# Health - General (GHG)

## Title 19. Health Care Facilities

### 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.

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Md. Code Ann., Health-Gen. (as displayed at mgaleg.maryland.gov, October 16, 2026)