Insurance (GIN) — Title 14. Entities That Act as Health Insurers

to regulate the formation and operation of nonprofit health service plans in the State; and

to promote the formation and existence of nonprofit health service plans in the State that:

provide affordable and accessible health insurance to the plan’s insureds and those persons insured or issued health benefit plans by affiliates or subsidiaries of the plan;

assist and support public and private health care initiatives for individuals without health insurance; and

promote the integration of a health care system that meets the health care needs of all the residents of the jurisdictions in which the nonprofit health service plan operates.

Subject to paragraph (2) of this subsection, this section applies to:

To the extent that the legislatively enacted charter of an entity subject to this section, or the laws or administrative rules or regulations of the jurisdiction of domicile of an entity subject to this section, prohibit the entity from complying with a requirement of subsection (c) of this section, the legislatively enacted charter, laws, and administrative rules and regulations of the jurisdiction of domicile shall supersede and take precedence over the requirement of subsection (c) of this section.

this subtitle;

Title 2, Subtitle 2 of this article and §§ 1–206, 3–127, and 12–210 of this article;

Title 2, Subtitle 5 of this article;

§§ 4–113, 4–114, and 4–503 of this article;

Title 5, Subtitles 1, 2, 3, 4, and 5 of this article;

Title 7 of this article, except for § 7–706 and Subtitle 2 of Title 7;

Title 9, Subtitles 1, 2, and 4 of this article;

Title 10, Subtitle 1 of this article;

Title 27 of this article;

Title 33 of this article; and

any other provision of this article that:

podiatric;

chiropractic;

pharmaceutical;

dental;

psychological; or

optometric.

surgical procedures performed by two or more surgeons;

services provided in-area by nonparticipating providers; and

services provided out-of-area by affiliated plans and affiliated providers.

the person knowingly or willfully made or caused to be made:

the person:

is in a form approved by the Commissioner; and

demonstrates that the plan has used funds equal to the value of the premium tax exemption provided to the plan under § 6–101(b) of this article, in a manner that serves the public interest in accordance with this section.

increased access to, or the affordability of, one or more health care products or services by offering and selling health care products or services that are not required or provided for by law;

provided financial or in–kind support for public health programs;

employed underwriting standards in a manner that increases the availability of one or more health care services or products;

employed pricing policies that enhance the affordability of health care services or products and result in a higher medical loss ratio than that established by a comparable for–profit health insurer; or

served the public interest by any method or practice approved by the Commissioner.

Notwithstanding subsection (c) of this section, a nonprofit health service plan that is subject to this section and issues comprehensive health care benefits in the State shall:

For any year, the subsidy and funding required under this subsection by a nonprofit health service plan subject to this section may not exceed the value of the nonprofit health service plan’s premium tax exemption under § 6–101(b) of this article.

for the period of January 1, 2006 through June 30, 2006, may not exceed $8,000,000;

for fiscal years 2008 through 2021, may not exceed $14,000,000;

for fiscal year 2022, may not exceed $14,000,000; and

for any year after fiscal year 2022, may not exceed the value of the nonprofit health service plan’s premium tax exemption under § 6–101(b) of this article.

Subject to paragraph (2) of this subsection, each report filed with the Commissioner under subsection (b) of this section is a public record.

In accordance with § 4–335 of the General Provisions Article, the Commissioner shall deny inspection of any part of a report filed under subsection (b) of this section that the Commissioner determines contains confidential commercial information or confidential financial information.

for a period of time beginning with the date the plan was determined to be out of compliance with § 14–106 of this subtitle; and

in an amount equal to the amount by which the value of the nonprofit health service plan’s premium tax exemption under § 6–101(b) of this article exceeds the sum of:

articles of incorporation, including the applicant’s corporate mission statement, with all amendments;

bylaws with all amendments;

each contract executed or proposed to be executed by the corporation and a health care provider, embodying the terms under which health care services are to be furnished to subscribers to the plan;

each form of contract issued or proposed to be issued to subscribers to the plan and a table of the rates charged or proposed to be charged to subscribers for each form of contract;

a financial statement of the corporation, including the amount of each contribution paid or agreed to be paid to the corporation for working capital, the name of each contributor, and the terms of each contribution;

a list of the names and addresses of and biographical information about the members of the board of directors of the corporation;

a list of the total compensation paid or proposed to be paid to each officer and member of the board of directors of the corporation;

a list of the beginning and ending terms of membership for each member of the board of directors of the corporation; and

any other information or documents that the Commissioner considers necessary to ensure compliance with this subtitle.

the applicant has paid the applicable fee required by § 2-112 of this article; and

the Commissioner is satisfied:

is being operated for profit;

is being fraudulently conducted;

is not complying with this subtitle or article;

knowingly is failing to comply with a rule, regulation, or order of the Commissioner; or

has violated the provisions of Title 6.5 of the State Government Article.

In this section the following words have the meanings indicated.

“Board” means the board of directors of a nonprofit health service plan.

“Immediate family member” means a spouse, child, child’s spouse, parent, spouse’s parent, sibling, or sibling’s spouse.

issued a certificate of authority in the State; and

organized under the laws of the State.

The business and affairs of a nonprofit health service plan shall be managed under the direction of a board of directors.

The principal functions of the board shall include:

Each member of the board shall demonstrate a commitment to the mission of the nonprofit health service plan as required by § 14-102(c) of this subtitle.

An officer or employee of a nonprofit health service plan or any of its affiliates or subsidiaries may not be appointed or elected to the board.

A nonprofit health service plan is subject to the provisions of § 2-419 of the Corporations and Associations Article.

This subsection applies to a corporation that is:

The board shall be composed of at least 11 members and no more than 23 members, including:

No more than five members of the board may be:

To the extent possible, the board shall seek to include individuals with a diverse range of experience relevant to the mission of the corporation as a nonprofit health service plan as required under § 14–102 of this subtitle, including experience in data, consumer experience, government programs, population health, geriatrics, diversity, equity and inclusion, audit, human resources, benefit consulting, executive level, actuarial, accounting, information technology, finance, law, large and small businesses, nonprofit businesses, and organized labor.

Except for nonvoting members under paragraph (2)(i) and (ii) of this subsection, the board shall be self–perpetuating.

The board shall have the following standing committees whose duties shall include:

Each standing committee shall have representation from:

The compensation committee and the nominating committee shall each include either the appointee of the President of the Senate or the appointee of the Speaker of the House of Delegates.

Each board member shall serve on at least one standing committee.

The chairman of the board shall select a chairman for each board committee.

The board shall take and retain complete minutes of all board and committee meetings.

The three consumer members shall be either subscribers or certificate holders of the nonprofit health service plan or its affiliates at the time of their initial election to the board.

Each consumer member of the board:

A consumer member of the board may not:

This subsection does not apply to a board that has fewer than three authorized members.

The term of a member is 3 years.

The terms of the members of a board shall be staggered over a 3–year period as required by the terms provided for members of the board in the bylaws filed and approved by the Commissioner on or after June 1, 2003.

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

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.

A member may not serve for more than:

A person may not be a member of the board if the person:

A member shall meet any other qualifications set forth in the bylaws of the nonprofit health service plan.

A member may not be an immediate family member of another board member or an officer or employee of the nonprofit health service plan.

The board shall elect a chairman from among its members.

Board members may receive the following compensation:

A board member may not receive more than the amount specified in paragraph (1) of this subsection for serving on more than one board of a corporation subject to this section.

An officer of a nonprofit health service plan shall act:

Except for the receipt of reasonable remuneration in conformity with § 14-139 of this subtitle, an officer of a nonprofit health service plan may not use the position of officer for personal or financial enrichment.

A violation of this subsection shall be considered an unsound or unsafe business practice under § 14-116 of this subtitle.

In this section, “unsound or unsafe business practice” means a business practice that:

“Unsound or unsafe business practice” includes:

If the Commissioner believes that an officer or director of a nonprofit health service plan has engaged in an unsound or unsafe business practice, the Commissioner shall send a warning to that individual.

If the Commissioner believes that an officer or director of a nonprofit health service plan has failed to take appropriate action in response to a warning received under paragraph (1) of this subsection, the Commissioner may impose a civil penalty not exceeding $125,000 for each warning.

The Commissioner shall send a copy of the warning or, if a civil penalty is imposed under paragraph (2) of this subsection, a copy of the order:

If the nonprofit health service plan is incorporated in this State, the Commissioner may remove the officer or director if the Commissioner determines after a hearing that the unsound or unsafe business practice continued after the warning.

A copy of the removal order shall be served on the individual removed and each director of the nonprofit health service plan.

The individual removed is entitled to a hearing under Title 2 of this article.

Any person aggrieved by a final decision of the Commissioner under this section may appeal the decision under § 2-215 of this article.

form or organize under the laws of another jurisdiction unless the Commissioner determines that it is in the public interest; or

alter its structure, operations, or affiliations, if such alteration results in the for-profit activities of the plan becoming so substantial that the Insurance Commissioner determines that the purpose of the nonprofit health service plan may no longer be characterized as operating a nonprofit health service plan.

the foreign corporation operates a nonprofit health service plan that is affiliated with a nonprofit health service plan formed or organized under the laws of this State; and

the affiliation between the foreign nonprofit health service plan and the nonprofit health service plan formed or organized under the laws of this State is terminated.

If the Attorney General has reason to believe that a nonprofit health service plan is engaging in an unsound or unsafe business practice, the Attorney General shall notify the Commissioner.

If the Commissioner fails to take action under this section within 60 days after notification by the Attorney General, the Attorney General may:

In the course of any investigation conducted by the Attorney General, the Attorney General may:

In this section the following words have the meanings indicated.

“Earned premium” means earned premiums under:

“Surplus” means the amount by which assets exceed liabilities described in § 5-103 of this article.

$75,000; and

8% of the total earned premium received by the corporation in the immediately preceding calendar year.

The surplus of a corporation authorized under this subtitle may be considered to be excessive only if:

After the Commissioner has determined the surplus of a corporation authorized under this subtitle to be excessive, the Commissioner:

A distribution ordered under paragraph (2) of this subsection may be made only to subscribers who are covered by the corporation’s nonprofit health service plan at the time the distribution is made.

the corporation may be considered insolvent; and

the Commissioner may institute delinquency proceedings against the corporation under Title 9, Subtitle 2 of this article.

The corporation may apply for a single extension of not more than 60 days to cure a deficiency.

The Commissioner may grant the extension if:

Except as provided in paragraph (2) of this subsection, a corporation subject to this subtitle may invest its funds only in assets allowed for the investment of the funds of life insurers under §§ 5-101 and 5-102 and Title 5, Subtitle 5 of this article.

If the Commissioner determines that a corporation subject to this subtitle is engaged principally in the business of group health care rather than the sale of an insurance product or plan described in § 14-102 of this subtitle, the Commissioner may allow the corporation to invest a sum not to exceed 50% of its assets in real estate for use as medical facilities and fixed medical equipment to be used solely for the purpose of engaging in group health care.

On or before March 1 of each year, unless the Commissioner extends the time for good cause, each nonprofit health service plan shall file with the Commissioner a complete statement of its financial condition, transactions, and affairs for the immediately preceding calendar year.

The annual statement shall:

The applicable fee required by § 2–112 of this article shall be submitted at the same time as the statement.

Unless the Commissioner extends the time for filing, a nonprofit health service plan that fails to file an annual statement on or before March 10 shall pay a penalty of:

With 90 days’ advance notice, the Commissioner may require a nonprofit health service plan to file an audited financial report earlier than the date specified in paragraph (1) of this subsection.

file a consolidated financial statement that:

provide a list of:

provide any other information or documents necessary for the Commissioner to ensure compliance with this subtitle.

$100 for each day from June 1 to June 10, both inclusive; and

$150 for each day from June 11 to the day before the Commissioner receives the report, both inclusive.

The Commissioner may conduct any investigation or hearing that the Commissioner considers necessary to enforce this subtitle.

In conducting a hearing or investigation under this section, the Commissioner has the same powers with respect to nonprofit health service plans as are granted to the Commissioner under Titles 2 and 4 of this article with respect to any other activity regulated under this article.

If another state enacts a law or takes a regulatory action that requires a nonprofit health service plan operating in this State to provide a program or benefits for the residents of the other state or to distribute or reduce its surplus on the grounds that the surplus is excessive in whole or in part, the Commissioner may hold a quasi–legislative hearing or a hearing under Title 2 of this article or conduct an examination to review and evaluate the impact of the law or regulatory action on the nonprofit health service plan, including the impact on:

Based on the review and evaluation under paragraph (3) of this subsection, the Commissioner shall determine whether the impact on the nonprofit health service plan is harmful to the interests of subscribers covered by policies issued or delivered in this State.

A nonprofit health service plan may not distribute or reduce its surplus under a law or regulatory action the impact of which is subject to a hearing or an examination under paragraph (3) of this subsection, except with the approval of the Commissioner.

shall have free access to all of the books and documents of the corporation and its affiliates or subsidiaries; and

may subpoena and examine under oath any person, including an officer, agent, or employee of the corporation or its affiliates and subsidiaries, in relation to the affairs, transactions, and condition of the corporation or its affiliates and subsidiaries.

A corporation subject to this subtitle may not amend its certificate of incorporation, bylaws, or the terms and provisions of contracts issued or proposed to be issued to subscribers to the plan until the proposed amendments have been submitted to and approved by the Commissioner and the applicable fees required by § 2–112 of this article have been paid.

The Commissioner shall approve an amendment to the articles of incorporation or bylaws under paragraph (1) of this subsection unless the Commissioner determines the amendment is contrary to the public interest.

A filing is deemed approved unless disapproved by the Commissioner within the waiting period or any extension of the waiting period.

On the adoption of an amendment or change, after approval by the Commissioner, the corporation shall file with the Commissioner a copy of the amendment or change that has been certified by at least two executive officers of the corporation.

If, after the applicable review period established under subsection (b) of this section, the Commissioner finds that a filing does not meet the requirements of this section, the Commissioner shall issue to the filer an order that specifies the ways in which the filing fails to meet the requirements of this section and states when, within a reasonable period after the order, the filing will no longer be effective.

An order issued under paragraph (1) of this subsection does not:

The Commissioner may adopt regulations to allow a type or kind of form to be effective upon receipt of the filing by the Commissioner.

If a nonprofit health service plan uses a form which becomes effective in accordance with the provisions of subparagraph (i) of this paragraph and the form would be subject to disapproval under subsection (b)(3) of this section, the Commissioner may:

If a nonprofit health service plan files a form with the Commissioner which becomes effective in accordance with paragraph (1) of this subsection, the nonprofit health service plan shall pay the applicable filing fee provided in § 2–112 of this article.

In this section the following words have the meanings indicated.

“Affiliate” means a person that directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with a corporation subject to this subtitle.

“Control” has the meaning stated in § 7–101(c) of this article.

“Subsidiary” has the meaning stated in § 7–101(g) of this article.

the affiliate or subsidiary is licensed by the Commissioner; or

A nonprofit health service plan shall submit a statement of proposed action to the Commissioner before the plan may:

The nonprofit health service plan shall file the statement of proposed action required under this subsection at least 60 days before the effective date of the proposed action.

The nonprofit health service plan may not engage in a proposed action described under paragraph (1)(i) through (iii) of this subsection unless the Commissioner approves the action in writing.

The Commissioner shall either approve or disapprove the proposed action within 60 days after the Commissioner receives the statement of proposed action.

The Commissioner shall approve a statement of proposed action under this section unless the Commissioner determines the proposed action is contrary to the public interest.

If an affiliate or subsidiary of a corporation regulated under this subtitle does not comply with this section, the Commissioner shall require the corporation to file a plan of divestiture or liquidation of the affiliate or subsidiary.

The plan of divestiture or liquidation:

Before a divestiture or liquidation under this section, the plan of divestiture or liquidation must be approved by the Commissioner.

Any action by the Commissioner under this section may be appealed in accordance with Title 2 of this article.

deny a claim made under a contract, certificate, or policy of a nonprofit health service plan for an unfair or unfairly discriminatory reason;

without just cause, require a person making a claim under a contract, certificate, or policy of a nonprofit health service plan to accept less than the amount due; or

fail to notify in writing a subscriber or certificate holder of a nonprofit health service plan of a denial of a properly completed claim within 60 days after the plan receives the claim.

to the individual or individual’s agent or representative; or

if the individual authorizes the disclosure.

to a medical review committee, accreditation board, or commission, if the information is requested by or is in furtherance of the purpose of the committee, board, or commission;

in response to legal process;

to another nonprofit health service plan, Blue Cross or Blue Shield plan, or insurer to coordinate benefit payments under multiple sickness and accident, dental, or hospital medical contracts;

to a government agency performing its lawful duties as authorized by an act of the General Assembly or United States Congress;

to a researcher, on request, for medical and health care research in accordance with a protocol approved by an institutional review board;

in accordance with a cost containment contractual obligation to verify that benefits paid by the nonprofit health service plan were proper contractually;

to a third party payor if:

to evaluate and adjust a claim for benefits under a policy or to evaluate and calculate provider fiscal incentives or other types of provider payments; or

to the individual’s treating providers for the sole purposes of enhancing or coordinating patient care or assisting the treating providers’ clinical decision making, provided that:

willfully violate a provision of this article or a regulation adopted under this article;

willfully misrepresent or conceal a material fact in a statement, report, record, or communication provided to the Commissioner;

willfully misrepresent or conceal a material fact to the board of directors;

misappropriate or fail to account properly for money that belongs to the corporation, an insurer, insurance producer, subscriber, or certificate holder;

engage in fraudulent or dishonest practices in connection with the provision or administration of a health service plan;

willfully fail to produce records or allow an examination under § 14-125 of this subtitle; or

willfully fail to comply with a lawful order of the Commissioner.

The compensation committee of the board shall:

The board shall review the proposed guidelines at least annually.

The board shall:

On an annual basis, the Commissioner shall review:

If the Commissioner finds that the compensation exceeds the amount authorized under the approved guidelines, the Commissioner shall issue an order prohibiting payment of the excess amount.

Except for an employee under subsection (c) of this section, a person that violates subsection (a) or (c) of this section is subject to a civil penalty not exceeding $10,000 for each violation.

Instead of or in addition to imposing a civil penalty, the Commissioner may require the violator to make restitution to any person that has suffered financial injury as a result of the violation.

the seriousness of the violation;

the good faith of the violator;

the violator’s history of previous violations;

the deleterious effect of the violation on the public and the nonprofit health service industry; and

the assets of the violator.

Before assessing a civil penalty or restitution, the Commissioner shall serve by certified mail, return receipt requested, on the person to be charged a notice that contains:

The Commissioner shall hold a hearing on the charges at least 20 days after the date of mailing the notice.

The Commissioner or designee of the Commissioner shall conduct a hearing on the charges in accordance with Title 2, Subtitle 2 of this article.

Subject to Title 2, Subtitle 2 of this article, an appeal may be taken from a final order of the Commissioner to the Circuit Court for Baltimore City.

A person may not engage in the business of operating a nonprofit health service plan unless the person has a certificate of authority issued by the Commissioner under this subtitle.

A person that violates this subsection is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $50,000 for each violation.

A person may not:

A person that violates this subsection is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $5,000 for each violation or imprisonment not exceeding 1 year or both.

a physician licensed in the State who is under contract to provide health care services to patients at a hospital; or

a group physician practice that includes physicians licensed in the State that is under contract to provide health care services to patients at a hospital.

measures the weighted average annual price change for various inputs needed to produce physician services; and

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.

has privileges at a hospital;

is required to respond within an agreed upon time period to provide health care services for unassigned patients at the request of a hospital or a hospital emergency department; and

is not a hospital–based physician.

a policy or insurance contract that is issued or delivered in the State by an insurer, under which health care services are to be provided to the insured by a preferred provider on a preferential basis; or

another contract that is offered by an employer, third party administrator, or other entity, under which health care services are to be provided to the subscriber by a preferred provider on a preferential basis.

for a physician:

for a health care provider who is not a physician, a health care provider who holds the same type of license or certification.

This subtitle applies to insurers that issue or deliver individual or group health insurance policies in the State.

The provisions of this subtitle that apply to insurers also apply to nonprofit health service plans that issue or deliver individual or group health insurance policies in the State.

A preferred provider insurance policy offered by an insurer under this subtitle shall provide for payment of services rendered by nonpreferred providers as provided in this subsection.

Unless the insurer demonstrates to the satisfaction of the Commissioner that an alternative level of payment is more appropriate, for each covered service under a preferred provider insurance policy, the difference between the coinsurance percentage applicable to nonpreferred providers and the coinsurance percentage applicable to preferred providers may not be greater than 20 percentage points.

If the preferred provider insurance policy contains a provision for the insured to pay the balance bill, the provision may not apply to an on–call physician or a hospital–based physician who has accepted an assignment of benefits in accordance with § 14–205.2 of this subtitle.

The insurer’s allowed amount for a health care service covered under the preferred provider insurance policy provided by nonpreferred providers may not be less than the allowed amount paid to a similarly licensed provider who is a preferred provider for the same health care service in the same geographic region.

In this subsection, “unfair discrimination” means an act, method of competition, or practice engaged in by an insurer:

If the rates for each institutional provider under a preferred provider insurance policy offered by an insurer vary based on individual negotiations, geographic differences, or market conditions and are approved by the Health Services Cost Review Commission, the rates do not constitute unfair discrimination under this article.

for emergency services, as defined in § 19–701 of the Health – General Article;

for an unforeseen illness, injury, or condition requiring immediate care; or

as required under § 15–830 of this article.

If an employer, association, or other private group arrangement offers health benefit plan coverage to employees or individuals only through preferred providers, then the insurer or nonprofit health service plan with which the employer, association, or other private group arrangement is contracting for the coverage shall offer an option to include preferred and nonpreferred providers as an additional benefit for an employee or individual, at the employee’s or individual’s option, to accept or reject.

The insurer or nonprofit health service plan shall provide to each employer, association, or other private group arrangement a disclosure statement on the group application that an option to include preferred and nonpreferred providers is available for the individual or employee to accept or reject.

are nonpreferred providers;

obtain an assignment of benefits from an insured; and

notify the insurer of an insured in a manner specified by the Commissioner that the on–call physician or hospital–based physician has obtained and accepted the assignment of benefits from the insured.

Except as provided in paragraph (3) of this subsection, an insured may not be liable to an on–call physician or a hospital–based physician subject to this section for covered services rendered by the on–call physician or hospital–based physician.

An on–call physician or hospital–based physician subject to this section or a representative of an on–call physician or hospital–based physician subject to this section may not:

An on–call physician or hospital–based physician subject to this section or a representative of an on–call physician or hospital–based physician subject to this section may collect or attempt to collect from an insured of an insurer:

This subsection applies only to on–call physicians subject to this section.

For a covered service rendered to an insured of an insurer by an on–call physician subject to this section, the insurer or its agent:

This subsection applies only to hospital–based physicians subject to this section.

For a covered service rendered to an insured of an insurer by a hospital–based physician subject to this section, the insurer or its agent:

For the purposes of subsections (c)(2)(ii)1 and (d)(2)(ii)1 of this section, an insurer shall calculate the average rate paid to similarly licensed providers under written contract with the insurer for the same covered service by summing the contracted rate for all occurrences of the Current Procedural Terminology Code for that covered service and then dividing by the total number of occurrences of the Current Procedural Terminology Code.

For the purposes of subsection (c)(2)(ii)2 of this section, an insurer shall calculate the average rate paid to similarly licensed providers not under written contract with the insurer for the same covered service by summing the rates paid to similarly licensed providers not under written contract with the insurer for all occurrences of the Current Procedural Terminology Code for that covered service and then dividing by the total number of occurrences of the Current Procedural Terminology Code.

An insurer may seek reimbursement from an insured for any payment under subsection (c)(2)(ii) or (d)(2)(ii) of this section for a claim or portion of a claim submitted by an on–call physician or hospital–based physician subject to this section and paid by the insurer that the insurer determines is the responsibility of the insured based on the insurance contract.

The insurer may request and the on–call physician or hospital–based physician shall provide adjunct claims documentation to assist in making the determination under paragraph (1) of this subsection or under subsection (c) of this section.

An on–call physician or hospital–based physician subject to this section may enforce the provisions of this section by filing a complaint against an insurer with the Administration or by filing a civil action in a court of competent jurisdiction under § 1–501 or § 4–201 of the Courts Article.

The Administration or a court shall award reasonable attorney’s fees if the Administration or court finds that:

prohibit the assignment of benefits to a provider who is a physician by an insured; or

refuse to directly reimburse a nonpreferred provider who is a physician under an assignment of benefits.

the specific claim covered by the payment;

the amount paid for the claim;

the amount that is the insured’s responsibility; and

a statement instructing the insured to use the payment to pay the nonpreferred provider in the event the insured has not paid the nonpreferred provider in full for the health care services rendered by the nonpreferred provider.

a statement informing the insured that the physician is a nonpreferred provider;

a statement informing the insured that the physician may charge the insured for noncovered services;

a statement informing the insured that the physician may charge the insured the balance bill for covered services;

an estimate of the cost of services that the physician will provide to the insured;

any terms of payment that may apply; and

whether interest will apply and, if so, the amount of interest charged by the physician.

the insurer receives notice of the assignment of benefits after the time the insurer has paid the benefits to the insured;

the insurer, due to an inadvertent administrative error, has previously paid the insured;

the insured withdraws the assignment of benefits before the insurer has paid the benefits to the nonpreferred provider; or

the insured paid the nonpreferred provider the full amount due at the time of service.

a written summary description and a prototype copy of:

any other related documents or information that the Commissioner requires.

a dentist or professional dental corporation that accepts payment on a fee-for-service basis for providing specific dental services to individual patients for whom the services have been prediagnosed;

an authorized insurer whose activities are authorized and regulated under other provisions of this article;

a nonprofit health service plan that is subject to Subtitle 1 of this title;

a health maintenance organization that is authorized by and subject to Title 19, Subtitle 7 of the Health - General Article; or

a dental plan whose regulation by the State is preempted by federal law.

$50,000; or

2% of the organizations’ annual gross premium income, up to a maximum of the required capital and surplus of a stock insurer under § 4-103 of this article.

Except as provided in subsection (d) of this section, a dental plan organization shall deposit with the Commissioner or with any organization or trustee acceptable to the Commissioner through which a custodial or controlled account is used, cash, securities, or any combination of these or other measures that is acceptable to the Commissioner in an amount equal to $25,000 plus 25% of the surplus required in subsection (a) of this section, provided that the deposit shall not be required to exceed $100,000.

The deposit shall be:

All income from deposits shall be an asset of the dental plan organization.

A dental plan organization may withdraw a deposit or any part thereof after making a substitute deposit of equal amount and value.

A substitute deposit of any securities is subject to the approval of the Commissioner.

did not have any enrollees as of January 1, 2000;

held a certificate of authority as of January 1, 2000;

maintains a current certificate of authority; and

complies with all applicable laws and regulations, as determined by the Commissioner.

file with the Commissioner an application, verified by an officer or authorized representative of the dental plan organization, on the form that the Commissioner provides; and

pay to the Commissioner an application fee of $200.

the basic organizational documents of the dental plan organization, including the articles of incorporation, articles of association, partnership agreement, trade name certificate, trust agreement, and shareholder agreement;

all amendments to the organizational documents of the dental plan organization;

the bylaws, rules and regulations, or similar documents that regulate the conduct or internal affairs of the dental plan organization;

the names, addresses, and official positions of the individuals who are responsible for conducting the affairs of the dental plan organization, including:

each contract made between a dentist and the dental plan organization;

each contract made between a dentist and an individual listed in item (4) of this subsection, a consultant, or a business manager;

a description of the dental plan organization and its dental plan or plans, facilities, and personnel;

the form of evidence of coverage to be issued to enrollees;

the form of each group contract that is issued to employers, unions, trustees, or others;

a financial statement that details the assets, liabilities, and sources of financial support for the dental plan organization or, if the financial affairs are audited by an independent certified public accountant, a copy of the most recent regular certified financial statement, unless the Commissioner determines that additional or more recent financial information is required for the proper administration of this subtitle;

the proposed method of marketing the dental plan, a financial plan with a 3-year projection of the initial operating results, and a statement of the sources of working capital and any other sources of funding;

if a dental plan organization is not domiciled in the State, an executed power of attorney that appoints the Commissioner as attorney for service of process issued against the dental plan organization in the State;

a description of the geographic area to be served by the dental plan organization; and

any other information that the Commissioner requires.

the dental plan organization is operating in a manner significantly contrary to that described in §§ 14-403, 14-405, 14-407, and 14-408 of this subtitle;

the dental plan organization issues evidence of coverage that does not comply with § 14-410 of this subtitle;

the dental plan organization can no longer be expected to meet its obligations to enrollees;

the agreements of the dental plan organization with dentists are not sufficient to provide the dental services covered by the dental plan;

the dental plan organization, or authorized person acting on its behalf, has advertised or merchandised its services in an untrue or misleading manner;

the conditions or methods of operation of the dental plan organization make continued operation hazardous to enrollees or the public; or

the dental plan organization has failed to comply with this subtitle or any regulations adopted under this subtitle.

If the Commissioner revokes the certificate of authority, the dental plan organization shall dissolve its structure immediately after the effective date of the order of revocation and may not conduct further business, except as essential to the orderly conclusion of the affairs of the dental plan organization.

By written order, the Commissioner may allow further operation of the dental plan organization if the Commissioner finds that it is in the best interest of enrollees and that enrollees will be afforded the greatest practical opportunity to obtain continuing dental plan coverage.

impose on the holder a penalty of not less than $1,000 but not exceeding $50,000 for each violation of this subtitle; and

require the holder to make restitution to any person who has suffered financial injury because of a violation of this subtitle.

Notwithstanding subsections (c), (d), and (e) of this section, a dental plan organization that has had its certificate of authority suspended or revoked, has been ordered to pay a penalty or make restitution, or has suffered an adverse decision by the Commissioner is entitled to a hearing under § 2-210 of this article.

Hearings and appeals from orders of the Commissioner are governed by §§ 2-203 and 2-210 through 2-215 of this article.

Except as provided under paragraph (2) of this subsection, a dental plan organization shall issue evidence of coverage to each enrollee of the dental plan organization.

If an individual enrollee obtains coverage through a policy or through a contract issued by a medical or dental service corporation, the insurer that issued the policy or the medical or dental service corporation shall issue evidence of coverage.

a clear and complete statement if a contract, or a reasonably complete summary if a certificate, of:

a clear and understandable description of the dental plan organization’s method for resolving enrollee complaints.

A dental plan organization shall preserve its books, accounts, and records for at least 5 years.

Preservation by photographic reproduction shall constitute compliance with this subtitle.

A dental plan organization shall establish and maintain a complaint system to provide reasonable procedures for the resolution of written complaints initiated by enrollees about services of the dental plan organization.

The dental plan organization shall maintain records of all written complaints initiated by enrollees.

The Commissioner may examine the complaint system of a dental plan organization.

If the Commissioner determines that the complaint system is inadequate, the Commissioner may require a revision of the complaint system.

be in the form and have the content approved for current use by the National Association of Insurance Commissioners or its successor organization; and

contain any additional information that the Commissioner requires.

$100 for each day from March 1 to March 10, both inclusive; and

$150 for each day from March 11 to the day before the Commissioner receives the report, both inclusive.

Except as provided in paragraph (5) of this subsection, on or before June 1 of each year, each dental plan organization shall file with the Commissioner an audited financial report for the immediately preceding calendar year.

The dental plan organization shall have the audited financial report prepared by an independent certified public accountant.

The Commissioner may:

Unless the Commissioner extends the time for filing, a dental plan organization that fails to file an audited financial report on or before June 10 shall pay a penalty of:

With 90 days’ advance notice, the Commissioner may require a dental plan organization to file an audited financial report earlier than the date specified in paragraph (1) of this subsection.

advertising that is untrue or misleading;

solicitation that is untrue or misleading; or

any form of evidence of coverage that is deceptive.

the words “insurance”, “assurance”, “casualty”, “surety”, or “mutual”; or

any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of an insurer authorized to do business in the State.

Within 20 days after service of the cease and desist order, the dental plan organization or its representative may request a hearing to determine whether a violation of this subtitle has occurred.

A hearing under this subsection shall be conducted in accordance with § 2-213 of this article and is subject to judicial review in accordance with § 2-215 of this article.

the dental plan organization becomes insolvent or suspends its ordinary business for lack of funds; or

the Commissioner finds, as a result of an examination authorized by this subtitle or in any other manner, that:

proceed in the action in a summary manner or otherwise;

grant injunctive relief and appoint a receiver, with power to:

cause the receiver to continue the existing operations of the dental plan organization, under court supervision, until the next anniversary of the subscription certificates and contracts then in force.

Except as provided in paragraph (2) of this subsection, information obtained by a dental plan organization about the diagnosis, treatment, or health of an enrollee is confidential and may not be disclosed.

A dental plan organization may disclose information described in paragraph (1) of this subsection:

“Discount drug plan” means a business arrangement or contract in which a person, in exchange for fees, dues, charges, or other financial consideration paid by or on behalf of a plan member, provides the right to receive discounts on specified pharmaceutical supplies, prescription drugs, or medical equipment and supplies from specified providers.

“Discount drug plan” does not include:

contracts directly or indirectly with providers or provider networks to provide pharmaceutical supplies, prescription drugs, or medical equipment and supplies at a discount to plan members; and

determines the charge to plan members.

contracts directly or indirectly with providers or provider networks to provide medical services at a discount to plan members; and

determines the charge to plan members.

any person or institution which is contracted, directly or indirectly, with a discount medical plan organization to provide medical services to plan members; or

any person or institution which is contracted, directly or indirectly, with a discount drug plan organization to provide pharmaceutical supplies, prescription drugs, or medical equipment and supplies to plan members.

comply with §§ 14–606 through 14–611 of this subtitle;

notify the Commissioner in writing that it sells, markets, or solicits a discount medical plan or discount drug plan in the State; and

An entity shall register with the Commissioner as a discount medical plan organization before a discount medical plan established by that entity is sold, marketed, or solicited in the State.

A discount medical plan may not be sold, marketed, or solicited in the State unless the discount medical plan organization that established the discount medical plan is registered with the Commissioner.

An entity shall register with the Commissioner as a discount drug plan organization before a discount drug plan established by that entity is sold, marketed, or solicited in the State.

A discount drug plan may not be sold, marketed, or solicited in the State unless the discount drug plan organization that established the discount drug plan is registered with the Commissioner.

file with the Commissioner an application on the form that the Commissioner requires; and

pay to the Commissioner an application fee of $250.

otherwise is entitled to be registered;

files with the Commissioner a renewal application on the form that the Commissioner requires; and