of a guardian, petition the appropriate circuit court for an order or injunction directing the resident or agent of the resident to request and pursue the determination with due diligence or granting other appropriate relief to enforce the obligations under this section.

    (vi) If a resident or agent of the resident fails to pay for the cost of the resident's care from funds that the medical assistance program has determined to be available to pay for that care, the facility may, without requesting the appointment of a guardian, petition the appropriate circuit court for an order directing the resident or agent of the resident to pay the facility from the funds determined by the medical assistance program to be available.

  (5)

    (i) An applicant, a resident, or the agent of an applicant or resident shall seek and pursue with due diligence, on behalf of the applicant or resident, all assistance from the medical assistance program which may be available to the applicant or resident.

    (ii) The facility shall cooperate with and assist the agent in seeking assistance from the medical assistance program on behalf of the applicant or resident.

    (iii) If a resident or the agent of a resident fails to seek assistance from the medical assistance program or to cooperate fully in the eligibility determination process, a facility providing care to the resident may, without requesting the appointment of a guardian, petition the appropriate circuit court for an order or injunction requiring the resident or agent of the resident to seek assistance from the medical assistance program or to cooperate in the eligibility determination process with due diligence or granting other appropriate relief to enforce the obligations under this section.

  (6)

    (i) Any agent who willfully or with gross negligence violates the requirements of paragraph (4) of this subsection regarding the distribution of the applicant's or resident's funds is subject to a civil penalty not less than the amount of funds subject to the violation.

    (ii) Any agent who willfully or with gross negligence violates the requirements of paragraph (5) of this subsection regarding an application for medical assistance by or on behalf of an applicant or resident is subject to a civil penalty not exceeding $10,000.

    (iii) The Attorney General is responsible for the enforcement and prosecution of violations of the provisions of paragraphs (4) and (5) of this subsection.

  (7) Nothing in this subsection may be construed to prohibit any person from knowingly and voluntarily agreeing to guarantee payment for the cost of an applicant's care.

(d) Each facility shall:

  (1) On or before admission of an individual, give the individual a written statement of:

    (i) The services of the facility, including each service that is required to be offered on an as-needed basis; and

    (ii) Related charges, including any charges for services that are not covered by Medicare, Medicaid, or the basic rate of the facility; and

  (2) Keep a written receipt for the statement that is signed by the individual.

(e) Unless it is medically inadvisable, the resident physician of a facility or attending physician of its resident shall give the resident information about the diagnosis, treatment, and prognosis of the resident that is complete and current and is stated in language that the resident reasonably can be expected to understand.

(f)

  (1) A resident of a facility:

    (i) Shall participate in the planning of the medical treatment;

    (ii) May refuse medication or treatment; and

    (iii) May know the medical consequences of these actions.

  (2) The facility shall:

    (i) Have the informed consent of a resident before the resident participates in any experimental research; and

    (ii) Keep the resident's written acknowledgment of that consent.

  (3) The resident shall receive information about the relationship of the facility to other health care institutions if the information relates to the care of the resident.

  (4) The resident shall receive reasonable continuity of care, including information as to the availability of physicians and times for medical appointments.

(g)

  (1) Any case discussion, consultation, examination, or treatment of a resident of a facility:

    (i) Is confidential;

    (ii) Is to be done discreetly; and

    (iii) Is not open to an individual who is not involved directly in the care of the resident unless the resident permits the individual to be present.

  (2) Except as necessary for the transfer of a resident from the facility to another health care institution or as required by law or a third-party payment contract, the personal and medical records of a resident are confidential and may not be released without the consent of the resident to any individual who:

    (i) Is not associated with the facility; or

    (ii) Is associated with the facility, but does not have a demonstrated need for the information.

(h) If it is feasible to do so and not medically contraindicated, spouses or domestic partners who are both residents of the facility shall be given the opportunity to share a room.

(i) A resident of a facility alone or with other individuals is entitled to present any grievance or recommend a change in a policy or service to the staff or administrator of the facility, the Department of Aging, or any other person, without fear of reprisal, restraint, interference, coercion, or discrimination.

(j)

  (1) Each facility shall place at the bedside of each resident the name, address, and telephone number of a physician who is responsible for the resident's care.

  (2) A resident shall have access at any reasonable time to a telephone where the resident may speak privately.

  (3) A resident shall have access to writing instruments, stationery, and postage.

  (4) The correspondence of a resident shall be sent to the addressee without delay and without being opened.

  (5) Every patient and resident may associate and communicate privately and without restriction with persons and groups of his choice on his own or their initiative at any reasonable hour.

(k)

  (1) Each married resident of a facility shall have privacy during a visit by the spouse.

  (2) Each resident of a facility who has a domestic partner shall have privacy during a visit by the other domestic partner.

(l) To a reasonable extent, a resident of a facility shall have the right to possess and use clothing and other personal effects and to have security for those effects.

(m) A resident of a facility may not be assigned to do any work for the facility without personal consent and without written approval of the attending physician of the resident.

(n) A resident of a facility shall receive a reasonable response from an administrator or staff to a personal request of the resident.

(o)

  (1) A resident of a facility shall enjoy privacy in the room of the resident.

  (2) Unless the staff member knows that the resident is asleep, the member shall knock on the door before the member enters the room of the resident.

(p) The administrator of a facility is responsible for carrying out this section.

(q)

  (1) A resident of a facility or the next of kin or domestic partner or guardian of the person of a resident may file a complaint about an alleged violation of this section.

  (2) The complaint may be filed with the Department of Aging or the Department.

  (3) The Secretary of Aging shall:

    (i) Investigate the complaint; and

    (ii) After the investigation, report the findings to the complainant.

  (4) After receipt of the report, the complainant shall be given an opportunity for a hearing before the Department in accordance with the rules and regulations that the Department adopts.

  (5) The Secretary of Aging or the Secretary's designee may request a hearing and act as a representative of the resident at the hearing under paragraph (4) of this subsection when:

    (i) There is no guardian able and available or family member able, willing, and available; and

    (ii) The resident consents.

  (6) The Secretary of Aging or the Secretary's designee may, in any hearing under paragraph (4) of this subsection to which it is not a party under paragraph (5) of this subsection, take part as an interested party.

(r) If a resident is adjudicated a disabled person, is found to be medically incompetent by the attending physician of the resident, or is unable to communicate with others, the rights of the resident may be exercised by:

  (1) The next of kin of the resident;

  (2) The guardian of the person of the resident;

  (3) The sponsoring agency of the resident; or

  (4) Unless the facility is the representative payee, the representative payee that the Social Security Administration designates for the resident.

#### Section 19-345

(a) A resident of a facility may not be transferred or discharged from the facility involuntarily except for the following reasons:

  (1) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;

  (2) The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility;

  (3) The health or safety of an individual in a facility is endangered;

  (4) The resident has failed, after reasonable and appropriate notice, to pay for, or under Medicare or Medicaid or otherwise, to have paid for a stay at the facility; or

  (5) The facility ceases to operate.

(b) A resident of a facility that is transferred or discharged from the facility involuntarily may not be transferred or discharged:

  (1) To a location other than the location identified in the notice required under Sec. 19-345.1(b)(3) of this subtitle, such as a hotel, shelter, or other temporary housing;

  (2) Before the facility to which the resident is to be transferred has confirmed that:

    (i) The resident may be transferred to the facility; and

    (ii) The facility is prepared to accept the resident.

(c)

  (1) A Medicaid certified facility may not:

    (i) Include in the admission contract of a resident any requirement that, to stay at the facility, the resident will be required to pay for any period of time or amount of money as a private pay resident for any period when the resident is eligible for Medicaid benefits; or

    (ii) Transfer or discharge a resident involuntarily because the resident is a Medicaid benefits recipient.

  (2)

    (i) Except as provided in subparagraph (ii) of this paragraph, a Medicaid certified facility is presumed to be transferring or discharging a resident in violation of this subsection, if the resident is or becomes eligible for Medicaid benefits.

    (ii) A Medicaid certified facility is not presumed to be transferring or discharging a resident in violation of this subsection for transferring or discharging a resident for nonpayment for services while the resident was ineligible for assistance under the medical assistance program.

#### Section 19-345.1

(a)

  (1) A facility shall provide the resident with written notice of:

    (i) Any proposed discharge or transfer; and

    (ii) The opportunity for a hearing in accordance with the provisions of this section before the discharge or transfer.

  (2) The notice required under paragraph (1) of this subsection shall include, at a minimum, the information listed under subsection (b) of this section.

(b) The Department shall prepare and provide each facility with a standardized form that provides, in clear and simple language, at least the following information:

  (1) Notice of the intended discharge or transfer of the resident, including the proposed date of the intended discharge or transfer, which may change as a result of an appeal or the discharge planning process;

  (2) Each reason for the discharge or transfer;

  (3) The location to which the resident will be discharged or transferred, which may change as a result of an appeal or the discharge planning process;

  (4) The name of the social worker or other professionally qualified staff, which may change during the discharge planning process, who:

    (i) Is designated to provide social services and discharge planning services to the resident in connection with the discharge or transfer; and

    (ii) Will be responsible for the development of the post discharge plan of care under subsection (g) of this section;

  (5) A proposed date within 10 days after the date of the notice for a meeting between the resident, the resident's representative, and facility staff to develop the post discharge plan of care under subsection (g) of this section;

  (6)

    (i) The right of the resident to request a hearing;

    (ii) The name, mailing address, e-mail address, and telephone number of the entity to which the resident must submit a request for a hearing; and

    (iii) Instructions for obtaining, completing, and submitting a request for a hearing;

  (7) The right of the resident to consult with any lawyer the resident chooses;

  (8) The availability of the services of Maryland Legal Aid, the Older American Act Senior Legal Assistance Programs, and other agencies that may provide assistance to individuals who need legal counsel;

  (9)

    (i) The availability of the Long-Term Care Ombudsman Program to assist the resident; and

    (ii) The mailing address, e-mail address, and telephone number of the Long-Term Care Ombudsman Program;

  (10) The mailing address, e-mail address, and telephone number of Disability Rights Maryland; and

  (11) The provisions of this section.

(c) Except as otherwise provided in this section, at least 30 days before the facility involuntarily transfers or discharges a resident, the facility shall:

  (1) Provide to the resident the written notice required under subsection (a) of this section; and

  (2) Provide the written notice required under subsection (a) of this section to:

    (i) The resident;

    (ii) The next of kin, guardian, or any other individual known to have acted as the resident's representative, if any;

    (iii) The Long-Term Care Ombudsman; and

    (iv) The Department.

(d)

  (1)

    (i) In accordance with regulations adopted by the Secretary, the facility shall provide the resident with an opportunity for a hearing on the proposed transfer or discharge.

    (ii) The regulations adopted by the Secretary may provide for the establishment of an escrow account when:

      (1) The basis for the discharge is nonpayment; and

      (2) The resident continues to reside in the facility while the appeal is pending.

  (2) Except as otherwise provided in this subsection, hearings on proposed transfers or discharges shall be conducted in accordance with the provisions of Title 10, Subtitle 2 of the State Government Article and the Medicaid Fair Hearing Procedures.

  (3) Any hearing on a proposed discharge or transfer of a resident:

    (i) Is not a contested case as defined in Sec. 10-202 of the State Government Article; and

    (ii) May not include the Secretary as a party.

  (4) A decision by an administrative law judge on a proposed discharge or transfer of a resident:

    (i) Is not a decision of the Secretary;

    (ii) Unless appealed, is final and binding on the parties; and

    (iii) May be appealed in accordance with Sec. 10-222 of the State Government Article as if it were a contested case but the appeal does not automatically stay the decision of the administrative law judge.

(e) The facility shall provide the written notice required in subsection (a) of this section as soon as practicable before discharge or transfer if an emergency exists and health or safety of the resident or other residents would be placed in imminent and serious jeopardy if the resident were not transferred or discharged from the facility as soon as possible.

(f)

  (1) If the information in the notice provided under subsection (c) of this section changes before the discharge or transfer, the facility shall provide the changes to the recipients of the notice as soon as practicable after the new information becomes available.

  (2) If a new notice is provided under paragraph (1) of this subsection, the following time requirements apply to the discharge or transfer of the resident:

    (i) The resident may not be discharged or transferred for at least 30 days after the new notice has been provided to the resident if the new notice is provided before:

      (1) The expiration of the time period required under subsection (c) of this section; or

      (2) The date of an order of discharge issued by an administrative law judge under subsection (d) of this section; and

    (ii) If the new notice is provided after a date described under item (i) of this paragraph:

      (1) If the original notice indicated a discharge location that was a licensed skilled nursing facility and the new notice changes the date of discharge or transfer only, the resident may be discharged on the earliest date that a bed is available at the facility;

      (2) If the new notice changes the location of discharge or transfer from a licensed skilled nursing facility to a different licensed skilled nursing facility, the resident may not be discharged or transferred for at least 7 days after the new notice has been provided to the resident; and

      (3) If the new notice changes the location of discharge or transfer from a licensed skilled nursing facility to a location that is not a licensed skilled nursing facility but is otherwise determined to be a safe discharge location under an appropriate clinical evaluation and as set forth in the post discharge plan of care, the resident may not be discharged or transferred for at least 30 days after the new notice has been provided to the resident.

  (3) A new notice provided under this subsection shall:

    (i) Indicate any differences between the prior notice and the new notice; and

    (ii) Include a notice of the right to appeal the new notice:

      (1) For any discharge or transfer described under paragraph (2)(i) of this subsection; or

      (2) For a discharge or transfer described under paragraph (2)(ii)3 of this subsection, if the underlying basis of the original notice has changed.

  (4) For a discharge or transfer described under paragraph (2)(ii)1 or 2 of this subsection, a new notice is not required to include a notice of the right to appeal the new notice.

(g)

  (1) Before any discharge or transfer and subject to paragraphs (4) and (5) of this subsection, a facility shall develop a post discharge plan of care for the resident to assist the resident with adjusting to the resident's new living environment and that:

    (i) Addresses the resident's post discharge goals of care and treatment preferences;

    (ii) Identifies each of the resident's reasonably anticipated medical and basic needs after discharge or transfer and establishes a plan for meeting those needs;

    (iii) Identifies the address at which the resident will reside post discharge; and

    (iv) In accordance with regulations adopted by the Secretary, provides a safe, secure, and sustainable environment for the resident.

  (2) The facility shall designate a social worker or other professionally qualified staff member to coordinate the development of the resident's post discharge plan of care.

  (3) The facility shall, if possible, meet with the resident and, with the resident's consent, the resident's representative within 10 days after providing the notice required under subsection (a) of this section to discuss the post discharge plan of care for the resident.

  (4)

    (i) The resident's post discharge plan of care shall be developed with the participation of the resident and, with the resident's consent, the resident's representative.

    (ii) If the post discharge plan of care was developed without the participation of the resident or the resident's representative, the facility shall include in the resident's medical record an explanation of why the resident or the resident's representative did not participate.

  (5) The resident's post discharge plan of care shall be developed in consultation with:

    (i) The resident's attending physician;

    (ii) A registered nurse responsible for the care of the resident; and

    (iii) Any other appropriate staff or professional involved with meeting the resident's medical needs.

#### Section 19-345.2

(a) In addition to the provisions of Sec.Sec. 19-345 and 19-345.1 of this subtitle, a facility may not involuntarily discharge or transfer a resident unless, within 48 hours before the discharge or transfer, the facility has:

  (1) Provided or obtained:

    (i) A comprehensive medical assessment and evaluation of the resident, including a physical examination, that is documented in the resident's medical record;

    (ii) A post discharge plan of care for the resident that is developed, if possible, with the participation of the resident's next of kin, guardian, or legal representative in accordance with Sec. 19-345.1 of this subtitle; and

    (iii) Written documentation from the resident's attending physician indicating that the transfer or discharge is in accordance with the post discharge plan of care and is not contraindicated by the resident's medical condition; and

  (2) Provided information to the resident concerning the resident's rights to make decisions concerning health care, including:

    (i) The right to accept or refuse medical treatment;

    (ii) The right to make an advance directive, including the right to make a living will and the right to appoint an agent to make health care decisions; and

    (iii) The right to revoke an advance directive.

(b) Except as provided in subsection (d)(3) of this section, and at least 24 hours before discharge or transfer, the facility shall provide the resident and the resident's next of kin, guardian, or legal representative with:

  (1) The written statement of the medical assessment and evaluation and written documentation from the resident's attending physician required under subsection (a) of this section;

  (2) The post discharge plan of care developed under Sec. 19-345.1 of this subtitle;

  (3) The information necessary to assist the resident and the resident's next of kin, guardian, or legal representative in obtaining additional prescriptions for necessary medication through consultation with the resident's treating physician; and

  (4) A written statement containing the date, time, method, mode, and destination of discharge.

(c) To the extent authorized under State and federal law, a facility shall provide at least a 3-day supply of medications currently being taken by the resident at the time of discharge or transfer.

(d)

  (1) Except as provided in paragraphs (2) and (3) of this subsection, a facility may not discharge or transfer a resident unless the resident is capable of and has consented in writing to the discharge or transfer.

  (2) A facility may discharge or transfer a resident without obtaining the written consent of the resident for one of the reasons listed in Sec. 19-345(a) of this subtitle if the discharge or transfer:

    (i) Is in accordance with a post discharge plan of care developed under Sec. 19-345.1 of this subtitle;

    (ii) Is to the community in which the resident resided before becoming a resident of the facility unless the facility documents why it is in the best interest of the resident to be discharged to another location;

    (iii) Is to another licensed provider, unless:

      (1) The resident is being discharged or transferred because the resident's health has improved sufficiently and the resident no longer needs the services provided by the facility;

      (2) The resident has no pending application to the medical assistance program or is ineligible for the medical assistance program and is being discharged or transferred for nonpayment under Sec. 19-345(a)(4) of this subtitle; or

      (3) If the resident is or may be eligible for the medical assistance program:

      (A) The facility has fulfilled its obligation under Sec. 19-344(c) of this subtitle to cooperate with and assist the resident or the resident's representative in seeking assistance from the medical assistance program and has documented the cooperation and assistance;

      (B) The resident or resident's representative has refused to apply for or seek assistance from the medical assistance program or has repeatedly failed, despite the facility's documented assistance, to make good-faith efforts to supply information or materials necessary for the medical assistance program to enroll the resident; and

      (C) The resident is being discharged for nonpayment under Sec. 19-345(a)(4) of this subtitle; and

    (iv) Is to a safe and secure environment.

  (3) A facility that is certified as a continuing care provider under Title 10, Subtitle 4 of the Human Services Article is not subject to the provisions of subsection (b) of this section if:

    (i) The facility transfers a resident to a lesser level of care within the same facility in accordance with a contractual agreement between the facility and the resident; and

    (ii) The transfer is approved by the attending physician.

(e)

  (1) If the requirements of Sec.Sec. 19-345 and 19-345.1 of this subtitle and subsections (a) and (b) of this section have been met, the resident's next of kin or legal representative shall cooperate and assist in the discharge planning process, including:

    (i) Contacting, cooperating with, and assisting other facilities considering admitting the resident; and

    (ii) Cooperating with governmental agencies, including meeting the requirements of Sec. 19-344(c) of this subtitle to seek and pursue with due diligence assistance from the medical assistance program.

  (2) A facility may, without requesting the appointment of a guardian, petition the appropriate circuit court for an order or injunction directed at the resident or agent of the resident for appropriate relief to enforce this subsection.

(f) If requested by any person during the process of transferring or discharging a resident or on its own initiative, the Office of the Attorney General may investigate whether an abuse of funds under Sec. 19-346 of this subtitle contributed to the decision to transfer or discharge the resident and may make appropriate referrals of the matter to other government agencies.

#### Section 19-345.3

(a) The Secretary may impose a civil money penalty not to exceed $10,000 for:

  (1) Each violation by a facility of Sec. 19-345, Sec. 19-345.1, or Sec. 19-345.2 of this subtitle; or

  (2) Each willful or grossly negligent violation by a resident's agent or legal representative of Sec. 19-345, Sec. 19-345.1, or Sec. 19-345.2 of this subtitle.

(b) If a civil money penalty is imposed under this section, the facility or agent or legal representative of the resident shall have the right to appeal from an order imposing the civil money penalty in accordance with Title 10, Subtitle 2 of the State Government Article.

(c)

  (1) A resident, resident's agent, or resident's attorney, or the Attorney General on behalf of the resident, who believes that an involuntary discharge or transfer that violates the requirements of Sec. 19-345, Sec. 19-345.1, or Sec. 19-345.2 of this subtitle is imminent or has taken place may request injunctive relief from a circuit court.

  (2) To prevent irreparable harm to residents in a facility, the Attorney General may seek injunctive relief on behalf of the State on the basis of an imminent or ongoing violation of a basic right of residents of facilities provided under Sec. 19-343(b)(2)(ii), (iv), (v), (viii), or (x) of this subtitle.

  (3) In an action brought by the Attorney General under this subsection, the Attorney General may request that the court impose a civil penalty not to exceed $100,000 for each violation by a facility of Sec. 19-345, Sec. 19-345.1, or Sec. 19-345.2 of this subtitle.

  (4) In exercising the authority granted under paragraphs (2) and (3) of this subsection, the Attorney General may not duplicate any corrective action imposed by the Department for the same violation.

#### Section 19-346

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Abuse of funds" means using the assets or income of a resident:

    (i) Against the express wish of the resident, if the expenditure was not necessary for the direct and immediate benefit and welfare of the resident; or

    (ii) For the use or benefit of a person other than the resident if the expenditure is not also for the direct and immediate benefit of the resident or consistent with an express wish and past behavior of the resident.

  (3) "Bank" means a bank, trust company, savings bank, or savings and loan association that:

    (i) Is authorized to do business in this State; and

    (ii) Is insured by the Federal Deposit Insurance Corporation, Federal Savings and Loan Insurance Corporation, or the State of Maryland Deposit Insurance Fund Corporation.

  (4) "Facility" means:

    (i) A hospital that is classified as a special hospital; or

    (ii) A related institution.

(b) This section provides rights and remedies in addition to, and not in derogation of, any right or remedy that a resident of a facility has under any other law.

(c) Each resident of a facility may:

  (1) Keep control over personal financial transactions unless:

    (i) A court adjudicates the resident as a disabled person, in accordance with Title 13 of the Estates and Trusts Article; or

    (ii) The Social Security Administration designates a representative payee to receive the Social Security funds for the use and benefit of the resident; and

  (2) Choose any person, including the administrator of the facility or a designee of the administrator, to handle the financial transactions.

(d)

  (1) Each facility shall have adequate safeguards for property of a resident that is entrusted to the facility.

  (2)

    (i) A facility to which money is entrusted shall deposit the money in an account if the facility cannot keep the money safely.

    (ii) If the facility is operated by a State, county, or municipal agency and one resident entrusts more than $300 to the facility, the facility shall deposit the amount in excess of $300.

    (iii) If the facility is operated by a person other than a State, county, or municipal agency and one resident entrusts more than $100 to the facility, the facility shall deposit the amount in excess of $100.

    (iv) If the total amount of money that is entrusted to the facility by its residents exceeds $50 per resident, the facility shall deposit the amount in excess of $50 per resident or $1,000, whichever is less.

  (3) A facility that is a related institution caring for individuals and whose administrator or bookkeeper has control over or access to the funds of a resident of the facility shall provide, as determined by the Department, either:

    (i) A bond in an amount the Department requires;

    (ii) A letter of credit equal to 3 times the average yearly balance of funds of all residents of the facility; or

    (iii) Self-insurance if the net worth of the facility is at least 3 times the average yearly balance of funds of all residents of the facility.

(e)

  (1) A facility shall keep the accounts of its residents separate from the accounts of the facility.

  (2) A facility that is operated by a person other than a State, county, or municipal agency shall:

    (i) Establish a separate account with a bank in the name of each resident who entrusts more than $100 to the facility; and

    (ii) Deposit other money that the facility is required to deposit, in either:

      (1) A separate account in the name of the resident; or

      (2) An account that is designated "General Fund of the Participating Residents of the (name of facility)".

  (3) If the facility is operated by a State, county, or municipal agency, the facility may establish any required accounts with a bank or with the State, county, or municipal treasurer.

(f)

  (1) The accounts established by facilities shall be interest bearing accounts.

  (2) All interest on money of a resident shall be credited to the resident.

  (3) The State Treasurer or a county or municipal treasurer shall:

    (i) Credit interest to the total account at a rate that equals the average interest rate on short term investments of the government; and

    (ii) Allocate the interest among each resident participating in the account in proportion to the resident's participation in the total account.

(g)

  (1) A resident may get money as follows:

    (i) If the facility has the money in possession, during the business hours of the facility; or

    (ii) If a bank or the State or a county or municipal treasurer holds the money, within 3 banking days.

  (2) A resident may give a licensed employee of the facility a limited power of attorney for the account of the resident. The Department shall prescribe the form to be used for this limited power of attorney.

(h) A facility may:

  (1) Include in its operating costs the cost of establishing and servicing accounts for private, State, and federally funded residents; and

  (2) Recover the cost through a daily or monthly charge for care or as provided in rules or regulations that the Secretary of Health and Human Services adopts under the Social Security Act.

(i)

  (1) A facility:

    (i) Shall make an accounting of money of a resident to the resident or personal representative of the resident; and

    (ii) In accordance with Department rules and regulations:

      (1) Shall keep, at the facility, records of all transactions with money of residents; and

      (2) Shall be subject to audit.

  (2) Each facility that, under the rules and regulations of the Department, is a comprehensive care facility or an extended care facility shall:

    (i) Have a monthly accounting available for inspection; and

    (ii) Provide a quarterly statement on money of a resident:

      (1) To the resident; or

      (2) To a person exercising the right of the resident under Sec. 19-344(r) of this subtitle.

(j)

  (1) If a facility discharges a resident, the facility shall:

    (i) Return, on demand, the money of the resident that the facility has in possession to the resident or a designee of the resident if the resident or designee signs a receipt; and

    (ii) Make the money of the resident in an account with a bank or the State, county, or municipal treasurer available to the resident or designee within 3 banking days.

  (2)

    (i) This paragraph does not apply to a resident who is transferred temporarily to an acute care facility.

    (ii) If a facility discharges a resident and the facility is the representative payee of the resident, the facility shall:

      (1) Promptly seek designation of a new representative payee; and

      (2) Transfer all money of the resident to the new representative payee.

(k)

  (1) If a resident has been absent from a facility for 1 year, the facility shall make reasonable attempts to find the resident or the personal representative or heirs of the resident to turn over the property of the resident unless the resident or the attending physician of the resident gives the facility written notice that the resident:

    (i) Is expected to be readmitted to the facility; and

    (ii) Wants the facility to continue to hold the property.

  (2) All property and any income from property that a facility holds for a discharged or deceased resident are presumed abandoned in accordance with Title 17 of the Commercial Law Article, if the property and income are not claimed by the resident, personal representative, or heir within 1 year.

(l)

  (1) If the ownership of a facility changes, the transferor shall give the transferee a certified written audit of all funds that residents have entrusted to the facility.

  (2) The transferee shall give to the transferor a signed receipt acknowledging the receipt of the accounts.

(m) A resident is not liable for any act or omission of the facility concerning the finances of the facility or the resident.

(n)

  (1) A person, including the legal representative of the resident, may not use the assets or income of a resident for any purpose that is not authorized by the resident, a designee, or a legal representative, including a representative payee of the resident.

  (2)

    (i) A person may make a written or oral complaint if the person believes that there has been an abuse of funds.

    (ii) The complaint shall set forth each reason for the belief that there has been an abuse of funds and any facts that the complainant has to support the complaint.

    (iii) The complaint shall be made:

      (1) To the local department of social services for the county where the facility is located; or

      (2) If the patient is 65 years old or older, to the Secretary of Aging.

  (3) The recipient of the complaint shall:

    (i) Immediately give the administrator of the facility written notice of the complaint, unless the administrator is the alleged abuser and the recipient believes that the notice would affect an investigation adversely;

    (ii) Investigate the complaint, as appropriate; and

    (iii) Give the alleged abuser specific notice of the alleged abuse and an opportunity to reply to the charges stated in the complaint.

  (4) On request of the Secretary of Aging or the local department of social services, a State's Attorney shall help in the investigation.

  (5) If, after the completion of an investigation, there is probable cause to believe that there has been an abuse of funds, the Secretary of Aging or the local department of social services may:

    (i) Refer the matter to the State's Attorney for appropriate action; and

    (ii) On behalf of the resident, bring suit to recover the misused money, costs, and attorney's fees.

  (6) A person who acts in good faith is not civilly or criminally liable for:

    (i) Making a complaint under this subsection;

    (ii) Participating in an investigation arising out of a complaint under this subsection; or

    (iii) Participating in a judicial proceeding arising out of a report under this subsection.

(o)

  (1) If there is an abuse of funds, a person who misused the money is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $10,000.

  (2) Any person who violates another provision of this section is subject to a fine of $10,000.

#### Section 19-347

(a)

  (1) In this section the following words have the meanings indicated.

  (2)

    (i) "Abuse" means the non-therapeutic infliction of physical pain or injury, or any persistent course of conduct intended to produce or resulting in mental or emotional distress.

    (ii) "Abuse" does not include the performance of an accepted medical procedure that a physician orders.

  (3) "Law enforcement agency" means the Department of State Police or a police agency of a county or municipal corporation.

(b)

  (1) A person who believes that a resident of a related institution has been abused shall report promptly the alleged abuse to an appropriate law enforcement agency and the Office of Health Care Quality in the Department.

  (2) A report:

    (i) May be oral or written; and

    (ii) Shall contain as much information as the reporter is able to provide.

  (3)

    (i) Unless the administrator is the alleged abuser, a recipient of a report promptly shall notify, to the extent allowed by federal and State law, the administrator of the related institution.

    (ii) If the Office of Health Care Quality receives a report under paragraph (1) of this subsection, the Office promptly shall notify the Long-Term Care Ombudsman Program established under Sec. 10-902 of the Human Services Article.

(c) Any employee of a related institution who is required to report alleged abuse under subsection (b) of this section, and who fails to report the alleged abuse within 3 days after learning of the alleged abuse, is liable for a civil penalty of not more than $1,000.

(d)

  (1) Unless otherwise provided, the law enforcement agency, with the assistance of the Secretary, shall:

    (i) Investigate thoroughly each report of an alleged abuse; and

    (ii) Attempt to ensure the protection of the alleged victim.

  (2) The investigation shall include:

    (i) A determination of the nature, extent, and cause of the abuse;

    (ii) The identity of the alleged abuser; and

    (iii) Any other pertinent fact or matter.

  (3) Within 10 working days after the completion of the investigation, the law enforcement agency shall submit a written report of its findings to:

    (i) The State's Attorney;

    (ii) The Secretary;

    (iii) The local long-term care ombudsman entity, as defined in Sec. 10-901 of the Human Services Article;

    (iv) Unless the administrator is the alleged abuser, the administrator of the related institution; and

    (v) The Office of Health Care Quality of the Maryland Department of Health.

(e) The law enforcement agency:

  (1) Shall refer to the Secretary for investigation reported instances of abuse involving any persistent course of conduct intended to produce or resulting in mental or emotional distress; and

  (2) May refer to the Secretary for investigation reported instances of patient-to-patient abuse.

(f) Within 10 working days after the completion of an investigation under subsection (d) of this section, the Secretary shall submit a written report of its findings to:

  (1) The State's Attorney;

  (2) The local long-term care ombudsman entity, as defined in Sec. 10-901 of the Human Services Article; and

  (3) Unless the administrator is the alleged abuser, the administrator of the related institution.

(g) A person shall have the immunity from liability described under Sec. 5-631 of the Courts and Judicial Proceedings Article for:

  (1) Making a report under this section;

  (2) Participating in an investigation arising out of a report under this section;

  (3) Participating in a judicial proceeding arising out of a report under this section; or

  (4) Participating in transferring, suspending, or terminating the employment of any individual who is believed to have abused or aided in abusing a resident under this section.

(h)

  (1) The Department shall provide each related institution with signs that set forth the reporting requirements under this section.

  (2) The related institution shall post the signs conspicuously in the employee and public areas of the related institution.

#### Section 19-347.1

(a) In this section, "inappropriate sexual behavior" has the meaning stated in COMAR 10.01.18.02.

(b) A privately owned and operated residential treatment center shall be subject to the reporting requirements established by the Department under COMAR 10.01.18.05 that apply when a staff member observes, receives a complaint regarding, or otherwise has reason to believe that an individual has been subjected to inappropriate sexual behavior.

#### Section 19-348

(a)

  (1) Each hospital shall offer to each adult female inpatient of the hospital a Papanicolaou smear for detection of cervical cancer unless:

    (i) The attending physician orders otherwise; or

    (ii) The patient has had the examination within the preceding year.

  (2) A patient may refuse the examination.

(b)

  (1) Each hospital shall offer mammography educational materials to each female patient when medically appropriate for the patient.

  (2) The Department, in collaboration with the Maryland Hospital Association, the Medical and Chirurgical Faculty of Maryland, and appropriate advocacy groups, shall select and approve, or develop and print, and update as necessary, mammography educational materials for the purposes of paragraph (1) of this subsection.

#### Section 19-349

At least 45 days before a related institution increases any fee or charge for a service of the related institution, the related institution shall give each resident or the authorized representative of the resident written notice of the amount of the increase.

#### Section 19-349.1

(a) A hospital shall provide oral and written notice to a patient of the patient's outpatient status, the billing implications of the outpatient status, and the impact of the outpatient status on the patient's eligibility for Medicare rehabilitation services if:

  (1) The patient receives on-site services from the hospital for more than 23 consecutive hours;

  (2) The on-site services received by the patient include a hospital bed and meals that have been provided in an area of the hospital other than the emergency room; and

  (3) The patient is classified as an outpatient at the hospital for observation rather than an admitted inpatient.

(b) The Department, in consultation with hospitals in the State, shall adopt by regulation standardized elements to be included in the written notice required under subsection (a) of this section.

#### Section 19-349.2

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Electronically" means a secure digital or electronic transmission in compliance with federal and State law, including by:

    (i) Patient Internet portal;

    (ii) Encrypted e-mail; or

    (iii) Text message with a link to an encrypted notice.

  (3)

    (i) "Outpatient facility fee" means a hospital outpatient charge approved by the Commission for an outpatient clinic service, supply, or equipment, including the service of a nonphysician clinician.

    (ii) "Outpatient facility fee" does not include:

      (1) A charge billed for services delivered in an emergency department; or

      (2) A physician fee billed for professional services provided at the hospital.

  (4)

    (i) "Patient" means an individual who receives health care.

    (ii) "Patient" includes:

      (1) A person authorized to consent to health care for an individual consistent with the authority granted, including a guardian, surrogate, or person with a medical power of attorney;

      (2) An individual who is a minor, if the minor seeks treatment to which the minor has the right to consent and has consented under Title 20, Subtitle 1 of this article;

      (3) A parent, guardian, custodian, or representative of an individual who is a minor; and

      (4) A person authorized to consent to health care for an individual who is a minor consistent with the authority granted.

(b) Subject to subsections (c), (d), (e), and (f) of this section, if a hospital charges an outpatient facility fee, the hospital shall provide the patient with a written notice, separate from any other forms or notices, in the following form or a substantially similar form:

IMPORTANT FINANCIAL INFORMATION

(Patient Name)________________ Appointment Date:___________________

Notice Of Hospital Outpatient Facility Fee And Billing Disclosure

a.    Your appointment with (provider, practice, or outpatient facility name) will take place in an outpatient department of (hospital name).

b.    (Hospital name) will charge an outpatient facility fee that is separate from and in addition to the bill you will receive from (provider).

c.    You will receive two charges for your visit:

  (1) a provider services bill from (provider); and

  (2) a hospital facility bill from (hospital name).

  Expected Fee

  (if known) The amount of the facility fee that will be charged by (hospital name) for your appointment is $ ____________. or

  (if unknown) (Hospital name's) facility fee is likely to range from $___________ to $_____________. and

  (if unknown) Based on appointments like the one you are scheduled for, we estimate the facility fee to be $____________. and

  (if unknown) We are providing you with a range of fees and an estimate because the actual amount of the facility fee will depend on the hospital services that are actually provided. The fee could be higher if you require services during your appointment that we cannot reasonably predict today.

  Financial help for your portion of the outpatient facility fee bill may be available. If you need financial help with the outpatient facility bill, please contact (hospital financial assistance office, with telephone number and direct website address).

  Receiving services here may result in greater financial liability than receiving services at a location where a facility fee may not be charged.

  (if applicable) No Facility Fee Location

  You can see (provider) at another location that does not charge a facility fee.

  (address and contact information)

  Contact your insurance carrier to see if (provider) is a participating provider and in-network at the (address of alternative location) location.

  Insurance Information

  (1) The amount of the facility fee that you will be responsible for paying will depend on your insurance coverage.

  (2) Insurance companies could impose deductibles or higher copayment or coinsurance amounts for services provided in hospital outpatient departments.

  (3) If you have insurance, you should contact your carrier to determine your insurance coverage and your estimated financial responsibility for the facility fee, including copayments, coinsurance, and deductible amounts for the outpatient facility fee.

  Facility Fee Complaints

  If you have a complaint about an outpatient facility fee charge, please first contact the hospital, (hospital billing office contact information).

  If the complaint is unresolved, you may then file the complaint with the Health Services Cost Review Commission, (contact information).

  If you need additional information regarding your facility fee charges or if you need assistance mediating a facility fee complaint against a hospital, contact the Health Education and Advocacy Unit of the Office of the Attorney General, 1-877-261-8807 | Heau@oag.state.md.us | www.MarylandCares.org.

  Acknowledgment

  (1) I understand that I will be billed a hospital facility fee and a provider fee.

  (2) (Hospital name) provided me with information on the facility fees that will be billed for my appointment.

  (3) I understand that the fee could vary based on conditions and services provided to me that the hospital cannot reasonably predict today.

  (4) I understand that my out-of-pocket costs will depend on my insurance coverage.

  ________(initial here) - by initialing here, I confirm that I received the facility fee information at the time I made my appointment with (provider).

  By signing this form, I acknowledge that I have received this information before receiving services today.

  _____________________________            _______________________________

  Signature                            Date

  To request this notice in an alternative format, please call (contact information) or e-mail (contact information).

  (Same sentence in Spanish).

(c) If a patient does not speak English or requires the notice required under subsection (b) of this section to be in an alternative format, the hospital shall, to the extent practicable, provide the notice in a language or format that is understood by the patient.

(d)

  (1) A hospital shall determine the range of hospital outpatient facility fees and fee estimates, based on typical or average facility fees for the same or similar appointments, to be provided in the notice required under this section, consistent with the hospital's most recent rate order as approved by the Commission.

  (2) Each hospital that charges an outpatient facility fee shall use the range of hospital outpatient facility fees and fee estimates determined under paragraph (1) of this subsection.

(e)

  (1) For an appointment made in person or by telephone:

    (i) Oral notice of all the information that would be provided in the form required under subsection (b) of this section shall be given at the time the appointment is made; and

    (ii) Except as provided in paragraph (3) of this subsection, the written notice required under subsection (b) of this section shall be sent to the patient electronically at the time the appointment is made.

  (2) For an appointment made electronically or using a website, the written notice required under subsection (b) of this section shall be:

    (i) Provided at the time the appointment is made; and

    (ii) Sent to the patient electronically at the time the appointment is made.

  (3) If the patient refuses electronic communication under paragraph (1)(ii) of this subsection, the written notice shall be sent to the patient by first-class mail at the time the appointment is made.

(f) Before professional medical services are provided on the date of the appointment, the patient shall acknowledge in writing that the notice required under this section was provided at the time the appointment was made.

(g) A hospital may not charge, bill, or attempt to collect an outpatient facility fee unless the patient was given notice in accordance with this section.

(h)

  (1) On or before January 31 each year, beginning in 2022, each hospital shall report to the Health Services Cost Review Commission a list of the hospital-based, rate-regulated outpatient services provided by the hospital.

  (2) On or before February 28 each year, beginning in 2022, the Health Services Cost Review Commission annually shall:

    (i) Post on its website the list of the hospital-based, rate-regulated outpatient services reported by each hospital under paragraph (1) of this subsection; and

    (ii) Provide the list of the hospital-based, rate-regulated outpatient services reported by each hospital to the Maryland Insurance Administration and the Health Education and Advocacy Unit in the Office of the Attorney General.

  (3) When lack of notice in accordance with this section is alleged in a consumer complaint, the Commission shall give consideration in its investigatory and audit procedures as to whether notice was not feasible due to circumstances beyond the hospital's control.

#### Section 19-350

(a)

  (1) This section applies only to:

    (i) Related institutions as defined in Sec. 19-301 of this subtitle; and

    (ii) Hospitals as defined in Sec. 19-301 of this subtitle.

  (2) Nothing in this section shall apply to charges for services that are set pursuant to Sec. 16-201 of this article.

(b)

  (1)

    (i) On request of a patient made before or during treatment, a hospital shall provide to the patient a written estimate of the total charges for the hospital services, procedures, and supplies that reasonably are expected to be provided and billed to the patient by the hospital.

    (ii) The written estimate shall state clearly that it is only an estimate and actual charges could vary.

    (iii) A hospital may restrict the availability of a written estimate to normal business office hours.

    (iv) This paragraph does not apply to emergency services.

  (2) Within 30 days after discharge of an individual from a hospital, the hospital shall give the individual a summary financial statement that clearly describes:

    (i) The total charges incurred;

    (ii) If readily ascertainable, a summary of the total charges under the major services categories, including:

      (1) Room and board;

      (2) Diagnostic services;

      (3) Therapeutic services;

      (4) Emergency room services;

      (5) Drugs and IV solutions; and

      (6) Miscellaneous other supplies and services;

    (iii) If applicable, the name of the primary and secondary insurer to which a claim has been or will be filed on the individual's behalf;

    (iv) That charges for services provided by a physician are not included in the total hospital charges and are billed separately; and

    (v) The individual's right to request an itemized statement of the account within 1 year of receipt of the summary statement.

  (3) Within 30 days after an individual's request as provided under paragraph (2)(v) of this subsection, the hospital shall provide the individual a statement of the account that:

    (i) Is itemized; and

    (ii) Describes briefly but clearly each item and the amount charged for it.

(c)

  (1) Unless a related institution contracts with its residents to provide care for an all-inclusive preestablished fee, on demand made within 90 days after service is provided to a resident, the related institution shall give the resident or representative of the resident a financial statement that:

    (i) Is itemized;

    (ii) Describes briefly but clearly each item and the amount charged for it; and

    (iii) Identifies the payor to whom a claim has been forwarded.

  (2) A related institution may not be required to give a resident more than 1 itemized statement in any 90-day period.

(d)

  (1) On demand made within 30 days after payment of any charge for an individual, a hospital or related institution shall give the individual or representative of the individual a financial statement that:

    (i) Is itemized; and

    (ii) Describes briefly but clearly each item and the amount charged for it.

  (2) A hospital or related institution is subject to a fine of $300 if it fails to:

    (i) Comply with this subsection; or

    (ii) Give the individual or representative a reasonable written explanation for any delay in complying with this subsection.

(e) A hospital or related institution may not demand or accept final payment or recover for money unless the hospital or related institution has given the financial statements required under this section.

#### Section 19-350.1

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Third party payor" means any person that administers or provides reimbursement for hospital benefits on an expense incurred basis including:

    (i) A health maintenance organization issued a certificate of authority in accordance with Subtitle 7 of this title;

    (ii) A health insurer or nonprofit health service plan authorized to offer health insurance policies or contracts in this State in accordance with the Insurance Article; or

    (iii) A third party administrator registered under the Insurance Article.

  (3) "Uniform claims form" means the claim or billing form for reimbursement of hospital services adopted by the Insurance Commissioner under Sec. 15-1003 of the Insurance Article.

(b) When submitting a claim or bill for reimbursement to a third party payor, a hospital shall use the uniform claims form.

(c) The uniform claims form submitted under this section:

  (1) Shall be properly completed; and

  (2) May be submitted by electronic transfer.

(d) The Secretary may impose a penalty not to exceed $500 on any hospital that violates the provisions of this section.

#### Section 19-351

(a) Except as provided in subsections (b) and (d) of this section, this subtitle does not affect the right of a hospital or related institution to employ or appoint staff.

(b)

  (1) A hospital or related institution that provides services that licensed podiatrists are authorized to perform under Title 16 of the Health Occupations Article, other than incidental care, shall include, in its bylaws, rules, or regulations, provisions for use of facilities by and staff privileges for qualified podiatrists.

  (2) The hospital or related institution may restrict use of facilities and staff privileges by podiatrists to those podiatrists who meet the qualifications that the hospital or related institution sets for granting those privileges.

  (3) The qualifications that the hospital or related institution sets for granting privileges for services that licensed podiatrists are authorized to perform under Title 16 of the Health Occupations Article shall include consideration of the training, education, and experience of the podiatrist.

(c)

  (1) A hospital or related institution shall include in its bylaws, rules, or regulations provisions for use of facilities by and staff privileges for qualified dentists.

  (2) The hospital or related institution may restrict use of facilities and staff privileges by dentists to those dentists who meet the qualifications that the hospital or related institution sets for granting those privileges.

(d)

  (1) A hospital or related institution that provides services of the type that licensed psychologists are permitted to perform under Title 18 of the Health Occupations Article shall include in its bylaws, rules, or regulations, provisions for use of facilities by and staff privileges for qualified psychologists.

  (2) The hospital or related institution may restrict use of facilities and staff privileges by psychologists to those psychologists who meet the qualifications that the hospital or related institution sets for granting those privileges.

  (3)

    (i) Nothing in this subsection shall be construed to require a hospital to:

      (1) Grant admitting privileges to a psychologist; or

      (2) Permit the exercise of those privileges granted by the hospital board of trustees to psychologists without appropriate collaboration with the physician who has privileges to admit and attend patients in the unit of the facility where the patient is being treated and who has ongoing responsibility for the patient.

    (ii) In the event of a disagreement between the psychologist and the physician concerning the patient's treatment, the decision of the physician who has ongoing responsibility for the patient shall govern.

#### Section 19-352

(a) In this section, "nursing home" means a related institution that is classified as a nursing home.

(b) A nursing home may not assess an interest penalty on charges for services provided to a resident until, whichever is later in time:

  (1) 45 days after the nursing home mails an itemized statement of the charges to the person responsible for payment of the charges; or

  (2) 30 days after the end of the period for which the itemized statement of the charges covers.

(c) The nursing home shall include on the itemized statement of charges a statement in bold and conspicuous print as to when interest may be assessed consistent with the provisions of subsection (b) of this section.

#### Section 19-353

A health care facility that is not covered under Sec. 19-342 or Sec. 19-343 of this subtitle shall include in a patient's bill of rights or similar document that is provided to the patient or resident a statement that a patient or resident has the right to expect and receive appropriate assessment, management, and treatment of pain as an integral component of that patient's or resident's care.

#### Section 19-354

A hospital or related institution that is a charitable institution shall have the immunity from liability described under Sec. 5-632 of the Courts and Judicial Proceedings Article.

#### Section 19-355

(a) In this section, "gender identity" and "sexual orientation" have the meanings stated in Sec. 20-101 of the State Government Article.

(b) This section does not prohibit a hospital or related institution that is licensed or otherwise regulated by the Department or a unit of the Department from refusing, withholding from, or denying any person services for failure to conform to the usual and regular requirements, standards, and regulations imposed by the licensed or regulated hospital or related institution, unless the refusal, withholding, or denial is based on discrimination on the grounds of race, color, religion, sex, age, national origin, marital status, sexual orientation, gender identity, or disability.

(c) A hospital or related institution may not discriminate against any individual with respect to the individual's medical care because of the race, color, religion, sex, age, national origin, marital status, sexual orientation, gender identity, or disability of the individual.

(d) The Commission on Civil Rights shall enforce this section as provided in Title 20 of the State Government Article.

#### Section 19-356

(a) A hospital or related institution may not grant a discount to or receive a discount from any medical referral service or in any manner split fees with a medical referral service.

(b) A person who violates any provision of this section is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $100 for the first offense and not exceeding $500 for each subsequent conviction for a violation of the same provision.

#### Section 19-357

(a) A person who operates a hospital or related institution may not ask for or receive any rebate, commission, or other consideration from a pharmacy or other provider of drugs, prescriptions, or pharmaceutical services.

(b) A person who violates this section is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $500 and is subject to suspension or revocation of the license.

(c) In addition to the penalties provided in subsection (b) of this section, the Department may declare a person who violates this section to be ineligible to participate in the Maryland Medical Assistance Program.

#### Section 19-358

(a) A person may not operate a hospital or related institution unless issued a registration permit or licensed by the Secretary.

(b) A hospital may not provide or hold itself out as providing comprehensive physical rehabilitation services, as defined in Sec. 19-1201 of this title, or operate as a special rehabilitation hospital unless the hospital is classified as a special rehabilitation hospital by the Secretary.

(c) Unless a health care facility is classified as a special rehabilitation hospital by the Secretary, a health care facility may only offer those physical rehabilitation services which are appropriate and necessary to the care, treatment, or support of the acute, chronic disease, or long-term care patient.

(d)

  (1) A person who violates any provision of this section is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000 for the first offense and not exceeding $10,000 for each subsequent conviction for a violation of the same provision. Each day a violation is continued after the first conviction is a subsequent offense.

  (2) The Secretary may impose a civil money penalty not to exceed $10,000 for each offense under this section.

#### Section 19-359

(a) A person who operates a related institution in violation of the rules and regulations that the Secretary adopts for related institutions is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000. Each day a violation is continued after the first conviction is a separate offense.

(b) The Secretary may impose a civil money penalty not to exceed $10,000 for each offense under this section.

(c)

  (1) If a civil money penalty is imposed under this section or under Sec. 19-358 of this subtitle, the Secretary shall issue an order which shall state the basis on which the order is made, the amount of the civil money penalty imposed, and the manner in which the amount of the civil money penalty was calculated.

  (2) The operator of an unlicensed hospital or an unlicensed or unregistered related institution shall have the right to appeal from the order imposing the civil money penalty in accordance with Title 10, Subtitle 2 of the State Government Article (Administrative Procedure Act - Contested Cases).

#### Section 19-360

(a) This section applies to:

  (1) Nonaccredited hospitals found in violation of the standards adopted under this subtitle;

  (2) Accredited hospitals:

    (i) Found deficient as a result of the complaint review process; or

    (ii) Subject to inspection by the Department under Sec. 19-2302(e) of this title as a result of a serious or life-threatening patient care deficiency identified by the Joint Commission on Accreditation of Healthcare Organizations, the Centers for Medicare and Medicaid Services, or the Department;

  (3) Accredited residential treatment centers subject to inspection by the Department under Sec. 19-2302(e) of this title as a result of a serious or life-threatening patient care deficiency identified by the Joint Commission on Accreditation of Healthcare Organizations, the Commission on Accreditation of Rehabilitation Facilities, the Council on Accreditation, the Centers for Medicare and Medicaid Services, or the Department; and

  (4) Health care facilities that fail to achieve substantial compliance with the standards of an approved accreditation organization under Sec. 19-2302(c)(2) of this title.

(b)

  (1) If conditions are found to be detrimental to patient health, safety, or welfare, the Department shall allow the hospital, residential treatment center, or health care facility 30 days to address the deficiencies in other than serious or life-threatening situations.

  (2) If corrections cannot be completed within the 30-day period, the Department may accept a plan of correction from the hospital, residential treatment center, or health care facility based upon evidence that corrective action has been undertaken by the hospital or residential treatment center.

  (3) Periodic updates of the plan of correction from the hospital, residential treatment center, or health care facility may be requested by the Department.

(c) If a serious or life-threatening condition is found to exist, the Department may order the hospital, residential treatment center, or health care facility to initiate immediate corrective action, and the hospital or residential treatment center shall be subject to inspection by the Department under Sec. 19-308 of this subtitle.

(d) If the Secretary determines that a serious or life-threatening patient care deficiency exists and the hospital, residential treatment center, or health care facility fails to correct the deficiency through implementation of immediate corrective action, the Secretary may:

  (1) For an accredited hospital or accredited residential treatment center:

    (i) Revoke or restrict the licensure entitlement of Sec. 19-319(c)(2) of this subtitle;

    (ii) Impose a civil monetary penalty of not more than $10,000 per instance or per day;

    (iii) Impose a directed plan of correction; and

    (iv) Impose appropriate operating conditions.

  (2) For an unaccredited hospital or health care facility:

    (i) Revoke or restrict the license to operate;

    (ii) Impose a civil monetary penalty of not more than $10,000 per instance or per day;

    (iii) Impose a directed plan of correction; and

    (iv) Impose appropriate operating conditions.

(e) In determining the action to be taken under subsection (d) of this section, the Secretary shall consider the following factors:

  (1) The number, nature, and seriousness of the patient care deficiencies;

  (2) The extent to which the patient care deficiency or deficiencies are part of an ongoing pattern during the preceding 24 months;

  (3) The degree of risk to the health, life, or safety of the patients of the hospital, residential treatment center, or health care facility caused by the patient care deficiency or deficiencies;

  (4) The efforts made by, and the ability of, the hospital, residential treatment center, or health care facility to correct the patient care deficiency or deficiencies through implementation of immediate corrective action; and

  (5) The hospital's, residential treatment center's, or health care facility's history of compliance.

(f) The remedies provided by this section are in addition to any other remedies available to the Department at law or equity.

#### Section 19-361

(a) In this part the following words have the meanings indicated.

(b) "Hazardous condition" means a condition existing in a related institution that does not constitute a life-threatening, health, or fire safety deficiency, as described in Sec. 19-328 of this subtitle, but which is a violation of departmental regulations which is likely to endanger the health, life, or safety of patients.

(c) "Intermediate sanction" means the establishment of an escrow account by a related institution.

#### Section 19-362

(a)

  (1) An intermediate sanction may be imposed consistent with this section when a hazardous condition exists in a related institution and that condition is not remedied pursuant to the following sections.

  (2) In determining whether a hazardous condition exists, the following factors shall be considered:

    (i) The potential impact of the condition on the health, life, or safety of patients;

    (ii) The period of time during which the condition has existed;

    (iii) The frequency of occurrence of the condition; and

    (iv) The efforts made by the related institution to correct the condition.

  (3) Upon determination by the Department that a hazardous condition exists, the Department will notify the facility that a hazardous condition exists which may subject the facility to a sanction.

(b)

  (1) The Department shall order that a plan of correction which is acceptable to the Department be submitted within 10 working days.

  (2) The Department shall notify the related institution within 3 working days of receipt of the plan of correction as to whether it is or is not acceptable.

  (3) If the Department determines that the plan is not acceptable, the related institution will resubmit a revised plan within 5 working days of such notification.

  (4) The Department will schedule reinspections of the facility based on time frames established in the plan of correction.

(c)

  (1) If the Department determines that an acceptable plan of correction has not been submitted, that the hazardous condition has not been corrected, or that progress satisfactory to the Department has not been accomplished, the Department shall order the facility ownership and appropriate administrative personnel to appear before a representative of the Department.

  (2) Following the appearance, or if the facility ownership fails to appear, a decision may be issued which:

    (i) Extends the time frame in which the hazardous condition must be corrected; or

    (ii) Proposes the imposition of the sanction.

(d)

  (1) If a sanction is proposed, or if at the end of the extended time frame the hazardous condition has not been corrected, the Secretary may issue a sanction order.

  (2) The sanction order shall state the number of days within which the hazardous condition must be corrected and shall require the related institution to establish an escrow account in accordance with Sec. 19-363 of this subtitle.

#### Section 19-363

(a) The funds in the escrow account shall be used only for the purposes of remedying the hazardous condition.

(b) The amount of the escrow account shall be the estimated cost of correcting the hazardous condition or $5,000 whichever is greater.

(c) The escrow account is to be established by the related institution at an authorized financial institution selected by the related institution.

(d) Current operating funds may not be used to establish the escrow account.

#### Section 19-364

(a) The related institution shall have the right to appeal from the order within 5 working days from the receipt of the order.

(b) The appeal shall be heard by the hearings office of the Department, which shall render the final agency decision for purposes of judicial review.

(c) Imposition of the sanction shall be stayed until the final decision is issued pursuant to subsection (m) of this section.

(d) A hearing on the sanction shall be held within 10 working days of the request for hearing.

(e) The parties to the hearing shall be the aggrieved related institution and the Secretary.

(f) The parties are entitled to be represented by counsel.

(g) The hearings office may permit, modify, or deny a timely request by the related institution for prehearing discovery.

(h) The hearings office, upon its own motion or upon motion of either party, may subpoena any person or evidence, administer oaths, and take depositions and other testimony.

(i) The hearing shall inquire fully into all of the matters at issue and shall receive into evidence the testimony of witnesses and any documents which are relevant and material to such matters.

(j) The parties shall have the right to present evidence and testimony and to cross-examine that presented by the opposing party.

(k) The purpose of the hearing is to consider and render a decision on the following matters:

  (1) The existence of a hazardous condition;

  (2) If a hazardous condition exists, the amount of money to be placed into the escrow account; and

  (3) The length of time in which the hazardous condition must be corrected.

(l) The burdens of proof are as follows:

  (1) The related institution has the burden of proof with respect to establishing the lack of the cited deficiency or deficiencies; and

  (2) The Secretary has the burden of proof with respect to the establishment of a deficiency or deficiencies as constituting a hazardous condition.

(m) A decision shall be rendered by the hearings office within 7 days of the hearing. The decision shall be the final agency decision of the Department, subject to appeal pursuant to Sec. 19-367 of this part.

#### Section 19-365

(a) Escrowed funds may be released by the escrow agent:

  (1) If the related institution can present specific bills (vouchers) for correcting the hazardous condition which have been certified by the Secretary as appropriate; and

  (2) In the absence of bills or vouchers, the related institution has received written approval from the Secretary that the expenditure is appropriate for correcting the hazardous condition.

(b) The escrow is terminated and the balance, if any, in the account is returned to the related institution when:

  (1) The Secretary certifies that the hazardous condition is corrected;

  (2) After the time period set by the Secretary, the Secretary certifies that adequate progress has been made toward correcting the hazardous condition; or

  (3) The related institution changes ownership.

#### Section 19-366

(a) If the related institution fails to establish the escrow account as ordered, the Secretary may petition the appropriate circuit court to require compliance with the sanction order.

(b) If the hazardous condition is not corrected or progress acceptable to the Secretary is not made within the time frame set by the sanction order, the Secretary may:

  (1) Petition the appropriate circuit court to require the related institution to comply with the sanction order; or

  (2) Order the forfeiture of the escrowed funds and/or remove all patients and initiate procedures to revoke the related institution's licensure in accordance with Sec. 19-327 of this subtitle.

(c) Upon petition to the circuit court under subsection (b)(1) of this section, and following notification to the Secretary by the circuit court that the related institution has failed to comply with a court order, the Secretary may impose further sanctions in accordance with subsection (b)(2) of this section. This sanction is in addition to all remedies otherwise available to the circuit court for enforcement of a court order.

#### Section 19-367

(a) Either party aggrieved by the decision of the hearings office shall have the right to appeal that decision.

(b) A related institution subject to a sanction shall have the right to appeal a decision by the Secretary that the hazardous condition has not been corrected or that inadequate progress has been made toward correcting the hazardous condition.

(c) Such appeal shall be filed within 30 days of the action to be appealed.

(d) The appeal shall be taken directly to the circuit court of the jurisdiction in which the related institution is located.

(e) Appeal to the circuit court does not stay the imposition of the sanction.

#### Section 19-370

(a) In this Part IX of this subtitle the following words have the meanings indicated.

(b) "Advice" means the recommendations of the advisory committee.

(c) "Advisory committee" means a patient care advisory committee.

(d) "Petitioner" means one of the following individuals who is responsible for making a decision with a medical consequence for a patient:

  (1) A patient;

  (2) A physician;

  (3) A registered nurse;

  (4) A social worker;

  (5) A family member;

  (6) A guardian;

  (7) An individual with a power of attorney to make a decision with a medical consequence for a patient; or

  (8) Any other health care practitioner directly involved in the care of the patient.

(e) "Related institution" does not include a domiciliary care home that is operated independent of any other related institution.

#### Section 19-371

(a) Each hospital and each related institution shall establish:

  (1) An advisory committee as provided in this Part IX of this subtitle; and

  (2) A written procedure by which the advisory committee shall be convened.

(b) An advisory committee at a related institution may function:

  (1) Solely at that related institution;

  (2) Jointly with a hospital advisory committee; or

  (3) Jointly with an advisory committee representing no more than 30 other related institutions.

#### Section 19-372

(a)

  (1) Each advisory committee shall consist of at least 4 members, including:

    (i) A physician not directly involved with the care of the patient in question;

    (ii) A registered nurse not directly involved with the care of the patient in question;

    (iii) A social worker; and

    (iv) The chief executive officer or a designee from each hospital and each related institution represented on that advisory committee.

  (2) The advisory committee may consist of as many other individuals as each represented hospital and related institution may choose, including:

    (i) Representatives of the community; and

    (ii) Ethical advisors or clergy.

  (3) As part of the advisory committee's deliberations, the advisory committee, in appropriate cases, shall consult:

    (i) All members of the patient's treatment team;

    (ii) The patient;

    (iii) The patient's family; and

    (iv) In a case involving the options for medical care and treatment of a child with a life-threatening condition, a medical professional familiar with pediatric end-of-life care, if a medical professional with this expertise is not already a member of the committee.

(b) The petitioner may be accompanied by any persons the petitioner desires.

#### Section 19-373

(a) In addition to any other duties or responsibilities, and on the request of a petitioner, the advisory committee shall offer advice in cases involving individuals with life-threatening conditions.

(b) In addition to any other duties or responsibilities, the advisory committee may:

  (1) Educate represented hospital and related institution personnel, patients, and patients' families concerning medical decision-making; and

  (2) Review and recommend institutional policies and guidelines concerning the withholding of medical treatment.

#### Section 19-374

(a) On the request of a petitioner, an advisory committee shall give advice concerning the options for medical care and treatment of an individual with a life-threatening condition.

(b)

  (1) The advisory committee shall make a good faith effort to notify a patient, a patient's immediate family members, a patient's guardians, and an individual with a power of attorney to make a decision with a medical consequence for a patient, of the individual's right:

    (i) To be a petitioner;

    (ii) To meet with the advisory committee concerning the options for medical care and treatment; and

    (iii) To receive an explanation of the basis of the advisory committee's advice.

  (2) Any information or document that indicates the wishes of the patient shall take precedence in the deliberations of the advisory committee.

(c) An advisory committee or a member of an advisory committee who gives advice in good faith may not be held liable in court for the advice given.

(d) A person that assists one or more hospitals or related institutions in the establishment of an advisory committee may not be held liable in court for any advice given in good faith by that person, the related institution, the advisory committee, or any member of the advisory committee and the committee and its members may not be held liable for any advice given in good faith.

(e)

  (1) The proceedings and deliberations of an advisory committee are confidential as provided in Sec. 1-401 of the Health Occupations Article.

  (2) The advice of an advisory committee concerning a patient's medical care and treatment shall become part of the patient's medical record and is confidential under Sec.Sec. 4-301 and 4-302 of this article.

(f) A hospital or related institution may not be held liable in a civil action for failing to carry out the advice of an advisory committee concerning a patient's medical care if the advice given is inconsistent with the written policies of the hospital or related institution.

#### Section 19-377

(a) In this section, "safe patient lifting" means the use of mechanical lifting devices by hospital employees, instead of manual lifting, to lift, transfer, and reposition patients.

(b) On or before December 1, 2007, each hospital shall establish a safe patient lifting committee with equal membership from management and employees.

(c)

  (1) On or before July 1, 2008, the safe patient lifting committee shall develop a safe patient lifting policy for the hospital.

  (2) The goal of the policy shall be to reduce employee injuries associated with patient lifting.

(d) While developing a safe patient lifting policy, the committee shall consider, based on the patient population of that hospital, the appropriateness and effectiveness of:

  (1) Developing or enhancing patient handling hazard assessment processes;

  (2) Enhanced use of mechanical lifting devices;

  (3) Developing specialized lift teams;

  (4) Training programs for safe patient lifting required for all patient care personnel at the hospital;

  (5) Incorporating physical space and construction design  for mechanical lifting devices in any architectural plans for hospital construction or renovation; and

  (6) Developing an evaluation process to determine the effectiveness of the policy.

#### Section 19-380

(a) In this part the following words have the meanings indicated.

(b)

  (1) "Aftercare" means any assistance provided by a lay caregiver to a patient after discharge of the patient.

  (2) "Aftercare" includes tasks that are limited to the patient's condition at the time of discharge that do not require a licensed professional.

(c) "Discharge" means the exit or release of a patient from inpatient care in a hospital to the residence of the patient.

(d) "Lay caregiver" means an individual who:

  (1) Is an adult;

  (2) Is designated as a lay caregiver by a patient or the legal guardian of a patient under this part; and

  (3) Performs aftercare for the patient at the residence of the patient.

(e)

  (1) "Residence" means a dwelling that a patient considers to be home.

  (2) "Residence" does not include:

    (i) A rehabilitation facility;

    (ii) A hospital;

    (iii) A nursing home;

    (iv) An assisted living facility; or

    (v) A group home licensed by the State.

#### Section 19-381

(a) A hospital shall provide a patient or the legal guardian of a patient with an opportunity to designate one lay caregiver before discharge of the patient.

(b) If a patient or the legal guardian of a patient declines to designate a lay caregiver:

  (1) The hospital shall document the decision in the patient's medical record; and

  (2) The hospital shall be deemed to be in compliance with the provisions of this part.

(c) If a patient or the legal guardian of a patient designates a lay caregiver, the hospital shall:

  (1) Record in the patient's medical record:

    (i) The designation of the lay caregiver;

    (ii) The relationship of the lay caregiver to the patient; and

    (iii) The name, telephone number, and address of the lay caregiver; and

  (2) Request the written consent of the patient or the legal guardian of the patient to release medical information to the lay caregiver in accordance with:

    (i) The procedures of the hospital for releasing personal health information; and

    (ii) All applicable federal and State laws.

(d) If a patient or the legal guardian of a patient declines to consent to the release of medical information to the lay caregiver, the hospital is not required to:

  (1) Provide to the lay caregiver the notice required under Sec. 19-382 of this part; or

  (2) Consult with the lay caregiver or provide to the lay caregiver information contained in the discharge plan issued under Sec. 19-383 of this part.

(e) A patient or the legal guardian of a patient may change the designation of a lay caregiver in the event the lay caregiver becomes incapacitated.

(f) A designation of a lay caregiver by a patient or the legal guardian of a patient under this section does not obligate an individual to perform any aftercare for the patient.

(g) This section may not be construed to require a patient or the legal guardian of a patient to designate a lay caregiver.

#### Section 19-382

If a patient or the legal guardian of a patient has designated a lay caregiver under Sec. 19-381 of this part, the hospital shall notify the lay caregiver of the discharge of the patient or the transfer of the patient to another hospital or facility licensed by the State as soon as practicable.

#### Section 19-383

(a) As soon as practicable before discharge of a patient, a hospital shall attempt to:

  (1) Consult with the patient's lay caregiver to prepare the lay caregiver for aftercare; and

  (2) Issue a discharge plan that describes the aftercare needs of the patient.

(b) The inability of a hospital to consult with a patient's designated lay caregiver may not interfere with, delay, or otherwise affect the medical care provided to the patient or the patient's discharge.

#### Section 19-384

A hospital's discharge process may incorporate established evidence-based practices, including those described in:

(1) Standards for accreditation adopted by The Joint Commission or another nationally recognized hospital accreditation organization; and

(2) The Conditions of Participation for hospitals adopted by the Centers for Medicare and Medicaid Services.

#### Section 19-385

(a) This part may not be construed to:

  (1) Affect the rights of an agent to make health care decisions under Title 5, Subtitle 6 of this article; or

  (2) Create a private right of action against a hospital, a hospital employee, or a duly authorized agent of a hospital, or otherwise supersede or replace existing rights or remedies under any other State or federal law.

(b) No federal or State:

  (1) Funds may be used for payment of a lay caregiver; and

  (2) Program funding may be impacted by this part.

#### Section 19-388

(a) In this part the following words have the meanings indicated.

(b) "Coordinators" means the pediatric overstay coordinator in the Department and the pediatric overstay coordinator in the Department of Human Services.

(c) "Pediatric hospital overstay patient" means a patient under the age of 22 years who remains in an inpatient unit or emergency department of a hospital for more than  48 hours after being medically cleared for discharge or transfer.

#### Section 19-389

(a)

  (1) Except as provided in paragraph (2) of this subsection, the Department shall ensure that a pediatric hospital overstay patient is transferred to and treated in the least restrictive setting when clinically indicated and when possible.

  (2) The Department of Human Services, in coordination with the Department, shall ensure that a pediatric hospital overstay patient who is a child committed to the care and custody of the Department of Human Services is transferred to and treated in the least restrictive setting when clinically indicated and when possible.

(b) If a pediatric hospital overstay patient remains in the hospital for more than 48 hours and the registry established under Sec. 7.5-802 of this article indicates that an appropriate inpatient bed is available, the hospital shall seek the transfer to maintain the clinical stability of the patient.

(c) Notwithstanding any other provision of law, to ensure that a pediatric hospital overstay patient is treated in the least restrictive setting, a hospital may concurrently explore in-State and out-of-state placement options.

#### Section 19-390

(a) The Department and the Department of Human Services shall establish a pediatric hospital overstay coordinator within each department.

(b) The coordinators shall act in the best interest of a pediatric overstay patient by coordinating between hospitals, relevant State agencies and programs, and providers of mental health and substance use disorder services.

(c) The coordinators shall:

  (1) Advocate on behalf of pediatric hospital overstay patients while maintaining appropriate patient confidentiality;

  (2) Review policies and procedures of relevant State agencies and make recommendations for necessary changes to the policies and procedures to better serve pediatric hospital overstay patients;

  (3) Maintain data on each pediatric hospital overstay patient, including:

    (i) Patient's length of stay;

    (ii) The responsible State agency, if applicable;

    (iii) Services needed;

    (iv) Placement options being sought by the patient;

    (v) Information regarding previous hospital admissions for a behavioral health diagnosis;

    (vi) Information regarding whether the admission was based on an emergency petition and, if so, whether the emergency petition was executed in a school; and

    (vii) Any other relevant data; and

  (4) Provide monthly reports on the data collected under this subsection to the Secretary, the Secretary of Human Services, and the Child and Youth Placement Review Panel in the Governor's Office for Children.

  (5) A hospital immediately shall notify the coordinators, through a system designated by the Department, about a pediatric hospital overstay patient.

#### Section 19-393

(a) In this part the following words have the meanings indicated.

(b) "Clinical staffing committee" means a committee established by a hospital in accordance with Sec. 19-394(c) of this subtitle.

(c) "Clinical staffing plan" means a plan developed under Sec. 19-394(d) of this subtitle.

#### Section 19-394

(a) This part does not apply to State hospitals.

(b)

  (1) Each hospital licensed under this title shall comply with the staffing standards of:

    (i) The accreditation body that accredits the hospital; and

    (ii) The federal Centers for Medicare and Medicaid Services conditions of participation.

  (2) A clinical staffing plan developed under this part shall comply with this subsection.

(c)

  (1) Each hospital licensed under this title shall establish and maintain a clinical staffing committee that:

    (i) If the hospital has 150 or fewer licensed beds, has 3 managers and 2 employees; or

    (ii) If the hospital has 151 or more licensed beds, has 5 managers and 4 employees.

  (2) Each clinical staffing committee established under this part may include:

    (i) A certified nursing assistant;

    (ii) A dietary aide;

    (iii) A licensed nurse;

    (iv) An environmental service worker;

    (v) A medical resident, if the committee is in a teaching hospital;

    (vi) A staff physician who is not a hospital employee or administrator;

    (vii) A technician; or

    (viii) An employee whose duties include patient advocacy.

(d)

  (1) The chief nurse executive of each hospital shall produce a draft clinical staffing plan and submit it to the clinical staffing committee of the hospital.

  (2) Each clinical staffing committee shall finalize a clinical staffing plan that meets patient needs using the plan submitted under paragraph (1) of this subsection.

(e) When finalizing a clinical staffing plan, the clinical staffing committee shall consider:

  (1) Existing staffing levels;

  (2) Methods to secure coverage needs as necessary;

  (3) Existing gaps in staffing and how to address the gaps;

  (4) Any available evidence-based staffing standards;

  (5) A schedule for periodic review of the staffing plan;

  (6) Appropriate skill mix and competency of staff;

  (7) Standards required by:

    (i) The Centers for Medicare and Medicaid Services conditions of participation; and

    (ii) The accreditation body that accredits the hospital;

  (8) The average number of patients of the hospital during the immediately preceding year and relevant information regarding patient discharges, potential admissions, and transfers;

  (9) The average level of acuity for patients of the hospital during the immediately preceding year and the corresponding level of nursing care required; and

  (10) An estimate of the appropriate combination of skill, experience level, and specialty certification or training of staff that is required to adequately provide care to patients of the hospital.

#### Section 19-395

On or before July 1 each year, beginning in 2028, each hospital shall:

(1) Implement the clinical staffing plan finalized under Sec. 19-394 of this subtitle; and

(2) Assign personnel to each patient care unit in accordance with the clinical staffing plan.

#### Section 19-396

Each hospital shall provide the clinical staffing plan to staff on request.

#### Section 19-397

This part may not be construed to require a hospital to take actions that are inconsistent with the Centers for Medicare and Medicaid Services conditions of participation or the accreditation standards of the accreditation body that accredits the hospital.

### Subtitle 3A. Freestanding Medical Facilities

#### Section 19-3A-01

In this subtitle, "freestanding medical facility" means a facility:

(1) In which medical and health services are provided;

(2) That, except for a freestanding medical facility established as a result of a conversion of a licensed general hospital under Sec. 19-120(o)(3) of this title, is physically separate from a hospital or hospital grounds;

(3) That is an administrative part of a hospital, as defined in Sec. 19-301 of this title; and

(4) That meets the requirements for provider-based status under the certification for an affiliated hospital as set forth by the Centers for Medicare and Medicaid Services in 42 C.F.R. Sec. 413.65.

#### Section 19-3A-02

(a) On or before January 1, 2006, the Department shall adopt regulations for licensing a freestanding medical facility that uses in its title or advertising the word "emergency" or other language indicating to the public that medical treatment for immediately life-threatening medical conditions is available at that freestanding medical facility.

(b) The regulations shall require the freestanding medical facility to:

  (1) Be open 24 hours a day, 7 days a week;

  (2) Have available at all times:

    (i) At least 1 physician who is credentialed in emergency medicine by the hospital of which the freestanding medical facility is an administrative part;

    (ii) A sufficient number of registered nurses and other health care professionals to provide advanced life support;

    (iii) Basic diagnostic and laboratory facilities and technicians;

    (iv) Resuscitation supplies and equipment, including monitors, defibrillators, cardiac medications, intubation equipment, and intravenous line equipment;

    (v) A commercial ambulance for transport of individuals in need of hospitalization or other emergency care; and

    (vi) Emergency services to all individuals, regardless of ability to pay;

  (3) Comply with all Maryland Institute for Emergency Medical Services Systems emergency transport protocols established for the freestanding medical facility;

  (4)

    (i) Comply, except in a life-threatening emergency in which compliance is not feasible or practicable, with the federal Centers for Disease Control and Prevention guidelines on universal precautions; and

    (ii) Display the notice developed under Sec. 1-207 of the Health Occupations Article that explains the federal Centers for Disease Control and Prevention's guidelines on universal precautions at the entrance to the freestanding medical facility;

  (5) Refrain from use of the words "emergency department", "emergency room", or "hospital"; and

  (6) Meet any other standard that the Secretary deems necessary to ensure the quality and safety of services provided by a freestanding medical facility.

#### Section 19-3A-03

(a) The Department shall issue a license to a freestanding medical facility that:

  (1) Meets the licensure requirements under this subtitle; and

  (2) Receives a certificate of need or an exemption from obtaining a certificate of need from the Maryland Health Care Commission under Sec. 19-120 of this title.

(b) A freestanding medical facility that uses in its title or advertising the word "emergency" or other language indicating to the public that medical treatment for immediately life-threatening medical conditions exist at that facility shall be licensed by the Department before it may operate in this State.

(c) Notwithstanding subsection (a)(2) of this section, the Department may not require a freestanding medical facility pilot project to be approved by the Maryland Health Care Commission as a condition of licensure.

#### Section 19-3A-04

The governing body of any county may adopt rules and regulations governing freestanding medical facilities more restrictive than the regulations adopted by the Department.

#### Section 19-3A-05

(a) Except as provided in subsection (b) of this section, a person who violates any provision of this subtitle is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $5,000 or imprisonment not exceeding 1 year or both.

(b)

  (1) In addition to other penalties available under law, the Department may impose sanctions against a freestanding medical facility that fails to comply with this subtitle or regulations adopted under this subtitle.

  (2) The sanctions imposed by the Department under paragraph (1) of this subsection include:

    (i) A civil penalty not to exceed $10,000;

    (ii) Restrictions on the operation of the freestanding medical facility;

    (iii) A directed plan of correction; and

    (iv) Suspension or revocation of the freestanding medical facility's license.

(c)

  (1) Except as otherwise provided under the Administrative Procedure Act, before the Department may impose sanctions under subsection (b)(2)(i), (ii), or (iv) of this section, the Department shall give the freestanding medical facility notice and the opportunity for a hearing and judicial review under the Administrative Procedure Act, as provided in Title 10, Subtitle 2 of the State Government Article.

  (2) Before the Department may impose a directed plan of correction, the Department shall give the freestanding medical facility notice and the opportunity for a prompt informal hearing with the Director of the Office of Health Care Quality.

#### Section 19-3A-06

The circuit court for a county in which a person is operating a freestanding medical facility in violation of a provision of this subtitle may enjoin further operation of the freestanding medical facility that violates this subtitle.

#### Section 19-3A-07

(a) There are two freestanding medical facility pilot projects that shall operate in two jurisdictions in the State.

(b) The Department shall issue a freestanding medical facility license to:

  (1) One freestanding medical facility pilot project if:

    (i) The freestanding medical facility pilot project is established by, and will operate administratively as part of, an acute care general hospital;

    (ii) The acute care general hospital is part of a merged asset system with all of its existing Maryland acute care general hospitals located in a single jurisdiction;

    (iii) There are not more than 5 acute care general hospitals in the jurisdiction;

    (iv) One or more of the existing acute care general hospitals in the merged asset system has an emergency department volume of 75,000 or more visits for the 12 months ending June 30, 2004;

    (v) The freestanding medical facility pilot project will operate in Montgomery County;

    (vi) The capital expenditure to implement the freestanding medical facility pilot project otherwise meets the requirements of Sec. 19-120(k)(6)(viii) of this title; and

    (vii) The freestanding medical facility pilot project meets the requirements under Sec. 19-3A-02(b) of this subtitle; and

  (2) One freestanding medical facility pilot project if:

    (i) The freestanding medical facility pilot project is established by, and will operate administratively as part of, an acute care general hospital located in Talbot County;

    (ii) The freestanding medical facility pilot project will operate in Queen Anne's County;

    (iii) The capital expenditure to implement the freestanding medical facility pilot project otherwise meets the requirements of Sec. 19-120(k)(6)(viii) of this title; and

    (iv) The freestanding medical facility pilot project meets the requirements under Sec. 19-3A-02(b) of this subtitle.

(c)

  (1) A freestanding medical facility pilot project shall provide to the Maryland Health Care Commission information, as specified by the Commission, on the configuration, location, operation, and utilization, including patient-level utilization, of the pilot project.

  (2) A certificate of need is not required for a freestanding medical facility pilot project.

(d) The provisions of Sec.Sec. 19-3A-01 through 19-3A-06 of this subtitle shall apply to a freestanding medical facility pilot project.

#### Section 19-3A-08

(a) This section applies to all payors subject to the rate-setting authority of the Health Services Cost Review Commission, including:

  (1) Insurers, nonprofit health service plans, and health maintenance organizations that deliver or issue for delivery individual, group, or blanket health insurance policies and contracts in the State;

  (2) Managed care organizations, as defined in Sec. 15-101 of this article; and

  (3) The Maryland Medical Assistance Program established under Title 15, Subtitle 1 of this article.

(b) A payor subject to this section shall pay rates set by the Health Services Cost Review Commission under Subtitle 2 of this title for hospital services provided at:

  (1) A freestanding medical facility pilot project authorized under this subtitle prior to January 1, 2008; and

  (2) A freestanding medical facility licensed under Sec. 19-3A-03 of this subtitle.

### Subtitle 3B. Freestanding Ambulatory Care Facilities

#### Section 19-3B-01

(a) In this subtitle the following words have the meanings indicated.

(b)

  (1) "Ambulatory surgical facility" means any center, service, office facility, or other entity that:

    (i) Operates exclusively for the purpose of providing surgical services to patients requiring a period of postoperative observation but not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following admission; and

    (ii) Seeks reimbursement from payors as an ambulatory surgery center.

  (2) "Ambulatory surgical facility" does not include:

    (i) The office of one or more health care practitioners seeking only professional reimbursement for the provisions of medical services, unless:

      (1) The office operates under contract or other agreement with a payor as an ambulatory surgical facility regardless of whether it is paid a technical or facility fee; or

      (2) The office is designated to receive ambulatory surgical referrals in accordance with utilization review or other policies adopted by a payor;

    (ii) Any facility or service owned or operated by a hospital and regulated under Subtitle 2 of this title;

    (iii) The office of a health care practitioner with not more than one operating room if:

      (1) The office does not receive a technical or facility fee; and

      (2) The operating room is used exclusively by the health care practitioner for patients of the health care practitioner;

    (iv) The office of a group of health care practitioners with not more than one operating room if:

      (1) The office does not receive a technical or facility fee; and

      (2) The operating room is used exclusively by members of the group practice for patients of the group practice; or

    (v) An office owned or operated by one or more dentists licensed under the Health Occupations Article.

(c) "Freestanding ambulatory care facility" means:

  (1) An ambulatory surgical facility;

  (2) A freestanding endoscopy facility;

  (3) A freestanding facility utilizing major medical equipment;

  (4) A kidney dialysis center; or

  (5) A freestanding birthing center.

(d)

  (1) "Freestanding birthing center" means a facility that provides nurse midwife services under Title 8, Subtitle 6 of the Health Occupations Article.

  (2) "Freestanding birthing center" does not include:

    (i) A hospital regulated under Subtitle 2 of this title; or

    (ii) The private residence of the mother.

(e)

  (1) "Freestanding endoscopy facility" means a facility:

    (i) For the testing, diagnosis, or treatment of a medical disorder in conjunction with the use of microscopic, endoscopic, or laparoscopic equipment that is inserted in a naturally occurring orifice of the body; and

    (ii) That seeks reimbursement as a freestanding endoscopy facility from payors or Medicare.

  (2) "Freestanding endoscopy facility" does not include:

    (i) The office of one or more health care practitioners unless:

      (1) The office operates under a contract or other agreement with a payor as a freestanding endoscopy facility regardless of whether it is paid a technical or facility fee; or

      (2) The office is designated to receive endoscopic referrals in accordance with utilization review or other policies adopted by a payor; or

    (ii) Any facility or service operated by a hospital and regulated under Subtitle 2 of this title.

(f)

  (1) "Freestanding facility operating major medical equipment" means a facility using major medical equipment.

  (2) "Freestanding facility operating major medical equipment" does not include any facility or service owned or operated by a hospital and regulated under Subtitle 2 of this title.

(g) "Health care practitioner" means a person who is licensed, certified, or otherwise authorized under the Health Occupations Article to provide medical services in the ordinary course of business or practice of a profession.

(h)

  (1) "Kidney dialysis center" means a facility that provides hemodialysis or chronic peritoneal dialysis.

  (2) "Kidney dialysis center" does not include any facility or service owned or operated by a hospital and regulated under Subtitle 2 of this title.

(i) "License" means a license issued by the Secretary under this subtitle.

(j) "Major medical equipment" means:

  (1) Cardiac catheterization equipment;

  (2) A computer tomography (CT) scanner;

  (3) A lithotripter;

  (4) Radiation therapy equipment, including a linear accelerator; or

  (5) A magnetic resonance imager (MRI).

(k) "Nonsterile procedure room" means a room:

  (1) In which minor surgical procedures are performed, including endoscopy and endoscopic procedures requiring deep sedation;

  (2) That can only be accessed from a semi-restricted corridor or an unrestricted corridor;

  (3) That is not used for open surgical procedures that:

    (i) Enter the thorax, abdomen, pelvis, cranium, or spine; or

    (ii) Routinely require induction of deep sedation or general anesthesia for the entirety of the surgical procedure; and

  (4) In which deep sedation or general anesthesia may be induced if:

    (i) Warranted by the clinical situation; and

    (ii) The room is equipped to safely conduct the required level of anesthesia.

(l) "Payor" means:

  (1) A health insurer, nonprofit health service plan, or health maintenance organization that holds a certificate of authority to offer health insurance policies or contracts in the State in accordance with this article or the Insurance Article;

  (2) A third party administrator or any other entity under contract with a Maryland business to administer health benefits; or

  (3) A self-insured group.

(m) "Sterile operating room" means a room in a surgical suite that meets the requirements of a restricted area and is designated and equipped for performing surgical operations or other invasive procedures that may require an aseptic field.

(n) "Surgical services" has the meaning incorporated in the Centers for Medicare and Medicaid Services State Operations Manual - Guidance for Surveyors: Ambulatory Surgical Centers.

#### Section 19-3B-02

(a) A freestanding ambulatory care facility may not operate in the State unless the Secretary has granted the facility a license.

(b) The Secretary shall issue a license to an applicant that meets the requirements of this subtitle and all applicable regulations adopted by the Secretary.

(c) A license issued under this subtitle is not transferable.

#### Section 19-3B-03

(a)

  (1) After consultation with representatives of payors, health care practitioners, and freestanding ambulatory care facilities, the Secretary shall by regulation establish:

    (i) Procedures to implement the provisions of this subtitle; and

    (ii) Standards to ensure quality of care and patient safety that shall include:

      (1) Procedures for credentialing and practitioner performance evaluation;

      (2) Qualifications of health care practitioners and support personnel;

      (3) Procedures to be followed in the event of an emergency, including a requirement that in the event of an emergency the patient be transported to the nearest appropriate emergency care facility;

      (4) Procedures for quality control of any biomedical equipment;

      (5) Procedures for postoperative recovery;

      (6) Procedures for discharge;

      (7) Procedures for ensuring that an anesthesia practitioner is not precluded from providing the highest level of anesthesia support that may be required to safely treat patients undergoing procedures in a freestanding ambulatory surgical facility performed in a nonsterile procedure room or a sterile operating room;

      (8) The use of ultrasound imaging in a freestanding birthing center;

      (9) Minimum perinatal care standards for a freestanding birthing center that meet or exceed the Maryland Perinatal System Standards that a freestanding birthing center shall meet as a condition of licensure; and

      (10) Any other procedures that the Secretary considers necessary for quality of care and patient safety.

  (2) The procedures for practitioner performance evaluation required under paragraph (1)(ii)1 of this subsection shall include a review of care provided to patients at the freestanding ambulatory care facility by members of the medical staff.

  (3) The review of care shall:

    (i) Be undertaken for cases chosen at random and for cases with unexpected adverse outcomes;

    (ii) Be based on objective review standards;

    (iii) Include a review of the appropriateness of the plan of care for the patient, particularly any medical procedures performed on the patient, in relation to the patient's condition; and

    (iv) Except as provided in paragraph (4) of this subsection, be conducted by at least two members of the medical staff who:

      (1) As appropriate, are of the same specialty as the member of the medical staff under review; and

      (2) Have been trained in the freestanding ambulatory care facility's policies and procedures regarding practitioner performance evaluation.

  (4) A review of the care provided by a member of the medical staff who is a solo practitioner shall be conducted by an external reviewer.

  (5) A freestanding ambulatory care facility shall take into account the results of the practitioner performance evaluation process for a member of the medical staff in the reappointment process.

(b) If appropriate certification by Medicare is available, obtaining the certification shall be a condition of licensure for:

  (1) An ambulatory surgical facility; and

  (2) A kidney dialysis center.

(c) Each freestanding ambulatory care facility shall provide assurances satisfactory to the Secretary that the freestanding ambulatory care facility does not discriminate against patients, including discrimination based on ability to pay for nonelective procedures.

(d) The Secretary may delegate to the Kidney Disease Commission the Secretary's authority under Sec. 19-3B-07 of this subtitle to inspect kidney dialysis centers.

(e)

  (1) Except as provided in paragraph (2) of this subsection, the Department shall survey freestanding ambulatory care facilities in accordance with federal regulations.

  (2) The Department shall survey each freestanding birthing center at least once per calendar year.

#### Section 19-3B-03.1

(a) If a newborn is delivered in a freestanding birthing center following a high-risk pregnancy, the freestanding birthing center shall:

  (1) Complete a postpartum infant and maternal referral form and submit the form to the local health department for the county in which the birthing parent resides;

  (2) Provide to the birthing parent resources and information specific to the circumstances of the birthing parent, including information regarding the risks, signs, preventive measures, and treatment needs for postpartum complications, including cardiovascular conditions, chronic disease, substance misuse, and mental health conditions; and

  (3) Call the birthing parent at least 24, but not later than 48, hours after discharging the parent to evaluate the parent's status and, as necessary, provide information about postpartum complications.

(b) 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 based on the referral forms submitted to the local health department in accordance with subsection (a)(1) of this section.

#### Section 19-3B-04

(a) An applicant for a license shall submit an application to the Secretary.

(b) The application shall:

  (1) Be on a form and accompanied by any supporting information that the Secretary requires, including documentation that the Maryland Health Care Commission has determined that the freestanding ambulatory care facility either received a certificate of need or is exempt from certificate of need requirements; and

  (2) Be signed and verified by the applicant.

#### Section 19-3B-05

A license does not entitle the licensee to an exemption from other provisions of law relating to:

(1) The review and approval of hospital rates and charges by the Health Services Cost Review Commission; or

(2) The review and approval of new services or facilities by the Maryland Health Care Commission.

#### Section 19-3B-06

The Secretary, by regulation, may encourage the joint acquisition, purchase, or operation of major medical equipment by two or more health care practitioners, despite the fact that such joint acquisition, purchase, or operation may limit free economic competition.

#### Section 19-3B-07

(a) The Secretary may investigate complaints concerning the conformance of a freestanding ambulatory care facility to the requirements of this subtitle or to the regulations adopted under this subtitle.

(b) If the complaint concerns health care practitioner performance or standards of medical practice, the complaint shall be referred to the board that licenses, certifies, or otherwise authorizes the health care practitioner under the Health Occupations Article to provide medical services.

#### Section 19-3B-08

(a)

  (1) The Secretary may deny a license to any applicant, or suspend, restrict, or revoke a license if the applicant has been convicted of:

    (i) A felony that relates to Medicaid; or

    (ii) A crime involving moral turpitude.

  (2) The Secretary may deny a license to any applicant or may restrict, suspend, or revoke any license if the applicant does not meet the requirements of this subtitle or any regulation that the Secretary adopts under this subtitle.

(b)

  (1) Before denying, suspending, restricting, or revoking a license or a provisional license under this section, the Secretary shall provide the applicant an opportunity for a hearing.

  (2) The Secretary shall send a hearing notice to any applicant by certified mail, return receipt requested, at least 30 days before the hearing.

#### Section 19-3B-09

(a) A person who violates any provision of this subtitle or any regulation adopted under this subtitle is guilty of a misdemeanor and on conviction is subject to a penalty not exceeding $1,000 or imprisonment not exceeding 1 year or both. Each day a violation is continued after the first conviction is a separate offense.

(b)

  (1) In addition to the provisions of subsection (a) of this section, the Secretary may impose an administrative penalty of up to $1,000 for a violation of any provision of this subtitle or any regulations adopted under this subtitle.

  (2) The Secretary shall adopt regulations to provide standards for the imposition of an administrative penalty under paragraph (1) of this subsection.

### Subtitle 3C. Cosmetic Surgical Facilities

#### Section 19-3C-01

(a) In this subtitle the following words have the meanings indicated.

(b)

  (1) "Cosmetic surgical facility" means an office or a facility in which a cosmetic surgical procedure is performed.

  (2) "Cosmetic surgical facility" does not include:

    (i) An ambulatory surgical facility regulated under Subtitle 3B of this title;

    (ii) A hospital regulated under Subtitle 3 of this title; or

    (iii) An office owned or operated by one or more dentists providing services within the scope of practice of dentistry under Title 4 of the Health Occupations Article.

(c)

  (1) "Cosmetic surgical procedure" means the use of surgical services to reshape the structure of a human body to change the appearance of an individual.

  (2) Except as provided in paragraph (3) of this subsection, "cosmetic surgical procedure" does not include:

    (i) A procedure done under local anesthesia or mild sedation; or

    (ii) Liposuction that removes less than 1,000 cubic centimeters of aspirate.

  (3) "Cosmetic surgical procedure" includes any procedure under paragraph (2) of this subsection that, under the circumstances established by the Secretary in regulations adopted under Sec. 19-3C-02(d) of this subtitle, is a cosmetic surgical procedure.

#### Section 19-3C-02

(a) The Secretary may adopt regulations for cosmetic surgical facilities in the State.

(b) Regulations adopted by the Secretary under this section shall include deeming a cosmetic surgical facility to meet specified requirements, if the cosmetic surgical facility is accredited by:

  (1) The American Association for Accreditation of Ambulatory Surgical Facilities;

  (2) The Accreditation Association for Ambulatory Health Care;

  (3) The Joint Commission; or

  (4) Any other accreditation organization, as determined by the Secretary.

(c) Regulations adopted under this section may not require higher standards for cosmetic surgical facilities than the standards required for ambulatory surgical facilities under Subtitle 3B of this title.

(d)

  (1) The Secretary may adopt regulations that establish the circumstances under which a procedure is a "cosmetic surgical procedure" under Sec. 19-3C-01(c)(3) of this subtitle.

  (2) The regulations adopted under paragraph (1) of this subsection shall be based on a finding by the Secretary that the procedure raises substantial health and safety concerns that warrant regulation of the procedure under this subtitle.

  (3) In adopting regulations under paragraph (1) of this subsection, the Secretary shall consider available studies, reports, and other literature related to:

    (i) The safety or risks of the procedure;

    (ii) The education and training of the health care practitioners administering anesthesia for the procedure;

    (iii) The education and training of the health care practitioners performing the procedure; and

    (iv) The setting in which the procedure is performed.

#### Section 19-3C-03

(a) The Secretary may investigate complaints concerning the conformance of a cosmetic surgical facility to the requirements of regulations adopted under Sec. 19-3C-02 of this subtitle.

(b) If the complaint concerns health care practitioner performance or standards of medical practice, the complaint shall be referred to the appropriate health occupations board that licenses, certifies, or otherwise regulates the health care practitioner under the Health Occupations Article.

### Subtitle 4. Home Health Agencies

#### Section 19-401

(a) In this subtitle the following words have the meanings indicated.

(b) "Home health agency" means a health-related institution, organization, or a part of an institution that:

  (1) Is owned or operated by 1 or more persons, whether or not for profit and whether as a public or private enterprise; and

  (2) Directly or through a contractual arrangement, provides to a sick or disabled individual in the residence of that individual skilled nursing services, home health aid services, and at least one other home health care service that are centrally administered.

(c)

  (1) "Home health care" means any of the following services that are provided under the general direction of a licensed health professional practicing within the scope of their practice:

    (i) Audiology and speech pathology;

    (ii) Dietary and nutritional services;

    (iii) Drug services;

    (iv) Home health aid;

    (v) Laboratory;

    (vi) Medical social services;

    (vii) Nursing;

    (viii) Occupational therapy;

    (ix) Physical therapy; or

    (x) Provision of medically necessary sickroom equipment and supplies.

  (2) However, the provisions of this subsection do not apply to:

    (i) A nursing referral service agency that is licensed as a nursing referral service agency under the provisions of Subtitle 4B of this title; or

    (ii) A home-based hospice care program that is licensed as a home-based hospice care program under the provisions of Subtitle 9 of this title.

  (3) A home health agency shall also be licensed as a hospice care program if the home health agency operates a hospice care program that is distinct from its other services.

#### Section 19-402

The purpose of home health care is:

(1) To avoid institutionalization;

(2) To shorten hospital stays;

(3) To speed recovery; and

(4) To bridge the gap in community health services for patients who otherwise could not get adequate health care.

#### Section 19-403

This subtitle does not:

(1) Limit the right of any person to practice a health occupation that the individual is authorized to practice under the Health Occupations Article;

(2) Limit the right of any person who holds a license under this article to act as authorized by that license; or

(3) Prohibit the care of an individual who relies on treatment in accordance with the tenets and practices of a recognized church or religious denomination and, with or without compensation, is cared for in accordance with those tenets and practices.

#### Section 19-404

(a) The Department shall adopt rules and regulations that set standards for the care, treatment, health, safety, welfare, and comfort of patients of home health agencies.

(b) The rules and regulations shall provide for the licensing of home health agencies and shall establish standards that require as a minimum, that all home health agencies:

  (1) Within 10 days of acceptance of a patient for skilled care, make and record all reasonable efforts to contact a physician to obtain the signed order required under item (2) of this subsection;

  (2) That accept patients for skilled care do so only on the signed order of a physician obtained within 28 days after acceptance;

  (3) Adopt procedures for the administration of drugs and biologicals;

  (4) Maintain clinical records on all patients accepted for skilled care;

  (5) Establish patient care policies and personnel policies;

  (6) Have services available at least 8 hours a day, 5 days a week, and available on an emergency basis 24 hours a day, 7 days a week;

  (7) Make service available to an individual in need within 24 hours of a referral when stipulated by a physician's order;

  (8) Have a designated supervisor of patient care who is a full-time employee of the agency and is available at all times during operating hours and additionally as needed; and

  (9) Have as the administrator of the agency a person who has at least 1 year of supervisory experience in hospital management, home health management, or public health program management and who is:

    (i) A licensed physician;

    (ii) A registered nurse; or

    (iii) A college graduate with a bachelor's degree in a health-related field.

(c) The rules and regulations may include provisions that:

  (1) Deal with the establishment of home health agencies;

  (2) Require each home health agency to have its policies established by a professional group that includes at least:

    (i) 1 physician;

    (ii) 1 registered nurse;

    (iii) 1 representative of another offered service; and

    (iv) 1 public member;

  (3) Govern the services provided by the home health agencies;

  (4) Require keeping clinical records of each patient, including the plan of treatment to be provided;

  (5) Govern supervision of the services, as appropriate, by:

    (i) A physician;

    (ii) A registered nurse; or

    (iii) Another health professional who is qualified sufficiently by advanced training to supervise the same kind of services in a hospital; and

  (6) Require submission of an annual report which includes service utilization statistics.

(d) The provisions of this section do not waive the requirement for a home health agency to obtain a certificate of need.

#### Section 19-405

Except as otherwise provided in this subtitle, a person shall be licensed by the Department before the person may operate a home health agency.

#### Section 19-406

To qualify for a license, an applicant shall:

(1) Show that the home health agency will provide:

  (i) Appropriate home health care to patients who may be cared for at a prescribed level of care, in their residence instead of in a hospital; and

  (ii) Skilled nursing, home health aid, and at least one other home health care service that is approved by the Secretary; and

(2) Meet the requirements of Subtitle 1 of this title for certification of need.

#### Section 19-407

The Department shall:

(1) Inspect the operations of each home health agency at least every 3 years to determine whether it is meeting the requirements of this subtitle and the rules and regulations adopted under it; and

(2) Issue, deny, suspend, or revoke a home health agency license in accordance with the rules and regulations adopted under this subtitle.

#### Section 19-408

(a) A person may not operate, attempt to operate, or hold one's self out as operating a home health agency unless licensed under this subtitle.

(b) A home health agency may not withhold any home health care services from an individual because of the individual's age, sex, sexual orientation, gender identity, disability, race, color, creed, national origin, source of payment, or ability to pay.

#### Section 19-409

A person who operates a home health agency without a license is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000 for the first offense and not exceeding $10,000 for each subsequent offense.

#### Section 19-410

A home health agency may not hold itself out as providing a complete array of physical rehabilitation services unless the home health agency:

(1) Provides a program of coordinated interdisciplinary rehabilitative care, including at a minimum, physical and occupational therapy, speech and language therapy, audiology therapy, psychotherapy, and social work services;

(2) Holds interdisciplinary meetings with the involvement of a physician to plan and monitor patient care; and

(3) Meets any other standard that the Secretary may adopt by regulation.

#### Section 19-411

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "COVID-19" means, interchangeably and collectively, the coronavirus known as COVID-19 or 2019-nCoV and the SARS-CoV-2 virus.

  (3) "COVID-19 test" means an in vitro diagnostic test for the detection of SARS-CoV-2 or the diagnosis of the virus that causes COVID-19, as described in Sec. 3201 of the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act.

(b) For calendar years 2021 and 2022, a home health agency shall adopt and implement a COVID-19 infection control and prevention plan for patients and staff who provide home health care services to patients of the home health agency.

(c)

  (1) The plan required under subsection (b) of this section shall:

    (i) Be adopted and implemented in accordance with any applicable federal orders and guidance; and

    (ii) Ensure that patients and staff who provide home health care services to patients of the home health agency are screened for COVID-19 on a regular basis and tested or referred for testing for COVID-19, if required or recommended under applicable federal orders or guidance, to control and prevent the spread of COVID-19 among staff and patients of the home health agency.

  (2) The screening required under paragraph (1) of this subsection shall include reporting to the home health agency of any:

    (i) Symptoms related to COVID-19 experienced by patients and staff; and

    (ii) Known exposures of patients and staff to individuals who have been diagnosed with COVID-19.

(d) A home health agency shall provide the plan required under subsection (b) of this section to:

  (1) Patients and staff; and

  (2) Members of the public on request.

### Subtitle 4A. Residential Service Agencies

#### Section 19-4A-01

(a) In this subtitle the following words have the meanings indicated.

(b) "Home health care" includes any of the following services:

  (1) Audiology and speech pathology;

  (2) Dietary and nutritional services;

  (3) Drug services;

  (4) Home health aide;

  (5) Laboratory;

  (6) Medical social services;

  (7) Nursing;

  (8) Occupational therapy;

  (9) Physical therapy;

  (10) Provision of invasive medical equipment; and

  (11) Home medical equipment services.

(c) "Home medical equipment services" means the delivery, installation, maintenance, or replacement of, or instruction in the use of, medical equipment used by a sick or disabled individual to allow the individual to be maintained in a noninstitutional environment.

(d) "Medical equipment" means technologically sophisticated medical devices including:

  (1) Oxygen and oxygen delivery systems;

  (2) Ventilators;

  (3) Respiratory disease management devices;

  (4) Electronic and computer driven wheelchairs and seating systems;

  (5) Apnea monitors;

  (6) Transcutaneous electrical nerve stimulator (T.E.N.S.) units;

  (7) Low air loss cutaneous pressure management devices;

  (8) Sequential compression devices;

  (9) Neonatal home phototherapy devices;

  (10) Feeding pumps; and

  (11) Other similar equipment as defined in regulations established by the Secretary.

(e) "Personal care aide" means an individual who provides personal care as defined in Sec. 19-301 of this title.

(f)

  (1) "Residential service agency" means any person that is engaged in a nongovernmental business of employing or contracting with individuals to provide home health care for compensation to an unrelated sick or disabled individual in the residence of that individual.

  (2) "Residential service agency" includes any agency that employs or contracts with individuals directly for hire as home health care providers.

  (3) "Residential service agency" does not include:

    (i) A home health agency that is licensed under the provisions of Subtitle 4 of this title;

    (ii) A person required to be licensed as a home health agency under the provisions of Subtitle 4 of this title;

    (iii) A home-based hospice care program that is licensed under the provisions of Subtitle 9 of this title;

    (iv) A hospital that is licensed under the provisions of Subtitle 3 of this title;

    (v) A related institution that is licensed under the provisions of Subtitle 3 of this title;

    (vi) Personal care providers under the Medical Assistance Personal Care Program;

    (vii) Any person practicing a health occupation that the person is authorized to practice under the Health Occupations Article;

    (viii) A nursing referral service agency that is licensed under Subtitle 4B of this title;

    (ix) A group of persons licensed under the same title of the Health Occupations Article practicing as a business; or

    (x) Residential rehabilitation services providers approved under regulations adopted by the State mental health authority.

#### Section 19-4A-02

This subtitle does not:

(1) Limit the right of any person who holds a license under this article to act as authorized by that license; or

(2) Prohibit the care of an individual who relies on treatment in accordance with the tenets and practices of a recognized church or religious denomination and, with or without compensation, is provided care in accordance with those tenets and practices.

#### Section 19-4A-03

(a) The Department shall adopt regulations that set standards for the care, treatment, health, safety, welfare, and comfort of individuals who receive home health care services through a residential service agency.

(b) The regulations shall provide for the licensing of residential service agencies.

(c) The regulations shall include provisions that:

  (1) Provide for the establishment of residential service agencies;

  (2) Establish qualifications for licensure;

  (3) Set minimum standards for individuals who provide home health care services through a residential service agency;

  (4) Require the residential service agency to screen and verify the character references of all home health care providers that are employed by the residential service agency; and

  (5) Authorize a residential service agency to provide training to a licensed nurse after hire in accordance with Sec. 19-4A-03.2 of this subtitle.

#### Section 19-4A-03.1

(a) In this section, "supervisory staff" means an individual who supervises direct care staff in the individual's clinical role.

(b) This section does not apply to a residential service agency that only provides durable medical equipment.

(c)

  (1) Except as provided in subsection (d) of this section, beginning July 1, 2022, each residential service agency shall ensure that:

    (i) Within 45 days after an individual's start of employment as part of the residential service agency's direct care or supervisory staff, the individual is trained to provide the care required by the clients of the residential service agency by, at a minimum, providing 3 hours of online or in-person training regarding dementia, including training regarding:

      (1) An overview of Alzheimer's disease and dementia;

      (2) Person-centered care;

      (3) An understanding of the assessment and care planning process;

      (4) Activities of daily living; and

      (5) Alzheimer's disease and dementia-related behaviors and communication; and

    (ii) Each member of the residential service agency's direct care or supervisory staff receives 2 hours of online or in-person continuing education training regarding Alzheimer's disease and dementia each calendar year.

  (2) The training required under paragraph (1) of this subsection may be provided by a supervisory staff member who is responsible for developing an individual's plan of care and assigning appropriate personnel.

(d) A residential service agency is not required to provide the training:

  (1) Described under subsection (c)(1)(i) of this section if the individual has:

    (i) Provided Alzheimer's disease or dementia-related direct care or supervisory services for at least 24 consecutive months before beginning employment with the residential service agency; and

    (ii) Received from a residential service agency or other entity a certificate of completion issued under subsection (e) of this section; or

  (2) Described under subsection (c)(1)(ii) of this section if the individual has completed the training described under subsection (c)(1)(ii) of this section in the immediately preceding 12 months.

(e) A person providing the training described under subsection (c) of this section shall issue a certificate of completion to each individual who completes the training.

(f) Each residential service agency shall maintain records that indicate the type of training received by each individual who has received a certificate of completion issued under subsection (e) of this section while employed by the residential service agency.

#### Section 19-4A-03.2

(a) A residential service agency that provides private duty nursing services may employ a licensed nurse who does not meet the clinical experience requirements established by the Department if the residential service agency provides training and a competency evaluation in accordance with this section.

(b) A residential service agency that seeks to employ a nurse described under subsection (a) of this section shall:

  (1) Establish and implement a training program designed to ensure safe and competent care based on patient needs;

  (2) Ensure the nurse receives clinical supervision by a registered nurse qualified in private duty nursing services;

  (3) Assign the nurse to a qualified preceptor or clinical supervisor until competency is demonstrated;

  (4) Document satisfactory completion of required competency standards in the nurse's personnel file; and

  (5) Conduct competency evaluations of the nurse:

    (i) Annually; or

    (ii) For disciplinary purposes, on a more frequent schedule as required by the Department.

(c) A training program and competency evaluation required under this section are subject to approval by the Department.

(d) This section may not be construed to affect requirements relating to occupational licensure, scope of practice, or standards of care.

#### Section 19-4A-04

Except as otherwise provided in this subtitle, a person shall be licensed by the Department before the person may operate a residential service agency.

#### Section 19-4A-05

To qualify for a license, an applicant:

(1) Shall show that the residential service agency will provide appropriate home health care providers to sick or disabled individuals who may be provided care in the individual's residence, instead of in a hospital;

(2) Shall meet any additional requirements that the Department adopts; and

(3) May not be required to meet the requirements of Subtitle 1 of this title for certificate of need.

#### Section 19-4A-06

The Department shall:

(1) Inspect the operations of each residential service agency to determine whether the agency is meeting the requirements of this subtitle and the regulations adopted under this subtitle; and

(2) Issue, deny, suspend, or revoke a residential service agency license in accordance with the regulations adopted under this subtitle.

#### Section 19-4A-07

A person may not operate, attempt to operate, or hold one's self out as operating a residential service agency, unless the person is licensed under this subtitle.

#### Section 19-4A-08

A person who operates a residential service agency without a license is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000 for the first offense and not exceeding $10,000 for each subsequent offense.

#### Section 19-4A-09

A person who operates a residential service agency in violation of the regulations adopted under this subtitle is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000. Each day a violation is continued after the first conviction is a separate offense.

#### Section 19-4A-10

(a) Except as provided by federal law, licensure under this subtitle does not entitle a residential service agency to reimbursement by a third party payor.

(b) The Department may reimburse a residential service agency for personal assistance services only if the personal assistance services are provided by an individual classified as an employee.

#### Section 19-4A-11

(a)

  (1) On or before December 30, 2021, the Office of the Attorney General, in consultation with the Department and the Maryland Department of Labor, shall produce a guidance document concerning the application of employee protection laws in the Labor and Employment Article, to the use of personal care aides by residential service agencies.

  (2) The guidance document required under paragraph (1) of this subsection shall:

    (i) Describe with specific reference to the residential service care industry:

      (1) Relevant definitions of "employ", "employee", "employer", and "independent contractor";

      (2) The concept of independent contractor misclassification and the potential for legal liability including monetary damages for employees; and

      (3) Steps a residential service agency may take to ensure compliance with the Labor and Employment Article;

    (ii) Be three pages or fewer and, to the extent feasible, written in plain language; and

    (iii) Be revised and updated on an annual basis.

(b)

  (1) As a condition of obtaining an initial license from the Department to operate as a residential service agency and every 3 years thereafter, a residential service agency shall certify to the Department, on a form developed by the Department and through the signature of an individual with authority over the residential service agency's pay or employment practices, that:

    (i) The individual has read and understood the guidance document produced under subsection (a) of this section; and

    (ii) The residential service agency will comply with the relevant requirements of the Labor and Employment Article.

  (2) On an annual basis, the Secretary shall provide the most current version of the guidance document to each licensed residential service agency.

  (3) A form developed by the Department for use under paragraph (1) of this subsection shall include a checkbox by which a residential service agency that receives Medicaid reimbursement for the provision of home care or similar services by a personal care aide shall indicate whether the residential service agency uses personal care aides designated as independent contractors.

(c) On or before October 1 each year, each residential service agency receiving Medicaid reimbursement for the provision of home care or similar services by a personal care aide shall report to the Department, on a form or in an electronic manner developed by the Department, the number of personal care aides classified by the residential service agency as:

  (1) Employees; and

  (2) Independent contractors.

(d)

  (1) On or before July 1 each year, the Department shall use the information reported under subsection (c) of this section to create a report concerning:

    (i) Medicaid reimbursement rates;

    (ii) The cost of delivering services; and

    (iii) Aggregated employment classifications of individuals who provide personal care.

  (2) Data included in the report under this subsection:

    (i) May only be in aggregate; and

    (ii) May not identify a specific residential service agency.

  (3) The Department shall submit each report created under paragraph (1) of this subsection to the Senate Finance Committee and the House Health and Government Operations Committee in accordance with Sec. 2-1257 of the State Government Article.

### Subtitle 4B. Nursing Referral Service Agencies

#### Section 19-4B-01

(a) In this subtitle the following words have the meanings indicated.

(b) "Background check" has the meaning stated in Sec. 19-1901 of this title.

(c) "Care provider" means an individual who provides health care services and assistance to a client in the activities of daily living, including:

  (1) Bathing, toileting, and personal hygiene;

  (2) Dressing;

  (3) Meal preparation and eating;

  (4) Companionship; and

  (5) Assistance in physical transfer and ambulation.

(d) "Central Repository" means the Criminal Justice Information System Central Repository of the Department of Public Safety and Correctional Services.

(e) "Home health aid services" means personal and health care services delivered to a client by a care provider.

(f) "License" means a nursing referral service agency license.

(g) "Licensed health professional" means an individual who is licensed or certified under the Health Occupations Article to provide health care services.

(h) "Nursing referral service agency" means one or more individuals engaged in the business of screening and referring, directly or in accordance with contractual arrangements that may include independent contractors, licensed health professionals or care providers to clients for the provision of nursing services, home health aid services, or other home health care services at the request of the client.

(i) "Private agency" has the meaning stated in Sec. 19-1901 of this title.

#### Section 19-4B-02

This subtitle does not limit the right of any person who holds a license under this article to act as authorized by that license.

#### Section 19-4B-03

(a)

  (1) A nursing referral service agency may receive a fee or other compensation for providing its services.

  (2) A contractual arrangement may provide that a nursing referral service agency is not responsible for paying any part of the compensation to the licensed health care professionals or care providers that the nursing referral service agency screens or refers to clients.

  (3) A nursing referral service agency may provide administrative assistance.

(b) A nursing referral service agency shall:

  (1) Obtain a license from the Department prior to operating as a nursing referral service agency;

  (2) Develop and implement a procedure to screen licensed health professionals and care providers that includes the following:

    (i) In accordance with subsection (c) of this section:

      (1) A State criminal history records check; or

      (2) A private agency background check;

    (ii) Verification of current licensure or certification under the Health Occupations Article;

    (iii) A basic health screening, including a tuberculosis screening;

    (iv) Verification of references;

    (v) Verification of employment history;

    (vi) Completion of I-9 forms; and

    (vii) An in-person interview of a licensed health professional and care provider before any referral of the individual is made to a client;

  (3) Institute an internal client complaint investigation process that includes:

    (i) Notice to the client or client's representative of the complaint process; and

    (ii) Protocols to investigate complaints;

  (4) Provide notice to clients of the Department's complaint hotline number for complaints about the services provided by an individual referred by the nursing referral service agency; and

  (5) Allow clients to accept or reject, at their discretion, any licensed health professional or care provider referred by the nursing referral service agency.

(c)

  (1) For each licensed health professional and care provider, a nursing referral service agency shall:

    (i) Apply to the Central Repository for a State criminal history records check; or

    (ii) Request a private agency to conduct a background check.

  (2)

    (i) As part of the application for a criminal history records check, the nursing referral service agency shall submit to the Central Repository:

      (1) Two complete sets of legible fingerprints of the licensed health professional or care provider taken on forms approved by the Director of the Central Repository; and

      (2) The fee authorized under Sec. 10-221(b)(7) of the Criminal Procedure Article for access to Maryland criminal history records.

    (ii) In accordance with Sec.Sec. 10-201 through 10-228 of the Criminal Procedure Article, the Central Repository shall forward to the licensed health professional or care provider and the nursing referral service agency a printed statement listing the criminal convictions of the licensed health professional or care provider.

    (iii) Information obtained from the Central Repository under this subsection:

      (1) Is confidential and may not be redisseminated; and

      (2) May be used only for the screening purpose authorized by this subsection.

    (iv) The subject of a criminal history records check under this subsection may contest the contents of the printed statement issued by the Central Repository as provided in Sec. 10-223 of the Criminal Procedure Article.

  (3) If a nursing referral service agency requests a private agency to conduct a background check:

    (i) The private agency shall:

      (1) Conduct a background check in each state in which the nursing referral service agency knows or has reason to know the licensed health professional or care provider worked or resided during the past 7 years; and

      (2) Issue a statement of its findings to:

      (A) On request, the licensed health professional or care provider; and

      (B) The nursing referral service agency; and

    (ii) The licensed health professional or care provider shall have an opportunity to contest the findings.

#### Section 19-4B-04

(a)

  (1) The Department shall adopt regulations to implement the requirements of this subtitle.

  (2) The regulations may not preclude a nursing referral service agency from operating with independent contractors.

(b) The Department shall issue a license to a nursing referral service agency after the nursing referral service agency completes an application for licensure.

(c) The Department may suspend or revoke a license issued under this section if the nursing referral service agency is operating in violation of the requirements of this subtitle.

#### Section 19-4B-05

(a) An individual may not operate or engage in, or attempt to operate or engage in, or hold one's self out as operating or engaging in the business of a nursing referral service agency unless the individual is licensed under this subtitle.

(b)

  (1) An individual who violates this section is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000 for the first offense and not exceeding $10,000 for any subsequent offense.

  (2) Each day a violation is continued after the first conviction is a separate offense.

#### Section 19-4B-06

For the purposes of any other provision of law, the granting of a license under this subtitle does not constitute a finding of any fact on which the granting of the license was based and may not give rise to any presumption regarding the existence of any fact on which the granting of the license was based.

### Subtitle 5. Chronic Disease Centers

#### Section 19-501

(a) In this subtitle the following words have the meanings indicated.

(b) "Board" means a citizens' advisory board for a center.

(c) "Center" means a chronic disease center.

#### Section 19-502

(a) There are chronic disease centers in the State for individuals who:

  (1) Need constant medical and nursing care by reason of chronic illness or infirmity; or

  (2) Have a chronic disability amenable to rehabilitation.

(b) One center shall be located in each of the following places:

  (1) The Eastern Shore; and

  (2) The western part of this State.

(c) The Secretary also shall operate any other centers established by law and placed under the jurisdiction of the Secretary for the care of individuals who have chronic diseases.

#### Section 19-503

The Secretary shall adopt rules and regulations that set:

(1) The services to be provided by centers; and

(2) The qualifications and standards for admission to and discharge from the centers.

#### Section 19-504

Each center may:

(1) Establish any outpatient clinic for preadmission evaluation, aftercare, or other home health care service;

(2) Further medical knowledge by having a facility to explore new ways of treating problems peculiar to chronically ill and disabled individuals;

(3) Conduct any educational and training program to improve the knowledge and skills of physicians and ancillary professional, scientific, and other staff of the center and other treatment facilities and, thus, to improve a high standard of patient care; and

(4) Add a unit to treat chronic diseases of children.

#### Section 19-505

(a) Admission of an individual to a center shall be based on:

  (1) The statement of a physician who, after an examination of the individual, finds that the individual needs care at a center; and

  (2) The review and approval of an application for admission of the individual by the center.

(b) If an individual cannot be placed in a special facility in this State that can treat the condition of the individual, the individual may be admitted to a center.

(c) A center may not admit an individual who has:

  (1) A mental disorder of the type that requires care in a mental health facility; or

  (2) An orthopedic disease for which medical treatment is available in a special orthopedic hospital.

(d)

  (1) The centers shall be operated primarily for residents of this State.

  (2) A center may admit an individual who is not a resident of this State if:

    (i) The individual is admitted and discharged in accordance with a specific regional health program or specific demonstration or study project approved by the Department; and

    (ii) This State is reimbursed for the full cost of services to the individual.

#### Section 19-506

(a) If the medical staff of a center determines that an individual cannot receive any further benefit at the center, the individual shall be discharged on the written order of a medical staff member.

(b) If, after a competent authority directs a discharged individual to leave the center, the individual fails to do so, the administrative head of the center may take any legal step needed to remove the individual from the center, under an adequate plan for treatment and care.

#### Section 19-507

(a) If this State is paying any of the costs of an individual at a center, the individual may be transferred to another facility that is approved under a federal program.

(b) If the individual refuses to apply for assistance from any applicable State, federal, or local program, the administrative head of the center or the designee of the administrative head may apply for the assistance and transfer the individual to another facility.

#### Section 19-508

There is a citizens' advisory board for each center.

#### Section 19-509

(a)

  (1) Each board consists of 7 members appointed by the Governor.

  (2) The Governor shall appoint the members from a list of qualified individuals submitted to the Governor by the Secretary.

(b) Each member of the board for a center:

  (1) Shall be a citizen of this State;

  (2) Shall be a resident of a county that the center serves;

  (3) Shall be representative of the community; and

  (4) Shall be known for an interest in civic and public affairs and for concern about the care of chronically ill individuals.

(c)

  (1) The term of a member is 4 years.

  (2) The terms of members are staggered as required by the terms provided for members of each board on July 1, 1982. The terms of those members end as follows:

    (i) 1 in 1983.

    (ii) 4 in 1984.

    (iii) 1 in 1985.

    (iv) 1 in 1986.

  (3) At the end of a term, a member continues to serve until a successor is appointed and qualifies.

  (4) A member who is appointed after a term has begun serves only for the rest of the term and until a successor is appointed and qualifies.

  (5) A member who serves 2 consecutive full 4-year terms may not be reappointed for 4 years after completion of those terms.

#### Section 19-510

(a) From among its members, each board shall elect a chairman and other officers that the board considers necessary.

(b) The manner of election of officers and their terms of office shall be as the board determines.

#### Section 19-511

(a) Each board shall meet at least 4 times a year, at the times and places that the board determines.

(b) A member of a board may not receive compensation.

#### Section 19-512

(a) Each board may adopt rules and regulations for the conduct of its meetings.

(b)

  (1) Each board serves in an advisory capacity.

  (2) Each board shall:

    (i) Submit to the Secretary an annual report on:

      (1) The needs of chronically ill individuals; and

      (2) The extent to which its center meets these needs;

    (ii) Advise the administrative head of the center on its facilities, goals, programs, and policies;

    (iii) Help in evaluating the degree to which these goals are achieved;

    (iv) Review and make recommendations about the annual budget of the center;

    (v) Assume leadership in developing community understanding of the needs of chronically ill individuals; and

    (vi) Carry out any other responsibility that the administrative head of the center requests.

#### Section 19-513

(a) Except with the approval of the administrative head of a center, a person other than an employee of the center may not bring any alcoholic beverage into any area of the center that is used by individuals under treatment in the center.

(b) An employee of the center may not:

  (1) Drink any alcoholic beverage while on duty; or

  (2) Give any alcoholic beverage to an individual who is under treatment in the center.

(c) A person who violates any provision of this section is guilty of a misdemeanor and on conviction is subject to a penalty not exceeding $100 or imprisonment not exceeding 60 days or both.

### Subtitle 7. Health Maintenance Organizations

#### Section 19-701

(a) In this subtitle the following words have the meanings indicated.

(b) "Benefit package" means a set of health care services to be provided to a member of a health maintenance organization under a contract that entitles the member to the health care services, whether the services are provided:

  (1) Directly by a health maintenance organization; or

  (2) Through a contract or arrangement with another person.

(c) "Commissioner" means the State Insurance Commissioner.

(d) "Covered service" means a health care service included in the benefit package of the health maintenance organization and rendered to a member or subscriber of the health maintenance organization by:

  (1) A provider under contract with the health maintenance organization, when the service is obtained in accordance with the terms of the benefit contract of the member or subscriber; or

  (2) A noncontracting provider under Sec. 19-710.1 of this subtitle, when the service is:

    (i) Obtained in accordance with the terms of the benefit contract of the member or subscriber;

    (ii) Obtained pursuant to a verbal or written referral by:

      (1) The health maintenance organization of the member or subscriber; or

      (2) A provider under written contract with the health maintenance organization of the member or subscriber; or

    (iii) Preauthorized or otherwise approved either verbally or in writing by:

      (1) The health maintenance organization of the member or subscriber; or

      (2) A provider under written contract with the health maintenance organization of the member or subscriber.

(e) "Emergency medical condition" means a medical condition, including a mental health condition or substance use disorder, that manifests itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in a condition described in Sec. 1867(e)(1) of the Social Security Act.

(e-1)

  (1) "Emergency services" means, with respect to an emergency medical condition:

    (i) A medical screening examination that is within the capability of the emergency department of a hospital or freestanding medical facility, including ancillary services routinely available to the emergency department to evaluate an emergency medical condition;

    (ii) Any other examination or treatment within the capabilities of the staff and facilities available at the hospital or freestanding medical facility that is necessary to stabilize the patient, regardless of the department of the hospital in which the examination or treatment is furnished; or

    (iii) Except as provided in paragraph (3) of this subsection, additional covered items and services furnished by a health care provider of emergency services that does not have a contractual relationship with the carrier after the patient is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in items (i) and (ii) of this paragraph are furnished.

  (2) "Emergency services" includes services described in paragraph (1) of this subsection that are provided in specialized facilities that are staffed by behavioral health providers trained to provide crisis services.

  (3) Subject to Sec. 19-710(p) of this subtitle and Sec. 14-205.2 of the Insurance Article, "emergency services" does not include items and services described in paragraph (1)(iii) of this subsection if all of the conditions in 45 C.F.R. Sec. 149.410(b) are met.

(f)

  (1) "Health care services" means services, medical equipment, and supplies that are provided by a provider.

  (2) "Health care services" includes:

    (i) Ambulance services;

    (ii) Appliances, drugs, medicines, and supplies;

    (iii) Chiropractic care and services;

    (iv) Convalescent institutional care;

    (v) Dental care and services;

    (vi) Extended care;

    (vii) Family planning or infertility services;

    (viii) Health education services;

    (ix) Home health care or medical social services;

    (x) Inpatient hospital services;

    (xi) Laboratory, radiological, or other diagnostic services;

    (xii) Medical care and services;

    (xiii) Mental health services;

    (xiv) Nursing care and services;

    (xv) Nursing home care;

    (xvi) Optical care and services;

    (xvii) Optometric care and services;

    (xviii) Osteopathic care and services;

    (xix) Outpatient services;

    (xx) Pharmaceutical services;

    (xxi) Physical therapy care and services;

    (xxii) Podiatric care and services;

    (xxiii) Preventive medical services;

    (xxiv) Psychological care and services;

    (xxv) Rehabilitative services;

    (xxvi) Surgical care and services;

    (xxvii) Treatment for alcoholism or drug abuse; and

    (xxviii) Any other care, service, or treatment of disease or injury, the correction of defects, or the maintenance of the physical and mental well-being of human beings.

(g) "Health maintenance organization" means any person, including a profit or nonprofit corporation organized under the laws of any state or country, that:

  (1) Operates or proposes to operate in this State;

  (2) Except as provided in Sec. 19-703(b) and (e) of this subtitle, provides or otherwise makes available to its members health care services that include at least physician, hospitalization, laboratory, X-ray, emergency, and preventive services, out-of-area coverage, and any other health care services that the Commissioner determines to be available generally on an insured or prepaid basis in the area serviced by the health maintenance organization, and, at the option of the health maintenance organization, may provide additional coverage;

  (3) Except for any copayment or deductible arrangement, is compensated only on a predetermined periodic rate basis for providing to members the minimum services that are specified in item (2) of this subsection;

  (4) Assures its subscribers and members, the Commissioner, and the Department that one clearly specified legal and administrative focal point or element of the health maintenance organization has the responsibility of providing the availability, accessibility, quality, and effective use of comprehensive health care services; and

  (5) Primarily provides services of physicians:

    (i) Directly through physicians who are either employees or partners of the health maintenance organization; or

    (ii) Under arrangements with one or more groups of physicians, who are organized on a group practice or individual practice basis, under which each group:

      (1) Is compensated for its services primarily on the basis of an aggregate fixed sum or on a per capita basis; and

      (2) Is provided with an effective incentive to avoid unnecessary inpatient use, whether the individual physician members of the group are paid on a fee-for-service or other basis.

(h) "Member" means a person who makes a contract or on whose behalf a contract is made with a health maintenance organization for health care services.

(i) "Provider" means any person, including a physician or hospital, who is licensed or otherwise authorized in this State to provide health care services.

(j) "Subscriber" means a person who makes a contract with a health maintenance organization, either directly or through an insurer or marketing organization, under which the person or other designated persons are entitled to the health care services.

#### Section 19-702

(a) In adopting this subtitle, the General Assembly intends to:

  (1) Provide alternative methods for the delivery of health care services to residents of this State, with a view toward achieving greater efficiency and economy in providing these services;

  (2) Encourage the formation of health maintenance organizations that provide health care services to subscribers or groups of subscribers who contract for these services under a system of prepayments; and

  (3) Encourage the formation of health maintenance organizations by such diverse groups as:

    (i) Nonprofit health service plans;

    (ii) Medical health service plans;

    (iii) Medical care foundations;

    (iv) Groups of professionals, either in the form of partnerships or professional corporations;

    (v) Consumer sponsored organizations; or

    (vi) Business or legal entities.

(b) To carry out the intent of subsection (a) of this section, the policy of this State is to:

  (1) Provide one overall State law that:

    (i) Regulates health maintenance organizations;

    (ii) Allows flexibility for the many forms these health maintenance organizations may take; and

    (iii) Facilitates public understanding and uniform administration of the rules and regulations that are adopted under this subtitle;

  (2) Eliminate legal barriers to the organization, promotion, and expansion of health maintenance organizations;

  (3) Provide for regulation of:

    (i) The quality of health care, by the Department and by professional standards review organizations where appropriate; and

    (ii) All other matters covered under this subtitle, by the Commissioner; and

  (4) Exempt health maintenance organizations from the insurance laws of this State, except as set forth in this subtitle.

#### Section 19-703

(a) This subtitle does not:

  (1) Authorize any person to engage directly or indirectly in the practice of any health occupation except as otherwise authorized by law;

  (2) Authorize any person to regulate, interfere, or intervene in the relationship between any provider of health care services and the patients of the provider; or

  (3) Prohibit any health maintenance organization from meeting the requirements of any federal law that authorizes the health maintenance organization to:

    (i) Receive federal financial assistance; or

    (ii) Enroll beneficiaries assisted by federal funds.

(b) A health maintenance organization or a part of it that is also a community health center organized under the federal Public Health Service Act and receives federal funds under 42 U.S.C. Sec. 254c is not required to provide hospitalization for individuals for whom services are provided by those funds.

(c) Health maintenance organizations shall offer as an option to all of their members or subscribers benefits for hospice services provided by a hospice care program, as defined in Sec. 19-901(c) of this title.

(d) Health maintenance organizations shall provide continuation coverage required under Sec.Sec. 15-407 through 15-409 of the Insurance Article.

(e) Notwithstanding any other provision of this subtitle, a health maintenance organization may provide a limited set of health benefits if the limited set of health benefits is for subscribers or members who are enrolled in a county program to provide health care services for low-income individuals.

(f)

  (1) In addition to the requirements of Sec. 15-10B-09 of the Insurance Article, whenever a mother is required to remain hospitalized after childbirth for medical reasons and the mother requests that the newborn remain in the hospital, a health maintenance organization shall provide as part of its hospitalization services provided to members and subscribers payment for the cost of additional hospitalization for the newborn for up to 4 days.

  (2) The attending physician or certified nurse midwife of the mother, or the designee of the attending physician or certified nurse midwife, shall provide notice to the mother of the provisions of paragraph (1) of this subsection.

#### Section 19-704

A health maintenance organization may operate as authorized by this subtitle notwithstanding any prohibition against the corporate practice of medicine.

#### Section 19-705

(a)

  (1) The Secretary may adopt rules, regulations, and standards for the quality of health care services provided by a health maintenance organization through its benefit packages.

  (2) With the advice of the Department, the Commissioner shall adopt reasonable rules and regulations as necessary to carry out any other provisions of this subtitle.

(b)

  (1) The Commissioner and the Department shall adopt joint internal procedures to help them work together to carry out their duties under this subtitle.

  (2) The joint internal procedures shall establish means by which the Commissioner and the Department may inform each other promptly on matters that affect any health maintenance organization, including:

    (i) Any important action, change, or rearrangement that a health maintenance organization may undertake; and

    (ii) Any regulatory problem.

#### Section 19-705.1

(a) The Secretary shall adopt regulations that set out reasonable standards of quality of care that a health maintenance organization shall provide to its members.

(b)

  (1) The standards of quality of care shall include:

    (i) A requirement that a health maintenance organization shall provide for regular hours during which a member may receive services, including providing for services to a member in a timely manner that takes into account the immediacy of need for services;

    (ii) A requirement that a health maintenance organization shall have a system for providing a member with 24-hour access to a physician in cases where there is an immediate need for medical services, and for promoting timely access to and continuity of health care services for members, including:

      (1) Providing 24-hour access by telephone to a person who is able to appropriately respond to calls from members and providers concerning after-hours care; and

      (2) Providing a 24-hour toll free telephone access system for use in hospital emergency departments in accordance with Sec. 19-705.7 of this subtitle;

    (iii) A requirement that any nonparticipating provider shall submit to the health maintenance organization the appropriate documentation of the medical complaint of the member and the services rendered;

    (iv) A requirement that a health maintenance organization shall have a physician available at all times to provide diagnostic and treatment services;

    (v) A requirement that a health maintenance organization shall ensure that:

      (1) Each member who is seen for a medical complaint is evaluated under the direction of a physician; and

      (2) Each member who receives diagnostic evaluation or treatment is under the medical management of a health maintenance organization physician who provides continuing medical management;

    (vi) A requirement that each member shall have an opportunity to select a primary physician, a physician assistant, a certified nurse-midwife, a licensed certified midwife, or a certified nurse practitioner from among those available to the health maintenance organization; and

    (vii) A requirement that a health maintenance organization print, in any directory of participating providers or hospitals, in a conspicuous manner, the address, telephone number, and facsimile number of the State agency that members, enrollees, and insureds may call to discuss quality of care issues, life and health insurance complaints, and assistance in resolving billing and payment disputes with the health plan or health care provider, as follows:

      (1) For quality of care issues and life and health care insurance complaints, the Maryland Insurance Administration; and

      (2) For assistance in resolving a billing or payment dispute with the health plan or a health care provider, the Health Education and Advocacy Unit of the Consumer Protection Division of the Office of the Attorney General.

  (2) This subsection may not be construed to require that a health maintenance organization include certified nurse practitioners on the health maintenance organization's provider panel as primary care providers.

(c)

  (1) The health maintenance organization shall make available and encourage appropriate history and baseline examinations for each member within a reasonable time of enrollment set by it.

  (2) Medical problems that are a potential hazard to the person's health shall be identified and a course of action to alleviate these problems outlined.

  (3) Progress notes indicating success or failure of the course of action shall be recorded.

  (4) The health maintenance organization shall:

    (i) Offer or arrange for preventive services that include health education and counseling, early disease detection, immunization, and hearing loss screening of newborns provided by a hospital before discharge;

    (ii) Develop or arrange for periodic health education on subjects which impact on the health status of a member population; and

    (iii) Notify every member in writing of the availability of these and other preventive services.

  (5) The health maintenance organization shall offer services to prevent a disease if:

    (i) The disease produces death or disability and exists in the member population;

    (ii) The etiology of the disease is known or the disease can be detected at an early stage; and

    (iii) Any elimination of factors leading to the disease or immunization has been proven to prevent its occurrence, or early disease detection followed by behavior modification, environmental modification, or medical intervention has been proven to prevent death or disability.

(d)

  (1) To implement these standards of quality of care, a health maintenance organization shall have a written plan that is updated and reviewed at least every 3 years.

  (2) The plan shall include the following information:

    (i) Statistics on age, sex, and other general demographic data used to determine the health care needs of its population;

    (ii) Identification of the major health problems in the member population;

    (iii) Identification of any special groups of members that have unique health problems, such as the poor, the elderly, the mentally ill, and educationally disadvantaged; and

    (iv) A description of community health resources and how they will be used.

  (3) The health maintenance organization shall state its priorities and objectives in writing, describing how the priorities and objectives relating to the health problems and needs of the member population will be provided for.

  (4)

    (i) The health maintenance organization shall provide at the time membership is solicited a general description of the benefits and services available to its members, including benefit limitations and exclusions, location of facilities or providers, and procedures to obtain medical services.

    (ii) The health maintenance organization shall place the following statement, in bold print, on every enrollment card or application: "If you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact a membership services representative before signing this application or card".

  (5) The plan shall contain evidence that:

    (i) The programs and services offered are based on the health problems of and the community health services available to its member population;

    (ii) There is an active program for preventing illness, disability, and hospitalization among its members; and

    (iii) The services designed to prevent the major health problems identified among child and adult members and to improve their general health are provided by the health maintenance organization.

(e)

  (1) The health maintenance organization shall have an internal peer review system that will evaluate the utilizational services and the quality of health care provided to its members.

  (2) The review system shall:

    (i) Provide for review by appropriate health professionals of the process followed in the provision of health services;

    (ii) Use systematic data collection of performances and patient results;

    (iii) Provide interpretation of this data to the practitioners;

    (iv) Review and update continuing education programs for health professionals providing services to its members;

    (v) Identify needed change and proposed modifications to implement the change; and

    (vi) Maintain written records of the internal peer review process.

(f)

  (1) Except as provided in paragraph (5) of this subsection, the Department shall conduct an annual external review of the quality of the health services of the health maintenance organization in a manner that the Department considers to be appropriate.

  (2) The external review shall be conducted by:

    (i) A panel of physicians and other health professionals that consists of persons who:

      (1) Have been approved by the Department;

      (2) Have substantial experience in the delivery of health care in a health maintenance organization setting, but who are not members of the health maintenance organization staff or performing professional services for the health maintenance organization; and

      (3) Reside outside the area serviced by the health maintenance organization; or

    (ii) The Department.

  (3) The final decision on the type of external review that is to be employed rests solely with the Secretary.

  (4) The external review shall consist of a review and evaluation of:

    (i) An internal peer review system and reports;

    (ii) The program plan of the health maintenance organization to determine if it is adequate and being followed;

    (iii) The professional standards and practices of the health maintenance organization in every area of services provided;

    (iv) The grievances relating specifically to the delivery of medical care, including their final disposition;

    (v) The physical facilities and equipment; and

    (vi) A statistically representative sample of member records.

  (5) A health maintenance organization accredited by an accreditation organization approved by the Secretary in accordance with Sec. 19-2302 of this title shall be exempt from the external review.

#### Section 19-705.2

(a) With the advice of the Secretary, the Commissioner shall adopt regulations to establish a system for the receipt and timely investigation of complaints of members and subscribers of health maintenance organizations concerning the operation of any health maintenance organization in this State.

(b) The complaint system shall include:

  (1) A procedure for the timely acknowledgment of receipt of a complaint;

  (2) Criteria that the Secretary shall adopt by regulation for determining the appropriate level of investigation for a complaint concerning quality of care, including:

    (i) A determination as to whether the member or subscriber with the complaint previously attempted to have the complaint resolved; and

    (ii) A determination as to whether a complaint should be sent to the member's or subscriber's health maintenance organization for resolution prior to investigation under the provisions of this section; and

  (3) A procedure for the referral of quality of care complaints to the Secretary for an appropriate investigation.

(c) If a determination is made to investigate a complaint under the provisions of this section prior to the member or subscriber attempting to otherwise resolve the complaint, the reasons for that determination shall be documented.

(d) Notice of the complaint system established under the provisions of this section shall be included in all contracts between a health maintenance organization and a member or subscriber of a health maintenance organization.

(e) For quality of care complaints referred to the Secretary for investigation under subsection (b)(3) of this section, the Secretary shall report to the Commissioner in a timely manner on the results and findings of each investigation.

#### Section 19-705.3

(a) In this section, "health maintenance organization" means a health maintenance organization where health care services are delivered by health care providers to subscribers at a central facility or centralized system of facilities operated by the health maintenance organization.

(b) The Department shall adopt regulations to require health maintenance organizations to:

  (1) Adopt, implement, and enforce a policy that requires, except in an emergency life-threatening situation where it is not feasible or practicable, all employees and medical staff involved in patient care services to comply with the Centers for Disease Control and Prevention's guidelines on universal precautions; and

  (2) Display the notice developed under Sec. 1-207 of the Health Occupations Article at the entrance to the health maintenance organization.

(c) If the health maintenance organization fails to comply with the requirements of this section the Secretary may impose a penalty of up to $500 per day per violation for each day a violation continues.

#### Section 19-705.4

(a) Any limitation imposed by a health maintenance organization on the receipt of covered services provided to a member or subscriber by a physical therapist licensed under Title 13 of the Health Occupations Article may only be imposed per incident or per injury within a contract period.

(b) This subsection may not be construed to prohibit a health maintenance organization from imposing any limitations on the number of visits permitted for a member or subscriber.

#### Section 19-705.5

(a)

  (1) In this section the following words have the meanings indicated.

  (2)

    (i) "Inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry.

    (ii) "Inherited metabolic disease" includes a disease for which the State screens newborn babies.

  (3)

    (i) "Low protein modified food product" means a food product that is:

      (1) Specially formulated to have less than 1 gram of protein per serving; and

      (2) Intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease.

    (ii) "Low protein modified food product" does not include a natural food that is naturally low in protein.

  (4) "Medical food" means a food that is:

    (i) Intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation; and

    (ii) Formulated to be consumed or administered enterally under the direction of a physician.

(b) A health maintenance organization shall include as part of its benefit package of health care services to be provided to members and subscribers coverage for medical foods and low protein modified food products for the treatment of inherited metabolic diseases if the medical foods and low protein modified food products are:

  (1) Prescribed as medically necessary for the therapeutic treatment of inherited metabolic diseases; and

  (2) Administered under the direction of a physician.

#### Section 19-705.6

(a) If it is necessary to provide emergency services, authorization shall be presumed for utilizing the medical or surgical provider on call for unassigned patients or the appropriate specialist on call for the hospital on that date if:

  (1) A telephone access system is not operational at the time of the call; or

  (2) A member's primary care provider or the specialist needed by a member cannot be determined within a reasonable time, as determined by the treating emergency physician but not to exceed 30 minutes after the initial documented call to the telephone access system.

(b) This section may not be construed to require a health maintenance organization to have contracted specialist providers at hospitals outside of the service area of the health maintenance organization.

#### Section 19-705.7

The 24-hour toll free telephone access system provided by each health maintenance organization shall:

(1) Enable members and providers to determine, with one telephone call, the primary care provider assigned to a member; and

(2) Enable providers to determine, with one telephone call, the names of three contracted specialist providers for the health maintenance organization who also have staff privileges at a particular hospital in the State.

#### Section 19-705.8

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "HMO Quality Assurance Unit" means the Health Maintenance Organization (HMO) Quality Assurance Unit in the Department.

  (3) "Quality Assurance Medical Director" means the Medical Director of the HMO Quality Assurance Unit.

(b) There is a Health Maintenance Organization (HMO) Quality Assurance Unit in the Department.

(c)

  (1) The Secretary shall appoint the Quality Assurance Medical Director.

  (2) The Quality Assurance Medical Director shall:

    (i) Be a physician who is licensed in the State;

    (ii) Be board certified in at least one specialty;

    (iii) Have experience in primary care and administrative medicine; and

    (iv) Have broad knowledge of health maintenance organizations and managed care organizations.

  (3) The Quality Assurance Medical Director is entitled to the compensation provided in the State budget.

  (4) Subject to the authority vested in the Secretary by law, the Quality Assurance Medical Director is in charge of and responsible for the clinical operations of the HMO Quality Assurance Unit.

  (5) In accordance with the State budget the Secretary may employ staff for the HMO Quality Assurance Unit.

(d) The HMO Quality Assurance Unit shall:

  (1) Enforce all requirements established under Sec.Sec. 19-705 and 19-705.1 of this subtitle and the regulations adopted under these provisions regarding the quality of health care provided by a health maintenance organization; and

  (2) Investigate quality of care complaints referred to the Secretary under Sec. 19-705.2(b)(3) of this subtitle.

(e) The Quality Assurance Medical Director shall:

  (1) Determine whether a health maintenance organization meets the requirements established under Sec.Sec. 19-705 and 19-705.1 of this subtitle and the regulations adopted under these provisions regarding the quality of health care provided by a health maintenance organization; and

  (2) Make recommendations to the Secretary for corrective action necessary to meet these requirements.

(f) If the Secretary agrees with a determination made by the Quality Assurance Medical Director that a health maintenance organization does not meet the requirements established under Sec.Sec. 19-705 and 19-705.1 of this subtitle or the regulations adopted under these provisions regarding the quality of health care provided by a health maintenance organization, the Secretary may issue an order under Sec. 19-731 of this subtitle.

#### Section 19-706

(a) Each health maintenance organization that is issued a certificate of authority by the Commissioner shall be regulated under this subtitle.

(b)

  (1) Any health maintenance organization that is regulated by Title 14, Subtitle 1 of the Insurance Article is subject also to this subtitle.

  (2) This subsection applies to a corporation described in Title 14, Subtitle 1 of the Insurance Article, but only if it is a health maintenance organization.

(c) Except as otherwise provided in this subtitle or expressly provided in the Insurance Article, a health maintenance organization is not subject to the insurance laws of this State.

(d) Only the Commissioner may issue, suspend, or revoke a certificate of authority of a health maintenance organization.

(e) The provisions of Title 27, Subtitle 8 of the Insurance Article shall apply to health maintenance organizations.

(f) The provisions of Title 15, Subtitle 10B of the Insurance Article shall apply to health maintenance organizations.

(g) The provisions of Title 6.5 of the State Government Article shall apply to the acquisition of a health maintenance organization owned by a nonprofit entity.

(h) The provisions of Sec. 27-210 of the Insurance Article apply to health maintenance organizations.

(i) The provisions of Sec. 15-145 of this article apply to health maintenance organizations.

(j) The provisions of Title 15, Subtitle 16 of the Insurance Article apply to health maintenance organizations.

(k) The provisions of Sec. 2-517 of the State Personnel and Pensions Article apply to health maintenance organizations.

(l) The provisions of Sec. 15-134 of the Insurance Article apply to health maintenance organizations.

(m) The provisions of Title 4, Subtitle 5 of the Insurance Article apply to health maintenance organizations.

(n) The provisions of Title 9, Subtitle 4 of the Insurance Article apply to health maintenance organizations.

(o) The provisions of Title 33 of the Insurance Article apply to health maintenance organizations.

(p) The provisions of Sec. 12-211 of the Insurance Article apply to health maintenance organizations.

#### Section 19-706.1

(a) Subject to this section, the provisions of Title 9, Subtitle 2 of the Insurance Article regarding the rehabilitation and liquidation of insurers are applicable to health maintenance organizations.

(b)

  (1) Subject to paragraph (2) of this subsection, any rehabilitation or liquidation of a health maintenance organization shall be deemed to be the rehabilitation or liquidation of an insurer and shall be conducted under the supervision of the Commissioner under the law governing the rehabilitation or liquidation of insurers.

  (2) The provisions of Sec.Sec. 9-224 and 9-225 of the Insurance Article do not apply to the rehabilitation or liquidation of a health maintenance organization.

(c) The Commissioner may apply for an order directing the Commissioner to rehabilitate or liquidate a health maintenance organization:

  (1) Upon any one or more grounds set out in Title 9, Subtitle 2 of the Insurance Article; or

  (2) When in the Commissioner's opinion the continued operation of the health maintenance organization would be hazardous either to its members or to the people of this State.

(d)

  (1) In addition to the Commissioner's authority under Title 9, Subtitle 2 of the Insurance Article, the Commissioner as a rehabilitator of a health maintenance organization may, subject to approval by a court:

    (i) Change premium rates and other terms of an individual or group contract;

    (ii) Terminate or change the terms of:

      (1) Provider contracts; or

      (2) Contracts with participating entities for the provision of administrative, financial, or management services; and

    (iii) Negotiate and, if the assuming health maintenance organization agrees:

      (1) Transfer the coverage obligations of the impaired health maintenance organization to an assuming health maintenance organization; and

      (2) Assign the provider contracts of the impaired health maintenance organization to an assuming health maintenance organization.

  (2) Before taking any action under paragraph (1)(ii) of this subsection, the Commissioner shall consider:

    (i) The interests of providers and other participating entities under contract with the impaired health maintenance organizations; and

    (ii) The viability of continuing the health plan.

  (3) If a court under paragraph (1)(ii) of this subsection approves a change to the terms of a contract that diminishes the compensation of a provider or a participating entity providing administrative, financial, or management services, the change may not:

    (i) Be effective for more than 60 days; and

    (ii) Except by mutual consent, be renewed or extended.

(e) In addition to the Commissioner's authority under Title 9, Subtitle 2 of the Insurance Article, the Commissioner as a liquidator may, subject to approval by a court:

  (1) Contract with a solvent health maintenance organization or other appropriate entity to operate the insolvent health maintenance organization, including the provision of medical care, on a short-term basis;

  (2) Operate the insolvent health maintenance organization, which may include compensating health care providers in accordance with the terms of the health care provider's contract with the insolvent health maintenance organization;

  (3)

    (i) Direct all other health maintenance organizations that participated in an open enrollment process with the insolvent health maintenance organization at a group's last regular open enrollment period to offer enrollees or subscribers of the insolvent health maintenance organization a 30-day open enrollment period to begin on the date of the insolvency; and

    (ii) Require each health maintenance organization directed to offer enrollees or subscribers of the insolvent health maintenance organization a 30-day open enrollment period to offer the enrollees of the insolvent health maintenance organization the same coverage and rates that it offered the enrollees at the last regular open enrollment period;

  (4)

    (i) Equitably allocate the insolvent health maintenance organization's group contracts of those groups not offered other coverage under item (3) of this subsection, among all health maintenance organizations operating within a portion of the insolvent health maintenance organization's service area, except that before allocating the group contracts under this item, the Commissioner shall consider the health care delivery system and financial resources of all possible successor health maintenance organizations;

    (ii) Require each health maintenance organization allocated a group or groups under item (i) of this item to offer the group or groups the health maintenance organization's existing coverage which is most similar to each group's coverage with the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization's existing rate methodology; and

    (iii) Ensure that any enrollee or subscriber whose group coverage had terminated prior to the date of the insolvency and who converted their group coverage into individual conversion coverage is offered the same conversion coverage that is offered by the successor health maintenance organization to persons converting from the group of which the enrollee or subscriber had been a former member;

  (5)

    (i) Equitably allocate the insolvent health maintenance organization's nongroup individual contracts of those nongroup individuals not offered other coverage under item (3) of this subsection, among all health maintenance organizations operating within a portion of the insolvent health maintenance organization's service area, except that before allocating the nongroup individual contract or contracts under this item, the Commissioner shall consider the health care delivery system and financial resources of all possible successor health maintenance organizations; and

    (ii) Require each health maintenance organization allocated a nongroup individual or individuals under item (i) of this item to offer the nongroup individual or individuals the health maintenance organization's existing coverage which is most similar to the nongroup individual's coverage with the insolvent health maintenance organization at rates determined in accordance with the successor health maintenance organization's existing rate methodology; and

  (6) Take any other action deemed necessary by the Commissioner.

(f) The claims and expenses of health care providers incurred by the Commissioner, as a receiver, in continuing plan benefits as provided in the insolvent health maintenance organization's plan of insolvency adopted under Sec. 19-710(q) of this subtitle shall:

  (1) Be considered expenses for the administration of the receivership; and

  (2) Have priority over all other expenses.

(g) In the event of the liquidation or rehabilitation of a health maintenance organization under this section:

  (1) Members of the health maintenance organization shall have the same priority of claims as provided in Sec. 9-227(c) of the Insurance Article; and

  (2) For claims for health care services rendered to members before an order of receivership has been entered, the following health care providers shall immediately follow in priority claims of the members of the health maintenance organization:

    (i) Health care providers under contract with the health maintenance organization;

    (ii) Health care providers that rendered health care services to members of the health maintenance organization upon referral from a health care provider under contract with the health maintenance organization; and

    (iii) A hospital.

(h)

  (1) A health care provider may not assert a claim of subrogation against:

    (i) A member of an insolvent health maintenance organization; or

    (ii) Any individual, organization, or government agency which has made payments to the health maintenance organization on behalf of a member.

  (2) Notwithstanding paragraph (1) of this subsection, a health care provider may assert any claim it may have against the receiver of the insolvent health maintenance organization.

#### Section 19-707

(a) A health maintenance organization shall obtain from the Commissioner a certificate of authority to operate as a health maintenance organization before it may issue any contract or certificate to a member, provide any health care services to a member, or otherwise operate in this State.

(b) Except as permitted by the Commissioner and subject to the rules and regulations adopted under this subtitle, a health maintenance organization that does not have a certificate of authority may not contact potential members to discuss the health care services the health maintenance organization proposes to offer if a certificate of authority is granted.

#### Section 19-708

(a) An applicant for a certificate to operate as a health maintenance organization shall submit an application to the Commissioner on the form that the Commissioner requires.

(b) The application shall include or be accompanied by:

  (1) A copy of the basic health maintenance organizational document and any amendments to it that, where applicable, are certified by the Department of Assessments and Taxation;

  (2) A copy of the bylaws of the health maintenance organization, if any, that are certified by the appropriate officer;

  (3) A list of the individuals who are to be responsible for the conduct of the affairs of the health maintenance organization, including all members of the governing body, the officers and directors if it is a corporation, and the partners or associates if it is a partnership or association;

  (4) The addresses of those individuals and their official capacity with the health maintenance organization;

  (5) A statement by each individual referred to in item (3) of this subsection that fully discloses the extent and nature of any contract or arrangement between the individual and the health maintenance organization and any possible conflict of interest;

  (6) A resume of the qualifications of:

    (i) The administrator;

    (ii) The medical director, who shall be a physician licensed in this State and certified under Title 15, Subtitle 10C of the Insurance Article;

    (iii) The enrollment director; and

    (iv) Any other individual who is associated with the health maintenance organization that the Commissioner and the Secretary request under their joint internal procedures;

  (7) A statement that describes generally:

    (i) The health maintenance organization, including:

      (1) Its operations;

      (2) Its enrollment process;

      (3) Its quality assurance mechanism; and

      (4) Its internal grievance procedures;

    (ii) The methods the health maintenance organization proposes to use to offer its members and public representatives an opportunity to participate in matters of policy and operation;

    (iii) The location of the facilities where health care services will be available regularly to members;

    (iv) The type and specialty of physicians and health care personnel who are engaged to provide health care services;

    (v) The number of physicians and personnel in each category; and

    (vi) The health and medical records system to provide documentation of use by members;

  (8) The form of each contract that the health maintenance organization proposes to offer to subscribers showing the benefits to which they are entitled and a table of the rates charged or proposed to be charged for each form of contract;

  (9) A statement that describes with reasonable certainty each geographic area to be served by the health maintenance organization;

  (10) A statement of the financial condition of the health maintenance organization, including:

    (i) Sources of financial support;

    (ii) A balance sheet showing assets, liabilities, and minimum tangible net worth; and

    (iii) Any other financial information the Commissioner requires for adequate financial evaluation;

  (11) Copies of any proposed advertising and proposed techniques and methods of selling the services of the health maintenance organization;

  (12) A power of attorney that is executed by the health maintenance organization appointing the Commissioner as agent of the organization in this State to accept service of process in any action, proceeding, or cause of action arising in this State against the health maintenance organization; and

  (13) Copies of the agreements proposed to be made between the health maintenance organizations and providers of health care services.

#### Section 19-709

(a) When a health maintenance organization files its initial application for a certificate of authority to operate, it shall pay to the Commissioner a fee of $300.

(b) In addition to the fee required under subsection (a) of this section, each health maintenance organization shall pay a reasonable sum that the Commissioner finds to be the cost of the investigations made by the Commissioner and the Department as required under this subtitle.

#### Section 19-710

(a) To qualify for a certificate of authority to operate as a health maintenance organization, an applicant shall satisfy the Commissioner that the applicant will meet the requirements of this section.

(b) The applicant shall conform to the definition of a health maintenance organization.

(c) The applicant shall establish and operate a bona fide health maintenance organization that can provide health care services in the proposed geographic area.

(d)

  (1) The health maintenance organization shall be actuarially sound.

  (2)

    (i) Except as otherwise provided in this paragraph, the surplus that the health maintenance organization is required to have shall be paid in full.

    (ii) The health maintenance organization licensed on or after July 1, 1989 shall have an initial surplus that exceeds the liabilities of the health maintenance organization by at least $1,500,000.

    (iii) All health maintenance organizations shall maintain a surplus that exceeds the liabilities of the health maintenance 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 health maintenance organization with the Commissioner.

    (iv) No health maintenance organization shall be required to maintain a surplus in excess of a value of $3,000,000.

  (3)

    (i) For the protection of the health maintenance organization's members 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 Sec. 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 Title 5, Subtitle 7 of the Insurance Article.

      (2) For the purpose of applying this subparagraph, a health maintenance organization shall be treated as an insurer.

  (4) The Commissioner may waive the surplus and deposit requirements contained in this subsection if the Commissioner is satisfied that:

    (i) The health maintenance organization has sufficient net worth and an adequate history of generating net income to assure financial viability for the next year;

    (ii) The health maintenance organization's performance and obligations are guaranteed by another person with sufficient net worth and an adequate history of generating net income; or

    (iii) The assets of the health maintenance organization or contracts with insurers, governments, providers, or other persons are sufficient to reasonably assure the performance of the health maintenance organization's obligations.

(e) The provisions of Title 4, Subtitle 3 (Risk Based Capital Standards for Insurers) and Sec. 15-604 (Rates for Payments to Hospitals) of the Insurance Article apply to health maintenance organizations in the same manner as they apply to insurers.

(f) The terms of contracts, including any medical assistance program contracts under Title XVIII or Title XIX of the Social Security Act or Title III of the Public Health Service Act, proposed to be made or made with government or private agencies that cover all or part of the cost of subscriptions to provide health care services, facilities, appliances, medicines, or supplies shall be financially sound, based on reasonable actuarial assumptions that the health maintenance organization can meet its obligations to the agencies and their beneficiaries by reason of the health maintenance organization's net worth position, stop loss, reinsurance arrangements with authorized insurers, or other arrangements that are satisfactory to the Commissioner.

(g)

  (1) The terms of the contracts to be offered to subscribers shall provide that the health care services provided to members of the health maintenance organization will meet reasonable standards of quality of care that are applicable to the geographic area to be served, as approved by the Department.

  (2) If a health maintenance organization offers services that are within the scope of practice of a physician and another health care practitioner who is licensed under the Health Occupations Article, the health maintenance organization shall offer those services through other licensed health care practitioners, where appropriate, as determined by the health maintenance organization.

(h)

  (1) The procedures for offering health care services and offering and terminating contracts to subscribers may not discriminate unfairly on the basis of age, sex, sexual orientation, gender identity, religious beliefs, disability, race, health, or economic status.

  (2) The requirement under paragraph (1) of this subsection does not prohibit:

    (i) Reasonable underwriting classifications for establishing contract rates; or

    (ii) Experience rating.

(i)

  (1) The terms of the agreements between a health maintenance organization and providers of health services shall contain a "hold harmless" clause.

  (2) The hold harmless clause shall provide that the provider may not, under any circumstances, including nonpayment of money due the providers by the health maintenance organization, insolvency of the health maintenance organization, or breach of the provider contract, bill, charge, collect a deposit, seek compensation, remuneration, or reimbursement from, or have any recourse against the subscriber, member, enrollee, patient, or any persons other than the health maintenance organization acting on their behalf, for services provided in accordance with the provider contract.

  (3) Collection from the subscriber or member of copayments or supplemental charges in accordance with the terms of the subscriber's contract with the health maintenance organization, or charges for services not covered under the subscriber's contract, may be excluded from the hold harmless clause.

  (4) Each provider contract shall state that the hold harmless clause will survive the termination of the provider contract, regardless of the cause of termination.

(j) The health maintenance organization shall provide evidence of adequate insurance coverage or an adequate plan for self-insurance to satisfy claims for injuries that may occur from providing health care.

(k) The health maintenance organization shall provide for having its health and medical facilities and services audited and reviewed periodically:

  (1) By personnel outside the health maintenance organization who:

    (i) Act in a manner that is approved by the Department; and

    (ii) Use methods that will assure objective evaluation and keep the identity of patients as confidential as possible;

  (2) By the health maintenance organization's own internal quality of care committee audit procedures, if the Department approves the procedures; or

  (3) By a professional standards review organization, as described in Title XI of the Social Security Act, that is certified by the Department of Health and Human Services as capable of serving individuals in the area where the health maintenance organization operates who are receiving benefits under Title XVIII or Title XIX of the Social Security Act or Title III of the Public Health Service Act, if the professional standards review organization is acting consistently with its certification.

(l)

  (1) With the approval of the Department, the health maintenance organization shall provide continuous internal peer review for monitoring and evaluating patient records for:

    (i) Quality of care; and

    (ii) Overuse and underuse of provider care; and

  (2) The health maintenance organization shall meet the requirements of Subtitle 13 of this title and all regulations for the performance of utilization review.

(m) The health maintenance organization shall provide an internal grievance system to resolve adequately any grievances initiated by any of its members, in a manner approved by the Department on matters concerning quality of care and by the Commissioner on all other matters covered by this subtitle, under rules and regulations adopted under this subtitle.

(n) The health maintenance organization shall establish procedures to offer each member an opportunity to participate in matters of policy and operation.

(o) The health maintenance organization shall maintain a health and medical records system that:

  (1) Under procedures assuring maximum confidentiality, is readily accessible to authorized persons;

  (2) Can accurately document use by each member; and

  (3) At a minimum:

    (i) Identifies clearly each patient by:

      (1) Name;

      (2) Number;

      (3) Age; and

      (4) Sex; and

    (ii) Shows clearly:

      (1) The services provided;

      (2) When the services are provided;

      (3) Where the services are provided;

      (4) By whom the services are provided;

      (5) The diagnosis and prognosis, if appropriate;

      (6) The treatment;

      (7) Any drug therapy; and

      (8) The health status of the patient, if appropriate.

(p)

  (1) Except as provided in paragraph (3) of this subsection, individual enrollees and subscribers of health maintenance organizations issued certificates of authority to operate in this State may not be liable to any health care provider for any covered services provided to the enrollee or subscriber.

  (2)

    (i) A health care provider or any representative of a health care provider may not collect or attempt to collect from any subscriber or enrollee any money owed to the health care provider by a health maintenance organization issued a certificate of authority to operate in this State.

    (ii) A health care provider or any representative of a health care provider may not maintain any action against any subscriber or enrollee to collect or attempt to collect any money owed to the health care provider by a health maintenance organization issued a certificate of authority to operate in this State.

  (3) Notwithstanding any other provision of this subsection, a health care provider or representative of a health care provider may collect or attempt to collect from a subscriber or enrollee:

    (i) Any copayment or coinsurance sums owed by the subscriber or enrollee to a health maintenance organization issued a certificate of authority to operate in this State for covered services provided by the health care provider;

    (ii) If Medicare is the primary insurer and a health maintenance organization is the secondary insurer, any amount up to the Medicare approved or limiting amount, as specified under the Social Security Act, that is not owed to the health care provider by Medicare or the health maintenance organization after coordination of benefits has been completed, for Medicare covered services provided to the subscriber or enrollee by the health care provider; or

    (iii) Any payment or charges for services that are not covered services.

(q)

  (1) The Commissioner shall require each health maintenance organization to have an insolvency plan by January 1, 1990 which provides for:

    (i) Continuation of benefits to subscribers and enrollees for the duration of the contract period for which premiums have been paid; and

    (ii) Continuation of benefits to subscribers or enrollees who are admitted to an inpatient health care facility on the date of insolvency until, the earlier of:

      (1) The subscriber or enrollee is discharged from the inpatient health care facility; or

      (2) 365 days.

  (2) In determining the adequacy of any insolvency plan, the Commissioner may consider:

    (i) The existence of insurance to cover expenses incurred in continuing benefits after an insolvency;

    (ii) Provisions in provider contracts obligating providers to continue to provide services to enrollees or subscribers:

      (1) For the duration of the contract period for which premiums have been made; and

      (2) If admitted to an inpatient health care facility, until the enrollee or subscriber is discharged or 365 days, whichever occurs first;

    (iii) Reserves;

    (iv) Letters of credit;

    (v) Guarantees; or

    (vi) Any other arrangement to assure that benefits are continued in accordance with the provisions of paragraph (1) of this subsection.

(r) Repealed.

(s)

  (1) In this subsection, "practice profile" means a profile, summary, economic analysis, or other analysis of data concerning services rendered or utilized by a provider under contract with or employed by a health maintenance organization for the provision of health care services by the provider to enrollees or subscribers of the health maintenance organization.

  (2) If a health maintenance organization uses a practice profile as a factor in its contract review to evaluate a provider's status on a provider panel, the health maintenance organization shall disclose at the commencement and renewal of the contract and, not more often than annually, upon the request of the provider:

    (i) A description of the criteria used to compile the practice profile concerning the provider; and

    (ii) The manner in which the practice profile is used to evaluate the provider.

  (3) The information provided under this subsection may not be used to create a cause of action.

  (4) A health maintenance organization may not terminate a provider contract or provider's employment with the health maintenance organization on the basis of a practice profile without first informing the provider of the findings of the practice profile and the provider specific data underlying those findings.

(t) A health maintenance organization may not by contract, or in any other manner, require a provider to indemnify the health maintenance organization or hold the health maintenance organization harmless from a coverage decision or negligent act of the health maintenance organization.

#### Section 19-710.1

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Adjunct claims documentation" means an abstract of an enrollee's medical record which describes and summarizes the diagnosis and treatment of, and services rendered to, the enrollee, including, in the case of trauma rendered in a trauma center, an operative report, a discharge summary, a Maryland Ambulance Information Systems form, or a medical record.

  (3) "Berenson-Eggers Type of Service Code" means a code in a classification system developed by the Centers for Medicare and Medicaid Services that groups Current Procedural Terminology codes together based on clinical consistency.

  (4) "Enrollee" means a subscriber or member of a health maintenance organization.

  (5) "Evaluation and management service" means any service with a Berenson-Eggers Type of Service Code in the category of evaluation and management.

  (6) "Institute" means the Maryland Institute for Emergency Medical Services Systems.

  (7) "Medicare Economic Index" means the fixed-weight input price index that:

    (i) Measures the weighted average annual price change for various inputs needed to produce physician services; and

    (ii) Is used by the Centers for Medicare and Medicaid Services in the calculation of reimbursement of physician services under Title XVIII of the federal Social Security Act.

  (8) "Similarly licensed provider" means:

    (i) For a physician:

      (1) A physician who is board certified or eligible in the same practice specialty; or

      (2) A group physician practice that contains board certified or eligible physicians in the same practice specialty;

    (ii) For a health care provider that is not a physician, a health care provider that holds the same type of license.

  (9)

    (i) "Trauma center" means a primary adult resource center, level I trauma center, level II trauma center, level III trauma center, or pediatric trauma center that has been designated by the institute to provide care to trauma patients.

    (ii) "Trauma center" includes an out-of-state pediatric facility that has entered into an agreement with the institute to provide care to trauma patients.

  (10) "Trauma patient" means a patient that is evaluated or treated in a trauma center and is entered into the State trauma registry as a trauma patient.

  (11) "Trauma physician" means a licensed physician who has been credentialed or designated by a trauma center to provide care to a trauma patient at a trauma center.

(b) In addition to any other provisions of this subtitle, for a covered service rendered to an enrollee of a health maintenance organization by a health care provider not under written contract with the health maintenance organization, the health maintenance organization or its agent:

  (1) Shall pay the health care provider within 30 days after the receipt of a claim in accordance with the applicable provisions of this subtitle; and

  (2) Shall pay the claim submitted by:

    (i) A hospital at the rate approved by the Health Services Cost Review Commission;

    (ii) A trauma physician for trauma care rendered to a trauma patient in a trauma center, at the greater of:

      (1) 140% of the rate paid by the Medicare program, as published by the Centers for Medicare and Medicaid Services, for the same covered service, to a similarly licensed provider; or

      (2) The rate as of January 1, 2001 that the health maintenance organization paid in the same geographic area, as published by the Centers for Medicare and Medicaid Services, for the same covered service, to a similarly licensed provider; and

    (iii) Any other health care provider:

      (1) For an evaluation and management service, no less than  the greater of:

      (A) 125% of the average rate the health maintenance organization paid as of January 1 of the previous calendar year in the same geographic area, as defined by the Centers for Medicare and Medicaid Services, for the same covered service, to similarly licensed providers under written contract with the health maintenance organization; or

      (B) 140% of the rate paid by Medicare, as published by the Centers for Medicare and Medicaid Services, for the same covered service to a similarly licensed provider in the same geographic area as of August 1, 2008, inflated by the change in the Medicare Economic Index from 2008 to the current year; and

      (2) For a service that is not an evaluation and management service, no less than 125% of the average rate the health maintenance organization paid as of January 1 of the previous calendar year in the same geographic area, as defined by the Centers for Medicare and Medicaid Services, to a similarly licensed provider under written contract with the health maintenance organization for the same covered service.

(c) For the purposes of subsection (b)(2)(iii) of this section, a health maintenance organization shall calculate the average rate paid to similarly licensed providers under written contract with the health maintenance organization for the same covered service by summing the contracted rate for all occurrences of the Current Procedural Terminology Code for that service and then dividing by the total number of occurrences of the Current Procedural Terminology Code.

(d) A health maintenance organization shall disclose, on request of a health care provider not under written contract with the health maintenance organization, the reimbursement rate required under subsection (b)(2)(ii) and (iii) of this section.

(e)

  (1) Subject to paragraph (2) of this subsection, a health maintenance organization may require a trauma physician not under contract with the health maintenance organization to submit appropriate adjunct claims documentation and to include on the uniform claim form a provider number assigned to the trauma physician by the health maintenance organization.

  (2) If a health maintenance organization requires a trauma physician to include a provider number on the uniform claim form in accordance with paragraph (1) of this subsection, the health maintenance organization shall assign a provider number to a trauma physician not under contract with the health maintenance organization at the request of the physician.

  (3) A trauma center, on request from a health maintenance organization, shall verify that a licensed physician is credentialed or otherwise designated by the trauma center to provide trauma care.

  (4) Notwithstanding the provisions of Sec. 19-701(d) of this subtitle, for trauma care rendered to a trauma patient in a trauma center by a trauma physician, a health maintenance organization may not require a referral or preauthorization for a service to be covered.

(f)

  (1) A health maintenance organization may seek reimbursement from an enrollee for any payment under subsection (b) of this section for a claim or portion of a claim submitted by a health care provider and paid by the health maintenance organization that the health maintenance organization determines is the responsibility of the enrollee.

  (2) The health maintenance organization may request and the health care provider shall provide adjunct claims documentation to assist in making the determination under paragraph (1) of this subsection or under subsection (b) of this section.

(g)

  (1) A health care provider may enforce the provisions of this section by filing a complaint against a health maintenance organization with the Maryland Insurance Administration or by filing a civil action in a court of competent jurisdiction under Sec. 1-501 or Sec. 4-201 of the Courts Article.

  (2) The Maryland Insurance Administration or a court shall award reasonable attorney fees if the complaint of the health care provider is sustained.

(h) The Maryland Health Care Commission annually shall review payments to health care providers to determine the compliance of health maintenance organizations with the requirements of this section and report its findings to the Maryland Insurance Administration.

(i) The Maryland Insurance Administration may take any action authorized under this subtitle or the Insurance Article, including conducting an examination under Title 2, Subtitle 2 of the Insurance Article, to investigate and enforce a violation of the provisions of this section.

(j) In addition to any other penalties under this subtitle, the Commissioner may impose a penalty not to exceed $5,000 on any health maintenance organization which violates the provisions of this section if the violation is committed with such frequency as to indicate a general business practice of the health maintenance organization.

(k) The Maryland Insurance Administration, in consultation with the Maryland Health Care Commission, shall adopt regulations to implement this section.

#### Section 19-710.2

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Carrier" means:

    (i) An insurer;

    (ii) A nonprofit health service plan;

    (iii) A health maintenance organization;

    (iv) A dental plan organization; or

    (v) Any other person or organization that provides health benefit plans subject to State regulation.

  (3) "Point-of-service option" means a health benefit plan that permits a member or subscriber of a health maintenance organization to receive any health care service outside the provider panel of the health maintenance organization that is covered under the member's or subscriber's contract with the health maintenance organization.

  (4) "Provider panel" means those providers with which a health maintenance organization contracts to provide services to the health maintenance organization's members or subscribers under the health maintenance organization's health benefit plan.

(b)

  (1) If an employer, association, or other private group arrangement offers health benefit plan coverage to employees or individuals only through a health maintenance organization, the health maintenance organization with which the employer, association, or other private group arrangement is contracting for the coverage shall offer, or contract with another carrier to offer, a point-of-service option to the employer, association, or other private group arrangement in conjunction with the health maintenance organization as an additional benefit for an employee or individual, at the employee's or individual's option, to accept or reject.

  (2) When a health maintenance organization is the sole delivery system offered to employees by an employer, the health maintenance organization:

    (i) Shall offer the employer a point-of-service option for the individual employee to accept or reject;

    (ii) May not impose a minimum participation level on the point-of-service option; and

    (iii) As part of the group enrollment application, shall provide to each employer a disclosure statement for each point-of-service option offered that conforms to regulations, for the point-of-service option required under paragraph (1) of this subsection, adopted by:

      (1) The Maryland Health Care Commission for the small group market; and

      (2) The Maryland Insurance Administration for the non-small group market.

(c)

  (1) An employer, association, or other private group arrangement may require an employee or individual that accepts the additional coverage under a point-of-service option under subsection (b) of this section to be responsible for the payment of a premium over the amount of the premium for the coverage offered by the health maintenance organization.

  (2) A carrier may impose different cost-sharing provisions for the point-of-service option based on whether the service is provided through the provider panel of the health maintenance organization or outside the provider panel of the health maintenance organization.

#### Section 19-711

(a) Within 90 days after the filing of an application for a certificate of authority to operate as a health maintenance organization, the Commissioner shall issue the certificate of authority to the applicant if:

  (1) The application conforms with Sec. 19-708 of this subtitle;

  (2) The applicant has paid the fees required by Sec. 19-709 of this subtitle;

  (3) The Department has advised in writing that the health maintenance organization's proposed health-related services, operations, and functions that fall under the regulatory jurisdiction of the Department appear to meet its requirements or are approved by the Department; and

  (4) The Commissioner is satisfied that the requirements of Sec. 19-710 of this subtitle are met.

(b)

  (1) Subject to paragraph (2) of this subsection, the provisions of Title 7 of the Insurance Article apply to health maintenance organizations.

  (2) Before approving a transaction under Sec. 7-306 of the Insurance Article, the Insurance Commissioner shall consult with the Secretary.

(c) Subsection (b) of this section may not apply to any transaction preempted by federal law.

#### Section 19-711.3

In any case where a health maintenance organization is being merged or consolidated with or acquired by another person, any current financing money provided by the health maintenance organization to a hospital, in accordance with regulations adopted by the Health Services Cost Review Commission, in return for a discount in rates charged by the hospital shall be deemed to be security for the amount of outstanding charges owed by the health maintenance organization to the hospital for bills or claims for services provided by the hospital prior to the merger, consolidation, or acquisition.

#### Section 19-712

(a) Subject to the provisions of subsection (b) of this section, a person who holds a certificate of authority to operate a health maintenance organization under this subtitle may:

  (1) Exercise the power that professional and other corporations, partnerships, associations, or other business entities have under their organizational documents and any laws of this State that do not conflict with this subtitle;

  (2) Provide health care services to nonmembers who present themselves on other than a prepaid basis;

  (3) Provide health care services on a prepaid basis through licensed providers of these services who are under contract with or employed by the health maintenance organization;

  (4) Contract with any person to perform, on behalf of the health maintenance organization, functions such as marketing, enrollment, and administration;

  (5) Contract for insurance, reinsurance, or indemnity or reimbursement against the cost of health care services provided by the health maintenance organization with:

    (i) Any insurance company licensed to do health business in this State; or

    (ii) Any hospital, nonprofit health service plan, medical health service, nursing service, optometric service, podiatry service, dental service, pharmaceutical service plan corporation, or similar entity authorized to do business in this State;

  (6) Accept from government or private agencies payments that cover all or part of the cost of subscriptions to provide health care services, facilities, appliances, medicines, and supplies;

  (7) Buy, lease, construct, renovate, operate, or maintain:

    (i) A hospital, medical facility, and ancillary equipment; and

    (ii) Property that is reasonably required for its principal office or for any other purpose necessary in the business of the health maintenance organization; and

  (8) Offer indemnity benefits that cover out-of-area and emergency services.

(b)

  (1) A person who holds a certificate of authority to operate a health maintenance organization under this subtitle and who enters into any administrative service provider contract, as defined in Sec. 19-713.2 of this subtitle, with a person or entity for the provision of health care services to subscribers shall be responsible for all claims or payments for health care services:

    (i) Covered under the subscriber's contract; and

    (ii) Rendered by a provider, who is not the person or entity which entered into the administrative service provider contract with the health maintenance organization, pursuant to a referral by a person or entity which entered into the administrative service provider contract with the health maintenance organization.

  (2) Responsibility for claims and payments under this subsection is subject to the provisions of Sec. 15-1005 of the Insurance Article.

(c) The responsibility of a health maintenance organization for claims or payments for health care services in accordance with subsection (b) of this section under an administrative service provider contract:

  (1) Is not limited by the amount in a segregated fund established under Sec. 19-713.2 of this subtitle;

  (2) Exists irrespective of the insolvency or other inability or failure of a contracting provider, as defined in Sec. 19-713.2 of this subtitle, to pay;

  (3) Exists irrespective of the delegation or further subcontracting of health care services by a contracting provider to an external provider, as defined in Sec. 19-713.2 of this subtitle;

  (4) May not be altered by contract; and

  (5) Applies to all health care services, including those provided under State and federal programs, unless preempted by federal law.

(d) Subsections (b) and (c) of this section apply to a contract between a health maintenance organization and any company affiliated with the health maintenance organization through common ownership within an insurance holding company system, that meets the definition of a contracting provider under Sec. 19-713.2 of this subtitle.

#### Section 19-712.2

(a) A health maintenance organization that provides pharmaceutical benefits shall notify all pharmacies under contract with the health maintenance organization in writing of changes in the pharmaceutical benefit program rules or requirements at least 30 days before the change is effective.

(b) Changes that require 30 days' advance written notice under subsection (a) of this section are:

  (1) Exclusion of coverage for classes of drugs as specified by contract;

  (2) Changes in prior or preauthorization procedures; and

  (3) Selection of new prescription claims processors.

(c) A health maintenance organization that fails to provide advance notice as required under subsection (a) of this section 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.

#### Section 19-712.4

(a) In this section the terms "health care practitioner", "health care entity", and "health care service" have the same meanings as provided in Sec. 1-301 of the Health Occupations Article.

(b) A health maintenance organization may seek repayment from a health care practitioner of any money paid for any claim, bill, or other demand or request for payment for the health care services that were determined by the appropriate regulatory licensing board to be furnished as a result of a referral prohibited by Sec. 1-302 of the Health Occupations Article.

(c) Every contract between a health maintenance organization and its subscribers or a group of subscribers for the provision of health care services shall include a provision excluding payment of any claim, bill, or other demand or request for payment for health care services determined to be furnished as a result of a referral prohibited by Sec. 1-302 of the Health Occupations Article.

(d) A health maintenance organization subject to the provisions of this section shall report to the Commissioner and the appropriate regulatory board any pattern of claims, bills or other demands or requests for payment submitted for a health care service provided as a result of a referral prohibited by Sec. 1-302 of the Health Occupations Article within 30 days after that health maintenance organization has knowledge of that pattern.

(e)

  (1) Notwithstanding the provisions of this section, a health maintenance organization reimbursing for health care services is not required to audit or investigate any claim, bill, or other demand or request for payment for the purpose of determining whether those services were the result of a prohibited referral.

  (2) Any audit or investigation of any claim, bill, or other demand or request for payment for the purpose of determining whether those services were the result of the prohibited referral are not grounds to delay payment or waive the provisions of Sec. 15-1005 of the Insurance Article.

(f) For any claim, bill, or request for payment that is paid and is subsequently determined to be the result of a prohibited referral, a health maintenance organization may seek a refund of that payment in accordance with the provisions of Sec. 1-305 of the Health Occupations Article.

#### Section 19-712.5

(a) A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services provided to a member or subscriber of the health maintenance organization if the health maintenance organization authorized, directed, referred, or otherwise allowed the member or subscriber to use the emergency facility and the medically necessary services are related to the condition for which the member was allowed to use the emergency facility.

(b) A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medically necessary services that relate to the condition presented and that are provided by the provider in the emergency facility to a member or subscriber of the health maintenance organization if the health maintenance organization fails to provide 24-hour access in accordance with the standards of quality of care required under Sec. 19-705.1(b)(1)(ii) of this subtitle.

(c) A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable co-payments, for medical screening, assessment, and stabilization services rendered to meet the requirements of the federal Emergency Medical Treatment and Active Labor Act.

(d) Notwithstanding any other provision of this subtitle, a provider may not be required to obtain prior authorization or approval for payment from a health maintenance organization in order to obtain reimbursement under subsection (a), (b), or (c) of this section.

(e) Notwithstanding any other provision of this article, a hospital emergency facility or provider or a health maintenance organization that has reimbursed a provider may collect or attempt to collect payment from a member or subscriber for health care services provided for a medical condition that is determined not to be an emergency as defined in Sec. 19-701(e) of this subtitle.

(f) If a health maintenance organization authorizes, directs, refers, or otherwise allows a member or subscriber to access a hospital emergency facility or other urgent care facility for a medical condition that requires emergency surgery, the health maintenance organization:

  (1) Shall reimburse the physician, oral surgeon, periodontist, or podiatrist, who performed the surgical procedure, for follow-up care that is:

    (i) Medically necessary;

    (ii) Directly related to the condition for which the surgical procedure was performed; and

    (iii) Provided in consultation with the member's or subscriber's primary care physician; and

  (2) May not impose on the member or subscriber any co-payment or other cost-sharing requirement for any follow-up care that exceeds what a member or subscriber is required to pay for services rendered by a physician, oral surgeon, periodontist, or podiatrist who is a member of the provider panel of the health maintenance organization.

#### Section 19-712.6

(a) Whenever a subscriber or an enrollee of a health maintenance organization is a resident of a continuing care facility that is regulated under Title 10, Subtitle 4 of the Human Services Article and received health care services in an acute care health care facility, the resident's primary care physician shall refer, if medically appropriate, the resident to the skilled nursing unit at the resident's continuing care facility for the provision of health care services included in the resident's health maintenance organization Medicare contract if:

  (1) The primary care physician and the resident or the designated representative of the resident do not choose an alternative course of treatment;

  (2) The continuing care facility becomes a contracting provider in accordance with the health maintenance organization's standard terms and conditions for its participating providers and meets the credentialing criteria for becoming a participating provider;

  (3) The continuing care facility meets all the guidelines established by the Division of Licensing and Certification of the Department, including Medicare certification; and

  (4) The continuing care facility's skilled nursing unit is certified as a Medicare skilled nursing facility.

(b)

  (1) The continuing care facility is not obligated to accept for the provision of health care services anyone other than a resident of the continuing care facility.

  (2) The health maintenance organization and the continuing care facility are not obligated to advertise in any manner that the continuing care facility is a participating provider with respect to coverage offered by the health maintenance organization for Medicare benefits or other treatment in the skilled nursing unit for anyone other than residents of the continuing care facility.

#### Section 19-712.7

To the extent required under federal law, a health maintenance organization shall reimburse a community health resource, as defined in Sec. 19-2101 of this title, for covered services provided to a member or subscriber of the health maintenance organization.

#### Section 19-713

(a)

  (1) Each health maintenance organization shall file with the Commissioner and pay the applicable filing fee as provided in Sec. 2-112 of the Insurance Article, before they become effective:

    (i) All rates that the health maintenance organization charges subscribers or groups of subscribers; and

    (ii) The form and content of each contract between the health maintenance organization and its subscribers or groups of subscribers.

  (2)

    (i) A health maintenance organization that offers a health benefit plan, as defined in Sec. 11-601 of the Insurance Article, is subject to Title 11, Subtitle 6 of the Insurance Article for the health benefit plan.

    (ii) If the provisions of Title 11, Subtitle 6 of the Insurance Article conflict with the provisions of this section, the provisions of Title 11, Subtitle 6 of the Insurance Article shall prevail.

(b)

  (1) Rates of a health maintenance organization may not be excessive, inadequate, or unfairly discriminatory in relation to the services offered.

  (2) A health maintenance organization that includes a subrogation provision in its contract as authorized under Sec. 19-713.1(d) of this subtitle shall:

    (i) Use in its rating methodology an adjustment that reflects the subrogation; and

    (ii) Identify in its rate filing with the Maryland Insurance Administration, and annually in a form approved by the Insurance Commissioner, all amounts recovered through subrogation.

(c)

  (1) If, at any time, a health maintenance organization wishes to amend any contract with its subscribers or change any rate charged, the health maintenance organization shall file with the Commissioner the number of copies of the amendment or rate change that the Commissioner requires.

  (2) The Commissioner shall provide the Department with the number of copies it requires.

(d) The Commissioner shall coordinate the contract and related rate filing review under this section.

(e)

  (1) If within 60 days after a filing made pursuant to this section, the Commissioner finds the filing does not meet the requirements of subsection (f) of this section, the filer shall be sent notice of disapproval specifying in what respects the Commissioner finds that the filing fails to meet the requirements of this section and stating that the filing shall not become effective.

  (2) The Commissioner may extend the initial review period described in paragraph (1) of this subsection for up to an additional 30 days if the Commissioner gives notice to the health maintenance organization of the extension before the initial review period ends.

  (3) The Commissioner may not issue a notice of disapproval of a filing under subsection (f) of this section without a statutory or regulatory basis for the disapproval and an explanation of the application of the statutory or regulatory basis which resulted in the disapproval.

(f) The Commissioner shall disapprove any form filed, or withdraw any previous approval, if the form:

  (1) Is in any respect in violation or does not comply with this article or applicable regulations;

  (2) Contains, or incorporates by reference, any inconsistent or inapplicable clauses, exceptions, or conditions which affect the risk purported to be assumed in the general coverage of the contract;

  (3) Has any title, heading, or other indication of its provisions which is likely to mislead the subscriber or member;

  (4) Includes provisions that are inequitable, or provisions that lack any substantial benefit to the subscriber or member;

  (5) Is printed or otherwise reproduced in a manner as to render any provision of the form substantially illegible; or

  (6) Provides benefits that are unreasonable in relation to the premium charged.

(g)

  (1) Except as provided in paragraph (2) of this subsection, unless the Commissioner disapproves a filing under this section, the filing becomes effective:

    (i) 60 days after the office of the Commissioner receives the filing;

    (ii) If the Commissioner extends the review period under subsection (e)(2) of this section, on the date specified in the notice required under subsection (e)(2) of this section; or

    (iii) On any other date that the Commissioner sets.

  (2) The Commissioner may adopt regulations to allow a type or kind of form to be effective upon receipt of the filing by the Commissioner.

  (3) If a health maintenance organization uses a form which becomes effective in accordance with the provisions of paragraph (2) of this subsection and the form would be subject to disapproval under subsection (f) of this section, the Commissioner may:

    (i) Subsequently disapprove the form; and

    (ii) Find the health maintenance organization to be in violation of Sec. 19-729 of this subtitle and impose a penalty as provided in Sec. 19-730 of this subtitle.

  (4) If a health maintenance organization files a form with the Commissioner which becomes effective in accordance with the provisions of paragraph (2) of this subsection, the health maintenance organization shall pay the applicable filing fee provided in Sec. 2-112 of the Insurance Article.

#### Section 19-713.1

(a) A contract between a health maintenance organization and its subscribers or a group of subscribers may contain nonduplication provisions or provisions to coordinate the coverage with subscriber contracts of other health maintenance organizations, health insurance policies, including those of nonprofit health service plans, and with other established programs under which the subscriber or member may make a claim.

(b) Notwithstanding the provisions of subsection (a) of this section, a contract between a health maintenance organization and its subscribers or a group of subscribers may not contain nonduplication provisions or provisions to coordinate coverage with any individually underwritten and issued, guaranteed renewable, specified disease policy, as defined in Sec. 15-109 of the Insurance Article, or intensive care policy, which does not provide benefits on an expense incurred basis.

(c) For purposes of this section, "intensive care policy" means a health insurance policy that provides benefits only when treatment is received in that specifically designated facility of a hospital that provides the highest level of care and which is restricted to those patients who are physically, critically ill or injured.

(d) Notwithstanding Sec. 19-701(g)(3) of this subtitle, a contract between a health maintenance organization and its subscribers or a group of subscribers may contain a provision allowing the health maintenance organization to be subrogated to a cause of action that a subscriber has against another person:

  (1) To the extent that any actual payments made by the health maintenance organization result from the occurrence that gave rise to the cause of action; or

  (2) For a nonprofit health maintenance organization that exclusively contracts with a group of physicians to provide or to arrange for the provision of health care services for its enrollees, for any service provided by the health maintenance organization as a result of the occurrence that gave rise to the cause of action, per the fee schedule established by the nonprofit health maintenance organization.

(e)

  (1) Subsection (d) of this section does not allow a contract between a health maintenance organization and its subscribers or a group of subscribers to contain a provision allowing the health maintenance organization to recover any payments made to a subscriber under the personal injury protection coverage of a motor vehicle liability insurance policy.

  (2) A contract between a health maintenance organization and its subscribers or a group of subscribers may not contain a provision that requires personal injury protection benefits under a motor vehicle liability insurance policy to be paid before benefits under the contract.

(f) Subsection (d) of this section does not allow a health maintenance organization to recover medical expenses from a subscriber under a subrogation provision unless the subscriber recovers for medical expenses in a cause of action.

#### Section 19-713.2

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Administrative service provider contract" means a contract or capitation agreement between a health maintenance organization and a contracting provider which includes requirements that:

    (i) The contracting provider accept payments from a health maintenance organization for health care services to be provided to members of the health maintenance organization that the contracting provider arranges to be provided by external providers; and

    (ii) The contracting provider administer payments pursuant to the contract with the health maintenance organization for the health care services to the external providers.

  (3)

    (i) "Contracting provider" means a person who enters into an administrative service provider contract with a health maintenance organization.

    (ii) "Contracting provider" does not include a medical laboratory as defined in Sec. 17-201 of this article.

  (4) "External provider" means a health care provider, including a physician or hospital, who is not:

    (i) A contracting provider; or

    (ii) An employee, shareholder, or partner of a contracting provider.

(b) This section does not apply to a contract between a health maintenance organization and a contracting provider that is affiliated with the health maintenance organization through common ownership within an insurance holding company system, if the health maintenance organization:

  (1) Files with the Commissioner consolidated financial statements that include the contracting provider; and

  (2) Records a reserve for the liabilities of the contracting provider in accordance with Sec. 5-201 of the Insurance Article.

(c) A health maintenance organization may not enter into an administrative service provider contract unless:

  (1) The health maintenance organization files with the Insurance Commissioner a plan that satisfies the requirements of subsection (d) of this section; and

  (2) The Insurance Commissioner does not disapprove the filing within 30 days after the plan is filed.

(d) The plan required under subsection (c) of this section shall:

  (1) Require the contracting provider to provide the health maintenance organization with monthly reports, within 30 days of the end of the month reported, that identify payments made or owed to external providers in sufficient detail to determine if the payments are being made in compliance with law;

  (2) Require the contracting provider to provide to the health maintenance organization a current annual financial statement of the contracting provider each year, within 90 days of the end of the year reported;

  (3) Require the health maintenance organization to establish and maintain a segregated fund, in a form and an amount approved by the Commissioner, which may include withheld funds, escrow accounts, letters of credit, or similar arrangements, or require the availability of other resources that are sufficient to satisfy the contracting provider's obligations to external providers for services rendered to members of the health maintenance organization;

  (4) Require the contracting provider to submit to the health maintenance organization information demonstrating that the fund established under item (3) of this subsection is sufficient to satisfy the contracting provider's obligations to external providers for services rendered to members of the health maintenance organization; and

  (5) Require the health maintenance organization, at least quarterly, to review and inspect the contracting provider's books, records, and operations relevant to the provider's contract for the purpose of determining the contracting provider's compliance with the plan.

(e) In determining the sufficiency of a segregated fund, the Commissioner may consider whether external providers are owned or controlled by the contracting provider.

(f) The segregated fund or other resources established as a result of an administrative service provider contract:

  (1) Shall be held in trust for payment to external providers; and

  (2) May not be considered an asset or an account of the contracting provider for the purpose of determining the assets or accounts of a bankrupt contracting provider.

(g) The health maintenance organization and the contracting provider shall comply with the plan.

(h)

  (1) The health maintenance organization shall monitor the contracting provider to assure compliance with the plan, and the health maintenance organization shall notify the contracting provider whenever a failure to comply with the plan occurs.

  (2) Upon the failure of the contracting provider to comply with the plan following notice of noncompliance, or upon termination of the administrative service provider contract for any reason, the health maintenance organization shall notify the Commissioner and shall assume the administration of any payments due from the contracting provider to external providers on behalf of the contracting provider, as required under Sec. 19-712 of this subtitle.

(i) The health maintenance organization shall file with the Commissioner, the results of each quarterly review required under subsection (d)(5) of this section.

(j) The plan and all supporting documentation submitted in connection with the plan shall be treated as confidential and proprietary, and may not be disclosed except as otherwise required by law.

(k) A health maintenance organization and a contracting provider shall comply with the terms of an administrative service provider contract as required under this section and Sec. 19-712 of this subtitle.

(l) If a contracting provider fails to comply with the plan or the administrative service provider contract, as required under subsections (g) and (k) of this section, the Commissioner may impose a fine not exceeding $125,000 or suspend or revoke the registration of the contracting provider under Sec. 19-713.3 of this subtitle, or both.

#### Section 19-713.3

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Administrative service provider contract" has the meaning stated in Sec. 19-713.2 of this subtitle.

  (3) "Contracting provider" has the meaning stated in Sec. 19-713.2 of this subtitle.

(b)

  (1) A person must register with the Commissioner before the person acts as a contracting provider in this State.

  (2) A health maintenance organization may not enter into an administrative service provider contract with a contracting provider that has not registered with the Commissioner.

(c)

  (1) An applicant for registration shall submit an application to the Commissioner in a form approved by the Commissioner and include any information required under subsection (e) of this section.

  (2) A registration under this section expires 2 years from the date the application is approved.

(d) The Commissioner may charge a registration fee sufficient to cover the cost of implementing this section.

(e) The Commissioner may adopt regulations to carry out the provisions of this section and Sec. 19-713.2 of this subtitle.

#### Section 19-713.4

(a) In this section, "health maintenance organization" or "HMO" includes any agent of a health maintenance organization.

(b)

  (1) A health maintenance organization that issues a request for proposal, including changes in terms to an existing contract to provide pharmaceutical services, shall notify the Maryland Pharmacists Association of the request for proposal to provide pharmaceutical services within 10 days after issuing that request.

  (2) The Maryland Pharmacists Association may inform licensed pharmacists of the request.

(c) A health maintenance organization may not charge a fee for processing or accepting an application to provide pharmaceutical services.

(d) This section does not apply to a health maintenance organization if the health maintenance organization provides pharmaceutical services from a pharmacy that is:

  (1) Located on the site of the health maintenance organization; and

  (2) Wholly owned and operated by the health maintenance organization.

#### Section 19-713.5

(a) If a health maintenance organization requires its subscribers to have a referral to receive consultation services in writing, the health maintenance organization shall use the uniform consultation referral form adopted by the Commissioner under Sec. 15-120 of the Insurance Article as the sole instrument for referrals for consultation services.

(b) A health maintenance organization may not impose as a condition of coverage any requirement to:

  (1) Modify the uniform consultation referral form; or

  (2) Submit additional consultation referral forms.

(c) The uniform consultation referral form shall be properly completed by the health care provider referring the subscriber for consultation services.

#### Section 19-713.6

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Documented informed consent" means:

    (i) A written consent form signed by a patient; or

    (ii) Verbal or otherwise communicated consent signified by a notation in a patient's electronic medical record maintained by a group model health maintenance organization.

  (3) "Drug therapy management" means treatment of a patient using drug therapy, laboratory tests, or medical devices under conditions or limitations set forth in a protocol specified in a physician-pharmacist agreement for the purpose of improving patient outcome.

  (4) "Group model health maintenance organization" means a health maintenance organization that:

    (i) Contracts with one multispecialty group of physicians who are employed by and shareholders of the multispecialty group; and

    (ii) Provides and arranges for the provision of physician services to patients at medical facilities operated by the health maintenance organization.

  (5) "Licensed pharmacist" means an individual who is licensed to practice pharmacy under Title 12 of the Health Occupations Article.

  (6) "Licensed physician" means an individual who is licensed to practice medicine under Title 14 of the Health Occupations Article.

  (7) "Patient" means:

    (i) A patient who is a member of a group model health maintenance organization; or

    (ii) An individual to whom the group model health maintenance organization is contractually or legally obligated to provide, or arrange to provide, health care services.

  (8) "Physician-pharmacist agreement" means an agreement between a licensed physician and a licensed pharmacist that is disease-state specific and specifies the protocols that may be used.

  (9) "Protocol" means a course of treatment predetermined by the licensed physician and licensed pharmacist according to generally accepted medical practice for the proper completion of a particular therapeutic or diagnostic intervention.

(b)

  (1) In a group model health maintenance organization, a licensed physician and a licensed pharmacist who wish to provide drug therapy management to patients shall have a physician-pharmacist agreement.

  (2) Drug therapy management shall be provided under this section only:

    (i) In accordance with a physician-pharmacist agreement; and

    (ii) Through the internal pharmacy operations of the group model health maintenance organization.

  (3) A licensed physician who has entered into a physician-pharmacist agreement shall submit to the State Board of Physicians a copy of the physician-pharmacist agreement and any subsequent modifications made to the physician-pharmacist agreement or the protocols specified in the physician-pharmacist agreement.

  (4) A licensed pharmacist who has entered into a physician-pharmacist agreement shall submit to the State Board of Pharmacy a copy of the physician-pharmacist agreement and any subsequent modifications made to the physician-pharmacist agreement or the protocols specified in the physician-pharmacist agreement.

(c) A licensed pharmacist is authorized to enter into a physician-pharmacist agreement if the licensed pharmacist:

  (1) Has a Doctor of Pharmacy degree or equivalent training as established in regulations adopted by the State Board of Pharmacy;

  (2) Is approved by the State Board of Pharmacy to enter into a physician-pharmacist agreement with a licensed physician; and

  (3) Meets any other requirements established by regulation by the State Board of Pharmacy.

(d) A physician-pharmacist agreement shall prohibit the substitution of a chemically dissimilar drug product by the pharmacist for the product prescribed by the physician, unless permitted in the protocol specified in the physician-pharmacist agreement.

(e) A patient may decline to participate or withdraw from participating in drug therapy management in a group model health maintenance organization at any time.

(f) A licensed physician or licensed pharmacist or both shall inform a patient:

  (1) Regarding the procedures that will be utilized for drug therapy management under the associated protocols;

  (2) That the patient may decline to participate or withdraw from participating in the drug therapy management at any time; and

  (3) That neither the physician nor the pharmacist has been coerced, given economic incentives, excluding normal reimbursement for services rendered, or involuntarily required to participate.

(g) A licensed physician or a licensed pharmacist or both shall obtain documented informed consent from a patient after disclosing the information required to be disclosed under subsection (f) of this section.

#### Section 19-714

Each marketing document that sets forth the health care services of a health maintenance organization shall describe fully and clearly:

(1) The health care services under each benefit package and every other benefit to which a member is entitled;

(2) Where and how services may be obtained;

(3) Each exclusion or limitation on any service or other benefit that it provides;

(4) Each deductible feature;

(5) Each copayment provision; and

(6) All information required by Sec. 15-1206 of the Insurance Article.

#### Section 19-715

Each health maintenance organization application or offer of enrollment shall contain or be accompanied by, and each form of health maintenance organization subscriber contract shall contain, a full and clear statement of:

(1) The items specified in Sec. 19-714 of this subtitle;

(2) The rate of periodic payment;

(3) When the coverage is effective and what restrictions, if any, apply to preexisting conditions;

(4) All standards for cancellation of enrollment or denial of reenrollment; and

(5) Service priorities, if any, in epidemic or other emergency or catastrophic conditions that may cause an unusually high demand for medical services.

#### Section 19-716

Annually, each health maintenance organization shall provide to its members and make available to the general public, in clear, readable, and concise form:

(1) A summary of the most recent financial report that the health maintenance organization submits to the Commissioner under Sec. 19-717 of this subtitle;

(2) A description of the benefit packages available and the nongroup rates required by the Commissioner;

(3) A description of the accessibility and availability of services, including where and how to obtain them;

(4) A statement of the potential responsibility of a member for payment for services the member seeks to obtain from a provider, including a physician or hospital, that does not have a written contract with the health maintenance organization;

(5) A description of procedures to be followed for emergency services, including:

  (i) The appropriate use of hospital emergency facilities;

  (ii) The appropriate use, location, and hours of operation of any urgent care facilities operated by the health maintenance organization; and

  (iii) The potential responsibility of subscribers and enrollees for payment for emergency services or nonemergency services rendered in a hospital emergency facility;

(6) A statement that shows, by category, the percentage of members assisted by public funds;

(7) The information required to be disclosed by Sec. 15-1206 of the Insurance Article; and

(8) Any other information that the Commissioner or the Department requires by rule or regulation.

#### Section 19-717

(a) Except as provided in subsections (b) and (c) of this section and unless, for good cause shown, the Commissioner extends the time for a reasonable period:

  (1) On or before March 1 of each year, each health maintenance organization shall file with the Commissioner a report that shows the financial condition of the health maintenance organization on the last day of the preceding calendar year and any other information that the Commissioner requires by rule or regulation; and

  (2) On or before June 1 of each year, each health maintenance organization shall file with the Commissioner an audited financial report for the preceding calendar year.

(b) A health maintenance organization that has a fiscal year other than the calendar year may request permission to file both the annual report required under subsection (a)(1) of this section and the audited financial report required under subsection (a)(2) of this section at the end of its fiscal year rather than the preceding calendar year. If the Commissioner grants this permission, the health maintenance organization shall file the annual report with the Commissioner within 60 days after the end of its fiscal year, and the health maintenance organization shall file the audited financial report with the Commissioner within 150 days after the end of its fiscal year.

(c) With 90 days' advance notice, the Commissioner may require a health maintenance organization to file an audited financial report earlier than the date specified in subsection (a) of this section.

(d) The annual report shall:

  (1) Be on the forms that the Commissioner requires; and

  (2) Include a description of any changes in the information submitted under Sec. 19-708 of this subtitle.

(e) The audited financial report shall:

  (1) Be on the forms that the Commissioner requires; and

  (2) Be certified by an audit of a certified public accounting firm.

(f) Each financial report filed under this section is a public record.

#### Section 19-719

Under rules, regulations, and procedures that the Secretary approves and using methods that keep the identity of patients as confidential as possible, assure objective evaluation, and are consistent with Sec. 19-710 of this subtitle, the Department may do periodic examinations to:

(1) Determine the quality of health care services being provided by health maintenance organizations; and

(2) Develop statistical information.

#### Section 19-720

(a) The State Health Services Cost Review Commission promptly shall give the Commissioner and the Secretary any financial information that the Commission acquires about each facility that is:

  (1) Under the jurisdiction of the Commission; and

  (2) Subject to this subtitle.

(b) If requested by the Commissioner or the Secretary, the State Health Services Cost Review Commission shall provide any other information that the Commission is authorized to acquire about health maintenance organizations regulated under this subtitle.

#### Section 19-721

(a) Unless previously suspended or revoked, each original and renewal certificate of authority issued under this subtitle to a health maintenance organization expires at midnight on the November 30 after its effective date.

(b) On payment of an annual renewal fee of $25 by the health maintenance organization before the expiration date of its certificate of authority, its certificate remains in effect until a new certificate of authority is issued or specifically refused.

#### Section 19-722

(a) The Commissioner may refuse to renew a certificate of authority for any reason for which the Commissioner may:

  (1) Refuse to issue an original certificate; or

  (2) Suspend or revoke an existing certificate.

(b) If the Commissioner refuses to renew a certificate of authority, the applicant has the same administrative and legal remedies as those provided under this subtitle for the suspension or revocation of a certificate of authority.

#### Section 19-723

(a) At all times, each health maintenance organization is subject to the supervision of the Commissioner and the Department as provided in this subtitle.

(b) Any health maintenance organization that contracts with the Department and is subject to this subtitle shall act in concert with the Department or with the written consent of the Department concerning all information that the Commissioner requires.

#### Section 19-724

(a) Except as provided in subsection (b) of this section, a health maintenance organization may solicit members through advertising its services, charges, or nonprofessional aspects of its operation.

(b) A health maintenance organization may not use any advertising that makes any qualitative judgment about any person who provides services for a health maintenance organization.

#### Section 19-725

(a) A health maintenance organization may not cancel the enrollment of a member or refuse to transfer a member from a group to an individual basis because of age, sex, sexual orientation, gender identity, religious beliefs, disability, race, or health status.

(b) A health maintenance organization may cancel a contract with a member who violates any published policy of the health maintenance organization that has been approved by the Commissioner and the Department under their joint internal procedures.

#### Section 19-726

(a)

  (1) A health maintenance organization may not include in its name:

    (i) The words "insurer", "casualty", "surety", or "health and accident"; or

    (ii) Any other words generally regarded as descriptive of the insurance industry.

  (2) This subsection does not apply to an insurer or health service corporation that is licensed and regulated under the laws of this State, except as to its health maintenance organization activities that are authorized and regulated under this subtitle.

(b) Except as authorized by the Commissioner under this subtitle, a person other than a health maintenance organization regulated under this subtitle may not designate its services, operations, or functions as a "health maintenance organization" or use any other title or designation if the arrangement of services, operations, or functions substantially fall under the definition of a health maintenance organization in Sec. 19-701 of this subtitle.

#### Section 19-727

(a) Except as provided in subsection (b) of this section, a health maintenance organization is not exempted from any State, county, or local taxes solely because of this subtitle.

(b)

  (1) A nonprofit health maintenance organization that is exempt from taxation under Sec. 501(c)(3) of the Internal Revenue Code is not subject to the insurance premium tax under Title 6, Subtitle 1 of the Insurance Article.

  (2) Premiums received by an insurer under policies that provide health maintenance organization benefits are not subject to the premium tax imposed under Title 6, Subtitle 1 of the Insurance Article to the extent:

    (i) Of the amounts actually paid by the insurer to a nonprofit health maintenance organization that operates only as a health maintenance organization; or

    (ii) The premiums have been paid by that nonprofit health maintenance organization.

#### Section 19-728

(a) The Commissioner is responsible for:

  (1) Determining whether each health maintenance organization is or will be able to provide a fiscally sound operation and adequate provision against risk of insolvency and may adopt reasonable rules and regulations designed to achieve this goal; and

  (2) Actuarial and financial evaluations and determinations of each health maintenance organization.

(b)

  (1) If the Commissioner determines that a health maintenance organization is not operating in a fiscally sound manner, the Commissioner shall notify the Department of the determination.

  (2) After notifying the Department in accordance with the provisions of paragraph (1) of this subsection, the Commissioner shall monitor the health maintenance organization on a continuous basis until the Commissioner determines that the health maintenance organization is operating in a fiscally sound manner.

#### Section 19-729

(a) A health maintenance organization may not:

  (1) Violate any provision of this subtitle or any rule or regulation adopted under it;

  (2) Fail to fulfill its obligations to provide the health care services specified in its contracts with subscribers;

  (3) Make any false statement with respect to any report or statement required by this subtitle or by the Commissioner under this subtitle;

  (4) Advertise, merchandise, or attempt to merchandise its services in a way that misrepresents its services or capacity for service;

  (5) Engage in a deceptive, misleading, unfair, or unauthorized practice as to advertising or merchandising;

  (6) Prevent or attempt to prevent the Commissioner or the Department from performing any duty imposed by this subtitle;

  (7) Fraudulently obtain or fraudulently attempt to obtain any benefit under this subtitle;

  (8) Fail to fulfill the basic requirements to operate as a health maintenance organization as provided in Sec. 19-710 of this subtitle;

  (9) Violate any applicable provision of Title 15, Subtitle 12 of the Insurance Article;

  (10) Fail to provide services to a member in a timely manner as provided in Sec. 19-705.1(b)(1) of this subtitle;

  (11) Fail to comply with the provisions of Title 15, Subtitle 10A, 10B, 10C, or 10D or Sec. 2-112.2 of the Insurance Article;

  (12) Violate any provision of Sec. 19-712.5 of this subtitle; or

  (13) Violate any provision of Title 33 of the Insurance Article.

(b) If any health maintenance organization violates this section, the Commissioner may pursue any one or more of the courses of action described in Sec. 19-730 of this subtitle.

#### Section 19-730

(a) If any person violates any provision of Sec. 19-729 of this subtitle, the Commissioner may:

  (1) Issue an administrative order that requires the health maintenance organization to:

    (i) Cease inappropriate conduct or practices by it or any of the personnel employed or associated with it;

    (ii) Fulfill its contractual obligations;

    (iii) Provide a service that has been denied improperly;

    (iv) Take appropriate steps to restore its ability to provide a service that is provided under a contract;

    (v) Cease the enrollment of any additional enrollees except newborn children or other newly acquired dependents of existing enrollees; or

    (vi) Cease any advertising or solicitation;

  (2) In addition to suspending or revoking a certificate of authority:

    (i) Impose a penalty of not less than $100, but not more than $125,000 for each violation; and

    (ii) Order the health maintenance organization to pay restitution to any person who has suffered financial injury because of the violation;

  (3) Suspend, revoke, or refuse to renew the certificate of authority to do business as a health maintenance organization;

  (4) Suspend, revoke, or refuse to renew the certificate of a medical director of a health maintenance organization; or

  (5) Apply to any court for legal or equitable relief considered appropriate by the Commissioner or the Department, in accordance with the joint internal procedures.

(b) If the Commissioner issues an order or imposes any penalty under this section, the Commissioner immediately shall provide written notice of the order or penalty to the Secretary.

#### Section 19-731

(a) If a person violates any provision of Sec.Sec. 19-705 and 19-705.1 of this subtitle, the Secretary may:

  (1) Issue an administrative order that requires the health maintenance organization to:

    (i) Cease inappropriate conduct or practices by it or any of the personnel employed by or associated with it and comply with the standards established by the Department; or

    (ii) Provide any service required by Sec.Sec. 19-705 and 19-705.1 of this subtitle that has been denied improperly;

  (2) Impose a penalty of not less than $100 and not more than $125,000 for each violation; or

  (3) Apply to any court for legal or equitable relief considered appropriate by the Secretary.

(b) If the Secretary issues an order or imposes any penalty under this section, the Secretary immediately shall provide written notice of the order or penalty to the Commissioner.

#### Section 19-732

(a) Except as otherwise provided in Title 15, Subtitle 10A of the Insurance Article, a party aggrieved by a final action of the Commissioner under this subtitle has the right to a hearing and the right to appeal from the action of the Commissioner under Sec.Sec. 2-210 through 2-215 of the Insurance Article.

(b) A party aggrieved by an order of the Secretary under this subtitle may petition for judicial review as provided by the Administrative Procedure Act.

#### Section 19-734

This subtitle may be cited as the "Maryland Health Maintenance Organization Act".

#### Section 19-735

(a) Any foreign health maintenance organization with a certificate of authority to operate a health maintenance organization in this State may become a domestic health maintenance organization of this State by complying with all of the requirements of the law relating to the formation and organization of a domestic health maintenance organization and by designating its principal place of business at a place in this State. On becoming a domestic health maintenance organization, the health maintenance organization shall be entitled to certificates and licenses to transact business in this State issued to domestic health maintenance organizations, and shall be given recognition in all respects as a health maintenance organization formed under the laws of this State as of the date of authorization as a health maintenance organization in its original domiciliary state, district, territory, commonwealth, or possession of the United States of America, and shall be subject to the authority and jurisdiction of this State.

(b)

  (1) The certificate of authority, insurance producers' appointments, rates, and other forms which the Commissioner allows which are in existence at the time any foreign health maintenance organization with a certificate of authority to operate a health maintenance organization in this State transfers its corporate domicile to this State or to any other state by merger, consolidation, or any other lawful method shall continue in full force and effect on transfer if the health maintenance organization at all times retains a certificate of authority in this State.

  (2) All outstanding subscriber contracts of a transferring health maintenance organization shall remain in full force and effect and need not be endorsed as to the new name of the health maintenance organization or its new domiciliary and location unless so ordered by the Commissioner.

  (3) A transferring health maintenance organization may file new contract forms with the Commissioner on or before the effective date of the transfer, or may use any existing contract form previously filed with the Commissioner with appropriate endorsements if allowed by and under such conditions as approved by the Commissioner.

  (4) A foreign health maintenance organization transferring its domicile to another state shall notify the Commissioner of the details of the proposed transfer, and shall file promptly any resulting amendments to corporate documents and other items on file with the Commissioner.

### Subtitle 7A. Provider-Sponsored Organizations

#### Section 19-7A-01

(a) In this subtitle the following words have the meanings indicated.

(b) "Commissioner" means the Maryland Insurance Commissioner.

(c) "Health care services" means a health or medical care procedure or service rendered by a health care provider that:

  (1) Provides testing, diagnosis, or treatment of a human disease or dysfunction; or

  (2) Dispenses drugs, medical devices, medical appliances, or medical goods for the treatment of a human disease or dysfunction.

(d) "License" includes a certificate of authority, as defined in Sec. 1-101 of the Insurance Article.

(e) "Provider" means any person, including a physician or hospital, that is licensed or otherwise authorized in this State to provide health care services.

(f) "Provider-sponsored organization" means an entity that:

  (1) Is a legal aggregation of providers operating collectively for the purpose of providing health care services to Medicare beneficiaries under the federal Medicare+Choice Program;

  (2) Acts through a licensed entity, such as a partnership, corporation, limited liability company, limited liability partnership, or sole proprietorship, that has authority over the entity's activities and responsibility for satisfying the requirements of Sec. 19-7A-02 of this subtitle; and

  (3) Provides a substantial proportion of the health care services required to be provided under the federal Medicare+Choice Program directly through providers or affiliated groups of providers.

#### Section 19-7A-02

(a) A license issued to a provider-sponsored organization under this subtitle authorizes the licensee to provide health care services only to Medicare beneficiaries under the federal Medicare+Choice Program.

(b) Nothing in this subtitle may be construed to limit a provider-sponsored organization from participating in the Medicaid program as a managed care organization.

#### Section 19-7A-03

(a)

  (1) Before an entity may operate as a provider-sponsored organization under the federal Medicare+Choice Program, the entity must obtain a license from the Commissioner.

  (2) The Commissioner shall issue a license under paragraph (1) of this subsection to any entity to operate as a provider-sponsored organization that meets the requirements of subsection (b) of this section.

(b) To operate as a provider-sponsored organization under the federal Medicare+Choice Program in this State, an entity shall:

  (1) Meet the definition of a provider-sponsored organization under Sec. 19-7A-01 of this subtitle; and

  (2) Meet the requirements applicable to a health maintenance organization under Subtitle 7 of this title to the extent those requirements are not preempted by federal law.

#### Section 19-7A-04

(a) The Commissioner shall adopt regulations to implement the provisions of this subtitle.

(b) Except as provided in subsection (c) of this section, regulations relating to the solvency of a provider-sponsored organization adopted under subsection (a) of this section shall impose solvency requirements the same as required under federal law.

(c) Upon the expiration, repeal, or termination of solvency requirements under federal law for provider-sponsored organizations, the requirements of Sec. 19-710(d) of this title shall apply.

### Subtitle 8. Problem Gamblers

#### Section 19-801

In this subtitle, "problem gambler" means an individual:

(1) Who is preoccupied chronically and progressively with gambling and the urge to gamble; and

(2) Whose gambling behavior compromises, disrupts, or damages the individual's personal, family, or vocational pursuits.

#### Section 19-802

The General Assembly finds that:

(1) Problem gambling is a serious social problem;

(2) There is evidence that the availability of gambling increases the risk of becoming a problem gambler; and

(3) This State, with its extensive legalized gambling, has an obligation to provide a program of treatment for problem gamblers.

#### Section 19-803

The Secretary shall establish a network of clinically appropriate services to problem gamblers throughout the State.

#### Section 19-804

(a)

  (1) The Secretary shall make grants from or agreements for the use of State funds, including the funds provided under Sec. 9-1A-33 of the State Government Article, and federal funds to help public agencies or nonprofit organizations operate the network of clinically appropriate services for problem gamblers who reside in the State to provide the following:

    (i) Inpatient and residential services;

    (ii) Outpatient services;

    (iii) Intensive outpatient services;

    (iv) Continuing care services;

    (v) Educational services;

    (vi) Services for victims of domestic violence; and

    (vii) Other preventive or rehabilitative services or treatment.

  (2) Research and training that are designed to improve or extend these services are proper items of expense.

(b) The Secretary shall conduct a prevalence study and replication prevalence studies to measure the rate of problem and pathological gambling in the State.

(c)

  (1) Subject to paragraph (2) of this subsection, the Secretary shall contract with an independent researcher to conduct the prevalence studies.

  (2) The Secretary shall utilize the most current psychiatric or diagnostic criteria for problem and pathological gambling as the basis for the prevalence studies.

(d) The initial prevalence study shall be completed on or before July 1, 2009.

(e) Replication prevalence studies shall be conducted no less than every 5 years with measures taken to permit comparisons between the initial prevalence study and subsequent replication prevalence studies.

(f) Services under this subtitle shall be provided by public agencies or, under contract, by nonprofit organizations.

### Subtitle 9. Hospice Care Facilities

#### Section 19-901

(a) In this subtitle the following words have the meanings indicated.

(b) "General hospice care program" means a coordinated, interdisciplinary program of hospice care services for meeting the special physical, psychological, spiritual, and social needs of dying individuals and their families, by providing palliative and supportive medical, nursing, and other health services through home or inpatient care during the illness and bereavement:

  (1) To individuals who have no reasonable prospect of cure as estimated by a physician; and

  (2) To the families of those individuals.

(c) "General license" means a license issued by the Secretary to operate a general hospice care program.

(d) "Home-based hospice care program" means a program that directly or through a contractual arrangement provides a hospice care program in the residence of the patient.

(e) "Hospice facility" means a facility that:

  (1) Provides a hospice care program;

  (2) Is separate from any other facility; and

  (3) Admits at least 2 individuals who:

    (i) Are unrelated; and

    (ii) Have no reasonable prospect of a cure.

(f) "Limited hospice care program" means a coordinated, interdisciplinary program of hospice care services for meeting the special physical, psychological, spiritual, and social needs of dying individuals and their families, by providing palliative and supportive nonskilled services through a home-based hospice care program during illness and bereavement:

  (1) To individuals who have no reasonable prospect of cure as estimated by a physician; and

  (2) To the families of those individuals.

(g) "Limited license" means a license issued by the Secretary to operate a limited hospice care program.

#### Section 19-902

The purposes of this subtitle are:

(1) To simplify and clarify the laws that govern the use of a hospice care program by individuals who want a supportive environment;

(2) To encourage the establishment of hospice care programs; and

(3) To ensure the quality of these hospice care programs.

#### Section 19-903

(a)

  (1) The Secretary shall adopt regulations to carry out the provisions of this subtitle.

  (2) The regulations for general hospice care programs shall set standards for general hospice care programs that are comparable to the standards established by the National Hospice Organization.

  (3) The Secretary, by regulation, after consultation with interested groups, including The Hospice Network of Maryland, Inc., shall establish standards for the operation of a hospice care program.

(b)

  (1) The regulations shall set qualifications for medical directors of hospices. A medical director of a hospice care program need not be an employee or a contractee of a hospice care program.

  (2) The regulations for a hospice facility shall require:

    (i) The medical director to be a physician licensed to practice medicine in this State;

    (ii) The dietary, nursing, pastoral care, pharmaceutical, and social worker services to be adequate; and

    (iii) A physician other than an attending physician to be on call and available at all times.

  (3) The regulations for a home-based hospice care program shall require:

    (i) The medical director to be a physician licensed to practice medicine in this State;

    (ii) The provision of bereavement services;

    (iii) The provision of services to meet the spiritual or social needs of dying individuals and their families;

    (iv) The provision of palliative and supportive medical, nursing, and other health services:

      (1) Directly or by contract for a general licensee; or

      (2) By referral only for a limited licensee;

    (v) Submission of an annual report which includes service utilization statistics in the format prescribed;

    (vi) Written transfer agreements to provide acute inpatient care as needed; and

    (vii) Minimum standards concerning the training and role of volunteers in a hospice care program.

#### Section 19-904

(a) A building that contains a hospice facility shall:

  (1) Be constructed soundly; and

  (2) Meet the standards for construction and safety that the county or municipality imposes on a single-family residence.

(b) A building that contains a hospice facility may not be required to comply with health and safety standards for an institution.

#### Section 19-905

(a) A person shall be licensed by the Secretary before a person may operate a hospice care program.

(b) A home health agency, hospital, related institution, or other licensed facility that operates a hospice care program that is distinct from the other services that the home health agency or facility offers shall be licensed by the Secretary as a hospice care program before the home health agency or facility may operate that hospice care program.

#### Section 19-906

(a) To qualify for a license, an applicant and the hospice care program and its medical director shall meet the requirements of this section.

(b) An applicant who is an individual, and any individual who is applying on behalf of a corporation, association, or government agency shall be:

  (1) At least 18 years old; and

  (2) Of reputable and responsible character.

(c)

  (1) Except for a limited licensee, the applicant shall have a certificate of need, as required under Subtitle 1 of this title, for the hospice care program to be operated.

  (2) The Secretary, in consultation with the Maryland Health Care Commission, shall specify those jurisdictions in which a general hospice is authorized to provide home-based hospice services.

  (3) A general hospice may not be licensed to provide home-based hospice services in a jurisdiction unless the general hospice or an entity acquired by the general hospice provided home-based hospice services to a patient in the jurisdiction during the 12-month period ending December 31, 2001.

  (4) Notwithstanding paragraph (3) of this subsection:

    (i) A general hospice may provide home-based hospice services to a specific patient outside of the jurisdictions in which the hospice is licensed if the Maryland Health Care Commission approves the service provision; and

    (ii) A general hospice that is a hospital-based hospice or that had an affiliation agreement before April 5, 2003 with a health care facility or health care system may serve patients immediately upon discharge from the hospital, health care facility, or health care system, regardless of the jurisdiction in which the patient resides.

  (5) Upon the notification by the Maryland Health Care Commission of the issuance of a certificate of need to a general hospice, the Secretary shall append to the general hospice license any additional jurisdictions in which the general hospice may provide home-based hospice services.

  (6) The hospice care program to be operated and its medical director shall meet the requirements that the Secretary adopts under this subtitle.

#### Section 19-907

(a) An applicant for a license shall submit an application to the Secretary.

(b) The application:

  (1) Shall be on the form that the Secretary requires;

  (2) Shall be signed and verified by the individual; and

  (3) Shall include:

    (i) The name of the applicant;

    (ii) A statement that the applicant meets the requirements of this subtitle;

    (iii) The location of the proposed hospice;

    (iv) The name of the individual who is to be the medical director of the hospice care program; and

    (v) Any other information that the Secretary requires.

#### Section 19-908

The Secretary shall issue a license to any applicant if the applicant and the hospice care program and its medical director meet the requirements of this subtitle.

#### Section 19-909

(a) While it is effective, a general license authorizes the general licensee to operate a general hospice care program.

(b)

  (1) While it is effective, a limited license authorizes the limited licensee to operate a limited hospice care program.

  (2) A limited licensee may not provide any medical, nursing, or other health services directly or through a contractual arrangement.

#### Section 19-911

(a) The Secretary shall deny a license to any applicant or revoke a license if the applicant or licensee has been convicted of a felony that relates to Medicaid or to a nursing home.

(b) The Secretary may deny a license to an applicant or revoke a license if the applicant or licensee does not meet the requirements of this subtitle or any rule or regulation that the Secretary adopts under this subtitle.

(c)

  (1) In addition to the provisions of subsections (a) and (b) of this section, the Secretary may, for a violation of any provision of this subtitle or any regulation adopted under this subtitle, impose an administrative penalty of up to:

    (i) $500 for a first violation; and

    (ii) $1,000 for a subsequent, repeated violation.

  (2) The Secretary shall adopt regulations to provide standards for the imposition of an administrative penalty under paragraph (1) of this subsection.

#### Section 19-912

A person may not operate a hospice care program unless licensed by the Secretary.

#### Section 19-913

A hospice facility may not admit an individual unless a physician estimates that the individual has no reasonable prospect of cure.

#### Section 19-914

(a)

  (1) This section applies to a general hospice care program only when providing hospice services in an in-home setting.

  (2) This section does not apply to a general hospice care program when providing hospice services in a nursing home, assisted living facility, or a general hospice care program facility.

(b) A general hospice care program shall establish a written policy that outlines the procedures for the collection and disposal of a patient's unused prescription medication, including a procedure that requires a general hospice care employee, at the time that a patient is enrolled in the general hospice care program, to:

  (1) Discuss with the patient and the patient's family member or personal representative the requirements under subsection (c) of this section; and

  (2) Provide a written copy of the unused prescription medication collection and disposal policy to the patient and the patient's family member or personal representative.

(c)

  (1) In accordance with a general hospice care program's policy and subject to paragraphs (2) and (3) of this subsection, a general hospice care program employee shall, as soon as practicable, collect and dispose of a patient's unused prescription medication on:

    (i) The death of the patient; or

    (ii) The termination of a prescription medication by the patient's prescriber.

  (2) Before a general hospice care program employee collects or disposes of a patient's unused prescription medication under paragraph (1) of this subsection, the employee shall provide to the patient or the patient's family member or personal representative a written request for authorization to collect and dispose of the patient's unused prescription medication in accordance with the patient's care plan.

  (3) A general hospice care program employee may not collect or dispose of a patient's unused prescription medication unless the patient or the patient's family member or representative provides written authorization to the general hospice care program.

  (4) If a patient or the patient's family member or personal representative refuses to authorize the collection or disposal of the patient's unused prescription medication, the general hospice care program employee shall urge that the patient or the patient's family member or personal representative dispose of any unused prescription medication in a safe and legal manner in accordance with federal Environmental Protection Agency and federal Drug Enforcement Administration guidelines for the safe disposal of prescription drugs.

(d) If authorized, a general hospice care program employee shall, as soon as practicable, dispose of a patient's unused prescription medication at the site where hospice care was provided:

  (1) In accordance with federal Environmental Protection Agency and federal Drug Enforcement Administration guidelines for the safe disposal of prescription drugs; and

  (2) Under the witness of:

    (i) The patient or the patient's family member or personal representative;

    (ii) Another general hospice care program employee; or

    (iii) If none of the individuals under items (i) or (ii) of this item are available, a local law enforcement officer.

(e)

  (1) The collection and disposal of a patient's unused prescription medication by the general hospice care program shall be documented in the patient's medical record by the general hospice care program employee who conducted the collection and disposal.

  (2) The medical record shall include the following information:

    (i) The name and quantity of each unused prescription medication;

    (ii) The name of the individual who authorized the collection and disposal of the unused prescription medication and the individual's relationship to the patient;

    (iii) The date of disposal for each unused prescription medication;

    (iv) The name of the individual who conducted the collection and disposal; and

    (v) The name of the individual who witnessed the disposal of unused prescription medication by the employee as required under subsection (d)(2) of this section.

  (3) If a patient or the patient's family member or personal representative refuses to authorize the collection and disposal of the patient's unused prescription medication by the general hospice care program, the general hospice care program employee shall document in the patient's medical record:

    (i) The refusal to authorize the collection and disposal of the patient's unused prescription medication; and

    (ii) The name and quantity of each unused prescription medication not surrendered.

(f) A general hospice care program may not be held liable in a civil or criminal action for any good faith act or omission taken in accordance with the requirements of this section.

### Subtitle 10

#### Section 19-1001

(a) In this subtitle the following words have the meanings indicated.

(b) "Health care facility" means:

  (1) A hospital, as defined in Sec. 19-301 of this title;

  (2) A limited service hospital, as defined in Sec. 19-301 of this title;

  (3) A related institution, as defined in Sec. 19-301 of this title;

  (4) An ambulatory surgical facility; or

  (5) A freestanding medical facility, as defined in Sec. 19-3A-01 of this title.

(c) "Smoke evacuation system" means equipment that effectively captures and filters surgical smoke at the site of origin before the surgical smoke makes contact with the eyes or respiratory tract of occupants in the room.

(d) "Surgical smoke" means the gaseous by-product produced by energy-generating devices, including surgical plume, smoke plume, bio-aerosols, laser-generated airborne contaminants, or lung-damaging dust.

#### Section 19-1002

By January 1, 2028, each health care facility that performs surgical procedures shall adopt and implement policies that require the use of a smoke evacuation system during a surgical procedure that may generate surgical smoke.

### Subtitle 12. Comprehensive Physical Rehabilitation Facilities

#### Section 19-1201

(a) In this subtitle the following words have the meanings indicated.

(b) "Comprehensive physical rehabilitation services" means:

  (1) A program of coordinated, integrated, interdisciplinary, physician-directed services provided by or under the supervision of physicians qualified or experienced in rehabilitation that:

    (i) Includes evaluation and treatment of individuals with physical disabilities;

    (ii) Emphasizes education and training of individuals with disabilities; and

    (iii) Incorporates:

      (1) At least 4 of the following core disciplines:

      (A) Physical therapy;

      (B) Occupational therapy;

      (C) Speech and language therapy;

      (D) Psychotherapy;

      (E) Rehabilitation nursing; and

      (F) Social work; and

      (2) At least 2 of the following disciplines:

      (A) Psychology;

      (B) Audiology;

      (C) Respiratory therapy;

      (D) Therapeutic recreation;

      (E) Orthotics;

      (F) Prosthetics;

      (G) Special education or instruction; and

      (H) Vocational rehabilitation; and

  (2) Any other service that the Secretary may designate by regulation.

(c) "Comprehensive rehabilitation facility" means:

  (1) Any person that provides or holds himself out as providing comprehensive physical rehabilitation services on an out-patient basis; or

  (2) A hospital that is licensed as a special rehabilitation hospital under Subtitle 3 of this title.

(d)

  (1) "Health care facility" includes any facility defined in Sec. 19-114(d) of this title.

  (2) "Health care facility" does not include a home health agency that is licensed under Subtitle 4 of this title.

(e) "Specialized rehabilitation program" means any of the specialty programs that the Commission on Accreditation of Rehabilitation Facilities accredits, including:

  (1) Spinal cord injury programs;

  (2) Head injury programs; and

  (3) Infant and early childhood developmental programs.

#### Section 19-1202

A comprehensive rehabilitation facility shall meet the requirements of this subtitle before the facility may provide:

(1) Comprehensive physical rehabilitation services; or

(2) Any specialized rehabilitation program.

#### Section 19-1203

(a) This section does not apply to a special rehabilitation hospital that is licensed under Subtitle 3 of this title.

(b) Any person that provides or holds himself out as providing comprehensive physical rehabilitation services on an out-patient basis shall obtain a comprehensive rehabilitation license before the person may provide comprehensive physical rehabilitation services in the State.

(c) The Department shall issue a comprehensive rehabilitation license to any person for whom a comprehensive rehabilitation license is required if the person submits an application on the form established and provided for the Secretary.

(d) While it is effective, a comprehensive rehabilitation license authorizes the licensed person to provide comprehensive physical rehabilitation services.

(e) A person may not provide or hold himself out as providing comprehensive physical rehabilitation services on an out-patient basis unless the person has been issued a comprehensive rehabilitation license under this section.

#### Section 19-1204

A comprehensive rehabilitation facility shall meet any standard that the Secretary adopts by regulation.

#### Section 19-1205

The Secretary may inspect a comprehensive rehabilitation facility to assure that the facility meets the requirements of this subtitle.

#### Section 19-1206

The Secretary may revoke a license issued under this subtitle or may revoke the authority to provide comprehensive physical rehabilitation services for any health care facility or person that does not meet each requirement of this subtitle or any regulation adopted by the Secretary under this subtitle.

#### Section 19-1207

(a) A person may not hold himself out as providing a complete array of rehabilitation services unless the person provides comprehensive physical rehabilitation services.

(b) A health care facility may not provide or hold itself out as providing any specialized rehabilitation program unless the facility is licensed by the Department.

(c) A person may not provide comprehensive physical rehabilitation services unless the person meets the requirements of this subtitle.

#### Section 19-1208

A person who violates any provision of this subtitle is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $5,000, or imprisonment not exceeding 1 year, or both.

### Subtitle 14. Nursing Homes

#### Section 19-1401

(a) In this subtitle the following words have the meanings indicated.

(b) "Actual harm deficiency" means a condition existing in a nursing home or an action or inaction by the nursing home staff that has caused physical or emotional injury or impairment to a resident.

(c) "Concurrent review" means daily rounds by a licensed nurse which include:

  (1) Appraisal and observation of each resident by the licensed nurse to determine any change in the resident's physical or mental status; and

  (2) If there is a change in the resident's physical or mental status, an evaluation by the licensed nurse of:

    (i) The resident's medications;

    (ii) Laboratory values relating to the resident;

    (iii) Clinical data relating to the resident, including the resident's:

      (1) Hydration and nutritional need;

      (2) Skin integrity;

      (3) Noted weight changes; and

      (4) Appetite;

    (iv) Injuries sustained by the resident that result from accident or incidents involving the resident; and

    (v) Any other relevant parameters affecting or reflecting the resident's physical and mental status.

(d) "Deficiency" means a condition existing in a nursing home or an action or inaction by the nursing home staff that results in potential for more than minimal harm, actual harm, or serious and immediate threat to one or more residents.

(e)

  (1) "Nursing home" means a facility that offers nonacute inpatient care to patients suffering from a disease, chronic illness, condition, disability of advanced age, or terminal disease requiring maximal nursing care without continuous hospital services and who require medical services and nursing services rendered by or under the supervision of a licensed nurse together with convalescent, restorative, or rehabilitative services.

  (2) "Nursing home" does not mean a facility offering domiciliary care or personal care as those terms are defined in Sec. 19-301 of this title.

(f) "Ongoing pattern" means the occurrence of any potential for more than minimal harm or greater deficiency on two consecutive on-site visits as a result of annual surveys, follow-up visits, any unscheduled visits, or complaint investigations.

(g) "Potential for more than minimal harm deficiency" means a condition existing in a nursing home or an action or inaction by the nursing home staff that has the potential to cause actual harm to a resident.

(h) "Serious and immediate threat" means a situation in which immediate corrective action is necessary because a nursing home's noncompliance with one or more State regulations has caused or is likely to cause serious injury, harm, impairment to, or death of a resident receiving care in the nursing home.

(i) "Sustained compliance" means a period of 30 days following the date of notice of corrective action with no deficiencies.

#### Section 19-1401.1

(a)

  (1) In addition to the requirements for licensure of a related institution as provided in this title, an applicant for licensure of a nursing home shall include in the application the identity of:

    (i) Any person with an ownership interest in the nursing home; and

    (ii) Any management company, landlord, or other business entity that will operate or contract with the applicant to manage the nursing home.

  (2)

    (i) The person acquiring a nursing home shall provide the Department with written notice of the acquisition or change in operator at the same time as the notice required under Sec. 19-120.2 of this title is filed with the Maryland Health Care Commission.

    (ii) For other changes to the information required under paragraph (1) of this subsection, the nursing home shall notify the Department within 30 days after the effective date of the change.

(b) An applicant for licensure shall submit to the Secretary or the Secretary's designee evidence:

  (1) That affirmatively demonstrates the ability of the applicant to comply with minimum standards of:

    (i) Medical care;

    (ii) Nursing care;

    (iii) Financial condition; and

    (iv) Other applicable State or federal laws and regulations;

  (2) Regarding the regulatory compliance history and financial condition of any health care facility owned or operated by the applicant in other jurisdictions; and

  (3) That a request for acquisition for the nursing home was approved in accordance with Sec. 19-120.2 of this title.

#### Section 19-1401.2

(a) On review of the information required under Sec. 19-1401.1 of this subtitle and any other information that is relevant to the ability of the applicant to operate a nursing home, the Secretary may:

  (1) Approve an application for a license;

  (2) Deny an application for a license;

  (3) Approve an application for a license subject to conditions; or

  (4) Revoke a license.

(b) Before taking action on a license under subsection (a) of this section, the Secretary shall consider any findings and decisions of the Maryland Health Care Commission provided to the Office of Health Care Quality under Sec. 19-120.2 of this title.

#### Section 19-1401.3

(a) A licensee shall report to the Secretary or the Secretary's designee any significant change in the financial condition of the nursing home, including cash flow or any other circumstances that could adversely affect the nursing home's delivery of essential services to patients, including nursing services, dietary services, and utilities.

(b) Except as provided by subsection (c) of this section, any information obtained by the Secretary under this section is confidential and may not be disclosed without the consent of the licensee.

(c) The provisions of subsection (b) of this section do not apply to:

  (1) The holder of a license that has been suspended or revoked; or

  (2) The use of information in:

    (i) An administrative proceeding initiated by the Department; or

    (ii) A judicial proceeding.

#### Section 19-1402

(a) If a deficiency exists, the Secretary may impose sanctions that include:

  (1) A directed plan of correction with corrective measures necessary to protect residents;

  (2) Imposing adequate staffing levels in a nursing home;

  (3) Appointing a State monitor subject to Sec. 19-1405 of this subtitle; and

  (4) Imposing a civil money penalty.

(b) A civil money penalty may be imposed when a deficiency exists or an ongoing pattern of deficiencies exists in a nursing home.

(c) In determining whether a civil money penalty is to be imposed, the Secretary shall consider, pursuant to guidelines set forth in regulations promulgated by the Secretary, the following factors:

  (1) The number, nature, and seriousness of the deficiencies;

  (2) The extent to which the deficiency or deficiencies are part of an ongoing pattern during the preceding 24 months;

  (3) The degree of risk to the health, life, or safety of the residents of the nursing home caused by the deficiency or deficiencies;

  (4) The efforts made by, and the ability of, the nursing home to correct the deficiency or deficiencies; and

  (5) A nursing home's prior history of compliance.

(d) Upon determination by the Department that a deficiency or deficiencies exist, the Department shall notify the nursing home that:

  (1) Unless corrective action taken pursuant to this section is substantially completed, a civil money penalty will be imposed; or

  (2) An order imposing a civil money penalty will be issued, pursuant to Sec. 19-1403 of this subtitle which shall include a list of all deficiencies and notice that a civil money penalty may be imposed until the time that the cited deficiencies have been rectified.

#### Section 19-1403

(a) If a civil money penalty is proposed, the Secretary shall issue an order which shall state the basis on which the order is made, the deficiency or deficiencies on which the order is based, the amount of civil money penalties to be imposed, and the manner in which the amount of civil money penalties imposed was calculated.

(b) An order issued pursuant to subsection (a) of this section shall be void unless issued within 60 days of the inspection or reinspection at which the deficiency is identified.

#### Section 19-1404

(a) A civil money penalty imposed under this section for potential for more than minimal harm deficiencies:

  (1) May not exceed $10,000 per instance; or

  (2) May not exceed $1,000 per day for an ongoing pattern of deficiencies until the nursing home is in compliance.

(b) A civil money penalty imposed under this subtitle for actual harm deficiencies:

  (1) May not exceed $10,000 per instance; or

  (2) May not exceed $5,000 per day for an ongoing pattern of deficiencies until the nursing home is in compliance.

(c) A civil money penalty imposed under this section for a serious and immediate threat:

  (1) May not exceed $10,000 per instance; or

  (2) May not exceed $10,000 per day for an ongoing pattern of deficiencies until the nursing home is in compliance.

(d) In setting the amount of a civil money penalty under this section, the Secretary shall consider, pursuant to guidelines set forth in regulations promulgated by the Secretary, the following factors:

  (1) The number, nature, and seriousness of the deficiencies;

  (2) The degree of risk to the health, life, or safety of the residents of the nursing home caused by the deficiency or deficiencies;

  (3) The efforts made by the nursing home to correct the deficiency or deficiencies;

  (4) Current federal guidelines for money penalties;

  (5) Whether the amount of the proposed civil money penalty will jeopardize the financial ability of the nursing home to continue operating as a nursing home; and

  (6) Such other factors as justice may require.

#### Section 19-1405

(a) When the Department determines that there is a deficiency in a nursing home, the Department may appoint an independent monitor to oversee efforts made by the nursing home to achieve compliance with State and federal regulations governing nursing homes that participate in the Medicare and Medicaid programs.

(b) The appointment of a State monitor is an intermediate sanction that may be in addition to or in lieu of other sanctions.

(c) The State monitor's duties may include:

  (1) Periodic inspections of a nursing home for the purpose of assessing the nursing home's compliance with State and federal regulations; and

  (2) Reporting to the Department and the nursing home its findings.

(d) The State monitor may not be an employee of the Department.

(e) A nursing home shall be responsible for the costs associated with the appointment of a State monitor to the nursing home.

#### Section 19-1406

(a) Within 15 days of the request for an appeal by a nursing home, the nursing home shall deposit the amount of the civil money penalty in an interest bearing escrow account, the nursing home shall bear any cost associated with establishing the escrow account, and the account shall be titled in the name of the nursing home and the Maryland Department of Health as joint owners.

(b) When the Secretary issues the final decision of the Department:

  (1) If the decision upholds the imposition of the full civil money penalty, the escrow funds will be released to the Department within 15 days from the date of the decision;

  (2) If the decision upholds the imposition of a civil penalty, but reduces the amount of the civil penalty, the amount due the Department will be released to the Department with accrued interest within 15 days of the date of the decision and the balance will be released to the nursing home within 15 days of the date of the decision; or

  (3) If the decision reverses the imposition of the civil penalty, the escrow funds will be released to the nursing home within 15 days of the decision.

(c)

  (1) A hearing on the appeal shall be held in accordance with the Administrative Procedure Act, under Title 10, Subtitle 2 of the State Government Article.

  (2) The Secretary shall have the burden of proof with respect to the imposition of civil money penalties under Sec. 19-1404 or Sec. 19-1413.1 of this subtitle.

  (3) A decision shall be rendered by the Office of Administrative Hearings within 10 working days of the hearing.

(d) A nursing home is entitled to a 40% reduction in the amount of the civil money penalty if it waives its right to a hearing within 30 days of the Department's order.

#### Section 19-1407

(a)

  (1) There is a Health Care Quality Account established in the Department.

  (2) The Health Care Quality Account shall be funded by civil money penalties paid by nursing homes and other penalties that the Office of Health Care Quality may assess.

  (3) The Department shall pay all penalties collected under this title to the Comptroller of the State.

  (4) The Comptroller shall distribute the funds collected under this title to the Health Care Quality Account.

  (5) The Health Care Quality Account is a continuing, nonlapsing fund, not subject to Sec. 7-302 of the State Finance and Procurement Article.

  (6) Any unspent portions of the Health Care Quality Account may not be transferred or reverted to the General Fund of the State, but shall remain in the Health Care Quality Account to be used for the purposes specified in this section.

(b) The Health Care Quality Account shall be used for training, grant awards, demonstration projects, or other purposes designed to improve the quality of care.

(c) The Department shall adopt regulations for the distribution of funds from the Health Care Quality Account.

#### Section 19-1408

(a)

  (1) Subject to subsection (c) of this section, the Department shall make a site visit and conduct a full survey of each licensed nursing home at least once per calendar year.

  (2) Unless otherwise required by federal law, all surveys shall be unannounced.

(b)

  (1) Subject to paragraphs (2) and (3) of this subsection, the Department shall initiate an investigation of a nursing home complaint alleging actual harm within 10 business days after receiving the complaint.

  (2) If the Department receives a complaint against a nursing home alleging immediate jeopardy to a resident, the Department:

    (i) Shall make every effort to investigate the complaint within 24 hours after receiving the complaint; and

    (ii) Shall investigate the complaint not later than 48 hours after receiving the complaint.

  (3)

    (i) If the Department initiates an investigation of a nursing home complaint under this subsection, the Department shall:

      (1) Notify the local health department for the county in which the nursing home is located within 24 hours after initiating the investigation; and

      (2) To the extent practicable and as permitted by federal law, consult and coordinate with the local health department on the complaint investigation and response.

    (ii) This paragraph may not be construed to require a local health department to assist with or otherwise assume the nursing home oversight responsibilities of the Department as required by federal or State law.

(c) If ownership of a licensed nursing home is transferred to a person that does not own or operate another nursing home in the State at the time of the transfer, the Department shall conduct:

  (1) The first full survey of the licensed nursing home as required under subsection (a) of this section within 3 months after the date of transfer; and

  (2) An unannounced, on-site follow-up survey of the licensed nursing home that covers any deficiencies noted in the full survey within 120 days after the full survey was completed.

(d)

  (1) Beginning July 1, 2025, and every 3 months thereafter, the Department shall report to the Senate Finance Committee and the House Health Committee, in accordance with Sec. 2-1257 of the State Government Article, the number of surveys conducted in each county, disaggregated by the following types of surveys:

    (i) Standard survey;

    (ii) Complain survey;

    (iii) Follow-up survey;

    (iv) Revisit survey;

    (v) Special focus facility survey;

    (vi) Abbreviated survey; and

    (vii) Life safety code survey.

  (2) Beginning July 1, 2025, and every 6 months thereafter, the Office of Health Care Quality shall report to the local area agency on aging for each county the name of each nursing home in the county that was surveyed in the immediately preceding 6 months and the date each survey was conducted.

#### Section 19-1408.1

(a) The Department shall develop a clear and easy-to-understand graphic data dashboard that includes:

  (1) The number of staff hired by the agency in each unit in the fiscal year to date;

  (2) The number of surveyors employed by the agency in each unit in the fiscal year to date; and

  (3) The number of vacancies within the agency in each unit in the fiscal year to date.

(b) The Department shall:

  (1) Update the data dashboard developed under subsection (a) of this section at least every 2 weeks; and

  (2) Post the most recent updated data dashboard prominently on its website.

#### Section 19-1409

(a) There is an Oversight Committee on Quality of Care in Nursing Homes and Assisted Living Facilities.

(b) The Oversight Committee shall consist of the following members:

  (1) One member of the Senate Finance Committee, appointed by the President of the Senate;

  (2) One member of the House Health Committee, appointed by the Speaker of the House;

  (3) The Secretary of Aging, or the Secretary's designee;

  (4) The Director of the Office of Health Care Quality, or the Director's designee;

  (5) The Deputy Secretary for Behavioral Health, or the Deputy Secretary's designee;

  (6) The Secretary of Human Services, or the Secretary's designee;

  (7) The Secretary of Disabilities, or the Secretary's designee;

  (8) The State Long-Term Care Ombudsman;

  (9) Two representatives of area agencies on aging, one of which shall be a member of a local long-term care ombudsman program established under Title 10, Subtitle 9 of the Human Services Article, selected by the President of the Maryland Association of Area Agencies on Aging;

  (10) One representative of a local long-term care ombudsman entity, selected by the State Long-Term Care Ombudsman;

  (11) Three consumer members, selected by the State Long-Term Care Ombudsman, all of whom shall be consumers living in an assisted living facility or a nursing home or have a family member living in an assisted living facility or a nursing home;

  (12) The following representatives, selected by the organizations the individual represents:

    (i) One representative from the Mid-Atlantic LifeSpan;

    (ii) One representative of the Hospice Network of Maryland;

    (iii) One representative of the Maryland Hospital Association;

    (iv) One representative of 1199SEIU United Health Workers East;

    (v) One representative of the Maryland Chapter of AARP;

    (vi) One representative of United Seniors of Maryland;

    (vii) One representative of the Mental Health Association of Maryland knowledgeable in issues of aging;

    (viii) One representative of the Greater Maryland Chapter of the Alzheimer's Association;

    (ix) One representative of the Maryland Association for Medical Adult Day Services; and

    (x) One representative of LeadingAge Maryland; and

  (13) Three representatives from the assisted living industry, of which, to the extent practicable, one shall represent a program that cares for one to four residents, one shall represent a program that cares for five to nine residents, and one shall represent a program that cares for more than 10 residents.

(c) The Secretary of Aging, or the Secretary's designee, shall chair the Oversight Committee.

(d) The Oversight Committee shall evaluate the progress in improving nursing home care quality and assisted living facility quality statewide, which may include consideration of:

  (1) Quality of care standards for nursing homes and assisted living facilities;

  (2) Standards for the identification of the onset of dementia and Alzheimer's disease;

  (3) Standards for the identification of conditions appropriate for hospice services;

  (4) Staffing patterns and staffing standards;

  (5) Policies and procedures for inspecting nursing homes and assisted living facilities, and responding to quality of care complaints;

  (6) A comparison of Maryland standards, policies, and procedures to those in other states;

  (7) The labor pool available to fill nursing and nursing aide jobs;

  (8) State funding mechanisms for nursing homes and assisted living facilities, including the Medicaid Nursing Home Reimbursement System, potential barriers to eligibility in the Maryland Medical Assistance Program, potential barriers to the timely payment of claims submitted to the Maryland Medical Assistance Program, and regulation of nursing homes;

  (9) The provision and quality of dementia care and behavioral health supports and services to meet the needs of nursing home and assisted living facility residents;

  (10) Staff training and development;

  (11) The rights of residents;

  (12) Data on resident satisfaction;

  (13) Resident assessments;

  (14) Resident care planning;

  (15) The monitoring of residents; and

  (16) The change of resident status.

(e) The Office of Health Care Quality in the Maryland Department of Health shall submit a report to the Oversight Committee annually on the status of quality of care in nursing homes and assisted living facilities.

(f) The Deputy Secretary of Health Care Financing, or the Deputy Secretary's designee, shall report annually to the Oversight Committee on the status of the Medicaid Nursing Home Reimbursement System, which shall include but not be limited to:

  (1) Elements of the existing methodology that are no longer relevant;

  (2) Elements of the existing methodology that can be revised;

  (3) The appropriateness of redesigning the system given changing demographics of the target population; and

  (4) General Fund and federal fund savings from a system redesign that may be redirected to nursing home staff development in the nursing cost center.

(g) The Oversight Committee shall review the reports of the Office of Health Care Quality and the Deputy Secretary of Health Care Financing and develop recommendations to continue improvement in nursing home and assisted living facility care.

(h) The Oversight Committee may:

  (1) Review legislation introduced in the General Assembly that may affect nursing home and assisted living facility care; and

  (2) Make recommendations about the legislation to the General Assembly.

(i) The Oversight Committee may:

  (1) Review proposed regulations that may affect nursing home and assisted living facility care; and

  (2) Make recommendations about the regulations to the departments proposing the regulations and to the Joint Committee on Administrative, Executive, and Legislative Review.

(j) The Oversight Committee shall report its findings and recommendations to the Governor and, subject to Sec. 2-1257 of the State Government Article, to the General Assembly on or before December 1 of each year.

(k) The Department of Aging, with assistance from the Maryland Department of Health, the Department of Human Services, and the Department of Legislative Services, shall provide staff support for the Oversight Committee.

#### Section 19-1410

(a) Each nursing home shall develop and implement a quality assurance program.

(b)

  (1) Each nursing home shall designate a qualified individual to coordinate and manage the nursing home's quality assurance program.

  (2) Each nursing home shall establish a quality assurance committee and shall include at least the following members:

    (i) The nursing home administrator;

    (ii) The director of nursing;

    (iii) The medical director;

    (iv) A social worker;

    (v) A licensed dietitian; and

    (vi) A geriatric nursing assistant.

  (3) The quality assurance committee shall:

    (i) Meet at least monthly;

    (ii) Maintain records of all quality assurance activities;

    (iii) Keep records of committee meetings that shall be available to the Department during any on-site visit; and

    (iv) Prepare monthly reports that shall be presented to the ombudsman, the resident's council, and the family council.

  (4) The quality assurance committee for a nursing home shall review and approve annually the quality assurance plan for the nursing home.

  (5) Each nursing home shall establish a written quality assurance plan that:

    (i) Includes procedures for concurrent review for all residents;

    (ii) Provides criteria that routinely monitors nursing care including medication administration, prevention of decubitus ulcers, dehydration and malnutrition, nutritional status and weight loss or gain, accidents and injuries, unexpected deaths, changes in mental or psychological status, and any other data necessary to monitor quality of care;

    (iii) Includes methods to identify and correct problems; and

    (iv) Is readily available to nursing home residents and their families, guardians, or surrogate decision makers.

  (6) The quality assurance plan shall be submitted to the Department every 2 years.

  (7) The nursing home administrator shall take appropriate remedial actions based on the recommendations of the nursing home's quality assurance committee.

  (8) The Secretary may not require the quality assurance committee to disclose the records and the reports prepared by the committee except as necessary to assure compliance with the requirements of this section.

  (9) If the Department determines that a nursing home is not implementing its quality assurance program effectively and that quality assurance activities are inadequate, the Department may impose appropriate sanctions on the nursing home to improve quality assurance including mandated employment of specified quality assurance personnel.

(c)

  (1) Each nursing home shall display on each floor of the nursing home a notice that explains the current ratio of licensed personnel to residents and unlicensed personnel to residents.

  (2) The notice shall be:

    (i) Posted in a location that is visible and accessible to residents and their family or guardians and any potential consumers; and

    (ii) On a form provided by the Department.

#### Section 19-1410.1

(a) On or before December 1, 2008, each nursing home shall establish a safe patient lifting workgroup with equal membership from management and employees.

(b)

  (1) On or before July 1, 2009, the safe patient lifting workgroup shall develop a safe patient lifting policy for the nursing home.

  (2) The goal of the policy shall be to reduce employee injuries associated with patient lifting.

(c) While developing a safe patient lifting policy, the workgroup shall consider, based on the patient population of that nursing home, the appropriateness and effectiveness of:

  (1) Developing or enhancing patient handling hazard assessment processes;

  (2) Enhanced use of mechanical lifting devices;

  (3) Developing specialized lift teams;

  (4) Training programs for safe patient lifting required for all patient care personnel at the nursing home;

  (5) Incorporating physical space and construction design for mechanical lifting devices in any architectural plans for nursing home construction and renovation; and

  (6) Developing an evaluation process to determine the effectiveness of the policy.

#### Section 19-1410.2

(a) In this section, "workplace safety" means the prevention of any physical assault or threatening behavior against an employee in a nursing home.

(b) This section applies to nursing homes that are licensed for 45 beds or more.

(c) Each nursing home shall assign to an appropriate committee the task of:

  (1) Conducting an annual assessment of workplace safety issues; and

  (2) Making recommendations to the nursing home for reducing workplace injuries.

(d) In conducting an annual assessment of workplace safety issues, the committee assigned to conduct the assessment under subsection (c)(1) of this section shall consult with geriatric nursing assistants and other employees of the nursing home who are involved in assisting residents with activities of daily living.

#### Section 19-1410.3

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Catastrophic health emergency" means a health emergency with regard to which the Governor issues a proclamation under Sec. 14-3A-02 of the Public Safety Article.

  (3) "Compassionate care visitor" means a family member or legal guardian of a resident or any individual who is important to the mental, physical, or social well-being of the resident during critical situations including the end of the resident's life, the significant mental or physical decline of the resident, or when exigent circumstances exist regarding the resident.

  (4) "COVID-19" means, interchangeably and collectively, the coronavirus known as COVID-19 or 2019-nCoV and the SARS-CoV-2 virus.

  (5) "Personal care visitor" means a family member or legal guardian of a resident who is important to the mental, physical, or social well-being of the resident.

(b)

  (1) Consistent with federal requirements, the Department shall develop guidelines relating to the restrictions on visitation that a nursing home may impose to reduce the spread of COVID-19 or another disease that constitutes a catastrophic health emergency.

  (2) The guidelines shall:

    (i) Describe the circumstances under which visitation may be restricted to only compassionate care visitors and personal care visitors;

    (ii) Limit the movement of visitors within the nursing home, which may include restricting visitors to the resident's room or another designated room;

    (iii) Require each visitor to follow safety protocols to limit the spread of COVID-19 or another disease that constitutes a catastrophic health emergency, which may include:

      (1) Testing for COVID-19 or another disease that constitutes a catastrophic health emergency;

      (2) Checking body temperature;

      (3) Health screenings;

      (4) The use of personal protective equipment;

      (5) Social distancing; and

      (6) Any other safety protocol that the Department considers appropriate to limit the spread of COVID-19 or another disease that constitutes a catastrophic health emergency in a nursing home;

    (iv) Require, as practicable and when available, alternative means of communication with visitors if a nursing home determines that an in-person visit would endanger the health and safety of a patient, resident, or member of the staff; and

    (v) Provide additional guidance necessary to promote access to residents by compassionate care visitors.

  (3) In addition to the requirements in paragraph (2) of this subsection, the guidelines regarding personal care visitation shall:

    (i) Establish procedures for the designation of a personal care visitor by a resident or a legal representative of the resident that:

      (1) May include requiring a health care professional to determine whether a personal care visitor is necessary for the mental, physical, or social well-being of the resident; and

      (2) If a determination is required, authorize the determination to be made by a health care professional who is not affiliated with the nursing home;

    (ii) Provide that a resident may designate not more than one personal care visitor;

    (iii) Establish procedures for changing the designation of a resident's personal care visitor;

    (iv) Require a personal care visitor to waive a nursing home from liability for exposure to COVID-19 or another disease that constitutes a catastrophic health emergency;

    (v) Establish the circumstances under which visitation by a personal care visitor may be limited, suspended, or terminated, including increased local infection rates and health care capacity;

    (vi) Establish standards for the frequency and duration of personal care visits; and

    (vii) Establish the total number of personal care visitors authorized to visit a nursing home facility at any one time.

#### Section 19-1411

(a)

  (1) Each nursing home shall designate a physician to serve as medical director.

  (2) The medical director is responsible for monitoring physician services at the nursing home.

  (3) The medical director shall report monthly to the quality assurance committee on the quality of medical care at the nursing home.

(b) The Secretary, in consultation with the Medical and Chirurgical Faculty of Maryland, and representatives of the nursing home industry, shall:

  (1) Establish qualifications for the medical director of a nursing home or anyone acting for the medical director in his or her absence;

  (2) Define the duties of the medical director; and

  (3) Adopt regulations for the attending physicians who treat residents of nursing homes that will provide for physician accountability.

#### Section 19-1412

(a) The Secretary shall:

  (1) Establish a technical assistance unit within the Department to support compliance efforts and best practices; and

  (2) Establish a list of approved medical automated systems.

(b) The Secretary may:

  (1) Partially reimburse a nursing home for installation of automated systems that have been approved by the Department;

  (2) Develop guidelines for reimbursement; and

  (3) Adopt regulations for the implementation of this subtitle.

#### Section 19-1413

Each nursing home shall:

(1) Establish a procedure to provide for the smooth and orderly transfer of residents in the event of closure;

(2) Provide a 30-day notice to residents and their families or guardians prior to closure of the nursing home unless the Department waives the notice requirement;

(3) Provide a 15-day notice to residents and their families or guardians prior to termination of public funding unless the Department waives the notice requirement; and

(4) Immediately notify, if known, a resident's family or guardian of:

  (i) An accident involving the resident which results in injury and has the potential for requiring physician intervention;

  (ii) A significant change in the resident's physical, mental, or psychosocial status; or

  (iii) A need to alter the resident's treatment significantly.

#### Section 19-1413.1

(a) A nursing home that violates Sec. 19-1413(2) of this subtitle is subject to a civil money penalty not exceeding expenses incurred by the Office of Health Care Quality in ensuring a smooth and orderly transition of residents, including payroll expenses.

(b) If a civil money penalty is imposed on a nursing home under subsection (a) of this section, the nursing home is subject to Sec. 19-1406 of this subtitle.

#### Section 19-1414

The Department may review financial and performance records of an applicant for a license or management firm under contract with an applicant for a license to determine ability of the applicant or management firm to comply with appropriate laws and regulations.

#### Section 19-1415

(a) In this section, "change in condition" means a significant change in the resident's physical, mental, or psychological status including:

  (1) Life-threatening conditions such as heart attack or stroke;

  (2) Clinical complications such as:

    (i) Development of a pressure sore;

    (ii) Onset of recurrent periods of delirium;

    (iii) Onset of recurrent urinary tract infection;

    (iv) Onset of depression; or

    (v) Onset of aggressive or inappropriate behavior;

  (3) The need to discontinue a medication or treatment because of:

    (i) Adverse consequences; or

    (ii) The need to begin a new form of treatment;

  (4) Evaluation at or admission to a hospital; and

  (5) Accidents that result in injury having the potential for requiring a physician's intervention.

(b) Consistent with State and federal confidentiality laws and in a timely manner, a nursing home shall notify a resident and, if applicable, the resident's representative or interested family member of any:

  (1) Change in condition;

  (2) Adverse event that may result in a change in condition;

  (3) Outcome or care that results in an unanticipated consequence; or

  (4) Corrective action, if appropriate.

(c) If the Department determines that a nursing home failed to notify a resident, resident's representative, or interested family member under subsection (b) of this section, the Department shall require as part of a plan of correction that the nursing home notify the resident, the resident's representative, or interested family member as soon as possible.

#### Section 19-1416

(a) In this section, "family council" means a group of individuals who work together to protect the rights of and improve the quality of life of residents of a nursing home.

(b)

  (1) A family council for a nursing home may consist of the following members:

    (i) Members of a resident's family; or

    (ii) An individual appointed by the resident, or if the resident is incapable of appointing an individual, an individual appointed by the resident's family.

  (2)

    (i) Subject to subparagraph (ii) of this paragraph, a family council may be created by the owner, operator, or staff of a nursing home.

    (ii) Except as provided in paragraph (3) of this subsection, in order to facilitate the development of a family council, the owner, operator, or staff of a nursing home may lead the family council for no longer than 6 months at which time the family council shall be led by a member of the family council.

  (3) On the written request of a family council, the nursing home may assist the family council in the administrative functions of operating the family council in a mutually agreed upon manner.

(c) A nursing home shall give each new or prospective resident the following written information about the family council:

  (1) The name, address, and phone number of a current member of the family council;

  (2) A brief description of the purpose and function of the family council;

  (3) Instructions on how the resident or prospective resident may review the public files described in subsection (e) of this section; and

  (4) The name, address, and phone number of the State or local ombudsman.

(d) A nursing home shall respond in writing to any written grievance or other written communication from the family council within 14 calendar days after receiving a communication.

(e)

  (1) A nursing home shall create and maintain a public correspondence file and a regulatory correspondence file for communications with a family council.

  (2) The correspondence files shall include a copy of each written communication and response described in subsection (d) of this section.

  (3)

    (i) The records in the regulatory file shall be unedited.

    (ii) The records in the public file shall delete any information that identifies an individual resident.

  (4) The public file may be reviewed by a resident, prospective resident, or the representative of either a resident or prospective resident during normal business hours and at any other time the nursing home agrees to make the public file available.

  (5) The nursing home shall promptly comply with a request by a licensing authority to review the records in either the public or regulatory files.

#### Section 19-1417

(a) Each nursing home in the State shall notify each resident and prospective resident in writing or by written electronic communication if:

  (1) The nursing home does not maintain professional liability insurance coverage; or

  (2) The nursing home's professional liability insurance coverage has lapsed for any period of time and has not been renewed.

(b) The notification under subsection (a) of this section shall be:

  (1)

    (i) Provided to a prospective resident:

      (1) At the first visit by the prospective resident during any period during which the nursing home does not maintain professional liability coverage; and

      (2) If the nursing home does not maintain professional liability insurance at the time the prospective resident applies for admission, at the time of application; and

    (ii) If the professional liability insurance lapses, provided to each resident within 30 days after the date the coverage lapsed;

  (2) Signed by:

    (i) The prospective resident at the time of application for admission; or

    (ii) The resident at the time the notification of the lapse in coverage is provided under item (1)(ii) of this subsection; and

  (3) Retained by the nursing home as part of the nursing home's records.

(c) Each nursing home operating in the State that does not maintain professional liability insurance coverage shall post in a conspicuous place visible to residents and guests that the nursing home does not maintain professional liability coverage.

#### Section 19-1418

This subtitle may be cited as the "Maryland Nursing Home Quality Assurance Act".

### Subtitle 14A. Third Party Liability Reviews and Audits of Nursing Homes

#### Section 19-14A-01

(a) In this subtitle the following words have the meanings indicated.

(b) "Final report" means the third party liability audit report issued to a nursing home stating the total amount due to the Department as a result of the completed audit.

(c) "Nursing home" has the meaning stated in Sec. 19-1401(e) of this title.

(d)

  (1) "Third party" means any individual, entity, or program that is or may be liable to pay all or part of the medical cost of any medical assistance furnished to a recipient under the Medical Assistance Program.

  (2) "Third party" includes private health insurance, employment-related health insurance, medical support from absent parents, automobile insurance, court judgments or settlements from a liability insurer, State workers' compensation, first party probate-estate recoveries, or any federal programs.

(e) "Third party liability audit" means a financial review of Medical Assistance payments to a provider to ascertain the legal liability of third parties to pay for care and services available under the Medical Assistance Program.

(f) "Third party liability review" means a financial review of the credit balances of a nursing home to ascertain the legal liability of third parties to pay for care and services available under the Medical Assistance Program.

#### Section 19-14A-02

(a) A nursing home that receives payment from the Medical Assistance Program shall provide a report of the credit balances of the nursing home to the Department on a quarterly basis.

(b) The Department shall conduct a third party liability review of the report of the credit balances provided under subsection (a) of this section.

(c) The Department may conduct a third party liability audit of a random sample of the reports of credit balances reviewed under subsection (b) of this section.

(d)

  (1) Subject to paragraph (2) of this subsection, the Department may conduct a third party liability audit of a nursing home that is found to be noncompliant as a result of the audit conducted under subsection (c) of this section.

  (2) In conducting the third party liability audit authorized under paragraph (1) of this subsection, the Department may only review the financial information of the nursing home for the 2-year period immediately prior to the date of the audit period in which the nursing home was found to be noncompliant.

#### Section 19-14A-03

(a) A nursing home may appeal the results of a final report of a third party liability audit by filing written notice with the Department within 30 days after the nursing home receives the final report from the Department.

(b) An individual at the Department who did not participate in the final report shall:

  (1) Review the appeal authorized under subsection (a) of this section; and

  (2) Issue a report that either revises or concurs with the final report of the third party liability audit.

(c) A nursing home may appeal the results of the report issued by the Department under subsection (b) of this section by filing written notice with the Nursing Home Appeal Board within 30 days of receipt of the report.

#### Section 19-14A-04

The Department may adopt rules and regulations to carry out the provisions of this subtitle.

### Subtitle 14B. Pay-for-Performance Program for Nursing Homes

#### Section 19-14B-01

(a)

  (1) As provided in subsection (e) of this section, a portion of the revenues from the quality assessment that is assessed under Sec. 19-310.1 of this title shall be distributed to nursing facilities subject to Sec. 19-310.1 of this title based on accountability measures that indicate quality of care or a commitment to quality of care.

  (2) In consultation with representatives of the nursing facilities and other stakeholders, the Maryland Department of Health shall develop accountability measures to use in a pay-for-performance program that take into account both performance and improvement.

  (3) The accountability measures shall be objective, measurable, and when considered in combination with each other, deemed to have a correlation to residents' quality of life and care.

(b)

  (1) On or before December 1, 2009, and each year thereafter, the Department shall, in consultation with representatives of nursing facilities and other interested stakeholders, make necessary changes to the pay-for-performance program to determine the effect on providers and to determine if the measures satisfy the requirements of being objective, measurable, and, when considered in combination with each other, have a correlation to residents' quality of life and care.

  (2) In performing the review required under paragraph (1) of this subsection, on or before December 1, 2009, and on or before December 1, 2010, the Department shall examine and modify the pay-for-performance program to include improvement measures in the scoring criteria.

(c)

  (1) A portion of the revenues generated by the quality assessment under Sec. 19-310.1 of this title shall be in an incentive program to be distributed as provided in this section, to the extent federal law allows.

  (2) The distribution of revenues as provided in this section shall be used as an incentive for nursing facilities to provide quality care and may not be used to directly or indirectly hold harmless any nursing facility.

(d) On or before December 1, 2008, the plan required under this section shall be submitted by the Department, in accordance with Sec. 2-1257 of the State Government Article, to the General Assembly.

(e)

  (1) On or before July 1, 2009, the Department shall:

    (i) Score nursing facilities based on scoring criteria developed and reported to the General Assembly in the December 1, 2008 report as required by Chapter 200 of the Acts of the General Assembly of 2008; and

    (ii) Send each nursing facility a transmittal with the scoring criteria, the performance of the nursing facility relative to the scoring, and the money that would have been received by the nursing facility using the scoring criteria.

  (2) Beginning July 1, 2010, the Department shall distribute 50% of the revenues generated by the quality assessment that is assessed under Sec. 19-310.1 of this title and required for use in a pay-for-performance program to nursing facilities as provided in this section.

  (3) Beginning July 1, 2011, the Department shall fully implement the pay-for-performance program as provided in this section.

### Subtitle 14C. Maryland State-Owned Nursing Homes

#### Section 19-14C-01

(a) In this subtitle the following words have the meanings indicated.

(b) "Deficiency" has the meaning stated in Sec. 19-1401 of this title.

(c) "Monitoring agency" means:

  (1) The Centers for Medicare and Medicaid Services;

  (2) The Office of Health Care Quality within the Department;

  (3) The Maryland Department of Labor;

  (4) A local health department;

  (5) The U.S. Department of Veterans Affairs; or

  (6) The federal Occupational Safety and Health Administration.

(d) "Nursing home" has the meaning stated in Sec. 19-1401 of this title.

#### Section 19-14C-02

(a)

  (1) If a State-owned nursing home that is operated by a contractor receives a deficiency from or is subject to an enforcement action by a monitoring agency, within 15 days after the final survey finding, the department charged with oversight of the nursing home shall provide notice of the deficiency or enforcement action to:

    (i) The Governor;

    (ii) In accordance with Sec. 2-1257 of the State Government Article, the Senate Finance Committee, the House Health Committee, and the members of the General Assembly who represent the district in which the nursing home is located; and

    (iii) The local governing body of the county in which the nursing home is located.

  (2) Within 30 days after the contractor's final acceptance of a plan of correction or completion of an informal dispute resolution, the department charged with oversight of the nursing home shall provide to the Governor and, in accordance with Sec. 2-1257 of the State Government Article, the Senate Finance Committee, the House Health Committee, and the members of the General Assembly who represent the district in which the nursing home is located:

    (i) A statement of the deficiencies found by the monitoring agency;

    (ii) The plan of correction or results of the informal dispute resolution; and

    (iii) All communications from the monitoring agency regarding survey activities conducted at the nursing home.

(b) On or before January 1 each year, beginning in 2024, the Department shall report to the Governor and, in accordance with Sec. 2-1257 of the State Government Article, the General Assembly on all federal and State:

  (1) Survey activities conducted during the immediately preceding 12-month period at each State-owned nursing home that is operated by a contractor; and

  (2) Enforcement actions imposed during the immediately preceding 12-month period on each State-owned nursing home that is operated by a contractor.

### Subtitle 18. Assisted Living Programs

#### Section 19-1801

In this subtitle:

(1) "Assisted living program" means a residential or facility-based program that provides housing and supportive services, supervision, personalized assistance, health-related services, or a combination thereof that meets the needs of individuals who are unable to perform or who need assistance in performing the activities of daily living or instrumental activities of daily living in a way that promotes optimum dignity and independence for the individuals.

(2) "Assisted living program" does not include:

  (i) A nursing home, as defined under Sec. 19-1401 of this title;

  (ii) A State facility, as defined under Sec. 10-101 of this article;

  (iii) A program licensed by the Department under Title 7 or Title 10 of this article;

  (iv) A hospice care program regulated by the Department under Subtitle 9 of this title;

  (v) Services provided by family members;

  (vi) Services provided in an individual's own home; or

  (vii) A program certified by the Department of Human Services under Title 6, Subtitle 5, Part II of the Human Services Article as a certified Adult Residential Environment Program.

#### Section 19-1802

The Department shall be the lead agency for supervising and monitoring a statewide interagency system for regulating the establishment and operation of assisted living programs.

#### Section 19-1803

(a) The Department shall encourage, but may not require, providers of assisted living program services to offer a continuum of care.

(b) Providers of assisted living program services may provide services at a variety of levels and in a variety of settings.

#### Section 19-1804

The Department shall:

(1) Serve as the point of entry for persons desiring information on assisted living programs;

(2) Provide the Department of Aging and other State agencies that routinely receive inquiries from the public about assisted living with information that will enable the agencies to respond to the inquiries accurately and effectively; and

(3) Delegate various aspects of its responsibilities under this subtitle to monitor and inspect assisted living programs and facilities to the Department of Aging and the Department of Human Services, in accordance with an interagency agreement, for the purpose of ensuring compliance with the regulations adopted by the Department under this subtitle.

#### Section 19-1804.1

(a) A person shall be licensed by the Department to conduct, operate, or maintain an assisted living program in the State.

(b)

  (1) A person shall submit an application for licensure to conduct, operate, or maintain an assisted living program to the Secretary on a form developed by the Secretary.

  (2)

    (i) The Secretary shall develop the application for licensure required under paragraph (1) of this subsection.

    (ii) The application shall include the name and address of each officer, manager, alternate manager, and delegating nurse or case manager of the assisted living program.

  (3) In addition to the application, an applicant for initial licensure shall submit to the Secretary:

    (i) Information concerning any license or certification held by the applicant under the Health Occupations Article or under this article, including the prior or current operation by the applicant of a health care facility, residential facility, or similar health care program;

    (ii) Information demonstrating the financial and administrative ability of the applicant to operate an assisted living program in compliance with this subtitle;

    (iii) The policies and procedures to be implemented by the assisted living program;

    (iv) Identification of the personnel and relief personnel to be employed by the assisted living program; and

    (v) Any other information that is relevant to the ability of the applicant to care for the residents of the assisted living program.

(c)

  (1) The Secretary shall:

    (i) Review the application and information received under subsection (b) of this section; and

    (ii) Conduct an independent investigation of the assisted living program applying for initial licensure.

  (2) Based on the review and investigation conducted under paragraph (1) of this subsection, the Secretary shall:

    (i) Authorize the unconditional approval of the application;

    (ii) Authorize the conditional approval of the application; or

    (iii) Deny the application.

(d) The Secretary may issue a probationary license that is valid for a period of time determined by the Secretary in accordance with regulations adopted by the Secretary.

#### Section 19-1805

(a) The Department shall:

  (1) Define different levels of assisted living according to the level of care provided;

  (2) Require all assisted living programs to be licensed to operate according to the level of the program;

  (3) Develop a waiver process for authorizing an assisted living program to continue to care for an individual whose medical or functional condition has changed since admission to the program to an extent that the level of care required by the individual exceeds the level of care for which the program is licensed;

  (4) Promote affordable and accessible assisted living programs throughout the State;

  (5) Establish and enforce quality standards for assisted living programs;

  (6) Require periodic inspections of assisted living program facilities, including at least an annual unannounced on-site inspection;

  (7) Establish requirements for the qualifications or training or both of assisted living program employees;

  (8) Establish a "resident bill of rights" for residents of assisted living program facilities that includes, at a minimum:

    (i) The right to be treated with consideration, respect, and full recognition of human dignity and individuality;

    (ii) The right to receive treatment, care, and services that are adequate, appropriate, and in compliance with relevant federal and State laws, rules, and regulations;

    (iii) The right to be free from mental and physical abuse;

    (iv) The right to be free from mental, verbal, sexual, and physical abuse, neglect, or involuntary seclusion or exploitation;

    (v) The right to notice, procedural fairness, and humane treatment when being transferred or discharged from a facility;

    (vi) The right to participate in decision making regarding transitions in care, including a transfer or discharge from a facility;

    (vii) The right to be free from physical and chemical restraints, except for restraints that a physician authorizes for a clearly indicated medical need; and

    (viii) The right to manage personal financial affairs;

  (9) Define which, if any, assisted living programs may be exempt from the requirements of Sec. 19-311 of this title; and

  (10) For Alzheimer's special care units:

    (i) Establish the number of dementia-specific training hours to be completed for those staff working in Alzheimer's special care units;

    (ii) Determine the topic content for dementia-specific training required for those staff working in Alzheimer's special care units; and

    (iii) Require staff sufficient to meet the needs of residents in Alzheimer's special care units.

(b)

  (1) The Department, in consultation with representatives of the affected industry and advocates for residents of the facilities and with the approval of the Department of Aging and the Department of Human Services, shall adopt regulations to implement this subtitle.

  (2) The regulations adopted under paragraph (1) of this subsection shall:

    (i) Provide for the licensing of assisted living programs;

    (ii) Require the Department, during a survey or other inspection of an assisted living program, to review the number of waivers granted to the program under subsection (a)(3) of this section and determine whether a change in the program's licensure status is warranted; and

    (iii) Require an assisted living program facility to post in a conspicuous place visible to actual and potential residents of the facility and other interested parties:

      (1)

        (A) Its statement of deficiencies for the most recent survey;

      (B) Any subsequent complaint investigations conducted by federal, State, or local surveyors; and

      (C) Any plans of correction in effect with respect to the survey or complaint investigation; or

      (2) A notice of the location, within the facility, of the items listed in item 1 of this item.

#### Section 19-1805.1

(a) To prevent irreparable harm to residents in a program, the Attorney General may seek injunctive relief on behalf of the State on the basis of an imminent or ongoing violation of a basic right of assisted living program residents provided under Sec. 19-1805(a)(8)(i) through (viii) of this subtitle.

(b) In exercising the authority granted under this section, the Attorney General may not duplicate the corrective action imposed by the Department for the same violation.

#### Section 19-1806

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "Continuing care" has the meaning stated in Sec. 10-401 of the Human Services Article.

  (3) "Continuing care agreement" has the meaning stated in Sec. 10-401 of the Human Services Article.

(b) This section applies to assisted living programs that offer assisted living program services as part of a continuum of care in accordance with a continuing care agreement that does not require a subscriber to execute a separate assisted living agreement to receive those services.

(c)

  (1) An assisted living program subject to this section that meets the requirements of Title 10, Subtitle 4 of the Human Services Article with regard to assisted living is not required to execute a separate assisted living resident agreement that is in addition to the continuing care agreement.

  (2) For purposes of paragraph (1) of this subsection, if a separate assisted living resident agreement is not utilized, references to a resident agreement in any regulations adopted under this subtitle shall mean the continuing care agreement.

(d) A continuing care agreement that contains a provision to provide assisted living program services and does not require a subscriber to execute a separate assisted living agreement to receive those services is not required to contain general or specific contract provisions, except as required under Title 10, Subtitle 4 of the Human Services Article, that apply to assisted living programs that are not subject to this section.

(e)

  (1) In addition to subsection (c) of this section, an assisted living program subject to this section is not required to provide a disclosure statement relating to its assisted living program separate from any disclosure statement required by Title 10, Subtitle 4 of the Human Services Article for continuing care.

  (2) Any disclosure statement required to be provided to a resident under Title 10, Subtitle 4 of the Human Services Article shall include information that is required to be disclosed by an assisted living program in accordance with this subtitle.

(f) A transfer of a resident from an assisted living program subject to this section to another assisted living or continuing care arrangement governed by the same continuing care agreement may not be considered a relocation or discharge from the assisted living program for purposes of triggering any regulatory requirements adopted under this subtitle for matters relating to notice, financial accounting, or refunds.

#### Section 19-1807

(a)

  (1) Except as provided in subsection (d) of this section, an assisted living manager who is employed by an assisted living program shall have completed a manager training course that is approved by the Department and includes an examination.

  (2) The manager training course shall:

    (i) Consist of at least 80 hours; and

    (ii) Provide the training through in-person courses, virtual training methods, or a combination of both.

(b) An assisted living manager employed by a program shall be required to complete 20 hours of Department-approved continuing education every 2 years.

(c) In addition to the sanctions specified in COMAR 10.07.14.48, an assisted living program that fails to employ an assisted living manager who meets the requirements of this section may be subject to a civil money penalty not to exceed $10,000.

(d)

  (1) The requirements of subsection (a) of this section do not apply to an individual who:

    (i) Is employed by an assisted living program and has enrolled in a Department-approved manager training course that the individual expects to complete within 6 months;

    (ii) Is temporarily serving as an assisted living manager under Sec. 9-3A-01 of the Health Occupations Article due to an assisted living manager leaving employment and prior to the hiring of a permanent assisted living manager; or

    (iii) Subject to paragraph (2) of this subsection:

      (1) Has been employed as an assisted living manager in the State for 1 year prior to January 1, 2006; or

      (2) Is licensed as a nursing home administrator in the State.

  (2) The Department may require an individual who is exempt under paragraph (1)(iii) of this subsection to complete a manager training course and examination if the Department finds that the assisted living manager repeatedly has violated State law or regulations on assisted living and that those violations have caused actual physical or emotional harm to a resident.

(e) The Department shall ensure that manager training courses approved by the Department are affordable and accessible to assisted living programs and to individuals seeking to enroll in the courses.

#### Section 19-1808

(a) The Department, in consultation with the Maryland Health Care Commission and stakeholders, including advocates, consumers, and providers of assisted living services, shall develop a standard assisted living program services disclosure statement.

(b) The purpose of the assisted living program services disclosure statement is to inform potential consumers about the services provided by an assisted living program in order to assist a consumer in choosing the most appropriate assisted living program.

(c)

  (1) An assisted living program, as part of the application for licensure, shall file with the Office of Health Care Quality the assisted living program services disclosure statement developed by the Department.

  (2) If an assisted living program changes the services reported on the assisted living program services disclosure statement, the assisted living program shall file with the Office of Health Care Quality an amended assisted living program services disclosure statement within 30 days of the change in services.

(d)

  (1) If an individual requests a copy of an assisted living program's services disclosure statement, the assisted living program shall provide a copy of the services disclosure statement to the individual making the request.

  (2) An assisted living program shall provide a copy of the services disclosure statement to individuals as part of the program's marketing materials.

#### Section 19-1808.1

(a) Each assisted living program in the State shall notify a resident or prospective resident in writing or by written electronic communication if:

  (1) The assisted living program does not maintain professional liability insurance coverage; or

  (2) The assisted living program's professional liability insurance coverage has lapsed for any period of time and has not been renewed.

(b) The notification under subsection (a) of this section shall be:

  (1)

    (i) Provided to a prospective resident:

      (1) At the first visit by the prospective resident during any period in which an assisted living program does not maintain professional liability insurance; and

      (2) If the assisted living program does not maintain professional liability insurance at the time the prospective resident applies for admission, at the time of application; and

    (ii) If the professional liability coverage lapses, provided to each resident within 30 days after the date the coverage lapsed;

  (2) Signed by:

    (i) The prospective resident at the time of application for admission; or

    (ii) The resident at the time the notification of the lapse in coverage is provided under item (1)(ii) of this subsection; and

  (3) Retained by the assisted living program as part of the assisted living program's records.

(c) Each facility-based assisted living program in the State that does not maintain professional liability insurance coverage shall post a notification in a conspicuous place visible to residents and guests that the assisted living program does not maintain professional liability insurance.

#### Section 19-1809

(a)

  (1) A person may not knowingly and willfully operate, maintain, or own an assisted living program without a license.

  (2) A person who violates paragraph (1) of this subsection is guilty of a felony and on conviction is subject to:

    (i) For a first offense, a fine not exceeding $10,000 or imprisonment not exceeding 5 years or both; or

    (ii) For a subsequent offense, a fine not exceeding $20,000 or imprisonment not exceeding 5 years or both.

  (3) If the Department finds a credible allegation that an assisted living program is operating without a license, the Department, or the Office of Health Care Quality, shall investigate whether residents in the assisted living program have been subjected to neglect, exploitation, or abuse.

  (4)

    (i) On receipt of a credible allegation, or after an investigation that results in a finding that residents in an unlicensed assisted living program have been subjected to neglect, exploitation, or abuse, the person operating the unlicensed program shall be subject to immediate prosecution under paragraph (2) of this subsection.

    (ii) If the person operating an unlicensed assisted living program fails or refuses to cooperate fully in an investigation by the Department, or the Office of Health Care Quality, conducted under paragraph (3) of this subsection, the person operating the unlicensed assisted living program shall be subject to immediate prosecution under paragraph (2) of this subsection.

  (5) If the Department finds, after an investigation conducted under paragraph (3) of this subsection, that there is no reason to believe that residents in the assisted living program operating without a license have been subject to exploitation, neglect, or abuse:

    (i) The Department shall provide written notice to the unlicensed assisted living program that the program shall come into compliance with licensure requirements within 30 days after receipt of the written notification; and

    (ii) The person operating the program may not be subject to prosecution under paragraph (2) of this subsection if the person has:

      (1) Promptly and in good faith submitted a complete application to the Department for an assisted living program license;

      (2) Is awaiting a decision from the Department regarding the application; and

      (3) Has not been denied an assisted living program license on a prior occasion.

  (6) In recommending the amount of the criminal penalty under paragraph (2) of this subsection, the State shall consider factors including the nature, number, and seriousness of the violations.

  (7) The Department, the Attorney General, a State's Attorney, or a local health officer may petition a circuit court for injunctive relief against the operation of an assisted living program operating without a license.

  (8) A violation of paragraph (1) of this subsection shall be a violation of the Consumer Protection Act.

(b)

  (1)

    (i) A person may not advertise, represent, or imply to the public that an assisted living program is authorized to provide a service that the program is not licensed, certified, or otherwise authorized by the Department to provide when the license, certificate, or authorization is required under this subtitle.

    (ii) A person may not advertise an assisted living program in a misleading or fraudulent manner.

  (2)

    (i) A person who violates paragraph (1) of this subsection is subject to a civil money penalty imposed by the Secretary not exceeding $10,000 for each offense.

    (ii) In setting the amount of a civil money penalty on the program under subparagraph (i) of this paragraph, the Secretary shall consider factors including the nature, number, and seriousness of the violations and the ability of the assisted living program to pay the penalty.

(c)

  (1) A person may not willfully and knowingly refer another person to an assisted living program that is operating without a license.

  (2) A person who violates paragraph (1) of this subsection is subject to the following civil penalties:

    (i) For a first offense, a civil penalty not exceeding $1,000;

    (ii) For a second offense, a civil penalty not exceeding $2,000; or

    (iii) For a third or subsequent offense, a civil penalty not exceeding $3,000.

  (3) The Secretary shall remit all civil penalties collected under this subsection to the Office of Health Care Quality for the purposes of carrying out the provisions of Sec. 19-1813 of this subsection.

(d) The Department may adopt regulations to carry out this section.

#### Section 19-1810

(a) An assisted living program may request an appeal of a civil money penalty imposed under this subtitle.

(b) A hearing on the appeal shall be held in accordance with:

  (1) The Administrative Procedure Act under Title 10, Subtitle 2 of the State Government Article; and

  (2) Regulations adopted by the Secretary.

#### Section 19-1811

(a)

  (1) There is a Health Care Quality Account for Assisted Living Programs established in the Department.

  (2) The Account shall be funded by civil money penalties paid by assisted living programs and other penalties that the Office of Health Care Quality may assess.

  (3) The Department shall pay all penalties collected under this title to the Comptroller.

  (4) The Comptroller shall distribute funds collected under this title to the Health Care Quality Account for Assisted Living Programs.

  (5) The Account is a continuing, nonlapsing fund, not subject to Sec. 7-302 of the State Finance and Procurement Article.

  (6) Any unspent portions of the Account may not be transferred or reverted to the General Fund of the State, but shall remain in the Account to be used for the purposes specified in this section.

(b) The Health Care Quality Account for Assisted Living Programs shall be used for training, grant awards, demonstration projects, or other purposes designed to improve the quality of care.

(c) The Department shall adopt regulations for the distribution of funds from the Health Care Quality Account for Assisted Living Programs.

#### Section 19-1812

(a) Except as provided in subsections (g) and (h) of this section, the Department shall require that each assisted living program facility that provides services to 50 or more individuals have an emergency electrical power generator on the premises.

(b) The Department shall require that each facility provide emergency electrical power as provided in this section.

(c)

  (1) The emergency power source shall be a generating set and prime mover located on the facility premises with automatic transfer.

  (2) An emergency power system shall meet the following requirements:

    (i) In the event of failure of the normal electric service, the emergency electrical power shall be activated immediately;

    (ii) The emergency generator set shall come to full speed and load acceptance within 10 seconds; and

    (iii) The emergency generator shall have the capability of 48 hours of operation from fuel stored on-site.

  (3)

    (i) The emergency power system shall be tested one time each month.

    (ii) The emergency power system test shall require that the generator be exercised for a minimum of 30 minutes under normal emergency facility connected load.

    (iii) The test shall be recorded in a permanent log book maintained for that purpose.

(d) The emergency power system shall provide lighting in the following areas of the facility:

  (1) Areas of egress and protection as required by the State Fire Prevention Code and Life Safety Code 101 adopted by the State Fire Prevention Commission;

  (2) Nurses' station;

  (3) Drug distribution station or unit dose station;

  (4) An area for emergency telephone use;

  (5) Boiler or mechanical room;

  (6) Kitchen;

  (7) Emergency generator location and switch gear location;

  (8) Elevator, if operable on emergency power;

  (9) Areas where life support equipment is used;

  (10) If applicable, common areas or areas of refuge; and

  (11) If applicable, toilet rooms of common areas or areas of refuge.

(e) Emergency electrical power shall be provided for the following:

  (1) Nurses' call system;

  (2) At least one telephone in order to make and receive calls;

  (3) Fire pump;

  (4) Sewerage pump and sump pump;

  (5) If required for evacuation purposes, an elevator;

  (6) If necessary, heating equipment needed to maintain a minimum temperature of 70 degrees Fahrenheit (24 degrees Celsius) in all common areas or areas of refuge;

  (7) Life support equipment; and

  (8) Nonflammable medical gas systems.

(f)

  (1) If the emergency power system does not provide heat to all patient rooms or toilet rooms in the event of a loss of electricity from the main source of power, the facility shall provide common areas or areas of refuge for all patients.

  (2) The Department shall adopt regulations regarding the requirements for designating parts of the facility as common areas or areas of refuge.

(g) An assisted living program facility shall be exempt from the requirements of this section if the facility can safely transfer residents through an enclosed corridor to a building that is equipped with an electrical power generator that satisfies the requirements of this section.

(h)

  (1) The Department may grant a facility a waiver from the requirements of this section if the facility:

    (i) Provides evidence to the Department that the requirements of this section will create an undue financial burden on the facility and will require the facility to cease operation; and

    (ii) Discloses to the residents of the facility that the facility does not have an emergency electrical power generator that meets the requirements of this section.

  (2) Subject to paragraph (3) of this subsection, a waiver granted under paragraph (1) of this subsection may not exceed a period of 3 years.

  (3) The Department may extend a waiver granted under paragraph (1) of this subsection for an additional period of 2 years beyond the period specified in paragraph (2) of this subsection.

#### Section 19-1813

(a) In this section, "assisted living referrer" means an individual or agency that:

  (1) Makes referrals to assisted living programs without cost to the person receiving the referral; and

  (2) Is compensated by an assisted living program or other third party for referring individuals to a licensed assisted living program.

(b) Each assisted living referrer:

  (1) Shall register with the Office of Health Care Quality;

  (2) Shall disclose to a client or potential client of the assisted living referrer all financial relationships the assisted living referrer has with assisted living programs;

  (3) If referring a client or potential client to an assisted living program, shall affirm that the assisted living program is licensed;

  (4) If referring a client or potential client to an assisted living program, may refer the client or potential client only to a licensed assisted living program;

  (5) Shall maintain general liability insurance;

  (6) Shall require employees to obtain a criminal history records check;

  (7) Shall provide to the client or the client's representative a description of the services that will be provided by the referrer;

  (8) If the referrer has a financial agreement with the client or the client's representative, shall provide the agreement to the client or the client's representative in writing or by electronic means; and

  (9) Shall notify the Office of Health Care Quality immediately on learning that the assisted living program is operating without a license.

(c) An assisted living referrer may not:

  (1) Receive funding from the Department if the assisted living referrer is in violation of this subtitle;

  (2) Make referrals only to licensed assisted living programs from which the assisted living referrer receives compensation as described in subsection (a)(2) of this section; or

  (3) Request payment of a referral fee from an assisted living program more than 2 years after the assisted living referrer provided the referral.

(d) If requested by any person or on its own initiative, the Office of the Attorney General may investigate whether an assisted living referrer violated this subtitle and may seek appropriate relief.

(e) The Office of Health Care Quality shall maintain a user-friendly database of licensed assisted living programs.

(f)

  (1) On or before September 30, 2025, an assisted living referrer:

    (i) Shall keep a client or potential client's medical record, as defined in Sec. 4-301 of this article, confidential and may disclose the medical record only for the purpose of making a referral if the client or potential client gives informed written, electronic, or audio recorded consent; and

    (ii) May not sell the personal data of a client, potential client, or client's representative to another person unless the client or the client's representative gives informed written, electronic, or audio recorded consent.

  (2) On or after October 1, 2025, an assisted living referrer shall comply with all applicable data privacy laws.

#### Section 19-1814

The Office of Health Care Quality within the Department shall refer an allegation of an unfair, abusive, or deceptive trade practice by an assisted living program to the Division of Consumer Protection of the Office of the Attorney General and to the Office of the Inspector General within the Department.

#### Section 19-1815

(a)

  (1) In this section the following words have the meanings indicated.

  (2) "COVID-19" means, interchangeably and collectively, the coronavirus known as COVID-19 or 2019-nCoV and the SARS-CoV-2 virus.

  (3) "COVID-19 test" means an in vitro diagnostic test for the detection of SARS-CoV-2 or the diagnosis of the virus that causes COVID-19, as described in Sec. 3201 of the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act.

(b) For calendar years 2021 and 2022, an assisted living program shall adopt and implement a COVID-19 testing plan for residents of the assisted living program and staff who provide services to residents of the assisted living program.

(c) The COVID-19 testing plan shall ensure that residents and staff are tested for COVID-19 on a regular basis and at a frequency that is sufficient to prevent the spread of COVID-19 among residents and staff of the assisted living program.

(d)

  (1) The Department shall adopt regulations that set standards for a COVID-19 testing plan required under this section.

  (2) The standards set by the Department under this subsection shall:

    (i) Be guided by applicable federal orders and policies; and

    (ii) Include requirements for testing frequency that are reasonably related to the COVID-19 testing positivity rate in the local jurisdiction in which an assisted living program is located.

### Subtitle 19. Adult Dependent Care Programs -- Criminal History Records Checks and Background Checks

#### Section 19-1901

(a) In this subtitle the following words have the meanings indicated.

(b) "Adult dependent care program" means:

  (1) An adult day care facility regulated under Title 14, Subtitle 2 of this article;

  (2) An assisted living program facility regulated under Subtitle 18 of this title;

  (3) A group home regulated under Title 10, Subtitle 5 or Title 7, Subtitle 6 of this article;

  (4) A home health agency regulated under Subtitle 4 of this title;

  (5) A congregate housing services program regulated under Title 10, Subtitle 2 of the Human Services Article;

  (6) A residential service agency as defined under Sec. 19-4A-01 of this title;

  (7) An alternative living unit as defined under Sec. 7-101 of this article;

  (8) A hospice facility regulated under Subtitle 9 of this title; or

  (9) A related institution regulated under Subtitle 3 of this title.

(c) "Background check" means a check of court and other records by a private agency.

(d) "Conviction" means a:

  (1) Plea or verdict of guilty;

  (2) Plea of nolo contendere;

  (3) Disposition of probation before judgment; or

  (4) Disposition of not criminally responsible.

(e) "Criminal history records check" means a check of criminal history record information, as defined in Sec. 10-201 of the Criminal Procedure Article, by the Department of Public Safety and Correctional Services.

(f) "Department" means the Department of Public Safety and Correctional Services.

(g) "Disclosure statement" means a sworn statement or affirmation of the existence of a criminal conviction or pending criminal charges without a final disposition.

(h)

  (1) "Eligible employee" means an individual:

    (i) Who, for compensation, works for an adult dependent care program;

    (ii) Who has routine, direct access to dependent adults in the program; and

    (iii) Who is not licensed or certified under the Health Occupations Article.

  (2) "Eligible employee" does not include an individual delivering or retrieving medical equipment.

(i) "Printed statement" means a document issued by the Criminal Justice Information System Central Repository in the Department of Public Safety and Correctional Services in response to an application for a criminal history records check.

(j) "Private agency" means a person that:

  (1) Is licensed as a private detective agency under Title 13, Subtitle 3 of the Business Occupations and Professions Article;

  (2) Maintains an errors and omissions insurance policy in an amount not less than $1,000,000;

  (3) Offers customer assistance in the use of background checks for employment purposes; and

  (4) Is capable of conducting a background check within the State within 2 working days of a request and outside the State within 5 working days of a request.

(k) "Secretary" means the Secretary of Public Safety and Correctional Services.

#### Section 19-1902

(a) Before an eligible employee may begin work for an adult dependent care program, each adult dependent care program shall, for each eligible employee:

  (1)

    (i) Apply for a State criminal history records check; or

    (ii) Request a private agency to conduct a background check; and

  (2) Request a reference from the potential employee's most recent employer.

(b) The reference request required under subsection (a)(2) of this section shall, at a minimum, seek information about any history of physical abuse on the part of the potential employee.

(c) An adult dependent care program shall pay for each eligible employee:

  (1) A State criminal history records check; or

  (2) A private agency background check.

(d) If an adult dependent care program requests a private agency to conduct a background check, the private agency shall conduct a background check in each state in which the adult dependent care program knows or has reason to know the eligible employee worked or resided during the past 7 years.

#### Section 19-1903

(a) In addition to the checks required under this subtitle, an adult dependent care program may require an alcohol or controlled dangerous substance test of the potential employee.

(b) An alcohol or controlled dangerous substance test conducted under this section shall comply with the provisions of Sec. 17-214 of this article.

#### Section 19-1904

(a) As part of the application for a State criminal history records check to be conducted by the Department, an eligible employee shall submit to the adult dependent care program:

  (1) Except as provided in subsection (c) of this section, a complete set of legible fingerprints taken on forms specified by the Director of the Criminal Justice Information System Central Repository; and

  (2) The disclosure statement required under Sec. 19-1905 of this subtitle.

(b) The adult dependent care program shall submit the fingerprints, disclosure statement, and payment for the costs of the criminal history records check.

(c) The requirement that a complete set of legible fingerprints taken on forms specified by the Director of the Criminal Justice Information System Central Repository be submitted as part of the application for a criminal history records check may be waived by the Department if:

  (1) The eligible employee has attempted to have a complete set of fingerprints taken on at least two occasions;

  (2) The taking of a complete set of legible fingerprints is not possible because of a physical or medical condition of the eligible employee's fingers or hands;

  (3) The eligible employee submits documentation satisfactory to the Department of the requirements of this subsection; and

  (4) The eligible employee submits the other information required for a criminal history records check to be conducted by the Department as part of the application process.

#### Section 19-1905

(a) As part of the application process for a criminal history records check, an eligible employee shall complete and sign a disclosure statement.

(b) The Department or its designee shall mail an acknowledged receipt of the application with a disclosure statement from an eligible employee within 3 days after receipt of the application to:

  (1) The adult dependent care program seeking to hire the eligible employee; and

  (2) The eligible employee.

#### Section 19-1906

(a) If the adult dependent care program requests a private agency background check:

  (1) The private agency shall issue a statement of its findings to:

    (i) On request, the eligible employee; and

    (ii) The adult dependent care program; and

  (2) The eligible employee shall have an opportunity to contest the findings.

(b) The adult dependent care program shall comply with the federal Fair Credit Reporting Act that includes the issuance of a statement by the program of its findings to an eligible employee when adverse information is obtained that precludes the hiring of that employee.

#### Section 19-1907

(a)

  (1) The Department shall conduct the criminal history records check and issue the printed statement provided for under this subtitle.

  (2) The Department shall update an initial criminal history records check and issue a revised printed statement, listing any of the convictions or pending charges occurring in the State after the date of the initial criminal history records check.

  (3) The Department shall provide an initial and a revised statement of an eligible employee's State criminal record to the recipients of the acknowledgments specified in Sec. 19-1905(b) of this subtitle.

  (4) The Department shall adopt regulations requiring employers to verify periodically the continuing employment of an employee.

(b) The Department shall provide a printed statement of the eligible employee's State criminal record to the recipients of the acknowledgments specified in Sec. 19-1905(b) of this subtitle.

(c) Information obtained from the Department or a private agency under this subtitle shall be confidential and may be disseminated only to the eligible employee who is the subject of the criminal history records check or private agency background check and to an adult dependent care program seeking to hire the eligible employee.

(d) Information obtained from the Department or a private agency under this subtitle may not:

  (1) Be used for any purpose other than that for which it was disseminated; or

  (2) Be redisseminated.

(e) Information obtained from the Department or a private agency under this subtitle shall be maintained in a manner to insure the security of the information.

#### Section 19-1908

(a) An eligible employee may contest the finding of a criminal conviction or pending charge reported in a printed statement issued by the Department as provided in this section.

(b)

  (1) In contesting the finding of a conviction or a pending charge, the eligible employee shall contact the office of the Secretary, or a designee of the Secretary, and a hearing shall be convened within 20 workdays, unless subsequently waived by the eligible employee.

  (2) The Secretary, or a designee of the Secretary, shall render a decision regarding the appeal within 5 workdays after the hearing.

(c)

  (1) For the purposes of this subtitle, the record of a conviction for a crime or a copy of the record certified by the clerk of the court or by a judge of the court in which the conviction occurred, shall be conclusive evidence of the conviction.

  (2) In a case where a pending charge is recorded, documentation provided by a court to the Secretary, or a designee of the Secretary, that a pending charge for a crime which has not been finally adjudicated shall be conclusive evidence of the pending charge.

(d) Failure of the eligible employee to appear at the scheduled hearing shall be considered grounds for dismissal of the appeal.

#### Section 19-1909

(a) An eligible employee who fails to disclose a conviction or the existence of pending charges for a criminal offense or attempted criminal offense as required under Sec. 19-1905 of this subtitle shall be guilty of perjury and on conviction is subject to the penalty provided by law.

(b) Unless otherwise provided, an eligible employee who violates any provision of this subtitle is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000 or imprisonment not exceeding 1 year or both.

#### Section 19-1910

The following persons or agencies shall have the immunity from civil or criminal liability described under Sec. 5-619 of the Courts and Judicial Proceedings Article in connection with a criminal history records check under this subtitle:

(1) An adult dependent care program; and

(2) A State agency.

#### Section 19-1911

(a) An employer providing a reference for employment under this subtitle and acting in good faith may not be held liable for disclosing any information about the job performance or the reason for termination of employment of an employee or former employee of the employer.

(b) An employer providing a reference under this subtitle shall be presumed to be acting in good faith unless it is shown by clear and convincing evidence that the employer:

  (1) Acted with actual malice toward the employee or former employee; or

  (2) Intentionally or recklessly disclosed false information about the employee or former employee.

#### Section 19-1912

Nothing in this subtitle may be construed to prevent an adult dependent care program from obtaining a criminal history records check or background check on any other individual applying for a job or volunteering services in the program.

### Subtitle 20. Health Care Staff Agencies

#### Section 19-2001

(a)

  (1) In this subtitle the following words have the meanings indicated.

  (2) "Client facility" means a health care facility that contracts with a health care staff agency for the referral of health care practitioners.

  (3) "Health care facility" means a hospital or related institution as defined in Sec. 19-301 of this title.

  (4)

    (i) Except as provided in subparagraph (ii) of this paragraph, "health care practitioner" means any individual licensed or certified under the Health Occupations Article who:

      (1) Is a licensed practical nurse, registered nurse, or certified nursing assistant; or

      (2) Practices in an allied health care field, as defined by the Office in regulation.

    (ii) "Health care practitioner" does not include:

      (1) An acupuncturist;

      (2) A dentist;

      (3) A nurse anesthetist;

      (4) A nurse midwife;

      (5) A nurse practitioner;

      (6) A pharmacist;

      (7) A physician;

      (8) A physician assistant; or

      (9) A podiatrist.

  (5)

    (i) "Health care staff agency" means any person, firm, corporation, partnership, or other business entity engaged in the business of referring health care practitioners as employees or independent contractors to render temporary health care services at a health care facility in the State.

    (ii) "Health care staff agency" does not include:

      (1) A health care staff agency operated by a health care facility or its affiliates solely for the purpose of procuring, furnishing, or referring temporary or permanent health care personnel for employment at that health care facility or its affiliates;

      (2) A home health agency regulated under Subtitle 4 of this title; or

      (3) Any health care practitioners procuring, furnishing, or referring their own services to a health care facility without the direct or indirect assistance of a health care staff agency.

  (6) "Initially providing or referring" means the first time a health care staff agency provides or refers a particular health care practitioner to a health care facility.

  (7) "Office" means the Office of Health Care Quality in the Department.

  (8) "Responsible party" means the individual at a health care staff agency who controls the day to day operation of the health care staff agency.

(b)

  (1) A health care staff agency shall be licensed by the Office before referring health care practitioners to a health care facility to render temporary health care services at a health care facility in this State.

  (2) All health care staff agencies shall submit to the Office:

    (i) The health care staff agency's:

      (1) Business name;

      (2) Business address;

      (3) Business telephone number; and

      (4) Responsible party; and

    (ii) Any other information the Office requires by regulation to ensure compliance with the provisions of this subtitle.

(c)

  (1) A health care staff agency shall notify the Office of any change in ownership, agency name, or address within 30 days of the change.

  (2) Notwithstanding the provisions of subsection (g)(1) of this section, if a health care staff agency fails to notify the Office within the time required under this subsection, the Office may impose a fine of $100.

(d)

  (1) Before initially providing or referring a health care practitioner to health care facilities to render temporary health care services, the health care staff agency shall verify the licensure or certification status of the health care practitioner.

  (2) At the time a health care practitioner who is being referred to health care facilities by a health care staff agency must renew the health care practitioner's license or certificate, the health care staff agency shall:

    (i) Submit the name and license or certificate number of the health care practitioner to the Office; and

    (ii) Verify the licensure or certification status of the health care practitioner.

(e) A health care staff agency may not knowingly provide or refer an individual who is not licensed or certified under the Health Occupations Article to a health care facility to render health care services.

(f)

  (1) Except as provided in paragraph (2) of this subsection:

    (i) If a health care staff agency knows of an action or condition performed by a health care practitioner provided or referred by that health care staff agency that might be grounds for action relating to a license or certificate issued under the Health Occupations Article, the health care staff agency shall report the action or condition to the appropriate health occupation board; and

    (ii) An individual shall have immunity from liability described under Sec. 5-709 of the Courts and Judicial Proceedings Article for making a report as required under this paragraph.

  (2) A health care staff agency is not required under this subsection to make any report that would be in violation of any federal or State law, rule, or regulation concerning the confidentiality of alcohol and drug abuse patient records.

(g)

  (1) Subject to the provisions of Title 10, Subtitle 2 of the State Government Article, the Office may impose a penalty for a violation of any provision of this section:

    (i) For a first offense, up to $2,500 per violation or up to $2,500 per day until the health care staff agency complies with the requirements of this subtitle;

    (ii) For a second offense, up to $5,000 per violation or up to $5,000 per day until the health care staff agency complies with the requirements of this subtitle; and

    (iii) For a third or subsequent offense, up to $10,000 per violation or up to $10,000 per day until the health care staff agency complies with the requirements of this subtitle.

  (2) Each day a violation continues is a separate violation.

(h) A health care staff agency is not a health care provider.

#### Section 19-2002

(a) In this section, "Office" means the Office of Health Care Quality in the Department.

(b) The Office may inspect a health care staff agency to verify compliance with this subtitle.

(c) When the Office conducts an inspection, the Office shall verify that the health care practitioners referred by the health care staff agency are licensed or certified by the appropriate health occupation board.

(d) When the Office conducts an inspection, the Office shall verify that the health care staff agency has developed, documented, and implemented procedures for:

  (1) Selecting and verifying the credentials of health care practitioners referred by the health care staff agency;

  (2) Validating experience of health care practitioners prior to referral by the health care staff agency;

  (3) Tracking and acting on serious or life-threatening complaints received by a client facility or the client facility's agent;

  (4) Reporting of an action or condition under Sec. 19-2001(f) of this subtitle;

  (5) Verifying that health care practitioners referred by the health care staff agency are of satisfactory health status and have received the necessary testing and immunization as required or requested by the client facility;

  (6) Verifying I-9 status;

  (7) Verifying, prior to initial referral of health care practitioners to a client facility by the health care staff agency, drug screening of health care practitioners referred by the health care staff agency if the client facility requires drug screening for facility employees;

  (8) Verifying, when there is probable cause to perform a drug test or when a client facility requests a drug test, drug testing of health care practitioners referred by the health care staff agency;

  (9) Verifying, prior to initial referral of health care practitioners to a client facility by the health care staff agency, criminal background checks of health care practitioners referred by the health care staff agency if the client facility requires criminal background checks for facility employees; and

  (10) Verifying the references of health care practitioners referred by the health care staff agency.

(e) A health care staff agency shall attest that the health care staff agency is in compliance with the:

  (1) Civil Rights Act of 1964;

  (2) Rehabilitation Act of 1973;

  (3) Americans with Disabilities Act of 1990; and

  (4) Drug Free Workplace Act of 1988, if applicable.

(f) The Office may inspect a health care staff agency upon receiving a complaint, and may give notice of the inspection to the health care staff agency.

### Subtitle 21. Maryland Community Health Resources Commission

#### Section 19-2101

(a) In this subtitle the following words have the meanings indicated.

(b) "Affordable Care Act" means the federal Patient Protection and Affordable Care Act, as amended by the federal Health Care and Education Reconciliation Act of 2010, and any regulations adopted or guidance issued under the Acts.

(c) "Commission" means the Maryland Community Health Resources Commission.

(d)

  (1) "Community health resource" means a nonprofit or for profit health care center or program that offers the primary health care services required by the Commission under Sec. 19-2109(a)(2) of this subtitle to an individual on a sliding scale fee schedule and without regard to an individual's ability to pay.

  (2) "Community health resource" includes:

    (i) A federally qualified health center;

    (ii) A federally qualified health center "look-alike";

    (iii) A community health center;

    (iv) A migrant health center;

    (v) A health care program for the homeless;

    (vi) A primary care program for a public housing project;

    (vii) A local nonprofit and community-owned health care program;

    (viii) A school-based health center;

    (ix) A teaching clinic;

    (x) A wellmobile;

    (xi) A health center controlled operating network;

    (xii) A historic Maryland primary care provider;

    (xiii) An outpatient behavioral health program; and

    (xiv) Any other center or program identified by the Commission as a community health resource.

#### Section 19-2102

(a) There is a Maryland Community Health Resources Commission.

(b) The Commission is an independent commission that operates within the Department.

(c) The purpose of the Commission is to increase access to health care through community health resources.

#### Section 19-2103

(a)

  (1) The Commission consists of eleven members appointed by the Governor with the advice and consent of the Senate.

  (2) Of the eleven members:

    (i) One shall be a representative of a nonprofit health maintenance organization;

    (ii) One shall be a representative of a nonprofit health service plan;

    (iii) One shall be a representative of a Maryland hospital;

    (iv) Four shall be individuals who:

      (1) Do not have any connection with the management or policy of a community health resource, nonprofit health service plan, or nonprofit health maintenance organization; and

      (2) Have a background or experience in health care;

    (v) One shall be an individual who has a background or experience with an outpatient mental health clinic within the past 5 years; and

    (vi) Three shall be individuals who have a background or experience with a community health resource within the past 5 years.

  (3) At least two of the eleven members shall be health care professionals licensed in the State.

(b) To the extent practicable, when appointing members to the Commission, the Governor shall assure geographic balance and promote racial and gender diversity in the Commission's membership.

(c)

  (1) On or after July 1, 2009, the term of a member is 4 years.

  (2) The terms of members are staggered as required by the terms provided for members of the Commission on July 1, 2009.

  (3) At the end of a term, a member continues to serve until a successor is appointed and qualifies.

  (4) A member who is appointed after a term has begun serves only for the rest of the term and until a successor is appointed and qualifies.

  (5) A member may not serve more than two consecutive terms, except that a member appointed before July 1, 2009, may serve one additional 4-year term when the member's current term expires.

  (6) The Governor may remove a member for neglect of duty, incompetence, or misconduct.

#### Section 19-2104

From among the members of the Commission:

(1) The Governor shall appoint a chair; and

(2) The chair shall appoint a vice chair.

#### Section 19-2105

(a) With the approval of the Governor, the Commission shall appoint an Executive Director, who is the chief administrative officer of the Commission.

(b) The Executive Director serves at the pleasure of the Commission.

(c) Under the direction of the Commission, the Executive Director shall perform any duty or function that the Commission requires.

#### Section 19-2106

(a)

  (1) A majority of the full authorized membership of the Commission is a quorum.

  (2) The decision of the Commission shall be by a majority of the quorum present and voting.

(b) The Commission shall meet at least six times a year, at the times and places that it determines.

(c) A member of the Commission is entitled to:

  (1) Compensation in accordance with the State budget; and

  (2) Reimbursement for expenses under the Standard State Travel Regulations, as provided in the State budget.

(d)

  (1) The Commission may employ a staff in accordance with the State budget.

  (2) The Commission, in consultation with the Secretary, shall determine the appropriate job classifications and grades for all staff.

  (3) The Commission, in consultation with the Secretary, may set the compensation of a Commission employee in a position that:

    (i) Is unique to the Commission;

    (ii) Requires specific skills or experience to perform the duties of the position; and

    (iii) Does not require the employee to perform functions that are comparable to functions performed in other units of the Executive Branch of State government.

  (4) The Secretary of Budget and Management, in consultation with the Commission, shall determine the positions for which the Commission may set compensation under paragraph (3) of this subsection.

#### Section 19-2107

(a) In addition to the powers set forth elsewhere in this subtitle, the Commission may:

  (1) Adopt regulations to carry out the provisions of this subtitle;

  (2) Create committees from among its members;

  (3) Appoint advisory committees, which may include individuals and representatives of interested public or private organizations;

  (4) Apply for and accept any funds, property, or services from any person or government agency;

  (5) Make agreements with a grantor or payor of funds, property, or services, including an agreement to make any study, plan, demonstration, or project;

  (6) Publish and give out any information that relates to expanding access to health care through community health resources that is considered desirable in the public interest;

  (7) Subject to the limitations of this subtitle, exercise any other power that is reasonably necessary to carry out the purposes of this subtitle; and

  (8) Assist community health resources in preparing to implement the Affordable Care Act.

(b) In addition to the duties set forth elsewhere in this subtitle, the Commission shall:

  (1) Adopt rules and regulations that relate to its meetings, minutes, and transactions;

  (2) Keep minutes of each meeting;

  (3) Prepare annually a budget proposal that includes the estimated income of the Commission and proposed expenses for its administration and operation; and

  (4) On or before October 1 of each year, submit to the Governor, to the Secretary, and, in accordance with Sec. 2-1257 of the State Government Article, to the General Assembly an annual report on the operations and activities of the Commission during the preceding fiscal year.

(c)

  (1) The Commission may contract with a qualified, independent third party for any service that is necessary to carry out the powers and duties of the Commission.

  (2) Unless permission is granted specifically by the Commission, a third party with whom the Commission contracts under paragraph (1) of this subsection may not release, publish, or use in a manner not authorized by the contract any information to which the third party has access under the contract.

#### Section 19-2108

(a) The power of the Secretary over plans, proposals, and projects of units in the Department does not include the power to disapprove or modify any decision or determination that the Commission makes under authority specifically delegated by law to the Commission.

(b) The power of the Secretary to transfer by rule, regulation, or written directive any staff, functions, or funds of units in the Department does not apply to any staff, functions, or funds of the Commission.

(c)

  (1) The power of the Secretary over the procurement procedure for units in the Department does not apply to the procurement procedure of the Commission.

  (2) Notwithstanding paragraph (1) of this subsection, when procuring services or supplies, the Commission is subject to the provisions of the State Finance and Procurement Article.

#### Section 19-2109

(a) In addition to the duties set forth elsewhere in this subtitle, the Commission shall, to the extent budgeted resources permit:

  (1) Establish by regulation the criteria to qualify as a community health resource under this subtitle;

  (2) Establish by regulation the services that a community health resource shall provide to qualify as a community health resource under this subtitle;

  (3) Require community health resources to submit a plan to the Commission on how the community health resource will provide or arrange to provide mental health services;

  (4) Identify and seek federal and State funding for the expansion of community health resources;

  (5) Establish by regulation the criteria for community health resources to qualify for operating grants and procedures for applying for operating grants;

  (6) Administer operating grant fund programs for qualifying community health resources;

  (7) Taking into consideration regional disparities in income and the cost of medical services, establish guidelines for sliding scale fee payments at community health resources that are not federally qualified health centers, for individuals whose family income is between 100% and 200% of the federal poverty guidelines;

  (8) Identify and implement programs and policies to encourage specialist providers to serve individuals referred from community health resources;

  (9) Identify and implement programs and policies to encourage hospitals and community health resources to partner to increase access to health care services;

  (10) Establish a reverse referral pilot program under which a hospital will identify and assist patients in accessing health care services through a community health resource;

  (11) Work with community health resources, hospital systems, and others to develop a unified information and data management system for use by all community health resources that is integrated with the local hospital systems to track the treatment of individual patients and that provides real-time indicators of available resources;

  (12) Work in cooperation with clinical education and training programs, area health education centers, and telemedicine centers to enhance access to quality primary and specialty health care for individuals in rural and underserved areas referred by community health resources;

  (13) Evaluate the feasibility of developing a capital grant program for community health resources that are not federally qualified health centers;

  (14) Develop an outreach program to educate and inform individuals of the availability of community health resources and assist individuals under 200% of the federal poverty level who do not have health insurance to access health care services through community health resources;

  (15) Study school-based health center funding and access issues including:

    (i) Reimbursement of school-based health centers by managed care organizations, insurers, nonprofit health service plans, and health maintenance organizations; and

    (ii) Methods to expand school-based health centers to provide primary care services;

  (16) Study access and reimbursement issues regarding the provision of dental services;

  (17) Evaluate the feasibility of extending liability protection under the Maryland Tort Claims Act to health care practitioners who contract directly with a community health resource that is also a Maryland qualified health center or a school-based health center; and

  (18) Establish criteria and mechanisms to pay for office-based specialty care visits, diagnostic testing, and laboratory tests for uninsured individuals with family income that does not exceed 200% of the federal poverty guidelines who are referred through community health resources.

(b) The reverse referral pilot program established under subsection (a)(10) of this section shall include at least one hospital and one community health resource from a rural, urban, and suburban area of this State.

(c) The Commission, in developing and implementing the outreach program established under subsection (a)(14) of this section, shall consult and coordinate with the Motor Vehicle Administration, workforce development boards, local departments of social services, local health departments, Medbank Inc., the Comptroller, the Maryland Health Care Commission, hospitals, community health resources, and physicians to provide outreach and consumer information.

(d) The Commission, in conducting the school-based health center study required under subsection (a)(15) of this section, shall:

  (1) Solicit input from and consult with local governments that operate school-based health centers, the State Department of Education, the Maryland Insurance Commissioner, representatives from school-based health centers, providers, and insurers; and

  (2) Identify the following:

    (i) A fee schedule for individuals accessing a school-based community health center;

    (ii) Reimbursement rates to be paid by managed care organizations and insurers, nonprofit health services plans, and health maintenance organizations to the school-based community health center;

    (iii) Insurance payments owed to school-based community health centers and how much of the payments should be collected to offset any State subsidy;

    (iv) Barriers to the reimbursement of licensed health care providers who provide services at school-based health centers, including nurse practitioners and physician assistants;

    (v) A system of registering individuals who receive health care services from a school-based community health center that requires an individual to pay premiums and sliding scale fees; and

    (vi) Security measures to be used by school-based community health centers.

(e) The Commission, in conducting the dental services study required under subsection (a)(16) of this section, shall select input from and consult with community health resources that provide dental services, managed care organizations, the University of Maryland School of Dentistry, and dental service providers.

#### Section 19-2111

(a) The Commission, in collaboration with community health resources and local health departments, shall develop a specialty care network for individuals:

  (1) With family income that does not exceed 200% of the federal poverty level; and

  (2) Who are referred through a community health resource.

(b) The specialty care network shall:

  (1) Consist of health care practitioners who agree to provide care to individuals referred through a community health resource for a discounted fee established by the Commission; and

  (2) Include health care practitioners who historically have served the uninsured.

(c) Individuals receiving health care through the specialty care network shall pay for specialty care according to a sliding fee scale developed by the Commission.

(d) In addition to patient fees, office-based specialty care visits, diagnostic testing, and laboratory tests shall be subsidized by funds provided from:

  (1) General funds; and

  (2) Money collected from a nonprofit health maintenance organization in accordance with Sec. 6-121(b)(3) of the Insurance Article.

(e) Subject to available funding, the Commission shall provide subsidies to community health resources for office-based specialty care visits, diagnostic testing, and laboratory tests.

### Subtitle 22. Community Health Resources Commission Fund

#### Section 19-2201

(a) In this section, "Fund" means the Community Health Resources Commission Fund.

(b) There is a Community Health Resources Commission Fund.

(c)

  (1) The Fund is a special, nonlapsing fund that is not subject to Sec. 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.

(d) The Fund consists of:

  (1) Money collected from a nonprofit health service plan in accordance with Sec. 14-106.1 of the Insurance Article;

  (2) Money from the Cigarette Restitution Fund, appropriated in accordance with Sec. 7-317 of the State Finance and Procurement Article;

  (3) Interest earned on investments;

  (4) Money donated to the Fund;

  (5) Money awarded to the Fund through grants; and

  (6) Any other money from any other source accepted for the benefit of the Fund.

(e)

  (1) Subject to paragraph (2) of this subsection, the Fund may be used only to:

    (i) Cover the administrative costs of the Commission;

    (ii) Cover the actual documented direct costs of fulfilling the statutory and regulatory duties of the Commission in accordance with the provisions of this subtitle;

    (iii) Provide operating grants to qualifying community health resources; and

    (iv) Provide funding for the development, support, and monitoring of a unified data information system among primary and specialty care providers, hospitals, and other providers of services to community health resource members.

  (2)

    (i) For fiscal years 2014, 2015, and 2016, the Fund may be used for any project or initiative authorized under Title 20, Subtitle 14 of this article and approved by the Commission if no less than $4,000,000 of the subsidy required under Sec. 14-106(d)(2)(ii)2 of the Insurance Article is used in each fiscal year for the purposes under paragraph (1) of this subsection.

    (ii) For fiscal year 2017, the Fund may be used for any project or initiative authorized under Title 20, Subtitle 14 of this article and approved by the Commission if no less than $8,000,000 of the subsidy required under Sec. 14-106(d)(2)(ii)2 of the Insurance Article is used in each fiscal year for the purposes under paragraph (1) of this subsection.

    (iii) For fiscal year 2018, the Fund may be used for any project or initiative authorized under Title 10, Subtitle 2 and Title 13, Subtitle 3 of this article and approved by the Commission if no less than $4,750,000 of the subsidy required under Sec. 14-106(d)(2)(ii)2 of the Insurance Article is used in that fiscal year for the purposes under paragraph (1) of this subsection.

    (iv) For fiscal years 2019 through 2021, the Fund may be used for any project or initiative authorized under Title 10, Subtitle 2 and Title 13, Subtitle 3 of this article and approved by the Commission if no less than $8,000,000 of the subsidy required under Sec. 14-106(d)(2)(ii)2 of the Insurance Article is used in each fiscal year for the purposes under paragraph (1) of this subsection.

    (v) For fiscal year 2022, the Fund may be used for any project or initiative authorized under Title 10, Subtitle 2 and Title 13, Subtitle 3 of this article and approved by the Commission if not more than $8,000,000 of the subsidy required under Sec. 14-106(d)(2)(ii)2 of the Insurance Article is used in that fiscal year for the purposes under paragraph (1) of this subsection.

  (3) The funding for a unified data information system under paragraph (1)(iv) of this subsection shall be limited to:

    (i) $500,000 in fiscal year 2006; and

    (ii) $1,700,000 in fiscal year 2007 and annually thereafter.

(f) The Commission shall adopt regulations that:

  (1) Establish the criteria for a community health resource to qualify for a grant;

  (2) Establish the procedures for disbursing grants to qualifying community health resources;

  (3) Develop a formula for disbursing grants to qualifying community health resources;

  (4) Establish criteria and mechanisms for funding a unified data information system; and

  (5) In consultation with the Secretary, implement a program to provide subsidies to community health resources for office-based specialty care visits, diagnostic testing, and laboratory tests.

(g) In developing regulations under subsection (f)(1) of this section, the Commission shall:

  (1) Consider geographic balance; and

  (2) Give priority to community health resources that:

    (i) In addition to normal business hours, have evening and weekend hours of operation;

    (ii) Have partnered with a hospital to establish a reverse referral program at the hospital;

    (iii) Reduce the use of the hospital emergency department for nonemergency services;

    (iv) Assist patients in establishing a medical home with a community health resource;

    (v) Coordinate and integrate the delivery of primary and specialty care services;

    (vi) Promote the integration of mental and somatic health with federally qualified health centers or other somatic care providers;

    (vii) Fund medication management or therapy services for uninsured individuals up to 200% of the federal poverty level who meet medical necessity criteria but who are ineligible for the public mental health system;

    (viii) Provide a clinical home for individuals who access hospital emergency departments for mental health services, substance abuse services, or both; and

    (ix) Support the implementation of evidence-based clinical practices.

(h) Grants awarded to a community health resource under this section may be used:

  (1) To provide operational assistance to a community health resource; and

  (2) For any other purpose the Commission determines is appropriate to assist a community health resource.

(i)

  (1) The Treasurer shall invest the money in 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.

(j) The Fund shall be subject to an audit by the Office of Legislative Audits as provided for in Sec. 2-1220 of the State Government Article.

### Subtitle 22A. School-based Health Centers

#### Section 19-22A-01

The Secretary, in consultation with the State Department of Education and other stakeholders, shall develop guidelines to support the expansion of school-based health centers.

#### Section 19-22A-04

(a) In this subtitle the following words have the meanings indicated.

(b) "Commission" means the Maryland Community Health Resources Commission.

(c) "Council" means the Maryland Council on Advancement of School-Based Health Centers.

#### Section 19-22A-05

(a) There is a Maryland Council on Advancement of School-Based Health Centers in the Department.

(b) The purpose of the Council is to improve the health and educational outcomes of students who receive services from school-based health centers by advancing the integration of school-based health centers into:

  (1) The health care system at the State and local levels; and

  (2) The educational system at the State and local levels.

(c)

  (1) Staff support for the Council shall be provided by the Commission.

  (2) The Commission may seek the assistance of organizations with expertise in school-based health care or other matters within the duties of the Council provided in Sec. 19-22A-08 of this subtitle to provide additional staffing resources to the Commission and the Council.

#### Section 19-22A-06

(a) The Council consists of the following 16 voting members and 6 ex officio members:

  (1) One member of the Senate of Maryland, appointed by the President of the Senate, as an ex officio member;

  (2) One member of the House of Delegates, appointed by the Speaker of the House, as an ex officio member;

  (3) The Secretary of Health, or a designee of the Secretary, as an ex officio member;

  (4) The State Superintendent of Schools as an ex officio member;

  (5) The Executive Director of the Maryland Health Benefit Exchange as an ex officio member;

  (6) The Chairman of the Commission, or a designee of the Chairman, as an ex officio member; and

  (7) The following 16 members, appointed by the Governor:

    (i) The President of the Maryland Assembly on School-Based Health Care, or a designee of the President;

    (ii) Three representatives of school-based health centers, nominated by the Maryland Assembly on School-Based Health Care:

      (1) From a diverse array of sponsoring organizations; and

      (2) For at least one of the representatives, from a nursing background;

    (iii) One representative of the Public Schools Superintendents Association of Maryland;

    (iv) One representative of the Maryland Association of Boards of Education;

    (v) One elementary school principal of a school that has a school-based health center;

    (vi) One secondary school principal of a school that has a school-based health center;

    (vii) One representative of the Maryland Hospital Association;

    (viii) One representative of the Maryland Association of County Health Officers;

    (ix) One representative of a federally qualified health center, nominated by the Mid-Atlantic Association of Community Health Centers;

    (x) One representative of a managed care organization;

    (xi) One representative of a commercial health insurance carrier;

    (xii) One pediatrician, nominated by the Maryland Chapter of the American Academy of Pediatrics;

    (xiii) One parent or guardian of a student who utilizes services at a school-based health center; and

    (xiv) One school nurse, nominated by the Maryland Association of School Health Nurses.

(b) In making the appointments required under this section, the Governor shall ensure that the Council is representative of:

  (1) The geographic regions of the State; and

  (2) Minority populations of the State.

(c)

  (1) The term of a member appointed under subsection (a) of this section is 3 years.

  (2) The terms of voting members are staggered as required by the terms provided for members of the Council on October 1, 2015.

  (3) At the end of a term, a member shall continue to serve until a successor is appointed and qualifies.

  (4) A member who is appointed after a term has begun shall serve for the rest of the term or until a successor is appointed and qualifies.

(d) The Governor shall appoint a successor in the event of a vacancy on the Council.

(e) From among the members of the Council, the voting members of the Council shall elect a chair for a 2-year term.

(f) A member of the Council may not receive compensation but is entitled to reimbursement for expenses under the Standard State Travel Regulations, as provided in the State budget.

#### Section 19-22A-07

(a) A majority of the members then serving on the Council is a quorum.

(b) The Council shall determine the times and places of its meetings and any other necessary operating procedures in accordance with the Open Meetings Act.

(c)

  (1) The Council may establish workgroups to advise the Council on specific issues, including behavioral health, oral health, and primary care.

  (2)

    (i) The chair of the Council shall appoint the members of a workgroup established by the Council under paragraph (1) of this subsection.

    (ii) The chair of the Council may appoint the following individuals to a workgroup:

      (1) Members of the Council with expertise in the issue to be studied; and

      (2) Members of the public, including consumers and stakeholder group representatives, with expertise in the area to be studied.

#### Section 19-22A-08

(a) The Council shall develop policy recommendations to improve the health and educational outcomes of students who receive services from school-based health centers by:

  (1) Supporting local community efforts to establish or expand school-based health center capacity in primary care, behavioral health, and oral health;

  (2) Integrating school-based health centers into existing and emerging patient-centered models of care;

  (3) Promoting the inclusion of school-based health centers in networks of managed care organizations and commercial health insurance carriers;

  (4) Advancing the public health goals of State and local health officials;

  (5) Promoting the inclusion of school-based health centers into networks of school health services and coordinated student service models for the range of services offered in school settings;

  (6) Supporting State and local initiatives to promote student success;

  (7) Reviewing and revising best practice guidelines; and

  (8) Supporting the long-term sustainability of school-based health centers.

(b) The Council shall review the collection and analysis of school-based health center data collected by the State Department of Education to:

  (1) Make recommendations on best practices for the collection and analysis of the data; and

  (2) Provide guidance on the development of findings and recommendations based on the data.

(c) The Council shall conduct other activities the Council considers appropriate to meet the purpose of the Council.

(d) On or before December 31 of each year, the Council shall report the findings and recommendations of the Council to the Maryland Department of Health, the State Department of Education, the Commission, and, in accordance with Sec. 2-1257 of the State Government Article, the General Assembly on improving the health and educational outcomes of students who receive services from school-based health centers.

### Subtitle 23. Accreditation of Health Care Facilities and Health Care Staff Agencies

#### Section 19-2301

(a) In this subtitle the following words have the meanings indicated.

(b) "Accreditation organization" means a private entity that conducts inspections and surveys of health care facilities or health care staff agencies based on nationally recognized and developed standards.

(c) "Deemed status" means a status under which a health care facility or a health care staff agency may be exempt from routine surveys conducted by the Department.

(d) "Health care facility" means:

  (1) A hospital as defined in Sec. 19-301 of this title;

  (2) A health maintenance organization as defined in Sec. 19-701(g) of this title;

  (3) A freestanding ambulatory care facility as defined in Sec. 19-3B-01 of this title;

  (4) An assisted living facility as defined in Sec. 19-1801 of this title;

  (5) A laboratory as defined in Sec. 17-201 of this article;

  (6) A home health agency as defined in Sec. 19-401 of this title;

  (7) A residential treatment center as defined in Sec. 19-301 of this title;

  (8) A comprehensive rehabilitation facility as defined in Sec. 19-1201 of this title;

  (9) A forensic laboratory as defined in Sec. 17-2A-01 of this article;

  (10) A substance-related disorder program as defined in Sec. 7.5-101 of this article; and

  (11) A mental health program as defined in Sec. 7.5-101 of this article.

(e) "Health care staff agency" has the meaning stated in Sec. 19-2001 of this title.

#### Section 19-2302

(a) An accreditation organization shall apply to the Secretary for approval.

(b) Prior to approval of an accreditation organization, the Secretary shall:

  (1) Determine that the standards of the accreditation organization are equal to or more stringent than existing State requirements;

  (2) Evaluate the survey or inspection process of the accreditation organization to ensure the integrity of the survey or inspection process; and

  (3) Enter into a formal written agreement with the accreditation organization that includes requirements for:

    (i) Notice of all surveys and inspections;

    (ii) Sharing of complaints and other relevant information;

    (iii) Participation of the Department in accreditation organization activities; and

    (iv) Any other provision necessary to ensure the integrity of the accreditation and licensure process.

(c)

  (1) When an approved accreditation organization has issued a final report finding a health care facility or a health care staff agency to be in substantial compliance with the accreditation organization's standards, the Department shall accept the report as evidence that the health care facility or health care staff agency has met State licensure requirements and shall grant the health care facility or health care staff agency deemed status.

  (2) A health care facility or a health care staff agency that fails to achieve substantial compliance with the standards of an approved accreditation organization may be subject to the provisions of Sec. 19-360 of this title.

(d)

  (1) An approved accreditation organization shall send the Department any preliminary and final report of each inspection and survey at the time it is sent to the health care facility or health care staff agency.

  (2) A final report of an approved accreditation organization shall be made immediately available to the public on request.

  (3) A preliminary or final report of an approved accreditation organization is not admissible in evidence in any civil action or proceeding.

(e) The Department may inspect an accredited health care facility or a health care staff agency to:

  (1) Determine compliance with any quality requirement;

  (2) Follow up on any serious problem identified by an approved accreditation organization;

  (3) Investigate a complaint; or

  (4) Validate the findings of an approved accreditation organization.

(f) The Department may participate in or observe a survey or inspection of a health care facility or a health care staff agency conducted by an approved accreditation organization.

(g) On a determination by the Secretary that an approved accreditation organization has failed to meet its obligations under this section, the Secretary may withdraw:

  (1) The approval from the accreditation organization; and

  (2) The deemed status given to a health care facility or a health care staff agency by the accreditation organization.

### Subtitle 24. Prince George's County Regional Medical Center

#### Section 19-2401

(a) The General Assembly finds that:

  (1) In 2011, the State, Prince George's County, and the University of Maryland Medical System came together in a historic public-private partnership to transition the last county-owned hospital system in the State to a private, nonprofit institution that is part of the State's largest academic medical system, with the goal of transforming health care delivery in the second most populous county in the State;

  (2) The goals established under the partnership include:

    (i) Growing access to high-quality clinical programs in Prince George's County;

    (ii) Establishing a delivery system that enables residents to receive care within Prince George's County;

    (iii) Addressing the disproportionate burden of chronic health conditions impacting residents of Prince George's County, including heart disease and cancer; and

    (iv) Serving as an anchor institution and engine of economic development for Prince George's County and the southern Maryland region;

  (3) Key to the transformation of care in Prince George's County are efforts to:

    (i) Build high-quality specialty clinical programs, such as cancer, cardiac, and stroke care;

    (ii) Expand primary care;

    (iii) Attract and retain highly qualified clinicians; and

    (iv) Preserve services that address community needs;

  (4) Since the establishment of the University of Maryland Capital Region Health as part of the University of Maryland Medical System in 2017, the organization has succeeded in advancing the vision articulated by the historic partnership between the State, Prince George's County, and the University of Maryland Medical System to transform care delivery in Prince George's County and the southern Maryland region; and

  (5) The University of Maryland Capital Region Health requires State support and investment to continue its mission to provide high-quality care and transform health care delivery in Prince George's County and the southern Maryland region.

(b)

  (1) Subject to subsection (c) of this section, for the purpose of providing an operating grant to ensure and assist in the transition of a new Prince George's County Regional Medical System to the University of Maryland Medical System Corporation:

    (i) For fiscal year 2018, the Governor shall include in the budget bill an appropriation of $28,000,000;

    (ii) For fiscal year 2019, the Governor shall include in the budget bill an appropriation of $27,000,000;

    (iii) For fiscal years 2020 and 2021, the Governor shall include in the budget bill an appropriation of $15,000,000; and

    (iv) For fiscal year 2022 and each fiscal year thereafter, the Governor shall include in the budget bill an appropriation of $10,000,000.

  (2) Subject to subsection (c) of this section, Prince George's County shall provide a combination of matching funds and other financial assistance to the University of Maryland Medical System Corporation that constitutes total financial assistance as follows:

    (i) $15,000,000 annually for fiscal year 2017 through fiscal year 2019; and

    (ii) $5,000,000 annually for fiscal years 2020 and 2021.

(c) The State and county funds described in subsection (b) of this section:

  (1) Shall be used to support the transition of the Prince George's County Regional Medical Center from operation under the Dimensions Health Care System to operation as a participating institution of the University of Maryland Medical System Corporation; and

  (2) May be used only for:

    (i) Providing increased access to critical health care services for the region served by the Prince George's County Regional Medical Center and improving the quality of the services provided; and

    (ii) Facilitating cost containment measures to prevent additional operating losses for the Prince George's County Regional Medical Center and its affiliated institutions.

(d)

  (1) The Governor shall include in the capital or operating budget bill the following amounts that are equal to the capital funds committed by Prince George's County to be used for the construction of the Prince George's County Regional Medical Center:

    (i) $11,300,000 for fiscal year 2018;

    (ii) $48,000,000 for fiscal year 2019; and

    (iii) $56,200,000 for fiscal year 2020.

  (2) Prince George's County shall provide matching funds of $208,000,000 for the capital construction of the Prince George's County Regional Medical Center.

### Subtitle 25. Recovery Residences

#### Section 19-2501

(a) In this subtitle the following words have the meanings indicated.

(b) "Certificate of compliance" means a certificate that is issued to a recovery residence by a credentialing entity.

(c) "Certified recovery residence" means a recovery residence that holds a certificate of compliance.

(d) "Credentialing entity" means a nonprofit organization that develops and administers professional certification programs according to nationally recognized certification standards.

(e) "Recovery residence" has the meaning stated in Sec. 7.5-101 of this article.

#### Section 19-2502

(a) The Department shall approve a credentialing entity to develop and administer a certification process for recovery residences.

(b) The credentialing entity shall:

  (1) Subject to subsection (c) of this section, establish recovery residence certification requirements;

  (2) Establish processes to administer the application, certification, and recertification process;

  (3) Establish processes to monitor and inspect a recovery residence;

  (4) Conduct an on-site inspection of a recovery residence:

    (i) Before issuing a certificate of compliance; and

    (ii) At least once during each certification renewal period; and

  (5) Issue a certificate of compliance on approval of the application process and the inspection of the recovery residence.

(c) The requirements established by a credentialing entity under subsection (b)(1) of this section shall prohibit a certified recovery residence from:

  (1) Refusing services to an individual based on the individual receiving medication-assisted treatment for opioid use disorder; and

  (2) Requiring an individual to cease receiving or modify how the individual receives medication-assisted treatment for opioid use disorder before the individual may receive services at the recovery residence.

(d) A certificate of compliance issued by the credentialing entity is valid for 1 year from the date of issuance.

(e) The credentialing entity may revoke the certificate of compliance of a certified recovery residence if the credentialing entity finds that the recovery residence is not in compliance with the requirements established by the credentialing entity.

#### Section 19-2503

(a) On or before October 1, 2017, the credentialing entity shall submit a list to the Department of the recovery residences that have obtained a certificate of compliance.

(b)

  (1) On or before November 1, 2017, the Department shall publish on its website:

    (i) A list of each credentialing entity and the contact information for the credentialing entity; and

    (ii) A list of each recovery residence operating in each county in the State.

  (2) The list published under paragraph (1)(ii) of this subsection shall indicate whether the owner of a recovery residence has received a valid certificate of compliance.

(c)

  (1) On or before November 1, 2017, a credentialing entity shall publish on its website a list of each recovery residence that holds a valid certificate of compliance.

  (2) The list published under paragraph (1) of this subsection shall include only the owner of the recovery residence and the contact information of the owner.

#### Section 19-2504

(a) A person may not advertise, represent, or imply to the public that a recovery residence is a certified recovery residence unless the recovery residence has obtained a certificate of compliance under this subtitle.

(b)

  (1) A person who violates subsection (a) of this section is subject to a civil penalty imposed by the Department not exceeding $1,000 for each offense.

  (2) In setting the amount of a civil penalty under paragraph (1) of this subsection, the Department shall consider the nature, number, and seriousness of the violations, the ability of the certified recovery residence to pay the penalty, and any other factors the Department determines are relevant.

#### Section 19-2505

(a) In this section, "Program" means the Recovery Residence Grant Program.

(b)

  (1) There is a Recovery Residence Grant Program in the Department.

  (2) The purpose of the Program is to provide grants to recovery residences in the State in accordance with this section.

(c) The Department shall administer the Program.

(d) The Program shall award competitive grants to recovery residences to support operations, services, and programs.

(e) To qualify for a grant under the Program, a recovery residence must:

  (1) Be a nonprofit organization in good standing with the Internal Revenue Service;

  (2) Submit a current copy of the Form 990 that the organization files with the Internal Revenue Service;

  (3) Be certified by the credentialing entity as a Level I, Level II, or Level III recovery residence in accordance with the National Alliance for Recovery Residences standards;

  (4) Not accept or receive reimbursement from private insurance or the Maryland Medical Assistance Program; and

  (5) Meet any other requirement established by the Department in regulation.

(f)

  (1) The Department shall establish:

    (i) Application procedures;

    (ii) Criteria for prioritizing applications under the Program;

    (iii) Procedures for awarding grants under the Program; and

    (iv) Any other procedures or criteria necessary to carry out this section.

  (2) In establishing procedures and criteria under this subsection, the Department shall consult the credentialing entity.

(g) For each of fiscal years 2024 through 2030, the annual budget bill shall include an appropriation of $500,000 for the Program.

(h) On or before December 1 each year, beginning in 2024, the Department shall submit to the Governor and, in accordance with Sec. 2-1257 of the State Government Article, the General Assembly a report that includes, for the most recent closed fiscal year:

  (1) The number of grants distributed; and

  (2) Information about grant recipients and programs and services provided.

### Subtitle 26. Hospital Obstetric Services Policy

#### Section 19-2601

(a) In this subtitle the following words have the meanings indicated.

(b) "Doula" means a nonmedical professional who provides continuous physical, emotional, and informational support to the birthing parent throughout the prenatal, labor, and postpartum periods.

(c) "Hospital" means a hospital, as defined in Sec. 19-301 of this title, that provides obstetric care.

(d) "Significant medical intervention" means a cesarean section, induction of labor, augmentation of labor, operative vaginal delivery, or episiotomy.

#### Section 19-2602

(a) A hospital shall adopt and provide evidence to the Department that the hospital has:

  (1) A doula policy that allows every birthing parent to have at least one doula present during birth in addition to authorized guests;

  (2) An informed consent policy for significant medical intervention for the birthing parent; and

  (3) A transfer acceptance policy that includes the hospital's process for receiving:

    (i) A patient from a health care practitioner regulated under Title 8 of the Health Occupations Article who had provided services to a birthing parent in a home birth setting;

    (ii) A birthing parent's or newborn's medical information from the home birth provider; and

    (iii) A transfer from a licensed direct-entry midwife that is consistent with the requirements of Sec. 8-6C-08 of the Health Occupations Article.

(b) A hospital shall provide evidence to the Department that the hospital has adopted a policy under subsection (a) of this section:

  (1)

    (i) On or before January 1, 2026; or

    (ii) If the hospital is established after January 1, 2026, on the establishment of the hospital; and

  (2) Whenever the policy is updated.

(c) The Department shall adopt regulations to carry out this section, including regulations that establish the form and manner in which a hospital may prove to the Department that the hospital has adopted a policy in compliance with this section.

(d) The Department shall make the policies provided by a hospital under this section available to the public on request and in a manner determined by the Department.

(e) This section does not prohibit a hospital from setting a policy that restricts the number of doulas or authorized guests.

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Md. Code Ann., Health-Gen. (as displayed at mgaleg.maryland.gov, October 16, 2026)